Transcript Document

HIV Care Under the
Affordable Care Act
Addressing the Needs of
HIV Clinics and Clinicians in Florida
May 2015
Julia Hidalgo, ScD, MSW, MPH
Research Professor, George Washington University and
CEO, Positive Outcomes, Inc.
[email protected]
Today We Will Address
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Key provisions of the Patient Protection and Affordable Care
Act (ACA)
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Federal and State Medicaid policies
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Provider participation and covered benefit provisions
Eligibility, service delivery, and payment systems
Focus on challenges and opportunities for Florida HIV
clinical, social support, and prevention providers
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Maximizing third party reimbursement for HIV prevention, care, and support
services through collaborative strategies
ACA
Marketplace
From: Hidalgo J and Edelbrock E. Commercial Health Insurance Basics for HIV Prevention Programs Webinar. ETR and University of
Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-3-commercial-health-insurance-basics-for-hiv-prevention-programs/
US Census: Majority of Americans 19-64 Years
Are Enrolled in Commercial Insurance
Private
Public
Uninsured
70%
60%
50%
40%
30%
20%
10%
0%
19-25
26-34
35-44
Age Group
45-64
ACA Requirements: Essential Health Benefits (EHBs)
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Ambulatory patient services
Hospitalization
Emergency services
Pregnancy, maternity, newborn care, and pediatric services (oral and
vision care)
Mental health and substance abuse disorder services (i.e., behavioral
health treatment)
Prescription drugs
Rehab and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease
management
ACA Requirements: Essential Community Providers (ECPs)
ECP Category
ECP Provider Type
Federally Qualified
Health Centers
(FQHCs)
FQHCs and other community health centers, and healthcare
facilities operated by Indian tribes and other Indian
organizations
RWHAP Provider
Ryan White HIV/AIDS Program-funded providers
Family Planning
Provider
Title X family planning clinics and look alike family planning
clinics
Indian Health Provider
Indian Health Service (HIS) providers, Indian tribes
organizations, and urban organizations
Hospital
Disproportionate share hospitals (DSH) and eligible hospitals,
children’s hospitals, sole community hospitals, and other
similar facilities
Other ECP Providers
STD clinics, TB clinics, and other entities that serve
predominantly low-income, medically underserved individuals
ACA Requirements: ECPs
CMS issued a letter to Federally-Facilitated Marketplaces in December 2014
 QHPs must contract with at least 30% of ECPs in each QHP’s service area
 Offer contracts in good faith to all available Indian health providers in the service
area
 Offer contracts in good faith to at least one ECP in each ECP category in each
county in the service area
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Where an ECP in that category is available and provides medical or dental services
that are covered by the issuer plan type (i.e., Individual or SHOP)
To be in “good faith,” a contract should offer terms that a willing, similarlysituated, non-ECP provider would accept or has accepted
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Issuers must be able to provide verification of such offers if CMS chooses to review
the offers for compliance
ACA Requirements: Preventive Services
DHHS US Preventive Services Task Force (USPSTF) recommends
 “A” grade for HIV infection screening
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Adolescents and adults ages 15 - 65 years
Younger adolescents and older adults at increased risk
All pregnant women, including those presenting in labor who are untested and
whose HIV status is unknown
“A” grade for syphilis for all pregnant women and other persons at
increased risk for infection
 “B” grade for chlamydia screening for sexually active women age 24
or younger and in older women at increased risk for infection
 “B” grade for STD counseling for sexually active adolescents and for
adults at increased risk for STDs
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ACA Marketplace Lessons Learned in 2014
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Lack of health insurance “literacy” is a significant issue, with
the need to educate clients about
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Share of cost: Co-pays, co-insurance, deductibles, premiums
 Newly insured individuals may be unaware of providers’ collection
policies, resulting in high debt for unpaid medical bills
 Selection of primary providers, specialty referral requirements, prior
authorization, and medical necessity
 Network adequacy: primary care physicians, specialists
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Health plan care management strategies present serious
barriers to care for HIV+ individuals
Florida Marketplace
Individual Plans
On-Exchange
Off-Exchange Only
Small Group Plans
On-Exchange
Off-Exchange Only
Carriers
Premium Increase
2014 2015
11
14
13.5%
6
7
0.0%
Carriers
Premium Increase
2014 2015
5
6
11.4%
15
13
5.7%
Florida QHPs Sold On and Off the Federally-Facilitated Marketplace
Carriers
Aetna Health Inc.
Aetna Life Insurance Company
All Savers Insurance Company
AvMed, Inc.
Blue Cross Blue Shield of FL
Cigna Health and Life Insurance Company
Coventry Health and Life Insurance Company
Coventry Health Care of FL, Inc.
Coventry Health Plan of FL, Inc.
FL Health Care Plan, Inc.
Freedom Life Insurance Company of America
Health First Health Plans, Inc.
Health First Insurance, Inc.
Health Options, Inc.
Humana Health Insurance Company
Humana Health Insurance Company of FL, Inc.
Humana Medical Plan, Inc.
John Alden Life Insurance Company
Molina Healthcare of FL, Inc.
Neighborhood Partnership, Inc.
Preferred Medical Plan, Inc.
Sunshine State Health Plan
Time Insurance Company
UnitedHealthCare Life Insurance Company
UnitedHealthCare of FL, Inc.
Individual
On-Market
Off-Market
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Impact of the
ACA on State
Medicaid
Programs
From: Hidalgo J and Edelbrock E. Medicaid Basics for HIV Prevention Program. ETR and University of Washington, Oct 2014.
http://www.etr.org/CIS/webinars/webinar-2-medicaid-basics-for-hiv-prevention-programs/
Medicaid Overview
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Federal and state entitlement program
Medical assistance for people with limited income and resources
Covers 60 million adults and children
Enrollment in “traditional” Medicaid is commonly via TANF, Aged,
Blind, Disabled or other Categorical Programs
Supplements Medicare benefits for 9 million low income aged and/or
disabled individuals
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Beginning in 2014, the ACA permitted states to expand Medicaid
optionally to non-disabled individuals
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Disability continues to be a common pathway to Medicaid and Medicare for HIV+ adults
Anyone who is poor (include < $16,104 or 138% of the FPL)
4.8 million Americans enrolled in expanded Medicaid
In FL, Medicaid is operated by the FL Agency for Health Care Agency (ACHA)
Until ACA Medicaid expansion implementation, FL HIV+ adults commonly enroll in Medicaid through
enrollment in Social Security Administration (SSA) disability or TANF benefits. In FL, applications for SSA
disability benefits are determined by the FL DOH Division of Disability Determinations.
SSA Initial Allowance Rates in FL, By Month, October 2000 to March 2015
ACA-Related Medicaid Benefits
NON-EXPANSION STATES
 Can voluntarily cover EHBs under their traditional Medicaid
benefit packages
 Coverage of preventive services in traditional Medicaid
benefit packages is optional
 Some groups, such as the disabled, dual eligible, and
medically frail individuals, are exempt from enrollment in
ABPs and may choose to obtain traditional Medicaid
services
New Opportunities for Medicaid Payment for Preventive Services
CMS published a final rule effective in January 2014
 Before the rule change: preventive services could only be
provided by a physician or other licensed practitioner (OLPs) of
the healing arts to be paid by Medicaid
 After the rule change: other practitioners, not just physicians and
OLPs, can be paid to provide preventive services recommended
by a physician or OLP
 Assigns authority to State Medicaid Programs to
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Define practitioner qualifications
Ensure appropriate services are provided by qualified practitioners
Define the preventive services to be provided
Design the reimbursement methods
Does not define the type of personnel to be covered
FL Statewide Medicaid Managed Care (SMMC) Recipient Eligibility
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Assistance categories that enroll in a Managed Care Plan (MCP)
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Temporary Assistance to Needy Families (TANF)
SSI (Aged, Blind, and Disabled)
Hospice
Institutional Care
Medicaid (MEDS) - Sixth Omnibus Budget Reconciliation Act (SOBRA) for
children born after September 30, 1983 (age 18 to 19)
MEDS AD (SOBRA) for aged and disabled
Protected Medicaid (aged and disabled)
Full-Benefit Dual Eligibles (Medicare and Medicaid -FFS)
Full-Benefit Dual Eligibles enrolled in Part C – Medicare Advantage Plans that
are not fully liable for all Medicaid services
FL Assertive Community Treatment Team (FACT Team)
FL Statewide Medicaid Managed Care (SMMC) Recipient Eligibility
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Recipients who may ENROLL VOLUNTARILY include
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Recipients who have other creditable health care coverage, excluding Medicare
 Persons eligible for refugee assistance
 Residents of a developmental disability center
 Enrollees in the developmental disabilities home and community based services
waiver or Medicaid recipients waiting for waiver services
 Children receiving services in a prescribed pediatric extended care center
 Residents of a group home facility licensed under Chapter 393
FL Statewide Medicaid Managed Care (SMMC) Recipient Eligibility
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The following recipients INELIGIBLE to enroll
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Women who are eligible only for family planning services or through the
breast and cervical cancer services program
 Persons who are eligible for emergency Medicaid for aliens
 Dual eligible recipients whose Medicaid benefits are limited (partial duals)
Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Medicare
Beneficiaries (SLMBs), and Qualifying Individuals
 Medically needy recipients will not experience a change in benefits at the
time that they meet their share of cost and will continue to receive services
through Medicaid fee-for-service (FFS)
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Home and Community-Based Services (HCBS) Waiver programs
are subject to a federal transition requirement, with the transition
plan comment period recently closed
Medicaid Managed Medical Assistance Specialty Plans
Child Welfare Specialty Plan
Children’s Medical Services Network Plan
HIV/AIDS Special Plans
Serious Mental Illness Specialty Plan
Freedom Health Special Plans for Dual Eligible Recipients
Recipients Eligible for More Than One Specialty Plan
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A ranking system determines specialty plan assignment
 The recipient is automatically assigned to the special plan highest
in the ranking
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Ranking includes
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A recipient can still chose from any other MMA specialty plan if he/she is
eligible for any other standard plan in their region
Child welfare specialty plan
Children’s Medical Services Network plan
HIV/AIDS specialty plans
SMI specialty plan
Freedom Health specialty plans for dual eligibility recipients (i.e., individuals
enrolled in Medicare and Medicaid)
In applying this ranking system, HIV+ recipients with SMI are
assigned to an HIV/AIDS specialty plan, but can alternatively select
an SMI specialty plan
FL SMMC Standard and Specialty MCPs
STANDARD PLANS
Amerigroup
Better Health
Coventry
Humana
Integral
Molina
Preferred Medical
Prestige
SFCCN (South FL Community Care Network)
Simply
Staywell
Sunshine
UnitedHealthCare
SPECIALTY PLANS
Children’s Medical Services (CMS)- Children With Chronic Conditions
Clear Health Alliance- HIV/AIDS (Simply Healthcare Plans, Inc.)
Freedom Health- Duals Chronic Conditions
Magellan Complete Care- SMI
Positive Health Care FL- HIV/AIDS (AIDS Healthcare Foundation)
Sunshine Health Plan- Child Welfare
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FL SMMC HIV/AIDS Specialty Plan Requirements
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Specialized provider education, and HIV Specialist PCP criteria (including CME)
Provider responsibility for HIV primary and secondary prevention activities and risk reduction
education
Provision of care in accordance with the most recent clinical practice guidelines for HIV/AIDS
treatment
Treatment adherence services available from the Specialty Plan
Required use of approved assessment tools for behavioral health and substance abuse
Specialist Case Management policies and procedures including provider’s role in the
Specialty Plan’s MCM/care coordination services
Referral to services, including services outside of the Specialty Plan’s covered services and
services provided through interagency agreements
Quality measurement standards for providers
Exchange of data
Extensive requirements regarding care management, including linkage with community HIV,
other support services, RWHAP, and PAC Waiver
Opportunities for
HIV Core Medical,
Support, and
Prevention
Providers in the
ACA and Medicaid
Reform
Addressing Health Insurers’ Interests Via Services Offered by HIV Providers
Health Insurers’ Interests
Services That HIV Providers Might
Offer
Identify enrolled members that do not obtain
preventive or other services
Essential covered benefits
Outreach, linkage, patient
navigation
RWHAP core medical providers
Address members’ healthcare and health
insurance literacy needs
Prevent communicable diseases including HIV,
STDs, TB, and HCV
Non-MCM, patient navigation,
health education
nPEP and PrEP support, HIV/STD
CTS, behavioral prevention,
condom distribution and
education, HERR
Translation and health education
Address members’ linguistic and numeracy
needs to ensure that they can participate actively
in health promotion, prevention, and care
Culturally competent care coordination, disease Culturally competent workers with
management, treatment education
expertise in serving racial, ethnic,
and sexual minority populations
Addressing Health Insurers’ Interests Via Services Offered by HIV Providers
Services That HIV Providers Might
Offer
Ensure access to physical, behavioral,
MCM, navigation, behavioral
and other outpatient services to promote health tx support, medical
health, and prevent and treat disease
transportation
Ensure HIV+ clients receive and optimally MCM, navigation, tx education
benefit from ARVs and other medications and adherence counseling,
MCM
Coordinate services provided by the care MCM
team with the client, his/her family, and
community resources
Disease management
MCM
Discharge planning and readmission
MCM
prevention interventions for hospitalized
patients
Health Insurers’ Interests
ACA Essential, RWHAP, and CDC-Covered Services
ACA Essential Covered Benefits
RWHAP Service Categories
Ambulatory patient services
Hospitalization
Emergency services
Pregnancy, maternity,
newborn care
Pediatric services
Mental health (MH) services
Substance abuse (SA)
disorder services
Prescription drugs
OAMC, hospice care
Rehab & habilitative services
& devices
Laboratory services
Oral health services (peds)*
Preventive & wellness
services & chronic disease
management
Home health care, HCBHS
CDC HIV High Impact Services
OAMC visits for PrEP & PEP
OAMC
OAMC
MH services, hospice care
Outpt SA tx services,
residential SA tx
OAMC, ADAP, LAPA
OAMC, EIS, lab tests
Oral health services
OAMC, MCM, EIS, HERR, tx
adherence counseling
HIV biomedical prevention:
meds for PrEP & nPEP
HIV & STD testing
HIV test counseling, HIV
behavioral prevention, HERR,
PrEP and nPEP tx adherence,
prevention case management
Non-Essential ACA, RWHAP, and CDC-Covered Services
RWHAP Service Categories
ACA Non-essential
Covered Benefits
Medical nutrition therapy
Medical transportation
services
Linguistic services
Outreach services
Rehabilitation services
CDC HIV High Impact
Services
Outreach & linkage
services
Align With Your Organization Before Seeking New Opportunities
Before moving forward, it is critical to
 Ensure your HIV program’s efforts are aligned with your
organization’s overarching readiness efforts
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An important step for HIV practices in large integrated health systems,
hospital-based or university-affiliated health systems, local health
departments, large FQHCs
Contracts may have been negotiated or are being negotiated
QHP and Medicaid MCO contracts have probably been finalized for the
current year
 Engage
organizational leadership, including corporate board
support
 Identify organizational resources that can be applied to your
contracting and collaboration activities
Medicaid
Independent
Contracting
Model
HospitalBased HIV
Clinic
MCO
FQHCs
CBOs
Health
Dept
Collaborative Integration Strategies
QHP
or
MCO
Contract for services using “grant” type budget, FFS, sub-capitated arrangements
Augment care management services provided by the insurer through contract
Contract with provider networks to provide HIV and HIV services
Hospital Provide subcontracted essential and other covered services
Systems Coordinate and collaborate to serve HIV+ and non-HIV+ clients
Subcontract with CBOs and handle their billing
FQHCs
& HIV
Clinics
CBOs
Provide subcontracted essential and other covered services
Coordinate and collaborate to serve HIV+ and non-HIV+ clients
Subcontract with CBOs and handle their billing
Provide subcontracted outreach, HIV and STD testing, linkage, home
visits, MCM, preventive services
On Our
Own
Virtual
Integration
Physical
Integration
Acquisitions
& Mergers
• Chart your own organizational course
• Enhance your TPR capacity, join insurers’ FFS programs and networks
• Crush the competition
• Adopt a “trade association” model
• Collaborate in information gathering, purchasing, and marketing
• ASOs seek out and create formal relationships with HIV clinics, community health
centers, or other core providers
• Co-locate services but remain independent organizations
• Share infrastructure costs
• Identify agencies with services strengthening your capacity and “buy them”
• Identify similar agencies but different service areas or populations and merge
• Transfer clients to a fiscally solvent, culturally competent, and high quality agency
close HIV program
Integrated
Healthcare
Facilities and
Community-Based
Organization
(CBOs)
Contracting Model
Medicaid
FFS
MCO
Hospitals
FQHCs
Hospitals
FQHCs
CBOs
CBOs
CBOs
CBOs
QHP
Integrated Public
Health Department
and CBO
Contracting Model
State and
County HDs
Public HealthFunded HIV/STD
Surveillance
CBOs
How to Learn
More About
ACA and
MedicaidRelated Health
Insurers in My
State