Policy Update: Federal AIDS Policy Partnership Meeting Notes

On Wednesday, May 15th I traveled down to Washington DC to attend the quarterly Federal AIDS Policy Partnership (FAPP) membership meeting. This partnership is a way for HIV providers, advocacy groups, health departments, and Ryan White grantees to combine efforts to promote national policies that ensure people living with HIV/AIDS have access to quality and affordable services, fight stigma and discrimination, and decrease health disparities. Membership is open to any organization with an interest in HIV policy. Membership is free but requires endorsement/support from two member organizations. 

You can see some of the materials from the meeting, including slide sets and the agenda here.

The meeting focused on the Affordable Care Act (ACA). A few of the highlights are outlined below.  Most of the conversation focused on the funding for the Ryan White program and how organizations can prepare for full implementation of the ACA in 2014.  I will share what I think are the most important points/facts from the 5 hour meeting.

Resources on ACA and Ryan White

HRSA's HIV/AIDS Bureau (HAB) has developed  and released documents and other tools that will be helpful to Ryan White grantees and providers in preparing the implementation of health reform. Here's the webpage to find them. Sign up for updates on the right side of the page.

TARGET Center is another great resource with tools and best practices from the federal government and Ryan White grantees/providers.

Payer of Last Resort

It was made pretty clear by the end of the meeting from the guest speakers and others in the room that “Ryan White is payer of last resort” is something we are going to be hearing a lot of in the months and years to come. Here’s a paraphrase from the meeting:

If Medicaid or other insurance covers an activity within a visit, then Ryan White CANNOT be billed for that same activity. Generally, third-party payers pay for the activity/service, not the time taken to provide the service. Ryan White funds can ONLY be used for activities that are not covered by any other payer.

For further details, please see this policy clarification from HRSA. 

HRSA and CMS are working closely together to develop policies and guidance to direct Ryan White grantees and providers through this transitional time. Several documents and policies are expected to be officially released in the next several weeks.

Providers should maximize payer options:

• Find out more about Qualified Health Centers
• Contact top three insurers and join their networks
• Essential Community Provider list - get added if your organization is not included
• Contact State Medicaid office to join the networks
• Have flexibility in billing systems for 3rd party billing

Ryan White providers play a key role in enrollment.

Center for Consumer Information & Insurance Oversight (CCIO) is running navigator grant program for federally facilitated marketplaces. Funding Opportunity Announcement (FOA) and standards are posted at CCIO.  There are wide array of entities that are eligible to apply for navigator grants, focused populations or geographical areas.

All organizations should have staff trained to assist patients/clients with the application and enrollment process for marketplace plans and Medicaid

Funding for FY2013 and FY2014

Take a minute to read this blog post from March to get a feel for the kind of funding challenges we are likely to have this year.

There is no real good news about funding for Ryan White or really any other federally funded HIV/AIDS program. The sequester has reduced the amount of money available for non-defense discretionary programs by $25.8 billion (and that was before Congress started to monkey around with it). If President Obama and Congress can make the sequester go away, there's hope that funding for Ryan White and other essential programs can be protected and restored. At this point, good news is unlikely without a "Grand Bargain" between Democrats and Republicans for increases in revenue (taxes) and decreases in spending.

AIDS Budget and Appropriations Coalition - FY2014 Chart

Congress passed a Continuing Resolution in April 2013 for FY 2013. FY2014 budget is still being developed, currently the House and Senate each have their own versions. House bill has $92 billion less than Senate bill.

President’s budget FY2014 restores FY2013 cuts to Ryan White, but this is only a proposal. The House and Senate must agree on a bill, and that bill has to be signed into law by President Obama. We have a long way to go.

But here are some things we do know:

• Operating budgets for CDC and HRSA have been released for FY2013
• Ryan White Program is losing $121 million instead of the $166 million on the ABAC chart, because President Obama found a way to reinstate the $45 million "World AIDS Day funds" that were left out of the continuing resolution for FY2013.

So there you go. These are just the highlights (or is it lowlights?). Stay tuned for more updates on the federal policy and funding news as we move through the summer. Still no word on when we can expect our full FY2013 Part A award, sometime this summer we suspect. But we do still anticipate the 11% decrease, as discussed in this post from March.

The Big Picture - May 2013

This post is part of a monthly series published on the fourth Thursday of every month. It provides an overview of themes and topics from the general meetings and committee meetings of the Ryan White Planning Council and Prevention Planning Group each month. To view meeting materials and presentations, please visit www.hivphilly.org.
 

Ryan White Planning Council (RWPC)


This May, the Ryan White Planning Council (RWPC) received two separate presentations on the latest trends in HIV.  First up, Dr. Helena Kwakwa told RWPC members about the new health system navigators in the City's Health Centers.  This program helps people that just found out that they're HIV-positive into medical care.  It also helps people get back into care if they stopped going to the doctor.  Next, we had Evelyn Torres and Sebastian Branca from AACO give us an update on the Client Services Unit (CSU), the Housing Services Program (HSP), and Quality Management (QM).  You can get the full scoop here.

Treatment Cascade

Meanwhile, the Comprehensive Planning and Finance Committees held another joint meeting.  They talked about the priority setting process that the RWPC has to have at least every three years.  They use this process to organize service categories from highest priority to lowest priority.  There are going to be some major changes this year, so they updated their priority setting tool.  The new tool focuses more on the treatment cascade.  They also started to tackle the idea of cost-effectiveness for services.  The Comprehensive Planning Committee will move forward with priority setting, while the Finance Committee keeps working on allocations-related issues.

Both the Needs Assessment Committee and Points of Integration Workgroup (a joint venture of the RWPC and PPG) are plugging along with their work on linkage to care.  Linkage to care (making sure newly diagnosed HIV-positive people get into medical care) is one of the most challenging parts of the cascade for the Philadelphia area.  The Needs Assessment Committee kept working on specific questions they had for HIV testers about how currently they get their clients to the doctor.  The Points of Integration Workgroup agreed to create a new model for linkage to care for the Philadelphia area.  They're starting off by looking at research on current models.  Both groups talked about navigators, too.

The Positive Committee has also been discussing coming changes from the Affordable Care Act (ACA).  (Nicole is doing a great series on health reform and the average consumer.)  The Philadelphia Eligible Metropolitan Area (EMA) covers nine counties in two states.  Since New Jersey is expanding its Medicaid program but Pennsylvania isn't, we'll have some unique challenges in 2014.  Nicole also talked about Essential Health Benefits and other topics from the ACA. 

Prevention Planning Group (PPG)

Last year, the CDC came out with a new HIV Planning Guidance.  This changed the work required in prevention planning, shifting its focus to broad community engagement.  The PPG has been working to re-imagine itself for several months, in order to stay consistent with this changing landscape.  The PPG as we know it will cease to exist when all of its members' terms expire on June 30.  Its new incarnation, the Philadelphia HIV Prevention Planning Group (HPG), will kick off in July.  Their specific tasks are changing, but their work is just as important.  Apply for HPG membership by June 18, and help shape the future of HIV prevention in Philadelphia.



This is an exciting time to get involved in community planning for the Philadelphia area. To learn more, follow the links in this post, attend one of the meetings listed on our calendar, or email info@hivphilly.org to find out how to get involved. If you have questions, you can also call us at 215-574-6760.

Health Reform and You Part 1

Before we get into the specifics about how health reform and the Affordable Care Act (ACA) affect the lives and health insurance status of people living with HIV/AIDS, we should make sure everyone understands the basics of the law. If you already have the basics of Medicaid expansion, insurance reforms, state health insurance exchanges/marketplaces, federal subsidies for premiums and cost-sharing, and the individual mandate under control, then you can skip this post and wait for Part 2. Part 2 will focus on how the ACA impacts people living with HIV/AIDS. Part 3 will focus on how people receiving Ryan White services might be impacted by the ACA.

But wait! Take this quiz before you do anything. That way you can see what you actually know and what you might want to learn more about.

Leave your comments and questions in the Comments of this post, and I'll do my best to answer them and follow up.

The Basics

Kaiser Family Foundation is a great source for reliable, people-friendly information on health reform and the Affordable Care Act (ACA). I recommend checking them out from time to time or signing up for email updates. Here are some of the useful resources you can find there.

Health Reform Hits Main Street

An oldies but goodie - this animation was created in 2010, right after the health reform law (ACA) was passed by Congress and signed into law by President Obama. It goes over the big changes in the law. It's kind of cute and offers some good information, well worth 10 minutes of your time.

Interactive Health Reform Timeline

You can see what parts of the law have already taken affect and what will come in the months and years ahead. You can select what is featured in your timeline by topic or year.

FAQ - Frequently Asked Questions on Health Reform

Questions and facts about insurance, Medicaid, eligibility, federal subsidies for health insurance and more.

ACA 101 Briefing

On April 26, 2013 Kaiser Family Foundation hosted a briefing outlining the basics of the ACA, to help all of us understand it better and now what it will mean for our lives and our communities.

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Visualizing Health Insurance Coverage Under the ACA

This flowchart is probably the simplest explanation for how coverage and support for health insurance will change in 2014. Just answer the questions in the boxes with a 'yes' or 'no' and you will k now what your options are for health coverage next year.

Stay Tuned for Part 2

Next time we'll talk about how health reform affects people living with HIV/AIDS. Don't forget to leave your comments, questions and concerns about health reform in the comments here. That way I can answer your questions in future blog posts and see what other resources might be available for you and others that address your concerns. 

Policy Update for Providers

There has been so much going on in health policy over the last several weeks, especially concerning how Ryan White service providers are going to be doing business in the era of health reform. I pulled together several (but certainly not all) of the  developments and resources in order to help providers know where to start in preparing to meet the challenges that are sure to come, as well as to take advantage of all the opportunities for growth and sustainability. Last time, I wrote about what community planners need to know. Next up, I'll focus on what all of these changes mean to individuals.

But First

Before you do anything go here and sign up to receive bulletins from HRSA about Ryan White and Affordable Care Act (ACA) news. This is also the place to read all the latest developments and get copies of documents related to Ryan White and ACA.

Also HRSA will host a webcast on Tuesday, May 7th at 1pm EST on the Potential Impacts of the Affordable Care Act on Safety Net Providers in 2014

Eligibility for Ryan White services

In the era of health reform and the ACA, there are so many questions about the role of Ryan White funds and what impact health reform will have on consumers' eligibility for Ryan White services. HRSA released a policy clarification last month that lays out expectations and requirements for client re-certification and eligibility for Ryan White services:

Clarifications on Ryan White Program Client Eligibility Determinations and Recertifications Requirements

Re-certification is still required and important to determine eligibility of individuals. Providers and grantees are responsible to make sure that only eligible individuals receive Ryan White services, meaning all Ryan White clients must be HIV-positive and have low income, in order to be re-certified every six months. The policy statement includes the types of documentation needed and where individual declaration or self-reported status will be accepted for re-certification purposes.

HRSA also held a webinar on April 5th called Eligibility 101: The Affordable Care Act and Ryan White Program - New Opportunities for People Living with HIV/AIDS. You can watch the webinar at the link and download slides.

Essential Community Providers

Starting in 2014, the Affordable Care Act (ACA) will result in over 20 million people enrolling in private insurance coverage through health insurance marketplaces (or exchanges). These private plans, called “Qualified Health Plans” (QHP) must meet standards for inclusion of “Essential Community Providers” (ECPs) in their provider networks. ECPs serve predominantly low-income, medically underserved populations and include, but are not limited to, safety net providers who are eligible to participate in the 340B drug purchase program in these six categories: Federally Qualified Health Centers (FQHCs), Ryan White providers, family planning providers, Indian providers, specified hospitals*, and others. But inclusion in Qualified Health Plans’ provider networks is not automatic. Safety net providers must identify insurers offering plans on their state’s ACA marketplace and negotiate to be included. Keep in mind that ACA implementation is just beginning, and relationships that begin now can be built on in future years--  Essential Community Providers:Tips to Connect with Marketplace Plans from National Academy for State Health Policy

Official deadline for health plans on the federal-facilitated exchanges is Friday, May 3rd, but plans can add providers after that as well.  You can check out the list of Essential Community Providers and determine if your organization is included. Follow the steps in the fact sheet quoted above to work with marketplace plans.

Enrollment Assistance

Ryan White providers are expected to make every effort to assist clients in enrolling in appropriate health insurance, whether Medicaid, a health plan through the state marketplace, or through other public or private programs. 

A joint letter from Center for Medicaid and Medicare Services (CMS) and the Health Services and Resources Administration (HRSA) was released on May 1,2013 clarifying the importance of coordination between Medicaid and Ryan White programs.

HRSA also has a chart detailing how Ryan White providers and grantees can provide benefit enrollment and counseling to clients through  Outreach Services, Early Intervention Services, Medical Case Management, Non-medical Case Management, Health Education and Risk Reduction, and Referral for Health Care or Supportive Services under Parts A, B, and the Minority AIDS Initiative. 

On April 18th, there was an informative panel discussion with national experts on enrollment assistance, thanks to the Kaiser Family Foundation for the video.

You can also use a subsidy calculator to figure out what (if any) amount of federal subsidy you (or a client) might be eligible for in order to make purchasing health insurance on the exchange affordable for you.  

As you probably remember, most individuals will be required to purchase health insurance provided they meet these requirements:

Exchange Applications

Enrollment for the state insurance marketplaces (sometimes called exchanges) will be open on October 1, 2013 and coverage will begin on January 1, 2014 for those plans. The federal government just released the applications that individuals and families will use to apply for coverage on those exchanges. They have been simplified to 3 pages for individuals not offered affordable coverage by employers and 12 pages for families and individuals with employer coverage.  

The individual and small group insurance marketplaces for New Jersey and Pennsylvania will be federally-run, because New Jersey and Pennsylvania did not choose to run their own marketplaces. You can read more about the development of these exchanges at the links for each state.

Huh?!

So are you still unsure about who is going to be eligible for what come 2014? Well, here's a handy flowchart to get you on your way to understanding. Thanks to the folks at the Journal of the American Medical Association and Kaiser Family Foundation for the charts above and below. 

More general information about eligibility and enrollment can be found at Enroll America.

New Jersey and Pennsylvania also have websites to help consumers nad providers navigate insurance options:
New Jersey Department of Banking and Insurance
PA Health Options

Policy Update for Community Planners

There has been a lot of activity in the HIV policy world over the last several weeks. There has been so much going on that I decided to break up all the news and highlights into three blog posts. This post is for community planners, the other two will be for providers and individuals. I hope that you find one or more helpful and continue to educate yourself about health reform and the future of the Ryan White program. 

Ryan White Reauthorization

Ryan White Program Reauthorization Webinar from HIVHealthReform.org on Vimeo.

HIVhealthreform.org had a well-attended and informative webinar a few weeks ago on the reauthorization of the Ryan White Act (see above). You can read up a little bit on the issues on my past blog post. You can check out the slides from the webinar here. 

In short, the Ryan White Act will not be reauthorized this year, at least not in time for the "expiration" in the fall. No worries, the Ryan White program can and will still be funded and carry on. Budgets for 2014 from President Obama and Congress include funding for Ryan White.

Interesting fact: The law creating HOPWA (Housing Opportunities for People With AIDS) has never been reauthorized and the program carries on. 

New Kaiser Reports

Updating the Ryan White HIV/AIDS Program for a New Era: Key Issues and Questions for the Future - Kaiser Family Foundation

image courtesy of AIDSmap.org

This policy brief was released in April 2013 and highlights key issues and questions facing the Ryan White program, in light of recent scientific and policy developments.  The brief is divided into four main themes:

1. Supporting people with HIV at each stage of the Treatment Cascade, from diagnosis to viral suppression.
2. Building HIV care networks in underserved communities.
3. Integrating HIV care expertise into the mainstream health care system.
4. Effectively and fairly allocating Ryan White resources. 

Key issues from the brief for community planners: supporting the maximum number of people along the treatment cascade, integrating HIV care and prevention planning, updating the requirement that at least 75% of Part A funds go to "core services", payer of last resort concerns in the era of health reform, reconsideration of funding formulas to direct resources to communities of greatest need, and greater collaboration between HIV medical care and supportive services. 

Medicaid: A Primer - Kaiser Commission on Medicaid and the Uninsured

Kaiser also issued a comprehensive primer on Medicaid back in March. I recommend taking the time to read it, even if you think you know about Medicaid.  Topics include: Who is covered, what is covered, Medicaid's impact on access to care, costs of Medicaid, and who pays for Medicaid. 

Considering over half of the EMA's Ryan White clients are Medicaid-covered, an understanding of Medicaid's role in our health system is essential to good community planning, especially in the time of even more limited funding and health reform.

Kaiser has a great slide show about the role of Medicaid.

Payer of Last Resort

HRSA has released a few documents and resources concerning "payer of last resort" issues. It is important that Planning Council members have a clear understanding of what payer of last resort really means.

 ....“payer of last resort,” meaning that the Ryan White funds may not be used for any item or service for which payment has been made, or “can reasonably be expected to be made,” by any other payer. -- Joint CMS/HRSA informational bulletin (May 1, 2013)

There was another recent clarification released by HRSA concerning payer of last resort and eligibility of PLWHA for Ryan White services:


Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services by Ryan 
White HIV/AIDS Program

....once an individual is enrolled in Medicaid, RWHAP funds may be used to pay for any medically necessary services which Medicaid does not cover or where Medicaid coverage is limited in scope, as well as premiums, co-pays and deductibles if required. RWHAP funds will continue to cover other core medical services such as adult dental, vision, or enhanced adherence and prevention counseling services as a part of primary care if those services are not covered or are limited under Medicaid, even when those services are provided at the same visit as Medicaid-covered services.  Policy Clarification Notice (PCN) #13-01

These statements are clear. Ryan White program funds CANNOT be used when ANY other payer (private insurance, Medicaid, Medicare, etc.) could cover the service for a RW-eligible client. This does not mean that Ryan White funds can "fill in gaps" in reimbursement for particular services; i.e. bridging the difference between the cost of providing the service and the third-party reimbursement. Ryan White funds can cover services that CANNOT be billed to another third-party, even if these services happen within the same visit or interaction as the Medicaid (or otherwise) reimbursed visit. 

Payer of last resort is such an important issue, because the Affordable Care Act (health reform) will enable more people living with HIV/AIDS to gain access to health insurance and more Ryan White services will be eligible for other third-party reimbursement. The Planning Council is responsible for developing priorities for the allocation of Ryan White funds, and must do so in a manner that takes into account ALL available resources within our EMA's HIV care system. At this point in time, we do not understand the full impact of health reform on the Ryan White system or the clients. The issue of payer of last resort will continue to be important throughout the planning and allocations process for 2014.