Thursday, August 22, 2013

Quick Notes on the Uninsured

I was lucky enough to be a part of a 2-day training on health reform (Affordable Care Act/Obama Care) earlier this month and got some great information and resources that I will be sharing with you faithful readers over the next few blog post. Most of the information I'll share is collected and provided by Enroll America, a nonprofit dedicated to making sure every uninsured American knows about the increased coverage options under the ACA. You can find all sorts of community and consumer education materials at Get Covered America. Let's start off with understanding who are the uninsured and how we can reach them.

Guess how many uninsured Americas know about the expanded coverage options under health reform (ACA, Obama Care)?

22%. 78% of uninsured Americans have no idea of their expanded coverage options under health reform. They have no clue. We have to change that.

Graphic from Enroll America Presentation Materials.

Who are the uninsured?

Minorities in America are more likely to be uninsured than are Whites/Caucasians. Men are more likely to be uninsured than women. People living in poverty are more likely to be uninsured than those with more income, with an exception being those working but earning low income, who earn too much for safety net programs and not enough to make health insurance affordable. These low income workers also often work jobs part time or their employers do not offer health insurance. Most people who are uninsured are not uninsured by choice. They do not health insurance either because they can't afford it or because they are excluded because of a previously diagnosed health condition (diabetes, heart disease, HIV, cancer, etc.). Many have been uninsured for more than 2 years (67%).

How do people feel about insurance?

Almost all the people surveyed by Enroll America thought health insurance is important (91%). Cost and affordability are the biggest barriers to health insurance for people. Many of the uninsured have shopped for insurance in the individual insurance markets, outside employer offered insurance (44%). They found this experience stressful, confusing and frustrating. They want health insurance, for financial and health security, but have no real options under the current system.

How do we reach the uninsured?

People have some misconceptions about the uninsured, one might be that they are not online because of affordability or access to technology. We can see by the graph below, that the uninsured are using the internet and smart phones just like other Americans. We can use social media and technology to reach different segments of the uninsured to get the word out about enrollment and insurance coverage options. 

But even well-connected and savvy internet users prefer to do somethings offline. Shopping for and enrolling in insurance is one thing many prefer to have in-person assistance with, rather than to go it alone online. According to Enroll America's survey, 75% of uninsured people who are newly eligible for coverage would prefer in-person assistance for enrollment.  So this is where Certified Application Counselors, Navigators and other in-person assisters are going to be key to getting all eligible Americans enrolled in health insurance.

In our next installment we will explore the messages that will work best to help people get informed and enrolled. 

Thursday, August 15, 2013

Quick Notes: HRSA webinar on outreach and enrollment and policy clarifications

This webinar was one of a series by HRSA to offer clarifications on how the ACA (health reform) affects Ryan White grantees, consumers and providers. The focus of this webinar was on how Ryan White programs can support outreach and enrollment for the state Marketplaces, and the two policy clarifications released earlier this summer on Ryan White consumer certification (13-02) and Ryan White eligibility of Medicaid-eligible clients (13-01). I encourage you to take the time to listen to the whole webinar (less than an hour), because these are my key take-aways. You may find other points more relevant or important.

Ryan White is the payer of last resort. Always. 

Ryan White providers and grantees are expected to help clients review eligibility and enroll in appropriate health insurance coverage (Medicaid, Marketplace plans, etc.)

  • HRSA expects grantees to "vigorously pursue" enrollment in insurance for their clients.
  • Ryan White grantees and planning councils should reconsider their priorities and allocations to include support for ACA-related outreach and enrollment activities.
  • Outreach education, enrollment and benefits counseling can be provided under several Ryan White service categories: medical case management, early intervention services, care outreach, non-medical case management, health education and referral for health care and support services. More details from HRSA can be found here and here.  

Ryan White will continue to offer "coverage completion" and "wrap around services" for Medicaid eligible consumers. 

  • Includes those currently eligible (covered) and those who will become eligible through the expansion of Medicaid eligibility in some states.
  • Ryan White funds can cover services not covered or partially covered by third-party payers (Medicaid, private insurance, etc.). This means services, not money. If a provider can bill a third party for a service, then that is the reimbursement for that service. Ryan White cannot be billed for the same service. If the client's coverage has limits on the number of visits/units or specific activities, then Ryan White funds can pay for the services/activities not covered (the underinsured). The amount of third-party reimbursement does not affect "payer of last resort" requirements.
  • Medicaid should be back-billed for eligible services. Any reimbursement received from Medicaid for services previously paid for Ryan White should be applied to HIV programming.

Clarifications about Ryan White client certification and re-certification requirements.

  • Ryan White clients must be certified for eligibility for Ryan White services, with re-certification no less than every 6 months. 
  • Criteria for certification include low income as defined by the grantee and HIV+ status.
  • Information required for certification process include: residency, HIV status, income, and insurance. HIV status does not need to re-confirmed after initial certification. Once a year a client can be re-certified without producing documented proof of income, residence, insurance status. However, any changes in status should be documented. 
  • Grantees should make an effort to align certification processes with Medicaid eligibility re-certification processes to reduce burden on clients and providers.
  • More info on HRSA and CMS collaboration can be found here.
  • More info on Ryan White client eligibility determination can be found in HRSA policy clarification 13-03

Wednesday, August 7, 2013

The Big Picture - July 2013

This post is part of a monthly series. It provides an overview of themes and topics from the general meetings and committee meetings of the Ryan White Planning Council and HIV Prevention Planning Group. To view meeting materials and presentations, please visit

Ryan White Planning Council (RWPC)

The Ryan White Planning Council had an action (item)-packed meeting in July.  They started off the meeting by approving their allocations (budget) for the fiscal year, since the eligible metropolitan area (EMA) finally received its grant award - even though the fiscal year started on March 1.  Their first order of business was to approve budgets for the rest of the year.  Then they updated a couple of formal processes, starting with the resource allocation process.  The RWPC used to make advance plans in case the EMA got level funding, a 5% decrease, or a 10% increase.  But, given everything happening in Washington, D.C., they decided to stop planning for a 10% increase, and starting planning for a 10% decrease instead.  They also changed their reallocation process, which is what they use when a service can't spend all of its budgeted money.  The AIDS Activities Coordinating Office (AACO) has to follow the budget set by the RWPC, but they've always been able to move up to 5% of the money in a service in or out without clearing it first.  In July, the RWPC increased this to 10%, since there are so many changes happening.  Then, after all of that, the RWPC voted on the draft list of service priorities that was created by the Comprehensive Planning Committee.  The RWPC approved the list, but there were still some questions about the priority setting tool.  Everyone agreed to talk about the list again at a future meeting.

Most of the work at the committee level in July was spent preparing for that one busy RWPC meeting.  The Comprehensive Planning Committee met to go over their priority setting list and process; the Finance Committee voted on FY2013 allocations and updated the two process documents that they presented to the RWPC.  The Finance Committee also talked about the upcoming regional allocations meetings to plan for FY2014 - more information on the decisions from those meetings can be found below.  The Needs Assessment Committee didn't meet, and the Positive Committee got an update on everything happening at the RWPC meetings.  They also learned more about the allocations process
so they could better participate in those meetings.


Allocations Meetings

Every summer, the RWPC hosts three regional allocations meetings.  The Philadelphia EMA is made up of nine counties - four suburban PA Counties (Delaware, Chester, Montgomery, and Bucks), four New Jersey Counties (Gloucester, Salem, Camden, and Burlington), and Philadelphia itself.  The RWPC knows that each of these three regions has different needs, so they all budget separately.  These allocations meetings are held far in advance - the July 2013 meetings were for planning for the fiscal year starting on March 1, 2014.  This way, when the EMA finds out how much money they're actually getting from the federal government, there's already a plan in place.

This year, each region planned for what they would do if the EMA received level funding (the same amount as last year), a 5% decrease, or a 10% decrease.  They also have the option to provide instructions to the grantee (AACO).  The RWPC will vote on these plans and any instructions at their August 8, 2013 meeting.  The decisions from the meetings are here:

Level-funding budget: Philadelphia chose to fund services at the same level under a level-funding budget.

5% decrease budget: Philadelphia chose to spread a 5% decrease proportionally across all service categories (based on their level-funding budget).

10% decrease budget: Philadelphia chose to fund supportive services at the same level as the 5% decrease budget, spreading the decrease proportionally across all other service categories.

Instructions to the grantee: Philadelphia would like the grantee to investigate the non-Part A funding streams available to each service category.

PA Suburban Counties
Level-funding budget: Due to funding shifts within the EMA, the PA Counties would receive an increase if the EMA received level funding.  The PA suburban counties chose to spread the increase proportionally across all service categories.

5% decrease budget: The PA suburban counties chose to spread a 5% decrease proportionally across all service categories (based on their level-funding budget).

10% decrease budget: The PA suburban counties chose to spread a 10% decrease proportionally across all service categories (based on their level-funding budget).

Instructions to the grantee: None.

New Jersey Counties
Level-funding budget: The New Jersey counties chose to keep all services funded at the same levels in the case of level funding, with the exception of medical case management.  Due to funding shifts within the EMA, New Jersey would receive an additional $43,463 if the EMA received level funding.  The New Jersey counties agreed to place the entire amount of this increase in medical case management.

5% decrease budget: The New Jersey counties chose to spread a 5% decrease proportionally across all service categories (based on their level-funding budget).

10% decrease budget: The New Jersey counties chose to spread a 10% decrease proportionally across all service categories, with the exception of legal services, which would not receive a reduction (based on their level-funding budget).

Instructions to the grantee: None.

HIV Prevention Planning Group (HPG)

The new HIV Prevention Planning Group (HPG) met for the first time in July.  Welcome to the first twelve members!  The HPG took the place of the PPG, and will focus on gathering community input on Philadelphia's plan for HIV prevention.  For their first meeting, the new HPG got a presentation on Philadelphia's HIV prevention plan from AACO's Coleman Terrell.  Jen Chapman also talked about the concurrence process, explaining that the HPG would have to vote to either concur with the plan, concur with reservations, or not concur at all.  The HPG also voted to keep former PPG community co-chair Jen Chapman in her position on the new HPG.

Points of Integration Workgroup

Members from both the care and prevention planning bodies come together for the Points of Integration Workgroup.   In July, they continued their conversation about how to improve linkage to HIV care for those newly diagnosed with HIV.  They talked about programs in other areas, including Washington state and Lousiania, which were addressed in a webinar by the HIV Prevention Justice Alliance.  They also talked about the Anti-Retroviral Treatment and Access to Services (ARTAS) model.  One of the major points from the meeting was a need to develop clear and consistent messages so that people being tested for HIV would know that they could access free care at their choice of provider if they found out they were positive.

This is a great 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 to find out how to get involved. If you have questions, you can also call us at 215-574-6760.