Quick Notes from the Federal AIDS Policy Partnership meeting

The Office of HIV Planning is a member of the Federal AIDS Policy Partnership (FAPP), a coalition of organizations from all over the country that advocate for people living with HIV and the organizations that serve them. You can learn more about FAPP and how to become a member organization here. Individuals living with HIV are also encouraged to join.  The group meets about four times a year, our last meeting was on February 12th. At that meeting we had some informative discussions with Dr. Jonathan Mermin, Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC) and Dr. Laura Cheever, Associate Administrator for HRSA's HIV/AIDS Bureau.  We also discussed updates on implementation of the Affordable Care Act (ACA) and the reauthorization fo the Ryan White Program.

Dr. Mermin's presentation is well worth your time to review (slides here). He shared information on HIV prevention funding, national progress on the National HIV/AIDS Strategy (NHAS), and how the CDC is addressing HIV prevention in terms of the care continuum.  A few things really stuck with me. When talking about new HIV cases, Dr. Mermin mentioned that although incidence has been stable over all, there have been increases in the number of new HIV cases for men who have sex with men and young men who have sex with men, 12% and 22%, respectively. The CDC and it's partners are focusing on High Impact Prevention, as the future of HIV prevention. The keys to High Impact Prevention are aligning HIV prevention resources to the geographical areas and populations most affected by HIV, using cost-effective and evidence-based methods, maximizing the number of people living with HIV/AIDS with a suppressed viral load, and using data monitoring, dissemination and feedback to improve outcomes for organizations and jurisdictions.The CDC is also working closely with HRSA to align as much of the HIV care and prevention activities as possible; including community planning, data reporting, and policies.


A major topic of discussion with Dr. Cheever was the future of the Ryan White program, in the era of health reform (ACA). Much of the conversation was informed by the discussion  at the Ryan White Working Group meeting (the day before). That discussion focused mostly on when and how to advocate for the reauthorization of the law, and what it might include. Consensus from that discussion was it would be best for the community to wait until 2015 to push for reauthorization because so much is still unknown about how Ryan White programs will work in the context of expanded health coverage and other reforms of the ACA. The community of Ryan White providers and consumers need to collect stories of the successes of the program from the local levels: who is served, how their lives are improved, and what benefits and outcomes do we see on an aggregate level. There was also consensus that the next version of the Ryan White law will be transformative, in other words, it will include a lot of changes to how the program works, what services are provided and who is eligible.

Dr. Cheever also recommended that we need to focus our efforts to help people start and stay in HIV care. The local communities need to provide qualitative data (stories) about how and why people get lost and also linked to care. These qualitative data can work with the quantitative data (surveillance, program data) to develop effective plans for our HIV care systems, including Ryan White. Local communities, like the Philadelphia EMA, should focus on those who need the most help accessing and maintaining care and provide the supports they need. Those supports might include housing, mental health treatment, substance abuse treatment, child care, transportation or social support. The Ryan White program has the ability to meet these needs, but we have to direct resources to where they are most needed. We need to adapt the Ryan White system to work with the larger health care systems, not apart from them.

If I come away from these two meetings with any theme, it's "adapt or perish". We all need to become knowledgeable about the ACA and other changes in the science and policy world of HIV/AIDS. We have, as always, to do more with less. So we have to be informed, proactive, and deliberate.

Notes from the Health Reform and Advocacy Workshop

On October 16, 2013 I spent the day with 20 community leaders, learning about health reform and advocacy. We had an extra special guest, Joe Scarborough from the DE HIV Consortium, who shared some of his inside tips on advocacy. Below I'll share some of my visuals and notes from our discussion on the Myths of Health Reform. You can see all the visuals here.

Health Reform Myths - Busted

People are so confused by what they hear from friends, family, politicians and even the news. They have no idea what is fact or fiction. This list will help bust some of the most popular myths about the Affordable Care Act/Obamacare.

Myth #1: Obamacare takes away freedoms.
Truth: Nobody is forced to buy insurance or do anything else. 
There is a requirement to have health insurance, but there are also several exemptions to this rule including financial hardship, religious objections, and not being required to file a federal tax return. If people choose not to sign up for insurance, they may face a penalty. You can learn more about the penalty here.

Myth # 2: It's a government takeover of health care.
Truth: Obamacare helps people afford private insurance purchased through online marketplaces from insurance companies.
 It is not "single payer" federal health insurance like our friends to the North in Canada have. And let's be frank, we already have "socialized medicine", we call it Medicare. 

Myth #3: Obamacare only helps "those people".
Truth: Everyone benefits from a more fair, affordable health care system. 
Most people will experience lower premiums (over time). Insurance companies will not be allowed to discriminate based on gender, age, or health status. No lifetime or annual coverage caps. Wealthy people (making over $200,000/year) will pay more in taxes.

Myth #4: Obamacare rations health care.
Truth: We already have rationed health care, the insurance companies do the rationing in terms of coverage limits, revoking coverage and preapproval policies.
The Affordable Care Act puts an end to discrimination, denials, and protects consumers by limiting out of pocket spending and deductibles. The law also requires all plans to have 10 essential health benefits which include hospitalization, prescription drugs, labs and tests, mental health  and substance abuse treatment, maternity care, and others.

Myth #5: Obamacare is bad for seniors.
Truth: Seniors have a number of protections, including limits on how much more than can be charged for insurance premiums. 
NO DEATH PANELS. The part of the law that some people referred to as "death panels" was actually a provision that would allow Medicare to pay for end of life counseling for seniors and their families. The counseling would have been provided by the patient's doctor, not some government panel. But due to all the controversy that provision was removed from the final law. 
There will be a reduction in the federal subsidy sent to insurance companies who provide the Medicare Advantage plans for seniors. This subsidy reduction may result in changes in benefits, but will not effect essential services. The federal government made this change to reduce spending in Medicare Advantage, which is more than the spending for traditional Medicare and Medicaid combined.

Myth #6: Obamacare means more taxes and higher premiums for everybody.
Truth: Most uninsured people will save money.
Some people, those who make over $200,000 will have to pay a bit more in taxes. Many people will see reductions in their premiums, thanks to getting a tax break to pay for insurance through the health insurance marketplaces. Women will no longer pay higher premiums than men, neither will sick people. Since most people get their insurance through their jobs (about half of Americans), they won't see much changes, except for the regular fluctuations in premiums from year to year. Here's some more info about the tax changes in the ACA.

Myth #7: Congress is exempt from Obamacare.
Truth: Congress has to buy insurance through the insurance marketplaces too. They don't get some secret fancy plans.

The morale of this story: check your facts. Good places to check are Factcheck.org and Politifact.com. And of course, this little old blog right here. 

And there's always our friends the Youtoons.

Q and A from the front lines: What case managers want to know about health reform

Sometimes I get to go out into the world and learn from our amazing HIV community. On September 24th I got a chance to talk with about 30 case managers, social workers and other front line workers from a variety of HIV providers, health centers, and community organizations. It was a lively discussion about how health reform will help people living with HIV (PLWHA). We also covered some basics in communication; how to talk about health reform so people will understand and feel empowered to enroll in new coverage. You can read some about the communication tips here. I'm just going to cover the big topics and provide some links to my go-to health reform resources. You can also read my past posts about health reform here for more background and HIV-specific information.

Basic protections of the law

We started off reviewing the basic protections of the Affordable Care Act (a.k.a. Obamacare or Health Reform) and how they help PLWHA.
1. Insurance companies can't discriminate based on health status. Nobody can be denied coverage or lose coverage because of a new or pre-existing condition or diagnosis. This means no longer can PLWHA be denied coverage because of their HIV status or any other health conditions. This is big!

2. Insurance companies cannot charge women more for insurance. No more discrimination based on biological sex, everybody pays the same.

3. Essential Health Benefits (EHB) include many services either previously not guaranteed under private insurance or not offered by the Ryan White program. These will help fill in gaps of coverage for many PLWHA. You can find out more about EHB here.

4. No more lifetime caps on spending. Whether you cost the insurance company $100 or $10 million, they can't deny you coverage. Pretty awesome for people with complex and chronic health conditions.

Ryan White and health reform

Many people are wondering what health reform means for the Ryan White program. I can't see the future, but what we do know is this: The Ryan White program will continue as is for now. The long term changes and adjustments remain to be seen, and will depend on how PLWHA in different states fair in gaining health coverage, as well as what gaps and barriers remain that prevent PLWHA from access all the care they need to stay healthy. 

This brief is a good resource explaining how the Ryan White Program will interact and be influenced by health reform. I also wrote a blog post about the future of Ryan White earlier this year, so check that out for some more about Reauthorization.

Medicaid and ACA

Half of the PLWHA who receive Ryan White services (in the Philadelphia region) are covered by Medicaid. So for the most part, health reform doesn't really change anything for those individuals. They continue to be covered by Medicaid for many services, and Ryan White services can offer "coverage completion" to fill in any gaps to care. Just like always. 

Now this is where it gets tricky, the health reform law also allows states to expand Medicaid coverage to include low income adults below 133% of the Federal Poverty Line (about $15,000 for a single person). But states can choose not to expand coverage to those adults. Only half the states have decided to open up their Medicaid programs to low income adults. New Jersey has, and you can read more about it here. As of this writing, Pennsylvania has not. PA's Governor Corbett has offered a proposal for some serious Medicaid reforms (which we will dive into in another post), which he calls Healthy Pennsylvania. You can read the concept paper here. He has included expanding Medicaid eligibility to low income adults. We have at least several months to see what happens with Medicaid in PA. 

ADAP and health reform

NASTAD estimates that about 60% of PA's ADAP (AIDS Drug Assistance Program) clients will transition to a Marketplace plan for health care and prescription coverage. Many ADAP clients will transition from uninsured or under-insured to a Marketplace plan with the help of federal tax breaks to pay for insurance premiums. You can learn more about premiums and tax credits here. Those ADAP clients who do not qualify for enrollment in a Marketplace plan will stay on ADAP and continue to access Ryan White services, as appropriate.  People will not be covered by SPBP (ADAP in Pennsylvania) and a Marketplace plan, one or the other.

Helping clients understand options and enroll

Many case managers and social workers are concerned about their ability to assist clients in the health reform enrollment process. The process seems complicated and there is a lot to know. No doubt we will have some bumps on the road to coverage for all, but we can do it by working together. There are a few ways to offer assistance to individuals and families.

One easy option is to partner with a Navigator agency in PA or NJ. More information about those organizations here.

Your organization can apply to become a Certified Application Counselor (CAC) organization and offer help with the enrollment process to your clients. CMS offers an online training course for CACs, however there is no funding attached to these CACs.

Your organization can also become a Champion of Coverage to help share the news about coverage options. This one is easy, provide brochures and posters in your office, post some links on your website, or tell your clients about enrollment support in your community.

All Ryan White service providers are expected to help with outreach and enrollment for the Marketplaces. This is the top priority of the entire Department of Health and Human Services. 

Resources

Here are some of the best sources on health reform I have found. 

Healthcare.gov - the official place to get all your health reform information, find out about your state's Marketplace, enroll in coverage, print brochures, get live online help, and so much more.

HIVhealthreform - webinars, tools, blog posts, issue briefs - you'll find almost everything you need to know about health reform and HIV at this wonderful website. You should definitely sign up for their newsletter.

Kaiser Family Foundation - newly-updated subsidy calculator, interactive health reform timeline, state Marketplace profiles, and lots more.

Notes from the 2013 Pennsylvania Health Access Network Conference

I am grateful to the folks at PHAN for pulling together an informative conference for PA advocates, providers, and public health wonks like me. We mostly talked about health reform and the Affordable Care Act, with enrollment starting on October 1. Here are some of my notes and impressions. I would love to hear from others who attended.

The conference theme of Cover the Commonwealth informed the whole day's programming. We talked and talked about health reform in PA, including Gov. Corbett's proposal to reform (and expand) Medicaid, Healthy Pennsylvania. We also discussed how to talk to people about health reform and new coverage options. I wrote a separate post about communication tips. You can see all the tweets from the conference at #PHAN13

$467M in #pabudget savings in 2014 if PA does #MedicaidExpansion right away, according to PA #IFO: http://t.co/EEaJyGUo8r. #PHAN13 #pagovt
— PA Health Access (@pahealthaccess) September 23, 2013

Navigators and Certified Application Counselors

Every type of community organization and health care provider is encouraged to have Certified Application Counselors on staff to help individuals and families enroll in the Marketplace. You can find out how to become a Certified Application Counselor organization here. Keep in mind that there will be a delay between application and approval from CMS, I have heard 30-60 days. 

Three of the federally-funded Navigator organizations were on hand to talk about their plans to help enroll every eligible Pennsylvanian. They have some big goals and are going to need help to reach them. These organizations want to work with your CBO or community group, so contact them to set up a time for their navigators to come and help enroll your clients/members.

Resources for Human Development is focusing on the 10 PA counties with the most uninsured people. Philadelphia County has the most uninsured of any county (and the most people). 

Pennsylvania Association of Community Health Centers (PACHC) will support all the Navigators and Certified Application Counselors in the state. 

Mental Health Association of Pennsylvania will also have Navigators in the community throughout the state ready to help enroll people in the Marketplace. 

Medicaid

Ann Torregrosa: We really need to give governor our input on 'Healthy PA' Medicaid proposal. Send comments to RA-PWHealthyPA@pa.gov #PHAN13
— PA Budget and Policy (@PBPC) September 23, 2013

In mid-September, Governor announced his Medicaid reform plan, Healthy Pennsylvania. All we know about the reforms are contained in the concept paper, about 10 pages. So the details are unknown. Included in these reforms would be coverage for low income adults, regardless of health or disability status, essentially it is Medicaid expansion by another name. I can share with you my initial impressions and some of what I learned at the conference. Please remember that this is just a proposed plan, not a reality. The Governor must submit a Medicaid waiver application to the federal government for approval, which will take at least several months. At this point in time, Medicaid is going to work as it has, nothing new for the short term.

Proposed Medicaid reforms include requiring working-age, non-disabled recipients to actively looking for employment and/or enroll in a job training program. This kind of requirement is not allowed under current Medicaid law and is a big task to oversee and administer. Some people are thinking this could be a roadblock to federal approval.

Gov. Corbett would like to remove all co-pays associated with Medicaid coverage and start requiring a monthly premium (bill) based on income, no more than $25/month for an individual or $35 for a household. Many people would pay no premium or very little. 

With these reforms, Gov Corbett argues the state would be able to include more people in Medicaid, including low income adults. These newly-eligible recipients would be enrolled in the insurance Marketplace and given state/federal subsidies to pay for insurance just like other Pennsylvanians buying insurance through the state marketplace. These individuals/families would also be required to pay a monthly premium based on income. The will also have a choice to select a Marketplace plan or the Health Choices plans. 

Other items in the concept paper include a penalty of $10 for "inappropriate use" of the Emergency Room, reduction in the number of benefit packages offered to different categories of Medicaid enrollees from 14 to 2, and no changes to children's benefits under Medicaid/CHIP.

http://t.co/VtDfTvwjpN is a good resource for Pennsylvanians to learn more about coverage options #PHAN13
— Nicole Johns (@PublichealthNDJ) September 23, 2013

I encourage you to sign up for the PHAN newsletter to keep up to date on all the training and events they offer. They will be a great resource for health reform in PA. A member of PHAN will come to your organization to educate your clients or staff. You can also participate in webinars and conference calls.

What to say when you talk about health reform

Everything I am about to say comes from the great work of Enroll America. Those folks have done the research and pulled it all together so we can use it to make sure all Americans have the affordable quality care they need. So check out all of their resources for everything you need to plan your outreach and enrollment work.

The health reform law is so confusing and complicated. It doesn't surprise me that so many people feel like its just too much to understand, let alone do anything. So I'm going to try to break it down into some simple messages for you to share with people you want to encourage to sign up through the Marketplaces. (If you don't know what a Marketplace is, then start with this fun and simple video.

Some things to keep in mind when talking to people about health insurance:

1. Share personal stories about the uninsured and how health reform helps them be healthy and more secure.
2. Keep it simple and concrete.
3. Make sure the message is targeting the individual. Single people don't identify with messages about families and vice versa.
4. Share your values, like "security", "family", "fairness". Financial and health security are the biggest motivators for the uninsured to seek more information about the Marketplace.
5. There is deep confusion and skepticism among consumers, due to lack of experience with insurance or bad experiences. Be prepared for it.
6. Most people (91%) think that health insurance is necessary or very important.
7. Cost and affordability are the top barriers to coverage for most people.
8. Use examples and dollar amounts whenever possible, rather than percentage or other abstract concepts.

Four messages about health reform that will reach most uninsured people:

1. All insurance plans will have to cover doctor visits, hospitalizations, maternity care, emergency room care, and prescriptions.

This refers to the 10 Essential Health Benefits. You can learn more about them here.

2. You might be able to get financial help to pay for a health insurance plan.

People with income between 100% FPL and 400% FPL (Federal Poverty Line) will be eligible for tax breaks to pay for premiums. There is also help for some people to cover co-pays. You can learn more about ways to make health coverage affordable here.

3. If you have a pre-existing condition, insurance plans cannot deny coverage.

Health insurance companies cannot discriminate against anyone based on health status or pre-existing conditions, including HIV, cancer, diabetes, or any other chronic condition or infectious disease. More on these protections here.

 
4. All insurance plans will have to show the costs, and what is covered in simple language with no small print.

The health care law requires all coverage information to be simple, clear and comparable. So you can compare plans for the different services, doctors, and limits. No small print allowed.

Healthcare.gov is the place to go to learn about the Insurance Marketplaces and how to access insurance. Here's a great place to start to figure out what kinds of information you need to enroll and how to compare your options.

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. 

 

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

Health Reform Resources: Enrollment Support and Marketplaces

As the start of open enrollment (October 1, 2013) draws closer, there has been a flurry of resources concerning how to help consumers screen for eligibility and enroll in Marketplace plans and Medicaid. Below you will find several new resources relevant to the Philadelphia region. Community-based providers and AIDS service organizations are encouraged to explore all the resources and opportunities available to assist with the transition to the era of health reform and new coverage options. You can explore our

other blog posts about health reform here.

Stakeholder Call with HHS and CMS about the Health Insurance Marketplace in PA - July 31, 2013

This second in a series of three calls is intended specifically for stakeholders in Pennsylvania. HHS and CMS regional officials will give brief updates on the operational execution of the Marketplace including systems readiness; consumer support and outreach.   

Certified Application Counselor Organizations

There are going to be opportunities for organizations to be trained and certified to provide counseling to enrollees. As a CAC organization, your staff and volunteers will help people understand, apply, and enroll  for health coverage through the Marketplace. There are three official trainings on how to become a Certified Application Counselor Organization over the next couple of weeks. Register at the links below.

Date	Time	Webinar Link
July 31, 2013	1:30 – 3:00 pm ET	https://goto.webcasts.com/starthere.jsp?ei=1020077
August 6, 2013	1:30 – 3:00 pm ET	https://goto.webcasts.com/starthere.jsp?ei=1020167
August 7, 2013	1:30 – 3:00 pm ET	https://goto.webcasts.com/starthere.jsp?ei=1020171

Kaiser Family Foundation Issue Brief -- Helping people with HIV Navigate the Transition to ACA Coverage.

This issue brief is a summary of a roundtable discussion convened by Kaiser Family Foundation in March 2013 concerning planning for the coverage transition, helping people with HIV choose and enroll in coverage and troubleshooting during coverage transitions.
Key passages:
Pg. 5 - HIV community needs to plan for changes in the role of the Ryan White HIV/AIDS Program 
Pg. 5 - HIV community stakeholders need to be aware of their state's organizational structure and work to inform state policymakers about the needs of people with HIV and standards for HIV care.
Pg. 6 - HIV service providers may need to consider business re-design options to maximize their engagement with the health system.
Pg. 6 - Best practices and lessons learned from states and organizations that have begun navigating through HIV-related policy changes will help inform how to better plan for challenges that may occur
Pg. 8 - It may be important to differentiate between types of HIV enrollees in ACA coverage
Pg. 9 - While HIV providers and clinic staff are poised to play a central role in supporting coverage transitions, they may require specific training and support

Insurance Marketplace Pre-screening Tools and other Resources at HIVhealthreform.org

There are too many great resources on hivhealthreform.org to list here. One of the most interesting is the pre-screening tools (for both Medicaid-expansion states and those not currently expanding Medicaid coverage) from Duke Law Project.

Health Reform To-Do List

This presentation was designed specifically for people living with HIV/AIDS (PLWHA) who are uninsured or in need of affordable insurance options. Most of the information is general to PLWHA in the US, but some Pennsylvania information is included because the state is not expanding Medicaid coverage to low income adults (not at this time anyway). These slides are adapted from content developed by the Target Center. I highly recommend providers and consumers of Ryan White services check out the Target Center for great resources about Health Reform and so much more.

I created this interactive presentation in an effort to help more people understand how the Affordable Care Act, or "Obama Care" may affect them. It's intended to be used as a starting-off point to explore resources to help you make the best decisions for yourself and your family. Anything that is underlined is a link to something to help you understand your options or help plan for your new coverage in 2014. Please take time and explore the links.

If you have questions or comments, please be sure to leave comment here or email me. I will do my best to answer your question or lead you to a good resource.

Health Reform Resource Update

Over the last few days I have come across a few health reform resources I thought worth sharing. This post is one of a series of blog posts about health reform and the Affordable Care Act. You can read see all the previous posts by clicking on the label "ACA" at the bottom of this post.

Healthcare.gov or  Cuidadodesalud.gov

Want to learn more about the insurance marketplaces and what options are available to you or your clients? The first place you should go is healthcare.gov, the federal website set up to share information about insurance eligibility and enrollment. You can also call 1-800-318-2596 or TTY/TDD 1-855-889-4325 for more information about buying health insurance through the state marketplaces. Enrollment will begin October 1, 2013, but you can call and get your questions answered today. Translation and interpretation services available in 150 languages over the phone.

Potential Impact of the Affordable Care Act on the Ryan White HIV/AIDS Program

This report from Mathematica provides an in depth look into how the ACA impacts the Ryan White program and Ryan White clients. The report was released in November 2012, but still offers valuable insight and recommendations to Ryan White grantees and providers. 

NASTAD Essential Health Benefits Brief

This issue brief describes the essential health benefits (EHB) and how they impact people living with HIV/AIDS and viral hepatitis. Four of the EHBs are highlighted: preventative services, prescription drugs, mental health and substance abuse services, and chronic care management.

Engaging Safety Net Providers in Expanded Coverage: Tips on Enhancing Billing Capacities

A new fact sheet from NASHP (National Academy for State Health Policy) offers action steps and advice to safety net providers to expand billing options. This fact sheet will be a good companion to my policy updates for providers: here and here.

As I type Kaiser Family Foundation is hosting a briefing on Medicaid Managed Care in the Era of Health Reform. The video should be available this week.

Everyday there are new resources for helping us navigate the new landscape of health reform. I'll keep sharing what I find useful. Please share questions, comments and links in the comments or on our Facebook page.

Health Reform and HIV Providers: Part 2

The presentation below was given by Ann Ricksecker (Planning Council member and PA/MidAtlantic AETC staff) and myself at the PA HIV Provider Capacity Building Training on June 18, 2013. The purpose of the presentation is to provide some basic background on the ACA and  practical steps for organizations to prepare for the future of the Ryan White Program. Thanks to the  TARGET Center for providing some great materials to work from, especially the 6 steps.

If this is your first visit to our blog, you may want to check out my previous posts on some of the important issues covered in this presentation like: payer of last resort, providers' roles in health reform, and health reform resources. You need to have a background in health reform in order to get the most from this slides.  I will be creating a web-based presentation with audio for these steps as well, so stay tuned.





During this presentation a few questions came up that I needed to do some more research before I could answer. I decided to share those questions and my answers here. If you have questions, let me know in the comments and I'll post a follow up ASAP.

Question 1: Contracting with an insurance company is sometimes difficult and time consuming. What steps can an organization take to make it easier/more efficient?

Here's a good example from Kevin Moore of the AIDS Care Group about the difficulties some will face in dealing with health insurance companies. Here are some ways you may get some help if you run into a dead end:

1. Call your state insurance department and see what assistance they can provide. (PA, NJ)

2. Call your state's insurance marketplace to get some help facilitating the relationship with the insurer. At this time I couldn't find any contacts for either NJ or PA's marketplaces.  (Both PA and NJ will have federally-facilitated Marketplaces.)

3. Call a provider who is on the insurance plan and ask for a contact person in that agency's contract office. Then ask for a contact with the insurer who will actually help. 

I'm sure there are other options. Anybody have another option that worked?

Question 2:  Will case managers be expected to help consumers pick a health plan? Do case managers have a role in the state insurance marketplaces?

Short answer: Yes! 

Case managers already help people get enrolled in health insurance. Enrolling in a Marketplace plan is just another option. HRSA has been very clear that Ryan White providers are expected and encouraged to help consumers with eligibility and enrollment, including consumer education about health insurance and health reform. In the end, consumers are responsible for picking the appropriate health plan for their individual needs, but case managers and other providers will need to be available to help with those decisions. If the Ryan White provider is not staffed or resourced to provide this assistance, then a referral should be made to a local resource that can provide the required level of support and guidance.

The 4 E's are the latest buzzwords: education (about health reform), eligibility (for public and private insurance options), enrollment (in public and private insurance) and engagement (in care). Consumers will be looking to their case managers and medical providers for answers about insurance and eligibility. To learn more about consumer outreach and enrollment check out the resources at Enroll, America.

Question 3: What opportunities are there for community-based organizations in the era of coordinated care and health homes? 

There are opportunities for CBOs in this new world. CBOs have skills and services that support and promote whole-person care like cultural competency and care coordination (case management).  You can become a Federally Qualified Health Center (FQHC) or form a cooperative agreement with a FQHC. Either option would allow for the possibility of either becoming a Primary Care Medical Home or a Medicaid Health Home (which are essentially the same thing. Primary Care Medical Home (PCMH) is the general term and the Medicaid Health Home is a type of PCMH.).  

Here is a great step-by-step guide for CBOs to integrate with health homes.

You can download the slides from the hivhealthreform.org webinar for much more detail on how (and why) to integrate with a clinical provider: Pathways to Collaboration. 

Integrating with a clinical site is just one option for sustainability. We will explore other options in future posts.

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.