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 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 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.