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.

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.

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.