federal aids policy partnership us conference on aids september 10, 2013
TRANSCRIPT
PAST, PRESENT & FUTURE OF THE RYAN WHITE PROGRAM
Federal AIDS Policy Partnership
US Conference on AIDS
September 10, 2013
Presentation Overview
2006 and 2009 Reauthorizations Overview of 2009 community consensus process Overview of changes made in 2009 Ryan White
extension Ryan White 2013 and beyond Partners in process
Congress Administration
Next steps
2006 – Every HIV Organization for its Self
Very contentious process All major HIV organizations had own set of
recommendations House and Senate staff found it very difficult to
work with community and negotiate best possible bill
Community came to difficult compromises late in the game
In the end made major changes to Ryan White Program but also involved significant increases in funding $85 million to Ryan White Part B
2009 - Community Consensus Process
Community wanted to avoid repeat of 2006 process
Ryan White Work Group Original Working Group of the Federal AIDS
Policy Partnership (FAPP) (2003) Coalition of national, local and community-
based service providers and HIV/AIDS organizations
Consensus/Sign-on Process Sunset provision meant that action had to
be taken before September 30, 2009
2009 - Community Consensus Process
Issue Division: Implementation fixes needed before extension
Legislative or “technical” fixes Regulatory fixes
Issues to address in extension Issues for full reauthorization (2012) Issues addressed through other processes
1st 100 Days – new Obama Administration Development of National HIV/AIDS Strategy Health reform – knew Obama wanted to pass
major overhaul
2009 - Community Consensus Process
Consensus Document Agreement Final document six specific extension requests
and four “technical fixes” Initial release on March 10, 2009 Technical fixes previously released
323 organizations signed on Unprecedented level of support
At least one organization signed from almost every state
Congressional staff were very appreciative to have one set of recommendations from HIV community
2009 - Community Consensus Process
In September 2009, HRSA testified before Congress and recommended essentially the same changes made by the community Biggest difference was four year authorization
period Consensus document became basis for
legislation introduced by Senator Harkin and Representative Waxman
Signed into law Oct 30, 2009 Signing ceremony with HIV community leaders
Ryan White Extension of 2009
“Ryan White HIV/AIDS Treatment Extension Act of 2009” Authorized the program for four years (FY10-FY13) Removed “sunset” provision allowing program to
remain funded at end of authorization period Extended hold harmless protections Extended protection for code-based states during
final transition to name-based HIV reporting Increased unobligated amounts from 2 to 5 percent Included ADAP rebate language
Ryan White Extension of 2009
Included prevention provisions: EIIHA, 1/3 of Part A supplemental criteria
Changes to Ryan White Program with FY13 awards Hold harmless will decrease to 92.5 percent of
FY12 award FY13 funding distributed on names-based
cases reported to CDC. States can no longer report cases directly to HRSA and 5 percent penalty and cap will be eliminated.
Ryan White 2013 and Beyond
Ryan White will not see legislative action in 2013
Appropriations/debt ceiling/sequestration taking up much of legislative days left
Committees have other priority areas that MUST be worked on
Majority of Ryan White Work Group feels that not reauthorizing at this point is the best option for many reasons
Need real information about how ACA will impact Ryan White clients
Ryan White 2013 and Beyond
Budget/Appropriations environment continues to be quite constrained and Members looking at all programs for funds
Other programs currently under consideration for reauthorization are being given significantly reduced funding levels
Discretionary health programs continue to be target for offices not supportive of health reform
Impacts of sequestration and deficit reduction Less and less appetite in Congress to work on
disease-specific legislation
Ryan White 2013 and Beyond Ryan White’s authorization will lapse BUT
program will continue to be funded and implemented
Ryan White Work Group working to educate Members of Congress and their staff on importance of Ryan White post-ACA implementation
Partners in Process
Key Congressional Offices Senate HELP Committee
Tom Harkin (D-IA), Chair Mike Enzi (R-WY), Ranking Member
House Energy & Commerce Committee Fred Upton (R-MI), Chair Henry Waxman (D-CA), Ranking Member
House E&C Health Subcommittee Joe Pitts (R-PA), Chair Frank Pallone (D-NJ), Ranking Member
Key staff have had conversations about RW, but no plans for action at this point
Partners in Process Administration (White House, HHS, HRSA):
The HRSA HIV/AIDS Bureau (HAB) has begun process to engage community in future of Ryan White Federal Register notice and listening session last
summer HHS Assistant Secretary for Planning &
Evaluation (ASPE) has engaged Mathematica on studies focusing on health reform and future of Ryan White Currently conducting Ryan White grantee
interviews
Ryan White Work Group Next Steps
Currently meeting monthly to discuss Ryan White Program and possibilities
Continue to educate Members of Congress
Set-up process to being having conversations about larger scale reauthorization in 2014 or when Congress is ready to begin considerations
Ryan White Work Group Next Steps
Community must be prepared to have conversations about Ryan White that we have not had in quite a while: Part structure Funding formulas and multiple funding
streams Duplication of services with larger systems of
health care Specific populations Many others
ACA RW Cross WalkSERVICE QHP MEDICAID RW PART B / ADAP
RX Cost-sharing assistance
MEDICAL CASE MANAGEMENT
ORAL HEALTH
LABS Cost-sharing assistance
MENTAL HEALTH SERVICES
Cost-sharing assistance
SUBSTANCE ABUSE TREATMENT
Cost-sharing assistance
HIV PRIMARY CARE Cost-sharing assistance
MEDICAL TRANSPORTATION Limited Coverage
INPATIENT HOSPITAL SERVICES
Payer of Last Resort Requirements within the Context of the Affordable
Care Act By statute, RWHAP funds may not be used “for any item or service
to the extent that payment has been made, or can reasonably be expected to be made…” by another payment source
Grantees and their contractors are expected to vigorously pursue enrollment in other relevant funding sources (e.g., Medicaid, CHIP, Medicare, state-funded HIV/AIDS programs, employer-sponsored health insurance coverage, and/or other private health insurance)
RWHAP grantees must make every effort to ensure that individual clients who are not eligible for public programs (Medicaid, CHIP, Medicare, etc.) and are not exempt from the Affordable Care Act’s requirement to enroll in health coverage are assessed for eligibility for private health insurance. The RWHAP will continue to pay for items or services received by individuals who remain uninsured or underinsured
13-03: Eligibility Post-Affordable Care Act
Recommends grantees align program financial eligibility determinations with those for new coverage options, mainly modified adjusted gross income (MAGI)
Recommends grantees align client recertification processes with Marketplace eligibility and enrollment processes to reduce burden and increase coordination
Grantees may consider requiring that clients provide their Medicaid and/or Marketplace notice of eligibility determination when applying for or being recertified for RWHAP
13-04: Eligibility for Private Health Insurance and Coverage by RWHAP
Reiterates that RWHAP grantees must make every effort to ensure that eligible uninsured clients expeditiously enroll in private health insurance when possible; this requirement will be monitored
Grantees need to inform clients of the penalty for not enrolling
Clients who receive a certificate of exemption from the Internal Revenue Service (IRS) may continue to receive RWHAP services
13-04: Eligibility for Private Health Insurance and Coverage by RWHAP (cont.)
Open enrollment into private health plans is for a limited time during the year If the client misses the open enrollment period, the
grantee must make every effort to ensure the client enrolls in the next open enrollment period
Grantees must maintain policies regarding the required process for pursuing enrollment for all clients, documentation of steps to pursue enrollment, and establishment of monitoring and enforcement of sub-grantee processes to ensure enrollment
13-04: Eligibility for Private Health Insurance and Coverage by RWHAP (cont.)
RWHAP funds may be used to pay for services received during the time between which a client enrolls in third party coverage and it becomes effective
Once enrolled in a private health plan, RWHAP funds may only be used for services not covered or partially covered by a client’s plan
13-04: Eligibility for Private Health Insurance and Coverage by RWHAP (cont.)
RWHAP funds generally may NOT be used to pay for services outside of their insurance network unless services are not available from an in-network provider
RWHAP funds may be used to pay for higher co-pays and deductibles within “tiered” networks Grantees must consider availability of resources prior to
making such allocations
13-05 and 13-06: Use of RWHAP Funds for Premium and Cost-Sharing for Private Health
Insurance and Medicaid
Reiterates that RWHAP grantees must ensure that they vigorously pursue non-RWHAP funds whenever appropriate for services to clients before using RWHAP funds, and that eligible clients are expeditiously enrolled in health care coverage
Requires grantees to evaluate whether paying the cost for health care premiums or cost-sharing (such as co-pays or deductibles) is cost-effective and to pay it when grant funds are available
Funds for health insurance premiums and cost-sharing assistance are considered a core medical service
13-05 and 13-06: Use of RWHAP Funds for Premium and Cost-Sharing for Private Health
Insurance and Medicaid (cont.)
Funds for health insurance premiums and cost-sharing assistance must be used to purchase plans that have pharmaceutical benefits equivalent to the HIV antiretroviral and opportunistic infection-related medication on the ADAP formulary and provide coverage for other essential medical benefits
Grantees who plan to buy insurance should consider providing funds to the ADAP since many ADAPs have infrastructure to purchase insurance
Funds may not be used to pay for administrative costs outside of the premium payment of the health plans or risk pools
13-05: Cost-Effectiveness of Plans (Marketplace)
Need to consider premium tax credits and cost-sharing reductions that the individuals may be eligible for when calculating the cost of purchasing a qualified health plan
Need to document the methodology used to show it is cost-effective
Grantees are encouraged to analyze the formulary, other covered medical benefits, cost of premium, and cost-sharing reductions
Grantees do not need to select the most cost-effective plan, but the selected plan must be more cost-effective than if the RWHAP program were to pay for services and medications
RWHAP grantees and sub-grantees should inform clients regarding these considerations to assist in enrollment decisions
Action Steps
Align client eligibility determination with Marketplace enrollment periods
Reduce burden by using MAGI
Collect Marketplace/Medicaid notice of eligibility determination for annual RWHAP recertifications
Be able to document process for pursuing enrollment
Establish methodology for conducting Marketplace cost-effectiveness