June 2015

Julia Hidalgo, ScD, MSW, MPHResearch Professor, George Washington University and CEO, Positive Outcomes, Inc.Julia.hidalgo@positiveoutcomes.net

HIV Care Under the Affordable Care ActAddressing the Needs of HIV Clinics and Clinicians in Washington

Today We Will Address

• Key provisions of the Patient Protection and Affordable Care Act (ACA)

• provider participation and covered benefit provisions

• Federal and State Medicaid policies • Eligibility, service delivery, and payment systems

• Focus on challenges and opportunities for Washington HIV clinical, social support, and prevention providers

• Maximizing third party reimbursement for HIV prevention, care, and support services through collaborative strategies

ACA Marketplace

From: Hidalgo J and Edelbrock E. Commercial Health Insurance Basics for HIV Prevention Programs Webinar. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-3-commercial-health-insurance-basics-for-hiv-prevention-programs/

ACA Requirements: Essential Health Benefits (EHBs)

• Ambulatory patient services• Hospitalization • Emergency services• Pregnancy, maternity, newborn care, and pediatric services (oral

and vision care)• Mental health and substance abuse disorder services (i.e.,

behavioral health treatment)• Prescription drugs• Rehab and habilitative services and devices• Laboratory services• Preventive and wellness services and chronic disease management

ACA Requirements: Essential Community Providers (ECPs)

ECP Category ECP provider Type

Federally Qualified Health Centers (FQHCs)

FQHCs and other community health centers, and healthcare facilities operated by Indian tribes and other Indian organizations

RWHAP provider Ryan White HIV/AIDS Program-funded providers

Family Planning provider

Title X family planning clinics and look alike family planning clinics

Indian Health provider Indian Health Service (IHS) providers, Indian tribes organizations, and urban organizations

Hospital Disproportionate share hospitals (DSH) and eligible hospitals, children’s hospitals, sole community hospitals, and other similar facilities

Other ECP providers STD clinics, TB clinics, and other entities that serve predominantly low-income, medically underserved individuals

CMS issued a letter to Federally-Facilitated Marketplaces in December 2014 QHPs must contract with at least 30% of ECPs in each QHP’s service area Offer contracts in good faith to all available Indian health providers in the service

area Offer contracts in good faith to at least one ECP in each ECP category in each

county in the service area Where an ECP in that category is available and provides medical or dental services

that are covered by the issuer plan type (i.e., Individual or SHOP)

To be in “good faith,” a contract should offer terms that a willing, similarly-situated, non-ECP provider would accept or has accepted Issuers must be able to provide verification of such offers if CMS chooses to review

the offers for compliance

ACA Requirements: ECPs

ACA Requirements: Preventive Services DHHS US Preventive Services Task Force (USPSTF) recommends “A” grade for HIV infection screening

Adolescents and adults ages 15 - 65 years Younger adolescents and older adults at increased risk All pregnant women, including those presenting in labor who are untested and

whose HIV status is unknown

“A” grade for syphilis for all pregnant women and other persons at increased risk for infection

“B” grade for chlamydia screening for sexually active women age 24 or younger and in older women at increased risk for infection

“B” grade for STD counseling for sexually active adolescents and for adults at increased risk for STDs

ACA QHPs Offering Coverage on the WA Health Benefits Exchange

Issurer Plan Type Counties

BridgeSpan Individual Benton, Clark, Franklin, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Yakima

Columbia United Providers

Individual Clark

Community Health Plan of WA

Individual Adams, Benton, Chelan, Clark, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, King, Kitsap, Lewis, Okanogan, Pacific, Pend Oreille, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Yakima

Coordinated Care Individual Adams, Benton, Chelan, Douglas, Franklin, Grant, Jefferson, King, Lewis, Lincoln, Snohomish, Spokane, Stevens, Thurston, Walla Walla, Yakima

Group Health Cooperative

Individual Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, Yakima

Kaiser Foundation Health Plan

Individual and SHOP

Clark and Cowlitz

LifeWise Health Plan

Individual All 39 counties

Moda Health Plan Individual and SHOP

All 39 counties

Molina Health Care Individual Chelan, Douglas, Grant, King, Okanogan, Pierce, Spokane

Premera Blue Cross Individual All counties except Clark

Impact of the ACA on State Medicaid Programs

From: Hidalgo J and Edelbrock E. Medicaid Basics for HIV Prevention Program. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-2-medicaid-basics-for-hiv-prevention-programs/

Medicaid Overview Federal and state entitlement program Medical assistance for people with limited income and resources Covers 60 million adults and children Enrollment in “traditional” Medicaid is commonly via TANF, Aged,

Blind, Disabled or other Categorical Programs Supplements Medicare benefits for 9 million low income aged and/or

disabled individuals Disability continues to be a common pathway to Medicaid and Medicare for HIV+ adults

Beginning in 2014, the ACA permitted states to expand Medicaid optionally to non-disabled individuals Anyone who is poor (include < $16,104 or 138% of the FPL) 4.8 million Americans enrolled in expanded Medicaid

Until ACA Medicaid expansion implementation, WA HIV+ adults commonly enrolled in Medicaid through enrollment in Social Security Administration (SSA) disability or TANF benefits. In WA, applications for SSA disability benefits are determined by the WA State Department of Social and Health Services Disability Determination Services (DDS)

Average Monthly SSA Initial SSI Allowance Rates in GA, LA, PA, TX, WA, By Year, 2001 to 2014

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0

10.0

20.0

30.0

40.0

50.0

60.0

GA LA PA TX WA Linear (WA)

ACA-Related Medicaid BenefitsEXPANSION STATES ACA requires adults enrolling through Medicaid expansion must

receive “alternative benefit plans” (ABPs) Must include the ten “essential health benefits” (EHBs) required for

Marketplace QHPs Must provide the full range of prevention services, including

preventive services rated “A” or “B” by the USPSTF at no cost to beneficiaries

Must cover family planning services and supplies (e.g., condoms), parity between physical health and behavioral health services, non-emergency transportation, and FQHC and Rural Health Center services

New Opportunities for Medicaid Payment for Preventive Services

CMS published a final rule effective in January 2014 Before the rule change: preventive services could only be

provided by a physician or other licensed practitioner (OLPs) of the healing arts to be paid by Medicaid

After the rule change: other practitioners, not just physicians and OLPs, can be paid to provide preventive services recommended by a physician or OLP

Assigns authority to State Medicaid Programs to Define practitioner qualifications Ensure appropriate services are provided by qualified practitioners Define the preventive services to be provided Design the reimbursement methods

Does not define the type of personnel to be covered

WA Apple Health Managed Care Organizations (MCOs)

Apple Health MCOs• Amerigroup (AMG)• Community Health Plan

(CHP)• Coordinated Care (CCC)• Molina Healthcare (MHC)• UnitedHealthcare (UHC)

WA Apple Health Eligible Populations

Clients receiving Medicaid under SSA provisions for coverage of families receiving AH Family

Clients who are ineligible for cash assistance who remain eligible for medical services under Medicaid

Clients receiving Medicaid under the ACA effective January 1, 2014 Children, from birth - 18 years of age, eligible for Medicaid under

expanded SSA pediatric coverage provisions Pregnant women, eligible for Medicaid under expanded SSA maternity

coverage Children eligible for the Children’s Health Insurance Program (CHIP) Categorically Needy - Blind and Disabled Children and Adults who are

ineligible for Medicare

WA Apple Health MCO Contract Preventive Services SpecificationsPREVENTIVE SERVICES When possible, the MCO shall develop guidelines based on the USPSTF as the primary source MCOs may adopt guidelines developed by recognized sources that develop or promote evidence-

based clinical practice guidelines such as voluntary health organizations or NIH If the MCO does not adopt guidelines from recognized sources, board-certified practitioners must

participate in the development of the guidelines MCOs shall develop health promotion and preventive care educational materials for enrollees using

both print and electronic media

FORMULARY The MCO shall maintain an HCA-approved formulary that includes

All therapeutic classes in the HCA’s FFS drug file and a variety of drugs in each therapeutic class determined by HCA to be sufficient to meet enrollees’ medically necessary health care needs

A number of drugs in each US Pharmacopeia (USP) category and class equal to or greater than the number included in Washington State’s selected EHB benchmark plan

At least 1 drug in any USP category and class for which the EHB benchmark plan has no covered drugs

Additional drugs as determined necessary by HCA to meet enrollees’ medically necessary health care needs

WA Apple Health MCO Contract HIV and Related Specifications

Included Specifications Enrollee Self-Referral: STD screening and follow-up, HIV screening through and if

provided by a local health department Prescription and OTC Drug Products: according to the HCA-approved formulary Covered Drug Products: include all OTC contraceptives without a prescription

including but not limited to condoms

Missing Specifications USPSTF HIV recommendations not reflected Coverage of HIV prevention, screening, and clinical services are not explicitly

addressed Enhanced HIV/AIDS capitation rates Requirement for MCOs to coordinate with the RWHAP grantees or providers Infectious disease clinician network adequacy HIV quality measures (e.g., HIV screening and undetectable viral load rates)

WA Apple Health MCO Contract Local Health Department (LHDs) and Community Health Worker (CHW) Specifications

MCOs shall make a reasonable and fair effort to subcontract with all LHDs If MCOs subcontracts with LHDs as participating providers or refers enrollees

to them to receive services, MCOs shall pay for services provided up to the limits described in this Contract

Care Coordinator is a health care professional or group of professionals, licensed in WA, who is responsible for providing care coordination services to enrollees

Care Coordinators may be a RN or Social Worker employed by the Contractor or primary care provider and/or Individuals or groups of licensed professionals, or individuals working under their

licenses, subcontracted by the primary care provider/clinic Allied health care staff, such as CHWs and others, to facilitate the work of the care

coordinator

WA Apple Health Targeted HIV/AIDS Medical Case Management (MCM)

DOH screens applicants for eligibility Recipients cannot receive concurrent MCM from another program Applicants must require help obtaining and effectively using necessary medical, social, and

education services, or need 90 days of continued monitoring Have a benefit service package that covered Clients enrolled in MCOs may receive MCM services, without MCO referral

Proc Code

Modifier Dx Code Unit Payment Rate

Description

T2022 U8 Limited to diagnosis

042 or V08

CM, per month

$173.72 Full Month. A full-month rate applies when:• Criteria in WAC 182-539-0300 have been met; and• Individual service plan (ISP) in place > 20 days in that month

T2022 U9 CM, per month

$86.86 Partial Month. A partial-month rate applies when:• Criteria in WAC 182-539-0300 have been met• Individual service plan (ISP) has been in place < 20 days in that

month

T1023   Program intake

assess-ment

$139.12 Full Month. A full-month rate applies when:• Criteria in 182-539-0300 have been met.• An ISP has been in place > 20 days in that month.

Opportunities for HIV Core Medical, Support, and Prevention providers in the ACA and Medicaid Reform

Addressing Health Insurers’ Interests Via Services Offered by HIV providers

Health Insurers’ Interests Services That HIV providers Might Offer

Identify enrolled members that do not obtain preventive or other services

Outreach, linkage, patient navigation

Essential covered benefits RWHAP core medical providers

Address members’ healthcare and health insurance literacy needs

Non-MCM, patient navigation, health education

Prevent communicable diseases including HIV, STDs, TB, and HCV

nPEP and PrEP support, HIV/STD CTS, behavioral prevention, condom distribution and education, HERR

Address members’ linguistic and numeracy needs to ensure that they can participate actively in health promotion, prevention, and care

Translation and health education

Culturally competent care coordination, disease management, treatment education

Culturally competent workers with expertise in serving racial, ethnic, and sexual minority populations

Addressing Health Insurers’ Interests Via Services Offered by HIV providers

Health Insurers’ Interests Services That HIV providers Might Offer

Ensure access to physical, behavioral, and other outpatient services to promote health, and prevent and treat disease

MCM, navigation, behavioral health tx support, medical transportation

Ensure HIV+ clients receive and optimally benefit from ARVs and other medications

MCM, navigation, tx education and adherence counseling, MCM

Coordinate services provided by the care team with the client, his/her family, and community resources

MCM

Disease management MCMDischarge planning and readmission prevention interventions for hospitalized patients

MCM

Align With Your Organization Before Seeking New Opportunities

Before moving forward, it is critical to Ensure your HIV program’s efforts are aligned with your

organization’s overarching readiness efforts An important step for HIV practices in large integrated health systems,

hospital-based or university-affiliated health systems, LHDs, large FQHCs Contracts may have been negotiated or are being negotiated QHP and Medicaid MCO contracts have probably been finalized for the

current year

Engage organizational leadership, including corporate board support

Identify organizational resources that can be applied to your contracting and collaboration activities

Resources for Contracting for HIV Prevention and Care ServicesHealthHIV. Health Insurance Contracting for HIV Prevention and Wrap-around Service providers. 2015. Available at: http://wwwhealthhiv.org

HIV Medicine Association. Strategies for HIV Medical providers Contracting With Health Insurers. 2013. Available at: http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/Healthcare_Reform_Implementation/Resources/Strategies%20for%20HIV%20Medical%20providers.pdf

On Our Own

• Chart your own organizational course• Enhance your TPR capacity, join insurers’ FFS programs and networks • Crush the competition

Virtual Integration

• Adopt a “trade association” model • Collaborate in information gathering, purchasing, and marketing• ASOs seek out and create formal relationships with HIV clinics, community health

centers, or other core providers

Physica

l Integration

• Co-locate services but remain independent organizations• Share infrastructure costs

Acquisitions & Mergers

• Identify agencies with services strengthening your capacity and “buy them”• Identify similar agencies but different service areas or populations and merge • Transfer clients to a fiscally solvent, culturally competent, and high quality agency

close HIV program

Strategies for Strengthening the HIV Care Continuum

Collaborative Integration StrategiesContract for services using “grant” type budget, FFS, sub-capitated arrangements

Augment care management services provided by the insurer through contract

Contract with provider networks to provide HIV and HIV services

Provide subcontracted essential and other covered services

Coordinate and collaborate to serve HIV+ and non-HIV+ clients

Subcontract with CBOs and handle their billing

Provide subcontracted essential and other covered services

Coordinate and collaborate to serve HIV+ and non-HIV+ clients

Subcontract with CBOs and handle their billing

Provide subcontracted outreach, HIV and STD testing, linkage, home visits, MCM, preventive services

QHP or

MCO

Hospital Systems

FQHCs & HIV Clinics

CBOs

How to Learn More About ACA and Medicaid-Related Health Insurers in My State