May 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 Georgia

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 Georgia 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 (HIS) 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

Georgia QHPs Sold On and Off the Federally-Facilitated Marketplace

Individual Alliant Health Plans Ambetter from Peach State Health Plan Anthem Blue Cross and Blue Shield Assurant Health Blue Cross Blue Shield Healthcare Plan of GA Cigna Healthcare Coventry Health Care of GA, Inc. Humana Insurance Company Kaiser Foundation Health Plan of GA UnitedHealthcare

SHOP Alliant Health Plans Blue Cross and Blue Shield of GA Kaiser Permanente

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, GA HIV+ adults commonly enroll in Medicaid through enrollment in Social Security Administration (SSA) disability or TANF benefits. In GA, applications for SSA disability benefits are determined by the GA Vocational Rehabilitation Agency Disability Adjudication Services.

SSA Initial Allowance Rates in GA, By Month, October 2000 to March 2015

2000-10 2001-07 2002-04 2003-01 2003-10 2004-07 2005-04 2006-01 2006-10 2007-07 2008-04 2009-01 2009-10 2010-07 2011-04 2012-01 2012-10 2013-07 2014-04 2015-010.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

ACA-Related Medicaid Benefits

NON-EXPANSION STATESCan voluntarily cover EHBs under their traditional Medicaid

benefit packagesCoverage of preventive services in traditional Medicaid

benefit packages is optionalSome groups, such as the disabled, dual eligible, and

medically frail individuals, are exempt from enrollment in ABPs and may choose to obtain traditional Medicaid 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

Medicaid GA Families Recipient Eligibility Medicaid eligibility categories are required to enroll in Georgia

Families (GF) Low Income Families Transitional Medicaid Pregnant Women Children (Right from the Start Medicaid - RSM) Children (newborn) Women Eligible Due to Breast and Cervical Cancer Refugees Planning for Healthy Babies 1115 Demonstration Waiver Participants (i.e.,

P4HB Participants) PeachCare for Kids®

GA Medicaid GA Families Recipient Eligibility Exclusions

Recipients eligible for Medicare Recipients that are Members of a Federally Recognized Indian Tribe Recipients that are enrolled in fee-for-service (FFS) Medicaid through

Supplemental Security Income prior to enrollment in GF Children < 21 years of age who are

In foster care or other out-of-home placement, receiving foster care or other adoption assistance under Title IV-E of the Social Security Act (SSA), enrolled in the Children’s Medical Services program administered by the GA Department of Public Health, enrolled in the Georgia Pediatric Program

Recipients enrolled under group health plans for which DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the SSA

Individuals enrolled in a Hospice or a Nursing Home aid category Individuals enrolled in a Community-Based Alternative for Youths

GA Managed Care Plans Amerigroup Community Care WellCare of GA Peach State Health Plan

Managed Care Program Narrow eligibility parameters HIV coverage not addressed, or specifically excluded from coverage Likely most HIV+ beneficiaries remain in FFS

Reimbursement rates low Limited formulary for HIV medications HIV providers may not have sufficient experience in managed care contracting

Considerable opportunities for advocacy and education

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

Addressing Health Insurers’ Interests Via Services Offered by HIV ProvidersHealth Insurers’ Interests Services That HIV Providers Might

OfferIdentify 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

ACA Essential, RWHAP, and CDC-Covered ServicesACA Essential Covered Benefits RWHAP Service Categories CDC HIV High Impact Services

Ambulatory patient services OAMC, hospice care OAMC visits for PrEP & PEP

Hospitalization Emergency services

Pregnancy, maternity, newborn care

OAMC

Pediatric services OAMCMental health (MH) services MH services, hospice careSubstance abuse (SA) disorder services

Outpt SA tx services, residential SA tx

Prescription drugs OAMC, ADAP, LAPA HIV biomedical prevention: meds for PrEP & nPEP

Rehab & habilitative services & devices

Home health care, HCBHS

Laboratory services OAMC, EIS, lab tests HIV & STD testingOral health services (peds)* Oral health servicesPreventive & wellness services & chronic disease management

OAMC, MCM, EIS, HERR, tx adherence counseling

HIV test counseling, HIV behavioral prevention, HERR, PrEP and nPEP tx adherence, prevention case management

Non-Essential ACA, RWHAP, and CDC-Covered Services

ACA Non-essential Covered Benefits

RWHAP Service Categories CDC HIV High Impact Services

Medical nutrition therapyMedical transportation servicesLinguistic servicesOutreach services Outreach & linkage

servicesRehabilitation services

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, local health departments, 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://www.healthhiv.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

Medicaid

MCO

Hospital-Based HIV

ClinicFQHCs CBOs Health

Dept

Independent Contracting Model

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

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

Integrated Healthcare Facilities and Community-Based Organization (CBOs) Contracting Model

Medicaid

FFS

Hospitals

CBOs

FQHCs

CBOs

MCO

Hospitals

CBOs

FQHCs

CBOs

QHP

State and County HDs

Public Health-Funded HIV/STD

Surveillance CBOs

Integrated Public Health Department and CBO Contracting Model

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