ACA Update Part 1: New Rules and Regulations

1. ACA Update Part 1:New Rules and Regulations Federal AIDS Policy PartnershipAugust 7, 2013Andrea Weddle, Co-chair HIV Health Care Access Working Group

2. Medicaid Expansion Benefits • Referred to as “Alternative Benefits Package” • Regulation sets minimum standard – state flexibility to develop robust package • Can develop different benefits packages for different populations • “Medically Frail” population can choose traditional Medicaid benefits • Definition broad - should include PWA • See Final Rule at http://www.ofr.gov/(X(1)S(le1fsc4mockmw1tkuddol4r5))/OFRUpload/OFRData/2013-16271_PI.pdf

3. Complicated Process • State selects benchmark plan • Add EHB service if not covered • Add required Medicaid services • Option to submit Secretary-approved coverage • States use if want traditional Medicaid benefits Learn More: http://www.medicaid.gov/State-Resource-Center/Eligibility-Enrollment-Final-Rule/Alternative-Benefit-Plans-and-Essential-Health-Benefits.pdf

4. Retreat onDrug Coverage Requirement • Minimum coverage = number of drugs covered by the benchmark for a drug class or at least one drug in a class, whichever greater • Traditional Medicaid requires coverage of nearly all drugs • Monthly drug limits and prior authorization allowed • Must have process for accessing drugs not on formulary

5. Coverage for Antiretrovirals Will Combination ARVs be Covered? See US Pharmacopia Drug Classification at: http://www.usp.org/usp-healthcare-professionals/medicare-model-guidelines

6. New Medicaid Cost Sharing Rules Income Under 150% FPL: • Up to $8 for non-preferred drugs; $4 for preferred drugs • Physician can request non-preferred drug as preferred with justification • Up to $4 for office visits • Up to $8 for nonemergency of the ER • Up to $75 for inpatient stays

7. Medicaid Cost Sharing II • New rules apply to everyone – not just expansion population • Under 100% not denied for failure to pay (still) • New HAB Guidance – Ryan White A B C D can assist with Medicaid premiums & cost sharing depending on coverage adequacy and cost effectiveness

8. Take Away:State Advocacy Critical • Educate state Medicaid on importance of comprehensive coverage for people with HIV • Urge coverage of ARVs according to federal treatment guidelines, including combination ARVs • Comment on proposed Alternative Benefits Package

9. For Details… www.nastad.org Click on “Health Reform” in the feature box www.hivhealthreform.org

10. More Regulations/Guidance • Certified Application Counselor Guidance: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CAC-guidance-7-12-2013.pdf • Employer Mandate Delay Announcement:  http://www.treasury.gov/connect/blog/Pages/Continuing-to-Implement-the-ACA-in-a-Careful-Thoughtful-Manner-.aspx • Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions http://www.ofr.gov/OFRUpload/OFRData/2013-15530_PI.pdf • Eligibility for Minimum Essential Coverage for Purposes of the Premium Tax Credithttp://www.irs.gov/pub/irs-drop/n-13-41.pdf For a translation of latest rules and policies – check out Timothy Jost’sHealth Affairs Blog: http://healthaffairs.org/blog/author/jost/

11. Enrollment - Training Resources http://marketplace.cms.gov

12. New & Improved: • Tool to Evaluate Potential New Coverage Options • State-specific Information • Coverage Information

13. 55 Days Until Open Enrollment Next HHCAWG Call: August 14th – 4 pm ET HIV/AIDS Bureau Call on ACA Guidance: August 14th – 2:30 pm ET