Past, Present & Future of the Ryan White Program

1. Past, Present & Future of the Ryan White Program Federal AIDS Policy Partnership US Conference on AIDS September 10, 2013

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

18. ACA RW Cross Walk

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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