Emily McCloskey Intersection between the ACA and ADAP April 10, 2014

1. A Year of Change: ADAP's Successes and Challenges Implementing the Affordable Care Act Emily McCloskey Intersection between the ACA and ADAP April 10, 2014

2. Who is NASTAD? • NASTAD is a non-profit national association of state health department HIV/AIDS program directors who administer HIV/AIDS and viral hepatitis prevention, care and treatment programs funded by state and federal governments. • Domestic Programs • Health Care Access, Health Equity, Prevention, Viral Hepatitis • Policy and Legislative Affairs • Global Program

3. Mission NASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis. Vision NASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.

4. Presentation Overview Current State of ADAPs ADAPs in a Reformed Health System Enrollment into Coverage Insurance Assistance and Premiums Leveraging the ACA to Raise the Bars Questions and Answers

5. Current State of ADAPs

6. The National ADAP Budget, by source, FY1996-FY2013

7. ADAP Client Utilization

8. ADAP Client Demographics

9. ADAP Client Demographics (continued)

10. ADAP Insurance Coordination

11. FY2014 Final Funding • The Bipartisan Budget Act of 2013 increased non-defense discretionary funding by $22 billion • Final numbers for FY2014 included a $14 million increase for ADAP

12. FY2015 Budget Outlook • Caps for FY2015 are slightly larger than FY2014 • President Obama’s budget released on March 4 • ADAP and Part B were flat-funded • Congress is beginning work on the appropriations process

13. ADAPs in a Reformed Health System

14. ACA: Three Prongs • Medicaid expansion • Medicare Part D reforms • Marketplaces/exchanges • Prohibitions on discriminatory insurance practices • Investments in community health centers, health workforce, coordinated care, and prevention

15. Recap of 2014 Open Enrollment: Top Four Challenges and Solutions

16. ADAP in a Reformed Health System • What will ADAP “look like” after January 1, 2014? • Traditional ADAP • Full payment of medications for those not eligible for coverage under the Affordable Care Act • Insurance purchasing/continuation • Wrap-around of Medicaid and Medicare • Including Medicaid expansion and non-expansion states • Insurance purchasing – purchasing of a new policy • Including policies purchased through the Exchange • Insurance continuation – payment for an existing policy • Including policies purchased through the Exchange

17. Enrollment into Coverage

18. Case Study: Ryan White Program Clients ADAP Clients Served, by Income Level (June 2012) NASTAD Annual ADAP Monitoring Report, January 2013

19. Mapping Client Transitions

20. 16,000+ ACA-related Transitions Facilitated by State HIV Programs NH VT WA ME ND NY MT MN OR WI SD MI ID CT WA WY PA NJ OH IA NE MT IN DE NV IL OR CO WV UT KY VA MD KS MO ID CA WY NC DC TN OK AZ NV AR SC NM GA CO AL UT MS AK CA TX LA FL AZ NM AK HI HI

21. Enrollment into Coverage:Key Dates MARCH April 15th 30th Qualified Health Plans 31st PCIPs • Enrollment Deadline for a Plan Effective Date of May 1st • Deadline to switch plans • PCIP coverage ends • Enrollment Deadline for a Plan Effective Date of April 1st 31st CONTINUOUS ENROLLMENT Medicaid 2015 QHP Open Enrollment Period • November 15, 2014 to February 15, 2015 • Next open enrollment period pushed back

22. Enrollment into Coverage:Where States stand on Medicaid ME VT WA NH* MT ND MN OR MA NY WI* SD ID MI* RI CT WY PA* NJ IA* NE OH DE IN* IL NV MD CO UT WV VA CA DC KS MO KY NC TN AZ SC OK AR* NM GA AL MS AK LA TX FL HI Implementing Expansion in 2014 (27 States including DC) Open Debate (5 States) Not Moving Forward at this Time (19 States) Source: Kaiser Family Foundation

23. Enrollment into Coverage:Medicaid Expansion Options Traditional Medicaid State decides to expand Medicaid to people with income up to 138% FPL (Yay!) Alternative Benefits Plan that could be different from traditional Medicaid How to structure the expansion?? Premium assistance program to purchase Qualified Health Plans (QHPs) for Medicaid beneficiaries

24. Weighing the Pros and Cons of Premium Assistance Plans

25. Enrollment into Coverage:Mapping ACA Coverage Transitions Churning Grantees are defining how to“vigorously pursue” client eligibility for Medicaid and QHP coverage

26. Enrollment into Coverage:Addressing Churn Subsidies to Purchase QHP (income between 139 and 400% FPL) Income fluctuations Medicaid (income up to 138% FPL) Considerations to mitigate churn: • Eligibility for premium tax credits and cost-sharing is based on ANNUAL income • If a person switches from a QHP to Medicaid and back to a QHP, he/she will get credit for any cost-sharing charges paid before moving to Medicaid – BUT only if the the person re-enrolls in the same Marketplace plan from same insurer • This rule also applies any time someone re-enrolls in the same Marketplace plan they had during the same year. • State Medicaid policies (e.g., 12 month eligibility)

27. Enrollment into Coverage:The ACA and Immigrants Medicaid Qualified Health Plans • Special Consideration for • Mixed Status Families • Eligibility for coverage options and any applicable subsidies are available for the lawfully present members of the household Lawfully Present INDIVUAL MANDATE APPLIES (with exceptions as applicable) Not Lawfully Present INDIVUAL MANDATE DOES NOT APPLY

28. Enrollment into Coverage:Special Enrollment Periods

29. Enrollment into Coverage:Individual Mandate Exemptions

30. Enrollment into Coverage:Enforcement of the Individual Mandate

31. Enrollment into Coverage:Considerations for State HIV Programs • Medicaid Outreach and Enrollment Activities • Document vigorous pursuitof coverage options • Maintain awareness of client insurance status and special eligibility opportunities • Manage client churn • Advise special clients of special enrollment periods • Maintain awareness special and standard coverage effective dates • Ensure O&E staff understand coverage options for immigrants

32. Insurance Assistance and Premiums

33. Insurance Assistance and Premiums: :Top Four Challenges and Solutions

34. Insurance Assistance and Premiums:Ongoing Challenges

35. Insurance Assistance and Premiums:Health Insurance Literacy

36. Insurance Assistance and Premiums:Augmenting Benefits Across Insurance Programs

37. Insurance Assistance and Premiums: Prescription Drug Formulary Missing from USP classification system = combination therapies EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan

38. Insurance Assistance and Premiums:Assessing Provider Networks

39. PAYMENT Premium tax credit is paid in advance on a monthly basis directly to the health plan. Payment amounts are based on income. ADAP may cover amount not covered by federal subsidy. Insurance Assistance and Premiums: Tax Credits and Cost-Sharing Reductions RECONCILIATION When the person files a tax return for the actual year in which he/she received the tax credit, underpayments or overpayments are reconciled (overpayments are capped based on income). Premium Tax Credits (available to people with income between 100 and 400% FPL) APPLICATION Person applies for premium tax credit and cost-sharing reductions during exchange open enrollment periods with either most recent tax returns or other documentation of income (e.g., pay stubs). PAYMENT Cost sharing reductions mean that plans pay a greater amount of the covered costs, taking that burden off of the enrollee. The cost-sharing subsidies are paid directly to the plan. ADAP may cover amount not covered by federal subsidy. Cost-Sharing Reductions (available to people with income between 100 and 250% FPL)

40. Insurance Assistance and Premiums: Tax Credits and Cost-Sharing Reductions Consumer earns income and generates a modified adjusted gross income (MAGI) for the 2013 tax year Consumer receives advance premium tax credit and cost sharing reductions based on 2013 MAGI Consumer files 2014 tax return and reconciles 2013 MAGI with 2014 MAGI – under-/overpayment assessed by IRS

41. Leveraging the ACA to Raise the Bars

42. Leveraging the ACA to Raise the Bars:Translating Coverage into Care and Treatment Adapted from West Virginia Ryan White Part B Program

43. Preparing Providers for Health Reform

44. Leveraging the ACA to Raise the Bars:Translating Coverage into Care and Treatment

45. ACA Outreach and Enrollment Programs and Resources HIV/AIDS Programs and Providers

46. Breaking Down Program and Service Silos: Coordinated Care Opportunities through the ACA Coordinated Care Opportunities • Contracting arrangements • Between support services providers and medical providers • Medicaid Health Homes • Targets populations with chronic conditions, including HIV • Capitated payments • Starting to include support services • Patient Centered Medical Homes • Certification emphasizes whole-person care and role of vital enabling services in improving health outcomes • Quality and access measures • Include HIV quality measures • Emphasize care coordination

47. Resources • National Alliance of State & Territorial AIDS Directors (NASTAD), www.NASTAD.org • Amy Killelea, akillelea@nastad.org • Xavior Robinson, xrobinson@nastad.org • HIV Health Reform, http://www.hivhealthreform.org/ • Treatment Access Expansion Project, www.taepusa.org • HIV Medicine Association, www.hivma.org • Health Care Reform Resources • State Refo(ru)m, www.statereforum.org • Kaiser Family Foundation, www.kff.org • Healthcare.gov, www.healthcare.gov

48. Questions and Answers

49. Contact Information Emily McCloskey Manager, Policy and Legislative Affairs NASTAD Phone: (202) 434.8090 emccloskey@NASTAD.org www.NASTAD.org