affordable care act

Affordable Care ActWHAT AN HIV PROVIDER NEEDS TO

KNOW

Steve O’Brien, MDJanuary 28, 2013

Pacific AIDS Education Training CenterSteve O’Brien, MD

Agenda

• What is ACA?• What can Providers & Patients expect?• How will patients access care?• How do we prepare for ACA?

Affordable Care Act(ACA)

• Goals:– Expand access to care– Reduce uninsured– Payment reform &

innovation

• Implement 2010-2014


• Goals:– Expand access to care– Reduce uninsured– Payment reform &

innovation

• Implement 2010-2014HIV

ACA

Ryan White


• HIV treatment expansion– Individual Benefit

• Early treatment– Community Benefit

• Transmission VL related• 37% in treatment

National HIV/AIDS Strategy

• Goals1. Reduce new infections2. Increase access to care3. Reduce HIV health disparities

• ACA key to achieving goals

How Does ACA Affect Access to Care ?

Access to HealthcareBefore 2010

• Employer sponsored insurance– Most prominent source of insurance– Less with HIV pts



• Individual private insurance – mostly shut out HIV pts due to pre-existing condition or unaffordable



• Individual private insurance – mostly shut out HIV pts due to pre-existing condition or unaffordable

• Medicaid/Medicare/RW– More important for HIV than general pop– Medicaid eligibility:

• Before ACA, federal law excluded non-disabled adults w/o kids unless a waiver• Income & Categorical (kids, parent with kid, preg, disabled) : leaves out many men

– Medicare – eligibility >65 or permanently disabled– State “high risk” pools– Ryan White

• RW also wraps around other services

HIV Patient’s Insurance Coverage2010

Access to Healthcare with ACACoverage Expansion: 2010-2014

• Medicaid– Allows Coverage for Childless

Adults• 138% FPL• Optional by state

– Medical Homes• Now includes HIV

– Primary Care Pay• 100% Medicare 2013-14

Access to Healthcare with ACA Coverage Expansion: 2010-2014





• Medicare– ADAP Counts towards TrOOP– Closes Drug Coverage Gap

• Donut-hole rebate• Drug discounts

Access to Healthcare with ACACoverage Expansion: 2010-2014





• Medicare– ADAP Counts towards TrOOP– Closes Drug Coverage Gap

• Donut-hole rebate• Drug discounts

• Insurance Protections– No lifetime limits or

rescissions– Pre-Existing Condition

Insurance Plan (PCIP)– Dependents covered to 26

• Small Business Coverage Subsidies

Medicaid Childless Adult Coverage &

ADAP Waiting ListState Medicaid

CoverageMore Limited

Coverage Than Medicaid

Early ACA Medicaid Expansion

ADAP Waiting List

Arizona Yes (closed)

California Yes Yes

Hawaii Yes (closed) Yes Yes

Nevada

Oregon Yes

Washington Yes Yes

All State Total 9 20 8 20

Access to Healthcare with ACACoverage Expansion: 2014 and Beyond

• Medicaid up to 138% FPL – No categorical qualification– Enhanced Federal match (100% ->

90%)

– States cannot be penalized for not enacting this part

• Health Insurance Exchanges– Income based premium & cost-

sharing subsidies • (via tax credits)

– Individuals & businesses up to 100 employees

• Basic Health Plan– Optional State plan 138-200% FPL

Access to Healthcare with ACA Coverage Expansion: 2014 and Beyond


90%)






• US citizens & legal residents must have insurance– Individual mandate

• Up to 6mil may be penalized (avg $1200/yr)

• No Pre-Existing Condition denial– PCIP dissolve

• No annual limits• FQHC funding increase• New Insurance Regulations

– Essential Health Benefits



90%)








90%)






• US citizens & legal residents must have insurance– Individual mandate

• Up to 6mil may be penalized (avg $1200/yr)

• No Pre-Existing Condition denial– PCIP dissolve

• No annual limits• FQHC funding increase• New Insurance Regulations

– Essential Health Benefits

Essential Benefits PackageAmbulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including

behavioral health treatment Prescription drugs Rehabilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

What are the potential service gaps?Services Allowed in current RW In EHB?

HIV Medicines Yes, plus co-pay and premium cover in some places - core

Yes, but might have limits

Outpatient/Ambulatory Medical Care Yes, core Yes

Medical Case Management* Yes, core No

Emergency Financial Assistance Yes No

Mental Health Services Yes, core Yes

Substance Use Disorder Services Yes, core Yes

Food/Nutrition Services Yes (medical nutrition is a core service)

No

Psychosocial Support Services* Yes No

*Could be part of new structures for reaching “3 aims” such as PCMH

What are the potential service gaps? (cont.)Services Allowed in current RW In EHB?

Oral Health Yes, core No

Early Intervention Services* Yes, core No

Legal Services Yes No

Home Health Services Yes, core ?

Child Care Yes No

Non-Medical Case Management* Yes No

Housing Yes No

Transportation* Yes No

Hospice Yes, core ?

Vision Care Yes No

*Could be part of new structures for reaching “3 aims” such as PCMH

Huge Portions of Traditional RW Programs and Services

are NOT Covered!!!!

Access to Healthcare with ACA Quality & Financing

• Delivery Systems Reform– Prevention

• New Prevention/wellness fund• Free Prevention Services

– USPSTF – HIV screening

– Pt-centered outcome research– Community transformation

grants– Value Based Purchasing– Medicare shared savings

program (ACO’s)– Hospital readmission reduction– Bundled payment pilots– HACs payment reduction

• Financing – Tanning salon tax– DRG adjustments– Medicare Advantage payment

restructuring– Insurance industry fees– New taxes: Medicare, passive

income, medical devices– Individual/Employer penalties– DSH payment adjustments– Excise tax on “Cadillac” health

plans

Bottom Line:Reducing the Number of Uninsured

Estimated 32 Million will gain coverage

by 2019

Medicaid: 16 millionIncome Under 138% FPL

Exchange: 16 million Income 138%-400% FPL

Supreme Court & ACAConstitutional Discussion

• Individual Mandate:– Can the Feds compel individuals to

purchase health insurance?

• Medicaid Expansion:– Is the ACA’s Medicaid expansion a

violation of state’s rights?

• Severability:– Should the remainder of

the ACA stand if a portionis struck down?

Supreme Court Decision

Upheld– Under Congress’ power to impose

taxes

Upheld but…– Feds can’t withhold existing

Medicaid funds if states forgo expansion

The remainder of the law stands

ACA: HIV Concerns• Exclusion of immigrants• Ryan White – What’s the future

• Payer of last resort• Wrap-around services

• Provider reimbursement rates• Hospitals hit hard….some will close• Medicaid & HIE vs RW

• Cost containment• Critical Focus

• Doesn’t cover dental, vision

What are the practical implications of ACA implementation?

Larry Moe Shirley

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES

EMPLOYER-BASED OR PRIVATE

INSURANCE

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

YES

MEDICAID MEDICARE

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

YES

MEDICAID MEDICARE

NO

OTHERAFFORDAB

LECOVERAGEAVAILABLE?

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

YES

MEDICAID MEDICARE

NO

OTHERAFFORDAB


YES

OTHER COVERAGE:• STATE HIGH RISK

POOLS• STATE-ONLY

FUNDED PROGRAMS

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

YES

MEDICAID MEDICARE

NO

OTHERAFFORDAB


YES


POOLS• STATE-ONLY

FUNDED PROGRAMS

NORYAN

WHITE

RYAN WHITE WRAP-AROUND SERVICES

BEFORE 2010

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

YES

MEDICAID MEDICARE

NO

OTHERAFFORDAB


YES


POOLS• STATE-ONLY

FUNDED PROGRAMS• PCIP

NORYAN

WHITE

RYAN WHITE WRAP-AROUND SERVICES

2010-2013

ACA ALLOWS STATE MEDICAID EXPANSION TO

138% FPL

EMPLOYEROR

PRIVATEINSURANCE

?

YES


INSURANCE

NO

MEDICAIDOR

MEDICAREELIGIBLE?

YES

MEDICAID MEDICARE

NO

SUBSIDY ELIGIBLE?

ORAFFORD

HIE?

YES

HEALTH INSURANCE EXCHANGES

NORW??

????? RYAN WHITE WRAP-AROUND SERVICES ?????

2014+

ACA “MANDATES” STATE MEDICAID EXPANSION TO

138% FPL W/ NO PENALTY

Larry

PMD

Private Doctor’s Office

Moe

Ryan White Clinic

KC, MD

Shirley

FQHC

SOB, MD

Winners &Losers

Service

More Medicaid - ++ +/- ++

HIE + +/- +/-

Ryan White wrap around(not all services covered)

{legal, CM etc]

? ? - -- - -

High variation in coverage(Formularies, covered services)

+/- - +/- - +/- -

Complexity +/- - - - - -More Managed Care + +/- - - - -

Private RW FQHC

Winners &Losers

Service

More Medicaid - +++ +/- +++

HIE + +/- +/-


{legal, CM etc]

? ? - -- - -


+/- - +/- - +/- -


Private RW FQHC

Winners &Losers

Service


HIE + +/- ?- ? +/-


{legal, CM etc]

? ? - -- - -


+/- - +/- - +/- -


Private RW FQHC

Winners &Losers

Service


HIE + +/- ?- ? +/-


{legal, CM etc]

? ? - --- - -


+/- - +/- - +/- -


Private RW FQHC

Winners &Losers

Service


HIE + +/- ?- ? +/-


{legal, CM etc]

? ? - -- - -


+/- - +/- - +/- -


Private RW FQHC

Winners &Losers

Service


HIE + +/- ?- ? +/-


{legal, CM etc]

? ? - -- - -


+/- - +/- - +/- -

Complexity +/- - - - - -More Managed Care + +/- - -- - -

Private RW FQHC

Worries

• Managed Care – Private, Medicare, Medicaid– Are providers/patients ready?

• Formulary issues– ADAP rebate heavy – Managed care – data

driven & generic focused• Authorizations• Focus on Care Transitions &

Cost-containment• Contracting• Auto-assignment

Worries

• Managed Care – Private, Medicare, Medicaid– Are providers/patients ready?

• Formulary issues– ADAP rebate heavy – Managed care – data

driven & generic focused• Authorizations• Focus on Care Transitions &

Cost-containment• Contracting• Auto-assignment

• Who will help with complex transitions?

• Ryan White– Reauthorized 4 times– Will it survive?– What will it look like

• Unlikely to be undocumented immigrant, vision & dental program

• Will RW Providers survive?– Medicaid expansion favors FQHC’s– RW Providers are expensive– With increased Insurance choices,

patients may leave or at least healthiest may leave

What Should You Do?Clinics & Hospitals

• FQHC alignment– Become an FQHC – Align with an FQHC

• Co-manage patients• Disseminate care to specific FQHC’s and build expertise

• Managed Care experience– Partner with Medicaid managed care providers– Are you part of Managed Care Network?

• State-specific, enhanced reimbursement/chronic disease program (short term $$)

• Demonstrate Cost Efdfectiveness– This means REAL data

What Should You Do?EMAs & Counties

• Collaborations!• Benefits Advocacy• Prepare for insured clients with choices• Strategize: Ryan White must fill gaps–Crosswalk area coverage

• Policy Advocates– Expect many, rapid changes

Reason to…

Celebrate• Expanded Healthcare for

Americans

• Focus on cost-containment

• Focus on Quality– we have lots of experience

with that in HIV

Worry• Challenges to HIV

exceptionalism

• Focus on cost-containment

• Will our HIV standards be compromised?

Resourceswww.hivhealthreform.org Community based website with California sub-site

FamiliesUSAhttp://www.familiesusa.org/health-reform-central/

Summaries, fact sheets, issue briefs; Join listserv for information updates, including periodic national conference calls on health reform topics

Kaiser Family Foundationhttp://healthreform.kff.org/

Summaries and implementation timeline; Fact sheets on Part D, exchanges and subsidies

Treatment Access Expansion Projecthttp://www.taepusa.org/

Analysis of HIV-related provisions, including presentations

HealthReform.govhttp://www.healthreform.gov/

Administration website with information on the new law, including an ongoing Q&A forum and state-specific information

Center for Medicare Advocacyhttp://www.medicareadvocacy.org/

Policy analysis and beneficiary information on the new law’s impact on Medicare, including Part D

Thank you….

affordable care act

Documents

subset of overall healthcare

graphic showing hiv

hiv pts11access

hiv provider

affordable care actacagoals

aca affect access

hivprimary care pay100

fpltemporary insurance