bob bongiovanni presentation on the future of ryan white post aca

7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA

1/31

+

Where are we heading?

The Affordable Care Act andRyan White


2/31

WhatWilltheACAMeanforAddressingtheHIVEpidemic?


3/31

FromCDPHESurveillanceProgram

14,266

11,698

5,7554,875

3,728

0

2000

4000

6000

8000

10000

12000

14000

16000

HIV Infected Diagnosed Linked to Care Retained in

Care

Virally

Suppressed

NumberofIndividuals

Colorado Cascade of Care

82%

49%

42%32%


4/31

HelpingPeopleMove

ThroughtheCascade

First Diagnosis with

HIV

Linked to Care

Retained

in Care

Achieve Viral

Suppression


5/31

TheProcessisNOTLinear

First

Diagnosis

with HIV

Linked to Care

Retained

in Care

Achieved ViralSuppression

Lapsed in Care

Re-Engaged


6/31

nFocusonservicesthatareproventohelppeoplemovethroughthecascadetowardviralsuppression

n IfapersoniseligibleforMedicaid,Medicare,orcommercialinsurance,theRyanProgramisrequiredtovigorouslypursueenrollmentofthepersoninthesetypesofcoverage

n Ifthereisaservicethatwouldhelpmovepeoplethroughthecascadebutcannotbefundedfromathirdpartypayer,Ryan

Whitefundingcanbeusedtopayforthatservice.

nMonitorhowwelltheenresystemofcareisassisngwithachievementofviralsuppression,notjustthelong-standing

RyanWhitesystem.

Thepost-ACAapproachtoHIVcare:


7/31

Anewwaytotriageclients

Whatwouldhelpthisclientmovethroughthecarecascade?

UlizeRyanWhite

fundingtoprovidethe

service

Providetheserviceandbillthe

3rdpartypayerorrefertoa

providerwhocandoso

YESNO

YESNO

Eligiblefor

3rdparty

payment?

Serviceis

reasonably

accessible?


8/31

Services Diagnosed Linked Retained Viral Supp Re-engage

HIV Testing

Outreach

Linkage

Referral

Retention

Ambulatory care

Case management

Transportation

Adherence

Oral health

Financial Assist

ADAP

HousingNutrition/Food

Psychosocial

HE/RR

Mental health tx

Substance use tx


9/31

n BoththeCLIENTandtheSERVICENEEDEDmustbeevaluatedforpotenal3rdpartypayment

n Eligibilitycriteria:Residence,cizenship,incomelevel,householdsizen Payers:Medicaid,Medicare,PlansthroughtheMarketplace,EmployerBasedPlans

n Servicestheywillpayfor:theEssenalHealthServices(asinterpretedbythepayer)

n IftheclientisELIGIBLEbutnotENROLLEDmustvigorouslypursueenrollment.

Eligibilityfor3rdPartyPayment


10/31

+Mapping Client Transitions

Uninsured Lawfully present Income up to 138% FPL

Medicaid

Uninsured

Lawfully present Income 138 - 400% FPL

Subsidized private insurance throughMarketplace

Currently on Medicaid No transition

Currently on other government-sponsoredinsurance (e.g., Medicare, TRICARE)

No transition

Currently on or have access to employer-

based coverage

If plan is affordable and comprehensive,

no transitionCurrently on PCIP or high risk pool Medicaid or Marketplace coverage

Uninsured and categorically ineligible forfederal programs

No transition


11/31

+HRSA Policy Notice13-01: Clarifications

Regarding Medicaid-Eligible Clients andCoverage of Services

nGranteesandtheirsubgranteesareexpectedto:n VigorouslypursueMedicaidenrollmentforindividualswhoarelikelyeligibleforcoverage,

nSeekpaymentfromMedicaidwhentheyprovideaMedicaid-coveredserviceforMedicaidbeneficiaries

nBack-billMedicaidforRWHAP-fundedservicesprovidedforallMedicaid-eligibleclientsupondeterminaon.


12/31

+HRSA Policy Notice13-03: Eligibility

Post-Affordable Care Act

nRecommendsgranteesalignprogramfinancialeligibilitydeterminaonswiththosefornewcoverageopons,mainly

modifiedadjustedgrossincome(MAGI)

nRecommendsgranteesalignclientrecerficaonprocesseswithMarketplaceeligibilityandenrollmentprocessestoreduceburden

andincreasecoordinaon

nGranteesmayconsiderrequiringthatclientsprovidetheirMedicaidand/orMarketplacenoceofeligibilitydeterminaon

whenapplyingfororbeingrecerfiedforRWHAP


13/31

+HRSA Policy Notice13-04: Eligibility

for Private Health Insurance andCoverage by RWHAP

nReiteratesthatRWHAPgranteesmustmakeeveryefforttoensurethateligibleuninsuredclientsexpediouslyenrollinprivatehealthinsurancewhenpossible;thisrequirementwillbemonitored

nGranteesneedtoinformclientsofthepenaltyfornotenrollingnClientswhoreceiveacerficateofexemponfromtheInternalRevenueService(IRS)mayconnuetoreceiveRWHAPservices


14/31

+HRSA Policy Notice13-04 (continued)

nOpenenrollmentintoprivatehealthplansisforalimitedmeduringtheyear

Iftheclientmissestheopenenrollmentperiod,thegranteemustmakeeveryefforttoensuretheclientenrollsinthenextopenenrollmentperiod

nGranteesmustmaintainpoliciesregardingtherequiredprocessforpursuingenrollmentforallclients,

documentaonofstepstopursueenrollment,andestablishmentofmonitoringandenforcementofsub-granteeprocessestoensureenrollment


15/31

+

nRWHAPfundsgenerallymayNOTbeusedtopayforservicesoutsideoftheirinsurancenetworkunlessservicesarenotavailablefromanin-networkprovider

nRWHAPfundsmaybeusedtopayforhigherco-paysanddeducbleswithinerednetworksbutmustconsider

availabilityofresourcespriortomakingsuchallocaons

HRSA Policy Notice13-04 (continued)


16/31

nTheserviceisconsistentwiththeHIVCareandTreatmentProgramStandardsofCare;

nTheserviceisavailabletotheclientwithinsixtycalendardaysormorepromptlyifneededtopreventdeathor

substanal,irreversibleharmtotheclient;and,nTheserviceislocatedwithin70milesoftheclientresidence.

nThisisCDPHEsinterpretaonofHRSArulesandissubjecttoHRSArevision.OtherColoradoHRSAGrantees(PartA,

C,D)mayhavedifferentinterpretaons.

Reasonablyaccessible


17/31

+Colorado Service Cross Walk

SERVICE Qualified Health Plans MEDICAID RW / ADAP

RX Cost-sharingassistance

MEDICAL CASEMANAGEMENT

ORAL HEALTH Limited Coverage

LABS Cost-sharingassistance

MENTAL HEALTHSERVICES

Cost-sharingassistance

SUBSTANCE ABUSETREATMENT

Cost-sharingassistance

HIV PRIMARY CARE Cost-sharingassistance

MEDICALTRANSPORTATION

Limited Coverage

INPATIENTHOSPITAL SERVICES

X X

X

X

X


18/31

+HRSA Policy Notice13-01: Clarifications

Regarding Medicaid-Eligible Clients andCoverage of Services

nOnceanindividualisenrolledinMedicaid,RWHAPfundsmaybeusedtopayfor:nAnymedicallynecessaryserviceswhichMedicaiddoesnotcoverorwhereMedicaidcoverageislimitedinscope

nPremiums,co-paysanddeducblesifrequirednOthercoremedicalservicesasapartofprimarycareifthoseservicesarenotcoveredorarelimitedunderMedicaid,evenwhenthoseservicesareprovidedatthesamevisitasMedicaidcoveredservices.


19/31

+

nRWHAPfundsmaybeusedtopayforservicesreceivedduringthemebetweenwhichaclientenrollsinthirdpartycoverageanditbecomeseffecve

nOnceenrolledinaprivatehealthplan,RWHAPfundsmayonlybeusedforservicesnotcoveredorparallycovered

byaclientsplan

HRSA Policy Notice13-04: Eligibility

for Private Health Insurance andCoverage by RWHAP


20/31

+

Whataresomeother

implicaonsoftheAffordableCareActforPeopleLiving

withHIVorAIDS?


21/31

+Pre-ACA Scenario

for HIV negative people

nHIV and STIs are highly concentrated among the poorand the uninsured.

nLow cost STI care for the uninsured is very limited interms of geography and provider

nIf mental health or substance use issues are driving HIVrisk, low cost counseling is also very limited

nPrivate health care providers are identifying most newHIV cases, but there is still a fear of becominguninsurable due to HIV testing (even if negative)


22/31

+Post-ACA Scenario

for HIV negative people

nMost HIV negative people will be eligible forMedicaid or some other form of coverage.

nIfthey enroll, they shouldhave new coverage thatshouldreduce their vulnerability for HIV:

nSTI screening and treatmentnHIV testingnMental health carenSubstance abuse treatment


23/31

+

Hopefulresultsfrom

Massachuses,thepioneerinuniversalhealthcoverage


24/31

+

IN MEDICAL

CAREUS 41%MA 99%

TAKING HIVMEDICATIONS

US 36%MA 90%

Viral LoadSuppressed

US 28%MA 72%

Enormous IMPACT of HEALTH

REFORM on PLWH/A in Massachusetts


25/31

+

nWhile HIV Diagnoses increased by 2% nationallybetween 2006 and 2009, there was a 25%

DECREASE in HIV Diagnoses in Massachusetts.

nWhile there was a significant decrease in HIVDeaths during this period (33%), Massachusetts

beat this figure as well 44%)

DIAGNOSIS & DEATHS


26/31

+

Butthechangesin

Massachuseswerealsoverydramacforserviceproviders


27/31

+

nRegional STD clinic closures were completed inJune 2009.

nFour clinics maintained services, including a freeclinic and a fee-for-service clinic. Clinic hours

were reduced hours

nSTD services were transferred to private doctoroffices and clinics

Specialty STD clinics scaled back


28/31

+

nAccessCarenBenefitsofreformarenotuniformnMedicalprovidersmaynothavecapaciestoaddresseligiblepaentcareneeds

nSomepubliccostscannotbeshiedinahealthreformenvironment

nTrainingneedsforclinicalprovidersmaybesignificantasspecializedpublichealthfunconsarepushedintoprimary

carevenues.

nEstablishbaselineandfuturedataneeds,andvariablestotrackimpact

Preliminary Lessons Learned in

Massachusetts


29/31

+

WHATISNEXT?


30/31

Next steps . . . ProvidersofservicesforPLWH/Ashouldadoptthenewtriage

approachtotheirclientsandtheserviceprovided

Everyprovidershouldbuildtheircapacitytoscreenforeligibilityandvigorouslypursueenrollment

ProvidersareWELLADVISEDtobuildtheircapacitytobillMedicaidorother3rdpartypayersforatleastsomeofthe

servicestheyprovide

CurrentRyanWhitefundedserviceswillneedtobeparsedbetweenthosethatarereasonablyaccessiblethrougha3rd

partypayerandthosethatarenot.


31/31

RyanWhitewillcon>nuetobeimportantsourceofcareandservicesformanypeoplewithHIVorAIDS

MostRyanWhiteclientswillhavecoveragebutsllneedtheprogramtocompletetheircare,fillingaps,helpwithcosts.

RyanWhiteprovidesimportantHIV-relatedservicesthatarenotalwaysprovidedbyinsuranceplans

ThosewhoareundocumentedarenoteligibleforMedicaidormarketplaces;Legalresidentshave5yearwaingperiodfor

Medicaid

Next steps . . .

bob bongiovanni presentation on the future of ryan white post aca

Documents