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THE AIDS INSTITUTE
The AIDS Institute
HEALTH REFORM AND ADAP
Emily McCloskey, Public Policy AssociateCarl Schmid, Deputy Executive DirectorAIDS Drug Assistance Program Summit
Washington DCJuly 6, 2010
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The AIDS Institute
• Should greatly positively impact people with HIV/AIDS, including ADAP
• Most changes not implemented until 2014
• Overview• Components of health reform that will impact
ADAP
• What we need to do between now and 2014
• Post 2014 environment
Health Reform & ADAP
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The AIDS Institute
Health Reform• Health Coverage will be mandated
• Provide an estimated 32 million additional people with health care coverage
• Medicaid Expansion• Exchanges
• Private health insurance reform
• Medicare Part D reforms
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The AIDS Institute
Medicaid Expansion
• Medicaid Expansion for People with Incomes less than 133% federal poverty rate (beginning in 2014)
• Removes the disability requirement
• +16 million people• Including many Ryan White ADAP clients
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The AIDS Institute
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The AIDS Institute
Medicaid Expansion
• Federal Share 100% in 2014-16, phase down to 90% in 2020
• State Option to Expand Medicaid Now• But no increased Federal Match
• CT only state that has done this
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The AIDS Institute
Medicaid Expansion
• Standard Benefit for those who are newly eligible
• Not for Current Beneficiaries
• States key to Implementation• Drugs Included, but will there be limits, costs?
• State variation will continue
• Ryan White can wrap around and fill in the gaps
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The AIDS Institute
Closes the Medicare Part D “Donut Hole”
• 2010-Everyone who reaches the Donut Hole will receive a $250 rebate
• 2011-receive a 50% discount for brand name drugs while in the donut hole
• Each year, the “donut hole” will be incrementally closed for both brand and generic drugs
• By 2020-“Donut hole” closed, but beneficiary still responsible for 25% co-pay
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Post-Reform Medicare Part D Coverage: The Donut Hole in 2020 (brand-name)
$0- $310
Consumer Pays
Deductible“Donut Hole”
CoverageGap
Total Spending
≈ 95%
80% Feds Pay Reinsurance
15% Plan Pays
Catastrophic Coverage
Federal Government Pays
75% Plan Pays
25% out-of-pocket5% out-of-pocket
Private plan Pays
$630 $3,610Consumer
Out-Of-Pocket
$310
Total consumer out of pocket = $4,550
$2,830 -$6,440$310-$2,830
Total consumer out of pocket = $2,143
$1,203
- $7,643
50% ManufacturerDiscount as TrOOP
25% out-of-pocket
25% Plan Pays
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The AIDS Institute
ADAP Expenditures Count towards TrOOP
• Beginning in 2011, ADAP expenditures can count towards True Out of Pocket Expenses (TrOOP)
• High Priority Issue for Community
• Will help Medicare Part D Beneficiaries who are on ADAP
• Will help state ADAP budgets go further
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The AIDS Institute
Medicare Part D Impact on ADAP
• Allowing ADAP to count as TrOOP and closing the Donut hole will positively impact ADAP
• Only for those ADAP clients who are also eligible for Medicare
• 16% of ADAP clients or 17,000 clients (NASTAD)
• Ryan White can fill in the gaps• State decision
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The AIDS Institute
State High Risk Pools• Provides coverage to those with a pre-existing condition & no coverage for last 6 months
• Must have had a problem getting insurance due to a pre-existing condition
• Coverage begins August 2010, runs through 2013
• State can set up, or HHS will
• Enrollees receive both health care and treatment
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The AIDS Institute
State High Risk Pools• Premiums will vary state to state
• For a 50 year old enrollee, premiums could range from $3840 to $6840 annually.
• $5 billion• Not a sufficient amount – Medicare economists estimate the program could run out by 2011.
• Coverage Estimates: 200,000-400,000 people
• Less than 10 percent of people with pre-existing conditions
• Unknown how many people with HIV/AIDS will be included
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The AIDS Institute
Insurance Reform• Beneficiaries can not be removed from a plan
• Checks on Rate Increases
• Prohibition on life-time limits
• No discrimination based on pre-existing conditions (beginning in 2014 for adults)
• Cap on out-of-pocket expenses (beginning in 2014)
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The AIDS Institute
Insurance Reform & ADAP
• Private Insurance Reforms should avail more people with HIV/AIDS to access private insurance
• Will relieve some burden on Ryan White and ADAP
• Ryan White can wrap around and fill in gaps
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The AIDS Institute
Exchanges
• Private Exchanges Created at the State Level (beginning in 2014)
• +24 million people
• 4 Tiers of Coverage
• Subsidies for up to 400% of FPL
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The AIDS Institute
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The AIDS Institute
Exchanges• Impact on ADAP
• Non-medicaid eligible people with HIV/AIDS with income under 400% FPL, without Private Insurance, must be in Exchanges
• Some with private insurance will switch to exchanges
• Exchanges will offer Drug Coverage, but do not know limits and co-pays• Ryan White can wrap around, pay co-pays
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The AIDS Institute
Between Now & 2014• Most Coverage Expansion Begins in 2014
• Until then, Ryan White will remain the safety net for people with HIV/AIDS
• A few clients moved to High Risk Pools
• Work on Benefit Design• Medicaid-federal/state level• Exchanges-federal/state level
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The AIDS Institute
2014 & Beyond• Beginning in 2014 should see a shift of Ryan White patients to Medicaid & Exchanges
• Ryan White should help clients enroll
• Ryan White can pay for costs and cover drugs that are not covered by Medicaid & Exchanges
• Ryan White can provide care & treatment to those not covered by Health Reform (e.g. The undocumented)
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The AIDS Institute
2013 Reauthorization of Ryan White• Will have to defend future of the Program
in light of Health Reform before it is fully implemented
• Community is having Discussions to discuss long term
• Short term will be working on • Health Reform Implementation • Ensuring Adequate funding for ADAP and the entire Ryan White Program
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THE AIDS INSTITUTE
The AIDS Institute
THANK YOUEmily McCloskey -
[email protected] 202-835-8373
Carl Schmid - [email protected] 202-462-3042