PAST, PRESENT & FUTURE OF THE RYAN WHITE PROGRAM

Federal AIDS Policy Partnership

US Conference on AIDS

September 10, 2013

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

ACA RW Cross WalkSERVICE QHP MEDICAID RW PART B / ADAP

RX Cost-sharing assistance

MEDICAL CASE MANAGEMENTORAL HEALTH

LABS Cost-sharing assistance

MENTAL HEALTH SERVICES

Cost-sharing assistance

SUBSTANCE ABUSE TREATMENT

Cost-sharing assistance

HIV PRIMARY CARE Cost-sharing assistance

MEDICAL TRANSPORTATION Limited CoverageINPATIENT HOSPITAL SERVICES

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

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

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

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

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

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

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

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

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

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