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
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
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.
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
Current State of ADAPs
The National ADAP Budget, by source,
FY1996-FY2013
ADAP Client Utilization
ADAP Client Demographics
ADAP Clients Served, by Race/Ethnicity, June 2013
American
Indian/Alaskan
Native
<1%
ADAP Clients Served, by Gender, June 2013
Multi-Racial
1%
Native
Hawaiian/Pacific
Islander
<1%
Other
1%
Transgender
<1%
Unknown
<1%
Unknown
2%
Asian
2%
Female
21%
Hispanic
27%
Non-Hispanic
Black/African
American
34%
Male
78%
Non-Hispanic
White
33%
ADAP Client Demographics
(continued)
ADAP Clients Served, by Income Level, June 2013
ADAP Clients Served, by Age, June 2013
>64 Years
4%
Unknown
<1%
<12 Years
<1%
13-24 Years
4%
>400% FPL
1%
301-400% FPL
4%
45-64 Years
50%
25-44 Years
41%
Unknown
13%
≤100% FPL
43%
201-300% FPL
13%
139-200% FPL
15%
101-138% FPL
10%
ADAP Insurance Coordination
Clients Served and Estimated Expenditures in Insurance Purchasing and Continuation, 2013
52,568
60,000
$400
50,000
46,653
$397
41,095
$280
40,000
$240
34,341
$268
30,621
30,000
$227
$200
$194
$160
20,960
20,000
12,311
10,000
5,272
-
$19
2002
7,167
$38
2003
2004
$120
$159
$107
7,277
$30
15,843
13,744
$320
$80
$75
$75
$84
2005
2006
$40
$2007
2008
2009
2010
2011
2012
2013
Estimated Fiscal Year Expenditures (in millions)
Number of Clients (June)
$360
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
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
ADAPs in a Reformed Health System
ACA: Three Prongs
Public
insurance
reforms
•
•
•
Private
insurance
reforms
•
•
Health
infrastructure
reforms
Medicaid
expansion
Medicare Part D
reforms
Marketplaces/exchan
ges
Prohibitions on
discriminatory
insurance practices
Investments in
community health
centers, health
workforce,
coordinated care,
and prevention
Recap of 2014 Open Enrollment:
Top Four Challenges and Solutions
Challenges
Solutions
Healthcare.gov has
experienced significant
glitches
Programs worked directly with plans to enroll
clients; urging case managers to build in extra
time to assist clients
Limited coordination between Programs sent clients directly to Medicaid
Marketplaces and Medicaid
In certain states, participation
in ACA enrollment by state
employees is limited or
prohibited
Programs worked with community
organizations and coalitions to coordinate
client education, outreach, and enrollment
efforts
Qualified Health Plan (QHP)
information has been
incomplete or unavailable
Programs have had some success reaching out
directly to plans for information
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
Enrollment into Coverage
Case Study: Ryan White Program
Clients
2014 ACA Coverage Option
Income Eligibility Threshold
ADAP Clients Served, by Income Level (June 2012)
301-400%
FPL
6%
201-300%
FPL
15%
>400% FPL
2%
Unknown
<1%
139-200%
FPL
19%
101-138%
FPL
14%
≤100% FPL
45%
NASTAD Annual ADAP Monitoring Report, January 2013
Medicaid Expansion
Income up to 138% FPL
Advance Premium Tax Credit
for purchase of private
insurance through
exchanges/marketplaces
Income between 100 and
400% FPL (ineligible for
Medicaid or affordable
employer-based coverage)
Cost-sharing subsidies to
offset out-of-pocket costs of
private insurance through
exchanges/marketplaces
Income between 100 and
250% FPL (ineligible for
Medicaid or affordable
employer-based coverage)
Unsubsidized private
insurance coverage through
exchanges/marketplaces
Income below 100% FPL
(ineligible for Medicaid)
Mapping Client Transitions
Uninsured
• Lawfully present
• Income up to 138% FPL
Medicaid
Uninsured
• Lawfully present
• Income 138 - 400% FPL
Subsidized private insurance through
Marketplace
Currently on Medicaid
No transition (except for waiver
beneficiaries)
Currently on other government-sponsored
insurance (e.g., Medicare, TRICARE)
No transition
Currently on or have access to employerbased coverage
If plan is affordable and comprehensive, no
transition
Currently on PCIP or high risk pool
Medicaid or Marketplace coverage
Uninsured and categorically ineligible for
federal programs
No transition
16,000+ ACA-related Transitions
Facilitated by State HIV Programs
VT
WA
WA
ME
ND
MT
NY
MN
OR
WI
SD
ID
MI
WY
NV
CO
AZ
KS
OK
NM
IN
DE
WV
KY
MO
VA
NC
TN
AR
SC
GA
MS
AL
AK
TX
LA
FL
HI
Medicaid
10,282
QHPs
6,647
NJ
OH
IA
IL
CA
CT
PA
NE
UT
NH
MD
DC
Enrollment into Coverage:
Key Dates
Qualified Health Plans
•
Enrollment
Deadline for a
Plan Effective
Date of April 1st
MARCH
15th
•
Enrollment
Deadline for a
Plan Effective
Date of May 1st
Deadline to
switch plans
31st
•
Medicaid
31st
April
PCIPs
•
PCIP coverage
ends
CONTINUOUS ENROLLMENT
2015 QHP Open Enrollment Period
November 15, 2014 to February 15, 2015
Next open enrollment period pushed back
30th
Enrollment into Coverage:
Where States stand on Medicaid
VT
WA
MT
ME
ND
NH*
MN
OR
WI*
SD
ID
WY
NV
PA*
IL
UT
CO
CA
MI*
IA*
NE
IN*
OH
WV
KS
MO
KY
OK
NM
TX
AK
AL
DC
SC
AR*
MS
VA
CT RI
NJ
DE
MD
NC
TN
AZ
MA
NY
GA
LA
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
Enrollment into Coverage:
Medicaid Expansion Options
Traditional Medicaid
State decides to
expand Medicaid
to people with
income up to
138% FPL (Yay!)
How to structure
the expansion??
Alternative Benefits
Plan that could be
different from
traditional Medicaid
Premium assistance
program to purchase
Qualified Health Plans
(QHPs) for Medicaid
beneficiaries
Weighing the Pros and Cons of
Premium Assistance Plans
The Good
Politically feasible way to get state
to expand Medicaid
Reduces churn between Medicaid
and QHPs
May allow access to bigger provider
networks
The Concerns
May weaken Medicaid oversight and
protections
States are using 1115 waivers to ask for even
more flexibility from Medicaid rules
Private insurance is more expensive than
traditional Medicaid, so may be difficult to
show that costs are “comparable”
Enrollment into Coverage:
Mapping ACA Coverage Transitions
Medicaid
Uninsured
• Lawfully present
• Income 100 - 400% FPL
Subsidized private insurance through
Marketplace
Uninsured and in non-Medicaid
expansion state
• Lawfully present
• Income below 100% FPL
Unsubsidized private insurance through
Marketplace
Currently on Medicaid
No transition
Currently on other governmentsponsored insurance (e.g., Medicare,
TRICARE)
No transition
Currently on or have access to
employer-based coverage
If plan is affordable and comprehensive,
no transition
Currently on PCIP or high risk pool
Medicaid or Marketplace coverage
Uninsured & categorically ineligible for
federal programs
No transition
Churning
Uninsured
• Lawfully present
• Income up to 138% FPL
Grantees are defining how to“vigorously pursue” client eligibility for Medicaid
and QHP coverage
Income fluctuations
Enrollment into Coverage:
Addressing Churn
Subsidies to Purchase QHP
(income between 139 and 400% FPL)
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)
Enrollment into Coverage:
The ACA and Immigrants
Lawfully
Present
Medicaid
• >5 years in the country-Eligible
• >5 years in country – Eligible for PTC
o Lawfully present immigrants are
(100-400% of FPL) and Cost sharing
banned from Medicaid
eligibility
subsidy (100-250%
Special
Consideration
for of FPL)
for five years
• <5 years in country- Eligible for PTC
Mixed Status
Families
(0-400% of FPL) and Cost-sharing
subsidy (0-250% of FPL)
• Eligibility
coverage
INDIVUAL MANDATE
APPLIESfor
(with
exceptions as applicable)
•
Not Lawfully
Present
Qualified Health Plans
options and any applicable
Ineligible
• Ineligible for subsidies
subsidies
are
available
for
o Eligible for Ryan White
o Some State HIV Programs have
the lawfully present
had success enrolling
undocumented immigrants for
members of the household
unsubsidized QHPs outside of
the Marketplace
INDIVUAL MANDATE DOES NOT APPLY
Enrollment into Coverage:
Special Enrollment Periods
Trigger Event for Special Enrollment Period
Coverage Effective Date
Loss of minimum essential coverage (NOT due to failure
to pay premiums on time)
First day of month following plan
selection
Gain of dependent through birth or adoption
Day of birth, placement
Gain of an dependent through marriage
First day of month following plan
selection
Change in immigration status to citizen, national, or
lawfully present
Regular coverage effective dates
Unintentional, inadvertent, or erroneous enrollments
Regular coverage effective dates
Substantial violation of contract by insurance company
Regular coverage effective dates
Enrollee is newly eligible or newly ineligible for advance
payments of the premium tax credit or has a change in
eligibility for cost-sharing reductions
Regular coverage effective dates
Permanent moves that create access to new QHPs
Regular coverage effective dates
Certain American Indians may enroll in QHPs one time
per month
Regular coverage effective dates
Exceptional circumstances
Regular coverage effective dates
Enrollment into Coverage:
Individual Mandate Exemptions
Exemption
How to Apply
Below tax filing threshold (about
$10,000 for an individual in 2013)
No need to apply; exemption is automatic
Hardship exemption (includes
homelessness, natural disaster, and
situation where person would have
been eligible for Medicaid state had
expanded)
Marketplace application OR federal tax return
• Note: to be found eligible for the nonMedicaid expansion state exemption, a
person must receive a Medicaid denial.
Unaffordable coverage (defined as
over 8% of household income)
Marketplace application
• Note: a person eligible for an exemption
because coverage is unaffordable based on
expected income may qualify to buy
catastrophic coverage through the
Marketplace.
Short coverage gaps (a gap that last
less than three months)
Federal tax return
Indian Tribes
Marketplace application OR federal tax return
Insular areas and territories
No need to apply; exemption is automatic
Enrollment into Coverage:
Enforcement of the Individual Mandate
SelfAttestation
Marketplace
s
Employers
IRS
Medicare
Medicaid
(including
Advantage
plans)
(including
SCHIP)
Enrollment into Coverage:
Considerations for State HIV Programs
•
Medicaid Outreach and Enrollment Activities
o Document vigorous pursuit of coverage options
• Maintain awareness of client insurance status and
special eligibility opportunities
o Manage client churn
o Advise special clients of special enrollment
periods
 Maintain awareness special and standard
coverage effective dates
• Ensure O&E staff understand coverage options for
immigrants
Insurance Assistance and Premiums
Insurance Assistance and Premiums: :
Top Four Challenges and Solutions
Challenges
Solutions
Issuers in several jurisdictions refuse
to accept third-party premium
payments from Ryan White/ADAP
Multi-pronged state and federal
advocacy
Difficult coordination/communication Develop relationship with QHP
with QHPs for timely submission of
contacts as well as Marketplace
premium payments
Cost-effectiveness models have MANY Utilize NASTAD model; peer models
variables
for assessing cost
Medical co-pays continue to be
barrier to access to affordable care
Work across Ryan White Parts to
identify and fill affordability gaps
Insurance Assistance and Premiums:
Ongoing Challenges
Insurance
Company
Health
Department
Data Sharing
Provider
Insurance Assistance and Premiums:
Health Insurance Literacy
Insurance Assistance and Premiums:
Augmenting Benefits Across Insurance Programs
Types of Insurance
ADAP/Part B
Assists Clients to Purchase
Types of Costs
ADAP/Part B
Covers
Employer-based coverage
Premiums
COBRA
Prescription co-pays and co-insurance
PCIP
Prescription deductibles
State high risk pools
Medical co-pays and co-insurance
Individual plans
Medical deductibles
Medicare Part D
Medicaid
Insurance Assistance and Premiums:
Prescription Drug Formulary
 EHB Standard = same number of drugs per U.S. Pharmacopeia
(USP) category/class as state’s benchmark plan
USP
Category
USP
Class
Anti-viral
NRTIs
NNRTIs
Protease inhibitors
Anti-Cytomegalovirus (CMV)
agents
Anti-hepatitis agents
Other
Missing from USP
classification system =
combination therapies
Insurance Assistance and Premiums:
Assessing Provider Networks
HIV/Ryan White
Providers
• Must include “Essential
Community Providers,”
but plans still vary on
coverage
Pharmacy Network
• Are ADAP pharmacies
(or pharmacies who
will coordinate with
ADAP) included?
• Do network pharmacies
require mail order?
Insurance Assistance and Premiums:
Tax Credits and Cost-Sharing Reductions
Premium Tax Credits
(available to people with
income between 100 and
400% FPL)
Cost-Sharing Reductions
(available to people with
income between 100 and
250% 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
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.
PAYMENT
Cost sharing reductions
mean that plans pay a
greater amount of the
covered costs, taking
that burden off of the
enrollee. The costsharing subsidies are
paid directly to the plan.
ADAP may cover
amount not covered by
federal subsidy.
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).
Insurance Assistance and Premiums:
Tax Credits and Cost-Sharing Reductions
2013
Consumer earns
income and
generates a
modified
adjusted gross
income (MAGI)
for the 2013 tax
year
2014
Consumer
receives
advance
premium tax
credit and cost
sharing
reductions based
on 2013 MAGI
2015
Consumer files
2014 tax return
and reconciles
2013 MAGI with
2014 MAGI –
under/overpayment
assessed by IRS
Leveraging the ACA to Raise the Bars
Leveraging the ACA to Raise the Bars:
Translating Coverage into Care and Treatment
SERVICE
QHP
MEDICAID
RW/ ADAP/CDC
HIV Testing
Continue to cover in
certain settings
RX
Cost-sharing
assistance
MEDICAL CASE
MANAGEMENT
ORAL 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
INPATIENT HOSPITAL
SERVICES
Adapted from West Virginia Ryan White Part B Program
Limited Coverage
Preparing Providers for Health Reform
Relationship
w/safety net
providers
Strategic
planning to
negotiate new
health care
landscape
Local
preparation for
health reform
Preparation to provide
vital enabling services
not covered by ACA
insurance expansion
Preparation for
insured clients
(e.g., billing)
Leveraging the ACA to Raise the Bars:
Translating Coverage into Care and Treatment
90%
82%
80%
66%
70%
60%
0%
Virally
Suppressed
10%
33%
Prescribed
ART
20%
37%
Retained
30%
Diagnosed
40%
Linked to Care
50%
25%
ACA Outreach and Enrollment
Programs and Resources
HIV/AIDS Programs and
Providers
Insurance
Assisters
Patient
Navigator
Program
Certified
Application
Counselors
Consumer
outreach
and
enrollment
Community
Health
Centers
Enroll
America
Breaking Down Program and Service Silos:
Coordinated Care Opportunities through the
ACA
Coordinated Care Opportunities
Contracting arrangements
Medicaid Health Homes
-
-
Targets populations with
chronic conditions,
including HIV
Between support services
providers and medical
providers
Capitated payments
-
Starting to include
support services
Patient Centered Medical
Homes
Quality and access measures
-
-
Certification emphasizes
whole-person care and role
of vital enabling services in
improving health
outcomes
-
Include HIV quality
measures
Emphasize care
coordination
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
Questions and Answers
Contact Information
Emily McCloskey
Manager, Policy and Legislative Affairs
NASTAD
Phone: (202) 434.8090
emccloskey@NASTAD.org
www.NASTAD.org