Medicaid Expansion in the
District of Columbia
November 27, 2012
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
Background
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
2
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
Unique Environment
Grants
• Multiple Federal Grants
• CARE Act Part A $31.2 Million
• CARE Act Part B $20.2 Million
• HOPWA
$13.6 Million
• Multiple Federal Footprints
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Unique Environment Geography
• Part A
• Part B
• HOPWA
• CDC
DC
VA
MD WVa
X
X
X
X
X
X
X
X
x
x
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Unique Environment
DC
Department of Defense Drug Price
• Available to all ADAP
• Requires
• Centralized Purchase
• Centralized Delivery and Re-
Distribution
• Replenishment, not Reimbursement
• Low Prices
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Unique Environment
DC
• Robust Medicaid
• All FDA-Approved Medications
• Wide Range of Specialty Benefits
• 1115 Medicaid
• Cost Neutrality by DOD Drug Prices
• Applied to
• HIV Anti-Retrovirals
• Medicaid Fee-for-Service Clients with
HIV
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Unique Environment Alliance
• DC Locally Funded Health Insurance
• Eligible Residents
• Income Less than 200% FPL
• Not Medicaid Eligible
• “Carve Out” for HIV Anti-Retrovirals
• Forty Percent of ADAP Beneficiaries
were Alliance Enrollees
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Medicaid Expansion
DC
• Eligibility 133% FPL
July 1, 2010
• End of 1115 Waiver Sept 30, 2010
• Eligibility 200% FPL
Dec 1, 2010
• Alliance Enrollment Decreases
In the District of Columbia
• Adults with Coverage
• Children with Coverage
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
93%
96%
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Medicaid Expansion
ADAP Beneficiaries (Approx)
• Before Medicaid Expansion
• Enrolled into Medicaid
• Served (Monthly Avg)
• “Traditional” ADAP
• ADAP for Co-Payment
or Deductibles
ADAP
2,000
1,235
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
700
275
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Medicaid Expansion
ADAP
Implications
• Substantial Cost-Shifting from ADAP to
Medicaid
• Cost to the District of Columbia
• Increased for Drugs
• Decreased Cost for Primary Care,
Inpatient Care
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
11
Medicaid Expansion
ADAP
Implications for Pharmacy Points of Sale
• Revitalized Pharmacy Network
• Re-Framed Drug Assistance Program
• Single Standard Regardless of
Funding Source
• Increased Efficiency
• Reduced Costs
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Medicaid Expansion
Next Steps
• Medicaid Managed Care Organizations
• Provide Drugs through DOD Pricing
• 3,200 Beneficiaries
• Effective January 2013
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
13
Medicaid Expansion
Implications for Primary Care
• Little Disruption in Service Providers
• HIV Primary Care Providers
Supported by CARE Act, Medicaid
and Alliance
• Increased Emphasis on Health Care
Financing
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Medicaid Expansion
Implications for Support Service
Providers
• Increases Emphasis on Demonstrating
Health Outcomes
• Enhances Need for Coordination,
Collaboration and Partnership
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Medicaid Expansion
Financing Health Care
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Payor of Last Resort
• Core Requirement of the CARE Act
• Ensures All Other Payor Sources Used
• Some Exceptions
• Indian Health Service
• Veterans
• Competing “Payor of Last Resort”
Provisions, e.g., FQHC
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Payor of Last Resort
• Familiarity with Third Party Payor
•
Systems and Benefits
• Medicaid
• Medicare
• Indian Health Service
• Alliance
Ensure Clients are
• Screened
• Enrolled if Eligible
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Payor of Last Resort
• Ensure Claims are
• Billed
• Collected
• Returned as Program Income
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Payor of Last Resort
• Past Practices
• Parallel Systems of Care
 CARE Act Clients
 Medicaid Clients
• Fee for Service Reimbursement for
CARE Services
 Coding
 Cost Recovery
 Adoption of Medicaid Rates
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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“Whole Program”
• Allows a Single Standard of Care
•
•
•
without Regard to Funding Source
Maximizes Flexibility of Funding to
Support Whole Program
Requires Different Reimbursements
• Third Party
Fee-for-Service
• CARE Act
Cost Reimbursement
Results in Program Income
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Program Income
• Income Generated by Funded Program
• Third Party Payment
• Client Fees or Client Contribution
• Required
• Demonstrated Benefit the HIV
•
Program
Track and Report Monthly
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Program Income
•
•
•
Example
CARE Act Sub-Grant for Outpatient
Ambulatory Care
• Cost Reimbursement
• Pays Salaries
Salaried Staff
• Service Unit Paid by Medicaid
Medicaid Reimbursement is Program
Income
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Program Income
•
•
May Be Used in Ways Not Permitted
for CARE Act Funds
• Occupancy Costs
• Administrative Costs
• Drug Costs for non-HIV Conditions
Competing Federal Guidance
• Multiple Parts of CARE Act
• Federally Qualified Health Centers
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Whole Program
Medical Home
• Program Income Can Support “Medical
Home” Activities
• Ensuring Linkage from Testing
• Re-Engaging Lost-to-Care Clients
• Targeted Support for High-Need
Clients
• Liaisons with Support Organizations
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Prospects
• Single System of Services
• Consistently High Standards of Care
• Supported by Multiple Funding Sources
• Organized around Client Need
• Achieved through Dynamic
Partnerships
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Questions and Discussion
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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Contact Information
Gunther Freehill, Chief
Care, Housing and Support Services Bureau
HIV/AIDS, Hepatitis, STD and Tuberculosis
Administration (HAHSTA)
899 North Capitol Fourth Floor
Washington, DC 20002
Phone: 202/671-4900
Fax:
202/671-4860
E-mail: Gunther.Freehill@DC.Gov
Government of the District of Columbia, Department of Health
HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA)
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