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ADAP ADVOCACY
ASSOCIATION
PRESENTATION
Monday August 4, 2014
Denver Digital Photography
Transitioning ADAP
Clients to Medicaid
& Marketplace
Plans:
The Colorado
Success Story
Todd Grove
Colorado Department of Public
Health & Environment –
AIDS Drug Assistance Program
Rich Wolf Digital Photography
FEDERAL HIV AIDS RESOURCES
Health Resource Services Administration
HIV/AIDS Bureau (HRSA- HAB)
Ryan White Treatment Extension Act of 2009
RYAN WHITE CARE ACT
PART A
PART B
PART C
EMAs -TGAs
States and Territories
Denver Mayor's
Office of HIV Resources
ADAP & Base Funding
State of CO -CDPHE
Infectious Disease Clinics
Beacon, Denver,
Pueblo Comm., St. Mary's
PARTS D-F
WICY-DENTAL
SPNS
Children's University Hosp.
Other Federal and State
Programs
•Medicaid
•Colorado Indigent Care Program (CICP)
•Medicare
•Tobacco class action lawsuit funds
Minority AIDS Initiative
PARTS A B C
Part B- ADAP outreach
Part A- Sub. abuse, mental health
Colorado AIDS Drug Assistance Program
Cost & Clients Served -2013
HMAP … 2,039 enrollees – 42,150 prescriptions $12,571,539.58*
BTGC … 869 enrollees - 26,189 prescriptions $1,320,628.07*
HIAP … 690 – 10,887 prescriptions $1,022,003.61*
$1,125,840 premiums, deductibles and co-pays
Data provided by Colorado Department of Public Health & Environment
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What makes Colorado unique, (and
may make duplication difficult)
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Colorado had the nation’s largest
ADAP waitlist in 2004
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315 people
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Provided only 18 drugs (strictly
ARV)
Advocacy resulted in over $1
million in General Funding and
over $3 million in tobacco class
action lawsuit funds per year
Legislation allowed for ADAP
committee to direct $$, with
approval of the Medical Director

Allowed for innovative use of
monies:
 Creation of a Medicare State
Pharmaceutical Assistance
Program
 Reimbursement of insurance
premiums, as necessary
 Payment of inpatient medical care
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HIV incidence in Colorado is
“moderate” and efforts would be
extremely difficult to emulate in
higher incidence states, particularly
those without local funding of any
sort / states that did not expand
Medicaid
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Colorado’s decisions related to the
Affordable Care Act
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Expanded Medicaid (including
AwDC) to 133% of Federal
Poverty Level –MAGI
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Created an effective state-based
insurance marketplace w/
improved Medicaid interaction
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Supportive environment for
enrollment outreach
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Democratic Governor
Denver Digital Photography
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Democratic majorities in both
State House and Senate
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Colorado’s efforts to transition
enrollees to ACA plans
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Became a non-funded partner of
Health Coverage Guide network
sanctioned by the marketplace
“Connect for Health Colorado”
Paid for 14 individuals during open
enrollment to enroll members in
Medicaid, or ADAP-approved
marketplace insurance plans with
complete ADAP wrap-around
Identified Medicaid-eligible
members on Health Insurance
assistance to transition to Medicaid
(waiver offered)
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Co-located staff at larger HIV clinics
to apply patients for Medicaid online
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Purchased IT to allow Health
Coverage Guides to patient homes or
other locations to facilitate
enrollment
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Completed multiple attempts to
outreach to members
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Required a formal request to remain
uninsured if they refused
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Considering “off-marketplace”
insurance options for undocumented
patients next year
+25,000+ 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
NJ
OH
IA
IL
CA
CT
PA
NE
UT
NH
IN
DE
WV
KY
MO
VA
NC
TN
AR
MD
DC
SC
GA
MS
AL
AK
TX
LA
FL
HI
Medicaid
13,000
QHPs
12,500
Source: NASTAD
**Through end of
March 2014
Colorado ADAP / Insurance Status after
Implementation
10
2,100 individuals
300 individuals
1,181 insured patients
1,390 Medicaid /SWAP members
400 new HIAP members
110 new HIAP members
Ryan White Case Management Roles and Duties
CDPHE ADAP Office and Denver CAP for HIAP
CDPHE, DCAP,
ADAP OFFICE
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Program management
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Financial management
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Eligibility and enrollment verification
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Auditing/quality assurance
Social Workers, Medical & Non- Medical Case Managers
AIDS Service
Organizations &
Social Service
Entities
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All program areas
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Eligibility and enrollment assistance
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Trouble shooting and client support
Health Insurance Assistance Program Coordination
HIAP
Coordination
Entities
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Located at BCAP, DCAP, NCAP, SCAP & West CAP
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Coordination of premium, co-insurance, and co-payments
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No requirement for case management (can remain with other ASOs)
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Coordination of enrollment into marketplace by Health Coverage Guides
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Health Insurance Assistance
Program (HIAP)
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Wraps around employer, COBRA, and ACA marketplace insurance plans
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Pays remaining costs of marketplace insurance after the APTC and Cost
sharing assistance available has been applied
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Pays premiums, medical and pharmaceutical deductibles, co-pays, and
coinsurance
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Up to $10,000 in aggregate per client
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Works with providers who are willing to bill for services
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Pays for prescriptions through a Medication Assistance Card.
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Assistance in enrollment through Connect for Health Colorado marketplace
Insurance Enrollment Sites
Boulder County AIDS Project
Colorado AIDS Project
Northern Colorado AIDS Project
Southern Colorado AIDS Project
Western Colorado AIDS Project
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Supplemental Wrap Around Program (SWAP)
•
New ADAP program to cover all Medicaid-eligible clients
with medication co-pay coverage for ADAP formulary
•
Members will be able to use many more pharmacies if they
choose (rather than 4 previous ADAP pharmacies)
•
Recertification process easier (as member would have been
screened eligible for Medicaid) = eliminates need for
supporting documentation – income, residency.
•
ADAP suggests that patients continue to use HMAP network
pharmacy at least at first - easy movement to HIAP, or to
HMAP if “churning” is an issue – allows for back-billing.
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The problem of “CHURN”
Problems presented by loss of
Medicaid
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Loss of Medicaid may mean up to
45 days until access to insurance is
established;
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Enrollees can receive medication
assistance for ADAP formulary
drugs only through that time
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May not qualify for CICP or the
facility may not offer CICP
Problems presented by loss of job/
eligibility for marketplace insurance
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Enrollees often fail to notify
ADAP of change in situation
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Enrollees need to notify
marketplace of change in income
affecting eligibility; tax penalties
and credits difficult to manage by
the program
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Enrollees may not be able to
access same providers under
Medicaid, or may have a waitlist
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How to improve % of clients who
recertify every six months
Implications of not recertifying
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Can’t get medications, (missed
doses, would have to pay own costs)
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HIAP can’t pay premiums or pay
medical co-pays until recertification
is complete
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Medicaid and marketplace may not
be told of changes of income – affect
eligibility and APTC/ cost sharing
Patients are used to being able to
miss recertification and rectify the
situation with relative ease
Benefits to enrollee
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Colorado is working on a system
where recertifying with ADAP
would make individuals recertified
for all Ryan White services
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With a loss of Medicaid or
insurance temporarily, enrollees
can get medication through HMAP
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Members can get assistance in
enrolling in the proper assistance
program
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Instituting text message reminders
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Significant financial effect already:
UNINSURED PATIENTS
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From an average of 1,300 patients
provided direct medications in fall
2013, the average has dropped to
300 (largely categorically
ineligible for Medicaid or
insurance, or CHURN members)
INSURED PATIENTS
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Increased budget for Health
Insurance by close to $2 million
dollars
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Much smaller investment required
for Medicaid wrap -around
From over $1.2 million in costs,
estimates after back-billing to
Medicaid are $300,000 in expenses
per month.
Denver Digital Photography
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Net effect & concerns:
REBATE INCOME
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Robust application for partial pay
rebates have provided significant
program income
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HRSA requires states to spend
rebate income BEFORE Ryan
White dollars
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Results in large unexpended
balance that may be “carried
forward”, but will return to HRSA
for redirection to other states if not
spent in time
IMPLICATIONS of lost income
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While morally correct to do so, any
change in ability to apply for
rebates would cause huge decrease
in revenue…and lost Ryan White
dollars would be desperately
needed again
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Successful management of Ryan
White and funding offered by
individual states will be redirected
to states who refuse to expand
Medicaid or invest in the epidemic
in their own states
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Innovations to “Get to Zero”
PREVENTION and CARE
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Prevention planning to include
discussion of biomedical
components such as nPEP and
perhaps even PrEP
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Prevention planning may include
targeted $ resources to assist high
risk HIV – individuals to seek
behavioral health interventions and
other preventative financial
assistance
Denver Digital Photography
HIV Care Continuum as of December 31, 2013, Colorado
100%
100% of PLWH
90%
80% of PLWH
80%
73% of PLWH
70%
60%
65% of PLWH
7,689
50%
6,188
40%
5,610
4,968
30%
20%
10%
0%
People who have lived with
diagnosed HIV infection for at
least 12 months in Colorado with
laboratory evidence of medical
care in the last 5 years*
* Data
At least one care visit past year
Engaged in care or virologically
suppressed past year**
Virologic suppression***
source: Enhanced HIV/AIDS Reporting System (eHARS). Defined as persons diagnosed with HIV infection (regardless of stage of disease)
through year- end 2012, who were alive at year-end 2013.
**Data source: CDPHE's CD4/VL database and eHARS. Calculated as the percentage of persons who had ≥2 CD4 or viral load results at least 3 months
apart during 2013 among those diagnosed with HIV through year-end 2012 and alive at year-end 2013 or as the percentage of persons who were
virologically suppressed at the time of their last lab during 2013, but did not have any additional lab >90 days away from this during 2013.
*** Calculated as number of persons who had suppressed VL (<=200 copies/mL) at most recent test during 2013, among those diagnosed with HIV
through year-end 2012 and alive at year-end 2013.
Continuum of Care – Picture for ADAP Members
The post-ACA approach to HIV care:
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Focus on services that are proven to help people move through
the cascade toward viral suppression
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If a person is eligible for Medicaid, Medicare, or commercial
insurance, the Ryan White Program is required to “vigorously
pursue enrollment “ of the person in these types of coverage
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If there is a service that would help move people through the
cascade but cannot be funded from a third party payer, Ryan
White funding can be used to pay for that service.
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Monitor how well the entire system of care is assisting with
achievement of viral suppression, not just the long-standing
Ryan White system.
Helping People Move
Through the Cascade
Achieve Viral
Suppression
Retained
in Care
Linked to Care
First Diagnosis with
HIV
The Process is NOT Linear
Linked to Care
Retained
in Care
First
Diagnosis
with HIV
Re-Engaged
Achieved Viral
Suppression
Lapsed in Care
Ryan White services are
critical to engagement in care
ADAP Advocacy Association
Jeffrey S. Crowley
Distinguished Scholar/
Program Director, National HIV/AIDS Initiative
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Innovation in the use of DIS, LTC
and RTC personnel
PROVIDE RESOURCES AS
NECESSARY to ensure successful
linkage to care and treatment
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Disease Investigation Specialists –
immediate linkage to enrollment
services in ADAP, Medicaid, and
Ryan White $$ when a patient has
not enrolled in coverage
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Linkage to Care – in addition to
above, assessment of substance
abuse, mental health issues, and
access to resources through
“Critical Event” pilot (described
later)
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Retention in Care personnel from
State Health & partner agencies
reviewing patients who appear to
have dropped out of care, again,
with $$ resources to assist –
including housing, inpatient mental
health and substance abuse
treatment, medical transportation –
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Critical Event Initiative
What is a “critical event”?
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An event that makes it much more likely a client will drop out of medical
care or never seek medical care to begin with.
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A “marker” for a destabilizing crisis.
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A severe challenge to a client who wants to achieve and maintain viral
suppression.
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CE is an enhancement
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Focused on short term stabilization (<90 days)
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More structured approach to submitting and approving requests
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Expedited and simplified for clients
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Focused on clients at greatest risk of not achieving viral suppression
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Uniform eligibility and assistance statewide
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Coordinated across agencies and providers
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Is not affected by funding shortages at local agencies
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Two Targets for the Pilot
Newly
diagnosed with HIV
 (within
Recently
the prior 90 days)
lapsed in care
 (within
the prior year)
+ Critical Events for the Pilot
Recently homeless (within
prior 90 days)
 Recently unemployed (within
prior 90 days)
 Diagnosed with gonorrhea,
syphilis, or chlamydia (within
prior 180 days)
 Worsening health status due to
hepatitis C (within prior 180
days)
 Named as a partner, potentially
infected someone with HIV
(within prior 180 days)
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Domestic violence (within
prior 180 days)
 Diagnosed with another acute
illness requiring complex
medical treatment or
hospitalization, such as cancer
(within prior 180 days)
 Evidence based screening
shows potentially severe
addiction or drug dependence.
 Evidence based screening
shows potentially severe
mental illness.
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Additional protocol provisions
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Clients with multiple critical events prioritized higher than clients
with a single critical event.
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State health staff and community agencies use same data system to
track requests, plans, budgets, client progress, and case closure
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The process starts with a “CE Form” submitted by state health staff or
contractor
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Evaluation of requests coordinated by a state health staff person
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Each request has a “sponsor” at state health
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How is CE different from the support already available
to clients?
Existing Public Health Order (PHO)
Process
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Existing processes for housing, EFA, etc.

Clients experiencing critical events use
the “standard” process to request
assistance.
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Only a small range of critical events
are related to a PHO.
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Enhanced services are offered in lieu
of, or as part of, a public health
order.

Different levels of assistance and FPL
eligibility based on place of residence
(TGA)
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If the client is determined not to
meet PHO criteria, no enhanced
services are offered.
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Less involvement of community
contractors
Data sharing issues being addressed by
statewide taskforce – would those in
need want to identify themselves to
state health for fear of incrimination or
disease investigation concerns?
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Questions
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Contact information:
Todd Grove ADAP Coordinator
Rich Wolf Digital Photography
Colorado Department of Public Health & Environment
303-692-2783
todd.grove@state.co.us
www.colorado.gov/pacific/cdphe/services-people-hiv
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