Plan Assessment and Enrollment:
Considerations for HIV/AIDS Programs
Amy Killelea Britten Pund
August 21, 2014
Xavior Robinson
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Webinar Etiquette
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 Written Questions
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 Evaluation
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Presentation Outline
1. Introduction
2. Plan Assessment Considerations
– Cost
– Formulary
– Provider and pharmacy networks
3. ADAP Insurance Cost Effectiveness Model
4. Questions
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HRSA/HAB Policies and ADAP
Insurance Purchasing
 HRSA encourages state ADAP/Part B Programs to use their Ryan
White funding to help clients access insurance, as long as:
– Formulary includes at least one drug in each class of core ARVs from the HHS Clinical Guidelines
– It is cost-effective in aggregate as compared to purchasing medications
 Other Ryan White Program grantees may also use their funds to help clients with the cost of insurance
 The Ryan White Program is the payer of last resort and grantees must “vigorously pursue” client eligibility for public and private insurance
– Grantees may not dis-enroll clients from services for failure to enroll in public or private insurance coverage
 Ryan White Program funds may be used to cover services not covered or inadequately covered by public and private insurance
 HRSA is considering allowing ADAP insurance purchasing programs to cover client tax liabilities associated with an overpayment of the
PTC 4

Top Three Plan Assessment
Challenges in Year One
Strategies Challenges
Healthcare.gov and some statebased Marketplaces experienced significant glitches
CMS has invested significant resources into improving the performance healthcare.gov. A number of statebased Marketplaces are also trying to make improvements.
Qualified Health Plan (QHP) information was unavailable, inaccurate, or incomplete
QHP formulary, and provider and pharmacy networks information were not plan-specific
Final QHP application submissions are due on 9/4/14. Certification notices and QHP agreements are scheduled to be signed by 11/3/14
Provider networks and formularies must be directly linked to in the
Marketplace, and be plan-specific
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Cost Considerations
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Cost Considerations
Premiums
Monthly payment to plan
Out-of-pocket costs
Deductibles
Copayments
Coinsurance
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Navigating the Marketplace
Web Portal
Exchange/Marketplace Portal
Medicaid
Qualified Health Plan (QHP)
Federal Subsidies for Private
Insurance:
• Premium Tax Credits
• Cost-sharing reductions
Federal Data Services Hub
• SSN verification via SSA
• Citizenship and immigration status via DHS
• Incarceration verification via SSA
• Title II benefits information via SSA
• MAGI income from IRS
Apply for coverage through
Marketplace
Screen for
Medicaid and subsidy eligibility
Evaluate QHP options
Select QHP
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Pay first month’s premium

ACA Affordability Provisions
 Three ACA provisions that make insurance more affordable:
– Premium tax credits
 Available to people with income 100-400% FPL who have no other public or affordable employer-based coverage
– Cost-sharing reductions
 Available to people with income 100-250% FPL who have no other public or affordable employer-based coverage
– Out-of-pocket caps
 2015 maximum amounts: $6,600 individual/$13,200 family
 Applies to all Essential Health Benefits (medical AND pharmaceutical benefits)
 Only applies to in-network services
 Applies to ALL non-grandfathered private insurance plans
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Premium Tax Credits: How They Work and Program Considerations
 Premium Tax Credits for the vast majority people with income between 100 and 400% FPL
 Tax credit = difference between benchmark premium and taxpayer ’ s expected contribution
– Expected contribution based on annual income and increases from 2% of income to 9.5% as income increases
– Consumer may choose to take credit in advance instead of as tax refund
– Consumer responsible for overpayment at tax time
 Programs should consider:
– Requiring clients to take full amount of tax credit in advance
– Directing clients to tax preparation resources
– Aligning income criteria and verification with MAGI
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Premium Tax Credits: How They Work and Program Considerations
2014 2015 2016
Consumer earns income and generates a modified adjusted gross income (MAGI) for the 2014 tax year
Consumer receives advance premium tax credit and cost sharing reductions based on 2014 MAGI
Consumer files
2015 tax return and reconciles
2014 MAGI with
2015 MAGI – and under-
/overpayment assessed by IRS
Consumers must report changes in income to the Marketplace throughout the year!
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Cost-Sharing Reductions
 Cost-sharing reductions (CSR) for people with income between
100 and 250% FPL
– Increases actuarial value to reduce member contribution
– Only available if person enrolls in a SILVER LEVEL plan
Household
Income
AV Level
(Silver Level
Plans)
AV
Requirement w/CSR
Reduced OOP
Maximum
Plan Designs
100-150% FPL 70%
150-200% FPL 70%
200-250% FPL 70%
94%
87%
73%
~$2,250
~$2,250
~$5,200
Deductible
Copays
Coinsurance
Deductible
Copays
Coinsurance
Deductible
Copays
Coinsurance
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Assessing QHP Metal Tiers and OOP Plan Costs
QHP Metal
Tiers
Bronze
Silver
Gold
Platinum
What It Means
Plan pays 60% of costs (on average)/enrollee pays 40%
Plan pays 70% of costs (on average)/enrollee pays 30%
Plan pays 80% of costs (on average)/enrollee pays 20%
Plan pays 90% of costs (on average)/enrollee pays 10%
Lower premiums, but less generous
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Higher premiums, but more generous

OOP Costs In Action
Consumer pays 100% of costs until hit deductible
In-network
Out-ofnetwork
Deductible OOP Cap
$1,500
$5,500
Consumer pays co-pays, co-insurance
$6,600
No cap
Once consumer hits
OOP cap (for innetwork services) plan pays 100% of costs for rest of year
Primary
Care Visit
$25
50%
Specialist
Visit
$100
50%
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Client Archetypes:
Meet Julie and Murray
Julie
Age: 30
MAGI:$34,470
FPL: 300%
Resides in Camden, NJ
Murray
Age: 30
MAGI:$17,235
FPL: 150%
Resides in Newark, NJ
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Affordability Screenshot
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The OOP Max for 2015 is
$6,600 for individual coverage. Plans have the options of having a reduced OOP Max
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So which plans are the best fit for Julie and Murray?
Metal Level Monthly
Premium
Silver
Gold
Platinum
$50
$105
$294
Deductible Out-ofpocket
Maximum
$100/year $700
Specialist
Doctor Visit
$2,000/year $4,650
$0/year
$30
$30
$4,500/year $25
Metal Level Monthly
Premium
Silver
Gold
Platinum
$266
$321
$510
Deductible Out-ofpocket
Maximum
$2,000/year $6,350
Specialist
Doctor Visit
$35
$2,000/year $4,650
$0/year
$30
$4,500/year $25
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Summary of Cost Considerations for HIV Programs
 Require clients to take full amount of tax credit in advance
 Direct clients to tax preparation resources
 Align income criteria and verification with
MAGI
 Remind consumers to report changes in life circumstance throughout the year
 Preference for silver level plans for clients eligible for cost-sharing reductions
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Formulary Considerations
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Evaluating Scope of Coverage:
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
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Comparing Formularies Across Plans
Julie
• Treatment regimen:
 Prezista
 Norvir
 Truvada
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Utilization Management
Techniques
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Utilization Management
Noun.
set of techniques used by or on behalf of insurance carriers to manage the cost of health care before its provision by influencing patient-care decision making through case-by-case assessments and/or procedures of the appropriateness and cost of care based on accepted practices
Examples Include:
1. Quantity Limit
2. Prior Authorization
3. Step Therapy
4. Provider Prescribing Limits
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Assessing Formulary Affordability:
Silver vs. Platinum
Platinum Plan
Silver Plan
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Copayment vs. Coinsurance
Copayment
A copay is a fixed amount paid whenever a particular type of healthcare service or prescription drug.
Coinsurance
The consumer pays a percentage of the cost of a healthcare service or prescription drug.
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Putting It Together:
Premium Costs and Formulary Affordability
Prescription
Drug
Julie’s Platinum Plan Option
Tier Utilization
Management
Deductible Cost-sharing Maximum
Annual Cost
$40/month $480 Prezista 2 Prior Authorization,
Quantity Limit,
Specialty Formulary
0
Truvada 2
Norvir 3
Subtotal Drug Costs
Annual QHP Premium
Total Annual Premium and Drug Costs
0
0
$40/month $480
$50/month $600
$1,560
$3,528
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$5,088

Putting It Together:
Premium Costs and Formulary Affordability
Prescription
Drug
Prezista
Julie’s Silver Plan Option
Tier Utilization
Management
Deductible Costsharing
(50% after deductible)
2 Prior Authorization,
Quantity Limit,
Specialty Formulary
$2,000 $320/
Month
Maximum
Unadjusted
Annual Cost
$3,840
Truvada
Norvir
2
3
$2,000
$2,000
$320/
Month
$400/ month
$3,840
Subtotal Drug Costs ( Adjusted for OOP Maximum)
Total Annual Premiums Costs
Total Annual Premium and Drug Costs 30
$4,800
REMINDER:
$6,350
Costs = $5,088
$3,192
$9,542

Formulary Considerations
 Prioritize plans that cover the consumer’s existing medications regimen
– Including single-tablet regimens
– Assess formulary exceptions processes
 Investigate the utilization management techniques that are in place
 Prioritize low-deductible plans with co-payments instead of co-insurance
 Weigh premium cost against out-of-pocket maximums, deductibles, and cost-sharing
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Provider and Pharmacy Network
Considerations
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Assessing Provider and
Pharmacy 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?
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Mail-Order Pharmacy Considerations
Some QHPs rely heavily on mail-order pharmacies to provide prescriptions. Mail-order pharmacies may have issues coordinating with third party payers such as ADAPs.
Considerations Include:
– Plan opt out provisions
– State laws requiring an opt-out
– Pending litigation (e.g. United settlement)
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Dates to Consider for Plan Coverage
 Coverage begins with initial on-time payment of premium by consumer
– Marketplace plans must accept: paper check,
Electronic Funds Transfer, cashier’s check, money order, and pre-paid debit card
– Insurer sets deadline for payment of first premium
– Insurance may be cancelled for failure to pay first premium by specified deadline set by plan
 NOTE: unlike 90 day grace period once coverage begins, there is no initial grace period for late premium payments
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ADAP Insurance Purchasing Checklist
See NASTAD Assessment Tool:
 What is plan’s deductible?
 What is plan’s out-of-pocket cap (including costsharing reductions)?
 What is plan’s monthly premium (including premium tax credit)?
 What drugs are covered under plan’s formularies?
 Are their restrictions associated with drug coverage?
 What Ryan White services are covered by plan?
 What providers and pharmacies are included in plan network?
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ADAP Insurance
Cost-Effectiveness Model
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How to use the ADAP Insurance Cost- effectiveness Model
 Intended to assist in assessing if individual insurance plans are cost-effective.
– Information inserted into the tool should be based on an individual insurance plan for an average client, not the total cost of providing insurance for all of your ADAP clients.
– The cost-effectiveness model may be used and applied for any private insurance plan, including a qualified health plan
(QHP) available through either a state- or federally-run
Affordable Care Act (ACA) marketplace.
 The tool has been built with two completion approaches:
– The first aligned directly with HRSA guidelines outlined in
HRSA policy notice 07-05 and 13-05.
– The second providing a broader assessment of all costs associated with purchasing insurance.
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HRSA Criteria: Step One
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HRSA Criteria: Step Two
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HRSA Criteria: Step Three
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State Alternative: Step One
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State Alternative: Step Two
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State Alternative: Step Three
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Questions
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Resources
 National Alliance of State & Territorial AIDS Directors
(NASTAD), www.NASTAD.org
– Amy Killelea, akillelea@nastad.org
 HIV Health Reform, http://www.hivhealthreform.org/
 Treatment Access Expansion Project, www.taepusa.org
 HIV Medicine Association, www.hivma.org
 HRSA/HAB ACA and Ryan White Resources, http://hab.hrsa.gov/affordablecareact/
 Health Care Reform Resources
– State Refo(ru)m, www.statereforum.org
– Kaiser Family Foundation, www.kff.org
– Healthcare.gov, www.healthcare.gov
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