


Open enrollment ends on March 31st, 2014.
If you sign clients up for the marketplace
from now until March 31st, their coverage will
begin on May 1st, 2014.
The next open enrollment period begins
November 15th, 2014.


Anyone who is a U.S. citizen or legal resident can apply
for the marketplace no matter what income he/she
earns.
A person’s income only determines what cost shares
and/or tax credits he/she may be eligible for through
the Marketplace.
◦ Someone earning between 100%-250% FPL is eligible for
cost-sharing assistance when enrolled in a Silver Plan.
◦ Someone earning between 100%-400% FPL is eligible for tax
credits in any marketplace plan.
◦ All other incomes can still enroll in the marketplace, but just
won’t benefit from cost-share assistance or tax credits.

As a reminder, people earning between 0%-300% FPL
are eligible for the Louisiana Health Access Program
(L-DAP and HIP).

In Louisiana, Ryan White ADAP funds (which are used to provide medication
and insurance services to individuals with an HIV positive diagnosis) contract
through HIP to assist clients with paying for their health insurance premiums
and cost shares (copay, coinsurance, deductible).

In early 2014, some insurance companies in Louisiana decided NOT to accept
premium payments from HIP.

Lambda Legal filed a lawsuit on 2/20/14, which resulted in a U.S. District
Court hearing on 3/10/14.

As of 3/20/14:
 BCBSLA and HMO of LA decided to continue accepting Ryan White funds as
premium payments for individual policies for on-Marketplace and offMarketplace plans until 11/15/14.
 Louisiana Health Cooperative (LAHC) also confirmed that they will continue
accepting Ryan White funds as premium payments until 11/15/14. LAHC only
offers on-Marketplace plans.
 AAA Vantage will also continue accepting Ryan White funds as premium
payments until 11/15/14. AAA Vantage offers on-Marketplace and offMarketplace plans.
 Humana has been accepting Ryan White funds as premium payments and
confirmed they have no plan to change this stance. Humana has both onMarketplace and off-Marketplace plans. Humana on-Marketplace plans are
only available to persons who live in Jefferson Parish.


On 3/14/14 CMS released an interim final rule
regarding third party payment. The rule went
into effect immediately but will remain open for
comment for 60 days.
The rule requires issuers of qualified health
plans (QHPs), including stand-alone dental
plans (SADPs), to accept premium and costsharing payments made on behalf of enrollees
by the Ryan White HIV/AIDS Program, other
Federal and State government programs that
provide premium and cost sharing support for
specific individuals, and Indian tribes, tribal
organizations, and urban Indian organizations.

How do we know the insurance companies won’t change their minds and stop
taking payment again?
o
o
o
o

BCBSLA, HMO of LA, LAHC, and AAA Vantage all individually consented on
record at the hearing that they would continue accepting premium payments
from third parties until 11/15/14.
If the insurers were to go back on their consent, they would receive heavy
sanctions.
CMS released an interim final rule on 3/14/14 requiring QHP insurers to accept
payments made on behalf of health plan enrollees by the Ryan White HIV/AIDS
Program.
CMS says a failure to accept third-party payments as outlined in the rule would
be considered substantial non-compliance with an exchange standard, and
could also be considered a practice that would have the effect of denying or
discouraging enrollment into a QHP by qualified individuals whose medical
history suggests the need for a significant amount of services.
Continue to accept premium payments? I thought BCBSLA and LAHC stopped
accepting premium payments from HIP.
◦ While BCBSLA and LAHC internally stopped accepting premium checks from HIP,
the only publicly produced written statements from either insurer stated they
would continue accepting third party premium payments until 3/31/14.
◦ As a result of this discrepancy, many clients dropped out of these plans or
switched to another plan.
◦ The bottom line: the most recent decision of these insurance companies gives
clients more options (next slide).
Pay premium
themselves
Enroll in a plan
and
apply for HIP
Ryan White funded programs, including HIP, are not entitlement or required programs. If
financially capable, individuals can choose to pay their own insurance premiums and/or cost
shares. It may be helpful for these individuals to lower the metal level of their plan (e.g.
from a platinum level to a bronze level) potentially making their premium costs more
affordable.
Individuals have until 3/31/14 to enroll in a Marketplace plan for 2014. If they cannot
afford the premium and/or cost share costs themselves and have a household income <
300% FPL, they can apply for assistance through HIP.
With the 2014 Marketplace Open Enrollment period ending 3/31/14, providers are
encouraged to assist clients in signing up for the Marketplace plan that best suits
their needs.
HIP has received approval from SHP to resume issuing checks to BCBS and LAHC for the
payment of premiums.
Switch Plans
If a client switched to another plan and would like to switch back to the plan they originally
enrolled in, the client needs to check with the insurance company to find out if the plan has
been effectuated yet. A plan can be effectuated whether or not payment was received.
Client can choose to become / remain uninsured with the understanding of the
consequences of being uninsured, such as:
Be uninsured
-Penalty for not obtaining health insurance*
-Being reliant on LDAP and the public health medical care system
-LDAP open enrollment is dependant on the availability of funding and is subject to the
possibility of restricted access, such as waiting lists.
*The penalty in 2014 is calculated in 1 of 2 ways. You’ll pay whichever of these amounts is higher:
1. 1% of your yearly household income. The maximum penalty is the national average yearly premium for a bronze plan.
2. $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.
The fee increases every year. In 2015, it’s 2% of income or $325 per person. In 2016, and later years it’s 2.5% of income or $695 per person. After that, it is adjusted for inflation.
If you would have qualified for expanded Medicaid (0%-138% FPL), you’re exempt from the law’s requirements to buy coverage because Louisiana declined expansion.
Therefore, you won’t pay a penalty this year for not buying it. HOWEVER, this exemption must be applied for and a Medicaid denial letter is required for application.
138% FPL = $15, 856 for a single person household.
More information on penalty exemptions are available at www.healthcare.gov/exemptions
Effectuated is a term used by insurance companies
that means a plan has become active or gone into
effect.
o If an individual’s plan has already been effectuated, or gone
into effect, they do not have the option to switch plans until
2015 open enrollment unless they are eligible for a Special
Enrollment Period (SEP).
o If an individual’s plan has not yet been effectuated, they can
terminate their coverage with their current insurer and switch to
another plan.
o The only way to know if a plan is effectuated is to contact the
insurer directly.

While SHP will do our best to update you with
new information, be on the look out for
upcoming items:
◦ The CMS interim final rule entitled “Patient Protection and
Affordable Care Act; Third Party Payment of Qualified Health
Plan (QHP) Premiums (CMS-9943-IFC)” was released on
3/14/14 and is open for public comment for the next 60 days.
This rule requires that all QHPs accept premium payment from
the Ryan White HIV/AIDS Program.
◦ Legislation could be posed to bypass the governor and expand
Louisiana Medicaid. If passed, Louisiana voters would decide
whether to expand Medicaid on next November's election day
ballot.

Each insurance plan has a process for how to make an off-formulary request. Below are the
processes for Louisiana Marketplace plans.

Blue Cross Blue Shield/HMO of Louisiana
◦

Louisiana Health Cooperative:
◦
◦
◦

Contact LAHC. For more details use this link:
http://www.mylahc.org/Files/Repository/LAHC2014Formulary.pdf.
If approved, the drug will be covered at a “pre-determined cost-sharing level” and you will not be able
to ask LAHC for a lower cost-sharing level.
Providers must complete a Coverage Determination Request Form and fax it to the Pharmacy
Department available when providers log on to mylahc.org.
AAA Vantage Health Plan:
◦
◦

Call Express Scripts at 1-866-781-7533 to make an off-formulary request
File an “exception request” by calling AAA Vantage’s Member Service department at (318) 361-0900 or
(888) 823-1910.
The insured and the physician must request the formulary exception.
Humana:
◦
◦
◦
Off-formulary requests can be made by phone, mail, or fax.
Phone: The patient, provider, or appointed representative should call Humana Clinical Pharmacy Review
(HCPR) at 1-800-555-CLIN (2546), TTY: 711, Monday through Friday, 8 a.m. to 6 p.m. in your local
time zone.
Mail/Fax form “Prior Authorization Request Form: Administrative Product – Nonformulary” available
electronically - http://apps.humana.com/marketing/documents.asp?file=1312909



Medicare: HCPR, Attn: Medicare Coverage Determination, P.O. Box 33008, Louisville, KY 40232
Commercial: HCPR, Attn: Prior Authorizations, P.O. Box 33008, Louisville, KY 40232
Fax: 1-877-486-2621
Highlighed items are not covered on the listed plan's formulary
Listing of HIV Medicine on Louisiana Marketplace Plans
Louisiana Health Cooperative
Blue Cross Blue Shield & HMO of Louisiana
AAA Vantage *
Humana
Generic Name
Brand Name
Generic Name
Brand Name
Generic Name
Brand Name
Generic Name
Brand Name
Efavirenz/Emtricitabine/Tenofovir
Atripla (Sustiva/Truvada)
Efavirenz/Emtricitabine/Tenofovir
Atripla (Sustiva/Truvada)
Efavirenz/Emtricitabine/Tenofovir
Atripla (Sustiva/Truvada)
Efavirenz/Emtricitabine/Tenofovir
Atripla (Sustiva/Truvada)
Rilpivirine/Tenofovir/Emtricitabine
Complera
(Edurant/Viread/Emtriva)
Rilpivirine/Tenofovir/Emtricitabine
Complera
(Edurant/Viread/Emtriva)
Rilpivirine/Tenofovir/Emtricitabine
Complera
(Edurant/Viread/Emtriva)
Rilpivirine/Tenofovir/Emtricitabine
Complera
(Edurant/Viread/Emtriva)
Elvitegravir/Cobicistat/Emtricitabine/Tenofovi
r
Stribild
Elvitegravir/Cobicistat/Emtricitabine/Tenofov
ir
Stribild
Elvitegravir/Cobicistat/Emtricitabine/Tenofovi
r
Stribild
Elvitegravir/Cobicistat/Emtricitabine/Tenofov
ir
Stribild
Maraviroc
Selzentry
Maraviroc
Selzentry
Maraviroc
Selzentry
Maraviroc
Selzentry
Raltegravir
Isentress
Raltegravir
Isentress
Raltegravir
Isentress
Raltegravir
Isentress
Dolutegravir
Tivicay
Dolutegravir
Tivicay
Dolutegravir
Tivicay
Dolutegravir
Tivicay
Zidovudine/Lamivudine
Combivir
Zidovudine/Lamivudine
Combivir
Zidovudine/Lamivudine
Combivir
Zidovudine/Lamivudine
Combivir
Emtricitabine
Emtriva
Emtricitabine
Emtriva
Emtricitabine
Emtriva
Emtricitabine
Emtriva
Lamivudine (3TC)
Epivir
Lamivudine (3TC)
Epivir
Lamivudine (3TC)
Epivir
Lamivudine (3TC)
Epivir
Lamivudine/Abacavir
Epzicom
Lamivudine/Abacavir
Epzicom
Lamivudine/Abacavir
Epzicom
Lamivudine/Abacavir
Epzicom
Zalcitabine/Dideoxycytidine (ddC)
Hivid
Zalcitabine/Dideoxycytidine (ddC)
Hivid
Zalcitabine/Dideoxycytidine (ddC)
Hivid
Zalcitabine/Dideoxycytidine (ddC)
Hivid
Zidovudine (AZT)
Retrovir
Zidovudine (AZT)
Retrovir
Zidovudine (AZT)
Retrovir
Zidovudine (AZT)
Retrovir
Abacavir/Zidovudine/Lamivudine
Trizivir
Abacavir/Zidovudine/Lamivudine
Trizivir
Abacavir/Zidovudine/Lamivudine
Trizivir
Abacavir/Zidovudine/Lamivudine
Trizivir
Emtricitabine/Tenofovir
Truvada
Emtricitabine/Tenofovir
Truvada
Emtricitabine/Tenofovir
Truvada
Emtricitabine/Tenofovir
Truvada
Didanosine (ddI)
Videx / Videx EC
Didanosine (ddI)
Videx / Videx EC
Didanosine (ddI)
Videx / Videx EC
Didanosine (ddI)
Videx / Videx EC
Tenofovir
Viread
Tenofovir
Viread
Tenofovir
Viread
Tenofovir
Viread
Stavudine (d4T)
Zerit
Stavudine (d4T)
Zerit
Stavudine (d4T)
Zerit
Stavudine (d4T)
Zerit
Abacavir Sulfate
Ziagen
Abacavir Sulfate
Ziagen
Abacavir Sulfate
Ziagen (only as solution, not
tablet)
Abacavir Sulfate
Ziagen
Tipranavir
Aptivus
Tipranavir
Aptivus
Tipranavir
Aptivus
Tipranavir
Aptivus
Amprenavir
Agenerase
Amprenavir
Agenerase
Amprenavir
Agenerase
Amprenavir
Agenerase
Indinavir
Crixivan
Indinavir
Crixivan
Indinavir
Crixivan
Indinavir
Crixivan
Saquinavir
Fortovase
Saquinavir
Fortovase
Saquinavir
Fortovase
Saquinavir
Fortovase
Saquinavir Mesylate
Invirase
Saquinavir Mesylate
Invirase
Saquinavir Mesylate
Invirase
Saquinavir Mesylate
Invirase
Lopinavir/Ritonavir
Kaletra
Lopinavir/Ritonavir
Kaletra
Lopinavir/Ritonavir
Kaletra
Lopinavir/Ritonavir
Kaletra
Fosamprinavir
Lexiva
Fosamprinavir
Lexiva
Fosamprinavir
Lexiva
Fosamprinavir
Lexiva
Ritonavir
Norvir
Ritonavir
Norvir
Ritonavir
Norvir
Ritonavir
Norvir
Darunavir
Prezista
Darunavir
Prezista
Darunavir
Prezista
Darunavir
Prezista
Atazanvir
Reyataz
Atazanvir
Reyataz
Atazanvir
Reyataz
Atazanvir
Reyataz
Nelfinavir
Viracept
Nelfinavir
Viracept
Nelfinavir
Viracept
Nelfinavir
Viracept
Enfuvirtude
Fuzeon
Enfuvirtude
Fuzeon
Enfuvirtude
Fuzeon
Enfuvirtude
Fuzeon
Rilpivirine
Edurant
Rilpivirine
Edurant
Rilpivirine
Edurant
Rilpivirine
Edurant
Etravirine
Intelence
Etravirine
Intelence
Etravirine
Intelence
Etravirine
Intelence
Delavirdine
Rescriptor
Delavirdine
Rescriptor
Delavirdine
Rescriptor
Delavirdine
Rescriptor
Efavirenz
Sustiva
Efavirenz
Sustiva
Efavirenz
Sustiva
Efavirenz
Sustiva
Nevirapine
Viramune/Viramune XR
Nevirapine
Viramune/Viramune XR
Nevirapine
Viramune/Viramune XR
Nevirapine
Viramune XR
 Atripla is not covered as a single tablet, but its components are available
for a split treatment regimen

All HIV medicine listed is in Tier 5
 Complera is not covered as a single tablet, but its component are available
for a split treatment regimen

All HIV medicine listed is in Tier 5

All HIV medicine listed requires Prior Authorization
This information is available on lahap.org





On March 14th, 2014 it was announced that the federally-run
Pre-Existing Condition Insurance Plan (PCIP) will be extended
through April 30th, 2014.
Individuals with active PCIP, who have not yet found new
health insurance coverage through the Marketplace, can
purchase an additional month of PCIP coverage through April
30, 2014, while they continue their search.
Eligible enrollees can purchase PCIP transitional coverage by
sending in an April premium payment; which will be the same
monthly rate that they paid for January-March 2014.
If you have clients that were on PCIP and have since obtained
Medicaid, Medicare, or other currently active insurance
coverage PLEASE contact Brandy Davis at HIP immediately.
Brandy can be reached at 225-927-1269.






On March 18th, The Center for Consumer Information & Insurance
Oversight (CCIIO) clarified that if an individual selects PCIP
transitional coverage for April 2014 and then loses that coverage
before enrolling in a Marketplace plan, they would be eligible for a
special enrollment period (SEP) outside of open enrollment.
This SEP it is NOT a mass PCIP special enrollment period, but a
person specific one, which will need to be done on a case by case
basis.
Why a Special Enrollment Period?
◦ PCIP is considered minimum essential health coverage and the loss of
minimum essential health coverage is considered a qualifying life event that
could result in an SEP outside of open enrollment.
Most SEPs last 60 days from the date of the qualifying life event.
SEPs are an option, but they are NOT ideal. SEPs require additional
paper work, hoops to jump through, and may not be resolved
quickly.
The only way to help ensure that an individual with PCIP does not
experience a coverage gap is to make sure they are enrolled in a
Marketplace plan no later than March 31, 2014.
HIP Active PCIP Clients by Case Mgmt Agency
Case Mgmt Agency
HIP Active ACA Clients by Case Mgmt Agency
PCIP
Clients
Case Mgmt Agency
ACA
Clients
AC - Acadiana Cares
6
AC - Acadiana Cares
24
AHEC - Southeast Louisiana
1
AHEC - Southeast Louisiana
13
CCC - Comprehensive Care Clinic (WOM)
3
CCC - Comprehensive Care Clinic (WOM)
8
CLASS
6
CCFHC - Capital City Family Health
7
Earl K Long EIC Mid City
3
CLASS
10
ESS - Exchange Support Service
3
Earl K Long EIC Mid City
17
FACES
5
ESS - Exchange Support Service
9
FSGBR - Family Service of GBR
7
FACES
14
GO CARE
5
FSGBR - Family Service of GBR
7
HAART
7
GO CARE
38
HOP - HIV Outpatient Program
37
HAART
42
Tulane Alexandria (HPL)
1
HOP - HIV Outpatient Program
30
LJC - Chabert Medical Center
1
Tulane Alexandria (HPL)
1
LSU Shreveport
1
LSU Shreveport
Metro Health
1
NATF - NO AIDS Task Force
NATF - NO AIDS Task Force
5
156
242
Philadelphia Center
5
Priority Health Care
4
Priority Health Care
33
SLAC - SW Louisiana AIDS Council
1
SLAC - SW Louisiana AIDS Council
86
VOABR
4
University Medical Center
6
Self Referral
4
VOABR
33
VOAGNO
8
Total:
342
Self Referral
Total:
44
596





ADAP stands for AIDS Drug Assistance Program.
ADAP is a federal Ryan White funding source awarded
by the Health Resources and Services Administration
(HRSA).
ADAP funds can be used to provide medication and
insurance services to eligible individuals with a
positive HIV diagnosis.
The State STD/HIV Program (SHP) gets ADAP funding
from HRSA.
SHP uses ADAP funding to support medication and
insurance services through our programs called LDAP and HIP.
•
L-DAP - LOUISIANA DRUG ASSISTANCE PROGRAM
• covers drug costs for uninsured individuals only. Often
referred to as Traditional ADAP.
•
HIP -HEALTH INSURANCE PROGRAM
• covers insurance plan premiums as well as medical (nondrug) and drug copays, coinsurances, & deductibles
(known as cost shares) for insured individuals.
•
LA HAP processes L-DAP enrollment through SHP.
•
HIP processes HIP enrollment through HAART.
LA HAP
Manage LDAP & HIP Contracts
Process LDAP Enrollment
Louisiana Drug Assistance
Program
(LDAP)
•Drug costs for uninsured clients.
•Previously through 10 LSU Medical
Center Outpatient Pharmacies.
•Currently central distribution through
OPH Pharmacy.
Louisiana Health Insurance
Program (HIP) Services
& Enrollment
Insured plan premium
Drug cost share assistance
Medical cost share assistance
Participating HIP Pharmacies
To allow for better coordination of our programs you'll
see a few more changes with LDAP and HIP.
•L-DAP - LOUISIANA DRUG ASSISTANCE PROGRAM
•Will continue to cover drug costs for uninsured individuals
and will soon cover drug copays, coinsurances, & deductibles
(known as cost shares) for insured individuals.
•HIP -HEALTH INSURANCE PROGRAM
•Will continue to cover insurance plan premiums as well as
medical (non-drug) cost shares for insured individuals.
•LA HAP will soon process both L-DAP and HIP
enrollment through a single application.
LA HAP
Manage L-DAP & HIP Contracts
Process L-DAP & HIP
Enrollment
Louisiana Drug Assistance
Program (L-DAP)
•Drug costs for uninsured clients
•Drug cost shares for insured clients
Managed through Ramsell
Louisiana Health Insurance
Program (HIP) Services
Insured plan premium
Medical cost share assistance
Coordinated through HAART.

If you are uninsured and need assistance paying for your
HIV medications, apply to LDAP using the new LA HAP
application that was released in December 2013.
◦ LA HAP application is available on lahap.org

If you have any type of health insurance and need
assistance with your premiums* and cost shares, apply
to HIP using the HIP application
◦ HIP application is available on haartinc.org under “services”  “HIP”
*If you need assistance paying for premiums, please double check that the
insurance plan you sign up with will accept premium payments from HIP.
•Carefully consider the definition of “household” for the purposes of this application.
People in the same household MUST be related by blood, state legal marriage and/or state
legal adoption.
•Live-in boyfriends/girlfriends and/or same sex partners* are NOT considered part of the
same household and should not be included in this section or included as contributing to
household income.
•Common law marriage is not recognized in Louisiana.
•Louisiana does not recognize people as being “separated” in a marriage until they are
legally divorced. However, LA HAP recognizes it is likely that if someone has been
separated from his/her spouse for greater than six months, it may difficult for that person
to obtain income documentation from his/her estranged spouse. Therefore, income
eligibility can be determined on the separated individual’s income alone. Contact LA HAP
at 504-568-7474 for more information.
*For the purposes of this application, only state legal marriages are considered. Therefore, even if a couple has a federally
recognized marriage or was married in another state, they are not considered married unless the state of Louisiana
recognizes their marriage.
•The client needs to provide proof of income for anyone listed in the
“household” section that is 18 years of age or older and receives any source
of income.
•If the client’s household member(s) does not have any source of income, or
the client cannot provide a household members’ income then the client
needs to note that somewhere on the application. They can make a note in
the household section, cover letter, in the comments section on page 3, etc.
•If you are a case manager/social worker/advocate helping a client
complete this application, please remember to sign your name above
“person obtaining consent” and date it.
•Also print your name, agency, and phone number in the appropriate boxes
so that LA HAP can help your agency track which referrals you have
submitted.
Clients must complete a 12 month
recertification for HIP annually on their
month of birth. This requires them to fill
out an entire HIP application and check the
box on the HIP application.
Clients must also complete a 6 month
verification on the month that falls 6 months
after their birth month. This is a one page
document that can be found by clicking the
“6 month verification” link at haartinc.org

The new 2014 FPL guidelines have been released and are
what LA HAP and HIP are currently using to determine income
eligibility for their services.


My Contact Information:
◦ Julia Frisk, Public Health Associate, 504-568-8387, julia.frisk@la.gov
HIP: 225-927-1269
For assistance completing a HIP application ask for:
Brandy Davis (ext. 144)
For application status updates ask for:
◦ Regions 1, 2, 3 new & recertification - Vena Lewis ext. 147 (vlewis@haartinc.org)
◦ Regions 4, 5, 6, 8 new & recertification – Tanya Brown ext. 135 (tbrown@haartinc.org)
◦ Regions 7, 9 new & recertification AND 6 month verification for all regions - Kne-Kole
Gibson ext. 126 (kgibson@haartinc.org)
◦ ACA application for all Regions - Heather Faris ext 124 (hfaris@haartinc.org)

LAHAP – for application status updates, the CSS are usually the easiest to contact.
◦
◦
◦
◦
Jennifer Carlos Gomez, ADAP Coordinator
 504-568-5448
Rosaline Morgan, Client Services Specialist (CSS)
 504-568-8746
Markham Bradburn, Client Services Specialist (CSS)
 504-568-3623
Heather Weaver, TAB Coordinator
 504-568-5489

This presentation is available on lahap.org  “Links”  “Technical Assistance
Resources” or the direct link at http://lahap.org/information_links/default.html

Lahap.org

Haartinc.org under “services”

Healthcare.gov

HIV411.org

Cms.gov

Hivhealthreform.org

Enrollment Assistance:
Enroll Louisiana Inc. (www.enrolllouisianainc.com)
4664 Jamestown Ave, Suite 125
Baton Rouge, LA 70808
Office: 225-228-1515
Fax: 225-612-6395
Email: info@enrolllouisianainc.com