ADAP and Health Reform:

Conducting Outreach and

Enrollment

Amy Killelea, JD

NASTAD

HRSA/HAB Grantee Webinar

May 29, 2013

Presentation Overview

Part 1: Nuts and Bolts of ACA Eligibility and

Enrollment

Part 2: ACA Outreach and Enrollment Training and

Funding Opportunities and How HIV/AIDS Programs

Can Be Involved

Part 3: Case Study – Massachusetts HIV Drug

Assistance Program (Craig Wells)

Questions

Part 1: Nuts and Bolts of ACA

Eligibility and Enrollment

Medicaid (people w/income

up to 138% FPL)

Qualified Health Plan (QHP)

Federal Subsidies for Private

Insurance:

• Premium Tax Credits (people

w/income 100-400% FPL)

• Cost-sharing reductions (people

w/income 100-250% FPL)

Exchange/Marketplace Portal

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

Navigating the Marketplace

Web Portal

Calculating Income Eligibility:

MAGI

What is MAGI?

– Income eligibility for Medicaid expansion and private insurance

subsidies will be determined using Modified Adjusted Gross

Income

– MAGI is based on IRS definition of income:

No asset tests or income disregards

Adjusted Gross Income minus certain income (e.g., alimony

and business expenses)

Household = tax filing unit (individual and anyone the

individual can claim as tax dependent)

– MAGI may be different from ADAP definition of income

NOTE: only U.S. Citizens and lawfully present immigrants eligible for

marketplace coverage

MAGI in Action: Streamlined

Application

Advance Premium Tax Credits for 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

Based on end-of-year tax filings and paid in advance directly to plans

(member responsible for overpayment)

Income

(individual)

Second Lowest

Cost Silver Level

Plan Premium

Individual

Minimum

Contribution

Federal Premium

Tax Credit

Annual Monthly Annual Monthly Annual Monthly Annual Monthly

(Michael)

150%

FPL

$17,235 $1,436.25 $4,500 $375 $689.40 $57.45 $3,810.60 $317.55

(Michelle)

300%

FPL

$34,470 $2,872.50 $4,500 $375 $3,274.65 $272.89 $1,225.35 $102.11

Navigating the Marketplace

Web Portal: Premium Tax Credits

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% 94% ~$2,100 Deductible

Copays

Coinsurance

150-200% FPL 70% 87% ~$2,100 Deductible

Copays

Coinsurance

200-250% FPL 70% 73% ~$3,200 Deductible

Copays

Coinsurance

Navigating the Marketplace

Web Portal: Cost Sharing Reductions

When Does Coverage Start?

Medicaid QHP Through Exchange/Marketplace

90 day eligibility determination Eligibility determination “promptly and without undue

delay”

Continuous enrollment Open enrollment during specified times (with special

enrollment available for a set of specific circumstances)

Retroactive coverage up to 3

months prior to the date of

application

Coverage begins:

•If the plan selection is received by the

exchange/marketplace on or before December 15, 2013,

coverage begins January 1, 2014.

•If the plan selection is between the 1st and 15th day of any

subsequent month during open enrollment period,

coverage begins the first day of the following month.

•If the plan selection is received between the 16th and last

day of the month, coverage begins the first day of the

second following month.

How Will Clients Enroll in the

Right Plan?

Plan Analysis

Prescription drug formulary

• Must be comparable to ADAP for

ADAP to help with insurance

purchasing

Scope of benefits covered

• Limits on services (including prior

authorization)

Availability/amount of premium tax credits

and cost sharing reductions

Cost-sharing design

Provider networks

Cost-Effectiveness Analysis Is the cost of client premiums and co-pays

LESS than the cost of providing full-pay drug

coverage (aggregate)

Part 2: ACA Outreach and Enrollment

Training and Funding Opportunities

and How HIV/AIDS Programs Can Be

Involved

ACA Outreach and Enrollment

Programs and Resources

Consumer outreach

and enrollment

Patient Navigator Program

Insurance Assisters

Certified Application Counselors

Community Health

Centers

Enroll America

Has the state HIV/AIDS program applied for a Patient Navigator or

assister grant?

How is the health department supporting consortia of HIV/AIDS

providers to apply for Patient Navigator or assister grants?

Role of Case Managers

Where do case managers fit in outreach and

enrollment?

– Some states are already using medical case managers to

work with clients on insurance benefits counseling and

enrollment

– Other states are carving out “insurance benefits

counseling” from case management and developing new

positions

– All case managers need general training and information

on ACA coverage and enrollment to be able to direct

clients to appropriate resources

Part 3: The Massachusetts HIV Drug Assistance

Program (HDAP) and Navigating Health

Insurance post-Health Care Reform in

Massachusetts Craig Wells, MSL HDAP Program Director Community Research Initiative of New England

Massachusetts HIV Drug

Assistance Program (HDAP)

• Three program components:

• Full-pay (reimbursement to retail pharmacies for

drug costs)

• Co-pay (covers co-pay portion of drug costs not

covered by insurance)

• CHII (Comprehensive Health Insurance Initiative)

pays health insurance premiums, including non-

group, COBRA, employment-based, MassHealth

(Medicaid), and Commonwealth Care/Choice

HDAP/CHII profile

• Eligibility: individuals with a gross annual income up to 500% FPL

• HDAP is administered for the Massachusetts Department of Public Health by Community Research Initiative of New England (CRI)

• HDAP, combined with expanded Medicaid, enables Massachusetts to maintain a high level of treatment access for persons with HIV/AIDS

Comprehensive Health Insurance

Initiative (CHII)

CHII helps cover the costs of health insurance through

assistance with payment of:

• Non-group/small group premiums

• Employee premium deductions

• Self-employed insurance premiums

• COBRA payments

• Medicaid/MassHealth premiums

Comprehensive Health Insurance

Initiative (CHII)

• Originally created in 1999 under the HRSA insurance

continuation policy as a pilot program designed to

assist HIV+ consumers in obtaining/maintaining

health insurance to cover the cost of drug treatment

while increasing access to comprehensive care

• Enrollment voluntary until 2005, when, as cost-

savings measure, HDAP required all eligible program

enrollees to obtain health insurance coverage

CHII Limitations

• CHII cannot make direct payments to clients

• CHII does not cover out-of-pocket costs, such as co-pays and deductibles, for:

▪ office visits and outpatient services

▪ prescription drugs not covered by HDAP or client’s insurance company

▪ inpatient service, ambulatory care or surgical procedures

▪ emergency room visits

CHII Requirements

• Each HDAP client enrolled in CHII must:

Contact his/her health insurance company directly – HDAP staff are unable to contact the insurance company on behalf of client due to insurance/HIPAA regulations

Recertify for HDAP/CHII every 6 months

Re-apply to Medicaid every 12 months

Forward recent health insurance bills to HDAP staff

Inform HDAP/CHII staff of any changes in insurance premium (i.e. increase/decrease in premium amount)

Massachusetts Health Care

Reform

• Signed into law April, 2006

• Features: Innovative merger of small and individual insurance

markets

Attempt to improve quality and control costs

Completely subsidized, comprehensive health insurance

for residents earning up to 150% FPL

Substantial premium subsidies to residents earning 150%-

300% FPL

Reformed non-group/small group insurance markets to

lower the cost and offer more choices for residents

purchasing non-subsidized plans

Massachusetts Health Care

Reform

• Features (continued): Mandate for individuals to purchase coverage

New responsibilities for employers to ensure access for their

workers (employers with at least 11+ FTE’s)

Qualified aliens (i.e. “aliens with special status,” “documented immigrants,” or “legal immigrants”) are eligible

On-line portal for enrollment (“The Connector”) in subsidized

and non-subsidized plans

Educational and outreach initiatives on enrollment, plan

options

Massachusetts Health Care

Reform

• Subsidized insurance (clients w/incomes <300%

FPL): Commonwealth Care

No deductibles

Co-payments for some services

Eligibility determination concurrent with Medicaid

eligibility determination

Income level determines tier level/co-pay amounts

Massachusetts Health Care

Reform

• Non-subsidized insurance (clients w/incomes >300%

FPL): Commonwealth Choice:

Clients select and enroll in their own plans

Gold, Silver, and Bronze levels

Different levels: premium amounts, co-pays,

deductibles/out-of-pocket expenses

Post-Health Care Reform in Massachusetts

• Rate of uninsured residents (1.9% adults in 2010 survey)

lowest in the country (national average: 16.3%)

• Per capita health care costs remain the highest in the

country

• Additional state legislation designed to limit growth of

future health care costs through: alternative payment methodologies

increased reporting on cost trends and drivers

focus on wellness and prevention

adoption of workplace wellness programs

expansion of the primary care workforce

other measures

Role of Case Managers at

Massachusetts Health Care Sites

• Joint procurement HIV case manager initiative in

2011:

Collaborative effort by Ryan White Part B (Office of

HIV/AIDS at MDPH) and Part A (Boston Public Health

Commission) grantees

Designed to enhance case management delivery,

avoid duplication of services, and improve efficiency

of funding, evaluation, and reporting functions

Role of Case Managers at

Massachusetts Health Care Sites

• OHA/BPHC-funded HIV case managers required to

assist with health insurance access/benefits

counseling, including:

assessment of need for benefits/entitlements;

detailed knowledge of resources available through

SSI/SSDI, Medicaid/Medicare, HDAP/CHII, and

private health insurance options, including those

offered through the Connector; and other state/federal

benefits and entitlement programs

Challenges Facing HIV Case

Managers/ Client Advocates

• Funding reductions to agencies providing case

management

• Increased caseloads

• Staff turnover

• Reduction or elimination of training programs on

benefits/entitlements due to funding cuts

• Increasing complexity of private and public

insurance programs and dynamic health care

environment

Recent Changes in Health Insurance

Profile in Massachusetts

• Imposition of an annual “open enrollment” period

restricting enrollment in subsidized/non-subsidized

non-group insurance to one specific six-week

period/year

• Increased costs of monthly premiums and out-of-

pocket expenses

• Recent policy by one major insurance company to

require extensive documentation from subscribers of

Massachusetts residency -- a major barrier to HDAP

clients who are undocumented or who lack such

paperwork

Recent Changes in Health Insurance

Profile in Massachusetts

• Requirement that insurance applicants provide social

security numbers in order to enroll

• Recent policy by one major insurance company

mandating that “maintenance” medications (meds for

long-term, chronic health conditions) be obtained

only through 90-day mail order service through

Express Scripts

• Subsequent implementation of a maintenance

medication pharmacy network in response to

concerns about barriers to access

Recent Changes in Health Insurance

Profile in Massachusetts

• Growing trend replacing no- or low-deductible plans

with high-deductible plans featuring increased co-

pays for diagnostic and lab services, prescription

coverage caps, and other restrictions

Role of HDAP Enrollment

Specialists

• HDAP staff are increasingly expected to provide

benefits counseling and assistance with health

insurance selection and referrals

Role of HDAP Enrollment

Specialists

• Advantages:

HDAP staff have by necessity become health

insurance “experts”

Informed coverage selection and referral can help

ensure cost-effectiveness

We can guide clients to make appropriate choices

that help prevent future problems/gaps in coverage

Role of HDAP Enrollment

Specialists

• Challenges:

Detracts staff from enrollment/recertification tasks,

resulting in longer approval times

Absolves case managers/client advocates from

learning about all available insurance/benefits options

Requires additional ADAP staffing and training

resources

HDAP Enrollment Specialists:

Benefits Counseling

• We assist clients/case managers in plan selection.

What we look for:

▪ -0- or low deductibles (≤ $500)

▪ no cap on prescriptions

▪ affordable drug co-pays

▪ comprehensive drug formulary

(at least comparable to HDAP formulary)

▪ affordable co-pay costs for medical visits/labs

▪ these plans tend to be at the “Gold” level

HDAP Enrollment Specialists:

Benefits Counseling

• What we do:

▪ Review insurance options with case managers and/or

clients

▪ Remind clients of upcoming open enrollment periods

▪ Identify clients who appear to be eligible for Part D and who

are not yet enrolled

▪ Assist clients in negotiating maintenance medication

pharmacy network

HDAP Enrollment Specialists:

Benefits Counseling

• What we do:

Conduct case-by-case analysis (when necessary) of cost-

effectiveness of client plan options

Monitor insurance plans and their coverage

limits/restrictions available on our state exchange

Review summaries of benefits of clients’ employer-

sponsored group plans

Provide updates on insurance programs and changes to

case managers/client advocates and other providers

ADAPs and the Affordable Care

Act

• What can help:

▪ Provide access to training opportunities for your staff

to learn more about the ACA as well as other public

and private insurance programs

▪ Identify and develop relationships with contacts at your

state’s insurance exchange early

▪ Work closely with your Part A grantees and Planning

Council members (if you have EMA(s) in your state)

on the need to support and train case managers/

client advocates as benefits counselors

ADAPs and the Affordable Care

Act

• What can help:

Encourage ASO/CBO/CHC partners to apply for

funding to support projects to increase capacity for

enhancing access to insurance through health

navigators, benefits specialists

Develop relationships with health care

advocates/lawyers with expertise in insurance issues

Share what you have learned with community

partners, i.e., case managers, clients, CABs,

ASOs/CBOs

ADAPs and the Affordable Care

Act

• What can help:

▪ Help your staff develop the ability to set limits in their

roles as enrollment specialists (not case managers)

▪ Expect the unexpected

How to Contact Us

Massachusetts HIV Drug Assistance Program c/o CRI of New England 38 Chauncy Street Suite 500 Boston, MA 02111 www.crine.org 800.228.2714 (toll-free) 617.259.1074 (fax) Craig Wells 617.502.1734 cwells@crine.org

How to Contact Us

Office of HIV/AIDS

Bureau of Infectious Disease Massachusetts

Department of Public Health 250 Washington Street, 3rd Fl. Boston, MA 02108 www.mass.gov/dph Annette Rockwell HDAP and Federal Grants Coordinator 617.624.5762 annette.rockwell@state.ma.us

Resources

National Alliance of State & Territorial AIDS Directors

(NASTAD), www.NASTAD.org

– Amy Killelea, akillelea@nastad.org

HRSA Ryan White and ACA Resources,

http://hab.hrsa.gov/affordablecareact/

Enroll America, www.enrollamerica.org

HIV Health Reform, http://www.hivhealthreform.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