ADAP and Health Reform: Conducting Outreach and Enrollment · Presentation Overview ... on ACA...
Transcript of ADAP and Health Reform: Conducting Outreach and Enrollment · Presentation Overview ... on ACA...
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 [email protected]
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 [email protected]
Resources
National Alliance of State & Territorial AIDS Directors
(NASTAD), www.NASTAD.org
– Amy Killelea, [email protected]
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