Ryan White Part B ServicesThe Impact of State Health Care Reform

2012 HRSA All Grantees MeetingWashington, D.C.

November 28, 2012

H. Dawn Fukuda, DirectorAnnette Rockwell, Federal Grants Coordinator

Office of HIV/AIDSMassachusetts Department of Public Health

Background—Massachusetts

Small state (geographically), densely populated High incidence jurisdiction Adequate public transportation system (varies by

region) Early investment in community health centers

and safety net hospitals (1990s) ADAP Insurance Continuation Program (1999) Medicaid expansion (2001)

Massachusetts Medicaid Expansion Lessons for Implementation of ACA

Expanded access to state Medicaid (MassHealth) for low income PLWHA up to 200% FPL irrespective of disability status

Required legislatively mandated allocation in state budget

The program enrolled 225 people under the expansion in 2001, and 1,314 are currently enrolled under the expansion component (2011)

Enrollment in HIV Waiver Medicaid (MassHealth)

State Fiscal Year (FY) HIV Waiver—Average Enrollment

FY04 509FY05 675FY06 932FY07 1,006FY08 1,067FY09 1,169FY10 1,233FY11 1,310

Massachusetts Health Care Reform Core Components

• Chapter 58, Laws of 2006– Elimination of preexisting condition clauses– Expanded Medicaid eligibility for low income

residents– Creation of Commonwealth Connector

(“Exchange”)– Private health insurance Subsidies according

to income level (<300% FPL)– Health Safety Net for “non-eligible” residents

Health Insurance CoveragePLWHA in Massachusetts

• HIV+ residents <200%FPL eligible for Medicaid• HIV+ residents 200% - 300% FPL purchase

subsidized health insurance plans—Commonwealth Care

• Over 300% FPL purchase non-subsidized plans via the Connector (<500% eligible for premium assistance through HDAP)

• Variety of coverage scopes, prescription medication formularies, deductibles, and co-pays

• PLWHA may require assistance to navigate coverage options

ADAP Role Post HCR

• Coverage completion services

• Determination of ADAP Structure– Premium continuation—plan selection– Medication co-payment assistance– Full-pay medication coverage

• Verification of eligibility as a component of ADAP application and 6-month recertification

HIV Drug Assistance Program Expenditures by Category

Fiscal Year Full Pay Co-Pay Premiums

FY03 $ 7,961,862.84 $ 963,205.88 $ 1,778,272.33

FY04 $11,174,879.98 $ 1,553,758.50 $ 3,159,200.01

FY05 $ 9,756,201.76 $ 1,839,807.23 $ 6,112,132.85

FY06 $ 4,634,683.35 $ 1,893,206.26 $ 7,015,306.89

FY07 $ 4,147,713.84 $ 2,071,118.94 $ 8,366,273.11

FY08 $ 4,184,279.93 $ 2,083,431.58 $ 9,323,821.42

FY09 $ 4,695,780.40 $ 2,567,789.28 $ 8,835,835.67

FY10 $ 4,635,751.00 $ 2,930,016.65 $ 9,320,425.00

FY11 $ 4,467,727.48 $ 3,175,917.00 $ 10,990,818.00

MA HIV Drug Assistance Program Enrollment & Expenditures by Year

State Fiscal Year Enrolled Total Expenditures

FY02 2301 $ 9,716,375

FY03 2716 $ 10,703,342

FY04 4399 $ 15,887,838

FY05 4738 $ 17,708,142

FY06 4668 $ 13,543,197

FY07 5141 $ 14,585,106

FY08 5601 $ 15,591,533

FY09 5882 $ 16,099,405

FY10 6543 $ 16,886,192

FY11 7009 $ 18,634,462

Administration of ADAP

• Administered by third party, Community Research Initiative of New England (CRI)

• Allows for flexibility in responding to changes in payer environment

• Ease in processing both premium and full pay claims

• Expertise in working with different insurers• Benefits counseling

Issues Related to Insurance

• Changes to major insurers’ eligibility documentation in the last year – Residency verification – Social Security Number submission

• Mandate of 90-day mail order Rx refills• Increases in deductibles and other

out-of-pocket costs

Other Ryan White Services Post HCR

• Ongoing importance of services that are not covered or adequately reimbursed by other payers

– Case management– Housing search and advocacy– Benefits Coordination– Adherence counseling– Transportation– Non-traditional mental health– Peer support– Food and nutrition

HIV Outcomes Post HCRN= 1,004

0102030405060708090

100

In medicalcare

Taking HIVmedications

Virallysuppressed

Health goodto excellent

Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc.

Source: R. Greenwald and M. Ellwood

Source: R. Greewald and M. Ellwood

Health Care ReformPlanning Checklist

#1 Build connections with state Medicaid program• Identify allies and formalize connections• Review Medicaid application• Understand plan types and coverage scopes• Train providers about Medicaid eligibility,

enrollment process, co-payment obligations, and recertification requirements

• Consider requiring Medicaid application as a component of ADAP recertification

Health Care Reform Planning Checklist—Continued

#2 Anticipate cost shifting, realistically • Eligibility determination/enrollment takes time• Full impact of PPACA may not be fully apparent for

years after 2014• Develop structural mechanisms to ensure coverage

completion• Transition to fund “essential enabling” services that

are not 3rd party reimbursed• Calculate impact on collection of medication rebates

Health Care Reform Planning Checklist—Continued

#3 Review ADAP coverage components• Assess the need for premium continuation

support for PLWHA over 133% FPL or ineligible for Medicaid

• Establish mechanism to administer medication co-pay coverage

• Preserve full-pay coverage during application submission and review period, or when clients lose coverage due to recertification gaps

• ADAP application process is opportunity to screen for eligibility across coverage options (Medicaid, Medicare, private insurance)

Health Care Reform Planning Checklist—Continued

#4 Educate Providers and Consumers• Develop fact sheets/literature about changing

health care landscape• Engage consumer advisory boards and planning

bodies• Identify expertise to support health insurance

navigation for HIV+ residents• Ensure readiness of the provider community—

clinical and non-clinical• Develop response plan for populations that will

remain ineligible for coverage under HCR

Contact Information• H. Dawn Fukuda, Director

Office of HIV/AIDSDawn.Fukuda@state.ma.us(617) 624-5303

• Annette Rockwell, HDAP & Federal Grants CoordinatorOffice of HIV/AIDSAnnette.Rockwell@state.ma.us(617) 624-5762