7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
1/31
+
Where are we heading?
The Affordable Care Act andRyan White
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
2/31
WhatWilltheACAMeanforAddressingtheHIVEpidemic?
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
3/31
FromCDPHESurveillanceProgram
14,266
11,698
5,7554,875
3,728
0
2000
4000
6000
8000
10000
12000
14000
16000
HIV Infected Diagnosed Linked to Care Retained in
Care
Virally
Suppressed
NumberofIndividuals
Colorado Cascade of Care
82%
49%
42%32%
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
4/31
HelpingPeopleMove
ThroughtheCascade
First Diagnosis with
HIV
Linked to Care
Retained
in Care
Achieve Viral
Suppression
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
5/31
TheProcessisNOTLinear
First
Diagnosis
with HIV
Linked to Care
Retained
in Care
Achieved ViralSuppression
Lapsed in Care
Re-Engaged
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
6/31
nFocusonservicesthatareproventohelppeoplemovethroughthecascadetowardviralsuppression
n IfapersoniseligibleforMedicaid,Medicare,orcommercialinsurance,theRyanProgramisrequiredtovigorouslypursueenrollmentofthepersoninthesetypesofcoverage
n Ifthereisaservicethatwouldhelpmovepeoplethroughthecascadebutcannotbefundedfromathirdpartypayer,Ryan
Whitefundingcanbeusedtopayforthatservice.
nMonitorhowwelltheenresystemofcareisassisngwithachievementofviralsuppression,notjustthelong-standing
RyanWhitesystem.
Thepost-ACAapproachtoHIVcare:
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
7/31
Anewwaytotriageclients
Whatwouldhelpthisclientmovethroughthecarecascade?
UlizeRyanWhite
fundingtoprovidethe
service
Providetheserviceandbillthe
3rdpartypayerorrefertoa
providerwhocandoso
YESNO
YESNO
Eligiblefor
3rdparty
payment?
Serviceis
reasonably
accessible?
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
8/31
Services Diagnosed Linked Retained Viral Supp Re-engage
HIV Testing
Outreach
Linkage
Referral
Retention
Ambulatory care
Case management
Transportation
Adherence
Oral health
Financial Assist
ADAP
HousingNutrition/Food
Psychosocial
HE/RR
Mental health tx
Substance use tx
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
9/31
n BoththeCLIENTandtheSERVICENEEDEDmustbeevaluatedforpotenal3rdpartypayment
n Eligibilitycriteria:Residence,cizenship,incomelevel,householdsizen Payers:Medicaid,Medicare,PlansthroughtheMarketplace,EmployerBasedPlans
n Servicestheywillpayfor:theEssenalHealthServices(asinterpretedbythepayer)
n IftheclientisELIGIBLEbutnotENROLLEDmustvigorouslypursueenrollment.
Eligibilityfor3rdPartyPayment
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
10/31
+Mapping Client Transitions
Uninsured Lawfully present Income up to 138% FPL
Medicaid
Uninsured
Lawfully present Income 138 - 400% FPL
Subsidized private insurance throughMarketplace
Currently on Medicaid No transition
Currently on other government-sponsoredinsurance (e.g., Medicare, TRICARE)
No transition
Currently on or have access to employer-
based coverage
If plan is affordable and comprehensive,
no transitionCurrently on PCIP or high risk pool Medicaid or Marketplace coverage
Uninsured and categorically ineligible forfederal programs
No transition
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
11/31
+HRSA Policy Notice13-01: Clarifications
Regarding Medicaid-Eligible Clients andCoverage of Services
nGranteesandtheirsubgranteesareexpectedto:n VigorouslypursueMedicaidenrollmentforindividualswhoarelikelyeligibleforcoverage,
nSeekpaymentfromMedicaidwhentheyprovideaMedicaid-coveredserviceforMedicaidbeneficiaries
nBack-billMedicaidforRWHAP-fundedservicesprovidedforallMedicaid-eligibleclientsupondeterminaon.
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
12/31
+HRSA Policy Notice13-03: Eligibility
Post-Affordable Care Act
nRecommendsgranteesalignprogramfinancialeligibilitydeterminaonswiththosefornewcoverageopons,mainly
modifiedadjustedgrossincome(MAGI)
nRecommendsgranteesalignclientrecerficaonprocesseswithMarketplaceeligibilityandenrollmentprocessestoreduceburden
andincreasecoordinaon
nGranteesmayconsiderrequiringthatclientsprovidetheirMedicaidand/orMarketplacenoceofeligibilitydeterminaon
whenapplyingfororbeingrecerfiedforRWHAP
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
13/31
+HRSA Policy Notice13-04: Eligibility
for Private Health Insurance andCoverage by RWHAP
nReiteratesthatRWHAPgranteesmustmakeeveryefforttoensurethateligibleuninsuredclientsexpediouslyenrollinprivatehealthinsurancewhenpossible;thisrequirementwillbemonitored
nGranteesneedtoinformclientsofthepenaltyfornotenrollingnClientswhoreceiveacerficateofexemponfromtheInternalRevenueService(IRS)mayconnuetoreceiveRWHAPservices
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
14/31
+HRSA Policy Notice13-04 (continued)
nOpenenrollmentintoprivatehealthplansisforalimitedmeduringtheyear
Iftheclientmissestheopenenrollmentperiod,thegranteemustmakeeveryefforttoensuretheclientenrollsinthenextopenenrollmentperiod
nGranteesmustmaintainpoliciesregardingtherequiredprocessforpursuingenrollmentforallclients,
documentaonofstepstopursueenrollment,andestablishmentofmonitoringandenforcementofsub-granteeprocessestoensureenrollment
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
15/31
+
nRWHAPfundsgenerallymayNOTbeusedtopayforservicesoutsideoftheirinsurancenetworkunlessservicesarenotavailablefromanin-networkprovider
nRWHAPfundsmaybeusedtopayforhigherco-paysanddeducbleswithinerednetworksbutmustconsider
availabilityofresourcespriortomakingsuchallocaons
HRSA Policy Notice13-04 (continued)
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
16/31
nTheserviceisconsistentwiththeHIVCareandTreatmentProgramStandardsofCare;
nTheserviceisavailabletotheclientwithinsixtycalendardaysormorepromptlyifneededtopreventdeathor
substanal,irreversibleharmtotheclient;and,nTheserviceislocatedwithin70milesoftheclientresidence.
nThisisCDPHEsinterpretaonofHRSArulesandissubjecttoHRSArevision.OtherColoradoHRSAGrantees(PartA,
C,D)mayhavedifferentinterpretaons.
Reasonablyaccessible
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
17/31
+Colorado Service Cross Walk
SERVICE Qualified Health Plans MEDICAID RW / ADAP
RX Cost-sharingassistance
MEDICAL CASEMANAGEMENT
ORAL HEALTH Limited Coverage
LABS Cost-sharingassistance
MENTAL HEALTHSERVICES
Cost-sharingassistance
SUBSTANCE ABUSETREATMENT
Cost-sharingassistance
HIV PRIMARY CARE Cost-sharingassistance
MEDICALTRANSPORTATION
Limited Coverage
INPATIENTHOSPITAL SERVICES
X X
X
X
X
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
18/31
+HRSA Policy Notice13-01: Clarifications
Regarding Medicaid-Eligible Clients andCoverage of Services
nOnceanindividualisenrolledinMedicaid,RWHAPfundsmaybeusedtopayfor:nAnymedicallynecessaryserviceswhichMedicaiddoesnotcoverorwhereMedicaidcoverageislimitedinscope
nPremiums,co-paysanddeducblesifrequirednOthercoremedicalservicesasapartofprimarycareifthoseservicesarenotcoveredorarelimitedunderMedicaid,evenwhenthoseservicesareprovidedatthesamevisitasMedicaidcoveredservices.
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
19/31
+
nRWHAPfundsmaybeusedtopayforservicesreceivedduringthemebetweenwhichaclientenrollsinthirdpartycoverageanditbecomeseffecve
nOnceenrolledinaprivatehealthplan,RWHAPfundsmayonlybeusedforservicesnotcoveredorparallycovered
byaclientsplan
HRSA Policy Notice13-04: Eligibility
for Private Health Insurance andCoverage by RWHAP
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
20/31
+
Whataresomeother
implicaonsoftheAffordableCareActforPeopleLiving
withHIVorAIDS?
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
21/31
+Pre-ACA Scenario
for HIV negative people
nHIV and STIs are highly concentrated among the poorand the uninsured.
nLow cost STI care for the uninsured is very limited interms of geography and provider
nIf mental health or substance use issues are driving HIVrisk, low cost counseling is also very limited
nPrivate health care providers are identifying most newHIV cases, but there is still a fear of becominguninsurable due to HIV testing (even if negative)
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
22/31
+Post-ACA Scenario
for HIV negative people
nMost HIV negative people will be eligible forMedicaid or some other form of coverage.
nIfthey enroll, they shouldhave new coverage thatshouldreduce their vulnerability for HIV:
nSTI screening and treatmentnHIV testingnMental health carenSubstance abuse treatment
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
23/31
+
Hopefulresultsfrom
Massachuses,thepioneerinuniversalhealthcoverage
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
24/31
+
IN MEDICAL
CAREUS 41%MA 99%
TAKING HIVMEDICATIONS
US 36%MA 90%
Viral LoadSuppressed
US 28%MA 72%
Enormous IMPACT of HEALTH
REFORM on PLWH/A in Massachusetts
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
25/31
+
nWhile HIV Diagnoses increased by 2% nationallybetween 2006 and 2009, there was a 25%
DECREASE in HIV Diagnoses in Massachusetts.
nWhile there was a significant decrease in HIVDeaths during this period (33%), Massachusetts
beat this figure as well 44%)
DIAGNOSIS & DEATHS
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
26/31
+
Butthechangesin
Massachuseswerealsoverydramacforserviceproviders
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
27/31
+
nRegional STD clinic closures were completed inJune 2009.
nFour clinics maintained services, including a freeclinic and a fee-for-service clinic. Clinic hours
were reduced hours
nSTD services were transferred to private doctoroffices and clinics
Specialty STD clinics scaled back
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
28/31
+
nAccessCarenBenefitsofreformarenotuniformnMedicalprovidersmaynothavecapaciestoaddresseligiblepaentcareneeds
nSomepubliccostscannotbeshiedinahealthreformenvironment
nTrainingneedsforclinicalprovidersmaybesignificantasspecializedpublichealthfunconsarepushedintoprimary
carevenues.
nEstablishbaselineandfuturedataneeds,andvariablestotrackimpact
Preliminary Lessons Learned in
Massachusetts
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
29/31
+
WHATISNEXT?
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
30/31
Next steps . . . ProvidersofservicesforPLWH/Ashouldadoptthenewtriage
approachtotheirclientsandtheserviceprovided
Everyprovidershouldbuildtheircapacitytoscreenforeligibilityandvigorouslypursueenrollment
ProvidersareWELLADVISEDtobuildtheircapacitytobillMedicaidorother3rdpartypayersforatleastsomeofthe
servicestheyprovide
CurrentRyanWhitefundedserviceswillneedtobeparsedbetweenthosethatarereasonablyaccessiblethrougha3rd
partypayerandthosethatarenot.
7/28/2019 Bob Bongiovanni presentation on the future of Ryan White post ACA
31/31
RyanWhitewillcon>nuetobeimportantsourceofcareandservicesformanypeoplewithHIVorAIDS
MostRyanWhiteclientswillhavecoveragebutsllneedtheprogramtocompletetheircare,fillingaps,helpwithcosts.
RyanWhiteprovidesimportantHIV-relatedservicesthatarenotalwaysprovidedbyinsuranceplans
ThosewhoareundocumentedarenoteligibleforMedicaidormarketplaces;Legalresidentshave5yearwaingperiodfor
Medicaid
Next steps . . .
Top Related