emily mccloskey national alliance of state & territorial aids directors august 4, 2014 adaps and...
TRANSCRIPT
Emily McCloskeyNational Alliance of State & Territorial AIDS Directors
August 4, 2014
ADAPs and the First Open Enrollment Period
Presentation Agenda
Inaugural Open Enrollment
ADAP Transitions
Looking Forward
Overview of NASTAD
NASTAD is an international non-profit association of U.S. state health department HIV/AIDS program directors who administer HIV/AIDS and viral hepatitis programs funded by U.S. state and federal governments.
NASTAD was established in 1992 as the voice of the states.
NASTAD is governed by a 20 member, elected Executive Committee charged with making policy and program decisions on behalf of the full membership.
NASTAD has a Washington, DC headquarters with 38 staff and field offices/programs in Bahamas, Botswana, Ethiopia, Guyana, Haiti, Trinidad, South Africa and Zambia with 65 staff.
NASTAD Mission and Vision
Mission
NASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis.
VisionNASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.
Inaugural Open Enrollment
Enrollment into Coverage:Where States stand on Medicaid
Source: Kaiser Family Foundation
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV NE
MT
MO
MS
MN
MI*MA
MD
ME
LA
KY KS
IA*
IN* IL
ID
HI
GA
FL
DC
DE
CT
CO CA
AR*AZ
AK
AL
Implementing Expansion in 2014 (27 States including DC)Open Debate (5 States)Not Moving Forward at this Time (19 States)
The Inaugural Open Enrollment Period
A multitude of challenges:– Healthcare.gov and state exchanges– 3rd party payer issues– Limited coordination between Marketplaces and
Medicaid– Availability of plan information– Formulary gaps– High cost sharing/co-insurance– Political environment in many states made it difficult for
state employees to participate in ACA implementation activities
– Many clients remain ineligible because their state has not expanded Medicaid
Insurance Assistance and Premiums: Prescription Drug Formulary
EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan
USP Category
USPClass
Anti-viral NRTIs
NNRTIs
Protease inhibitors
Anti-Cytomegalovirus (CMV) agents
Anti-hepatitis agents
Other
Missing from USP classification system = combination therapies
ADAP Transitions
HRSA/HAB Policies and ADAP Insurance Purchasing
HRSA encourages state ADAP/Part B Programs to use their Ryan White funding to help clients access insurance, as long as:– Formulary includes at least one drug in each class of core ARVs
from the HHS Clinical Guidelines– It is cost-effective in aggregate as compared to purchasing
medications Other Ryan White Program grantees may also use their funds to
help clients with the cost of insurance The Ryan White Program is the payer of last resort and grantees
must “vigorously pursue” client eligibility for public and private insurance– Grantees may not dis-enroll clients from services for failure to
enroll in public or private insurance coverage Ryan White Program funds may be used to cover services not
covered or inadequately covered by public and private insurance
25,000 ADAP Clients Transitioned to Medicaid Expansion and Qualified Health Plans (QHPs)
AL
ARGA
ID
IL IN
KY MO
MT
NV
NH
OH
SC
SD
TX
VA
WY
OK
ME
MD
NJ
NY
OR
AK
CO
LA
UT
CAKS
MS
FL
HI
NMAZ
ND
MN
IA
WIMI
NE
WA
PA
NCTN
WV
VT
DE
CT
DC
Medicaid QHPs Total12,004 13,129 25,133
Enrollments in the West
ID
MT
NV
WY
OR
AK
CO UT
CA
HI
NMAZ
WA
11,063 Enrollments
Medicaid QHPs
8,837 2,226
Enrollments in the Midwest
IL IN
MO
OH
SD
KS
ND
MN
IA
WIMI
NE
7,508 Enrollments
Medicaid QHPs
1,013 6,495
Enrollments in the East
NH
OH
ME
MD
NJ
NY
PA
WV
VT
DE
CT
DC
MA
RI
1,866 Enrollments
Medicaid QHPs
1,312 554
Enrollments in the South
Medicaid QHPs Total
842 3,854 4,696
AL
ARGA
SC
TX
VA
OK
LA
KY
MS
FL
NCTN
WV
Leveraging the ACA to Raise the Bars:Translating Coverage into Care and Treatment
SERVICE QHP MEDICAID RW/ ADAP/CDC
HIV Testing Continue to cover in certain settings
RX Cost-sharing assistance
MEDICAL CASE MANAGEMENT
ORAL HEALTH
LABS Cost-sharing assistance
MENTAL HEALTH SERVICES
Cost-sharing assistance
SUBSTANCE ABUSE TREATMENT
Cost-sharing assistance
HIV PRIMARY CARE Cost-sharing assistance
MEDICAL TRANSPORTATION Limited Coverage
INPATIENT HOSPITAL SERVICES
Adapted from West Virginia Ryan White Part B Program
Looking Forward
Enrollment into Coverage:Key Dates
15th
31st
Qualified Health PlansMARCH
• Enrollment Deadline for a Plan Effective Date of April 1st
• Enrollment Deadline for a Plan Effective Date of May 1st
• Deadline to switch plans
Medicaid CONTINUOUS ENROLLMENT
November 15, 2014 to February 15, 2015 Next open enrollment period pushed back
2015 QHP Open Enrollment Period
31stPCIPsApril
30th
• PCIP coverage ends
Enrollment into Coverage:Mapping ACA Coverage Transitions
Uninsured• Lawfully present• Income up to 138% FPL
Medicaid
Uninsured• Lawfully present• Income 100 - 400% FPL
Subsidized private insurance through Marketplace
Uninsured and in non-Medicaid expansion state• Lawfully present• Income below 100% FPL
Unsubsidized private insurance through Marketplace
Currently on Medicaid No transition
Currently on other government-sponsored insurance (e.g., Medicare, TRICARE)
No transition
Currently on or have access to employer-based coverage
If plan is affordable and comprehensive, no transition
Currently on PCIP or high risk pool Medicaid or Marketplace coverage
Uninsured & categorically ineligible for federal programs
No transition
Grantees are defining how to“vigorously pursue” client eligibility for Medicaid and QHP coverage
Churning
Addressing the “Medicaid Gap” in Non-Expansion States
68% of ADAP clients in non-Medicaid expansion states have an income
below 138% FPL
Ryan White Programs are: Purchasing insurance for
those in the “Medicaid Gap”
Providing safety net for those who cannot afford insurance or who are not otherwise eligible
To help fill the gap…
Challenges and Priorities
Challenges• Availability of plan information• Formulary gaps• High cost sharing/co-insurance• Political environment in many states made it difficult for state
employees to participate in ACA implementation activities• Many clients remain ineligible because their state has not
expanded Medicaid
Priorities/Solutions• Advocate for Medicaid expansion• Increase Ryan White capacity to assist clients with costs• Identify work-arounds to obtaining insurance information• Advocate with federal government, state government,
and insurers about importance of formulary coverage for ALL ARVs
• Continue to educate clients about ACA and prepare for continued enrollment efforts in November
Questions and Answers
Contact Information
Emily McCloskeyManager, Policy and Legislative Affairs
NASTADPhone: (202) 434.8090