policy update:the affordable care act and the ryan white program, presented by matthew mcclain

Policy Update:The Affordable Care Act and the

Ryan White Program

Philadelphia EMA Planning CouncilAugust 9, 2012

Presented by Matthew McClain

Today’s TopicsAffordable Care ActMedicaid expansionEssential Health Benefits

Ryan White ProgramFY 2013 AppropriationsReauthorization

Actions and Resources

August 2012 Policy Update 2

Today’s Handouts1. CAEAR Coalition Comments on the Future of the Ryan

White Program (July 31, 2012)2. Ryan White Work Group Comments on Next Steps for the

Ryan White Program (July 31, 2012) 3. AIDS Budget and Appropriations Coalition: FY 2013

Appropriations for HIV/AIDS Programs (August 2, 2012)4. NHeLP 50 Reasons for Medicaid Expansion (August 2,

2012)5. Urban Institute: Considerations in Assessing State-

Specific Fiscal Effects of the ACA’s Medicaid Expansion


The HIV Health Care Environment

August 2012 AACO Director’s Meeting Federal Policy Update 4

AffordableCareAct

Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act (March 2010)

National Federation of Independent Business versus Sebelius (June 28, 2012)

Policy Update 5August 2012

What Happened

First Supreme Court decision on ACA

Individual mandate is validInsurers must abandon pre-existing condition exclusions and lifetime caps on coverage

Essential health benefits upheld

Curbs the power of Federal government to enforce the Medicaid expansion


Implications for Medicaid Expansion States

Supreme Court did not strike the Medicaid expansion nor make it optional

Many implementation questions, some of which the President and HHS will address

Federal match will be 100% initially then 90% (now 57%)

States that expand must comply with all mandatory provisions such as reasonable promptness and due process


Implications for States Failing to ExpandStates that do not

expand must still cover all individuals under 133% FPL and meet other ACA and Medicaid Act requirements

Maintain Medicaid eligibility criteria and MAGI as of March 2010

States not allowed to expand to <138% FPL and get the ACA match

Uninsured people with incomes below FPL are ineligible for health exchange subsidies

Must extend Medicaid coverage to low income children aged 6-19 years


Uninsured Adults with Incomes Below 138% FPL by Medicaid Eligibility Status

Newly Eligible Currently Eligible

Total Eligible

Uninsured

<138% FPL

<100% FPL

<138% FPL

<138%FPL

US 15.0 million

11.4 million

4.3 million

19.4 million

PA 520,000 398,000 92,000 613,000

NJ 307,000 245,000 42,000 349,000

Source: The Urban Institute Health Policy Center


Reform Priorities for People Living with HIV/AIDS and HIV Advocates

Ensure that a comprehensive Essential Health Benefits package

Ensure access to essential services covering the gaps

Ensure smooth transition for vulnerable populations

Prepare service organizations for a changing healthcare landscape

Make Medicaid managed care work for people with HIV


Coverage Options by 2014


Essential Health BenefitsHighlights

• Qualified Health Plans offered through Exchanges

• State Medicaid programs for newly eligible beneficiaries

• Basic Health Plans for people between 133%-200% FPL

• No higher premiums based on health status or gender

• No cost sharing for preventive services


Required Essential Health Benefits

Ambulatory servicesEmergency servicesHospitalizationMaternity/newborn careMental health and substance use

disorder servicesPrescription drugsRehabilitative servicesLaboratory servicesPrevention, wellness, and chronic

disease management servicesPediatric services


EHB Package that Meets the Care and Treatment Needs of PLWHA

Unlimited access to antiretroviral drugs and viral hepatitis medications

Unlimited access to HIV/infectious disease specialists

Case managementMental health and substance abuse

servicesPreventive and wellness servicesLaboratory testingServices needed to meet national

standards of HIV care


EHB Process By September 28, 2012, States must tell Federal government which benchmark plan it selected and what additions are needed to meet EHB and non-discrimination mandates of ACA

HHS will review the plan to assure it meets the requirements


Questions Regarding EHBs to Meet the Needs of PLWHA

What are the most important benefits for PLWHA?

Which plans will be considered?

What benefits do those plans currently offer?

What are the concerns?Which plan looks best?What needs to be added?


Ryan White Program

Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87, October 30, 2009).

First enacted in 1990 as the Ryan White Comprehensive AIDS Resources Emergency Act.

Amended and reauthorized 4 times-1996, 2000, 2006, and 2009

Current law expires in 13 months but does not sunset, permitting appropriations and implementation after September 30, 2013


Status ofHIV/AIDSFY 2013 Appropria-tions

ProgramFY2012

(millions)FY2013 Obama

FY2013Need

FY2013Senate

RWP $ 2.392 +$ 80.0 +$ 483.0 +$ 30.0

CDC $ 1.11 +$36.0 +$ 684.0 +$ 2.0

HOPWA $ 332.0 -$ 2.0 +$ 48.0 -$ 2.0


HIV Care Advocacy Questions

• What is the future of the Ryan White Program?

• What will bridge services from the expiration of RW in 2013 to when coverage starts in 2014?

• Will RW need to focus on what and who won’t be covered such as wrap-around/support services, undocumented persons, accessing the new system, and quality?


Ryan White and ACA

RWP providers will be increasingly dependent on 3rd party payment (51% now to as much as 80% with ACA)

Number of entirely uninsured RWP clients should decrease dramatically

Gaps to be determined will remain: e.g. uninsured, those not enrolled, insurance coverage gaps, ineligibles, HIV prevention services


CAEAR Coalition Guiding Principles for ReauthorizationOpen access to quality health careEnsure continuity of careFortify resources and increase client capacity

Maintain and strengthen flexibility and adaptability

August 2012 AACO Director’s Meeting Federal Policy Update 21

Principle 1:Open Access to Quality Health Care

Access and accountabilityCultural competencyQuality medical training


Principle 2:Ensure Continuity of Care

Aligning and integrating systems of care

Linkage to appropriate careReducing HIV-related health disparities


Principle 3:

Fortify Resources and Increase Client Capacity

Sufficient funding and effective distribution of resources

Infrastructure and essential support services

Workforce developmentOrganizational and network capacity


August 2012

Principle 4:Maintain and Strengthen Flexibility and Adapta-bility

ACA transition flexibilitySupport local control


Local Activities to Prepare for ACA and Ryan White Reauthor-ization

• Use existing data systems (e.g., unduplicated RWP client data analysis of insurance status)

• Maximize 3rd party billing• Understand gaps in coverage• Participate in national and state advocacy group processes and decisions (e.g., CAEAR Coalition and PA Health Choices Work Group)


Act Now • Improve provider and organizational knowledge and skills (e.g., RWP monitoring standards, Medicaid participation, patient navigation, medical case management)

• Improve consumer knowledge and skills (e.g., rights, responsibilities, eligibility, program navigation)


General Resources

• HealthCare.gov• WhiteHouse.gov• HHS.gov• Families USA• Urban Institute• Kaiser Foundation• National Health

Law Program

• Trust for America’s Health• National Association of County

and City Health Officials• Association of State and

Territorial Health Officials• National Association of

Community Health Centers• State Healthcare Access

Research Project


HIV-Specific Resources

• AIDS.gov• Treatment Access

Expansion Project• Treatment Action Group• HIVhealthreform.org• Federal AIDS Policy

Partnership

• CAEAR Coalition• National Association of

State and Territorial AIDS Directors

• AIDS United• HIV Medicine

Association• Coalition for a National

AIDS Strategy


Thank you!

Matthew [email protected]


policy update:the affordable care act and the ryan white program, presented by matthew mcclain

Health & Medicine

acas medicaid expansion

themedicaid expansion

optional states

hiv health care environment

ryan white work group

appropriations coalition

caear coalition comments

federal match