The Affordable Care Act Implementation:

A National Overview

Spring 2015

 

American Academy of HIV Medicine

US Census: Majority of Americans 19-64 Years Of Age Are Enrolled in Commercial Insurance

19-25 26-34 35-44 45-640%

10%

20%

30%

40%

50%

60%

70%

Private Public Uninsured

Age Group

ACA Medicaid Expansion

Henry J. Kaiser Family Foundation, January 2015. http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/

Current Status of State Medicaid Expansion Decisions, January 2015

Medicaid Managed Care (MCOs)

ACA Marketplace

ACA Marketplace/Exchange

Online one-stop virtual “marketplace,” where individuals, families, and employees of small businesses can purchase health insurance from Qualified Health Plans (QHPs)• Individuals and families with incomes between 100-400% FPL

ineligible for other affordable employer-based or government-based may be eligible for premium tax credits and/or cost sharing reductions

• Cannot charge higher premiums based on gender or health status• Cannot deny coverage to individuals based on pre-existing conditions• Cannot set annual or lifetime limits on the amount of benefits paid• Extends dependent coverage up to 26 years of age• Prohibits imposing annual dollar limits on essential health benefits• Cover specified preventive health services without cost-sharing

QHPs Offer Premiums Based on “Metal Levels” or Actuarial Value”

Bronze: Member pays 40%, QHP pays 60%

Silver: Member pays 30%, QHP pays 70%

Gold: Member pays 20%, QHP pays 80%

Platinum: Member pays 10%, QHP pays 90%

Impact of the ACA Marketplace and Medicaid on the Ryan White HIV/AIDS Program

Impact of the ACA and Medicaid Expansion on RWHAP

• The HRSA HIV/AIDS Bureau (HAB) administers RWHAP• HAB determined that the RWHAP is the “payer of last

resort”• Grantees must “vigorously pursue” client enrollment in

private or public insurance– Some programs have been aggressive in enrolling clients without

adequate ongoing education and navigation assistance

• Grantees may not disenroll clients from services if they do not enroll in health insurance

Impact of the ACA and Medicaid Expansion on RWHAP

• HAB encourages ADAPs to assist clients to enroll in insurance if– Insurers’ formularies include at least one drug in each ARV class– It is cost-effective to support premiums compared to purchasing

medications

• RWHAP-funded providers have variable experience with public and commercial health insurance markets– Must enroll in QHP and Medicaid MCO provider networks– Credential their clinicians– Develop health insurance billing capacity– Undertake intensive “coordination of benefits” for clients enrolled ADAP

and QHPs or Medicaid MCOs

• The RWHAP’s future is unclear at the federal and state levels

ProblemAreas & Trends

National Trends

Positive Side• The number of Americans without health insurance has

been reduced by about 25 percent (8 to 11 million people)– Will continue

• HIV Patients that could not get covered before are now• Patient Protections under the law we never used to have

Issues: Patients

• Affordability Issues– True Out-of-Pocket

• Formulary Issues– Tiering of HIV meds– Coverage of Single Tablet Regimens (STRs)– Formulary Changes (Additions/Drops) throughout coverage year– Requirements based of the USP categories – Formulary Appeals Process cumbersome– Success Rate?

• Non Discrimination Requirements– Enforced?

Issues: Patients

• Loss of Case Management Services– RWCA levels vs. Medicaid

• Pharmacy Issues– Required use of Mail-Order Pharmacies– Adherence disruptions

• Provider Networks– Not Up-to-date Directories– Access &Travel Burden– Out-of-Network Standards

Issues: Patients – Premium Affordability

Issues: Patients – Formulary Tiering

Issues: Patients – Formulary Tiering

Issues: Patients - Gaps In Coverage

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

Issues: Patients – Medication Affordability

Issues: Patients - Pharmacy

Requirements to use Mail-Order Pharmacies: • Patient Adherence Subject to

Shipping• Loss of Adherence Counseling

Services• Outsourced services with

different coverage

Issues: Providers

• Prior Authorization Burden– Formulary not aligned with HIV Treatment Guidelines

• Step Therapy Requirements• Required use of components / generics

– Utilization Management Restrictions

• Provider Networks– Reports of closed networks– Unfamiliarity with contracting– Out of date Provider lists

• Reimbursement & Future Planning

Issues: Providers – Utilization Management

Issues: Providers – Formulary vs. Treatment Guidelines

• EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan

Federal Advocacy Efforts

Federal Advocacy Efforts

Federal AIDS Policy Partnership & Health Care Access Working Group• Comments on proposed rules and regulations.• Communications with federal law makers

– Administration- HHS, CMS, HRSA, etc.– Congress – Oversight committees

Federal Advocacy Efforts

CMS Notice of Payment and Benefit Parameters for 2016• Better definition of EHBs• Stronger Prescription Drug Standard

– Replace Benefits Managers with P&T Committees – Refer to National Treatment Guidelines as basis for coverage – Review new meds within 30 days and determination by 90 days

Federal Advocacy Efforts

• Move from USP to American Hospital Formulary Services (AHFS)– More nuanced subclasses of ARVs– Includes combination therapies

• Formulary Exceptions Process– 24 hour appeal process– Secondary external review process

• Formulary Transparency for Consumers– Ability to view PA or UM– Co-insurance & Cost-sharing– No changes mid-year

Federal Advocacy Efforts

• Mail Order Pharmacy – Optional brick & morter– Additional costs count towards Out of Pocket Max

• Non-Discrimination– Plan designs that impact HIV patients selection

• Network Adequacy– Reasonable access standard in terms of time and distance

• HRSA Standards

– Exception for Out-of-Network Providers– Transparency, Updated Lists, Identify ECPs

Changes in 2016

Final Rule – Changes to the 2016 plans • P&T Committees

– plans must establish pharmacy and therapeutics committees that will in turn develop drug formularies.

• Formularies – have to provide appropriate access to drugs included in broadly

accepted treatment guidelines and be consistent with best practice formularies

2016 Plans

• Exception Process – plans must make a decision and notify the enrollee or physician

within 24 hours of a request – New “standard exceptions process,”

• patient or physician can request coverage of a clinically appropriate non-formulary drug and receive a decision within 72 hours of a request.  

• State regulators will be primarily responsible for enforcing these requirements. 

Florida precedent

The AIDS Institute & National Health Law Project• Filed a complaint with the Office of Civil Right at HHS

(May 2014)– CoventryOne, Cigna, Humana, Preferred Medical– Allege discriminatory benefit design

• Aetna & Coventry voluntarily announced it will HIV medications to a generic brand tier that will lower co-payments to a range of $5-$100, after deductibles (effective June 1, 2015)

Louisiana Precedent

2014 Lambda Legal filed law suit• Blue Cross Blue Shield (BCBS) announced they would not

longer accept 3rd party payments– Ryan White Premium Assistance

• CMS clarification that they expect insurers to accept 3rd party payments

• The Louisiana Legislature passed, and Governor Jindal signed, Louisiana Revised Statute 22:1080(June 2014)– Forcing insurers to accept RW payments

Which cop is on the beat?

Federal Regulators

Federal Regulators

Federal Regulators

Advocacy on Your Behalf

The Most Important Thing:

Document and report discriminatory, illegal, and medically inadvisable practices & requirements!

AAHIVM Health Reform

Reporting Survey

www.aahivm.org

Project Speak Up! • HIVHealthReform.org and the Center

for Health Law and Policy Innovation Harvard Law School

http://www.hivhealthreform.org/speakup/

For more information contact:

Holly Kilness Packett

Director Public Policy

holly@aahivm.org