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ADAP ADVOCACY ASSOCIATION

PRESENTATION

Monday August 4, 2014

Denver Digital Photography

Transitioning ADAP Clients to Medicaid & Marketplace Plans: The Colorado Success Story

Todd Grove Colorado Department of Public Health & Environment – AIDS Drug Assistance Program

Rich Wolf Digital Photography

FED ER AL H IV A ID S R ESO U R C ES

P A R T AEM As -T G As

D enver M ayor'sO ffice of H IV R esource s

P A R T BS tates and T errito rie s

ADAP & Base Fundin gS tate of CO -CDPHE

P A R T CInfectious D isease C lin ic s

B eacon, D enver,P ueblo C om m ., S t. M ary 's

P A R T S D -FW IC Y -D E N T AL

S P NSC hild ren 's U n ivers ity H osp .

M in o rity A ID S In it ia t iveP A R T S A B C

Part B - ADAP outreac hPart A- Sub. abuse, mental health

H e a lth R e sou rc e S e rv ice s A dm in istra t ionH IV /A ID S B u re a u (H R S A - H A B )

R ya n W h ite T re a tm en t E x te ns io n A ct o f 2 0 09R Y A N W H IT E C A R E A C T

•Medicaid

•Colorado Indigent Care Program (CICP)

•Medicare

•Tobacco class action lawsuit funds

Other Federal and State Programs

Colorado AIDS Drug Assistance Program

H IV M ed ic a tionA ss is tan c e P ro g ram

(H M A P ) D ire c td is tribu tio n H IV m e d ica t io ns

H e a lth Insu ra n ceA ss is tan c e P ro g ram

(H IA P ) - A cce ss to m e d ica t io nsth ro ug h p riva te in s u ra n ce

B ridg in g th e G a p, C OS t. P ha rm . A s s ista n ceA cc e ss to m e d ica t io ns

th ro ug h M e d P t D o r A d v.

S u pp le m e n ta l W ra p A rou ndP ro g ra m (S W A P )

A cc ess to co pa ym e n t ass ista n cefo r P LW H /A o n M ed ica id

A ID S D ru g A ss is tan ce P ro g ram(A D A P )

"C O R E E LIG IB IL IT Y"

Cost & Clients Served -2013

HMAP … 2,039 enrollees – 42,150 prescriptions $12,571,539.58*

HIAP … 690 – 10,887 prescriptions $1,022,003.61* $1,125,840 premiums, deductibles and co-pays 

BTGC … 869 enrollees - 26,189 prescriptions $1,320,628.07* 

Data provided by Colorado Department of Public Health & Environment

+What makes Colorado unique, (and may make duplication difficult)

Colorado had the nation’s largest ADAP waitlist in 2004 315 people Provided only 18 drugs (strictly

ARV)

Advocacy resulted in over $1 million in General Funding and over $3 million in tobacco class action lawsuit funds per year

Legislation allowed for ADAP committee to direct $$, with approval of the Medical Director

Allowed for innovative use of monies: Creation of a Medicare State

Pharmaceutical Assistance Program Reimbursement of insurance

premiums, as necessary Payment of inpatient medical care

HIV incidence in Colorado is “moderate” and efforts would be extremely difficult to emulate in higher incidence states, particularly those without local funding of any sort / states that did not expand Medicaid

+Colorado’s decisions related to the Affordable Care Act Expanded Medicaid (including

AwDC) to 133% of Federal Poverty Level –MAGI

Created an effective state-based insurance marketplace w/ improved Medicaid interaction

Supportive environment for enrollment outreach

Democratic Governor

Democratic majorities in both State House and Senate

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+Colorado’s efforts to transition enrollees to ACA plans Became a non-funded partner of

Health Coverage Guide network sanctioned by the marketplace “Connect for Health Colorado”

Paid for 14 individuals during open enrollment to enroll members in Medicaid, or ADAP-approved marketplace insurance plans with complete ADAP wrap-around

Identified Medicaid-eligible members on Health Insurance assistance to transition to Medicaid (waiver offered)

Co-located staff at larger HIV clinics to apply patients for Medicaid on-line

Purchased IT to allow Health Coverage Guides to patient homes or other locations to facilitate enrollment

Completed multiple attempts to outreach to members

Required a formal request to remain uninsured if they refused

Considering “off-marketplace” insurance options for undocumented patients next year

+25,000+ ACA-related Transitions Facilitated by State HIV Programs**

ID

MT

NV

WY

OR

AK

CO UT

CA

HI

NMAZ

WA

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

CA KS

MS

FL

HI

NMAZ

NDMN

IA

WIMI

NE

WA

PA

NCTN

WV

VT

DE

CT

DC

Medicaid QHPs13,000 12,500

Source: NASTAD**Through end of

March 2014

UNINSURED AFTER HCR

IMPLEMENTATION – RYAN WHITE

INSURED AFTER HCR IMPLEMENTATION

UNINSURED USING CICP AND HMAP IN 2013

Colorado ADAP / Insurance Status after Implementation

10

2,100 individuals

110 new HIAP members

400 new HIAP members

1,390 Medicaid /SWAP members

300 individuals1,181 insured patients

Ryan White Case Management Roles and DutiesCDPHE ADAP Office and Denver CAP for HIAP

Program management Financial management Eligibility and enrollment verification Auditing/quality assurance

Social Workers, Medical & Non- Medical Case Managers All program areas Eligibility and enrollment assistance Trouble shooting and client support

CDPHE, DCAP, ADAP OFFICE

AIDS Service Organizations &

Social Service Entities

Health Insurance Assistance Program Coordination Located at BCAP, DCAP, NCAP, SCAP & West CAP Coordination of premium, co-insurance, and co-payments No requirement for case management (can remain with other ASOs) Coordination of enrollment into marketplace by Health Coverage Guides

HIAP Coordination

Entities

+ Health Insurance Assistance Program (HIAP)

Wraps around employer, COBRA, and ACA marketplace insurance plans

Pays remaining costs of marketplace insurance after the APTC and Cost sharing assistance available has been applied

Pays premiums, medical and pharmaceutical deductibles, co-pays, and coinsurance Up to $10,000 in aggregate per client

Works with providers who are willing to bill for services

Pays for prescriptions through a Medication Assistance Card.

Assistance in enrollment through Connect for Health Colorado marketplace

Insurance Enrollment Sites

Boulder County AIDS Project

Colorado AIDS Project

Northern Colorado AIDS Project

Southern Colorado AIDS Project

Western Colorado AIDS Project

+Supplemental Wrap Around Program (SWAP)• New ADAP program to cover all Medicaid-eligible clients

with medication co-pay coverage for ADAP formulary

• Members will be able to use many more pharmacies if they choose (rather than 4 previous ADAP pharmacies)

• Recertification process easier (as member would have been screened eligible for Medicaid) = eliminates need for supporting documentation – income, residency.

• ADAP suggests that patients continue to use HMAP network pharmacy at least at first - easy movement to HIAP, or to HMAP if “churning” is an issue – allows for back-billing.

+The problem of “CHURN”

Loss of Medicaid may mean up to 45 days until access to insurance is established;

Enrollees can receive medication assistance for ADAP formulary drugs only through that time

May not qualify for CICP or the facility may not offer CICP

Enrollees often fail to notify ADAP of change in situation

Enrollees need to notify marketplace of change in income affecting eligibility; tax penalties and credits difficult to manage by the program

Enrollees may not be able to access same providers under Medicaid, or may have a waitlist

Problems presented by loss of Medicaid

Problems presented by loss of job/ eligibility for marketplace insurance

+How to improve % of clients who recertify every six months

Can’t get medications, (missed doses, would have to pay own costs)

HIAP can’t pay premiums or pay medical co-pays until recertification is complete

Medicaid and marketplace may not be told of changes of income – affect eligibility and APTC/ cost sharing

Patients are used to being able to miss recertification and rectify the situation with relative ease

Colorado is working on a system where recertifying with ADAP would make individuals recertified for all Ryan White services

With a loss of Medicaid or insurance temporarily, enrollees can get medication through HMAP

Members can get assistance in enrolling in the proper assistance program

Instituting text message reminders

Implications of not recertifying Benefits to enrollee

+Significant financial effect already:

From an average of 1,300 patients provided direct medications in fall 2013, the average has dropped to 300 (largely categorically ineligible for Medicaid or insurance, or CHURN members)

From over $1.2 million in costs, estimates after back-billing to Medicaid are $300,000 in expenses per month.

Increased budget for Health Insurance by close to $2 million dollars

Much smaller investment required for Medicaid wrap -around

UNINSURED PATIENTS INSURED PATIENTS

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+Net effect & concerns:

Robust application for partial pay rebates have provided significant program income

HRSA requires states to spend rebate income BEFORE Ryan White dollars

Results in large unexpended balance that may be “carried forward”, but will return to HRSA for redirection to other states if not spent in time

While morally correct to do so, any change in ability to apply for rebates would cause huge decrease in revenue…and lost Ryan White dollars would be desperately needed again

Successful management of Ryan White and funding offered by individual states will be redirected to states who refuse to expand Medicaid or invest in the epidemic in their own states

REBATE INCOME IMPLICATIONS of lost income

+Innovations to “Get to Zero”

Prevention planning to include discussion of biomedical components such as nPEP and perhaps even PrEP

Prevention planning may include targeted $ resources to assist high risk HIV – individuals to seek behavioral health interventions and other preventative financial assistance

PREVENTION and CARE

Denver Digital Photography

People

who have lived

with

diagnosed H

IV in

fectio

n for a

t least

12 months .

..

At least

one care

visit p

ast yea

r

Engaged in

care

or viro

logically

suppre

ssed pas..

.

Virologic

suppre

ssion***

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100% of PLWH

80% of PLWH73% of PLWH

65% of PLWH

HIV Care Continuum as of December 31, 2013, Colorado

* Data source: Enhanced HIV/AIDS Reporting System (eHARS). Defined as persons diagnosed with HIV infection (regardless of stage of disease) through year- end 2012, who were alive at year-end 2013.**Data source: CDPHE's CD4/VL database and eHARS. Calculated as the percentage of persons who had ≥2 CD4 or viral load results at least 3 months apart during 2013 among those diagnosed with HIV through year-end 2012 and alive at year-end 2013 or as the percentage of persons who were virologically suppressed at the time of their last lab during 2013, but did not have any additional lab >90 days away from this during 2013.*** Calculated as number of persons who had suppressed VL (<=200 copies/mL) at most recent test during 2013, among those diagnosed with HIV through year-end 2012 and alive at year-end 2013.

7,689

4,968

5,6106,188

Continuum of Care – Picture for ADAP Members

Focus on services that are proven to help people move through the cascade toward viral suppression

If a person is eligible for Medicaid, Medicare, or commercial insurance, the Ryan White Program is required to “vigorously pursue enrollment “ of the person in these types of coverage

If there is a service that would help move people through the cascade but cannot be funded from a third party payer, Ryan White funding can be used to pay for that service.

Monitor how well the entire system of care is assisting with achievement of viral suppression, not just the long-standing Ryan White system.

The post-ACA approach to HIV care:

Helping People Move Through the Cascade

First Diagnosis with HIV

Linked to Care

Retained in Care

Achieve Viral Suppression

The Process is NOT Linear

First Diagnosis with HIV

Linked to Care

Retained in Care

Achieved Viral Suppression

Lapsed in Care

Re-Engaged

ADAP Advocacy Association

Jeffrey S. Crowley

Distinguished Scholar/

Program Director, National HIV/AIDS Initiative

O’Neill Institute

Georgetown Law

Ryan White services are critical to engagement in care

+Innovation in the use of DIS, LTC and RTC personnelPROVIDE RESOURCES AS NECESSARY to ensure successful linkage to care and treatment

Disease Investigation Specialists – immediate linkage to enrollment services in ADAP, Medicaid, and Ryan White $$ when a patient has not enrolled in coverage

Linkage to Care – in addition to above, assessment of substance abuse, mental health issues, and access to resources through “Critical Event” pilot (described later)

Retention in Care personnel from State Health & partner agencies reviewing patients who appear to have dropped out of care, again, with $$ resources to assist – including housing, inpatient mental health and substance abuse treatment, medical transportation –

+

What is a “critical event”?

An event that makes it much more likely a client will drop out of medical care or never seek medical care to begin with.

A “marker” for a destabilizing crisis.

A severe challenge to a client who wants to achieve and maintain viral suppression.

Critical Event Initiative

+

Focused on short term stabilization (<90 days)

More structured approach to submitting and approving requests

Expedited and simplified for clients

Focused on clients at greatest risk of not achieving viral suppression

Uniform eligibility and assistance statewide

Coordinated across agencies and providers

Is not affected by funding shortages at local agencies

CE is an enhancement

+

Newly diagnosed with HIV (within the prior 90 days)

Recently lapsed in care (within the prior year)

Two Targets for the Pilot

+

Recently homeless (within prior 90 days)

Recently unemployed (within prior 90 days)

Diagnosed with gonorrhea, syphilis, or chlamydia (within prior 180 days)

Worsening health status due to hepatitis C (within prior 180 days)

Named as a partner, potentially infected someone with HIV (within prior 180 days)

Domestic violence (within prior 180 days)

Diagnosed with another acute illness requiring complex medical treatment or hospitalization, such as cancer (within prior 180 days)

Evidence based screening shows potentially severe addiction or drug dependence.

Evidence based screening shows potentially severe mental illness.

Critical Events for the Pilot

+

Clients with multiple critical events prioritized higher than clients with a single critical event.

State health staff and community agencies use same data system to track requests, plans, budgets, client progress, and case closure

The process starts with a “CE Form” submitted by state health staff or contractor

Evaluation of requests coordinated by a state health staff person

Each request has a “sponsor” at state health

Additional protocol provisions

+ How is CE different from the support already available to clients?

Existing Public Health Order (PHO) Process Only a small range of critical events

are related to a PHO. Enhanced services are offered in lieu

of, or as part of, a public health order.

If the client is determined not to meet PHO criteria, no enhanced services are offered.

Less involvement of community contractors

Existing processes for housing, EFA, etc. Clients experiencing critical events use

the “standard” process to request assistance.

Different levels of assistance and FPL eligibility based on place of residence (TGA)

Data sharing issues being addressed by statewide taskforce – would those in need want to identify themselves to state health for fear of incrimination or disease investigation concerns?

+ Questions33

+Contact information:

Todd Grove ADAP Coordinator

Colorado Department of Public Health & Environment

303-692-2783 todd.grove@state.co.us

www.colorado.gov/pacific/cdphe/services-people-hiv

https://www.facebook.com/COADAP

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