Policy Update:The Affordable Care Act and the Ryan White Program, presented by Matthew McClain

1. Policy Update:
The Affordable Care Act and the
Ryan White Program
Philadelphia EMA Planning Council
August 9, 2012
Presented by Matthew McClain

2. Today’s Topics
Affordable Care Act
Medicaid expansion
Essential Health Benefits
Ryan White Program
FY 2013 Appropriations
Reauthorization
Actions and Resources
August 2012 Policy Update 2

3. Today’s Handouts
1. 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
August 2012 Policy Update 3

4. The HIV Health Care Environment
August 2012 AACO Director’s Meeting Federal Policy Update 4

5. Affordable
Care
Act
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

6. What
Happened
First Supreme Court decision
on ACA
Individual mandate is valid
Insurers 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
Policy Update 6August 2012

7. 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
Policy Update 7August 2012

8. Implications for States Failing to Expand
States 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
Policy Update 8August 2012

9. 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
August 2012 Policy Update 9

10. 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
Policy Update 10August 2012

11. Coverage Options by 2014
August 2012 Policy Update 11

12. Essential
Health
Benefits
Highlights
• 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
Policy Update 12August 2012

13. Required
Essential
Health
Benefits
Ambulatory services
Emergency services
Hospitalization
Maternity/newborn care
Mental health and substance use
disorder services
Prescription drugs
Rehabilitative services
Laboratory services
Prevention, wellness, and chronic
disease management services
Pediatric services
Policy Update 13August 2012

14. 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 management
Mental health and substance
abuse services
Preventive and wellness services
Laboratory testing
Services needed to meet national
standards of HIV care
Policy Update 14August 2012

15. 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
Policy Update 15August 2012

16. 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?
Policy Update 16August 2012

17. 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
Policy Update 17August 2012

18. Status of
HIV/AIDS
FY 2013
Appropria-
tions
Program
FY2012
(millions)
FY2013
Obama
FY2013
Need
FY2013
Senate
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
August 2012 Policy Update 18

19. 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?
August 2012 Policy Update 19

20. 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
Policy Update 20August 2012

21. CAEAR Coalition Guiding Principles for
Reauthorization
Open access to quality health care
Ensure continuity of care
Fortify resources and increase client
capacity
Maintain and strengthen flexibility and
adaptability
August 2012 AACO Director’s Meeting Federal Policy Update 21

22. Principle 1:
Open
Access to
Quality
Health
Care
Access and accountability
Cultural competency
Quality medical training
August 2012 Policy Update 22

23. Principle 2:
Ensure
Continuity
of Care
Aligning and integrating
systems of care
Linkage to appropriate care
Reducing HIV-related health
disparities
August 2012 Policy Update 23

24. Principle 3:
Fortify
Resources
and
Increase
Client
Capacity
Sufficient funding and effective
distribution of resources
Infrastructure and essential
support services
Workforce development
Organizational and network
capacity
August 2012 Policy Update 24
August 2012

25. Principle 4:
Maintain
and
Strengthen
Flexibility
and
Adapta-
bility
ACA transition flexibility
Support local control
August 2012 Policy Update 25

26. 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)
August 2012 Policy Update 26

27. 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)
August 2012 Policy Update 27

28. 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
August 2012 Policy Update 28

29. 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
August 2012 Policy Update 29

30. Thank you!
MatthewMcClain
AIDSpolicy@aol.com
August 2012 Policy Update 30