August 2013 PLUS Health care reform and people with HIV


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  • See last slide - 24% of the ~7,700 PLWH in SF who received Ryan White funded services in 2012 were uninsured. This is the primary populations we are talking about who are likely to be impacted the most by Health Care Reform implementation% adds up to 90 to account for Undocumented/new immigrants who are categorically excluded. This is a VERY rough estimate
  • August 2013 PLUS Health care reform and people with HIV

    1. 1. Health care reform and people with HIV/AIDS Courtney Mulhern-Pearson August 3, 2013
    2. 2. SAN FRANCISCO AIDS FOUNDATION 2 1 2 3 What does health care reform do? What’s going on in California? What can you do now?
    3. 3. SAN FRANCISCO AIDS FOUNDATION 3 Status quo = access to care crisis The Current Crisis 42-59% of low- income people living with HIV not in regular care Impossible to obtain individual insurance and few insured through employer system Medicaid/ Medicare are lifelines to care, but disability standard means they are very limited Demand for Ryan White care and services > funding 29% of people living with HIV uninsured
    4. 4. SAN FRANCISCO AIDS FOUNDATION 4 Ryan White program not keeping pace with need Sources: “Estimated Number of Persons Living with AIDS,” Centers for Disease Control and Prevention,; Ryan White Appropriations History, Heath Resources and Services Administration, Inflation calculated using;; “Funding, FY2007-FY2010 Appropriations by Program,
    5. 5. What does HCR actually do? • Individual mandate: U.S. Citizens and Legal Residents must maintain health insurance coverage. • Addresses Affordability:  Provides subsidies for lower income people;  Exemptions for hardship;  Out of pocket caps on coverage • Expands Coverage and creates a standard package of Benefits, including free preventive services • Provides Consumer Protections What does health care reform actually do?
    6. 6. New Insurance Options Improves Medicaid (~ 60% of currently uninsured people with HIV): • Expands eligibility to everyone below 138% FPL regardless of disability status • provides essential health benefits (EHB); same package as traditional Medi-Cal in CA • allows for free preventive services Creates Private Insurance Marketplaces (~ 30% of current uninsured people with HIV): • Federal subsidies up to 400% FPL • Called Covered California • eliminates premiums based on health/gender • provides EHB • supports outreach, navigation and enrollment • Allows for Basic Health Plan – not this year New insurance options
    7. 7. Who is left out? Undocumented immigrants: • Barred from state-based exchanges • Not eligible for non-emergency Medicaid • Eligible for restricted “emergency” Medicaid • Eligible for services through community health centers and/or safety-net providers, Ryan White, Healthy San Francisco Legally present immigrants: • Still face 5 year waiting period for Medicaid services – California has chosen to move legally present immigrants into the marketplace with full wrap-around • Can purchase with subsidies in Marketplace Medically Fragile and perpetually out-of-care Who’s left out?
    8. 8. Ryan White – Challenges for PLWH and their Providers • Ryan White program (RW) – patient centered comprehensive HIV care • Payer of last resort : RW can’t pay for services that can be provided under other coverage • HCR expanded coverage means transitions – Transitions to new plans, providers, pharmacies – Once in new coverage, may need continued access to some RW services: • Those not offered by other coverage: specific types of case management, adherence, linkage to housing • Help with costs: out of pocket and premium costs for care and medications Challenges for people with HIV and their providers
    9. 9. “A Bridge to Health Care Reform” July 2011 • Low Income Health Program (LIHP) Partial and temporary county – based Medicaid expansion: Health PAC in Alameda – Ends December 31, 2013 – State forgot to plan for people with HIV • Alameda and LA finish PLWH transition 07/08, 2013 – Eligibility & delivery system varies by county • Eligibility range from 25% FPL to 200% FPL – Met goal: serves > 550,000 uninsured Californians • Medi-Cal managed care expansion: moved most from fee-for-service into Medi-Cal managed care plans “A bridge to health care reform”
    10. 10. What Will Health Care Reform Bring in 2014? • Medi-Cal (California’s Medicaid program) expansion • A state run Marketplace - Covered California • Transitions for people with HIV and providers: – From LIHP and RW to Medi-Cal expansion and Covered California – Considerations: Continuity of care with providers and pharmacy and integration (RW services working with new forms of coverage) strategies What will change in 2014?
    11. 11. Covered California • Limited, standardized plan offerings • Open enrollment October, 2013 - March 31, 2014 • Assistance with enrollment and trouble shooting • Not clear how many HIV providers are in plan networks • Most people with HIV will need assistance with costs – Planning beginning for wrap around programs • HIV - small population; “issues not on front burner” – Won’t get all we need/want in first year of development Covered California
    12. 12. CA Assisters Program • Assisters: entities and people who will be compensated for enrolling individuals in plans – Applications should be out soon – Training begins in August, 2013 • Navigators: entities that will outreach to specific populations that are uninsured after initial enrollment The assisters program
    13. 13. Assisting with Cost in New Coverage • State Office of AIDS beginning to plan for assistance with out of pocket and premium costs in Covered California • Current programs OA Health Insurance Premium Payment Program (OAHIPP)and others pay only premiums – Programs not working well now – Need program development and improvement • ADAP pay co-pays for ADAP drugs only • Need wrap around for primary care costs Help with cost in new coverage
    14. 14. • Planning and funding services for new environment • Individual transition planning and assistance • Legal aid/benefits counseling for new systems • Does RW funding support outreach, linkage, engagement and retention in care? • HIV Services sustainability • Non-medical and prevention providers planning for sustainability • Strategic partnerships • Medical settings sustaining coordinated care model • CHC alignment, Medi-Cal managed care, Managed/Accountable Care structures, partnerships with community based organizations • One planning model: SF Health Care Reform Task Force • Helping clients and providers transition and integrate • Recommendations, provider road map & client education templates The role of local communities
    15. 15. Role of Individuals and Support Groups  Understand current health care coverage  What services do you depend on and where do they come from?  Begin to consider your options in new environment  What changes are coming in your area and how do they affect you  Begin conversation with your HIV providers including about how they expect to offer services after 2014  Read and save information you receive  Ask if you don’t understand materials  Each one, teach one Role of individuals and support groups
    16. 16. Health Care Reform Planning “If we wait for governments, it’ll be too little, too late. If we act as individuals, it’ll be too little. But if we act as communities, it might just be enough, just in time.” Transition network Health care reform planning
    17. 17. Resources State HCR Information - Enroll America  Center for Budget and Policy Priorities - Treatment Access Expansion Project – Kaiser Family Foundation – Families USA – NASTAD – Health Resources and Services Administration – Resources
    18. 18. CA Resources Covered California – Health Access - Western Center on Law and Poverty – National Senior Citizens Law Center – Health Consumer Alliance – California resources
    19. 19. Contact Courtney Mulhern-Pearson, San Francisco AIDS Foundation 415.487-8008 Contact
    20. 20. SAN FRANCISCO AIDS FOUNDATION 21 1035 Market Street, Suite 400 | San Francisco, CA 94103