Potential Impact of the Affordable Care Act on the Ryan White HIV/AIDS Program

Final Report

November 29, 2012

Margaret Hargreaves Vanessa Oddo Ann Bagchi Boyd Gilman

Contract Number: Potential Impact of the HHSH250200646027I/HHSH25034007T Affordable Care Act on the Ryan Mathematica Reference Number: White HIV/AIDS Program 06993.800

Submitted to: Final Report Department of Health & Human Services Health Resources & Services November 29, 2012 Administration 5600 Fishers Lane Parklawn Building, Room 7C-07 Margaret Hargreaves Rockville, MD 20857 Vanessa Oddo Contracting Officer Technical Ann Bagchi Representative: Alice Litwinowicz Boyd Gilman

Submitted by: Mathematica Policy Research 955 Massachusetts Avenue Suite 801 Cambridge, MA 02139 Telephone: (617) 491-7900 Facsimile: (617) 491-8044 Project Director: Margaret Hargreaves

ACKNOWLEDGMENTS

We wish to acknowledge and thank the many individuals who contributed to all aspects of this project, including this final report: Margaret Hargreaves, Ann Bagchi, Vanessa Oddo, Boyd Gilman, Debra Lipson, Margo Rosenbach, and Alexandra Clifford (Mathematica) and Deborah Bachrach (Manatt Health Solutions).

In addition, we acknowledge and thank the many experts who participated in this project, as well as the state Medicaid agency and Ryan White HIV/AIDS program managers and administrators from Colorado, Iowa, Maryland, Massachusetts, New York, Oregon, and Texas.

Last, we wish to thank our HRSA contracting officer technical representative, Alice Litwinowicz, for her guidance and support throughout the project.

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CONTENTS

EXECUTIVE SUMMARY ...... xi

I INTRODUCTION ...... 1

A. Study Goals, Methods, and Conceptual Framework ...... 1

1. Project Methods ...... 1 2. Conceptual Framework ...... 1

B. Study Context ...... 2

1. HIV/AIDS Epidemic ...... 2 2. Ryan White HIV/AIDS Program ...... 3 3. Affordable Care Act Provisions ...... 4 4. ACA Implementation Timeline ...... 5 5. State ACA Early Implementation Experiences ...... 5

II HEALTH INSURANCE ELIGIBILITY AND EXCHANGES ...... 9

A. Introduction ...... 9

B. Eligibility Reforms ...... 9

1. Guaranteed Issue and PCIPs ...... 9 2. Individual Insurance Mandate and Exemptions ...... 11 3. Expansion of Medicaid Eligibility ...... 12 3. Eligibility Recommendations ...... 16

C. Health Insurance Exchanges ...... 17

1. Creation of Affordable Insurance Exchanges ...... 17 2. ACA Citizenship Requirements ...... 22 3. Exchange Recommendations ...... 23

III INSURANCE BENEFITS AND COSTS ...... 24

A. Introduction ...... 25

B. Insurance Benefits ...... 25

1. Essential Health Benefits and Benchmark Plans ...... 25 2. Basic Health Plan ...... 29 3. Benefit Recommendations ...... 31

C. Insurance Costs ...... 32

1. Private Insurance Tax Credits and Cost Sharing Reductions ...... 32 2. Preventive Service Cost Sharing ...... 34 3. Medicare Part D Donut Hole ...... 36 4. Cost Recommendations ...... 37 v Contents Mathematica Policy Research

IV SERVICE DELIVERY AND PAYMENT REFORMS ...... 39

A. Introduction ...... 39

B. Integrated Models of Care ...... 39

1. Medicaid Managed Care ...... 39 2. Patient-Centered Medical Homes and Medicaid Health Homes ...... 41 3. HIV Workforce Capacity ...... 44 4. Service Delivery Recommendations ...... 46

C. Provider Payment Reforms ...... 47

1. Medicaid Provider Reimbursement Rates ...... 47 2. Other Integrated Payment Reforms ...... 49 3. Payment Recommendations ...... 51

V RECOMMENDATIONS ...... 53

A. Introduction ...... 53

1. Transition Leadership ...... 53 2. Collaborative Transition Planning ...... 54 3. Education and Technical Assistance...... 55 4. Future Role for RWHAP ...... 56

B. Conclusions...... 56

REFERENCES ...... 64

APPENDIX A: STUDY METHODS ...... A.1

APPENDIX B: SEVEN STATE SAMPLE: ACA IMPLEMENTATION EXPERIENCES ...... B.1

APPENDIX C: INSURANCE ELIGIBILITY AND EXCHANGES ...... C.1

APPENDIX D: INSURANCE BENEFITS AND COSTS ...... D.1

APPENDIX E: PROVIDER SERVICE DELIVERY AND FUNDING REFORMS ...... E.1

TABLES

II.1 Eligibility Recommendations ...... 16

II.2 Exchange Recommendations ...... 23

III.1 Benefit Recommendations ...... 31

III.2 Cost Recommendations ...... 37

IV.1 Service Delivery Recommendations ...... 47

IV.2 Payment Recommendations ...... 52

V.1 ACA Recommendations and Potential Implementers ...... 58

A.1 Technical Expert Consultation Participants ...... A.5

A. 2 HRSA/HAB Potential Impact of ACA Study: States Selected For Medicaid Program Discussions ...... A.8

B.I.1 Seven State Sample: Early ACA Implementation Experiences ...... B.3

B.I.2 Seven State Sample: Coordination with RWHAP and Other Stakeholders ...... B.7

B.II.1 Seven State Sample: Pre-Existing Condition Insurance Plans ...... B.9

B.II.2 Seven State Sample: Expansion of Medicaid Eligibility ...... B.11

B.II.3 Seven State Sample: Creation of Health Insurance Exchanges ...... B.13

B.III.1 Seven State Sample: Essential Health Benefits and Benchmark Benefits ...... B.17

B.IV.1 Seven State Sample: Integrated New Models of Care ...... B.19

B.IV.2 Seven State Sample: Provider Capacity Issues ...... B.21

B.IV.3 Seven State Sample: Provider Reimbursement Rates ...... B.23

C.1 Guaranteed Issue and Pre-Existing Condition Insurance Plan ...... C.3

C.2 Individual Mandate and Exemptions ...... C.5

C.3 Expansion of Medicaid Eligibility ...... C.7

C.4 Creation of Exchanges and Enrollment Processes ...... C.9

C.5 Citizenship Requirements ...... C.11

D.1 Essential Health Benefits and Benchmark Benefits ...... D.3

vii Tables Mathematica Policy Research

D.2 Basic Health Plan Option and Private Insurance Subsidies ...... D.5

D.3 Preventive Service Cost Sharing...... D.7

D.4 Medicare Part D Donut Hole ...... D.9

E.1 Medicaid Managed Care ...... E.3

E.2 Medicaid Health Homes ...... E.5

E.3 Provider Capacity Issues ...... E.7

E.4 Provider Reimbursement Rates ...... E.9

E.5 Payment Reforms ...... E.11

E.6 Other Reforms: Section 1115 Waivers ...... E.13

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FIGURES

I.1 Conceptual Framework for Potential Impact of the ACA on RWHAP ...... 2

I.2 ACA Timeline ...... 6

II.1 Status of State ACA Medicaid Expansion Plans ...... 15

II.2 Status of State Health Insurance Exchange Implementation ...... 20

III.1 EHB Service Categories ...... 25

III.2 Status of State Essential Health Benefit Plans ...... 28

III.3 Net Premium Cost Limit as a Percentage of Income ...... 32

III.4 Out-of-Pocket Limits Based on Income ...... 33

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

EXECUTIVE SUMMARY

A. Study Purpose, Methods, and Conceptual Framework

On March 23, 2010 the Patient Protection and Affordable Care Act was enacted (Pub. L. 111- 148), followed by the enactment of the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) on March 30, 2010. Together, they are known as the Affordable Care Act (ACA) (SSA 2010). To understand the potential impact of the ACA on the Ryan White HIV/AIDS Program (RWHAP), the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration (HRSA) contracted with Mathematica Policy Research in September 2011 to conduct a one-year study. The study has two goals: (1) to assess the potential impact of the ACA on RWHAP, its grantees, providers, clients, and people living with HIV/AIDS (PLWHA) and (2) to identify how HAB can help the RWHAP community navigate the changes associated with implementation of key provisions of the ACA.

To conduct the study, between October 2011 and August 2012, the Mathematica team gathered and analyzed information from three sources: (1) a comprehensive scan of reports and analyses in ACA topic areas of greatest potential impact; (2) consultations with technical experts with in-depth knowledge of ACA reform provisions, RWHAP, Medicaid, HIV/AIDS, and states’ experiences with early implementation of the ACA; and (3) discussions with seven state Medicaid programs involved in planning and implementing the ACA reforms. The seven states were Colorado, Iowa, Maryland, Massachusetts, New York, Oregon, and Texas. Findings from these data were summarized in several interim project deliverables and are updated in this report, which presents the study’s final findings and recommendations.

Through the study, we identified six areas in which ACA reforms are likely to have a significant impact on RWHAP grantees, providers, clients and others with HIV/AIDS. These six areas address (1) insurance eligibility, (2) health insurance exchanges, (3) insurance benefits, (4) insurance costs, (5) health care delivery, and (6) provider payments. These areas are important leverage points that are expected to significantly affect the implementation of the ACA. We used these areas to organize the final report’s findings and recommendations, which are presented in Chapters II, III, IV, and V.

B. HIV/AIDS, RWHAP, and the National HIV/AIDS Strategy

In the United States, the number of PLWHA has grown steadily since the start of the epidemic to almost 1.2 million; PLWHA are living longer (due to better testing and treatment practices), while, as of 2010, the rate of new infections has remained steady at about 50,000 new infections per year (Centers for Disease Control and Prevention [CDC] August 2011). In 2010, an estimated 24 percent of PLWHA in the United States lacked health insurance, and experienced gaps in their access to the medical and support services needed to maintain their health and independence (Crowley and Kates September 2012).

xi Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research three to five years (Kaiser Family Foundation December 2006). More changes are expected due in part to the passage of the ACA, which is expected to dramatically decrease the number of uninsured PLWHA in the United States.

One of the priorities of the federal government has been to develop a national strategy for addressing the HIV/AIDS epidemic in the United States. Published in June 2010, the National HIV/AIDS Strategy (NHAS) has three overall goals: (1) to reduce the incidence of HIV/AIDS, (2) to increase access to HIV care and optimize the health outcomes of that care, and (3) to reduce HIV-related health disparities (ONAP 2010). Key provisions of the ACA support the NHAS by removing barriers to health insurance for people with pre-existing conditions such as HIV/AIDS, offering tax credits and cost-sharing reductions to make health insurance more affordable for PLWHA, and by expanding Medicaid eligibility to low-income adults, including PLWHA.

C. Affordable Care Act Provisions

The ACA is expected to expand health insurance coverage for up to 30 million uninsured Americans, while controlling health care costs and improving the country’s health care delivery system (Kaiser Family Foundation April 2011; CBO 2012). However, it is hard to predict exactly how many uninsured PLWHA will gain access to Medicaid or private insurance under the ACA. Some estimate that 25-30 percent of uninsured PLWHA will qualify for some form of insurance coverage and subsidies (Donnelly 2011). Others estimate that in states that are expanding Medicaid, such as California, as many as 70 percent of uninsured PLWHA could become eligible for the program (Donnelly 2011). Regardless of the exact estimate, the ACA will significantly increase access to Medicaid and private insurance among PLWHA (Crowley and Kates September 2012).

The law is expansive, with many different provisions that will affect the RWHAP community, including federal RWHAP administrators, state and local RWHAP grantees, local service providers, RWHAP clients and other PLWHA. Although many provisions of the ACA law are not scheduled for implementation until January 2014, until then states are expected to meet interim planning deadlines and implementation milestones in order to prepare for the transition. Some provisions of the legislation were implemented almost immediately, while others are being phased in over time. Through these provisions, the ACA is expected to achieve the following changes in American health care system:

1 This is effectively 138 percent of the FPL because of a five percent income disregard.

xii Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

• Require all qualified health plans offered through health insurance exchanges to include, at minimum, a set of essential health benefits (EHBs) in 10 benefit categories and ensure that Medicaid expansion programs provide benefit plans that also contain these 10 categories of essential health benefits. • Reduce insurance costs by offering refundable and advanceable insurance premium tax credits to eligible individuals and families with incomes between 100 and 400 percent of the FPL (who are not otherwise eligible for Medicaid), as well as cost-sharing reductions to eligible individuals and families with incomes between 100 and 250 percent of the FPL, eliminating cost sharing for recommended preventive services, and incrementally filling in the Medicare Part D prescription drug benefit coverage gap. • Improve care coordination by supporting the development of patient-centered medical homes, creating the Medicaid health home option, and by improving health care integration and financing for people eligible for both Medicare and Medicaid. • Address provider access issues by increasing Medicaid reimbursement payment rates to primary care providers, including experienced HIV providers, and instituting other payment reforms, such as bundled payments, accountable care organizations, and other changes designed to reduce costs while maintaining health care quality.

D. Early State ACA Planning and Implementation

The full impact of the ACA will depend, in part, on the comprehensiveness of its implementation at the state level. To learn more about state implementation of the ACA’s provisions, we interviewed officials from seven state Medicaid agencies in Colorado, Iowa, Maryland, Massachusetts, New York, Oregon, and Texas. We found that these states varied widely in their implementation status, including their choice between operating a state-based exchange, starting a partnership exchange, or using a federally-facilitated exchange; their selection of an EHB benchmark benefit plan; and their decision to expand Medicaid eligibility. The states we interviewed also varied in the extent to which they have involved RWHAP grantees, providers, and clients in their ACA preparations. While several states have been proactive and inclusive in their planning and implementation activities, other states have been much more cautious, constrained by state and national politics, legal uncertainties, and/or delays in federal guidance.

Of the seven state Medicaid agencies we interviewed, four states reported moving steadily forward with Medicaid expansion, state insurance exchanges, and other ACA provisions (Maryland, Massachusetts, New York, and Oregon. The other three states (Colorado, Iowa, and Texas) that we interviewed reported less ACA activity. In July 2012, they were in the process of reviewing the Supreme Court rulings and considering their options to operate a state-based exchange, expand Medicaid, and select a state EHB benchmark benefit plan.

The variation in ACA implementation that we found among the seven states we interviewed is reflected in the variation of state ACA implementation at the national level.

• Medicaid expansion. As of November 15, 2012, 12 states and the District of Columbia had declared their intention to expand Medicaid and 4 states are leaning toward participating in the expansion; 6 other states have announced that they will not be expanding Medicaid, and the other states were undecided or have not finalized their position (The Advisory Board November 2012).

xiii Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

• Affordable insurance exchanges. As of November 8, 2012, 15 states and the District of Columbia had decided to create state-based health insurance exchanges, 3 states have opted to operate state-partnership exchanges, 10 states will be using the default federally facilitated exchange, and the other 22 states have not yet submitted their declaration letters selecting an option.

• EHB benchmark plans. Half of the states submitted letters by the September 30, 2012 deadline; the other states are undecided or have requested further federal guidance before making their decision.

The impact of this state variation in ACA implementation is significant for RWHAP. It creates a more complicated landscape for RWHAP planning, operations, and potential reauthorization because it creates a kind of “tale of two cities” policy environment, in which some states have opted not to expand Medicaid and/or are delayed in their ACA implementation, while others are well prepared for both Medicaid expansion and ACA implementation. As a consequence, instead of focusing primarily on the ACA’s overall impact at the national level, RWHAP grantees, providers, and advocates will have to develop state-specific responses to the ACA. We discuss these issues in more detail in Chapters II, III, and IV, and provide a full set of recommendations in Chapter V.

E. Transition Recommendations

This report identifies a number of ways in which the implementation of ACA health reforms could potentially impact the RWHAP community, and recommends a comprehensive set of 50 steps that could support a successful transition from current health care delivery, financing, and payment systems to those that will be in place when the ACA is fully implemented. Of these, we highlight 10 top priority recommendations that we think will have the greatest impact in terms of maximizing ACA’s potential benefits while minimizing its potential risks. HAB can work with the RWHAP community to support the ACA transition in the following ways:

• Provide transparent leadership, clear guidance, and cross-agency collaboration aligned at federal, state, and local levels to support the complex transition to the ACA’s Medicaid- and private insurance-based health care system for PLWHA. • Encourage the RWHAP community to actively engage in state-level ACA planning and implementation, joining work groups, task forces, community advisory boards, and ad hoc advocacy groups to inform and influence key policy decisions. • Encourage RWHAP stakeholders to engage with Medicaid directors, policymakers, and legislators in all states on the issue of Medicaid expansion. • Create and distribute outreach materials to help PLWHA to make informed choices between health plan options. • Work with states to ensure the development and approval of comprehensive EHBs that meet the health care needs of PLWHA. • Ensure that health plans provide continuity in access to antivetroviral medications through their pharmacy networks and formularies. • Identify ongoing service gaps in state and local health systems and assess potential for reallocating Part A and B funding from direct medical services to premium supports and wrap-around services.

xiv Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

• Help ensure that HIV specialists, nurse practitioners, and physician assistants are qualified as HIV primary care providers and included in provider networks, especially in rural or underserved areas. • Help medical providers and community-based organizations build their organizational billing capacity to manage the increased volume of third-party billing for insured clients and maximize billing revenue that is anticipated under the ACA. • Work with states to address Medicaid reimbursement rate issues for primary care providers, including HIV specialists.

HAB has an important role to play in helping all RWHAP stakeholders leverage ACA reforms to improve access to comprehensive coordinated HIV treatment and care for PLWHA. Continued high-quality care is needed to ensure these gains are realized and to meet the residual needs of those who do not have access to expanded Medicaid, or who remain uninsured or underinsured beyond 2014.

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

I. INTRODUCTION

A. Study Goals, Methods, and Conceptual Framework

This final report presents the study’s findings and recommendations. This introductory chapter describes the study’s goals, methods, and conceptual framework, and provides background information about the HIV/AIDS epidemic in the United States, the Ryan White HIV/AIDS Program, the ACA’s implementation timeline, and states’ progress implementing the ACA’s provisions. Chapter II addresses key eligibility and exchange provisions of the ACA. Chapter III provides an overview of key insurance benefit and cost provisions of the ACA. Chapter IV covers major service delivery and funding provisions of the ACA. Chapter V presents recommendations regarding how the RWHAP community can influence the implementation of these provisions for the benefit of PLWHA, as well as more general recommendations regarding HRSA’s potential role in this transition process. Note: throughout the report, we are using the long form “HIV/AIDS” to refer to the disease; for efficiency we are using the short form “HIV” to refer to its care, its providers, its programs, and other disease-related activities.

1. Project Methods

To conduct the study, between October 2011 and August 2012, the Mathematica team gathered and analyzed information from three sources: (1) a comprehensive scan of reports and analyses in ACA topic areas of greatest potential impact; (2) consultations with technical experts with in-depth knowledge of ACA reform provisions, RWHAP, Medicaid, HIV/AIDS, and states’ experiences with early implementation of the ACA; and (3) discussions with seven state Medicaid programs involved in planning and implementing ACA reforms affecting RWHAP. The seven states were Colorado, Iowa, Maryland, Massachusetts, New York, Oregon, and Texas. Findings from these data were summarized in several interim project deliverables and are updated in this report. More details of the study’s data sources and methods are described in Appendix A.

2. Conceptual Framework

Through the study, we identified six areas in which ACA reforms are likely to have a significant impact on RWHAP grantees, providers, clients and others with HIV/AIDS. These six areas address (1) insurance eligibility, (2) health insurance exchanges, (3) insurance benefits, (4) insurance costs, (5) health care delivery, and (6) provider payments. These areas were used to organize the findings presented in Chapters II, III, IV, and V, and are described in the left-hand column of the study’s conceptual framework (Figure I.1). These areas are important leverage points that are expected to significantly affect the implementation of the ACA, as shown in the middle column of the diagram.

1 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

These ACA provisions will affect RWHAP grantees, clients, and providers in ways described in the right-hand column of the diagram.

For example, through the ACA, many uninsured RWHAP clients are expected to become eligible for and enroll in expanded Medicaid or a qualified health plan (QHP) through a state insurance exchange. However, this transition may carry some risks for RWHAP providers, clients and PLWHA. For example, RWHAP providers are likely to need help improving their billing systems, electronic health records, and other functions to be reimbursed for their HIV services by third parties, such as a QHP or Medicaid managed care organization (MCO). RWHAP clients and PLWHA are also likely to need help navigating the online insurance exchange system. There are also likely to be gaps between the services offered through the exchanges and the HIV services needed by PLWHA. RWHAP grantees can fill those service gaps using a wrap-around approach.

Figure I.1. Conceptual Framework for Potential Impact of the ACA on RWHAP

B. Study Context

In this section, we provide a brief overview of the HIV/AIDS epidemic in the United States, RWHAP’s services for the care and treatment of PLWHA, key provisions of the ACA, the ACA implementation process and timeline, and states’ early experiences planning and implementing the ACA.

1. HIV/AIDS Epidemic

2 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research access to the medical and support services needed to maintain their health and independence (Crowley and Kates September 2012).

2. Ryan White HIV/AIDS Program

RWHAP is the largest federal funding program that specifically serves the needs of PLWHA and their families. Historically, RWHAP has served a critical role, providing HIV treatment and services to PLWHA who are uninsured and underinsured, including the most vulnerable groups of PLWHA—people with low incomes who cannot enroll in insurance, undocumented immigrants, and people who are homeless. Originally enacted in 1990 as the Ryan White Comprehensive AIDS Relief Emergency (CARE) Act, the program has changed substantially as the HIV/AIDS epidemic has evolved, and through programmatic changes made when the program was reauthorized every three to five years (Kaiser Family Foundation December 2006). For example, the 2006 reauthorization introduced a requirement that 75 percent of funding (after deducting funds for quality management and administrative services) must be reserved for core medical services, with the remaining 25 percent set aside for support services linked to outcomes affecting HIV-related clinical status, such as viral load suppression.

The program’s most recent reauthorization, the Ryan White HIV/AIDS Treatment Extension Act of 2009, retained most of the provisions of the 2006 reauthorization, but placed more emphasis on identifying and diagnosing people who are HIV positive and helping them to access HIV care. The 2009 reauthorization also included funding for technical assistance, clinical training, and research on innovative models of care, which are expected to improve the efficiency and quality of HIV/AIDS care and improve access, engagement, and retention in care for underserved populations. These changes are likely to increase the number of people seeking HIV care. RWHAP is next scheduled for reauthorization in 2013, when the current legislation sunsets. More changes are expected due in part to the passage of the ACA, which is expected to dramatically decrease the number of uninsured PLWHA in the United States.

RWHAP also functions as a “payer of last resort,” filling service gaps for PLWHA who have no insurance coverage or face coverage limits. In 2010, HAB reinforced the importance of this policy in its notice to grantees that RWHAP providers were expected to make “reasonable efforts to secure non-Ryan White HIV/AIDS Program funds whenever possible for services to individual clients” (HRSA 2010). Providers were also urged to ensure that “eligibility for other funding sources is aggressively and consistently pursued, (e.g., Medicaid, CHIP, Medicare, other local or State-funded HIV/AIDS programs, and/or private sector funding including private insurance)” (HRSA 2010). This policy will become even more important under the ACA, when many uninsured RWHAP clients become eligible for Medicaid or private insurance.

3 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

3. Affordable Care Act Provisions

The ACA is expected to expand health insurance coverage for up to 30 million uninsured Americans, while controlling health care costs and improving the country’s health care delivery system (Kaiser Family Foundation April 2011; CBO 2012). The law is expansive, with many different provisions that will affect the RWHAP community. Through these provisions, the ACA is expected to achieve the following:

• Increase insurance eligibility for PLWHA by prohibiting denial of health insurance coverage for pre-existing conditions, requiring U.S. citizens and lawfully present residents to have health insurance through an individual mandate, and giving states the option to expand Medicaid coverage to nearly all individuals younger than age 65 with incomes up to 133 percent of the federal poverty level (FPL).2 • Establish health insurance exchanges through which individuals and small businesses can purchase private insurance through qualified health plans that include essential community providers, using a streamlined “no wrong door” online eligibility and enrollment process with call centers for customer service and navigators to help uninsured individuals and families enroll in public or private insurance. • Require all qualified health plans offered through health insurance exchanges to include, at minimum, a set of essential health benefits (EHBs) in 10 benefit categories and ensure that Medicaid expansion programs provide benefit plans that also contain these 10 categories of essential health benefits. • Reduce insurance costs by offering refundable and advanceable insurance premium tax credits to eligible individuals and families with incomes between 100 and 400 percent of the FPL (who are not otherwise eligible for Medicaid), as well as cost-sharing reductions to eligible individuals and families with incomes between 100 and 250 percent of the FPL, eliminating cost sharing for recommended preventive services, and incrementally filling in the Medicare Part D prescription drug benefit coverage gap. • Improve care coordination by supporting the development of patient-centered medical homes, creating the Medicaid health home option, and by improving health care integration and financing for people eligible for both Medicare and Medicaid. • Address provider access issues by increasing Medicaid reimbursement payment rates to primary care providers, including experienced HIV providers, and instituting other payment reforms, such as bundled payments, accountable care organizations, and other changes designed to reduce costs while maintaining health care quality.

Since its enactment, the ACA has been subject to multiple legal challenges. In particular, more than half of the states challenged two specific ACA reforms: (1) the individual mandate to purchase insurance or pay a penalty and (2) the requirement to expand Medicaid income eligibility to 133 percent of the FPL or risk losing the federal match for Medicaid funding. Joined by 25 other states, Florida filed a lawsuit in federal district court in March 2010 challenging the constitutionality of those two provisions. Another lawsuit was filed by a business group in Florida (National Federation of Independent Businesses v. Sibelius).

2 This is effectively 138 percent of the FPL because of a five percent income disregard.

4 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

The Supreme Court accepted these challenges and considered the two cases together in March 2012 (Perkins July 2012). In total, 140 amicus briefs were filed in support of the ACA, including briefs from 13 states and the District of Columbia. While waiting for the Supreme Court rulings, many states stopped or slowed their ACA planning and implementation activities. On June 28, 2012, the Supreme Court upheld the constitutionality of the individual mandate, ruling that it was a valid exercise of the taxing power of Congress to require individuals to purchase health insurance. However, the Court ruled that Congress did not have the power under its spending clause to authorize termination of all existing federal Medicaid match funding for states that refused to expand Medicaid eligibility, effectively making Medicaid expansion optional for states (Perkins July 2012).

4. ACA Implementation Timeline

Some provisions of the legislation were implemented almost immediately on enactment, but others are being phased in over time. At the federal level, a number of agencies have been working together to coordinate the reform’s planning and implementation, including the Centers for Medicare & Medicaid Services (CMS) in the U.S. Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) in the U.S. Department of Treasury, and the Employee Benefits Security Administration in the U.S. Department of Labor. The agencies have issued planning and implementation grants, issued draft and final rules, and published other guidelines to help states move forward with implementation.

Although many provisions of the ACA law are not scheduled for implementation until January 2014, before then states are expected to meet a number of interim planning deadlines and implementation milestones to prepare for the transition (see Figure I.2). These decision deadlines are important leverage points where policy decisions will have a significant impact on the health insurance coverage, benefits, costs, and services available to PLWHA.

5. State ACA Early Implementation Experiences

The full impact of federal legislation depends, in part, on the comprehensiveness of its implementation at the state level. To learn more about state implementation of the ACA’s provisions, we interviewed officials from seven state Medicaid agencies in Colorado, Iowa, Maryland, Massachusetts, New York, Oregon, and Texas. We found that these states varied widely in their implementation status, including their choice between operating a state-based exchange, starting a partnership exchange, or using a federally-facilitated exchange, their selection of an EHB benchmark benefit plan, and their decision to expand Medicaid eligibility.

The states we interviewed also varied in the extent to which they have involved RWHAP grantees, providers, and clients in their ACA preparations. While several states have been proactive and inclusive in their planning and implementation activities, other states have been much more cautious, constrained by state and national politics, legal uncertainties, and delays in federal guidance. Details of the seven states’ ACA activities are provided in Appendix B, and are summarized below.

5 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Figure I.2. ACA Timeline

6 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Figure I.2 (continued)

Of the seven state Medicaid agencies we interviewed, four states reported moving steadily forward with Medicaid expansion, state insurance exchanges, and other ACA provisions (Maryland, Massachusetts, New York, and Oregon (see Table B.1). Massachusetts and Oregon had already begun Medicaid reform initiatives before the passage of the ACA, and so the ACA Medicaid expansion provisions allowed them to build on prior efforts. New York has incorporated the ACA’s Medicaid expansion provisions into a larger set of state Medicaid reforms. Led by the governor’s Health Reform Coordinating Council, Maryland has also worked actively to implement its own state-based insurance exchange and other aspects of the reform. All four states have also included RWHAP grantees and providers in their ACA planning activities (see Table B.2). For example, Maryland and Oregon have involved Part A and B grantees in the development of their states’ essential health benefits packages. In New York, The AIDS Institute (the state’s executive Office of AIDS) is part of the state’s interdepartmental ACA planning team.

7 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

The other three states (Colorado, Iowa, and Texas) that we interviewed reported less ACA activity. In July 2012, they were in the process of reviewing the Supreme Court rulings and considering their options regarding: operating a state-based exchange, expanding Medicaid, and selecting a state EHB benchmark benefit plan. Neither Colorado nor Iowa reported including RWHAP grantees or providers in their ACA planning activities. In Texas, however, the state Medicaid program has been working with RWHAP grantees and providers on ACA planning issues, supported by a grant from the National Academy for State Health Policy (NASHP).

The variation in ACA implementation that we found among the seven states we interviewed is reflected in the variation of state ACA implementation at the national level.

8 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

II. HEALTH INSURANCE ELIGIBILITY AND EXCHANGES

A. Introduction

A number of ACA insurance eligibility reforms are expected to significantly increase access to Medicaid and private health insurance. With only partial Medicaid expansion anticipated, the Congressional Budget Office estimates that by 2022, the number of uninsured people in the United States could be reduced by as many as 30 million people (CBO 2012). However, it is hard to predict exactly how many uninsured PLWHA will gain access to Medicaid or private insurance under the ACA. Some estimate that 25-30 percent of uninsured PLWHA will qualify for some form of insurance coverage and subsidies (Donnelly 2011). Others estimate that in states that are expanding Medicaid, such as California, as many as 70 percent of uninsured PLWHA could become eligible for the program (Donnelly 2011). Regardless of the exact estimate, the ACA will significantly increase access to Medicaid and private insurance among PLWHA (Crowley and Kates September 2012).

Through this study, we identified five ACA reforms as having the greatest potential impact on insurance eligibility and access among PLWHA: (1) pre-existing condition insurance plans (PCIPs), (2) the individual mandate, (3) Medicaid expansion, (4) health insurance exchanges, and (5) ACA citizenship requirements. In each area, we will briefly describe the provision and the status of its implementation, discuss the provision’s implications for the RWHAP community, and offer recommendations for what can be done to address the provision’s potential impact on PLWHA.

B. Eligibility Reforms

1. Guaranteed Issue and PCIPs

ACA reform. Before the ACA, many people with pre-existing conditions such as HIV/AIDS had limited options for affordable health insurance, because insurers were allowed either to deny coverage or to set premiums at unaffordable levels. The ACA facilitates insurance coverage for these people through the guaranteed issue provision, which prohibits denial of coverage based on pre- existing conditions and eliminates annual limits on coverage. The law also places limits on the amount of premium rate increases that insurance companies can impose. These changes went into effect for children in September 2010 and will take effect for adults in January 2014. In addition, all states were required to set up PCIPs within 90 days of the ACA’s passage in March 2010. PCIPs are temporary high-risk insurance pools for people with pre-existing conditions, which provide immediate access to health insurance before 2014. Those eligible for coverage under the PCIPs include U.S. citizens and “lawfully present” immigrants (that is, legal immigrants, regardless of years of U.S. residence) who have been without creditable insurance coverage for at least six months.

ACA implementation. States had the option of either operating the PCIP program themselves or having the United States Department of Health and Human Services (HHS) operate one for them (Robert Wood Johnson Foundation February 2011). Before the ACA, 34 states funded their own high-risk pools, some of which also offered insurance to some people with pre-existing conditions, such as HIV/AIDS, but most of which charged 125 to 200 percent of standard market premiums. These states were not allowed to eliminate their high-risk pools as a result of the PCIP; people in those existing pools would have to drop out and be uninsured for six months to qualify for coverage under the new PCIPs. Of the 34 states with previous high-risk pools, 14 chose to have the federal government run a new PCIP, along with another 9 (and the District of Columbia) that had no previous high-risk pool. The other 20 states with high-risk pools, plus another 7 without, elected to

9 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

have the state operate their PCIP (National Conference of State Legislatures December 2011). Of the 7 state Medicaid programs we interviewed, 5 are operating their own PCIPs (Colorado, Iowa, Maryland, New York, and Oregon) and two are using the federal PCIP administered by HHS (Massachusetts and Texas) (see Appendix B: Table B.I.1). PCIPs were operating in all 50 states in October 2011 and will be in operation until January 2014, when most of the major provisions of the ACA will take effect.

Although the availability of coverage through the PCIPs has enhanced access to coverage for some PLWHA, significant gaps remain for a number of reasons. First, among the states running their own PCIPs, not all states have chosen to create lists of conditions that automatically provide eligibility under medical certification requirements and, among those that have, HIV/AIDS is not always included on those lists (HealthCare.gov 2011).3 Second, states were given a set allocation of funds to set up and run their PCIP programs, based on the same funding formula used for the Children’s Health Insurance Program (CHIP) (CCIIO 2012). Although nine states (Alaska, California, Colorado, Montana, New Hampshire, New Mexico, Oregon, South Dakota, and Utah) have requested and received additional funding, other states have been able to afford coverage for only a limited number of residents, with funding allocations determining the number of program slots available (Adams 2012).

Third, although AIDS Drug Assistance Programs (ADAPs) have coordinated with PCIPs in some states to ensure wrap-around coverage, other states have not coordinated their ADAP and PCIP programs (Kaiser Family Foundation December 2011). According to the experts we interviewed, some states have also prohibited ADAP clients from enrolling in PCIPs because of their concern that the pharmaceutical drug costs of PLWHA would deplete the fixed amount of PCIP funding awarded to their state (Harvard Law School Health Law and Policy Clinic November 2010; National Alliance of State and Territorial AIDS Directors October 2011). According to data from the ADAP Monitoring Project’s 2012 annual report, only 24 states allowed coordination between ADAP and PCIPs; as of December 2011, 2,393 ADAP clients were covered by PCIPs, at an average annual cost to clients of $6,037 (NASTAD 2012).4

Fourth, because the ACA specifies that eligibility for PCIPs is restricted to people who have been without health insurance coverage for six months or more, in some state PCIPs, PLWHA have been required to provide evidence of denial by an insurance plan to qualify. According to our expert informants, this requirement has been burdensome to PLWHA in those states because many PLWHA lack the documentation required for a denial letter. Although HHS temporarily loosened eligibility requirements to allow PLWHA to submit a physician’s HIV diagnosis as evidence of PCIP eligibility in federally-administered PCIPs, HHS reinstated the federal requirement for proof of denial of coverage on May 1, 2012 (CCIIO May 2012). In addition, although premiums in the federally funded PCIPs are 10 to 50 percent lower than those in the previous state-funded high-risk

3 Conditions that commonly receiving automatic eligibility include arthritis, asthma, high cholesterol, hypertension, and obesity (HealthCare.gov 2011). 4 The following 24 states allowed ADAP clients to enroll in PCIPs: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Kentucky, Maine, Michigan, Missouri, Nebraska, New Hampshire, New Mexico, New York, Ohio, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, and Wisconsin.

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pools, the federal premiums are still considered too expensive for many PLWHA (Cauchi November 2011).

Finally, in some cases PCIPs provide only limited benefits (for example, limited coverage for skilled nursing, mental health, and substance abuse services) and do not provide access to HIV- experienced providers (Government Accountability Office [GAO] July 2011; National Alliance of State and Territorial AIDS Directors May 2011; Pund September 2011). As a result, enrollment in the PCIPs has been significantly lower than predicted. Although program administrators initially projected enrollment of more than 375,000 people by the end of 2010, enrollment in both federally and state-run PCIP programs stood at 86,072 as of August 31, 2012 (Kaiser Family Foundation October 2012).

Implications for RWHAP and PLWHA. When other provisions of the ACA take effect in January 2014, RWHAP grantees can play a significant role in helping PLWHA transition from PCIPs to subsidized private insurance plans offered through the state exchanges. Meanwhile, HAB can encourage greater use of PCIPs and high-risk pools by identifying states that have eased eligibility and streamlined enrollment requirements. For example, among the seven states we interviewed, Iowa’s state high-risk pool does not require the six-month period of lack of insurance (see Appendix B, Table B. II.1). In addition, Oregon’s federal PCIP is managed by the same state program as the one that runs the state’s high-risk pool (known as the Oregon Medical Insurance Pool [OMIP]). Enrollment is intended to be seamless; there is a single application for both pools. A person’s insurance status determines the pool for which he or she is eligible. If a person is uninsured for six months and has proof of citizenship, the individual is placed into the federal PCIP; a person who was not uninsured for the prior six months is placed into the state high-risk pool. States can also be encouraged to increase their use of ADAP funds to help pay premiums for PCIP coverage. In our interview with the Massachusetts’ Medicaid program, officials reported that Massachusetts has maximized the use of its ADAP funding by coordinating its ADAP and PCIP programs. Finally, states can also be encouraged to include HIV-experienced providers in state-run PCIP health plans.

2. Individual Insurance Mandate and Exemptions

ACA reform. One of the most significant changes under the ACA is the requirement, starting on January 1, 2014, that most residents of the United States purchase health insurance coverage for themselves and their dependents or pay a penalty for each month of noncompliance (this policy is commonly referred to as the individual mandate). The amount of the penalty is the greater of either (1) a percentage of the amount that the household’s income exceeds the federal tax filing threshold (a combination of personal and standard deductions, known as the applicable income amount), set at 1.0 percent in 2014, 2.0 percent in 2015, and 2.5 percent thereafter; or (2) a flat dollar amount assessed for the household (set at $95 in 2014, $325 in 2015, and $695 thereafter, with inflation adjustments) (Mulvey and Chaikind July 2012). The household penalty is further capped at a dollar figure based on the cost of a bronze-level health insurance policy (described in more detail in Chapter III). As mentioned in Chapter I, although 26 states challenged this provision of the ACA, the Supreme Court upheld the constitutionality of the individual mandate as a tax payable to the IRS.

Estimates suggest that the penalty will affect only 2 percent of Americans, (roughly 63,000 people) since it exempts several groups from having to carry health insurance, including those who have religious objections, people who do not meet citizenship requirements, members of Native American tribes, and people in prison or jail (DOC 2012). Other groups of people are required to

11 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

carry insurance, but are exempt from having to pay the penalty for lack of coverage, including people whose annual premiums would exceed 8 percent of their household’s adjusted gross income, people who receive hardship waivers, households with incomes below the federal tax filing threshold, and people who lacked insurance for fewer than three months in a given year (Kaiser Family Foundation July 2012c; Mulvey and Chaikind July 2012).

ACA implementation. Had the mandate been struck down, arguably, it might have placed the entire reform in jeopardy and likely would have resulted in a 10 to 25 percent increase in the cost of premiums after ACA’s full implementation by increasing the risk level of those enrolled in insurance exchanges’ qualified health plans (Buettgens and Carroll 2012). However, the experts we interviewed suggested that the penalty may not be applied to many PLWHA, for two reasons. First, most PLWHA proactively seek health care and do not need a mandate to encourage them to obtain insurance. Second, some experts argued that, economically, the mandate is not a very effective deterrent. As one interviewee noted, “The cost of the penalty is less than the cost of purchasing insurance, so there is not much incentive to buy insurance.”

Implications for RWHAP and PLWHA. Although the mandate, together with other insurance expansions in the ACA, is likely to increase the number of people covered by health insurance, those who are exempt from it will continue to rely on RWHAP for their medical and supportive care needs. HAB can work with states and other stakeholders to identify members of these exempt groups and ensure their coverage under RWHAP. In addition, RWHAP’s “payer of last resort” policy may have more influence on the insurance status of PLWHA than the individual mandate. This will be especially true if, under the ACA, RWHAP providers consistently screen for insurance status before enrolling clients into RWHAP-funded services, and require uninsured PLWHA to go through the exchange’s eligibility and enrollment process before receiving RWHAP services.

3. Expansion of Medicaid Eligibility

ACA reform. Currently, income eligibility for state Medicaid programs is determined by the level of income and assets and, in most states, childless adults cannot qualify for coverage. In addition, in 33 states parents can qualify for coverage, but only if their incomes are less than 100 percent of the FPL. As of 2010, there were an estimated 16 million uninsured adults with incomes below this income threshold. The ACA eliminated categorical eligibility criteria (for pregnancy and disability) and set a national Medicaid income eligibility threshold at 133 percent of the FPL ($14,400 for an individual and $29,300 for a family of 4).5

Originally, the ACA required all states to implement Medicaid expansion or risk losing their state’s federal matching funds for Medicaid. However, in its June 2012 ruling, the Supreme Court struck down the proposed state penalty, effectively making Medicaid expansion optional for states. If a state does choose to expand Medicaid, the Congressional Budget Office (CBO) estimates that 96 percent of the cost for Medicaid expansion will be covered by the federal government over the first 10 years (CBO March 2010). From 2014 to 2016, the federal government will cover 100 percent

5 In determining eligibility for expanded Medicaid services, states are required to include a 5 percent income disregard, effectively making the income eligibility threshold 138 percent of the FPL (Kaiser Commission on Medicaid and the Uninsured June 2011).

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of the costs of covering adults who will be newly eligible for Medicaid (Kaiser Family Foundation May 2010). States will have to pick up some of these costs incrementally, but the federal government’s share will remain at 90 percent in 2020 and beyond.

The ACA also requires that states maintain existing Medicaid eligibility rules and procedures that were in effect on the date the ACA was enacted (CMS June 2011). This state maintenance of effort requirement allows states some limited exemptions if they are able to certify that they are experiencing or projecting a budget deficit. In these situations, states are allowed to impose eligibility restrictions except for adults who are eligible for Medicaid on the basis of pregnancy or disability (CMS June 2011). However, states would have to submit a state plan amendment or Section 1115 Medicaid waiver to implement any changes that would result in restricted eligibility. States also have the option of implementing the eligibility restriction selectively, to ensure continuity of coverage for certain subgroups (CMS June 2011).

ACA implementation. In the past, states have expanded Medicaid eligibility through Section 1115 waivers, although that is not the sole purpose of those waivers. Since the passage of the ACA in 2010, states’ use of Medicaid Section 1115 waivers for a variety of purposes has increased; the number of states operating at least one 1115 waiver increased from 30 states in 2011 to 34 states in 2012, and the share of federal Medicaid funds spent on 1115 waivers increased from 20 percent to more than 30 percent during the same period (Kaiser Commission on the Medicaid and the Uninsured May 2012b).

Although a number of states have had 1115 waiver programs in the past that specifically expanded Medicaid coverage for PLWHA, most of these waivers have ended or been incorporated into broader Medicaid 1115 waivers. For example, Massachusetts had a separate HIV-specific 1115 waiver, but then included it into the state’s larger health reform effort. In fiscal year (FY) 2011, about 1,300 people were enrolled in Massachusetts’s Medicaid program through the HIV component of its 1115 health reform waiver. Currently, only Maine continues to operate an HIV- specific 1115 waiver program; the program allows individuals whose incomes are up to 250 percent of the FPL to receive a limited package of HIV services, including antiretroviral therapy (ART) and other HIV medications, office visits, lab tests, case management, and HIV-related hospitalizations (CMS October 2010).

The magnitude of the impact of the Medicaid expansion provision will ultimately depend on how many states adopt the expansion. As of April 1, 2010, states have had the option to phase in the expansion of Medicaid earlier than 2014 using the state plan amendment (SPA) process (CMS April 2010). By May 2012, six states (California, Colorado, Minnesota, Missouri, New Jersey, and Washington) and the District of Columbia had received federal approval for early Medicaid expansion initiatives and Connecticut received approval of a new state Medicaid option to cover adults up to 133 percent of the FPL (Kaiser Commission on the Medicaid and the Uninsured May 2012a). However, the Colorado Medicaid staff we interviewed in July noted that they were not sure whether they would carry out their original plan to expand Medicaid now that expansion has become optional (see Appendix B, Table B.II.2).

The Supreme Court ruling has led many states to reconsider their options before committing one way or another. A recent CBO report highlighted the factors that states are considering in deciding whether or not to expand Medicaid (CBO July 2012). The report highlighted certain incentives (for example, full federal funding for initial years and potential pressure from safety-net hospitals and other providers for the expansion) and disincentives for states (such as the fact that

13 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

states will have to bear some expansion costs, the potential for significant increases in Medicaid program enrollment among those previously eligible but not enrolled, and a fear that the federal government will eventually reduce its promised payment rate in future years as a result of budgetary pressures). CMS has indicated that there might be flexibility in states’ decisions regarding the timing and means of implementing the expansion (Sebelius July 2012).6 For example, a state might be able to opt in after one year, or choose to participate initially but then drop out later (Clark August 2012).

Given uncertainty regarding operational aspects of the expansion, several states have said they are awaiting further federal guidance before they decide how to proceed.7 Reflecting this concern, on July 3, 2012, the National Association of Medicaid Directors (NAMD) sent CMS a set of questions seeking clarification on how the program would be administered. Key questions included whether partial Medicaid expansion up to 100 percent of the FPL would be approved by HHS, whether partial expansion would affect the federal medical assistance percentage (FMAP) rate, whether states could phase in their expansion, and what else a state could do to help people with incomes below 100 percent of the FPL if the state opts not to expand Medicaid (NAMD July 2012; Kliff November 2012). Similarly, Iowa Medicaid officials were uncertain whether or how the expansion would affect their state’s current Medicaid eligibility groups, and whether the state could continue its existing Medicaid demonstration waivers, which are set to expire on December 31, 2013.

In July and August, we canvassed the study’s seven state Medicaid programs regarding their expansion plans. Of the 7 states, only 4 were planning to expand Medicaid (Maryland, Massachusetts, New York, and Oregon) (see Appendix B: Table B.I.2). With the presidential election over and the ACA less likely to be overturned, some states have begun to review their expansion decisions. The current map of state expansion decisions is in flux and is likely to continue changing over the next year (see map, Figure II.1).

As of November 15, 6 states (Alabama, Georgia, Louisiana, Mississippi, South Carolina, and Texas) reported that they would not support Medicaid expansion (Kliff November 2012). The governors of these states cited affordability concerns and the expansion of government-funded entitlement programs as reasons against Medicaid expansion (American Health Line Alerts September 2012).8 Another 6 states (Iowa, Maine, Nevada, Nebraska, New Jersey, and Virginia) were reportedly leaning toward not implementing the expansion (The Advisory Board November 2012).9 Although the governors of these states cited similar concerns about the expansion’s costs and increase in entitlement spending, other states have provided other reasons for why they might

6 In this letter, Sebelius also announced that low-income individuals under 133 percent of the FPL would not have to pay the penalty under the individual mandate for not purchasing private health insurance. 7 The fact that all states that have either rejected the expansion or are leaning toward rejection are led by Republican governors, whereas those that are supportive of the expansion are led by Democrats, suggests that final determinations for how states proceed could depend on the outcome of the general election in November. 8 However, local leaders in Texas have recently proposed developing a county-level Medicaid expansion for the state’s most populous counties (The Washington Post August 2012). 9 In four of the six states that have rejected the expansion (Georgia, Louisiana, Mississippi, and Texas) the income eligibility threshold for working parents was less than 50 percent of the FPL and was between 50 and 99 percent of the FPL in the other two (Florida and South Carolina) as well as in Iowa, Nebraska, and Nevada (Kaiser Family Foundation July 2012a).

14 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

decide against the Medicaid expansion. For example, the governor of Iowa reported that he did not support expansion of entitlement programs and preferred to look for other options at the state level to make insurance more affordable. New Jersey’s governor cited the state’s April 2011 expansion of Medicaid to approximately 70,000 childless adults through a Section 1115 waiver as one of the state’s reasons for not wanting to expand Medicaid further. In Maine, the state government recently requested approval to cut $20 million in Medicaid spending, which reportedly would have eliminated some residents with incomes between 100 and 133 percent of the FPL from the state’s Medicaid rolls (Goodnough and Pear July 2012).

Figure II.1. Status of State ACA Medicaid Expansion Plans

On the other hand, by mid-November, 12 states (Arkansas, California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont, and Washington) and the District of Columbia have made the commitment to move ahead with Medicaid expansion and another 4 states (Kentucky, New Hampshire, New York, and Oregon) are leaning toward doing so (The Advisory Board November 2012). The governors of these states cite the capacity for providing coverage to large numbers of currently uninsured residents and the ability of the ACA to enhance the quality of care provided to state residents as reasons for supporting the expansion. Some states have already undertaken Medicaid expansions and generally express support for the broader goals of the ACA. For example, New York’s governor issued an executive order to allow for Medicaid expansion for childless adults with incomes from 100 to 130 percent of the FPL, under which about 77,000 people will become newly eligible for Medicaid (see Appendix B, Table B.II.2). Under its

15 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Section 1115 waiver, Oregon expanded Medicaid benefits to individuals with an income under 100 percent of the FPL; under the ACA, the state will further expand Medicaid coverage to individuals with an income up to 133 percent of the FPL.

Although Massachusetts has already expanded eligibility for its Medicaid program in accordance with state health care reform legislation passed in April 2006, MassHealth staff noted that the ACA is using a different approach to fund Medicaid expansion. Accordingly, the state is modifying its health reform initiative to comply with ACA provisions. At present, individuals with an income under 300 percent of the FPL have access to subsidized health insurance in Massachusetts. Under the ACA, individuals with an income up to 133 percent of the FPL who are currently in one of the state’s health insurance programs will be transitioned into the state’s Medicaid state plan in 2014.

Implications for RWHAP and PLWHA. For PLWHA, Medicaid expansion means that if a person’s income is below the 133 percent FPL threshold, the ACA eliminates the person’s need to meet categorical eligibility requirements through a Social Security Administration disability determination. Low-income people who are HIV-positive will no longer have to wait until their infection progresses to an AIDS diagnosis and go through a disability determination process to become eligible for Medicaid. For many low-income people, Medicaid expansion is considered a better option than private insurance tax credits because Medicaid includes transportation assistance and other services that are not typically covered by private insurance plans. However, in Medicaid non-expansion states, there will be few affordable insurance options for PLWHA with incomes under 100 percent of the FPL, as the ACA does not provide premium tax credits or cost sharing reductions for those with incomes under the FPL.

3. Eligibility Recommendations

Key ACA insurance eligibility provisions, including guaranteed issue for pre-existing conditions, the individual insurance mandate, and expansion of Medicaid eligibility, will potentially impact many uninsured RWHAP clients and PLWHA. While some of these provisions have already taken effect, there is time for RWHAP administrators, grantees, providers, and clients to influence the implementation of other reforms, including state decisions to: expand Medicaid in 2014 or earlier; improve the operation of state and federal PCIPs; and help identify groups who are newly eligible for Medicaid or private insurance tax credits and cost sharing reductions. To address these ACA implementation issues, we recommend the following actions in Table II.3.

Table II.1. Eligibility Recommendations

A. Eligibility Recommendations 1. Encourage RWHAP stakeholders to work with Medicaid directors, policymakers, and legislators in all states on Medicaid expansion. 2. Work with federal and state agencies to ease the eligibility and enrollment requirements for PCIPs that limit PLWHA access to PCIPs. 3. Encourage state Medicaid programs to use 1115 waivers for early expansion of Medicaid as a bridge to 2014, to cover PLWHA without a disability diagnosis. 4. Continue and increase outreach to groups ineligible for ACA provisions, which will remain uninsured, including PLWHA with incomes of less than 100 percent of the FPL in non-Medicaid expansion states. 5. Provide guidance to state Medicaid programs on how to ensure access to Medicaid for eligible immigrants who are living with HIV/AIDS.

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C. Health Insurance Exchanges

1. Creation of Affordable Insurance Exchanges

ACA reform. Under the ACA, people with an income between 100 and 400 percent of the FPL who are not otherwise eligible for Medicaid will be able to purchase subsidized private insurance from qualified health plans offered through state insurance exchanges.10 An “affordable insurance exchange” is an online marketplace where individuals and some employers can determine their eligibility for public programs (Medicaid and CHIP), or for private insurance tax credits and cost sharing reductions. They can also compare qualified health plans offered through the exchange, and select the plan that best suits their needs. Open enrollment in the exchanges begins on October 1, 2013; coverage begins on January 1, 2014 (CMS May 2012).

These qualified health plans (QHPs) are for the individual market and for small businesses (up to 100 full-time equivalent employees) (State Health Access Data Assistance Center October 2010). Financial assistance for private insurance is available through premium tax credits that are paid out either as a refundable tax credit when filing a federal income tax return or as an advanceable tax credit that the federal government pays monthly directly to the insurer (Kaiser Family Foundation August 2010). To receive this financial assistance, people must be ineligible for other acceptable coverage (such as public programs or affordable employer-sponsored group insurance coverage), and the insurance must be purchased through a qualified health plan offered through the exchange (Blue Cross Blue Shield of North Carolina August 2011). People receiving unaffordable employer- sponsored coverage offers (that is, employer-sponsored plans that do not have an actuarial value equivalent to at least 60 percent of the person’s total medical costs, or the employee’s premium contribution is greater than 9.5 percent of the person’s income) are also eligible to purchase subsidized private insurance from an insurance exchange (Kaiser Family Foundation April 2010).

States have the option of running their own state-based exchange, having the federal government operate a federally-facilitated exchange (FFE) for them, or working in partnership with the federal government to operate a state partnership exchange (Jost May 2012; Sebelius July 2012). In an FFE, the federal government carries out all exchange functions, which include certifying which QHPs can be sold through the exchange, determining individuals’ eligibility for public health programs or private insurance premium tax credits and cost sharing reductions, and providing assistance to help consumers navigate the exchange’s eligibility and enrollment process. States will carry out these functions in their own state-based exchanges; the duties are shared in partnership exchanges (CMS May 2012). States have the option of structuring their state-based exchange as an independent public agency, as part of an existing state agency, or as a nonprofit entity, such as an insurance exchange board.

States also have the flexibility to decide how their state-based exchange will contract with private insurance plans. Although the exchanges can only contract with private insurance plans that meet the federal definition of a QHP, states have a range of plan management options. The state can contract with all QHPs that meet a checklist of requirements (known as a passive certification), or

10 In Medicaid expansion states, this provision applies to people with incomes too high to qualify for Medicaid (that is greater than 133 percent of the FPL) but below 400 percent of the FPL.

17 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research can contract with particular QHPs that meet additional state standards (known as enhanced certification) (HIV Health Reform November 2012). States can also contract selectively with a limited number of QHPs (for example, those that meet state-established premium levels), or can select QHPs through a competitive procurement process (known as active purchasing) (Kaiser Family Foundation August 2012a).

Through the FFE, the federal government is required to offer at least two multistate QHPs nationwide, which will compete with other private insurance plans. The premiums and benefits of these multistate plans will be negotiated by the United States Office of Personnel Management (OPM), the agency that currently manages the health benefits of federal employees (Pear October 2012). The ACA requires that at least one of these multistate contracts will be with a non-profit entity (ACA 2010). To ensure “a robust QHP market in each state where a FFE operates,” OPM plans to use a passive certification process, certifying as a QHP any private health plan in the state that meets all certification requirements (CMS May 2012).

HHS has offered funding to help states create their exchanges. As of August 2012, HHS had awarded up to $1 million in exchange planning grants to each of 49 states and the District of Columbia to assess the feasibility of establishing exchanges and to determine how they should be structured (HealthCare.gov August 2012). Six states and a New England multistate consortium also received more than $241 million in Early Innovator grants to develop transferable model exchange information technology (IT) systems (HealthCare.gov August 2012). HHS has also provided additional funding through Exchange Establishment cooperative agreements to support exchange development. As of June 2012, 34 states and the District of Columbia had received approximately $850 million in Exchange Establishment funds (Monegain June 2012). On June 29, 2012, HHS announced that it would allow states to apply for more cooperative agreement funding through the end of 2014, to provide further assistance in building exchanges and pay for exchange start-up costs (Center for Consumer Information & Insurance Oversight [CCIIO] July 2012).

State Medicaid directors have commented that the insurance exchanges will have to address the possibility of beneficiaries transferring (or “churning”) between Medicaid and exchange-based private insurance coverage as their monthly income and, thereby, their Medicaid eligibility, fluctuates (NAMD October 2011). According to recent estimates, more than 35 percent of adults with family incomes at or below 200 percent of the FPL will experience a transition in eligibility between Medicaid and private health insurance tax credits within their first year of enrollment (Sommers and Rosenbaum February 2011). Excessive churning could lead to temporary losses in insurance coverage and access to medications for PLWHA. They argue that greater coordination between state/local and public/private programs will help to ensure greater continuity of care for PLWHA. Therefore, to minimize disruptions, the exchanges are encouraged to provide an integrated process for evaluating eligibility for coverage under Medicaid, the Children’s Health Insurance Program (CHIP), and for federal premium tax credits (Bachrach et al. March 2011).

ACA implementation. States had until November 16, 2012, to submit a declaration letter informing HHS that they would be operating a state-based exchange. They were also required to submit a state-based exchange blueprint application by December 14, 2012, and to have their state exchange operational by January 1, 2014 (CMS August 2012; Sebelius November 2012). However, states can also delay their decision to implement a state-based exchange for a year; they can apply to operate a state-based exchange in January 2014 and launch their state-based exchange in January 2015 (HIV Health Reform November 2012). The deadline for the declaration letter and blueprint

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application for state partnership exchanges has also been extended to February 15, 2013 (Sebelius November 2012).

As of August, of the 7 state Medicaid programs we studied, 5 states were planning to operate a state-based exchange (Colorado, Maryland, Massachusetts, New York, and Oregon), Iowa was considering its options and Texas was planning to use a federally-facilitated exchange (see Appendix B: Table B.II.3 for details). However, other states have been slower to select an exchange option.

As of November 8, 2012, 15 states (California, Colorado, Connecticut, Hawaii, Kentucky, Maryland, Massachusetts, Nevada, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and West Virginia) and the District Of Columbia were planning to implement a state-based exchange (see Figure II.2). Three states (Arkansas, Delaware, and Illinois) were planning to operate a partnership-based exchange; and 10 states (Alaska, Florida, Louisiana, Kansas, Maine, Missouri, New Hampshire, South Carolina, South Dakota, and Texas) decided to use a federally-facilitated exchange. No decision had been made yet by the 22 other states (Kaiser Family Foundation August 2012b; Center on Budget and Policy Priorities November 2012).

However, a number of operational issues still need to be settled. HHS still has to work out the final details for how household income will be assessed through an exchange. The ACA introduced a new method for determining income eligibility, known as modified adjusted gross income (MAGI), which sets a common standard nationwide (Au-Yeung and Czajka July 2011). Under MAGI, income eligibility determinations are based on family size and household income, as reported through annual federal income tax filings. MAGI standards differ from those traditionally used by states to determine Medicaid eligibility (which assesses both income and assets in determining eligibility).

The use of MAGI helps to streamline program eligibility determinations by providing a single income standard nationwide by which to evaluate an applicant. However, it requires states to calculate household income for individuals not filing a federal tax return, and to set up a system for comparing state and MAGI calculations and reconciling federal and state income calculation differences (federal taxable income is assessed annually while state program eligibility is determined monthly). For example, using MAGI calculations, a person could be assessed as having annual household income of under 100 percent of the FPL (which would disqualify him or her from private insurance premium tax credits) but have current monthly income of between 100 percent and 133 percent of the FPL (which would meet the qualification for private insurance assistance). CMS has been asked by states to finalize and disseminate guidance on this issue as quickly as possible (GAO August 2012).

Insurance exchanges will also have to develop processes for helping applicants navigate the exchange eligibility determination and enrollment process. When California implemented its Medicaid expansion program, known as the Low Income Health Program (LIHP), it failed to provide funding for PLWHA. The state assumed PLWHA would remain on RWHAP, not recognizing that RWHAP was a payer of last resort. The state also failed to inform HIV providers and pharmacies of the transition of PLWHA into LIHP (Donnelly and Mulhern-Pearson July 2012). The result was that when many PWLHA transitioned onto LIHP managed care, they lost access to HIV providers and pharmacies that were not in LIHP’s provider and pharmacy networks. As a result, many faced abrupt disruptions in care until the problems could be addressed (see Chapter IV for more details).

19 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Figure II.2. Status of State Health Insurance Exchange Implementation

Based on our interviews with state Medicaid agencies, states have already begun considering ways to improve exchange navigation and streamline online enrollment. For example, Massachusetts is developing a new enrollment system whereby consumers will be able to enter data about their financial status on a website and, based on those data and information at the federal and state levels regarding their eligibility, the system will be able to make a real-time determination of program eligibility and placement. The system will also serve people with incomes greater than 400 percent of the FPL who want to use it to shop for coverage. Those in the higher income brackets will receive a message stating that they are not eligible for tax credits or cost sharing reductions, but they will still be able to shop for insurance through the exchange. Currently, the state uses a paper-based process that it described as cumbersome and that can take from three weeks to several months to complete.

New York’s insurance exchange, which is housed in the state’s health department, will allow for in-person, telephone, or online enrollment. The state plans to launch a marketing campaign in the summer of 2013 to make people aware of the exchange and new coverage options. It is currently writing the scripts for the telephone and online service centers. The state is also looking into developing its patient navigator program for the exchange. Though states are required to have navigators only for small business and individual exchange plans, New York is looking to develop a universal system.

20 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Implications for RWHAP and PLWHA. The availability of exchange-based coverage and federally funded tax credits and cost sharing reductions provides a new marketplace for affordable insurance coverage for PLWHA and is expected to reduce significantly the number of uninsured. However, PLWHA enrolled in private health insurance could face more cost-sharing requirements (particularly for prescription drugs) than they do now, under RWHAP, and some of the services they need might not be covered or might be limited by their insurance. Finally, in states that do expand Medicaid eligibility, PLWHA whose incomes fall below 100 percent of the FPL will not have any new public or private insurance options because they will not qualify for private insurance tax credits or cost sharing reductions under the ACA. For this group, RWHAP will remain an essential source of support.

States that do not already have an online Medicaid application process will have to make major changes in the way they conduct Medicaid eligibility and enrollment for individuals and families, including developing in-person navigation services to help vulnerable populations access and complete the exchange-based eligibility and enrollment process. The experts we interviewed suggested that HAB and RWHAP grantees could help federal and state agencies with coordination efforts to ease RWHAP clients and providers through the transition to Medicaid, which will help to minimize care disruptions and disengagement. For example: CMS could develop a simple, streamlined application process to facilitate program eligibility determinations (Harvard Law School Health Law and Policy Clinic November 2011b; Squires July 2011).

RWHAP could also fund other services, including patient navigation, benefits counseling, pharmacy assistance (for example, hiring more pharmacy technicians to help PLWHA with medication adherence), peer outreach (using community outreach workers and promotoras), and hiring individual transition coordinators to help existing RWHAP clients successfully complete the exchange-based eligibility and enrollment process.11 HAB could also work with CMS to ensure that exchanges and Medicaid MCOs include patient navigators with experience working with PLWHA (Harvard Law School Health Law and Policy Clinic November 2011b). For example, one of the experts we interviewed told us about several small RWHAP clinics in California that successfully used transition coordinators when their HIV clinic was subsumed under a federally qualified health center (FQHC). The coordinators helped keep their clinic’s retention-in-care rate at 98 percent. The state has also outlined its transition process from ADAP to LIHP, and developed a curriculum to help those who are interested in HIV transition assistance to become certified as “peer outreach workers” to lend further legitimacy to their coordination work (CDPH 2012).

Medicare has developed several mechanisms to assist beneficiaries in identifying the Medicare, Part D, and Medigap plans that best meet their health care needs. For instance, the Medicare Plan Finder allows beneficiaries to enter their zip code to conduct a general search, which they can refine by entering the names of drugs that they take, or enter more identifying information to obtain more customized results. Private companies have developed similar online systems whereby beneficiaries can enter their medications and the site will provide a list of plans that provide coverage (see, for example, http://www.q1medicare.com/PartD-SearchPDPMedicarePartDDrugFinder.php). The federal government also provides funding support to State Health Insurance Assistance and Counseling Programs (SHIPs) that provide personalized counseling to Medicare beneficiaries to help

11 A promotora is an outreach worker in a Hispanic community who is responsible for raising awareness of health and educational issues

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them evaluate plan choices. These types of systems could be developed through the exchanges to ensure that PLWHA identify the plans that best meet their health care needs.

2. ACA Citizenship Requirements

ACA reform. Under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), only citizens and legal residents who have lived in the United States for five years or longer are able to receive public benefits, such as Medicaid. However, the ACA allows immigrants “lawfully present” in the United States for less than five years to purchase private insurance coverage (and receive premium tax credits and cost sharing reductions) through health insurance exchanges. States also have the option to offer a Basic Health Plan (BHP) (described in more detail in Chapter III) to adult citizens with incomes between 133 and 200 percent of the FPL and to lawfully present immigrants with incomes under 133 percent of the FPL, who are barred from Medicaid because of their immigration status (NCLR 2011).

The BHP provides states with 95 percent of what the government would have spent on tax credits and subsidies for these two groups; however, people covered under the BHP do not receive federal subsidies directly (Dorn March 2011). Although these provisions might move a large number of people out of RWHAP and into private insurance coverage, they leave many people who do not meet citizenship or legal residency requirements without feasible insurance coverage options if they lack employer-based insurance and cannot afford private coverage.

ACA implementation. Several of the technical experts that we interviewed cited the ongoing coverage exclusion for people who do not meet citizenship or legal residency requirements as one of the most troubling aspects of the ACA. As several experts noted, this group includes people who might be infected with HIV but who have no regular access to care and treatment; excluding them creates a vector for the spread of the virus. In addition, experts noted that other potentially eligible populations are also likely to remain uninsured under the ACA. Such groups include migrant workers and other mobile populations, those who are homeless, and those living in poverty, all of whom tend to have higher rates of HIV infection and lower rates of HIV care access and use. Even with the financial assistance being provided, many people living in poverty, especially those living in states that are not expanding Medicaid, will not be able to afford the private insurance copayments offered under health reform. Uninsured, low-income, and low-literacy PLWHA are also less likely to know what services are available or how to assert themselves to get the services they need. The uninsured could also include low-income people with HIV who are otherwise relatively healthy. For economic and social reasons, members of these groups often do not seek health care until they become sick. Failure to enter treatment in the early stages of HIV infection creates another significant risk for spread of the virus.

Implications for RWHAP and PLWHA. In the interest of limiting the spread of the HIV/AIDS epidemic, some of the experts we interviewed encourage HAB to maintain and increase its leadership role in ensuring care for undocumented immigrants, lawfully present immigrants living the United State for less than five years, and other underserved populations that are potentially eligible but unlikely to seek public or private insurance coverage. However, they note that members of Congress who are looking to reduce the federal budget deficit might not be willing to continue funding programs for such marginalized populations. HAB can assist states and other stakeholders to conduct outreach to members of these groups, screen them for HIV through routine HIV testing, and help those who are HIV positive, to enter care.

22 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

3. Exchange Recommendations

The development of health insurance exchanges significantly changes the eligibility and enrollment process for public programs (Medicaid and CHIP) and private health insurance plans, especially for RWHAP clients and PLWHA who are newly eligible for these programs. For example, PLWHA in PCIPs will lose their insurance on January 1, 2014, and will need to be transitioned to Medicaid or private insurance before then. Also some frail, vulnerable, or high-need RWHAP clients may need to be exempted from Medicaid expansion programs, MCOs, or private insurance plans for health-related reasons. All RWHAP clients will benefit from a carefully coordinated transition to Medicaid and private health insurance plans. To help these groups successfully navigate these transitions, we recommend the following actions in Table II.4:

Table II.2. Exchange Recommendations

1. Work with state Medicaid programs to develop and implement transition plans for PLWHA enrolled in PCIPs. 2. Conduct outreach to uninsured PLWHA who are newly eligible for coverage under 1115 waivers or PCIPS before 2014. 3. Train HIV providers on eligibility for Medicaid and private insurance, the exchange enrollment process, copayment cost reductions, and recertification and exemption processes. 4. Work with states to use RWHAP case managers trained in exchange eligibility and enrollment processes as patient navigators and individual transition coordinators in exchanges. 5. Create and distribute outreach materials to help PLWHA to make informed choices between health plan options. 6. Help PLWHA determine whether they are required to enroll in an MCO and help them find information about which plan best meets their needs. 7. Help PLWHA seek exemption from automatic enrollment into health plans or MCOs that do not meet their coverage needs. 8. Help vulnerable PLWHA continue to see current providers and pharmacies through a continuity of care or medical exemption request. 9. Work with states to create a carefully planned, multi-phased transition of newly eligible PLWHA into expanded Medicaid.

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

III. INSURANCE BENEFITS AND COSTS

A. Introduction

Several ACA insurance benefit and cost provisions are expected to make insurance more affordable and promote more comprehensive and preventive care. Through the study’s document scan, consultations with technical experts, and interviews with state Medicaid officials, we identified the following reforms, which are likely to have the greatest impact on the RWHAP community: (1) essential health benefits and benchmark health plans, (2) basic health plans, (3) private health insurance tax credits and cost sharing reductions, (4) elimination of cost sharing for preventive services, including HIV testing, and (5) closure of the Medicare Part D medication coverage gap.

B. Insurance Benefits

1. Essential Health Benefits and Benchmark Plans

ACA reforms. Before the passage of the ACA, under the Deficit Reduction Act of 2005 Figure III.1. EHB Service Categories (DRA), states could vary the Medicaid benefit 1. Ambulatory patient services packages available to groups of beneficiaries and 2. Emergency services were allowed to establish new Medicaid benchmark 3. Hospitalization benefit packages that did not provide all of the 4. Maternity and newborn care same benefits that were available to other Medicaid beneficiaries (Solomon September 2006). In 5. Mental health and substance use disorder services, including behavioral addition, there were differences between the health health treatment insurance benefits offered through state Medicaid programs and benefits offered through private 6. Prescription drugs insurance. As a result, Medicaid benefits varied 7. Rehabilitative and habilitative services within and across states. and devices 8. Laboratory services The ACA authorized several changes that set a 9. Preventive and wellness services and minimum standard for the benefits offered chronic disease management through public and private insurance plans. First, 10. Pediatric services, including oral and the ACA required that all insurance offered under vision care (a) Medicaid expansion, (b) through QHPs in the state’s health insurance exchange, and (c) through the state’s Basic Health Plan (BHP), will offer a core package of items and services known as “essential health benefits” (EHBs). EHBs are required to include items and services in the 10 categories listed in Figure III.1 (National Health Council September 2010; Rosenbaum and Hayes October 2011).

Insurance policies must cover these benefits, at minimum, in order to be certified and offered as a QHP in a health insurance exchange. Under the ACA, such QHPs are required to (1) be certified by the exchange through which they are offered; (2) provide EHBs; (3) be offered by an insurer that is licensed and agrees to offer at least one plan at the silver (70 percent actuarial value) and gold (80 percent actuarial value) levels; (4) charge the same amount whether the plan is offered through an exchange or directly through an agent; and (5) comply with regulations developed by HHS (Hart Health Strategies November 2010).

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Although the original intent of the ACA was to have the federal government set a national EHB standard, in December 2011, the Center for Consumer Information and Insurance Oversight (CCIIO) at CMS issued a bulletin granting states the flexibility to select and use as a state-specific benchmark an existing health insurance plan that offered the scope of services provided by a typical employer plan (CCIIO December 2011). States were required to select a benchmark plan by September 30, 2012, from one of the following options: (1) one of the three largest small-group plans in the state (by enrollment); (2) one of the three largest state employee health plans (by enrollment); (3) one of the three largest federal employee health plans (by enrollment); or (4) the largest non-Medicaid health maintenance organization (HMO) plan offered in the state’s commercial market (by enrollment). If a state chose not to select its own benchmark plan, the state’s default plan would be the largest small-group plan with the largest enrollment in the state (HealthCare.gov January 2012; HHS November 2012).

On November 20, 2012, CMS issued a proposed rule providing additional EHB guidance (CMS November 2012b; HHS November 2012). The proposed rule makes a distinction between the benchmark plan selected by a state (called the base-benchmark plan), and the benchmark standard that insurance plans would need to meet in each state (called the EHB-benchmark plan). Under this rule, each state selects a “base-benchmark plan” from the 4 options mentioned above or the default plan. If the base-benchmark plan option selected by the state does not cover all 10 EHB categories, the state must supplement the plan by adding the missing categories in their entirety from other base-benchmark plan options (ASPE 2012). After the state applies adjustments to that plan to include all 10 EHB categories, the plan becomes known as the “EHB-benchmark plan.” This EHB- benchmark plan applies to non-grandfathered health insurance offered in the state’s individual or small group markets, and serves as a reference plan, reflecting the scope of services and limits offered by a typical employer plan in that state (HHS November 2012). The proposed rule also added more flexibility to EHB prescription drug coverage, in response to public comments. Under the proposed rule, a plan may cover at least one drug in every category and class or may have the same number of drugs in each category and class as the state’s EHB-benchmark plan (HHS November 2012).

In a November 20, 2012 letter to state Medicaid directors, CMS also provided more guidance regarding what EHBs would be applied to Medicaid expansion programs (CMS November 2012b). The letter explained that under the DRA, states have great flexibility in designing state Medicaid benefit packages, and so may provide Medicaid “benchmark” or “benchmark-equivalent” coverage to this newly eligible group of low-income adults, by selecting an “alternate benefit plan” from one of four options: (1) the Standard Blue Cross/Blue Shield Preferred Provider Option offered through the Federal Employees Health Benefit Program; (2) state employee coverage available to state employees; (3) a commercial HMO with the largest insured commercial, non-Medicaid enrollment in the state; or (4) coverage approved by the HHS Secretary (which can include the Medicaid state plan benefits package offered by the state).

As described above, if the selected option does not have all 10 EHB categories, the state must supplement their alternate benefit plan to ensure coverage in all 10 EHB categories. Newly eligible Medicaid enrollees must receive insurance benefits that are part of the state’s alternate benefit plan or in another plan that is equivalent in value. Coverage within a benefit category in these plans can be modified, as long as they do not reduce the overall value of the coverage. The letter also allowed states to select more than one alternate benefit plan to define EHBs for different segments of its Medicaid population (CMS November 2012b).

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Traditionally, Medicaid benchmark benefit packages are less comprehensive than Medicaid state plan benefits, and more often mirror those offered in commercial insurance plans. However, the ACA mandates several important additions to benchmark coverage, including mental health and substance abuse treatment services, rehabilitation, and habilitative services. Specifically, plans are required to cover mental health and substance abuse care, including behavioral health care at parity with physical health services. As noted above, states are also allowed to select their own Medicaid state plan benefit package as their alternate benefit plan. This is an attractive option for states that want to minimize disruptions in insurance benefits for people whose eligibility for public and private insurance fluctuates with their income.

ACA implementation. The experts consulted for this study identified the determination of the state’s essential health benefits as one of the highest-priority issues for PLWHA because the EHBs set the standard for what HIV-related services are available through public or private insurance. Because states are allowed to define their own state-specific EHB benchmark plans and alternative benefit plans, there is concern both with the variation in the content of the EHBs that will be available for PLWHA and with the potential for significant state-to-state variation in these benefit plans. In particular, the experts are concerned that some services currently funded by RWHAP are unlikely to be covered (or inadequately covered) by states’ EHB-benchmark and alternate benefit plans. Examples of services funded by RWHAP that are not included in the 10 EHB categories include nonmedical transportation, dental care, case management, substance abuse treatment, and interpreter services for patients with limited English proficiency.

By the end of September 2012, states were required to identify their state’s EHB plan option for the individual- and small-group qualified health plans (QHPs) that are sold through health insurance exchanges (Killela et al. July 2012). In the November rule, this was modified; states may now review and change their selection within the proposed rule’s public comment period (HHS November 2012).

Of the 7 state Medicaid programs we interviewed for this study, by August 2012 only 2 states (Colorado and Oregon) reported that their state had made a preliminary benchmark plan recommendation. Of the 2, only Oregon had finalized the selection of its EHB package (see Append B: Table B.III.1 for details). Although HIV care is not specifically mentioned in Oregon’s EHB package, Medicaid officials report that the state’s EHB package is broad enough to serve anyone with any disease in the state, including HIV/AIDS.

In Massachusetts, as in other states, the state’s EHB-benchmark plan will define what constitutes the state’s EHBs. While mental health and substance abuse services will be part of the state’s benchmark plan, the benchmark plan will not include details of its cost-sharing provisions (silver, gold, or platinum tiers) or which providers would be in its provider network (including what access will be provided to HIV specialists). Maryland reported that its Medicaid state plan benefits package will be offered to the state’s newly eligible Medicaid expansion beneficiaries, regardless of the EHB-benchmark plan selected by the state for QHPs.

On a national scale, by early September, a total of 30 states had formed EHB work groups; 30 states had also conducted assessments of the costs and benefits of various benchmark plan options. Of the 30 states, one-third (Arkansas, California, Colorado, Nevada, Oregon, Rhode Island, Utah, Vermont, Virginia, and Washington) and the District of Columbia had made preliminary benchmark plan recommendations; most had opted for a small-group market benchmark plan (National Academy for State Health Policy September 2012).

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By early November 2012, 12 states had not yet made their benchmark plan selection (Alaska, Georgia, Idaho, Maine, Minnesota, Missouri, Montana, North Carolina, South Carolina, South Dakota, Texas, and Wyoming) (see Figure III.2). Another 12 states had requested additional federal guidance before making their final selection decision (Alabama, Florida, Indiana, Iowa, Louisiana, New Jersey, Ohio, Oklahoma, Pennsylvania, Tennessee, West Virginia, and Wisconsin). However, the other 26 states and the District of Columbia have selected an EHB-benchmark plan. The majority (18 states and the District of Columbia) opted for a small group market plan, 4 states (Connecticut, Michigan, North Dakota, and Vermont) selected an HMO plan, 3 states (Arizona, Maryland, and Utah) chose a state employee plan, and one state (Nebraska) selected a high deductible health savings plan (State(Re)Form November 2012).

Figure III.2. Status of State Essential Health Benefit Plans

Implications for RWHAP and PLWHA. Allowing states to define their own state-specific EHBs using a benchmark plan approach will likely result in significant variation in the specific services covered from state to state. Because states have broad flexibility to define their own EHBs, it is currently unclear how uniform the EHBs will be across states, and whether certain services, such as behavioral healthcare, will be covered in all state EHBs. The level of affordability and comprehensiveness of the state’s benchmark plan will be an important issue for PLWHA, especially those with complex medical needs, requiring extensive healthcare services that may not be included in the state’s EHB-benchmark plan. Consequently, RWHAP funds will likely remain an important source of services not covered, or inadequately covered by QHPs after implementation of the ACA.

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Some experts and advocates also argue that PLWHA should have access to comprehensive HIV services regardless of their state of residence, suggesting that care could be disrupted if they move between states with different EHB-benchmark plans. There is also concern that state policymakers and program administrators will determine their state’s EHBs based more on efficiency considerations than on the comprehensiveness of the coverage. One state official we interviewed was concerned that “EHBs will get determined by politics; the question will not be, ‘How do we cover as many people as possible as completely as possible?’ but ‘How do we cover a lot of people at the lowest cost?’” Although state Medicaid programs have a financial incentive to make their alternative benefits package for Medicaid expansion enrollees as robust as possible (so that residents are not underinsured), there are also strong incentives to make their state’s alternate benefits package as lean as possible (to make the perception of the program’s costs more politically palatable).

Given this uncertainty, RWHAP grantees and advocates can take a leading role in ensuring that state-specific EHB coverage is sufficiently comprehensive to address the needs of PLWHA, following the benefits recommendations below. HAB also educate grantees on EHB policies, similar to the leadership role that the Substance Abuse and Mental Health Services Administration (SAMHSA) has taken to ensure adequate EHB coverage for people living with substance abuse and mental health disorders. For example, as part of its Health Reform Innovations Learning Collaborative, SAMHSA conducted a four-part series of webinars in the summer of 2012 to provide states a better understanding of EHBs and of the benchmark benefit plan options in their states.

In addition, the RWHAP community can work to ensure that all QHP and Medicaid expansion benefit plans, including benchmark-equivalent plans, include all of the benefits and services necessary to meet the health care needs of PLWHA (Presidential Advisory Council on HIV/AIDS August 2011). HAB should also consider expanding its role in monitoring compliance of states’ benchmark plans with national standards of HIV care. Finally, RWHAP grantees can help state Medicaid agencies develop and implement outreach plans to help PLWHA understand their state’s EHB-benchmark and alternate benefit plans (Technical Assistance Collaborative 2011) and help states to develop materials to help PLWHA make more informed choices between health plans (Technical Assistance Collaborative 2011).

2. Basic Health Plan

ACA reform. The ACA’s BHP option offers states a less expensive alternative to other QHPs offered through health insurance exchanges, for people with incomes from 133 to 200 percent of the FPL who would otherwise be eligible for premium tax credits in the exchange. The BHP option permits states to avoid potential affordability problems in the state health insurance exchanges when, for example, the premiums and out-of-pocket (OOP) costs of the private insurance plans offered through the exchange are expected to be too high for many low-income consumers.

BHP benefits must be at least as generous as the essential health benefits that enrollees would have received had they been enrolled in other QHPs through an exchange (Dorn March 2011; Bachrach et al. March 2012). States also have the option of including additional services to their BHP, such as dental care or transportation; states can also reduce the cost-sharing requirements of the BHP to Medicaid-like levels (Sebastian July 2011). BHPs must be delivered via contracts with private health plans, including plans provided by safety net providers. If a state chooses to exercise this BHP option, the state receives 95 percent of the private insurance tax credits and cost sharing reductions that the consumer otherwise would have otherwise received if they had enrolled in another QHP in the exchange (Dorn March 2011). 29 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

ACA implementation. Although private health insurance premium tax credits under the ACA are based on a sliding scale and intended to ensure affordability, even premiums as low as 2 percent of household income in private insurance plans might be cost prohibitive to PLWHA. Thus, the BHP option could be an affordable option to PLWHA in this income bracket. In addition, enrolling in a BHP may provide continuity of care for individuals whose income fluctuates above and below Medicaid eligibility levels. States can design their BHPs to enable these individuals to keep the same plan and provider as their income fluctuates (Bachrach et al. March 2012). However, although the BHP option offers states flexibility in selecting their provider networks, because BHPs are private insurance plans, their primary care providers are not eligible for an enhanced Medicaid reimbursement rate (described more in Chapter V). Typically, BHP providers are reimbursed at reimbursement rates that may be lower than the enhanced Medicaid payment rate, so sustaining robust BHP provider networks is also a concern (Bachrach et al. March 2012).

Another challenge for states that are evaluating whether or not to implement a BHP is predicting the impact it will have on the number of people who might otherwise enroll in a private insurance plan through the health insurance exchange. If a state has a BHP, fewer people will be left to participate in its exchange, which could affect the capacity of the exchange to have a robust risk pool (Sebastian July 2011). Traditionally, lower-income populations have poorer health outcomes. Therefore, some experts argue that removing the BHP population from the private insurance plans in an exchange will likely lower the cost of private health insurance premiums (Bachrach et al. March 2012). However, the BHP-eligible population is also younger and might have lower cost-sharing requirements, both of which are also associated with lower risk (Bachrach et al. March 2012). Although these issues might be more significant in states with a smaller state population, accurately predicting the risk profiles of the exchange populations in BHP versus private health plans is important for all states considering the BHP option (Sebastian July 2011).

Additional federal guidance on BHPs is expected later in 2012, however, BHP rulemaking is reportedly lagging behind the publication of draft and final rules for other ACA provisions (HIV Health Reform November 2012). As a result, it is not known when states will receive the federal guidance needed to assess the financial feasibility of the BHP option. In particular, states will need more information on how to calculate the value of the BHP’s premium tax credits and cost-sharing reductions. More information is also needed regarding the process that will be used to reconcile the annual MAGI income calculation that will be part of the BHP eligibility assessment and determination process, with the monthly income calculations that are used in the state’s Medicaid state plan eligibility assessment and determination process.

Among the 7 states consulted for this study, only Massachusetts indicated that it planned to implement a BHP option as an alternative to other QHPs offered through its health insurance exchange. Assuming that Massachusetts continues to pursue this option, its BHP will be administered through MassHealth, which is the state’s Medicaid program. Thus, PLWHA newly eligible for Medicaid expansion, whose incomes are between 133 to 200 percent of the FPL will go into the state’s BHP. Massachusetts is also looking closely at what benefits will be offered under the BHP, but has yet to make a final decision on which benefits will be included in the plan.

Although Massachusetts is the only state to have enacted legislation giving the state authority to create a BHP, at least 10 other states across the country are also considering this option (Kaiser Family Foundation August 2012a). For example, among the states we interviewed in July and August 2012, both Maryland and Iowa were considering exercising the BHP option. Iowa noted that it was trying to understand better what a BHP would look like and how it would operate in the state. The Maryland Medicaid officials were also uncertain about whether a BHP would be cost-effective, and 30 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research were seeking further federal guidance. Meanwhile, Tennessee has developed an alternative program called Bridge Option: One Family, One Card Over Time, that would allow individuals moving from Medicaid to a BHP to remain in a lower-cost Medicaid managed care plan by allowing individuals to retain coverage through the same insurer/provider network if their eligibility state were to change, (e.g., from Medicaid expansion to premium tax credits or vice versa) (Kaiser Family Foundation August 2012a).

Implications for RWHAP and PLWHA. PLWHA with incomes just above the FPL may experience monthly fluctuations in income that could cause them to change their Medicaid expansion eligibility status during the year, or require them to switch frequently between Medicaid expansion and private insurance. These changes could lead to churning—temporary lapses in insurance coverage or gaps in adherence to critical HIV treatments, such as ART prescription medications. As a result, BHPs might offer an attractive alternative for low-income RWHAP clients and other PLWHA who are concerned about potential disruptions in their continuity of care.

States have also been evaluating the potential impact of a BHP on the financial viability of their states’ health insurance exchanges (Bachrach et al. March 2012). If a state chooses to offer a BHP, it would also have to evaluate the adequacy of the supply of providers with HIV expertise in the plan’s provider networks and the BHP’s cost-sharing requirements. Further, it could be a challenge for states to facilitate seamless insurance transitions that would enable continuity of coverage across Medicaid, the BHP, and QHPs for PLWHA with fluctuating incomes. In states that choose the BHP option, HAB can help to identify and advocate for the key services and benefits that should be included in the BHP package, and educate policymakers and providers on the service needs of PLWHA, to ensure a more seamless transition into these new systems of care.

3. Benefit Recommendations

Although many key decisions have yet to be made regarding the final EHB-benchmark and alternate benefits packages that will be offered, the findings from this study suggest the importance of (1) advocacy to ensure that the benefits covered by Medicaid and private health plans reflect the full range of services that PLWHA need to manage and maintain their health; and (2) identifying potential gaps in coverage, which RWHAP grantees and providers can help to fill.

Currently, it is unclear what types of HIV medical and support services state Medicaid expansion programs and EHB-benchmark plans will cover. However, based on our discussions with state Medicaid directors, many services that are key elements of RWHAP-funded HIV primary and specialty care might not be covered under Medicaid expansion or private health insurance. At minimum, essential health benefit packages and benchmark plans will vary from state to state. In each state, RWHAP grantees and advocated will need to work with state Medicaid officials and others to ensure that essential health benefits (EHBs) and benchmark plans are comprehensive and address the needs of PLWHA. Specifically, we recommend the following actions in Table III.1:

Table III.1. Benefit Recommendations

1. Work with states to ensure the development and approval of comprehensive EHBs that meet the health care needs of PLWHA. 2. Encourage states to include HIV/AIDS prevention, testing, and counseling; access to newer ART medications; treatment adherence; unlimited medical and laboratory services; transportation; and other supportive services in the definition of EHB categories. 3. Work with state Medicaid programs to ensure that all state health plans, including benchmark- equivalent plans, include all the benefits and services necessary for HIV treatment and care.

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Table III.1 (continued)

4. Ensure that health plans provide continuity in access to ART medications through their pharmacy networks and formularies.* 5. Encourage CMS to conduct Medicaid reviews to ensure that PLWHA are receiving adequate access to covered services. 6. Inform PLWHA of their continued right to access the Medicaid state plan benefit through a disability determination if they need the services provided under Medicaid. 7. Work to ensure that medically frail PLWHA are not automatically assigned to a Medicaid expansion program on the basis of MAGI-adjusted eligibility determinations. 8. Given potential volatility in the Medicaid eligibility status of PLWHA (due to changes in income and health status), advocate for states to adopt a BHP that addresses HIV care needs. 9. Encourage the United States Preventive Services Task Force (USPSTF) to finalize its draft recommendations for routine HIV testing a covered service under all health plans. 10. Identify ongoing service gaps in state and local health systems and assess potential for working with RWHAP planning councils to reallocate Part A and B funding from direct medical services to premium supports and wrap-around services.*

C. Insurance Costs

1. Private Insurance Tax Credits and Cost Sharing Reductions

ACA Reform. The ACA introduced a number of provisions to make private health insurance more affordable, including premium tax credits and reduced cost-sharing, which are both aimed at reducing consumer spending. Beginning in 2014, citizens and legal residents, who are not otherwise eligible for Medicaid expansion, whose income is from 100 to 400 percent of the FPL ($89,000 for a family of four in 2011) are eligible for an advance tax credit to reduce the cost of premiums for QHPs purchased through a health insurance exchange. The ACA also offers a catastrophic insurance policy that is available to young adults and to people who cannot find a private insurance plan with a premium that costs less than 8 percent of their annual income.

To help differentiate the costs and benefits of different QHPs, the ACA set four levels of actuarial value for private insurance plans, stratified by “metal” tiers. The first level, Tier 1 (the bronze tier), sets the insurance plan’s actuarial value at 60 percent (that is, the plan covers 60 percent of total average costs for covered benefits and the consumer is responsible for the other 40 percent of the plan’s costs). The other tiered plans have the following actuarial values: Tier 2 (silver), 70 percent; Tier 3 (gold), 80 percent; and Tier 4 (platinum), 90 percent. Establishment of these tiers is intended to help consumers compare plans and select an insurance plan with a level of actuarial value that they can afford.

People with incomes between 100 and 400 percent of the FPL, who are not eligible for Medicaid, are eligible for Figure III.3. Net Premium Cost advance tax credits that are designed to reduce the cost of Limit as a Percentage of Income their private insurance premiums. In each state, the amount of the advance tax credit that a person can receive is based • 100 -- 133% FPL: 2% on the cost of the premium of the state’s second lowest cost • 133 – 150% FPL: 3 – 4% silver insurance plan, which has an actuarial value of 70 • 151 – 200% FPL: 4 – 6.3% percent. Tax credits are determined on a sliding scale based • 201 – 250% FPL: 6.3 – 8.05% on the person’s income, whereby the net cost of the • 251 – 300% FPL: 8.05 – 9.5% premium, including the tax credit, is not allowed to exceed a • 301 – 400% FPL: 9.5% particular percentage of one’s income (Figure III.3). People 32 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

with incomes between 100 and 250 percent of the FPL are also eligible for additional financial assistance through the exchange, including reduced cost-sharing requirements lowering insurance copayments, deductibles, and coinsurance.

ACA Implementation. Cost-sharing is limited on a sliding-scale basis for citizens with incomes between 100 and 400 percent of the FPL and for lawfully present immigrants with household incomes less than 100 percent of the FPL who are otherwise ineligible for Medicaid and who are purchasing insurance through a state health insurance exchange (Health Consumer Alliance August 2011). Limits apply to EHB covered by a qualified silver-level health plan purchased through an exchange (the individual must pay for benefits above and beyond these conditions). Health plans are responsible for implementing these cost-sharing provisions and will be reimbursed directly by HHS (Health Consumer Alliance August 2011).

The ACA also introduced out-of-pocket spending limits designed to protect lower-income Figure III.4. Out- of- Pocket Limits Based on Income people from high out-of-pocket costs at the point of service. Out-of-pocket costs are capped at annual • spending limits for the high-deductible health plans 100 – 200% FPL: $1,983/individual; associated with health savings accounts (HSAs).12 $3,967/family Out-of-pocket spending costs are limited on a sliding- • 201 – 300% FPL: $2,975/individual; scale basis for citizens with incomes between 100 to $5,950/family 400 percent of the FPL and for lawfully present • 301 –400% FPL: $3,967/individual; immigrants with household incomes less than 100 $7,933/family percent of the FPL who are ineligible for Medicaid and who are purchasing insurance through a state health insurance exchange as detailed in Figure III.4 (Health Consumer Alliance August 2011).13 For these low-income consumers, out-of-pocket limits are set at three levels: (1) one-third of the HSA limit for households with incomes from 100 to 200 percent of the FPL, (2) half of the HSA limit for households with incomes from 201 to 300 percent of the FPL, and (3) two-thirds of the HSA limit for households with incomes from 301 to 400 percent of the FPL (Bailey et al. February 2011).

The ACA further reduces cost-sharing beyond the out-of-pocket limits for households with incomes between 100 and 250 percent of the FPL (Health Consumer Alliance 2011). A person’s cost-sharing responsibility will range from 6 to 27 percent of the plan’s value. Special cost-sharing rules apply to Native Americans and households with undocumented immigrants (Health Consumer Alliance August 2011). The spending limits as defined in the ACA do not specify the combination of deductibles, copayments, and coinsurance that plans must use to meet these actuarial value (metal tier) requirements. Therefore, one plan could have a relatively high deductible but a low copayment

12 HSAs are tax-exempt trusts or custodial accounts that taxpayers can set up with a qualified trustee to assist with payment for medical expenses (Internal Revenue Service 2012). Generally, HSAs are established by people covered by high-deductible or otherwise unaffordable health plans. However, the Deficit Reduction Act allows states to impose higher cost-sharing on some groups with income above 100 percent of the FPL, as long as the family’s total cost-sharing is less than 5 percent of its income. The ACA gives states flexibility to design Medicaid benefit packages and cost-sharing rules for newly eligible populations covered under the expansion. 13 Limits apply to EHB covered by a qualified silver-level health plan purchased through an exchange (the individual must pay for benefits above and beyond these conditions). Health plans are responsible for implementing these cost-sharing provisions and will be reimbursed directly by HHS (Health Consumer Alliance August 2011).

33 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

for services provided. Another plan could choose a low deductible paired with high copayments (Kaiser Family Foundation July 2012b). At this time, neither HHS nor CMS has issued additional guidance on this provision.

Implications for RWHAP and PLWHA. Although the premium tax credits and reduced cost-sharing provisions are intended to make insurance more affordable for PLWHA, guidance on the details of how the exchanges will administer these subsidies has yet to be determined by CMS. There is also apparently a legal issue about whether the federally facilitated exchange has the authority to offer premium tax credits to consumers (HIV Health Reform November 2012).

For states that do not expand Medicaid, many questions remain regarding what financial assistance, if any, can be offered to people with incomes under 100 percent of the FPL. Although the advance tax credit and other private insurance cost reductions ensure increased access to affordable insurance for many, in the absence of Medicaid expansion, the most vulnerable adults with incomes under 100 percent of the FPL, are likely to be left without an affordable insurance coverage option because they are not eligible for private insurance advance tax credits or other cost reductions, and they are not eligible for traditional Medicaid as single adults without a disability or other insurance eligibility criteria.

Among the seven state Medicaid programs we interviewed for this study, three expressed concern and uncertainty regarding what they planned to do to address this gap. In particular, the Texas officials hoped to receive approval from CMS to make new subsidies available for people with incomes below 100 percent of the FPL, whereas everyone with incomes greater than 100 percent of the FPL would be placed into its state health insurance exchange. Similarly, Colorado and Iowa await further guidance from CMS regarding their available options, in case they do not expand Medicaid.

Although states can now consider expanding private insurance financial assistance and can provide a BHP option to people with incomes above 133 percent of the FPL, many advocates argue that Medicaid expansion is preferable to private insurance premium tax credits for people in this low-income bracket. In particular, they note that the Medicaid benefits package is tailored for very low-income populations, which is not necessarily true for other private insurance plans (Mahan August 2012). Further, they point out that Medicaid expansion will cost states less than offering private insurance subsidies to this low-income group. The Congressional Budget Office estimates the direct cost of the premium tax credits and cost-sharing reductions to be $350 billion from 2010 to 2019 (CBO March 2010), whereas expanded Medicaid coverage is projected to be less costly (Mahan August 2012).

2. Preventive Service Cost Sharing

ACA reform. The ACA also promotes the provision of preventive care by introducing new coverage options for preventive services under Medicaid, Medicare, and private health plans, and exempting certain preventive services from existing enrollee cost-sharing requirements such as copayments, deductibles, and coinsurance. For Medicaid, the ACA expands existing preventive care benefits by eliminating cost sharing for Medicaid preventive care services as a state plan option, which goes into effect on January 1, 2013. States that decide to offer covered preventive services without a cost sharing requirement can receive a 1-percentage-point increase in their federal medical assistance percentage (FMAP) rate (Amerigroup RealSolutions November 2010; Kaiser Commission September 2012).

34 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

One category of Medicaid covered preventive benefits is evidence-based screenings and counseling; these are preventive services that are endorsed with an A or B grade recommendation by the United States Preventive Services Task Force (USPSTF). HIV testing will be made available as an evidence-based screening without cost sharing as a Medicaid state plan option on January 1, 2013. Among the seven state Medicaid programs we interviewed, four (Maryland, Massachusetts, Oregon, and Texas) confirmed that HIV screening was a covered Medicaid benefit in their state. The USPSTF currently recommends HIV testing for all adolescents and adults at increased risk for HIV infection. This includes: (a) people reporting one or more risk factors, (b) those receiving health care in a high-prevalence or high-risk clinical setting and (c) pregnant women (Schmid May 2011; Kaiser Family Foundation September 2011).

The increased risk category includes people seeking treatment for sexually transmitted diseases (STDs); men who have sex with men; past or present injection drug users; people who exchange sex for money or drugs, and their sex partners; people who request a test; women and men whose past or present sex partners were HIV-infected, were bisexual, or were injection drug users; people with a history of blood transfusion between 1978 and 1985; and people who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. High- prevalence facilities are those known to have a 1 percent or greater prevalence of HIV infection (Schmid May 2011). In August 2011, HHS added sexually active women as a separate category eligible for HIV testing through a national coverage determination, which are decisions made by CMS regarding which services will be covered under the Medicare program and the circumstances under which the services will be covered. The requirement to cover HIV testing went into effect for all non- grandfathered private health insurance plans on September 23, 2010, and among all Medicare beneficiaries on January 1, 2011 (Kaiser Family Foundation September 2011).14

Under the ACA, private insurance plans are required to cover only preventive services that have been given a Grade A or B recommendation by the USPSTF. The exclusion of cost-sharing requirements for routine HIV testing applies only to groups that are defined as being at risk by HHS. Experts consulted for this study noted that relatively few people covered by private health insurance receive free HIV testing for two reasons. First, as many as 20 percent of PLWHA have not been tested and are not aware of their HIV serostatus. Second, because HIV risks are relatively difficult to assess and are open to subjective interpretation, many undiagnosed PLWHA might not be identified as being at risk of HIV and are therefore ineligible for free HIV testing. As a result, they may continue to face out-of-pocket costs for HIV testing and counseling.

ACA implementation. In 2006, CDC issued guidelines recommending routine HIV testing for people between the ages of 13 to 64. Since then, CDC has since joined professional groups such as the American College of Physicians and the HIV Medicine Association to advocate for this testing policy. Meanwhile, new scientific evidence has been published suggesting that early HIV detection

14 Grandfathered private health insurance plans are plans that were in existence before the enactment of the ACA, and, as a result are exempt from many ACA provisions, as long as no significant changes are made in the plans’ components. It is estimated that by January 1, 2014, over 90 percent of grandfathered private insurance plans will have lost this status because of changes made in the plans.

35 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research and treatment can reduce HIV transmission risk to uninfected partners by as much as 96 percent. The USPSTF has been reviewing this new evidence to upgrade its rating for routine HIV screening from Grade C (supporting routine screening in high-risk settings) to Grade A (supporting routine HIV screening for teens and adults) (Ebrahim August 2012). On November 19, 2012, the USPSTF upgraded its recommendation to Grade A, supporting one-time HIV screening for all adolescents and adults ages 15 through 65. The draft recommendation is open for public comment until December 17, 2012. When it is implemented, routine HIV screening will be covered by all payers, including Medicaid, Medicare, and private insurance plans (USPSTF November 2012).

Implications for RWHAP and PLWHA. HAB can play an integral role in the promotion of routine HIV testing and counseling, now that the USPSTF has revised its Grade A HIV testing recommendation and free routine HIV screening services are expanded under the ACA. HAB can also argue for the need for HIV preventive services to expand beyond primary prevention to include secondary (early detection and treatment) and tertiary prevention efforts (reducing HIV-related complications). In addition, HAB and RWHAP grantees can advocate for the elimination of cost sharing for the hepatitis B vaccine, as part of an overall HIV prevention strategy. Individual Hep B vaccine shots can cost up to $80, which can be cost-prohibitive for low-income PLWHA.

Further, providers are often not reimbursed for HIV testing in emergency department settings, in part because emergency department costs are typically reimbursed through bundled rates that do not include costs for HIV testing personnel time, counseling, or lab services. These ancillary costs are currently uncompensated and could be addressed in future in RWHAP planning. Finally, it is important for the RWHAP community to emphasize the importance of preventive HIV services as part of the National HIV AIDS Strategy.

Although the USPSTF recommendation for routine HIV testing is an important step, provider take-up of routine HIV testing as a part of standard clinical practice might initially be limited, especially in settings that have not done routine HIV testing and counseling in the past. In order to make routine HIV screening a financially and operationally sustainable, providers will have to make HIV testing part of a bundled payment (described in more detail in Chapter IV) and have an in- house champion to ensure that organizational HIV testing policies and procedures, such as changing clinic flow and staffing, are sustained and supported (HIV Health Reform August 2012).

3. Medicare Part D Donut Hole

ACA reform. Until the passage of the ACA, beneficiaries of Medicare’s Part D prescription drug program experienced a coverage gap, informally known as the donut hole, in which, after they surpassed the program’s initial drug coverage limit, they were responsible for the entire cost of their prescription drugs until their expenses reached a catastrophic coverage threshold. Several ACA provisions phase out this donut hole by 2020, and until then, allow ADAP benefits to be counted as true out-of-pocket (TrOOP) expenses for the Medicare Part D benefit (CMS October 2010; HRSA November 2010). Under the ACA, Medicare beneficiaries also receive a 50 percent discount on brand-name drugs while they are in the donut hole. Because ADAP benefits previously could not count towards the catastrophic expense threshold, it had been very difficult for PLWHA who received Medicare benefits to pass through the donut hole and qualify for catastrophic coverage (HIV AIDS Bureau November 2010).

This change in policy should reduce TrOOP costs for HIV prescription drugs for PLWHA who are dually eligible for Medicare and Medicaid. The new provisions should also reduce Medicare beneficiaries’ reliance on ADAP benefits, which could help ease overall demand for RWHAP drug

36 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research assistance services and could help reduce ADAP waiting lists. As of January 5, 2012, the ADAP waiting list stood at 4,606 people across 12 states (National Alliance of State and Territorial AIDS Directors 2012).

ACA implementation. Although this policy change will affect only the 7 to 12 percent of PLWHA who are currently enrolled in Medicare, as the population of PLWHA ages and becomes eligible for Medicare, more PLWHA should benefit from these savings in their prescription drug costs. However, if more Medicare beneficiaries begin taking ART medicine through preventive pre- and post-exposure prophylaxis treatments, the number of people who will benefit from the elimination of the donut hole and the allowance for ADAP benefits to count toward Medicare TrOOP costs could increase substantially.

Implications for RWHAP and PLWHA. By 2020, the Medicare Part D prescription drug coverage gap will be closed, but standard Medicare Part D cost-sharing requirements will still apply. Medicare beneficiaries will continue to be required to pay prescription copayments that are 25 percent of the cost of their medications. Without cost-sharing support funded by RWHAP, these Medicare benefits could still be too costly for many low-income PLWHA (Cross et al. April 2010). Consequently, PLWHA on Medicare will continue to need Medicare Part D cost sharing financial assistance from RWHAP in the foreseeable future.

4. Cost Recommendations

At present, insurance can be very expensive for people with greater-than-average need for health care, after taking into account premiums, deductibles, and co-pays, as well as out-of-pocket costs for services not covered by insurance. To reduce consumer costs, the ACA introduces a number of provisions that limit consumer cost-sharing and out-of-pocket expenses. Although general cost limits are important for all consumers, provisions related to eliminating cost sharing for HIV testing and counseling, and for Medicare Part D prescription drug expenses are especially important for PLWHA. To address these issues, we make the following recommendations in Table III.2:

Table III.2. Cost Recommendations

1. Provide outreach to educate RWHAP grantees, providers, clients, and PLWHA about the availability of cost-sharing reductions and OOP expense limits. 2. Seek elimination of cost-sharing for ART medications and other essential services for HIV care to reduce client cost-burden. 3. Monitor cost-sharing expenses to ensure that people eligible for cost-sharing reductions, including PLWHA, are not charged excessive cost-sharing amounts. 4. Allocate RWHAP funds to help cover cost-sharing amounts that remain unaffordable to PWLHA on private insurance.

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

IV. SERVICE DELIVERY AND PAYMENT REFORMS

A. Introduction

Several ACA provisions relating to service delivery and payment provisions are expected to improve the quality of health care while minimizing cost. Through our literature review, consultations with technical experts, discussions with state Medicaid programs, and input from HAB, we identified five service delivery and payment issues that will likely have a significant impact on HIV treatment and care. The issues concern (1) transitioning more PLWHA into Medicaid managed care, (2) developing more integrated models of care, including patient-centered medical homes and Medicaid health homes, (3) increasing HIV workforce capacity to managing growing demand for HIV care, (4) temporarily raising Medicaid provider reimbursement rates, and (5) implementing other ACA-related payment reforms.

B. Integrated Models of Care

1. Medicaid Managed Care

ACA reform. Managed care refers to health care programs that use a variety of mechanism to reduce health care costs while improving quality, including providing economic incentives to providers and patients to select less costly forms of care, contracting with networks of providers, and using service utilization reviews and quality improvement initiatives to improve health care efficiency and effectiveness. Managed care can be provided in a range of settings, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), and through fee for service (FFS) arrangements. An estimated 90 percent of insured Americans are enrolled in insurance plans that include some form of managed care (America’s Health Insurance Plans 2012). Managed care is also a primary service delivery model for most Medicaid beneficiaries and is expected to be one of the most common arrangements by which Medicaid enrollees will receive care under the ACA. In May 2012, CMS reported that 71 percent of Medicaid enrollees were served through some form of managed care, either through risk-based managed care organizations (MCOs) or primary care case management organizations (CMS May 2012).

MCOs are increasingly seen as an attractive alternative to FFS-based care. Over the past 15 years, an increasing number of state Medicaid programs have contracted with risk-based MCOs, which are paid a monthly capitated rate in advance for a package of services to help control health care costs (CMS 2012). Traditionally, Medicaid’s aged, blind, and disabled (ABD) beneficiaries have been exempted from managed care; only recently have states started mandating managed care for these groups, including PLWHA. As of October 2010, across all 50 states, only 3 (Alaska, New Hampshire, and Wyoming) reported not having any Medicaid MCOs. Of the 48 states and District of Columbia with comprehensive managed care programs, 36 reported contracting with risk-based MCOs (Gifford et al. September 2011).

Medicaid MCOs typically contract with a network of selected providers to provide certain health care services to a defined patient population. Because of their tight control on utilization and their closed networks, MCOs can be cost-efficient, but need to be tailored to fit the needs of high- need patients (American Health Lawyers Association August 2012). Many uninsured PLWHA who will become newly eligible for expanded Medicaid are likely to be high-need patients. Because the

39 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

ACA will increase the number of PLWHA enrolled in Medicaid MCOs, MCO networks are likely to face higher demand for HIV services.

ACA implementation. In a 2011 study, 20 states with Medicaid MCOs reported that their plans had, or could develop, sufficient network capacity to handle the increases in Medicaid enrollment expected under health reform. However, many states also reported that some Medicaid MCOs do not have adequate provider capacity, especially in specialty care (Gifford et al. September 2011). This could lead to disruptions in care for newly eligible Medicaid enrollees seeking HIV specialty care through managed care networks, especially if the MCOs do not anticipate or adequately prepare for an increased demand in HIV services. If too many newly eligible PLWHA enroll in managed care, the HIV specialists in those managed care networks could become oversubscribed. However, the MCOs would not be able to stop enrollment unless the state Medicaid agency closely monitored the MCOs’ provider network adequacy and suspended enrollment until they addressed the shortfall.

Although this scenario might seem unlikely, the situation happened in California in 2011 after the state implemented LIHP, its Medicaid expansion program, moving 500,000 low-income residents, many of whom were people with disabilities (including PLWHA) and seniors into managed care. The state agency did not adequately warn either MCOs or HIV providers of the influx of waiver enrollees. Thousands of PLWHA who transitioned from RWHAP to managed care had trouble accessing HIV providers and pharmacies that were not in MCO networks. Although medical exemption requests and continuity of care provisions could have been used to help waiver enrollees continue to see their FFS providers and pharmacists, these processes reportedly functioned poorly. Ten months after the waiver went into effect, some analysts reported that fewer than 15 percent of the state’s 12,800 medical exemption applications had been approved, leaving some PLWHA without adequate medical care or prescription drugs (Donnelly and Mulhern-Pearson July 2012).

This is important because a number of states have announced plans to implement new or significant expansions of their managed care programs (Smith et al. October 2011). Some states have already moved forward with their expansion of Medicaid managed care. For example, four states (California, Delaware, New York, and Texas) have had Medicaid 1115 waivers approved to mandate enrollment into managed care for some high-need individuals; four other states (Florida, Kansas, New Jersey, and New Mexico) have had waivers approved to move disabled enrollees and seniors into managed care (Kaiser Commission on the Medicaid and the Uninsured May 2012).

Among the states we interviewed, several are promoting new service delivery models and integrating a broader set of services into their Medicaid managed care programs. For example, Oregon is currently transitioning its model of care to align with the ACA. The state’s MCOs and mental health organizations (both capitated) functioned separately until they were merged into a “comprehensive care organization” (CCO) model that integrates physical, mental, and dental health care with long-term care services (Oregon Health Policy Board 2012). In this model, CCOs are paid flat per-member-per-month fees and must comply with specific quality requirements (see Appendix B, Table B.IV.1).

Implications for RWHAP and PLWHA. Although moving significant numbers of PLWHA into Medicaid is expected to substantially increase the number of PLWHA who have health insurance coverage, the experts we contacted pointed out that the move presents a number of potential challenges for RWHAP clients. For example, some experts were concerned about the adequacy of access to HIV specialists in the managed care model. Another concern was that the 40 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research average cost of treating patients with HIV could exceed the cost of treating the average health plan enrollee, which could lead plans to deny access to HIV services unless the capitated rates were adjusted to reflect higher average costs. Consequently, some states, such as New York, have carved out HIV care into separate managed care plans. It will be important for PLWHA and their advocates to assess and monitor the access and quality of care provided under these types of managed care arrangements (Project Inform October 2011).

Experts suggest that these concerns can be addressed by helping state Medicaid programs work with MCOs to recruit experienced HIV providers into their networks (Harvard Law School Health Law and Policy Clinic November 2011a). With appropriate medical exemption policies and continuity of care safeguards in place, states can also help PLWHA who are newly enrolled in Medicaid MCOs to continue to see their current providers, if necessary (Cross August 2011; Donnelly December 2011). It is also important to recognize that disabled PLWHA have a continued right to access traditional Medicaid benefits or Social Security Disability Insurance through a disability determination, if they need those services. It will also be important to ensure that medically frail PLWHA are not automatically enrolled in Medicaid expansion, instead of current Medicaid, on the basis of a MAGI-adjusted eligibility determination made in the online exchange eligibility and enrollment process. Such cases may need an additional or separate exchange eligibility verification process to review their disability status as well as their income eligibility. It is also important for CMS to clarify some policy questions, such as whether future CMS regulations will require Medicaid MCOs to pay out-of-network providers for HIV treatment to certain patients to maintain their continuity of care, if HIV specialists are not available inside the MCO’s provider network.

Experts have also noted that some general ACA provisions must be tailored to the particular needs of MCOs. For example, implementing the Medicaid provider reimbursement rate increase in 2014 (discussed below) within managed care will present some challenges. According to the Center for Health Care Strategies, CMS proposed a rule in May 2012 that seeks to ensure that MCOs implement the increase uniformly and that the contracted primary care providers are paid at the Medicare rate, just as they would under FFS. All MCO contracts must be revised to provide for payment at the minimum Medicare primary care payment levels for all eligible providers and must stipulate that eligible physicians receive the full and direct benefit of the increase. MCOs must report all information needed to adequately document expenditures eligible for a 100 percent federal match to the states which, in turn, will report these data to CMS. States also have the flexibility to define their MCO payment methodology and submit it to CMS for approval (CHCS May 2012).

2. Patient-Centered Medical Homes and Medicaid Health Homes

For several decades, medical homes have been used to enhance the quality and efficiency of health care. A patient-centered medical home is a team-based model of care in which each patient has an ongoing relationship with a personal physician who leads an interdisciplinary team that takes collective responsibility for the patient’s care, including preventive care, treatment of acute and chronic diseases, and referrals to other qualified physicians, if necessary (AMCHP 2010; Bernstein et al. 2010).

ACA reform. Several provisions of the ACA promote the patient-centered medical home model. Effective January 1, 2011, the ACA established a Center for Medicare and Medicaid Innovation (Sec. 3021) at CMS, with an appropriation of $10 billion over ten years to develop new payment and service delivery models, including patient-centered medical homes, for Medicare, Medicaid, and CHIP populations. In addition, the legislation authorized state grants (Sec. 3502) for community-based interdisciplinary teams to provide support services to primary care practices. The 41 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

ACA also authorized a community-based collaborative care network program (Sec. 10333) to develop provider consortia offering coordinated and integrated health care to low-income populations, emphasizing medical home models (AMCHP 2010). The ACA also identified having medical homes as one indicator of health care quality to be used in evaluating health plan performance (Bernstein 2010).

In addition, the ACA also provided states with a new state plan option to develop health home programs (Sec. 2703) within Medicaid to improve the care provided to high-risk beneficiaries with complex health needs.15 This new service delivery model expands on the patient-centered medical home model concept by enhancing the coordination and integration of physical and mental health care with acute and long-term services, and by building linkages to community-based social services and supports. States interested in receiving a planning grant to implement a health home program are required to submit a state plan amendment to CMS and provide 10 percent of the grant in state matching funds (AMCHP 2010). States receive a 90 percent FMAP match for health homes for the first two years that their state plan amendment (SPA) is in effect (Kaiser Commission on Medicaid and the Uninsured August 2012).

Medicaid beneficiaries are eligible for health home services if (1) they have at least two chronic conditions, (2) they have one condition and are at risk of developing another, or (3) they have at least one serious and persistent mental health condition. Covered chronic conditions include asthma, diabetes, heart disease, overweight, mental health condition, substance abuse disorder, and HIV/AIDS (Kaiser Commission on the Medicaid and the Uninsured May 2012a; CMS 2010). Although HIV/AIDS qualifies as an eligible condition under the health home option, an HIV/AIDS diagnosis by itself is not sufficient; to receive the health home standard of care; the enrollee must either have two or more chronic conditions or have an HIV/AIDS diagnosis and be at risk for another chronic condition (CMS June 2011).

Health home services include comprehensive case management, care coordination and health promotion, individual and family support, referrals to community-based social services and other supports, transition care from inpatient care to other settings, and the use of information technology to link services. These services can be provided by a designated provider, by a team of health professionals, or by a team of health professionals linked to a designated provider (Kaiser Commission on Medicaid and the Uninsured August 2012). However, designated home health providers are required to treat other chronic conditions in addition to HIV/AIDS. As a result, unless they can treat other conditions in addition to HIV/AIDS, experienced HIV providers might not qualify as designated Medicaid health home providers. This could compromise access to health home services for some PLWHA (Institute of Medicine January 2011).

ACA implementation. The health home option became available to states on January 1, 2012, and has attracted the attention of many states because of its focus on improving care for high-need patients while managing the cost of their care. By August 2012, 20 states had shown an interest in

15 CMS has also encouraged states to expand use of 1915(c): Home and Community-Based Services (HCBS) Waivers and 1915(i) State Plan Option: Home and Community-Based Long-Term Services to provide care to PLWHA (CMS June 2011). The 1915(c) waivers provide HCBS to people who require an institutional level of care, whereas the 1915(i) option allows states to provide HCBS to people who do not require such care and to target the benefit to a certain population. Thirteen states currently operate standalone Section 1915(c) waivers for people with HIV/AIDS, and 5 currently have approved section 1915(i) HCBS in their state plans (CMS June 2011).

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the Medicaid health home model, of which four had received approval for implementation. A total of six SPAs have been approved for four states (Missouri [2], New York, Oregon, and Rhode Island [2]) and two more SPAs are under review (in North Carolina and Washington). All four states target serious and persistent mental illness among other conditions. New York’s target populations include enrollees with two or more chronic conditions or enrollees with HIV/AIDS who are at risk of developing another chronic condition. Oregon targets the full list of federal chronic conditions, which includes HIV/AIDS. Of the remaining 20 states, five have drafted health home proposals (Alaska, Illinois, Iowa, Ohio, and Oklahoma) and 15 have had funding requests approved to develop a health home model (Kaiser Commission on Medicaid and the Uninsured August 2012).

Among the seven states we interviewed, several are moving forward with health home programs, including, Iowa, Maryland, New York, and Oregon. For example, Iowa plans to provide home health services to enrollees with two or more of the following chronic conditions: hypertension, overweight, heart disease, diabetes, asthma, substance abuse, and mental health. HIV/AIDS is not included as a chronic condition. CMS approved the state’s SPA with an effective start date of July 1, 2012. The state is continuously enrolling providers that meet certain criteria (including having an electronic health system and using population health management tools) and hopes to build a statewide network. Through an SPA, Maryland is developing a health home program for people with behavioral needs and other chronic conditions, which is budgeted to start in January 2013, through a phased roll-out that will eventually be statewide.

New York actually has two health home programs. One targets the standard federal set of eligible populations (asthma, diabetes, heart disease, overweight, mental health condition, substance abuse disorder, and HIV/AIDS). The other, set to start in July 2012, targets a smaller subset: dual eligible beneficiaries (people eligible for both Medicaid and Medicare) who have either two or more chronic conditions, or HIV/AIDS and/or one mental health illness, and do not require 120 or more days of long-term supports and services (New York State Department of Health May 2012).

Two of the states we interviewed have also developed patient-centered medical home programs for PLWHA. For example, Maryland has a state medical home program that it is piloting with MCOs, although the program is not HIV-specific (see Appendix B, Table B.IV.1). New York has a targeted managed care medical home model for PLWHA that has its own reimbursement structure with special capitated rates. In October 2011, New York added pharmaceuticals and other FFS services into its managed care benefit package for its HIV special needs plans and other Medicaid managed care plans, and adjusted its capitation rates accordingly (Gallant October 2011). In California, there is also interest in the promotion of patient-centered medical homes for PLWHA. In 2011, the California HIV/AIDS Research Program (CHRP) recently awarded three-year grants to five health care providers to establish patient-centered medical home demonstrations. The purpose of the demonstration is to evaluate the effectiveness of PCMHs as a model of care for PLWHA (CHRP 2011).

Implications for RWHAP and PLWHA. Several of the technical experts we interviewed acknowledged the important role that the comprehensive HIV model of care has played in improving clinical care and outcomes for PLWHA. They were enthusiastic about the prospect of incorporating the HIV care model into patient-centered medical homes and the Medicaid health home model under the ACA, especially if HIV providers can expand their clinical focus beyond traditional HIV primary care to include other chronic conditions. However, some operational health home issues need clarification from CMS. For example, the appropriate role of health homes has to be addressed in the context of other evolving integrated care and payment program models. States also have to find the budget resources to pay for their 10 percent share of the total health home 43 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

program cost (the federal government pays a 90 percent FMAP rate) (Kaiser Commission on Medicaid and the Uninsured August 2012).

3. HIV Workforce Capacity

ACA reform. Because HIV/AIDS disproportionately affects members of racial/ethnic minority groups and those living in poverty, ACA provisions include addressing the cultural competence of providers who are inexperienced or unaware of how to provide culturally and linguistically appropriate HIV care to racial/ethnic minorities. The ACA expands several initiatives designed to (1) increase racial and ethnic diversity in the health care professions; (2) strengthen training in cultural competence for all health care providers; and (3) implement comprehensive data collection of race, ethnicity, language, and other demographic information in all federally supported health care programs (Cartwright-Smith et al. March 2011). For example, in October 2011, the secretary of HHS announced $19.5 million in funding to enhance the primary care workforce through Primary Care Training and Enhancement grants, which prioritize training for members of underrepresented minority groups (HRSA October 2011). In 2011, HHS also released its first department-wide Action Plan to Reduce Health Disparities (HHS April 2011). These efforts to diversify the HIV workforce also support the National HIV/AIDS Strategy’s goal of improving HIV care and reducing HIV/AIDS-related health disparities (Office of AIDS Policy August 2011).

The ACA requires that exchanges’ qualified health plans contract with a sufficient number of essential community health providers (that is, those eligible for 340B drug pricing—including RWHAP clinics) that serve predominantly low-income, medically underserved people. This includes FQHCs and other RWHAP Part A, B, and C providers. Building on investments made under the American Recovery and Reinvestment Act of 2009, the ACA’s Community Health Center Fund provided $11 billion over five years for the Community Health Center program, the National Health Services Corps, and for the construction and renovation of FQHCs and other community health centers (HHS.gov January 2012).16 These ACA investments were designed to double community health center capacity from 20 to 40 million patients (AMCHP 2010; McKay February 2011). In 2010, FQHCs served 90,559 patients with a primary diagnosis of HIV/AIDS and recorded a total of nearly 406,000 encounters with patients with HIV/AIDS (McColgan November 2011). Expansion of community health centers and their HIV treatment capacity should increase access to care and enhance prevention efforts for PLWHA, including those who remain uninsured following full implementation of the ACA (McKay February 2011).

Because it is expected to significantly increase the number of PLWHA with insurance coverage, health care providers are expected to face higher demand for HIV care after the implementation of the ACA. Given current constraints on HIV clinician capacity, it is important to expand the HIV health care workforce to meet this increased demand. Through the ACA, increasing investment is being made to train nurse practitioners and physician assistants in HIV care as a means of expanding the HIV health care workforce (Kaiser Commission on Medicaid and the Uninsured March 2011; Institute of Medicine January 2011). For example, RWHAP’s Part F funds a network of 11 regional AIDS Education and Training Centers (AETCs) and 130 associated sites, and a training center

16 Of the ACA funds, $9.5 billion was originally set aside to expand operational capacity and $1.5 billion to fund capital improvements and construction of new centers. However, the discretionary (base program) of the Community Health Center Fund was reduced by about $600 million relative to FY 2010, which resulted in a scaling back of the expansion (McColgan November 2011).

44 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

program targeting multidisciplinary education and training programs for health care providers treating people with HIV/AIDS. AETCs are expanding training to support HIV care and treatment in FQHCs without RWHAP funding. AETCs are also expanding into HIV graduate medical education. To meet increased demand for trained HIV providers, HRSA also funded new AETC telehealth training centers and published a guide for HIV clinical care (HRSA May 2012).

ACA implementation. The increase in the number of clinics providing HIV care presents a number of challenges for RWHAP clients and other PLWHA. For example, PLWHA might worry about receiving care in facilities that are not oriented toward serving patients with HIV/AIDS. Concerns of HIV care quality, privacy, confidentiality, and stigma could also lead PLWHA to disengage from care. This is of particular concern for patients accustomed to receiving care from clinics and providers who specialize in one segment of the community (for example, Latinos, African Americans, gay men, or immigrants).

With so many PLWHA moving out of RWHAP-funded care systems into Medicaid provider networks, more community-based providers will be treating patients for HIV/AIDS for the first time; many of these providers will have little to no experience in HIV care. Because most existing Medicaid providers that are not funded by RWAHP have relatively little expertise in HIV/AIDS, it is unclear what the quality of care will be for patients served by non-RWHAP-funded Medicaid providers. With Medicaid expansion, these non-RWHAP clinics will have to scale up their systems to address the increased demand for HIV care. Also, because some HIV services will be lacking in any given health plan (for example, some health plans might have limited pharmacy networks and lack access to the full range of available antiretroviral medications), increased coordination between these agencies through a health insurance exchange could improve access to the full range of HIV- related benefits and services available within a state like California (Office of AIDS August 2011).

Interviewees cited a number of challenges in training the Medicaid provider workforce to provide HIV care. First, several of the experts we interviewed who are practicing physicians noted that HIV care is complex with many different guidelines for HIV physicians to follow. Second, although antiretroviral medications are the mainstay of HIV/AIDS treatment, PLWHA increasingly face comorbidities that complicate their care. One interviewee noted that over the past 30 years, “HIV/AIDS treatment is easier, but care is harder.” That is, although it has become relatively easy to develop algorithms for prescribing ART, PLWHA face other health and psychosocial needs that must be addressed within the health care system. Nonclinical services must have a defined and articulated relationship within this system of care.

The state Medicaid programs we interviewed differed in their perception of the issue of HIV workforce capacity. Although the state Medicaid agency is responsible for monitoring provider network adequacy in MCOs, one group of states (Colorado, Iowa, Oregon, and Texas) argued that it was the primary responsibility of the health plans or MCOs in the state to ensure an adequate supply of experienced HIV clinicians in their provider networks, and that the MCOs’ performance could be adequately tracked through the monitoring of quality assurance measures. A second group (Maryland and New York) acknowledged the need for some Medicaid providers to become more knowledgeable of HIV care, particularly in community health centers that do not routinely provide HIV care; they noted that more effort was needed to increase the HIV workforce capacity of those institutions. In contrast, the Massachusetts interviewees felt that they had an adequate HIV provider supply statewide, and, because of the state’s “culture of insurance,” most HIV providers were already Medicaid providers.

45 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Implications for RWHAP and PLWHA. Because medical providers are likely to face higher demand for HIV primary and specialty care after full implementation of the ACA, AETCs will likely be pressed to expand their education and training programs for primary care providers who encounter HIV patients for the first time in community health centers and other safety net settings, and in Medicaid managed care provider networks. It will be important to gather information about how state Medicaid programs, RWHAP grantees, and RWHAP providers build the medical expertise of their clinicians to provide high quality HIV treatment and care to PLWHA who enroll in expanded Medicaid or private insurance for the first time.

Interviewees suggested a number of ways to improve the HIV/AIDS provider workforce to help address the needs of PLWHA under health care systems created through the ACA. First, experts recommended that HAB and RWHAP grantees help to ensure that enough experienced HIV providers are included in the provider networks of MCOs and other insurance plans (Harvard Law School Health Law and Policy Clinic November 2011a). Second, AETCs could target more programs at primary care and community health physicians to ensure that they receive HIV/AIDS training. At minimum, chronic care clinicians should know how to perform standard HIV-related tests and write accurate prescriptions. As increasing numbers of PLWHA develop diabetes, heart disease, and cancer, community physicians also have to understand how to manage the complexities of age-related HIV comorbidities. In addition, HIV clinician trainings should address the unique behavioral health, mental health, and substance abuse issues that PLWHA face.

To coordinate these training efforts, some experts recommended that HAB develop a certificate program for new HIV/AIDS practitioners (such as medical home providers) who might become involved in HIV/AIDS care under the ACA. Interviewees also suggested that current HIV providers will also have an important role to play in training the next generation of providers. Some suggested that HIV specialists carve out a new role as consultants or take referrals and spend less of their time as practicing primary care providers. Similarly, experienced clinicians with HIV expertise might consider conducting half-day educational clinics for primary care and community-based providers to teach them about HIV/AIDS and help them transition into their new roles. Increases in the number of HIV providers, specifically from underrepresented racial/ethnic minority groups, will help to enhance care for PLWHA. HRSA’s Bureau of Primary Care could support this effort by adding RWHAP grantees and providers to its list of National Health Service Corps-eligible sites.

4. Service Delivery Recommendations

Through increased access to private health insurance and expanded Medicaid, health care providers will face increased demand for services to newly eligible populations with complex chronic conditions, including mental health conditions, substance abuse disorders, and HIV/AIDS. To help manage the cost of providing comprehensive care to these groups, the ACA has enacted important service delivery and workforce training and development initiatives. These opportunities also present several challenges for the RWHAP community, including the need to expand existing HIV training programs, develop more training materials, and add HIV providers to MCO networks. To address these issues, we provide the following recommendations in Table IV.1:

46 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table IV.1. Service Delivery Recommendations

1. Help to ensure that experienced HIV providers, nurse practitioners, and physician assistants are included in provider networks, especially in rural or underserved areas. 2. Encourage state Medicaid programs to require health plans to contract with experienced HIV providers in order to fulfill the requirement for contracting with essential community providers. 3. Help medical providers and community-based organizations build their organizational billing capacity to manage an increased volume of third-party billing for insured clients and maximize billing revenue. 4. Support a clearinghouse for HIV/AIDS clinical guideline updates and state and federal HIV/AIDS CME opportunities. 5. Provide more AETC training for primary care providers, including those working in community health centers, to build their capacity to serve PLWHA. 6. Share experienced HIV providers’ expertise in addressing cultural and linguistic competency and HIV/AIDS stigma and discrimination with new HIV providers. 7. Work with the Bureau of Primary Health Care to make RWHAP grantees and provider designated as National Health Service Corps-eligible sites. 8. Help RWHAP providers convert to FQHCs or become aligned or affiliated with FQHCs to serve PLWHA at enhanced rates.

C. Provider Payment Reforms

1. Medicaid Provider Reimbursement Rates

ACA reform. Historically, provider reimbursement rates have been so low under Medicaid that many medical providers have been unwilling to treat Medicaid patients. To prepare the primary care workforce for the influx of new Medicaid-eligible patients and to provide an incentive for providers to serve Medicaid clients, ACA provisions raised the payment rates for certain primary care services to the level of Medicare.17 To promote primary care provider participation in Medicaid, the ACA increased Medicaid reimbursements for evaluation, management, and immunization services to 100 percent of Medicare reimbursement rates in 2013 and 2014.18 The increase will apply to both FFS and Medicaid managed care plans.

The positive financial impact for physicians treating Medicaid patients is significant, because Medicaid in most states pays primary care providers at rates well below the reimbursement rates for Medicare and private insurance. In 2008, average Medicaid payment rates for primary care services were 66 percent of Medicare rates. Provider reimbursement rates also vary widely by state. In 2008, Wyoming’s FFS Medicaid reimbursement rates for primary care services were the highest in the country (excluding Alaska) at 67 percent above the national average; Rhode Island’s rates were the lowest at 57 percent of the national average (American College of Physicians 2011).

17 Federally qualified health centers and rural health centers are excluded because they are reimbursed at cost under the Medicaid prospective payment system. (Overview of Rule. CHCS May 2012).

18 The federal government pays 100 percent of the financing for the difference in payment between the original Medicaid payment amount and the amount paid at the Medicare rate.

47 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

ACA implementation. Higher provider reimbursement rates can improve access to HIV care by providing more funding to recruit and retain experienced HIV providers (Weddle and Hauschild September 2010). However, the ACA provisions for increasing Medicaid provider reimbursement rates originally applied only to primary care providers. Originally it was unclear whether the increased rates would also apply to HIV specialists acting in the capacity of a primary care provider (Wong August 2011). But, in May 2012, CMS released draft Medicaid reimbursement rates regulations, which stated that specialists (primary care physicians) and subspecialists (infectious diseases physicians (not all of whom are experienced in HIV care) would be eligible to bill for primary care of HIV patients. On November 1, CMS finalized this rule (CMS November 2012).

Some experts think that the reimbursement rate increase can be a powerful tool for states, especially if aligned with other efforts to strengthen primary care, including patient-centered medical homes, Medicaid health homes, and accountable care organizations (ACOs), which are discussed in the next section (CHCS May 2012). The technical experts we interviewed generally supported the enhanced provider reimbursement rate, but cautioned that it would be of limited value if it is not extended past 2014. It is also not clear how much of an impact the rate increase will have on RWHAP providers. Because Medicaid FFS rates for private health care providers are lower than provider costs paid by RWHAP, some advocates are concerned that some HIV providers currently funded through RWHAP may not be willing to continue providing HIV care, especially if compensated only at lower Medicaid rates (McKay February 2011).

The states we interviewed had different opinions about how much of an impact the rate increase would have on the RWHAP providers in their states. Three states (Texas, New York, and Maryland) were the most uncertain of the potential impact of the rate increase on their state’s supply of HIV providers. The Texas staff questioned whether states were required to use the increased reimbursement rate if the state was not going to expand its Medicaid program; state officials have asked CMS for guidance on the issue. The other two states (Maryland and New York) have been more proactive about addressing Medicaid provider reimbursement issues in their states. Both states are planning to implement the ACA’s raised reimbursement rate. New York, for example, has developed innovative medical models of care based on enhanced provider reimbursement rates (see Appendix B, Table B.IV.2). In Maryland, many HIV providers are hospital-based specialists, who are already paid a relatively high Medicaid reimbursement rate (94 percent of charges) compared to Medicaid providers working in other clinical settings, and so are not affected by the temporary reimbursement increase.

Implications for RWHAP and PLWHA. There are still some policy details and administrative capacity issues to work out. For example, recent CMS guidance clarified that a state Medicaid program is allowed to pay at least the Medicare rate for a Medicaid-covered service not covered by Medicare (American College of Physicians 2011). In addition, some community-based organizations will require technical assistance to learn how to negotiate with insurance plans for provider contracts. For example, the National Association of Community Health Centers is working with community-based organizations to help them become credentialed as Medicaid providers. Some experts also suggest that community-based organizations identify their clients’ current public and private insurers and seek those entities for provider contracts before 2014.

Some RWHAP clinics might lack the internal systems needed to manage the complex documentation and reporting requirements associated with billing multiple insurance plans. Consequently, some RWHAP grantees and providers will have to establish new computer systems for program administration, billing, and care coordination (HIV Health Care Access Working Group October 2010; Bachrach et al. March 2011; McKay February 2011; Office of AIDS August 2011). 48 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

RWHAP grantees may need to provide technical assistance to providers to help them build the billing systems needed to receive Medicaid reimbursements. For example, in Maryland, the Medicaid program has received a grant to provide technical assistance to community-based organizations that lack the billing infrastructure and resources to bill third parties.

In addition, providers interested in becoming designated as medical home or health home providers will also have to learn how to work with electronic medical records to empanel their patients (that is, to assign individual patients to a primary care provider who can track patient care at the population level). The new, reimbursement-based systems of care will also require a shift from quantitative HIV care measures of individual patient outcomes (for example, viral load and cluster of differential 4 [CD4] counts) to more qualitative quality measures (such as measures developed by CMS, the National Quality Forum, and the National Committee for Quality Assurance).

2. Other Integrated Payment Reforms

ACA reform. Through discussions with technical experts and state Medicaid staff, we identified three other payment reforms enacted by the ACA designed to promote integrated or coordinated care. Some of these reforms might affect some RWHAP providers, clients, and other PLWHA by offering payment incentives to HIV providers that may alter their health care practices. In this section, we review three reforms: (1) bundled provider payments for integrated care, (2) ACOs, and (3) demonstration programs aligning financing and service delivery for people who are eligible for both Medicaid and Medicare. Although none of these payment arrangements are likely to affect as many HIV providers as other integrated models of care, such as patient-centered medical homes or Medicaid health homes, these pilot payment reforms could be developed into much larger programs affecting more HIV providers and patients.

The ACA’s Medicare Bundled Payments for Care Improvement initiative is designed to improve patient care while minimizing cost by facilitating care coordination through four different patient-centered service delivery approaches: three models with retrospective payment arrangements and a target payment amount for a defined episode of care and one model with prospective payments. The models address various combinations of acute and post-discharge care for procedures such as hip replacement or heart bypass surgery. Through the program, providers can design their own models, selecting which health conditions to bundle, developing a specific health care delivery structure to support care integration, and determining how payments will be allocated among participating providers (CMS April 2012). Under the Bundled Payments initiative, payments for multiple services during an episode of care are linked; instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a bundled payment (CMS September 2012). CMS is in the process of convening technical panels to review the bundled payment proposals it has received. It will be important to determine whether any of the proposals approved by CMS bundle in-patient and out-patient services for PLWHA.

A second promising Medicare payment model is the ACO. ACOs are designed to slow the rise of health care costs while delivering quality care by changing the financial incentives that influence how doctors and hospitals operate, requiring them to share responsibility for providing quality care to their patients (Galewitz and Gold October 2011). The ACA amended Medicare’s Shared Savings Program to allow providers that voluntarily work together to coordinate and integrate Medicare

49 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research services for their patients, while meeting certain health care quality standards.19 ACOs make providers jointly accountable for the health of their patients by giving them financial incentives to cooperate and save money in various ways, such as sharing patient information and avoiding unnecessary tests and procedures. Shared savings (and shared losses) accrued to Medicare are distributed among the providers. The higher the quality of care delivered, the more an ACO can earn in shared savings, as long as the organization also lowers its growth in health care expenditures (CMS April 2012). The ACO’s performance is tracked through 33 quality indicators that measure the patient’s experience, care coordination, safety, use of preventive care, and receipt of services for high-risk populations, which could be a challenge for some RWHAP providers. By July 2012, HHS has approved 154 ACOs; as of July 1, more than 2.4 million Medicare beneficiaries were receiving care from providers one of these initiatives. In January 2013, when the next round of approved ACOs is announced, this number may double to 300 approved ACO contracts (HHS July 2012). It will be interesting to know how many PLWHA are being served through this initiative, and whether these new ACOs will affect the kind of HIV care they receive.

The third reform involves the development and implementation of financial alignment demonstrations for people who are dually eligible for Medicare and Medicaid. In this initiative, CMS is working with states to (1) design and implement financial alignment demonstrations that will develop new care delivery systems integrating and coordinating the physical health, behavioral health, and long term supports and services for dual eligible beneficiaries; and (2) create an integrated Medicare–Medicaid payment model that includes shared savings.

ACA implementation. The Medicare bundled payment program is at a much earlier state of development than the other two programs. In August 2011, CMS asked providers to apply to help develop and test four bundled payment models. Applications for Model 1 (an acute care model) were due in October; applications for the other models were due in March 2012. In September, external expert review panels will review the applications for Models 2–4 submitted by providers and provide recommendations to CMS. In October 2012, CMS planned to contact candidate awardees to discuss their proposals, ask questions, and address any issues raised. After the candidates’ models are approved, the contracts will be signed and the implementation of the program will begin (CMS September 2012).

The Medicare ACO program is being implemented on a slightly earlier time line. In October 2011, CMS issued final rules on the operation of ACOs (Gold October 2011). Under the new regulations, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years. The government began receiving its initial round of applications for the ACO Shared Savings Program in January 2012; the first ACOs were launched in April, 2012. Hospitals, physician practices, and insurers across the country have announced plans to form ACOs for Medicare beneficiaries and patients with private insurance. Some groups have already created ACOs, patterned after models developed at the Mayo Clinic in Minnesota and the Geisinger Health System in Pennsylvania (Galewitz and Gold October 2011).

For the financial alignment demonstration initiative, the Center for Medicare and Medicaid Innovations (CMMI) awarded design contracts up to $1 million each to 15 states in April 2011 to

19 Although an ACO might seem similar to an MCO, unlike an MCO an ACO does not require patients to stay within the ACO’s network of providers, limiting its care options.

50 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

develop service delivery and payment models integrating care for dual eligible beneficiaries (Kaiser Commission on the Medicaid and the Uninsured 2012a).20 In July 2011, CMS released a letter announcing new grant opportunities for states to test integrated care and financing models for dual eligible beneficiaries. As of May 2012, 26 states have submitted dual eligible financial alignment demonstration proposals, with plans to implement them in 2013 and 2014, pending approval by CMS. The projects are testing a range of models. For example, Delaware and Texas have pending proposals to require dual eligible beneficiaries to become enrolled in managed care plans (Kaiser Commission on the Medicaid and the Uninsured May 2012a).

Among the states we interviewed, several are planning or have already developed ACOs. For example, Colorado set up regional ACOs and is reforming the state’s payment system through that process (see Appendix B, Table B.IV.2). Iowa is also interested in the ACO model and is reviewing CMS guidance on how a state can develop its own ACO model. The state already has created a shared savings program which has established three or four ACOs. Massachusetts is pursuing an ACO option, patterned after its PCMH initiative and plans to roll out the program in early 2014. Texas is participating in a 14-month ACO learning collaborative with five other states to develop an ACO model that will be based on the RWHAP model of care; it will complement the regional Medicaid managed care model already operating in the state. Oregon’s CCOs may also be considering ACOs (Gold and Nysenbaum May 2012).

Implications for RWHAP and PLWHA. As these integrated payment reforms develop, it will be important to monitor whether these new payment arrangements will affect the type of HIV care offered to PWLHA. There are opportunities for RWHAP grantees and providers, and advocates to develop bundled payments, ACOs, and dual eligible demonstration projects that address the complex care needs of PLWHA, as exemplified by the work that Texas is doing with its ACO learning collaborative. Over the next year, CMS will also work closely with states to answer remaining questions about the implementation of the Medicaid provider reimbursement rate and how it interacts with other Medicaid and Medicare payment reforms (McGinnis May 2012).

On a regional level, there are also some antitrust concerns about ACOs. Some health care economists fear that the current push to create ACOs and integrated care systems could lead to hospital mergers and provider consolidation, as hospitals join forces and purchase physician practices, leaving fewer independent hospitals and doctors. Particularly in rural areas, there is concern that ACOs could grow so large that they would employ the majority of providers in a region (Gold October 2011). It will be important to track how such changes affect the supply of HIV providers, and the type of HIV care provided, especially in underserved areas.

3. Payment Recommendations

To help manage the cost of providing comprehensive health care, the ACA has enacted important provisions combining innovative financing and service delivery models, including dual eligible demonstrations, ACOs, and bundled payments programs. Below, we provide recommendations for how HRSA can work with the RWHAP community on these payment

20 California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin received design grants.

51 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research reforms. In addition, RWHAP grantees, providers, and advocates should also advocate for PLWHA interests on provider reimbursement rate issues in Table IV.2.

Table IV.2. Payment Recommendations

1. Advocate for state-specific provider reimbursement rates that adequately cover the full cost of providing HIV care. 2. Advocate for a permanent increase in Medicaid reimbursement rates for primary care providers, including HIV specialists. 3. Encourage states to tailor the Medicaid health home program to address HIV care needs and include experienced HIV providers as designated health home providers. 4. Provide information to RWHAP grantees and providers about new non-FFS models of integrated medical care. 5. Help HIV providers participate in non-FFS models of care (MCOs, patient-centered medical homes, health homes, dual eligible demonstrations, ACOs, and bundled payment initiatives).

52 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

V. RECOMMENDATIONS

A. Introduction

Previous chapters in this report have addressed the study’s first goal—to assess the potential impact of the ACA on RWHAP, its grantees, providers, clients, and PLWHA. This chapter addresses the project’s second goal—to identify how HAB can help the RWHAP community with the ACA transition, navigating the changes associated with implementation of major provisions of the legislation. Although many ACA provisions have already taken effect and much work is already under way to prepare for the transition, much more work needs to be done to ensure that RWHAP grantees, providers, clients, and PLWHA can transition successfully from current to new health care insurance, service delivery, and payment systems ushered in by the ACA. Several overarching themes emerged from this study regarding the ACA implementation process and the transition needs of the RWHAP community. In this final chapter, we address what can be done to address these needs while meeting the goals of the National HIV/AIDS Strategy (NHAS) (ONAP 2012; ONAP 2012). 21

These recommendations come from multiple sources, including consultations with technical experts; interviews with key staff in state Medicaid programs; and a literature review of more than 250 reports, policy briefs, agency regulations and websites, and advocates’ position papers and webinars. Based on this information, we have identified four areas of activity in which important transition work can be done: (1) transition leadership, (2) coordinated planning and implementation, (3) education and technical assistance, and (4) RWHAP’s future role funding HIV services following implementation. As a cross-reference, we have also organized the recommendations by the six ACA topic areas: eligibility, exchanges, benefits, costs, service delivery, and payment, and we identified who could be involved in the implementation of each recommendation (Table V.1).

1. Transition Leadership

Given current uncertainty surrounding ACA’s implementation and Medicaid expansion, experts reported anxiety among grantees, policy advocates, providers, clients, and PLWHA about what will happen to them and to RWHAP over the next several years. Some feel they are “in the dark” about the transition process and say they have been told to carry on as normal, with no specific instructions about how to prepare either for health reform or for RWHAP’s upcoming reauthorization in 2013. To remedy this, a number of advocates and experts are urging HAB to take a more visible leadership role in the transition process and become more transparent in its ACA transition planning activities so that the RWHAP community can stay informed of the change process.

In particular, experts recommend that HAB become more visibly engaged in collaborative planning at federal and state levels. For example, HRSA can inform and educate senior leadership in CMS, other federal agencies, and state legislative and executive policymakers to ensure that expanded Medicaid programs and the new insurance exchanges adequately address the needs of PLWHA. Specifically, HAB cannot advocate for specific reforms, but can identify the relative merits of particular policies and advocate for other stakeholders to be at the state policy table to discuss

21 The four goals of the NHAS are: to reduce HIV infections, improve HIV health outcomes, reduce HIV-related health disparities, and develop a more coordinated national response to the HIV/AIDS epidemic (ONAP 2010).

53 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

ACA topics, such as: (1) states’ EHB packages; (2) Medicaid expansion; (3) the BHP option s; (4) cost sharing for ART medications and other essential HIV services; and (5) Medicaid reimbursement rates for primary care providers, including HIV specialists.

In addition, experts recommended that HAB can provide national leadership in building HIV workforce capacity to meet increased demand for HIV services. For example, HAB can (1) provide more AETC training for primary care providers, including those working in community health centers; (2) support a national clearinghouse for HIV clinical guideline updates and for federal and state HIV continuing medical education (CME) opportunities; (3) work with the Bureau of Primary Health Care to designate RWHAP grantees and providers as National Health Service Corps-eligible sites; and (4) help to ensure that experienced HIV providers, nurse practitioners, and physician assistants are qualified as HIV primary care providers and are included in provider networks of the health plans that contract with Medicaid or participate in state insurance exchanges, especially in rural or underserved areas. Experts identified other national organizations, health coalitions, and federal agencies (such as the Substance Abuse and Mental Health Services Administration and national heart disease and diabetes associations) that have taken active roles in planning for implementation of the ACA as examples from which HAB can draw and with whom HAB can collaborate on common concerns (American Diabetes Association 2012; AHA 2012).

Experts and advocates also call for HRSA to evaluate the impact of the ACA on RWHAP. For example, several experts suggest the need for HAB to track the transition of PLWHA into new systems of care under the ACA and examine their care outcomes. These experts suggest collecting baseline data now, with both formative and outcome evaluations to follow. They also recommend developing guidance for tracking every patient transitioning from RWHAP to other systems of care, such as using a checklist to confirm the completion of specific transition activities (for example, applying for coverage, changing practitioners, and ensuring communication among providers). Other recommendations are for HRSA to encourage CMS to conduct more frequent and thorough reviews of state Medicaid agencies’ compliance with managed care provider network requirements to ensure that PLWHA are receiving adequate access to covered services after ACA implementation, for CMS to monitor Medicaid beneficiaries’ cost-sharing expenses to ensure that PLWHA are not charged excessive cost-sharing amounts, and for consumers to provide more feedback to managed care organizations about service issues.

Experts and advocates are also asking HAB to provide clearer guidance regarding HRSA’s expectations about other ways in which state Medicaid programs, RWHAP grantees, providers, and PLWHA should prepare for their transitions to implementation of the ACA. Experts also said that it should be HAB’s responsibility to ensure that grantees, providers, and clients understand the timeline for ACA planning and implementation milestones, so that they can be better prepared for providing input into important state policy decisions regarding what kind of insurance exchanges to develop (state-based, partnership- or federally facilitated exchanges), whether to expand Medicaid in whole or in part (if partial expansion is allowed by federal officials), and what should be included in states’ essential benefits packages and benchmark benefit plans. HAB can also develop more outreach and education networks, as well as programs and materials to inform grantees, providers, clients, and PLWHA about upcoming ACA changes.

2. Collaborative Transition Planning

We heard many recommendations for the RWHAP community, including administrators, grantees, providers, and policy advocates, to become more engaged in ACA planning and implementation processes at multiple levels to ensure that policy decisions take into account the 54 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

needs of RWHAP clients and other PLWHA. At the federal level, this involves providing input on federal rulemaking through public comment periods, interagency planning meetings, and other forms of policy advocacy. At the state level, this necessitates: (1) understanding what and who are the critical agencies, decision makers, and decision points involved in each state’s ACA planning process; and (2) gaining a seat at the policy table (such as taking part in policy task forces, work groups, and community advisory committees) for key policy decisions. Specifically, RWHAP grantees and advocates can (1) work with states to ensure the development and approval of a comprehensive EHB package that meets the health care needs of PLWHA; (2) work with state Medicaid programs to ensure that all state health plans, including benchmark-equivalent plans, include all the benefits and services necessary to ensure adequate HIV treatment and care; (3) advocate for state-specific provider reimbursement rates that cover the full cost of providing HIV care; and (4) encourage states to develop or modify their Medicaid health home programs to address HIV care needs and ensure that experienced HIV providers are designated as health home providers.

Technical experts also anticipate that RWHAP clients and PLWHA will need assistance transitioning to the new systems of care under the ACA. Many PLWHA who are currently uninsured and/or receiving care through RWHAP-funded services will transition to Medicaid or to private health insurance. Issues that could arise in the transition include the need to switch providers, pharmacists, or drug formularies; change health care plans and insurance benefits; and enroll in MCOs, patient-centered medical homes, Medicaid health homes, ACOs, dual eligible demonstration projects or other new health care models. To support these transitions, RWHAP grantees, providers, and advocates can work with state Medicaid programs to (1) develop and implement plans for outreach, benefits counseling, and enrollment of PLWHA in expanded Medicaid and subsidized private insurance plans; (2) create a carefully planned, multiphased transition of newly eligible PLWHA into expanded Medicaid or private insurance; (3) develop and implement plans for PLWHA now enrolled in PCIPs to enroll in other plans in 2014; (4) use RWHAP case managers trained in exchange eligibility and enrollment processes as patient navigators and individual transition coordinators in the exchanges; and (5) educate RWHAP grantees, providers, clients, and PLWHA about the availability of cost-sharing reductions and OOP expense limits.

3. Education and Technical Assistance

The ACA represents a significant change for RWHAP providers who are not accustomed to billing third-parties for a large proportion of their clients. Although RWHAP providers have already been required to screen for clients’ insurance status and bill third-parties under RWHAP’s “payer of last resort” policy, some providers may have more capacity to do this than others. It is likely that assistance will be needed to help some providers increase their capacity to screen for clients’ insurance eligibility and enrollment status and increase their billing of third parties for RWHAP services. In addition, to prepare for participating in managed care networks, some providers might have to develop or upgrade their electronic health record systems, through state or federal information technology improvement initiatives, to better measure their clinical performance and outcomes. (CMS July 2012). Some providers may also need to build the capacity of their billing systems to collect more third-party payments; empanel patients in registries (patient management databases) to better monitor their care; implement an integrated care model (such as a patient- centered medical home or Medicaid health home); expand their patient base to include patients with other chronic conditions; contract with managed care plans and insurance provider networks to continue serving their current HIV patients; or make other administrative and operational changes as needed to succeed in the new system. 55 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Similarly, experts, advocates, and policy analysts are calling for greater collaboration at the state and local levels among state Medicaid programs, RWHAP providers, community-based organizations, AIDS service organizations, insurance plans, MCOs, and other entities to develop new health care partnerships through the ACA’s service delivery and funding reforms. Specifically, RWHAP grantees, providers, and advocates can (1) encourage state Medicaid programs to require health plans to contract with HIV providers to fulfill the requirement for contracting with “essential community providers,” (2) work with insurance plans and FQHCs to contract with RWHAP providers, and (3) work with MCO contractors to design benefit packages and define quality of care standards for PLWHA.

We also heard recommendations that HRSA could act more as a policy translator, providing more information about the ACA provisions to RWHAP audiences while providing more information about RWHAP services to Medicaid officials and private insurance representatives. Sources also urge HAB to develop (1) a national campaign highlighting the changes RWHAP clients and providers can expect as the ACA moves forward (including glossaries of ACA-related terms based on resources that already exist; (2) provider-specific training programs on the care and treatment of HIV/AIDS (disseminating best practices); (3) checklists of action steps that grantees and providers can take to prepare themselves for operating in new systems of care; and (4) materials to help PLWHA make informed choices about insurance plans and provider networks. HRSA should also educate states, CMS, and other policy audiences about RWHAP programs and policies (such as being the payer of last resort), so that state and federal policymakers have a better understanding of the limitations of RWHAP services and eligibility. AETCs and community-based organizations could also play a significant role in providing educational and training materials, drawing on the information and lessons learned from states that have developed modules, best practices documents, and training programs.

In terms of organizational-level technical assistance, experts and advocates suggest that HAB can take several actions: (1) inventory and assess RWHAP clinics’ technical assistance needs for billing third parties, staffing HIV care teams, collecting quality measures, and fulfilling other requirements of the new integrated care models; (2) help medical clinics and community-based organizations build their organizational billing capacity to manage the anticipated increase in the volume of third-party billing for insured clients and to maximize their billing revenue; (3) help RWHAP providers convert to FQHCs or become aligned or affiliated with FQHCs to serve PLWHA at enhanced payment rates; (4) disseminate information to providers about the non-FFS models of care (MCOs, health homes, dual eligible demonstrations, ACOs, and bundled payment initiatives); and (5) help providers contract with these new models of care.

4. Potential Future Role for RWHAP

Finally, the information we gathered stressed the importance of continued high quality care for PLWHA, especially for those in states that are not expanding Medicaid, for those who are not eligible for expanded Medicaid or private health insurance tax credits or cost-sharing reductions, and for services that are not covered (or not adequately covered) through Medicaid or private insurance.

Over the next several years, RWHAP can play an important role in the post-reform era by (1) clarifying definitions of Medicaid, private insurance, and RWHAP service categories to help identify overlaps and gaps in services across the three programs; (2) identifying state-specific service gaps and reallocating RWHAP funding to cover those service gaps; and (3) continue working to meet NHAS goals to increase health care access and reduce health disparities among PLWHA.

56 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

B. Conclusions

This report identified a number of ways in which the implementation of ACA health reforms could potentially impact RWHAP, and recommended a comprehensive set of steps that could support a successful transition from current health care delivery, financing, and payment systems to those that will be in place when ACA is fully implemented. For HAB’s consideration, we complete the report with a short list of priority recommendations that we think can have the greatest impact in terms of maximizing ACA’s potential benefits while minimizing its potential risks. They are:

• Provide transparent leadership, clear guidance, and cross-agency collaboration aligned at federal, state, and local levels to support the complex transition to the ACA’s Medicaid- and private insurance-based health care system for PLWHA. • Encourage the RWHAP community to actively engage in state-level ACA planning and implementation, joining work groups, task forces, community advisory boards, and ad hoc advocacy groups to inform and influence key policy decisions. • Encourage RWHAP stakeholders to engage with Medicaid directors, policymakers, and legislators in all states on the issue of Medicaid expansion. • Create and distribute outreach materials to help PLWHA to make informed choices between health plan options. • Work with states to ensure the development and approval of comprehensive EHBs that meet the health care needs of PLWHA. • Ensure that health plans provide continuity in access to ART medications through their pharmacy networks and formularies. • Identify ongoing service gaps in state and local health systems and assess potential for reallocating Part A and B funding from direct medical services to premium supports and wrap-around services. • Help ensure that HIV specialists, nurse practitioners, and physician assistants are qualified as HIV primary care providers and included in provider networks, especially in rural or underserved areas. • Help medical providers and community-based organizations build their organizational billing capacity to manage increased third-party billing for insured clients and maximize billing revenue. • Work with states to address Medicaid reimbursement rate issues for primary care providers, including HIV specialists.

Table V.1. ACA Recommendations and Potential Implementers

HRSA Grantees Providers Clients Advocates

B. General Recommendations 1. Provide transparent leadership, clear guidance, and cross-agency collaboration   aligned at federal, state, and local levels to support the complex transition to the ACA’s public and private insurance-based health care system for PLWHA.a 2. Actively engage in state-level ACA planning and implementation, joining work     groups, task forces, community advisory boards, and ad hoc advocacy groups to inform and influence key policy decisions.* 3. Help state Medicaid programs develop and implement plans for outreach and      enrollment of PLWHA in expanded Medicaid and private insurance plans. 4. Develop outreach and education networks, programs, and materials to inform      RWHAP grantees, providers, clients, and PLWHA about upcoming changes under ACA. 5. Provide guidance to state Medicaid programs on RWHAP’s ongoing funding role as a   payer of last resort under the ACA.

58 6. Clarify definitions of Medicaid, private insurance, and RWHAP service categories,   

identifying overlaps and gaps in services across programs. 7. Learn the details of state Medicaid and exchange programs by reviewing state    waiver requests, SPAs, waiver transition plans, exchange blueprints, and other program documents related to health reform. 8. Inventory and assess provider technical assistance needs for billing, staffing HIV    care teams, collecting quality measures, and other expectations of managed care and of new service delivery models. 9. Consider the option of making little or no change in the RWHAP reauthorization in  2013, to provide time to assess the full impact of the ACA on HIV service needs. 10. Increase flexibility in RWHAP funding allocation restrictions (such as the 75–25 rule)  to address state variation in HIV service gaps. 11. Continue work to coordinate implementation of ACA reforms with the National   HIV/AIDS Strategy goals to increase HIV care access and reduce HIV health disparities.

C. Eligibility Recommendations 6. Encourage RWHAP stakeholders to work with Medicaid directors, policymakers, and      legislators in all states on Medicaid expansion.*

7. Work with federal and state agencies to ease the eligibility and enrollment      requirements for PCIPs that limit PLWHA access to PCIPs.

Table V.1 (continued)

HRSA Grantees Providers Clients Advocates

8. Encourage state Medicaid programs to use 1115 waivers for early expansion of    Medicaid as a bridge to 2014, to cover PLWHA without a disability diagnosis. 9. Continue and increase outreach to groups ineligible for ACA provisions, which will     remain uninsured, including undocumented immigrants and PLWHA in non-Medicaid expansion states, whose incomes are less than 100 percent of the FPL. 10. Provide guidance to state Medicaid programs on how to ensure access to Medicaid      for eligible immigrants who are living with HIV/AIDS. D. Exchange Recommendations 10. Work with state Medicaid programs to develop and implement transition plans for   PLWHA enrolled in PCIPs. 11. Conduct outreach to uninsured PLWHA who are newly eligible for coverage under     1115 waivers or PCIPS before 2014. 12. Train HIV providers on eligibility for Medicaid and private insurance, the exchange    enrollment process, copayment cost reductions, and recertification and exemption processes. 13. Work with states to use RWHAP case managers trained in exchange eligibility and    

59 enrollment processes as patient navigators and individual transition coordinators in

exchanges. 14. Create and distribute outreach materials to help PLWHA to make informed choices     between health plan options.* 15. Help PLWHA determine whether they are required to enroll in an MCO and help them    find information about which plan best meets their needs. 16. Help PLWHA seek exemption from automatic enrollment into health plans or MCOs    that do not meet their coverage needs. 17. Help vulnerable PLWHA continue to see current providers and pharmacies through a    continuity of care or medical exemption request. 18. Work with states to create a carefully planned, multiphased transition of newly     eligible PLWHA into expanded Medicaid. E. Benefit Recommendations 1. Work with states to ensure the development and approval of comprehensive EHBs    that meet the health care needs of PLWHA.*

Table V.1 (continued)

HRSA Grantees Providers Clients Advocates

2. Encourage states to include HIV/AIDS prevention, testing, and counseling; access to    newer ART medications; treatment adherence; unlimited medical and laboratory services; transportation; and other supportive services in the definition of EHB categories. 3. Work with state Medicaid programs to ensure that all state health plans, including    benchmark-equivalent plans, include all the benefits and services necessary for HIV treatment and care. 4. Ensure that health plans provide continuity in access to ART medications through    their pharmacy networks and formularies.* 5. Encourage CMS to conduct Medicaid reviews to ensure that PLWHA are receiving   adequate access to covered services. 6. Inform PLWHA of their continued right to access the Medicaid state plan benefit      through a disability determination if they need the services provided under Medicaid. 7. Work to ensure that medically frail PLWHA are not automatically assigned to a     Medicaid expansion program on the basis of MAGI-adjusted eligibility determinations.

60 8. Given potential volatility in the Medicaid eligibility status of PLWHA (due to changes    in income and health status), advocate for states to adopt a BHP that addresses HIV care needs. 9. Encourage USPSTF to finalize its draft recommendations for routine HIV testing a   covered service under all health plans. 10. Identify ongoing service gaps in state and local health systems and assess potential   for working with RWHAP planning councils to reallocate Part A and B funding from direct medical services to premium supports and wrap-around services.* F. Cost Recommendations 5. Provide outreach to educate RWHAP grantees, providers, clients, and PLWHA about   the availability of cost-sharing reductions and OOP expense limits. 6. Seek elimination of cost-sharing for ART medications and other essential services    for HIV care to reduce client cost-burden. 7. Monitor cost-sharing expenses to ensure that people eligible for cost-sharing   reductions, including PLWHA, are not charged excessive cost-sharing amounts. 8. Allocate RWHAP funds to help cover cost-sharing amounts that remain unaffordable   to PWLHA on private insurance.

Table V.1 (continued)

HRSA Grantees Providers Clients Advocates

G. Service Delivery Recommendations 1. Help to ensure that experienced HIV providers, nurse practitioners, and physician    assistants are included in provider networks, especially in rural or underserved areas.* 2. Encourage state Medicaid programs to require health plans to contract with   experienced HIV providers in order to fulfill the requirement for contracting with essential community providers. 3. Help medical providers and community-based organizations build their     organizational billing capacity to manage an increased volume of third-party billing for insured clients and maximize billing revenue.* 4. Support a clearinghouse for HIV/AIDS clinical guideline updates and state and  federal HIV/AIDS CME opportunities. 5. Provide more AETC training for primary care providers, including those working in    community health centers, to build their capacity to serve PLWHA. 6. Share experienced HIV providers’ expertise in addressing cultural and linguistic    competency and HIV/AIDS stigma and discrimination with new HIV providers.

61 7. Work with the Bureau of Primary Health Care to make RWHAP grantees and provider   

designated as National Health Service Corps-eligible sites. 8. Help RWHAP providers convert to FQHCs or become aligned or affiliated with FQHCs    to serve PLWHA at enhanced rates. H. Payment Recommendations 1. Advocate for state-specific provider reimbursement rates that adequately cover the   full cost of providing HIV care. 2. Work with states to address Medicaid reimbursement rate issues for primary care  providers, including HIV specialists.* 3. Encourage states to tailor the Medicaid health home program to address HIV care    needs and include experienced HIV providers as designated health home providers. 4. Provide information to RWHAP grantees and providers about new non-FFS models of   integrated medical care. 5. Help HIV providers participate in non-FFS models of care (MCOs, patient-centered    medical homes, health homes, dual eligible demonstrations, ACOs, and bundled payment initiatives).

Sources: 1. Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012.

Table V.1 (continued) 2. Interviews with technical experts conducted by Mathematica Policy Research, 2012.

3. Health reform documents and materials including the following: Gallant, Joel, Adaora Adimora, J. Kevin Carmichael, Michael Horberg, Mari Kitahata, E. Byrd Quinlivan, James Raper, Peter Selwyn, and Steven Williams. “Essential Components of Effective HIV Care: A Policy Paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition.” Clinical Infectious Disease, vol. 53, no. 11, October 2011, pp. 1043–1050. Available at [http://cid.oxfordjournals.org/content/early/2011/10/20/cid.cir689.full.pdf+html]. Accessed October 24, 2011. HIV Health Reform. “Breakin’ It Down: What the Affordable Care Act Means for People with HIV.” Webinar, March 23, 2012. Available at [http://www.hivhealthreform.org/wp-content/uploads/2012/03/HIVHealthreform-Presentation-March-23-2012-FINAL.pdf]. Accessed September 14, 2012. HIV Health Reform. “Working Together: The Ryan White Program & Health Care Reform.” Webinar, May 30, 2012. Available at [http://www.ohioaidscoalition.org/wp-content/uploads/RW-HCR-webinar-presentation.pdf]. Accessed September 12, 2012. HIV Health Reform. “How Will the Affordable Care Act Expand Access to HIV Prevention and Testing Services?” Webinar, August 23, 2012. Available at [http://www.hivhealthreform.org/wp-content/uploads/2012/08/Aug-2012-HHR-slides-Prevention.pdf]. Accessed September 14, 2012. National Alliance of State and Territorial AIDS Directors [NASTAD]. “National ADAP Monitoring Project: Annual Report.” Washington, DC: NASTAD, May 2011. Available at [http://www.nastad.org/Docs/035643_2011%20NASTAD%20National%20ADAP%20Monitoring%20Project%20Annual%20Report.pdf]. Accessed December 6, 2011. 62 National Alliance of State and Territorial AIDS Directors [NASTAD]. “Special Issue—The Affordable Care Act: How Your Program Can

Prepare for Health Reform.” HIV and Viral Hepatitis Policy Watch, vol. 7, October 28, 2011. Available at [http://www.nastad.org/Docs/ 104722_Policy%20Watch%2010.28.11%20website.pdf]. Accessed December 30, 2011. Harvard Law School Health Law and Policy Clinic. “HIV Health Access Working Group: Pre-Existing Condition Insurance Plan.” Treatment Access Expansion Project, November 2010. Available at [http://www.taepusa.org/LinkClick.aspx?fileticket=4JT9gAVctOk%3D&tabid=41]. Accessed December 6, 2011. Harvard Law School Health Law and Policy Clinic. “Health Care Reform Update: United States Conference on AIDS.” Treatment Access Expansion Project, November 2011a. Available at [http://www.taepusa.org/LinkClick.aspx?fileticket=gYBn6nnHrYQ%3d&tabid=41]. Accessed December 12, 2011. Harvard Law School Health Law and Policy Clinic. “Securing Health Care for People with HIV and AIDS: An Advocate’s Roadmap on Implementing Health Care Reform and Bridging Current and Ongoing Access to Care Gaps.” Treatment Access Expansion Project Treatment Access Expansion Project, November 2011b. Available at [http://www.taepusa.org/LinkClick.aspx?fileticket=NIFVBy- uvTk%3d&tabid=41]. Accessed November 1, 2011. HIV Health Care Access Working Group. “Planning and Establishment of State-Level Exchanges; Request for Comments Regarding Exchange-Related Provisions in Title I of the Patient Protection and Affordable Care Act, 75 Federal Register 45584.” October 4, 2010. Available at [http://www.taepusa.org/LinkClick.aspx?fileticket=UWzSde2YmkY%3D&tabid=65]. Accessed December 20, 2011. Office of AIDS. “Planning for Health Care Reform: The HIV Care, Detection, and Prevention Perspective.” Sacramento, CA: California Department of Public Health, August 31, 2011. Available at [http://www.cdph.ca.gov/programs/aids/Documents/ PlanningforHCROASummary.pdf]. Accessed December 28, 2011.

Table V.1 (continued) Presidential Advisory Council on HIV/AIDS. “Letter to Kathleen Sebelius.” August 8, 2011. Available at [http://aids.gov/federal-

resources/policies/pacha/meetings/august-2011/august-2011-pacha-letter-secretary.pdf]. Accessed December 30, 2011.

Squires, Kathleen E. “Patient Protection and Affordable Care Act: Establishment of Exchanges and Qualified Health Plans: Proposed Rule 76 Federal Register 136.” Letter to Donald Berwick, July 15, 2011. Available at [http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/ Ryan_White_Medical_Providers_Coalition/Comments/HIVMA%20Exchange%20Comments.pdf]. Accessed December 30, 2011. a Ten top priority recommendations.

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McKay, Emily Gantz. “HIV/AIDS and Health Care Reform: Implications for Safety-Net Clinics, 2009.” Washington, DC: Mosaica, February 2011. Available at [http://www.regionalprimarycare.org/spotlight-on-healthreform/documents/PolicyandPractice-HealthReformHIVClinics2-18-11.pdf]. Accessed November 4, 2011.

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Mulvey, Janemarie, and Hinda Chaikind. “Individual Mandate and Related Information Requirements under ACA.” Washington, DC: Congressional Research Service, July 2, 2012. Available at [http://www.fas.org/sgp/crs/misc/R41331.pdf]. Accessed September 4, 2012.

National Academy for State Health Policy. “State Progress on Essential Health Benefits.” State Reforum. September 13, 2012. Available at [http://www.statereforum.org/state-progress- on-essential-health-benefits]. Accessed September 13, 2012.

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National Alliance of State and Territorial AIDS Directors [NASTAD]. “Special Issue—The Affordable Care Act: How Your Program Can Prepare for Health Reform.” HIV and Viral Hepatitis Policy Watch, vol. 7, October 28, 2011. Available at [http://www.nastad.org/Docs/ 104722_Policy%20Watch%2010.28.11%20website.pdf]. Accessed December 30, 2011.

National Alliance of State and Territorial AIDS Directors [NASTAD]. National ADAP Monitoring Project Annual Report: Module Two: ADAP Coordination with Other Payers; Enrollment and Utilization Update. Washington, D.C.: NASTAD, March, 2012.

National Association of Community Health Centers. “Partnerships Between Federally Qualified Health Centers and Local Departments for Engaging in the Development of a Community- Based System of Care.” Bethesda, MD: National Association of Community Health Centers, October 2010. Available at [http://www.naccho.org/topics/HPDP/upload/Partnerships- Between-FQHCs-and-LHDs_Final_11_03_10.pdf]. Accessed November 1, 2011.

National Association of Medicaid Directors [NAMD]. “Letter to Donald Berwick and Steven Miller.” Washington, DC: NAMD, October 31, 2011. Available at [http://medicaiddirectors.org/sites/medicaiddirectors.org/ files/public/namd_comment_ltr_eligibility_exchange_regulation_111031.pdf]. Accessed December 15, 2011.

National Association of Medicaid Directors [NAMD]. “SCOTUS Questions.” Washington, DC: NAMD, July 3, 2012. Available at [http://medicaiddirectors.org/sites/medicaiddirectors.org/files/public/namd_submitted_quest ions_120703.pdf]. Accessed September 4, 2012.

National Conference of State Legislatures. “Coverage of Uninsurable Pre-Existing Conditions: State and Federal High-Risk Pools.” Washington, DC: NCSL, December 2011. Available at [http://www.ncsl.org/?tabid=14329#2011]. Accessed January 9, 2012.

National Council of La Raza [NCLR]. “Basic Health Programs: A New Pathway to Coverage for Legal Immigrants in Your State?” 2011. Available at [http://www.nclr.org/images/uploads/news/BHP_NewPathway102011.pdf]. Accessed November 26, 2012.

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National Federation of Independent Businesses et al. v. Sebelius Secretary of Health and Human Services et al. No. 11–393. Available at [http://www.supremecourt.gov/opinions/11pdf/11- 393c3a2.pdf]. Accessed September 14, 2012.

National Health Care for the Homeless Council. “State Options for Medicaid Expansion”. Nashville, TN: National Health Care for the Homeless Council, July 2011. Available at [http://www.nhchc.org/wp-content/uploads/2011/10/ PolicyBriefMedicaidExpansionOptions.pdf]. Accessed November 4, 2011 .

National Health Council. “Essential Health Benefits White Paper.” Washington, DC: National Health Council, September 2010. Available at [http://www.nationalhealthcouncil.org/ NHC_Files/files/EHB_WhitePaper.pdf]. Accessed December 13, 2011.

New York State Department of Health. “New York’s Dual Demonstration Proposal to CMS: Health Homes; FIDA; and OPWDD Models.” Albany, NY: NYSDH, May 2012. Available at [http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/dual_de mo_proposal_to_cms.htm]. Accessed September 14, 2012.

Office of AIDS. “Planning for Health Care Reform: The HIV Care, Detection, and Prevention Perspective.” Sacramento, CA: California Department of Public Health, Office of AIDS, August 31, 2011. Available at [http://www.cdph.ca.gov/programs/aids/Documents/ PlanningforHCROASummary.pdf]. Accessed December 28, 2011.

Oregon Health Policy Board. “Coordinated Care Organizations.” 2012. Available at [http://www.oregon.gov/OHA/OHPB/Pages/health-reform/ccos.aspx]. Accessed September 14, 2012.

Pear, Robert. “U.S. Set to Sponsor Health Insurance.” The New York Times, October 27, 2012. Available at [http://www.nytimes.com/2012/10-28/health/us-to-sponsor-health-insurance- plans-nation…] Accessed November 16, 2012.

Perkins, Jane. “Fact Sheet: The Supreme Court’s ACA Decision & Its Implications for Medicaid.” Washington, DC: National Health Law Program, July 2012. Available at [http://www.healthlaw.org/images/stories/ACA_July_2012_Fact_Sheet.pdf]. Accessed September 12, 2012.

Popper, Richard. “Pre-Existing Condition Insurance Plan Eligibility and Access to Other Creditable Coverage.” Policy Letter #5. Baltimore, MD: CMS, March 23, 2011. Available at [http://cciio.cms.gov/resources/files/pcip_policy_letter_5.pdf]. Accessed December 6, 2011.

Presidential Advisory Council on HIV/AIDS. “Letter to Kathleen Sebelius.” August 8, 2011. Available at [http://aids.gov/federal-resources/policies/pacha/meetings/august-2011/august- 2011-pacha-letter-secretary.pdf]. Accessed December 30, 2011.

Patient Protection and Affordable Care Act. Public Law No. 111-148, §2702, 124 Stat. 119, 318-319 (2010).

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Project Inform. “Frequently Asked Questions: Enrollment of Seniors and Persons with Disabilities into Medi-Cal (California’s Medicaid) Managed Care Plans.” San Francisco, CA: Project Inform, October 2011. Available at [http://www.projectinform.org/pdf/mmc_faq.pdf]. Accessed January 18, 2012.

Pund, Britten. “ADAPs and Pre-Existing Insurance Plans as a Bridge to 2014.” Washington, DC: NASTAD, September 27, 2011. Available at [http://www.doseofchange.org/wp- content/uploads/2011/09/Bridge-to-2014-Webinar-FINAL.pdf]. Accessed December 6, 2011.

Robert Wood Johnson Foundation [RWJF]. “State of the States: Laying the Foundation for Health Reform.” Report #71835. Princeton, NJ: Robert Wood Johnson Foundation, February 2011. Available at [http://www.rwjf.org/files/research/71835report.pdf]. Accessed November 1, 2011.

Rosenbaum, Sara, and Katherine Jett Hayes. “Update to Essential Health Benefits: The Institute of Medicine Report.” Princeton, NJ: Robert Wood Johnson Foundation, October 21, 2011. Available at [http://www.healthreformgps.org/ resources/update-on-essential-health-benefits- the-institute-of-medicine-report]. Accessed November 4, 2011.

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Sebastian, Christine. “The Basic Health Plan Option: Will It Work for Low-Income Consumers in Your State?” Washington, DC: Families USA, July 2011. Available at [http://familiesusa2.org/assets/pdfs/health-reform/Basic-Health-Option.pdf]. Accessed September 4, 2012.

Sebelius, Kathleen. “Blueprint for Approval of State-based and State Partnership Exchanges.” Letter to State Governors, November 9, 2012. Available at [http://www.healthreformgps.org/wp- content/uploads/Secretary-Sebelius-Letter-to-the-Governors-071012-3.pdf]. Accessed November 14, 2012.

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Schmid, Carl. “Opportunities for Expanding HIV Testing Through Health Reform.” Washington, DC: The AIDS Institute, May 2011. Available at [http://www.theaidsinstitute.org/sites/default/files/attachments/schmidhealthreformhivtestin g.pdf]. Accessed December 28, 2011.

Scott, Dylan. “Checking Up on Health Insurance Exchanges.” Governing the States and Localities, December 12, 2011. Available at [http://www.governing.com/blogs/view/gov-checking-up- health-insurance-exchanges.html#]. Accessed January 10, 2012.

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Smith, Vernon, Kathleen Gifford, Eileen Ellis, Robin Rudowitz, and Laura Snyder. “Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage, and Policy Trends.” Publication #8248. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2011. Available at [http://www.kff.org/medicaid/upload/8248.pdf]. Accessed November 4, 2011.

Social Security Administration (SSA). “Social Security Legislative Bulletin. March 24, 2010. Available at [http://www.ssa.gov/legislation/legis_bulletin_032310.html]. Accessed November 17, 2012.

Solomon, Judith. “The Illusion of Choice: Vulnerable Medicaid Beneficiaries Being Placed in Scaled- Back ‘Benchmark’ Benefit Packages.” Washington, DC: Center on Budget and Policy Priorities, September 14, 2006. Available at [http://www.cbpp.org/files/9-14-06health.pdf]. Accessed December 13, 2011.

Sommers, Benjamin, and Sara Rosenbaum. “Issues in Health Reform: How Changes in Eligibility May Move Millions Back and Forth Between Medicaid and Insurance Exchanges.” Health Affairs, vol. 30, no. 2, February 2011, pp. 228–236. Available at [http://op.bna.com/hl.nsf/id/nwel-8dqu2l/$File/Sommerstudy.pdf]. Accessed December 30, 2011.

Sommers, Benjamin, Katherine Swartz, and Arnold Epstein. “Policy Makers Should Prepare for Major Uncertainties in Medicaid Enrollment, Costs, and Needs for Physicians Under Health Reform.” Health Affairs, vol. 30, no. 11, October 2011, pp. 2186–2193. Available at [http://content.healthaffairs.org/content/early/2011/10/24/hlthaff.2011.0413.full.pdf]. Accessed December 30, 2011.

State Health Access Data Assistance Center. “Health Insurance Exchanges: Implementation and Data Considerations for States and Existing Models for Comparison.” Issue Brief #23. Minneapolis, MN: University of Minnesota, October 2010. Available at [http://www.shadac.org/files/shadac/publications/IssueBrief23.pdf]. Accessed January 10, 2012.

State Refor(u)m. “State Progress on Essential Health Benefits.” National Academy for State Health Policy Table. Available at [http://www.statereforum.org/state-progress-on-essential-health- benefits]. Accessed November 12, 2012.

Steinhauer, Jennifer. “For Opponents of Health Care Law, No Easy Road to Repeal.” New York Times, June 29, 2012. Available at [http://www.nytimes.com/2012/06/30/us/politics/politics- and-popular-provisions-make-health-law-hard-to-erase.html]. Accessed September 4, 2012.

Taylor, Jessamy. “The Primary Care Safety Net: Strained, Transitioning, Critical.” Background paper #79. Washington, DC: National Health Policy Forum, September 2010. Available at [http://www.nhpf.org/library/background-papers/BP79_PrimaryCareSafetyNet_09-28- 10.pdf]. Accessed December 23, 2011.

81 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Technical Assistance Collaborative. “Health Care Reform and Benchmark Plans: Considerations for Advocates.” Boston: Technical Assistance Collaborative, 2011. Available at [http://www.tacinc.org/downloads/Benchmark%20Plans%20and%20ACA%20final.pdf]. Accessed December 13, 2011.

The Advisory Board. “Where Each State Stands on ACA’s Medicaid Expansion.” November 14, 2012. Available at http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap]. Accessed November 16, 2012.

The Washington Post. “Medicaid Expansion Goes Local in Texas.” August 27, 2012. Available at [http://www2.tbo.com/news/nation-world/2012/aug/27/namaino15-medicaid-expansion- goes-local-in-texas-ar-474782/]. Accessed September 14, 2012.

The White House Office of National AIDS Policy [ONAP]. National HIV/AIDS Strategy for the United States. July 2010. Available at [http://www.whitehouse.gov/administration/eop/onap/nhas]. Accessed November 18, 2012.

The White House Office of National AIDS Policy [ONAP]. Update of 2011-2012 Federal Efforts to Implement the National HIV/AIDS Strategy. July 2012. Available at [http://www.aids.gov/federal- resources/national-hiv-aids-strategy/implementation-update-2012.pdf]. Accessed November 20, 2012.

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Weddle, Andrea, and Ben Hauschild. “HIV Medical Provider Experiences: Results of a Survey of Ryan White Part C Programs.” Presentation for the Institute of Medicine, Committee on HIV Screening and Access to Care, September 29, 2010. Available at [http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advocacy/Policy_Priorities/HIV _Medical_Workforce/Resources/Ryan%20White%20Part%20C%20Survey%20IOM%209%20 26%2010.pdf]. Accessed January 18, 2012.

Weiwel, Ellen, Hani Nasrallay, David Hannah, Colin Shepard, Lucia Torian, and Elizabeth Begier. “HIV Diagnosis and Care Initiation Among Foreign-Born Persons in New York City, 2001– 2007.” Presentation at the 16th Conference on Retroviruses and Opportunistic Infections, February 8–11, 2009, Montreal, Quebec. Available at [www.nyc.gov/html/doh/downloads/pdf/dires/2009_croi_poster_1034.pdf]. Accessed December 30, 2011.

Wong, Michael T. “Healthcare Reform and HIV Care.” Reston, VA: Clinical Care Options, August 2011. Available at [http://www.clinicaloptions.com/HIV/Annual%20Updates/ 2011%20Annual%20Update/Modules/Reform.aspx]. Accessed November 1, 2011.

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APPENDIX A

STUDY METHODS

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

STUDY METHODS

To conduct the study, between October 2011 and August 2012, the Mathematica team gathered analyzed, and presented findings from three sources of information: (1) a comprehensive scan of reports and analyses in ACA topic areas of greatest potential impact; (2) consultations with technical experts with in-depth knowledge of ACA reform provisions, Medicaid, and RWHAP; and (3) discussions with seven state Medicaid programs regarding their early experiences planning and implementing key provisions of the ACA.

1. Comprehensive Scan Methods

To start the comprehensive scan, in October 2011, we identified 26 ACA provisions or topics that could potentially affect RWHAP service use. We collected information in each identified topic. We also asked ACA experts to identify relevant issues not already captured in the set of topics. The initial scan included a review of ACA reports and analyses published from March 2010 to December 2011, for a preliminary scan report submitted to HAB in February 2012. Documents were collected from more than 100 sources, including foundation reports and policy briefs; issue briefs, webinar materials, and other publications from public policy organizations and advocacy groups; peer- reviewed literature; radio, print and electronic media (news stories of ACA developments); and ACA-related government reports, policy bulletins, letters to state Medicaid directors, draft and final rules regarding the legislation, including the ACA text.

The scan’s February 2012 report included a full list of the sources reviewed. Article titles and abstracts (when provided) were initially reviewed for relevance. Those deemed irrelevant were eliminated from the full review, which resulted in 180 articles that were read and analyzed for the scan report. After the scan report was submitted in February, the Mathematica team continued to collect, read, and analyze new ACA-related documents from February through November. These additional documents are included this final report, which includes over 150 references.

The scan team (a senior researcher and research analyst) reviewed the full text of the 180 articles, as well as about 30 additional articles that provided more general background information about the ACA. The team organized the scan information into six preliminary categories (insurance market reforms, insurance coverage, insurance benefits, consumer cost-sharing, provider reimbursement, and access to HIV providers and models of care). Many articles included information relevant to more than one topic and issue. For each issue, they gathered information regarding (1) the status of the issue before the passage of the ACA; (2) how the ACA was likely to change the issue; (3) the status of the implementation of the ACA-related change; (4) the potential impact of these ACA-related changes for RWHAP grantees, providers, clients, and PLWHA; and (5) recommendations made by experts and advocates on what can be done to address the issue. In the process, the 26 initial topics were condensed to a smaller set of 19 topics, which the team determined to have the greatest potential impact on the RWHAP community. The scan’s findings were summarized in a report with 19 accompanying tables, one for each topic, which was submitted to HAB and approved in February 2012 (Bagchi et al. February 2012). The scan’s topics were:

1. Pre-existing condition insurance plans (PCIPs) 2. Grandfathering of existing health plans 3. Medical loss ratio (MLR) 4. Individual mandate

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5. Medicaid expansion 6. State-based health insurance exchanges 7. Exclusion of undocumented immigrants 8. Medicaid household income calculations 9. Seamless eligibility process and coordination of coverage and care 10. Essential health benefits and benchmark plans 11. Preventive services 12. Consumer operated and oriented plans (CO-OPs) 13. Cost-sharing 14. Medicare Part D drug benefits and true out-of-pocket (TrOOP) costs 15. Federally Qualified Health Center (FQHC) funding 16. Medicaid reimbursement rates 17. Medicaid health homes 18. Medicaid managed care organizations (MCOs) 19. Expanding the HIV workforce

2. Technical Expert Consultation Methods

In the second phase of the project, the study team used the scan’s results to inform discussions with 15 HIV providers, policymakers, and advocates with expertise in the ACA, Medicaid, HIV/AIDS, and RWHAP. In each topic area, we asked the experts to identify issues of highest priority that offered the greatest opportunities and challenges to the RWHAP community, and how they were being or could be addressed. We also asked the experts to identify states with innovative or informative efforts to implement ACA provisions for PLWHA.

To initiate this task, we identified 29 potential candidates for the technical expert consultations, based on their organizational affiliations and presumed knowledge of the ACA, Medicaid, HIV/AIDS, and the RWHAP community. Working with the study’s contracting officer’s technical representative (COTR) who worked with HAB staff, we refined the list of candidates and prioritized a subset of them using the following criteria: (1) expertise in Medicaid and the ACA; (2) expertise on RWHAP and HIV/AIDS policy; (3) type of organizational setting/affiliation; and (4) geographical distribution. We also paired each priority expert with an alternate who matched the priority candidate’s key characteristics. This approach helped to ensure a breadth of technical expertise to address the project’s goals.

Using the findings from the comprehensive scan of the ACA literature, the Mathematica team developed a semi-structured discussion guide with both closed- and open-ended questions organized around six topics: insurance market reforms, insurance coverage, Medicaid and private health insurance benefits, consumer cost-sharing, provider reimbursement policies, and access to HIV providers. In each area, experts were asked to select the highest-priority issues and to describe what was being done currently to address those issues. Within these broad topic areas, the discussions probed specific subtopics that were identified as priority issues in the study’s comprehensive scan.

A.4 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table A.1. Technical Expert Consultation Participants

Name Organizational Affiliation Type of Interview C. Lynn Besch, M.D. Chief, Individual HIV Division of Infectious Diseases, Louisiana State Interview University, Health Care Services Lucy Bradley-Springer, Principal Investigator, Focus Group Ph.D. Mountain Plains AIDS Education and Training Center Anne Donnelly, M.A. Director, Individual Health Care Policy, Project Inform Interview Robert Greenwald, J.D. Cochair, Individual HIV Health Care Access Working Group, Harvard Law Interview School James Friedman, M.H.A. Executive Director, Focus Group American Academy of HIV Medicine Jennifer Kates, M.A., M.P.A. Vice President and Director, Individual Global Health Policy and HIV Policy, Kaiser Family Interview Foundation Ann Lefert, M.P.P. Associate Director, Focus Group Government Relations, National Alliance of State and Territorial AIDS Directors Kali Lindsey, M.A. Director, Focus Group Legislative and Public Affairs, National Minority AIDS Council Kathy McNamara, R.N. Assistant Director, Focus Group Clinical Affairs, National Association of Community Health Centers Matt Salo Executive Director, Individual National Association of Medicaid Directors Interview Judith Solomon, J.D. Vice President, Individual Center on Budget and Policy Priorities Interview Dana Van Gorder Executive Director, Focus Group Project Inform Andrea Weddle, M.S.W. Executive Director, Individual HIV Medicine Association Interview S. Bruce Williams, M.D. Professor of Internal Medicine, Individual University of New Mexico and Truman St. Health Interview Services Clinic, Albuquerque, NM

After finalizing the list of experts, introductory emails were sent to a subset of the 29 individuals to invite them to participate in the consultation calls. Within three business days, Mathematica followed up and contacted each person by telephone to reiterate the purpose of the expert consultations, confirm their willingness to serve as a technical expert, and schedule a time to conduct the individual or group consultations. During April and May 2012, Mathematica consulted with a total of 15 experts: we conducted individual discussions with 9 experts and focus groups with 6 experts. The interviewees included HIV/AIDS advocates, Medicaid policy experts, and health care providers (see Table A.1). Individual interviews lasted approximately 60 minutes and the focus groups about 90 minutes. Senior researchers led the individual and group consultations with a research analyst taking notes. To ensure consistent and high quality data, the consultations were recorded and the project director reviewed and finalized all consultation notes. Mathematica also received verbal consent to record the discussions from all interviewees before conducting the interviews.

A.5 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

After completing the group and individual consultation notes, the interviews were systematically coded by one of the senior researchers and the research analyst. The coders developed a theme- based structure for coding the interviews. The themes were aligned with the study’s research goals and objectives. The researcher and analyst manually coded the initial interviews, compared notes, and resolved any discrepancies between them. The results of the technical expert discussions were summarized in a memorandum submitted to HAB and approved in June 2012.

3. State Medicaid Program Discussion Methods

In the final phase of the study, the results of the comprehensive scan and technical expert discussions were used to recruit and conduct discussions with seven state Medicaid programs involved in planning and implementing ACA reforms. In conducting the interviews with the state Medicaid officials, we sought to gather detailed information about examples of how different Medicaid programs were incorporating issues affecting PLWHA into their planning and implementation of the ACA. Through these interviews, we also sought examples of effective strategies for preparing to transition and integrate HIV/AIDS clients, providers, and service models into the health plans and programs that will be offered after implementation of ACA provisions in 2014.

Based on findings from the ACA scan, the technical expert consultations, and input from HAB staff, we identified seven priority and three alternate state Medicaid programs. The seven priority states included Colorado, Iowa, Massachusetts, New York, Oregon, South Carolina, and Texas, with California, the District of Columbia, and Maryland serving as alternates. Working with the study’s COTR, we selected the priority states that satisfied our three selection criteria: (1) the status of early ACA implementation; (2) state demographics (geographic diversity and prevalence of HIV/AIDS); and (3) core Medicaid program components. The first set of criteria helped us to identify exemplary ACA-related practices; the second and third criteria identified a range of states with different political and cultural contexts and HIV populations.

After HAB approved the final list of state Medicaid programs and authorized the introductory emails that were sent to the seven priority states to invite them to participate in the group discussions. The group interviews were conducted in July 2012, after the U.S. Supreme Court decision was issued on the constitutional challenge to the ACA, in order to capture the states’ post- decision ACA plans. Mathematica followed up and contacted each Medicaid director by telephone to reiterate the purpose of the study and schedule a time to conduct the group discussion. One of the seven states (South Carolina) declined to participate in the study on the grounds that the state was refusing to implement the ACA. Consequently, the Mathematica team worked with the COTR and other HAB staff to select Maryland as a replacement state; Maryland had been identified earlier as one of three alternate states for the study (see Table A.2).

To conduct the state Medicaid program interviews, the Mathematica team used the findings from the scan and technical expert consultations to develop a semi-structured discussion guide with both closed- and open-ended questions. The discussion guide was structured to gather information in July 2012 regarding each state’s Medicaid program and ACA implementation activities, including components of its existing Medicaid eligibility, coverage and service delivery models, its plans to expand Medicaid and select a state EHB benchmark plans, its initial efforts to ensure coordination in the eligibility and enrollment processes between the state’s exchange program and RWHAP grantees, the states’ initial reactions to the U.S. Supreme Court’s June ACA decision, and other relevant topics. Further, in the discussions staff probed on subtopics identified as priority issues in

A.6 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

the technical expert consultations and, when appropriate, tailored questions to the specific characteristics of each state Medicaid program and set of informants.

Given the study’s goals, the technical nature of ACA-related topics, the complexity of the treatment and care of HIV/AIDS, and the structure of state Medicaid agencies, an overview of discussion topics was distributed to each state in advance to ensure that appropriate staff were included on the calls. The interviewees included Medicaid, Department of Health, and Division of Insurance officials. Specifically, the state Medicaid directors delegated deputy directors of Medicaid, directors of Infectious Disease, chief medical officers, policy specialists, and ACA project directors to participate in the discussions. The interviews lasted approximately 90 minutes, with a senior researcher leading the discussions and a research analyst documenting the discussion. To ensure consistent and high quality data collection, the discussions were also recorded. Mathematica received verbal consent to record the discussions from all interviewees before conducting the interviews.

After completing the discussion notes, the interviews were systematically coded by the research analyst and reviewed by the project director for completeness and accuracy. The project director and research analyst created a topic-based structure for analyzing the interview notes. The topics reflected the key issues that had emerged from previous tasks and aligned with the study’s research goals and objectives. The research analyst manually coded the initial interviews and organized the results in a set of topic-specific tables, which the project director reviewed to ensure comprehensiveness and accuracy. Information from the tables was also sent to the states for their review and comment. All states reviewed and approved the content of the state tables. The findings from the state interviews are presented in this final report.

4. Study Reports

In September 2012, Mathematica submitted the project’s draft final report, combining the findings from the scan, expert consultations, and state Medicaid program interviews. The study’s products were written jointly by Mathematica senior researchers Drs. Margaret Hargreaves, and Ann Bagchi, and research analyst Vanessa Oddo. The study’s interim reports received double quality assurance reviews from Mathematica senior researchers Dr. Boyd Gilman and Debra Lipson. In addition, Deborah Bachrach, an ACA expert from Manatt Solutions, contributed to the project reports and conducted a third quality assurance review of the ACA scan findings, presented in the scan report and updated in Appendices C – E. The study’s final report updated the draft final report with information gathered on ACA developments between mid-September and late November 2012, and responded to draft report comments. Contributors and reviewers of the final report were: Margaret Hargreaves, Ann Bagchi, Vanessa Oddo, Boyd Gilman, Margo Rosenbach (Mathematica), and ACA expert, Deborah Bachrach (Manatt Health Solutions).

A.7

Table A. 2. HRSA/HAB Potential Impact of ACA Study: States Selected For Medicaid Program Discussions

State Demographics Medicaid Generosity ACA Implementation

State-to- Percent of Income National States Number of People Living Eligibility for Medicaid Enrolling/ People Living with HIV/AIDS ABD Physician Fee Legislation Planning to with Enrolled in Population, Ratio for States Enacted to Enroll ADAP Census HIV/AIDS, Medicaid, 2009 Primary Care, Contesting Establish Clients in States Region 20081 2008 (%)1 (% FPL)2 20083 ACA Exchanges PCIPs Alabama South 10,406 4.75 75 1.11 Yes Pending --- Alaska West 610 2.99 109a 2.26 Yes Pending --- Arizona South 11,860 3.93 100 1.48 Yes Pending Yes Arkansas South 4,999 5.25 75 1.08 ------California West 103,645 4.22 100 0.76 --- Yes Yes Colorado West 10,727 11.22 75 1.33 Yes Yes Yes Connecticut Northeast 10,946 3.08 56 1.33 --- Yes Yes Delaware South 2,951 2.04 75 1.56 ------District of Columbia South 16,591 4.35 100 0.82 --- Yes --- Florida South 92,156 4.39 75 0.85 Yes --- Yes A. Georgia South 35,415 4.63 75 1.29 Yes Pending Yes 8

Hawaii West 2,203 4.38 100 1.03 --- Yes --- Idaho West 753 4.92 78 1.48 Yes Pending --- Illinois Midwest 33,155 3.85 75 0.90 --- Pending Yes Indiana Midwest 8,146 4.01 100 0.88 Yes --- Yes Iowa Midwest 1,551 2.67 75 1.27 Yes Pending --- Kansas Midwest 2,606 5.24 75 1.34 Yes ------Kentucky South 4,423 3.95 75 1.15 ------Yes Louisiana South 16,282 3.58 75 1.31 Yes --- Yes Maine Northeast 1,108 2.18 100 0.77 Yes Pending Yes Maryland South 28,595 3.69 75 1.32 --- Yes Yes Massachusetts Northeast 13,799 1.88 100 1.29 --- Yes --- Michigan Midwest 14,304 2.59 100 0.91 Yes Pending Yes Minnesota Midwest 6,121 3.93 100 0.85 --- Pending Yes Mississippi South 9,214 4.39 80 1.20 Yes ------Missouri Midwest 11,175 3.75 85 0.95 --- Pending Yes Montana West 514 3.89 75 1.38 ------Nebraska Midwest 1,561 4.34 100 1.16 Yes Pending Yes Nevada West 6,723 9.50 75 1.45 Yes Yes --- New Hampshire Northeast 1,201 4.98 79 1.04 ------Yes New Jersey Northeast 37,134 4.66 100 0.69 --- No ---

New Mexico West 3,668 7.21 75 1.44 --- Pending Yes

Table A.2 (continued)

State Demographics Medicaid Generosity ACA Implementation

State-to- Percent of Income National States Number of People Living Eligibility for Medicaid Enrolling/ People Living with HIV/AIDS ABD Physician Fee Legislation Planning to with Enrolled in Population, Ratio for States Enacted to Enroll ADAP Census HIV/AIDS, Medicaid, 2009 Primary Care, Contesting Establish Clients in States Region 20081 2008 (%)1 (% FPL)2 20083 ACA Exchanges PCIPs New York Northeast 135,659 2.43 85 0.60 --- Pending Yes North Carolina South 22,431 3.19 100 1.40 ------Yes North Dakota Midwest 171 3.29 75 1.43 Yes --- Yes Ohio Midwest 16,337 4.71 65 0.99 Yes Pending Yes Oklahoma South 4,762 4.51 80 1.42 Yes ------Oregon West 4,856 5.40 75 1.16 --- Yes Yes Pennsylvania Northeast 31,684 10.52 100 0.95 --- Pending --- Rhode Island Northeast 1,778 2.11 100 0.57 ------South Carolina South 13,763 4.13 100 1.24 Yes Pending Yes South Dakota Midwest 393 4.14 75 1.20 Yes --- Yes Tennessee South 14,589 4.40 75 ------Yes Texas South 61,826 7.53 75 1.00 Yes --- Yes Utah West 2,255 6.75 100 1.13 Yes Yes Yes

A. Vermont Northeast 405 1.19 101 1.36 --- Yes ---

9 Virginia South 20,554 6.66 80 1.34 Yes Pending Yes Washington West 10,173 3.48 75 1.43 Yes Yes Yes West Virginia South 1,427 3.17 75 1.10 --- Yes --- Wisconsin Midwest 4,831 3.21 84 0.97 Yes Pending Yes Wyoming West 211 4.14 75 1.67 Yes ------Sources: 1. 2008 MSIS data are tabulated by Acumen 2. Kaiser Commission on the Medicaid and the Uninsured. “Medicaid Financial Eligibility: Primary Pathways for the Elderly and People with Disabilities. Washington, DC, February 2010. Available at: [http://www.kff.org/medicaid/upload/8048.pdf]. 3. Zuckerman, Stephen, Aimee Williams, and Karen Stockley. "Medicaid Physician Fees Grew By More Than 15 Percent From 2003 to 2008, Narrowing Gap With Medicare Physician Payment Rates," Health Affairs, April 2009; Available at:[http://www.kff.org/medicaid/kcmu042809oth.cfm]. Notes: Pink shading indicates priority states and blue shading indicates alternate states. In all states but Virginia, the challenge was brought by the state's Attorney General. ABD= Aged, Blind, and Disabled; ACA= Affordable Care Act; ADAP= AIDS Drug Assistance Program; FPL= Federal Poverty Line; PCIP= Pre-Existing Condition Insurance Plan. Table created by Mathematica Policy Research, May 11, 2012.

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APPENDIX B

SEVEN STATE SAMPLE:

ACA IMPLEMENTATION EXPERIENCES

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Table B.I.1. Seven State Sample: Early ACA Implementation Experiences

Status of ACA State Implementation Comments

Colorado Planning As of July 2012, Colorado is planning various aspects of implementation. The overall message is projected through the governor’s office, whereas the steering committee spearheads implementation activities that specifically affect Medicaid. The steering committee reflects on Colorado’s higher-level strategy. Smaller committees are working on specific provisions. Although creating the steering committee is Colorado’s primary plan for implementing the ACA to date, it has procured an RWJF assistance grant and several CMS grants to facilitate additional planning activities. Largely, Colorado is working on ACA planning with state staff instead of outside consultant . However, external stakeholder input is sought for certain provisions, including eligibility reforms. In particular, the eligibility work group has collaborated with advocacy groups and eligibility sites regarding the application process and revised rules. Further, the steering committee collaborates with the exchange board, an outside entity. Colorado expressed that it is difficult to plan for specific populations further without guidance from CMS on its interpretation of the opinion of the Supreme Court on the Medicaid expansion provision.

Iowa Planning Iowa staff are working on the implementation of provisions that are linked to the programs for which they are responsible. Policy staff are collaborating with other state agencies to ensure that ACA policies are implemented appropriately and that they are attuned to federal guidance. Although Iowa does not have legislative authority for establishing an exchange, its interagency work group (composed of DPH, DHS, and the Insurance Division) works

B collaboratively on the planning and designing of the exchange. Iowa expects a decision from the governor and/or . 3 legislature that will formalize Iowa’s approach for establishing an exchange. While awaiting that formal guidance, Iowa continues to plan. Specifically, the state is keeping abreast of the regulations and thinking about vendor procurement. Iowa’s planning is facilitated by a CMS-funded Exchange Establishment grant received in December 2011. Iowa has sought targeted stakeholder involvement regarding planning. It held regional meetings with communities and stakeholders to gauge interest and perspective on the most important aspects of the ACA. Further, there will be some changes around provider enrollment and program integrity. Iowa has communicated with providers and sought their input regarding those areas. Iowa noted that further federal guidance is critical for moving forward with planning.

Maryland Implementing Maryland is implementing all aspects of the ACA . Led by the governor’s Health Reform Coordinating Council, Maryland began its planning activities shortly after the ACA was passed in 2010 and has committed to implementing a state-based exchange. Similarly, Maryland state staff are planning for the expansion of their Medicaid program. It has a long-standing advisory committee that offers its guidance to Medicaid on expansion implementation issues. The Maryland Health Benefit Exchange has formed various work groups, comprised of state staff, that focus on ACA-specific provisions, including setting up patient navigators; setting up the exchange; and including brokers in the planning process, among others. Stakeholders have been engaged extensively and include advocacy groups, other state agencies, industry representatives, and the RWHAP planning council.

Table B.I.1. (continued)

Status of ACA

State Implementation Comments

Massachusetts Implementing Massachusetts is implementing all aspects of the ACA . The secretary of Health and Human Services is overseeing statewide implementation and leads, the Overall ACA Implementation Work Group that facilitates the transition planning that must occur. The Implementation Work Group meets monthly and is made up of representatives from 17 agencies. Although Massachusetts implemented similar reforms and boasts a 98 percent coverage rate, the ACA includes many new requirements for the state to implement and opportunities for the state to improve its approach to health reform. To ensure that all aspects of the law are covered, subgroups are assigned to identifying policy that has to be refined by 2014. Subgroups are made up of representatives from various agencies who working on common issues. Massachusetts has already expanded Medicaid but will receive additional federal funding for those who are considered “newly eligible” under the ACA. It also received an early innovator grant from CMS to develop its data system and has secured a vendor under the grant to develop its “one-stop shopping experience.”

New York Implementing Before the ACA, the Governor established the Medicaid redesign team, which focused on Medicaid health care delivery reform. In particular, New York sought to manage its high-yield users better. Following passage of the ACA, the governor created an interdepartmental planning team made up of key staff from the Department of Health and the Insurance Department to address ACA-specific provisions. Primarily, they were tasked with centralizing Medicaid administration. Both groups work simultaneously and collaborate when appropriate. For example, the health disparities work group crosses ACA reform and Medicaid redesign. New York plans to establish an exchange and the governor has issued an executive order for Medicaid expansion.

B The state plans to have an integrated Medicaid, CHIP, and health plan eligibility on one centralized IT system. New .

4 York noted that it awaits federal guidance to complete all of its preparations.

Oregon Implementing In 2009, Oregon passed a law that enabled it to establish exchanges and expand Medicaid eligibility prior to the passage of the ACA. Thus, Oregon has been in the process of transforming its health care system for the past 2.5 years and will be ready to fully implement the ACA in January 2014. Currently, Oregon has capitated MCOs and mental health organizations that function separately. Beginning August 1, 2012, it will be merged into a CCO (that is, the physical health, mental health, dental health, and long-term care will be merged); this transition will align with the ACA. Notably, as part of the CCO transition, Oregon has committed to CMS to expand Medicaid; Oregon has the exchange, staff, and structure in place. Currently, the state is marketing the exchange and has processes in place to educate new enrollees. Its EHBs for that exchange have been approved and insurance companies will provide pricing for the EHBs by December 2012. In addition, the computer system, applications, and web portal are being built. Oregon’s exchanges will go live for state employees in January 2013 and statewide in January 2014.

Table B.I.1. (continued)

Status of ACA

State Implementation Comments

Texas Limited Planning Texas has been working on various aspects of implementation since 2010. Based on the governor’s direction, Texas returned most of the planning grant; as a result, their planning to establish an exchange has been limited. From the Medicaid agency’s perspective, Texas would like to retain the ability to facilitate the Medicaid CHIP eligibility determinations. As of July, Texas was awaiting further guidance from CMS. Despite returning ACA planning dollars, Texas Medicaid is refining its effort around developing integrated models of care for safety-net populations via a NASHP Learning Collaborative. HMOs in Texas serve a large portion of PLWHA in the state. Even without the expansion, Texas’ Medicaid agency will look to better integrate managed care programs and safety-net HIV providers within their state.

Source: Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. ACA = Affordable Care Act; CMS = Centers for Medicare & Medicaid Services; CCO = coordinated care organization; DPH = Department of Public Health; DHS = Department Human Services; EHB = essential health benefits; IT = information technology; MCO = managed care organization; NASHP = National Association for State Health Policy; PLWHA = people living with HIV/AIDS.

B . 5

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Table B.I.2. Seven State Sample: Coordination with RWHAP and Other Stakeholders RWHAP Others State Involved Involved Comments Colorado No Yes Colorado has been working on various aspects of implementation with state staff, of some ACA provisions. However, the eligibility group has been engaging stakeholders and speaking with advocacy groups regarding the application process. RWHAP grantees, providers, and clients have not been involved in Colorado’s planning process. Further, Colorado’s Medicaid agency does not often have direct contact with RWHAP grantees or providers. Iowa No Yes Stakeholder involvement in Iowa’s ACA planning process is provision-specific. For example, Iowa has engaged stakeholders in the discussion regarding the exchange. It has held both regional meetings and smaller targeted meetings with communities and stakeholders to discuss their perspectives on the most important aspects of the ACA. In addition, Iowa has communicated with providers regarding provider enrollment and program integrity. It has had contact with the DPH, which administers the RWHAP, regarding data sharing. As its implementation plans progress, Iowa intends to communicate with DPH regarding any decisions that could affect RWHAP enrollees’ benefits or eligibility. Notably, the Iowa DPH is working with the University of Iowa to explore the impact of the ACA on safety-net and RWHAP providers. In particular, they will consider how increases in the number of newly eligible enrollees will affect provider networks and provider capacity in Iowa. Maryland Yes Yes Maryland is engaging both its RWHAP planning council and other stakeholders, including advocacy

B groups, state agencies, and industry representatives. Local advocates are also participating in .

7 Maryland’s various work groups. For example, the Baltimore-Towson MSA has been heavily involved in ensuring that EHBs meet the needs of PLWHA and are comparable to the current benefits package. Further, Maryland has had extensive conversations with the Part A planning council for the Baltimore- Towson region. The planning council voiced concerns regarding coverage. For example, case management and oral health for adults is very important to members on the planning council. Traditionally RWHAP clients have received case management through the RWHAP and Maryland staff are uncertain how it will be implemented under the ACA in Medicaid and the exchange. Massachusetts Yes Yes In general, Massachusetts works closely with the strong advocacy community in the state. It has not engaged outside stakeholders in its Implementation Work Group, which is composed of state agency staff. However, on a quarterly basis its work group meeting is open to outside stakeholders and some subcommittees have held targeted public meetings or included key stakeholders in a in advisory capacity. The open stakeholder meeting is publicized to the RWHAP planning group. In addition, documents from the stakeholder meetings are posted online and Massachusetts sends out a weekly email update to stakeholders. Although the state has not targeted RWHAP stakeholders specifically, they can contribute through this general stakeholder process. Massachusetts’ individual mandate sub- work group has developed an advisory council and a number of advocacy groups, such as Health Care For All, have been engaged to participate. In addition, ADAP, administered by the Department of Public Health, and MassHealth are highly collaborative, particularly in regard to data sharing; representatives from both agencies sit on the RWHAP planning council. New York Yes Yes The New York AIDS Institute has been participating collaboratively in the redesign and reform efforts underway in New York. RWHAP participates in New York’s interdepartmental planning team.

Table B.I.2. (continued) RWHAP Others

State Involved Involved Comments Oregon Yes Yes Many non-governmental organization (NGO) in Oregon have been involved in the state’s planning process. Oregon has a culture that mandated that it talk to everyone in the state, including PLWHA; Oregon received input from CBOs, hospital systems, and MCOs, among others. Oregon sought input from various stakeholders statewide to bring the community into the process. Further, CCOs are required to have a community advisory committee that sets their policies. In addition, Part A and Part B groups have been active participants in transforming health care in Oregon for several years. Cascade AIDS was appointed to the policy committee to provide input regarding EHBs. Texas Yes Yes Texas is evaluating how Medicaid could benefit PLWHA. Texas has a history of working with nonprofits and other stakeholders and expects this will continue its participation in a NASHP Learning Collaborative, in which the Medicaid program will be working closely with managed care plans and providers. The technical assistance grant is important because (1) it will put a focus on PLWHA when educating Medicaid providers and (2) it enables the state to bring RWHAP HIV/AIDS providers into the larger insurance world. Further, the Department of Insurance will seek public input regarding EHBs as advocates are interested in having input into this process. RWHAP grantees have also been involved in ACA planning. Some Part A grantees have met quarterly and Texas anticipates working with additional stakeholders as they transition into implementation. Finally, the Department of State Health Services regularly surveys RWHAP providers regarding their enrollment status and their need for trainings. Source: Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. ACA =Affordable Care Act; ADAP = AIDS Drug Assistance Program; CCO = coordinated care organization; DPH = Department of Public Health; EHB = essential health benefit; NASHP = National Academy for State Health Policy; NGO = non-governmental organization; MSA = metropolitan statistical area; B

. PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. 8

Table B.II.1. Seven State Sample: Pre- Existing Condition Insurance Plans

State Versus Number of State Federal PCIP Enrolleesa Comments

Colorado State 1,333 NAb

Iowa State 310 Iowa’s state PCIP is under the direction of the Insurance Division. To be eligible for the state’s PCIP, a person would have to lack insurance for six months or more. Iowa also has a high-risk pool, which was in place before the ACA. While the benefits are similar, the programs’ eligibility requirements vary. Specifically, the state high-risk pool does not require the enrollee to be uninsured for six-months prior to enrollment. A person would not qualify for both the PCIP and the state high-risk pool.

Maryland State 999 Maryland had a high-risk pool in place before the ACA; Maryland Health Insurance Plan received the federal funds with which the state has been able to open up additional slots. Notably, Maryland has enrolled PLWHA enrolled in MHIP, their high-risk pool, for many years.

Massachusetts Federal 19 Massachusetts is a guaranteed issue state, so there was not a need for a state-run PCIP. Those Massachusetts enrollees in the federally-administered PCIP are people who likely missed the window for open enrollment in the state’s health reformexchange. B . 9

New York State 3,764 New York facilitates a state-run PCIP (NY Bridge Plan). New York indicated that approximately 900 of their PCIP enrollees are PLWHA. The pharmacy benefit management company (Medco) is unwilling and unable to coordinate benefits with RWHAP programs and enrollees are required to pay up front and then are reimbursed. Both of these practices hinder PLWHA participation in the state’s PCIP. However, this practice is not a barrier to care in New York because Medicaid pays the prescription costs up front and bills the plan after the fact to receive reimbursement. New York has worked collaboratively with the NY Bridge Plan and DHHS to assure that ADAP enrollees who meet the eligibility criteria for the plan are able to access the comprehensive coverage they need by assisting with premium payments and cost-sharing requirements.

Oregon State 1,556 Oregon’s PCIP is managed by the same state program as the state’s high-risk pool (Oregon Medical Insurance Pool). They are within the same administrative agency and are meant to be seamless; thus, there is a single application for both of the PCIP and the high-risk pool. A person’s insurance status determines the pool for which he or she is eligible: (1) if a person is uninsured for six months and has proof of citizenship, he or she is placed into the PCIP; and (2) if a person was not uninsured for six months prior, he or she is placed into the state high-risk pool. Currently, The Oregon Medical Insurance Pool also accepts undocumented immigrants.

Table B.II.1 (continued)

State Versus Number of

State Federal PCIP Enrolleesa Comments

Texas Federal 6,623 From the viewpoint of the Texas Department of State Health Services, the RHWAP has worked closely with the Texas Department of Insurance to provide education on the federally-run PCIP to HIV case managers and providers. However, the PCIP has not been embraced for several reasons, including cost and the creation of financial liabilities for inpatient charges. . Use of PCIP by RHWAP clients has been problematic for several reasons. First, the ADAP has mechanisms for paying for pharmaceutical co-pays and deductibles and paying premiums, but lacks the ability to easily pay non-drug deductibles. These latter payments must be made by community organizations or the client. The split of deductibles into drug and non-drug components, with very high non-drug deductibles made it more difficult to meet overall deductibles, A unitary deductible would have been easily satisfied by many ADAP clients, and could have created a cost-beneficial alternative for the Texas ADAP. Unfortunately, the split deductible placed the majority of the burden back on the client. Further, if RWHAP clients enroll in PCIP, they would become liable for co-payment for inpatient services.

Sources: 1. Kaiser Family Foundation. “State Health Data: Health Reform in the United States.” Washington, DC: Kaiser Family Foundation, August 2012b. Available at [http://www.statehealthfacts.org/index.jsp]. September 14, 2012. 2. Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. B . 10 a Number of enrollees as of June 30, 2012.

b CO was unable to answer our questions regarding PCIPs as the Department of Health Care Policy and Financing does not manage Colorado’s PCIP. c Health insurance sold on a guaranteed issue basis cannot reject applicants based on health or risk status. ACA = Affordable Care Act; ADAP = AIDS Drug Assistance Program; DHHS = U.S. Department of Health and Human Services; MHIP = Maryland Health Insurance Plan; NA= Not Available; PCIP= pre-existing condition insurance plans; PLWHA= people living with HIV/AIDS.

Table B.II.2. Seven State Sample: Expansion of Medicaid Eligibility

State Status of Medicaid Expansion Comments

Colorado Undecided Colorado was one of six states (plus the District of Columbia) that received a Section 1115 waiver to expand Medicaid early to adults in preparation for 2014. However, the state Medicaid staff we interviewed in July noted that a decision regarding Medicaid expansion has not yet been made. The governor was asked what his state’s plans were regarding Medicaid expansion and he said, “We are evaluating that.” If it does not expand Medicaid eligibility, Colorado Medicaid will be working hard to ensure the safety-net remains intact.

Iowa Leaning toward not participating Iowa is uncertain regarding the state’s plans for expanded eligibility for its Medicaid program. On July 2, 2012, The Governor reported that he expects to opt out of the expansion. Iowa is also awaiting further federal guidance, regarding how Medicaid expansion willaffects its current eligibility groups. Iowa has questions about its ability to maintain its demonstration waivers, as they are set to expire on December 31, 2013. The expectation is those members would transition into Medicaid if Iowa participates in the expansion.

Maryland Participating Maryland noted that it is implementing Medicaid expansion, supported by the governor

B and lieutenant governor’s public statement in support of the U.S. Supreme Court ruling .

11 in which they noted, “We remain as committed as ever to moving forward.”

Massachusetts Participating Although Massachusetts has already expanded eligibility for its Medicaid and other programs for people up to 300 percent FPL in accord with health care reform legislation passed in April 2006, MassHealth staff noted that the state is implementing Medicaid expansion for shifting certain populations from other subsidized programs to Medicaid. Currently, anyone whose income is under 300 percent of the FPL in Massachusetts has access to subsidized health insurance. Given that the Medicaid minimum income threshold will go up to 133 percent of the FPL, anyone whose income is up to 133 percent of the FPL and is currently in one of Massachusetts’ other health insurance programs will be transitioned into the Medicaid state plan in 2014.

New York Participating The New York governor issued an executive order to allow for Medicaid expansion. It is a relatively small expansion for New York, which needed only to expand childless adults from 100 to 130 percent of the FPL. New York estimated that under Medicaid expansion approximately 77,000 people will become newly eligible: 15.4 percent of the five million enrolled in Medicaid. Currently, New York is working on making statutory changes that align with the new Medicaid categories. Further, the state has received a waiver from CMS to streamline Medicaid enrollment for adults.

Table B.II.2 (continued)

State Status of Medicaid Expansion Comments

Oregon Participating CMS granted Oregon a waiver to expand Medicaid eligibility before 2014 as part of its CCO transition. Oregon is already serving some of the newly eligible population under its 1115 waiver. Compared to the ACA, Oregon’s 1115 waiver allows for a more limited benefit structure. Subsequently, savings enabled Oregon to expand Medicaid eligibility to more people. Under the 1115 waiver, Oregon expanded benefits to anyone whose income was less than 100 percent of the FPL. Under the ACA, Oregon will expand further, covering anyone with an income up to 133 percent of the FPL.

Texas Not participating On July 9, 2012, the governor released a statement that Texas would not be pursuing Medicaid expansion. As of July, the state’s Health and Human Services Commission was not moving forward with Medicaid expansion. Still, ome communities are discussing expanding Medicaid coverage in some of the state's biggest counties. A county-run Medicaid expansion effort would require the consent of the Texas legislature. Federal officials would have to waive requirements that states apply the same eligibility standards statewide. Also, people living in counties that participated in the expansion would be eligible for different Medicaid rules than those living in the rest of the state.

Sources: 1. American Health Line. “Medicaid Where Each State Stands on the Medicaid Expansion.” August 28, 2012. Available at [http://ahlalerts.com/2012/07/03/medicaid-where-each-state-stands-on-the-medicaid-expansion/]. Accessed September 10, 2012, 2. Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. B . 12 3. Kaiser Family Foundation, Kaiser Commission on the Medicaid and the Uninsured. “An Overview of Recent Section 1115 Medicaid

Demonstration Waiver Activity”. May 2012b. Available at [http://www.kff.org/medicaid/upload/8318.pdf]. Accessed August 28, 2012, 4. Governor Martin O’Malley and Lt. Governor Anthony Brown. “U.S. Supreme Court Ruling on Affordable Care Act”. June 28, 2012. Available at [http://www.governor.maryland.gov/ltgovernor/pressreleases/120628.asp]. Accessed August 28, 2012, 5. The Washington Post. “Medicaid Expansion Goes Local In Texas”. August 27, 2012. Available at [http://www2.tbo.com/news/nation- world/2012/aug/27/namaino15-medicaid-expansion-goes-local-in-texas-ar-474782/]. Accessed September 6, 2012. California, Colorado, the District of Columbia, Minnesota, Missouri, New Jersey, and Washington have obtained Section 1115 waivers to expand Medicaid early to adults in preparation for 2014. ACA = Affordable Care Act; CCO = coordinated care organization; FPL = federal poverty level.

Table B.II.3. Seven State Sample: Creation of Health Insurance Exchanges

Action Toward Creating Structure of State Exchangea Exchangeb Comments

Colorado Established state Quasi-governmental Colorado has passed the legislation necessary for establishing the exchange and exchange noted that the planning and implementation of the state-based exchange is ongoing. The Board of the Colorado Health Benefit Exchange, a separate entity, will spearhead the implementation. Colorado is not currently making plans regarding either patient navigators or specifically for PLWHA.

Iowa Studying n.a. The Iowa Insurance Division is spearheading the planning of its exchange. In July, options Iowa did not have legislative authority for establishing an exchange. Iowa’s interagency work group continues to work collaboratively on the planning and designing of the exchange, while it awaits legislative action or an executive order. When the decision is made (that is, state- or federal-based), Iowa will proceed with planning for program specifics. Currently, Iowa is trying to identify the requirements of the required functions for providing consumer assistance. Iowa has not done any planning about transitioning PLWHA from RWHAP to Medicaid, but noted that good communication between the B Department of Human Services and Department of Health will be critical, as decisions . 13 are made. The Medicaid agency intends to connect with RWHAP administrators.

Maryland Established state Quasi-governmental In 2011, Maryland established its exchange board, a quasi-governmental agency. To exchange date, the exchange board has put out several RFPs to develop the exchange. Specifically, the board will contract out the creation of the infrastructure and is developing the technology required for enrollment. Maryland’s enrollment system will enable potential enrollees pto go online and enter in basic information and will then be directed to Medicaid or an private insurance based on their income level. Provider information will be preloaded and if there is a particular provider an enrollee would like to see, he or she will be able to search and choose the MCO in which that provider participates. In July, the exchange was still developing its patient navigator system, in which . navigators will help new enrollees during the initial sign-up process. Regarding PLWHA, Maryland noted that it is important that its HIV case managers are educated about the exchange. Maryland intends to ensure RWHAP case managers understand the system and that they can educate clients and provide guidance on what to look for; their role is to help enrollees pick the appropriate plan.

Table B.II.3 (continued)

Action Toward

Creating Structure of State Exchangea Exchangeb Comments

Massachusetts Established state Quasi-governmental Although Massachusetts established the Health Connector in 2006. Several aspects of exchange the Health Connector will be modified to comply with the ACA’s exchange requirements. For example, while the Health Connector today provides premium subsidies to individuals and families up to 300 percent FPL, under the ACA, the Health Connector will provide premium subsidies to individuals and families up to 400 percent FPL in the form of advance tax credits. Massachusetts will continue to work with advocate groups in modifying their state’s exchange. The state facilitates a monthly/quarterly learning series and runs training forums whereby it teaches outreach workers how to enroll people in a way that meets their clinical needs. Massachusetts has outreach workers whose primary role is to make sure people have insurance and ensure that they understand the various programmatic rules. State staff work with outpatient clinics in hospitals and community health centers to update staff regarding new tools or program changes so that they are able to serve their population.

New York Established Operated by state The Exchange will be housed in the Health Department. New York intends to launch state exchange its marketing strategy during summer 2013 to make people aware of the exchange and the various options. New York will allow in-person, telephone, mail, or online enrollment. New York awaits additional federal guidance in order to finish its B .

14 preparations to create a seamless enrollment for those eligible

New York noted that under the ACA, navigators will assist new enrollees in indentifying an appropriate plan. New York does have community partners that hopefully will help with navigation. New York hopes to work toward universal navigation system in the future, in which navigators will respond to general questions and they will then triage HIV questions to more knowledgeable personnel.

Oregon Established state Quasi-governmental Oregon has its exchange, staff, and structure in place. In addition, the exchange’s exchange computer system, applications, and web portal are being built. Oregon will be ready to open enrollment n September 2013 and “go live” in January 2014. Care Assist provides coverage for PLWHA in Oregon and already has case mangers/case workers in place. Oregon will work with clients to help them select and enroll in an appropriate plan.

Table B.II.3 (continued)

Action Toward

Creating Structure of State Exchangea Exchangeb Comments On July 9, 2012, Texas the governor released a statement indicating that Texas will Texas Decision not to n.a. not implement a state exchange. A federally-run exchange is anticipated to be in create state place in 2014, but the timing is somewhat uncertain. Although the state may exchange indefinitely use a federal exchange, from Medicaid’s perspective, it would like to retain the ability to facilitate the Medicaid and CHIP eligibility determinations. Texas has several systems in place that will help PLWHA transition under the ACA. Those PLWHA in managed care will have an enrollment broker who will assist enrollees in identifying the right health plan with an appropriate provider. Currently, new enrollees are paired with a broker who advises individuals regarding available plans and networks. In addition, the state’s MCOs have a service coordination function whereby they work with an enrollee to help identify any additional resources that might be available. Those enrolled in Star Plus are assigned a “super case worker” who works with patients to schedule appointments and navigate the health care system. Finally, RWHAP clients are assigned a case manger. Under the ACA, Texas will work to educate brokers regarding changes in eligibility criteria, when appropriate.

Source: 1.Kaiser Family Foundation. “State Health Data: Health Reform in the United States.” Washington, DC: Kaiser Family Foundation, August 2012b. Available at [http://www.statehealthfacts.org/index.jsp]. Accessed September 14, 2012. 2. Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. B

. a 15 Action towards creating an exchange as of August 1, 2012.

b States have the option of establishing the exchange as part of an existing state agency or office (operated by the state), as an independent public agency (quasi-governmental), or as a nonprofit entity (nonprofit).Quasi-governmental exchanges are supported by the stategovernment but managed privately. ACA = Affordable Care Act; MCO = managed care organization; n.a. = not applicable; RFP = request for proposal; PLWHA = people living with HIV/AIDS.

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Table B.III.1. Seven State Sample: Essential Health Benefits and Benchmark Benefits

Workgroup on Assessed Essential Heath Benchmark Plan Recommended State Benefitsa Options Benchmark Plan Comments

Colorado Yes Yes Yes In Colorado, defining EHBs for plans in the exchange is under the purview of the exchange board. The exchange board has held stakeholder meetings and collected public comment on EHBs. Colorado has made a preliminary recommendation regarding its EHB benchmark plan and is opting to use Colorado’s largest small group plan, Kaiser. As of July , Colorado had not made a decision regarding a Medicaid benchmark benefit package given the uncertainty of Medicaid expansion in their state.

Iowa Yes No No EHBs will be determined based on currently available plans within Iowa. As of July, Iowa had not made a decision regarding a Medicaid benchmark benefit package given the uncertainty of Medicaid expansion in their state. Iowa is trying to identify what the Medicaid benchmark plan would be, should it expand

B Medicaid. . 17

Maryland Yes Yes No As of July 2012, Maryland has not determined its exchange benchmark or its EHBs, but notes that the Medicaid program intends to offer its current benefit package to newly eligible enrollees.

Massachusetts Yes Yes No Massachusetts is reviewing the benchmark benefits for QHPs that will be offered through the Health Connector. Massachusetts has not yet made a final decision regarding the Medicaid benchmark. It is considering the Essential Health Benefits option chosen by the state and is also looking at what is currently offered in its MassHealth standard benefits package, which is its most comprehensive plan. For all individuals who will move into the Medicaid benchmark plan, Massachusetts is trying to ensure that people will have access to the services they currently receive.

New York Yes Yes No New York is reviewing various options for its benchmark and EHB plans. New York planned to select their benchmark plan by September 29, 2012.

Table B.III.1 (continued)

Workgroup on Assessed

Essential Heath Benchmark Plan Recommended State Benefitsa Options Benchmark Plan Comments

Oregon Yes Yes Yes Oregon has made a preliminary recommendation regarding its EHB benchmark plan. HIV/AIDS-specific care is not defined in the state’s EHBs. Oregon believes the package is broad enough to serve anyone with any disease in the state, including HIV/AIDS.

Texas Yes No No Determination of the EHBs and the benchmark plan in the exchange is under the purview of the Texas Department of Insurance. At this time, Texas is not moving forward with benchmark benefits for a Medicaid expansion.

Sources: 1. National Academy for State Health Policy. “State Progress on Essential Health Benefits.” State Reforum, September 13, 2012. Available at [http://www.statereforum.org/state-progress-on-essential-health-benefits]. Accessed September 13, 2012.

2. Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. a CMS established September 4, 2012, as the submission deadline for insurers that are eligible to be the benchmark plan for EHBs. Largely, states will choose a benchmark plan and that benchmark plan will define the EHBs. If the selected benchmark plan does not include one of the 10 elements required for EHBs, a state would have to supplement its plan in some way. EHB = essential health benefit. B . 18

Table B.IV.1. Seven State Sample: Integrated Models of Care

Exemplary/ Innovative State Models Comments

Colorado Yes Colorado set up Regional Care Collaborative Organizations as part of its Accountable Care Collaborative Program (an ACO/PCCM hybrid). The state will be testing payment reforms through that process.

Iowa Yes Iowa is interested in the ACO model and is reviewing recently released CMS guidance on paths that a state may take to develop an ACO model. To date, several non-Medicaid ACO models have been implemented in Iowa. There is a shared savings program whose largest private insurer has established three or four ACO programs. Also, Iowa will provide health home services to enrollees with chronic conditions (not including HIV/AIDS). To enroll within Medicaid, the health home entities must meet Iowa’s various quality standards and qualifications, including having an electronic health record system and using population health management tools. CMS approved Iowa’s health home state plan amendment with an effective start date of July 1, 2012. Iowa is continuously enrolling providers and hopes to build the network statewide. Finally, Iowa has a relatively robust PCCM program.

Maryland No As of July 2012, Maryland had a state PCMH program led by the Maryland Health Care Commission; it is not HIV specific. In addition, Maryland is developing a chronic disease health home program for substance abuse treatment. Maryland’s chronic disease health home program will be implemented as a state plan option. A phased

B rollout is possible, the implementation strategy will depend somewhat on provider capacity. Currently, the state .

19 plan has budgeted the program to start in January 2013.

Massachusetts Yes Massachusetts created a complex care program that is a requirement for all MCOs serving the under 65 non-dual eligible program. In April 2011 Massachusetts also implemented a PCMH initiative with 47 medical homes statewide. Although PLWHA are treated in various medical homes, this initiative is not HIVspecific. Massachusetts’ payment reform initiatives seek to reduce the use of FFS payment arrangements for medical homes. The first payment reform will be the Primary Care Payment Reform, which aims to improve access to care, patient experience, quality and efficiency though care management and care coordination, and integrate behavioral health services. Massachusetts will build on the work done in the existing PCMH initiative in scaling up this program, with a a rollout planned for July 2013.

New York Yes New York’s innovative medical models of care use enhanced provider reimbursement rates. New York has had a continuously evolving system of care, and it is presently participating in the development of health homes for HIV/AIDS and other chronic conditions. New York’s HIV SNP covers special services for PLWHA. Currently, New York’s program model has a targeted managed care medical home for PLWHA.

Oregon Yes Oregon is transitioning its model of care to align with the ACA. Previously, Oregon’s MCOs and mental health organizations (both capitated) functioned separately. Starting August 1, 2012, they merged into a CCO that will combine physical health, mental health, dental health, and long-term care. Oregon pays CCOs a flat fee per member/per month, and the CCOs must meet specific requirements regarding quality.

Table B.IV.1. (continued)

Exemplary/

Innovative State Models Comments

Texas No Texas is participating in a 14-month ACO Learning Collaborative with six other states to determine what implementing an ACO model might look like in Texas. ACOs will build off the medical home model to make sure that care is coordinated and that there is some type of financial incentive for quality care. Texas believes this type of coordinated care model will complement the regional model of care that is currently operating in Texas.

Source: Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. ACA = Affordable Care Act; ACO = accountable care organization; CMMI = Centers for Medicare and Medicaid Innovation; CMS = Centers for Medicare & Medicaid Services; CCO = coordinated care organization; MCO = managed care organization; PCCM = primary care case management; PCMH = patient centered medical home; PCP = primary care physician; PLWHA = people living with HIV/AIDS; SNP = special needs plan.

B . 20

Table B.IV.2. Seven State Sample: Provider Capacity Issues

Concerns Regarding Provider State Capacity Comments

Colorado Unknown Colorado’s state Medicaid agency does not have much direct contact with RWHAP grantees. Regional Care Collaborative Organizations (CCOs) are the entities responsible for knowing the population within their region. Effectively, they will coordinate care and ensure that there are appropriate providers for PLWHA in the state’s regional networks.

Iowa Unknown Iowa Medicaid does not have specialists who identify themselves as HIV/AIDS providers. It does have the general gamut of providers enrolled in the Medicaid program, including infectious disease specialists. Iowa Medicaid believes that the Iowa Health Department is more concerned about the quality of services that are needed for a specialty population and less concerned about provider capacity if PLWHA are transitioned over into Medicaid in 2014.

Maryland No Maryland intends to provide the same benefit package for both existing enrollees and the newly eligible. Thus, it should be a fairly seamless transition in Maryland for MCOs and providers. In Maryland, MCOs must be able to serve special needs populations, which include PLWHA under Medicaid regulations.

B Further, many RWHAP providers are enrolled in at least one MCO. . 21 Maryland has had some discussion regarding Medicaid providers who are not HIV specialists. If Maryland

identified an “unqualified” HIV provider, it would ensure that the provider received training through AETCs. Maryland noted that if RWHAP funding were to be eliminated and/or scaled down, the AETCs may be more limited. Thus, their ability to provide training may be more limited. Maryland does anticipate some capacity issues among community-based organizations that lack the infrastructure needed to bill third parties under the ACA. Maryland expects that some community-based organizations may fall away, whereas others will build themselves up and become stronger. It is also possible that some community-based organizations will merge. Maryland applied for a grant to provide technical assistance to help community-based organizations build their capacity as it relates to the ACA. First, Maryland will assess their billing capacity (that is, their financial management and their accounting systems in place) and will determine whether community-based organizations have the financial resources to effectively manage this transition to the ACA.

Massachusetts No Massachusetts does not believe that HIV providers will opt out of Medicaid in 2014. In Massachusetts, everyone with an income up to 133 percent of the FPL with HIV/AIDS is already eligible for MassHealth. Thus, the state does not anticipate a large influx of that population into care. Currently, most providers, including infectious disease specialists, are Medicaid providers. Because the state has such a culture of insurance, most Ryan White providers who could provide Medicaid payable services are likely already enrolled. In addition, Massachusetts has also not heard concerns regarding unqualified HIV providers from its Ryan White Planning Council. The state has a robust provider supply statewide and has a robust mechanism for member complaints if a member experiences difficulty accessing an appropriate provider.

Table B.IV.2. (continued)

Concerns

Regarding Provider State Capacity Comments

New York Minimal Although most providers are currently in networks, New York believes it will need more physicians who are knowledgeable about HIV care to treat PLWHA, especially in rural areas. In New York, many of the FQHCs for the migrant, poor, and undocumented populations do not provide HIV care. Among those that do, some only provide HIV testing because HIV care is too expensive or there is a lack of capacity for these centers. More effort is needed to increase HIV workforce and capacity at FQHCs that serve these vulnerable populations.

Oregon Unknown CCOs are responsible for delivering health care and deciding who is appropriate to provide care. Oregon expects health care to be delivered, and it is up to CCOs to find the appropriate provider to treat the patient. Oregon monitors various indicators to ensure CCOs are providing quality care, including the number of ER visits, mortality rates, and CD-4 viral loads. Those indicators, among others, are detailed in CCOs’ quality assurance plans.

Texas Yes Managed care HMOs in Texas serve a large portion of PLWHA in the state. MCOs have requirements regarding access to care and ensuring there is an adequate network of providers. The ACA likely will not impact how Texas delivers managed care services or ensures provider access. However, HIV-experienced clinicians are beginning to retire or close practices, and providers report difficulty in recruiting new physicians. Many of the HIV-focused providers report being at capacity for primary care, and express B difficulty getting timely referral to specialists for their clients. Providers have also expressed concern . 22 about the ability of their organizations and practices to maintain financial stability if RWHAP funding is withdrawn even with robust Medicaid expansion.

Source: Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. ACA = Affordable Care Act; AETC = AIDS Education and Training Center; CCO = coordinated care organization; ER = emergency room; FPL = federal poverty level; FQHC = federally qualified health center; HMO = health maintenance organization; MCO = managed care organization; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program.

Table B.IV.3. Seven State Sample: Provider Reimbursement Rates

State Provider Impact Comments

Colorado Unknown Colorado noted that low reimbursement from Medicaid is always an issue and not specific to HIV/AIDS care. Currently, Colorado is paying around 75 percent of Medicare. If necessary, Colorado will address any concerns enrollees may have regarding access to providers.

Iowa Unknown NA Maryland Minimal Maryland intends to expand the enhanced reimbursement to both PCPs and specialists for evaluation and management coded visits in calendar years 2013 and 2014. Many HIV/AIDS providers in Maryland are hospital- based providers and the Health Services Cost Review Commission sets rates for inpatient and outpatient services. Medicaid pays 94 percent of these regulated hospital charges. Thus, many HIV/AIDS services are reimbursed at a high rate.

Massachusetts Unknown Like all states, Massachusetts struggles with the issue of reimbursement for Medicaid providers. To encourage participation, Massachusetts tries to make its enrollment as easy as possible.

New York Minimal As of July 2012, the effect of the enhanced reimbursement under the ACA was unknown. There is less rating setting by the state as PLWHA have been enrolled in Medicaid managed care. In managed care negotiation, reimbursement for providers varies based on the negotiation skill of the provider and how much the plan will B

. pay for services. When New York was developing HIV/AIDS SNPs, it developed the HIV/AIDS reimbursements via 23 a mechanism that recognized that appropriate reimbursement was needed to maintain quality service and providers. Thus far, it has been able to implement a successful level of reimbursement.

Oregon Unknown Oregon pays CCOs a per member/per month fee. Oregon does not carve out higher reimbursement rates for HIV providers.

Texas Unknown As of July 2012, HMOs had the flexibility to contract directly with providers and, subsequently, the rates that they pay to those providers. Under the traditional fee-for-service model, reimbursement is a flat rate and not specific to HIV/AIDS providers. Texas understands that the provider rate increase under the ACA is still required and PCPs will need to be reimbursed at parity with Medicare for certain services in calendar years 2013 and 2014. However, Texas was awaiting further clarification from CMS at the time of our interviews.

Source: Interviews with state Medicaid programs conducted by Mathematica Policy Research, 2012. ACA = Affordable Care Act; CCO = coordinated care organization; CMS = Centers for Medicare & Medicaid Services; HMO = health maintenance organization; MCO = managed care organization; NA = not available; PCP = primary care physician; PLWHA = people living with HIV/AIDS; SNP = special needs plan.

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APPENDIX C

INSURANCE ELIGIBILITY AND EXCHANGES

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.1. Guaranteed Issue and Pre- Existing Condition Insurance Plan*

Issue Information

Status Before • Private insurers are often denied coverage for individuals with pre-existing ACA conditions or charged significantly higher premiums (GAO March 2011). • High risk pools are open to enrollment in 34 states, charging 125 to 200 percent of standard market premiums, with waiting periods for coverage of pre-existing conditions.

ACA- Related • ACA prohibits denial of coverage based on pre-existing conditions [P.L. 111-148 & Change 111-152 SEC. 1201] and imposition of annual limits [P.L. 111-148 & 111-152 SEC. 1001] on coverage. This is currently in effect for children under age 19 and will go into effect for all individuals in 2014. • ACA created a temporary federal high-risk pool for individuals with pre-existing conditions as a bridge to coverage until 2014 [P.L. 111-148 & 111-152 SEC. 1101]. • Premiums for the federal high-risk pool are at standard market rates [P.L. 111-148 & 111-152 SEC. 1101]. • PCIP coverage is available to U.S. citizens, nationals, and legal immigrants who have been without creditable insurance coverage for at least six months [P.L. 111- 148 & 111-152 SEC. 1101]. • PCIPs will run until December 31, 2013, at which time enrollees can obtain insurance coverage under health insurance exchanges [P.L. 111-148 & 111-152 SEC. 1101] (GAO July 2011). • Not all states have chosen to include HIV/AIDS as a presumptively eligible pre- existing condition, though federally administered programs do not maintain a list (Harvard Law School Health Law and Policy Clinic November 2010). • States can limit number of slots available in PCIPs and can prohibit ADAP clients from enrolling in the program (NASTAD October 2011).

Implementation • 27 states run their own PCIPs; 23 states and the District of Columbia allow DHHS Status of Change to administer their PCIPs. • 34 states operate high-risk pools that predate the PCIP program. These states are not allowed to reduce their current high-risk pools as a result of the PCIP. PCIP premiums are 10 to 50 percent lower than current rates in the state high-risk pools. People in existing high-risk pools would have to drop out and be uninsured for six months to qualify for coverage under PCIP (Cauchi November 2011). • Enrollment in PCIPs has been lower than expected: 77,877 as of June 30, 2012 (Kaiser Family Foundation August 2012b). • Almost all state and federally run PCIPs limit coverage for some benefits (such as skilled nursing and mental health and substance abuse services) (GAO July 2011). • Challenges with ADAP-PCIP coordination include some PCIPs will not accept third- party payment of premiums, most PCIPs do not include providers with HIV-specific expertise, and most PLWHA served by ADAPs have not been without coverage for six months or longer (NASTAD May 2011; Pund September 2011). • States that require insurers to accept all applications (Maine, Massachusetts, New Jersey, New York, and Vermont) have experienced the greatest challenges in securing a portion of the $5 billion in federal funding for PCIPs. In these states, the federal government offered other eligibility criteria: coverage that is at least twice the standard rate (Vermont, Massachusetts); having a health condition that comports with a state-developed list (Maine, New York); and being offered a plan with a pre-existing condition exclusion (New Jersey) (RWJF February 2011).

C.3 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.1. (continued)

Issue Information

Implementation • In December 2011, the federal government announced the availability of additional Status of Change funds for the PCIP programs in California and New Hampshire, as well as the (continued) allowance to roll over funds from 2011 into 2012 (Galewitz and Gold October 2011). • Washington has indicated that it will allow PCIP enrollees to stay in the program after 2014 and expects PLWHA to remain in the PCIP, rather than enroll in a qualified health plan, due to lower cost-sharing in the PCIP.

Implications for • PLWHA previously denied insurance coverage due to their HIV-positive status can RWHAP Grantees, receive coverage through the PCIPs if uninsured for at least six months. Providers, • PLWHA covered under existing state high-risk pools who wish to receive lower Clients, and premiums, copayments, and deductibles under the federal program would have to PLWHA drop coverage and remain uninsured for at least six months to enroll in a PCIP. • Some PLWHA who enroll in the PCIPs may continue to have unmet health needs for services with limited coverage. • PLWHA who might be eligible for creditable coverage or other programs at lower cost may enroll in a PCIP (Popper March 2011). • Enrolling PLWHA in a PCIP would enable RWHAP grantees to shift funds to provide more cost-sharing and other wrap-around services. • Although DHHS has been monitoring cost-shifting by third-party payers, receipt of medical care from Ryan White clinics does not disqualify as insurance coverage for PCIP eligibility (Ryan White programs are grants, not insurance coverage, so do not count as creditable coverage) (HAB December 2010).

ACA = Affordable Care Act; ADAP = AIDS Drug Assistance Program; DHHS = U.S. Department of Health and Human Services; PCIP = pre-existing condition insurance plan; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

C.4 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.2. Individual Mandate and Exemptions*

Status Before • Individuals are not required to have health insurance. ACA • In 2010, 48.6 million people were uninsured (Cohen et al. June 2011).

ACA- Related • Beginning in January 1, 2014, most individuals will be required to have health Change insurance for themselves and their dependents [P.L. 111-148 & 111-152 SEC. 1501] or pay a penalty for each month of noncompliance. • The amount of the penalty is the greater of either (1) a percentage of the amount that an individual’s household income exceeds the filing threshold (a combination of personal and standard deductions, known as the applicable income amount), set at 1 percent in 2014, 2 percent in 2015, and 2.5 percent thereafter; or (2) a flat dollar amount assessed for taxpayers and their dependents (set at $95 in 2014, $325 in 2015, and $695 thereafter, with inflation adjustments). The household penalty is further capped at a dollar figure based on the cost of a bronze-level health insurance policy. [P.L. 111-148 & 111-152 SEC. 1501] (Mulvey and Chaikind July 2012). • Individuals exempt from the mandate to purchase insurance include those who have religious objections, those in health care-sharing ministries, people who do not meet citizenship requirements, members of Native American tribes, and people who are incarcerated. Other groups of people are exempt from paying the penalty for lack of coverage, including those whose annual premiums would exceed 8 percent of their household adjusted gross income, people who receive hardship waivers, people with incomes below the tax filing threshold, and people who lacked insurance for fewer than three months in a given year (Kaiser Family Foundation July 2012c; Mulvey and Chaikind July 2012) [P.L. 111-148 & 111-152 SEC. 1501].

Implementation • The change will take effect nationally on January 1, 2014. Status of • The constitutionality of the mandate was confirmed by the Supreme Court in rulings Change issued on June 28, 2012.

Implications • PLWHA who are currently uninsured but fall under the individual mandate to have for RWHAP insurance will require assistance in identifying the best plan to meet their medical Grantees, needs. Providers, • Some PLWHA who fall under exempted categories (for example, those who do not Clients, and meet citizenship requirements) will continue to require assistance from RWHAP for PLWHA medical care.

ACA = Affordable Care Act; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.3. Expansion of Medicaid Eligibility*

Status • Among PLWHA who are receiving medical care, an estimated 24 to 30 percent are Before ACA uninsured (Blair et al. September 2011; Crowley and Kates September 2012). • In 2011, Medicaid covered from 200,000 to 240,000 PLWHA (Kates October 2011). • Each state sets its own income thresholds and asset tests to determine eligibility for its Medicaid program. • National minimum thresholds exist for certain categories of Medicaid eligibles (for example, children and pregnant women). • States use mandatory (for example, low-income families with children) and optional (for example, the medically needy) groups to determine categorical eligibility for Medicaid. • States are required to cover parents only up to the state’s 1996 welfare levels; many states are well below the FPL. • Most states exclude nondisabled, childless adults from Medicaid eligibility, except in cases in which the state has implemented an 1115 Medicaid waiver to provide such coverage (seven states currently have such waivers). • In most states, single, childless adults and some parents cannot qualify for Medicaid eligibility until they meet disability criteria (for example, PLWHA usually become eligible for Medicaid after receiving an AIDS diagnosis). • States can choose to cover PLWHA through use of an 1115 Demonstration Waiver, which expands coverage to groups not included in the basic state Medicaid plan.

ACA- Related • National standard sets Medicaid eligibility for all states to expand Medicaid to newly Change eligible low-income parents and childless adults with incomes up to 133 percent of the FPL [P.L. 111-148 & 111-152 SEC. 2001]. • In making eligibility determinations, states are required to reduce countable income by 5percent of the FPL, effectively making the income threshold 138 percent of the FPL [P.L. 111-148 & 111-152 SEC. 2002] (Kaiser Commission on Medicaid and the Uninsured June 2011). • Requirement of a disability determination for coverage of PLWHA is removed [P.L. 111-148 & 111-152 SEC. 2001].

Implemen- • The change will take effect nationally on January 1, 2014. tation Status • States had the option to phase in Medicaid expansion using the state plan of Change amendment process starting on April 1, 2010 (CMS April 2010). As of May 2012, six states (California, Colorado, Minnesota, Missouri, New Jersey, and Washington) and the District of Columbia had received federal approval for early expansion initiatives and Connecticut received approval of a new state option to cover adults up to 133 percent of the FPL (Kaiser Commission on the Medicaid and the Uninsured May 2012a) • Although a number of states have had 1115 waiver programs in the past to expand Medicaid coverage for PLWHA, most have ended their waivers, such as the District of Columbia, or incorporated their HIV-specific waivers into broader waiver programs. • The requirement that states implement the expansion or risk losing federal funding for their state’s entire Medicaid program was struck done by the U.S. Supreme Court in its June 28, 2012, ruling (Perkins July 2012). • The Congressional Budget Office estimates that 96 percent of the cost for Medicaid expansion will be covered by the federal government over the first 10 years (CBO March 2010). From 2014 to 2016, the federal government will cover 100 percent of the costs for covering adults who will be newly eligible for Medicaid (Kaiser Family Foundation May 2010). States will have to pick up some of these costs incrementally, but the federal government’s share will remain at 90 percent in 2020 and beyond. • As of August 2012, 6 states have said they will not expand their Medicaid programs and another 5 have said they are leaning toward not expanding their programs. At the same time, 10 states have made a commitment to the expansion and to the ACA more broadly and another 3 states are leaning toward expansion (American Health Line Alerts September 2012).

C.7 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.3. (continued)

Implications • The increase in the populations covered by Medicaid will reduce the number of for RWHAP PLWHA who currently uninsured or who receive private insurance coverage. State- Grantees, specific eligibility expansion policies will complicate national- and state-level RWHAP Providers, grant planning, which will depend, in part, on how many PWLHA become eligible for Clients, and Medicaid in each state. PLWHA • The early expansion option allows states to receive federal matching funds. States that already expanded but are using only state funds would have free state dollars that could be used for expanded coverage for vulnerable populations, such as PLWHA (National Health Care for the Homeless Council July 2011). • Elimination of categorical eligibility rules (and elimination of the Medicaid disability requirement for low-income individuals) will significantly expand the number of PLWHA eligible to enroll in Medicaid, reducing demand for ADAP and easing ADAP waiting lists. • Receipt of health care soon after HIV diagnosis and ART drugs through Medicaid could reduce the number of PLWHA progressing to AIDS, thus reducing the number of PLWHA experiencing costly hospitalizations and HIV transmission to uninfected individuals.

ACA = Affordable Care Act; ADAP = AIDS Drug Assistance Program; ART = anti-retro viral therapy; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

C.8 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.4. Creation of Exchanges and Enrollment Processes*

Status Before • States generally do little to coordinate health care coverage under public health ACA benefits (for example, Medicaid and CHIP) and other sources of care (for example, RWHAP).

ACA- Related • The ACA requires a seamless eligibility and enrollment process between and Change among insurance affordability programs and qualified health plans [P.L. 111-148 & 111-152 SEC. 1413; 2201]. • Medicaid-eligible individuals may enroll in private coverage through an exchange, but they will not be eligible for tax credits if they do so. • The ACA requires that health plans operating in the exchanges contract with safety net providers (including RWHAP clinics) • The ACA requirement that exchanges help clients enroll in plans that include current providers helps to ensure continuity of care.

Implementation • States coordinate with ESI coverage (if it meets minimum essential coverage and Status of affordability tests) and states often use premium assistance to help individuals with Change access to ESI purchase the same. • Some states also coordinate eligibility and enrollment for Medicaid with the Supplemental Nutrition Assistance Program and cash assistance. • California was the first state to enact legislation creating a health insurance exchange under healthcare reform (Commonwealth Fund February/March 2011). • As of August 1, 2012, 15 states (California, Colorado, Connecticut, Hawaii, Kentucky, Maryland, Massachusetts, Nevada, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and West Virginia) and the District of Columbia had passed legislation to establish a state health exchange; 3 (Arkansas, Delaware, and Illinois) were in the process of planning for a partnership-based exchange; and 7 (Alaska, Florida, Louisiana, Maine, New Hampshire, South Carolina, and Texas) had decided not to create a state exchange (paving the way for establishment of a federal exchange in the state); no decision had yet been made in the remaining 25 states (Kaiser Family Foundation August 2012b). • Implementation of eligibility and enrollment processes will need to address the possibility of “churning” beneficiaries between Medicaid and exchange-based coverage (as income and, thereby, Medicaid eligibility fluctuates) (NAMD October 2011). • States have begun considering ways to improve navigation and streamline enrollment.

Implications • Enrollment problems might cause some PLWHA to lose access to health care and for RWHAP medications during the transition and enrollment processes. Grantees, • Churning of beneficiaries with income changes could lead to lapses in coverage Providers, and gaps in adherence to critical treatments (for example, prescription Clients, and medications). PLWHA

ACA = Affordable Care Act; ADAP = AIDS Drug Assistance Program; ESI = employer-sponsored insurance; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table C.5. Citizenship Requirements*

Status Before • Under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ACA (P.L. 104-193), only citizens and legal residents who have been present in the country for five years or longer are able to receive public benefits (except children and pregnant women, in accord with the Children’s Health Insurance Program Reauthorization Act). • Some of those who do not quality for public benefits due to citizenship requirements receive insurance benefits through private employer plans. • Some states use state-only dollars to provide health insurance coverage to these populations.

ACA- Related • Undocumented immigrants continue to be barred from public benefits; they are Change exempt from the individual mandate [P.L. 111-148 & 111-152 SEC. 1501] and may not purchase insurance in the exchanges [P.L. 111-148 & 111-152 SEC 1312]. • Legal residents may not qualify for Medicaid during the first five years they are present, but may purchase insurance coverage in the exchanges and can qualify for subsidies [P.L. 111-148 & 111-152 SEC. 1312].

Implementation • Availability of exchange-purchased coverage will take place on January 1, 2014. Status of Change

Implications • Citizenship requirements will create classes of people who might be living with HIV for RWHAP but are unable to obtain health insurance coverage. Grantees, • Other groups who might remain uninsured after implementation of the ACA include Providers, mobile populations, those who are homeless, and those living in poverty, all of whom Clients, and tend to have higher rates of HIV infection and lower rates of HIV care access and use. PLWHA These groups are more likely to seek care after acquiring an AIDS-defining illness and are therefore more likely to need intensive health services (Weiwel et al. February 2009).

ACA = Affordable Care Act; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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APPENDIX D

INSURANCE BENEFITS AND COSTS

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Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.1. Essential Health Benefits and Benchmark Benefits*

Issue Information

Status Before • Health insurance benefits offered through state Medicaid programs and private ACA insurance companies vary.

• Most benefit mandates for private insurance plans are established at the state level.

• States cannot mandate benefits for self-insured employer plans, which include about half of all covered workers. • Under the DRA of 2005, states can vary the Medicaid benefit packages available to groups of beneficiaries and establish “benchmark” packages that do not provide all of the benefits of standard Medicaid coverage (Solomon September 2006). • Benchmark coverage includes (1) health insurance coverage equivalent to the

Federal Employees Health Benefits Program; (2) state employee coverage; (3) the HMO plan with the largest insured commercial, non-Medicaid enrollment in the

state; or (4) other coverage that the secretary of DHHS determines provides appropriate coverage for the proposed population.

• Some groups of beneficiaries were exempted from mandatory enrollment in

benchmark plans (e.g., dual eligibles, pregnant women, people with disabilities), but states are allowed to use an opt-out option, whereby these beneficiaries are enrolled

in a benchmark plan with the option to change.

ACA- Related • 10 benefit categories are required: ambulatory patient services; emergency services;

Change hospitalizations; maternity and newborn care; mental health and substance use disorder services (including behavioral health treatment); prescription drugs;

rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services,

including oral and vision care [P.L. 111-148 & 111-152 SEC. 1302].

• EHBs must be offered by qualified health plans and individual and small-group plans (100 employees or fewer) [P.L. 111-148 & 111-152 SEC. 1302] (Rosenbaum and

Hayes October 2011; National Health Council 2010). • Standard Medicaid may offer more or fewer benefits and services than EHB (and

covers long-term care and home care services, which are not covered under EHB)— Research Policy Mathematica for example, rehabilitative and habilitative services are an optional benefit under standard Medicaid but are included under EHB [P.L. 111-148 & 111-152 SEC. 1302]. • Benchmark benefits are defined in the DRA. In addition, benchmark benefits for newly eligible beneficiaries must be no less than EHBs plus non-emergency medical transportation, family planning, and EPSDT for people up to age 21 [P.L. 111-148 & 111-152 SEC. 2001]. • Medicaid benchmark coverage must include EHB [P.L. 111-148 & 111-152 SEC. 2001].

• All or most newly eligible beneficiaries must be enrolled in Medicaid benchmark benefits. Newly eligible beneficiaries include all childless adults and parents above the state’s 1996 welfare level. States receive enhanced FMAP for newly eligible beneficiaries [P.L. 111-148 & 111-152 SEC. 2001]. • Ultimately, the benchmark benefit for newly eligibles must meet the above requirements and be approved by the secretary [P.L. 111-148 & 111-152 SEC. 1302].

D.3 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.1 (continued)

Issue Information

Implementation • The change goes into effect nationally on January 1, 2014. Status of • DHHS issued guidance giving states the flexibility to establish EHBs in their state Change until at least 2016. The EHB must be linked to one of the reference plans listed in the guidance, with the default plan being the largest plan by enrollment in the state’s small-group market (HealthCare.gov January 2012). • Benefits and services included in the benchmark health insurance plan selected by the state would be the essential health benefits package (HealthCare.gov January 2012). • State options for a benchmark plan include one of the three largest (as determined by enrollment numbers) small-group plans, state employee health plans, or federal employee health plan options, or the largest HMO plan offered in the state’s commercial market (HealthCare.gov January 2012). • If states choose not to select a benchmark, DHHS proposes that the default benchmark be the small-group plan with the largest enrollment in the state (HealthCare.gov January 2012). • Some populations are exempt from the benchmark (for example, the medically frail must receive standard Medicaid) and do not need a disability determination if the rules under the DRA apply; it is unclear whether these rules apply to newly eligible Medicaid beneficiaries under the expansion. • Eligibility determinations will be based on the new MAGI calculation—those found eligible under new adult Medicaid expansion category will be ineligible for evaluation for other coverage categories and would be enrolled in benchmark plan (Fitzpatrick October 2011). • Mental health and substance use services offered must be on parity with medical/surgical benefits, as defined by the Mental Health Parity and Addictions Equity Act of 2008. • Allowing states to define essential benefits using a benchmark approach will result Implications in variation in specific services covered from state to state. for RWHAP Grantees, • Plans that provide services defined under EHB are subject to the mental health parity Providers, law and may offer greater access to behavioral health and substance use treatments Clients, and for PLWHA than has been the case under standard Medicaid and many private plans. PLWHA Improved coverage of these services may allow the RWHAP to redirect its behavioral health funding to alternative support services; however, because states have broad flexibility to define EHB, it is currently unclear to what extent, and how uniformly across states, behavioral health care will be covered—RWHAP funds may still be an important source of these services after implementation of the ACA. • With more people receiving medical services and prescription drug coverage under Medicaid, RWHAP may be able to shift resources and funding from health insurance premium assistance and ADAP to other services. • FFS Medicaid provides greater access to long-term care services than do benchmark plans, which may be desirable for some PLWHA. • States can include additional benefits in benchmark-equivalent plans if services would be included in benchmark plans or could be covered under standard Medicaid; however, it is difficult to identify the implications because states have so many options and considerable flexibility in designing their EHB and benchmark benefit and also because additional CMS guidance is needed.

ACA = Affordable Care Act; ADAP = AIDS Drug Assistance Program; CMS = Centers for Medicare & Medicaid Services; DHHS = U.S. Department of Health and Human Services; DRA = Deficit Reduction Act; EHB = essential health benefit; EPSDT = early periodic screening, diagnosis, and treatment; FFS = fee for service; HMO = health maintenance organization; FMAP = federal medical assistance percentage; MAGI = Modified Adjusted Gross Income; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

D.4 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.2. Basic Health Plan Option and Private Insurance Subsidies*

Status Before • Individuals living above the income eligibility thresholds for Medicaid buy ACA individual insurance without government assistance; some approach a state high-risk pool (if available; they may be subject to a waiting period for coverage of preexisting conditions), and many remain uninsured. • In 2010, 48.6 million people were uninsured (Cohen et al. June 2011).

ACA- Related • Individuals with incomes between 100 percent and 400 percent of FPL (if Change ineligible for Medicaid) are eligible for refundable [P.L. 111-148 & 111-152 SEC. 1401] and “advanceable” tax credits [P.L. 111-148 & 111-152 SEC. 1412] (i.e., the federal government pays subsidies monthly directly to the insurer) to offset the cost of insurance premiums purchased through health insurance exchanges (Kaiser Family Foundation 2010b). • To be eligible for APTCs/CSRs, individuals must meet the following requirements: (1) be a citizen or a legal immigrant, (2) not be incarcerated, and (3) not have access to “affordable minimum essential coverage” (including the Veterans’ Administration, Medicaid, and employer-sponsored insurance) [P.L. 111-148 & 111-152 SEC. 1411]. • APTCs/CSRs are available only when coverage is secured through a qualified health plan offered in the exchange. • People receiving “unaffordable” employer-sponsored coverage (plans that do not have an actuarial value of at least 60 percent of the person’s share, or the premium is greater than 9.8 percent of the person’s income) are also eligible to purchase subsidized coverage on the exchanges [P.L. 111-148 & 111-152 SEC. 1401] (Kaiser Family Foundation April 2010). • Premium credits are tied to the second-lowest-cost silver plan (a plan that provides essential benefits and has an actuarial value of 70 percent) and are set on a sliding income scale; individuals can purchase whatever coverage is available [P.L. 111-148 & 111-152. SEC 1401] (Kaiser Family Foundation April 2010; BCBS of North Carolina August 2011). • People with incomes of 100 to 250 percent of FPL will also receive assistance with cost-sharing amounts so they can purchase coverage at higher actuarial value [P.L. 111-148 & 111-152 SEC. 1402] (Kaiser Commission on Medicaid and the Uninsured June 2011). • States have the option to offer the Basic Health Plan to adult citizens with incomes between 133 percent and 200 percent of FPL and to legal immigrants with incomes below 133 percent of FPL [P.L. 111-148 & 111-152 SEC. 1331]; BHP gives states 95 percent of what the federal government would have spent on tax credits and subsidies for these two groups (Dorn March 2011) • Those receiving BHP cannot receive federal subsidies—states contract with health plans or providers that provide the essential health benefits (Dorn March 2011).

Implementation • The change will take effect nationally on January 1, 2014. Status of Change • The Department of Treasury has published regulations that subsidies are not available to people with access to affordable employer-provided individual coverage (whether family coverage is affordable or not) (Jacobs et al. December 2011). • Two acts of Congress (that is, the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 and the Medicare and Medicaid Extenders Act of 2010 have cut into subsidies originally authorized by the ACA (BCBS of North Carolina August 2011). • With the exception of CHIP and state high-risk pools, individuals with incomes above Medicaid eligibility levels who do not receive employer-sponsored insurance must purchase coverage in the individual market.

D.5 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.2 (continued)

Implications for • Subsidies will help make private insurance policies bought through the RWHAP Grantees, exchanges more affordable by getting more people covered, including PLWHA; Providers, however, coverage will remain unaffordable for many, even with the subsidies. Clients, and • Those receiving coverage through exchanges may have more cost-sharing for PLWHA services (for example, prescription drugs) than they do now, and some of the services they need may not be covered or may have visit limits. • If eligibility for subsidies is tied only to the individual (versus family) coverage, many individuals may be forced to purchase more expensive employer- sponsored family coverage.

ACA = Affordable Care Act; APTC = advanceable premium tax credit; BHP = basic health plan; CHIP = Children’s Health Insurance Program; CSR = cost sharing reductions; EHB = essential health benefit; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

D.6 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.3. Preventive Service Cost Sharing*

Status Before • Preventive services are not always covered under private insurance plans. ACA • Since 2005, Medicare beneficiaries are entitled to an initial preventive physical examination, a one-time service that must be performed within the first 12 months of a beneficiary’s Part B effective date for coverage (Viggiani and Hitt June 2011). • Medicare provides additional preventive services relating to cardiovascular disease, diabetes, cancer, and vaccinations at usual cost-sharing rates (Viggiani and Hitt June 2011). • States may cover preventive services are available to Medicaid beneficiaries (at state option) with federal matching funds. • HIV testing is most commonly performed with CDC funding at CHCs, RWHAP- funded clinics, and other community-based organizations’ locations.

ACA- Related • The ACA requires coverage for preventive services for Medicaid, Medicare, and Change private health plans [P.L. 111-148 & 111-152 SEC. 1001]. • Private insurers and self-insured employer plans (with the exception of grandfathered plans) must provide coverage for preventive services with no beneficiary cost-sharing in four categories: (1) evidence-based screenings and counseling (i.e., those endorsed as A or B grade by the USPSTF); (2) immunizations recommended for routine use by the Advisory Committee on Immunization Practices; (3) preventive services recommended by HRSA’s Bright Futures Project; and (4) additional preventive services for women (including annual well-woman visits, testing for STIs and HIV, support for breast feeding, and screening, counseling for domestic violence, and all FDA-approved contraceptive methods as prescript by a clinician) [P.L. 111-148 & 111-152 SEC. 1001] (Kaiser Family Foundation September 2011). • Plans can impose cost-sharing only if (1) the office visit and preventive services are billed separately (cost-sharing may apply to the office visit), (2) the primary reason for the visit was not preventive services, or (3) the service is performed by an out- of-network provider [P.L. 111-148 & 111-152 SEC. 1302] (Kaiser Family Foundation September 2011). • Medicare beneficiaries qualify for an annual wellness visit as of 2011. The AWV focuses on preventive services and includes a review of the patient’s history and risk factors for disease, update of patient’s medication list, and provision of personalized health advice and counseling [P.L. 111-148 & 111-152 SEC. 4103] (Viggiani and Hitt June 2011). • Preventive services covered under Medicare must be provided without cost-sharing [P.L. 111-148 & 111-152 SEC. 4104]. • The current Medicaid State option for the provision of diagnostics, screening, preventive, and rehabilitative services is expanded to include (1) clinical preventive services graded A or B by the USPSTF, (2) immunizations for adults as recommended by the ACIP, and (3) medical or remedial services recommended by a provider for the maximum reduction in physical or mental disability and restoration to best functional level [P.L.111-148 SEC 4106] (Amerigroup RealSolutions in Healthcare November 2010).

D.7 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.3. (continued)

Implementation • Preventive services offered under first 3 categories are in effect as of September Status of 23, 2010; those for women’s services are in effect as of August 1, 2012. Change • USPSTF currently recommends HIV testing for all adolescents and adults at increased risk for HIV infection (i.e., those reporting one or more individual risk factors or receiving health care in a high-prevalence or high-risk clinical setting) and all pregnant women; DHHS added sexually active women as a category in August 2011 through a National Coverage Determination (Schmid May 2011). • Elimination of cost-sharing does not apply to all routine HIV testing, only those cases defined by DHHS. • Some states require routine HIV testing. • Starting August 1, 2012, HIV screening with no co-pays is available to all sexually active women as part of expanded women’s preventive services under ACA (DeNoon August 2011). • State Medicaid programs that elect to offer covered services without cost-sharing will receive a 1-percentage-point increase in their FMAP (Amerigroup RealSolutions November 2010).

Implications • Lack of USPSTF endorsement of routine HIV testing creates barriers to for RWHAP identification of HIV-positive people who are unaware of their serostatus. This may Grantees, change in late 2012, if the USPSTF upgrades its grade for HIV testing from C (for Providers, high-risk groups) to A (routine testing). Clients, and PLWHA

Notes: People placed into the higher-risk category include those seeking treatment for STDs; men who have sex with men; past or present injection drug users; persons who exchange sex for money or drugs and their sex partners; persons who request a test; women and men whose past or present sex partners were HIV-infected, were bisexual , or were injection drug users; persons with a history of blood transfusion between 1978 and 1985; and persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test (Schmid May 2011). High-risk settings include STD clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs (Schmid May 2011). High prevalence settings are defined as facilities known to have a 1 percent or greater prevalence of HIV infection (Schmid May 2011). ACA = Affordable Care Act; ACIP = Advisory Committee on Immunization Practices; AWV = annual wellness visit; CDC = Centers for Disease Control and Prevention; CHC = community health center; DHHS = U.S. Department of Health and Human Services; FDA = U.S. Food and Drug Administration; HRSA = Health Resources and Services Administration; FMAP = federal medical assistance percentage; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program; STD = sexually transmitted disease; STI = sexually transmitted infection; USPSTF = U.S. Preventive Services Task Force. * This table was updated through September 2012.

D.8 Potential Impact of the ACA on RWHAP: Final Report Mathematica Policy Research

Table D.4. Medicare Part D Donut Hole*

Status Before • ADAP payments count toward Medicaid spend-down but do not count toward ACA TrOOP costs in the Medicare Part D donut hole, making it nearly impossible for beneficiaries to reach the catastrophic coverage phase under Part D.

ACA- Related • ADAP payments for prescription drugs count toward TrOOP spending [P.L. 111- Change 148 & 111-152 SEC. 3314]. • Beneficiaries receive a 50 percent discount on brand-name drugs while they are in the donut hole; discounts do not apply to generic drugs. • The donut hole is eventually phased out of Medicare Part D [P.L. 111-148 & 111- 152 SEC. 3301]. • By 2020, the coverage gap will be closed, but standard cost-sharing will apply (i.e., average of 25 percent copays), which could still be prohibitive for PLWHA (Cross et al. April 2010).

Implementation • The change goes into effect at the national level on January 1, 2014. Status of • CMS issued guidance to HRSA on processing Part D-related claims and Change recommended that ADAPs use real-time processing to receive automatic refunds from Part D sponsors for overpaid amounts (CMS October 2010).

Implications • PLWHA who are Medicare beneficiaries will have lower OOP costs for prescription for RWHAP medications covered by Part D drug plans and will be able to reach the level of Grantees, catastrophic coverage. Providers, • ADAPs will have reduced demand for covering drug costs when beneficiaries reach Clients, and the catastrophic limit. PLWHA

ACA = Affordable Care Act; ADAP = AIDS Drug Assistance Program; CMS = Centers for Medicare & Medicaid Services; HRSA = Health Resources and Services Administration; OOP = out-of-pocket; PLWHA = people living with HIV/AIDS; RWHAP= Ryan White HIV/AIDS Program; TrOOP= true out-of-pocket. * This table was updated through September 2012.

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APPENDIX E

PROVIDER SERVICE DELIVERY AND FUNDING REFORMS

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Table E.1. Medicaid Managed Care*

Issue Information

Status Before • In FY 2011 and FY 2012, two-thirds of all Medicaid enrollees received care through ACA managed care organizations (Smith et al. October 2011). • Across all 50 states and DC, only three states (Alaska, New Hampshire, and Wyoming) reported that they did not have any Medicaid managed care organizations as of October 2010. Of the 48 states with comprehensive managed care programs, 36 reported contracting with risk-based MCOs (Gifford et al. September 2011).

ACA- Related • As the primary delivery arrangement for most Medicaid beneficiaries, enrollment Change in managed care is expected to be one of the most common arrangements by which new Medicaid enrollees under the ACA receive health care. • The ACA now allows states to collect rebates on prescription drug expenditures by MCOs [P.L. 111-148 & 111-152 SEC. 2501].

Implementation • Medicaid eligibility will expand in 2014; slightly more than half of the states with Status of MCOs (20) reported that their plans had or could develop enough network Change capacity to handle increased Medicaid enrollment expected under health care reform (Gifford et al. September 2011). • A few states have developed capitation rates under Medicaid managed care specifically to support HIV care (e.g., the Maryland Medicaid program pays special capitation rates for Medicaid beneficiaries with HIV and AIDS that are adjusted for geography and hepatitis C status) (Gallant et al. October 2011). • MCO rates are often tied to fee-for-service rates, so when states cut fee-for-service provider rates, this can affect MCO rates, too—in FY 2011, 18 states reported MCO rate increases and 11 states reported MCO rate cuts. • 17 states in FY 2011 and 24 in FY 2012 reported that they were expanding their managed care programs primarily by expanding the areas and populations covered by a managed care program (Smith et al. October 2011).

Implications • States are increasingly turning to MCOs to facilitate access to comprehensive for RWHAP quality care for PLWHA (Gifford et al. September 2011). Grantees, • Experienced HIV providers may not qualify as HIV primary care providers in all Providers, Medicaid MCO plans. Clients, and PLWHA • Many states report that Medicaid MCO enrollees sometimes face access problems, specifically regarding specialty care (Gifford et al. September 2011). • Although most states have an MCO, not all states have comprehensive MCO models—states that have non-comprehensive managed care (Alabama, Arizona, California, Colorado, the District of Columbia, Florida, Georgia, Iowa, Idaho, Kansas, Massachusetts, Maryland, Michigan, Mississippi, North Carolina, North Dakota, New Mexico, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Washington, and Wisconsin) often do not include services such as disease management, chronic care, and behavioral health, which are critical services for PLWHA (Gifford et al. September 2011). • States have expressed concern that it might be difficult for them to build appropriate provider networks (Gifford et al. September 2011). • Patients need referrals to specialists under the managed care model, which might hinder access to needed services. • Switching to managed care arrangements could disrupt existing relationships between patients and their usual providers.

ACA = Affordable Care Act; FY = fiscal year; MCO = managed care organization; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Table E.2. Medicaid Health Homes*

Status Before • Medicaid programs might fall short in supporting comprehensive care for HIV ACA (Gallant et al. October 2011).

ACA- Related • Section 2703 of the ACA offers a new Medicaid state plan option to provide Change coordinated care to individuals with chronic conditions [P.L. 111-148 & 111-152 SEC. 2703].

Implementation • 21 states indicated that they planned to adopt or implement the Section 2703 Status of health home option during FY 2012 (Smith et al. October 2011). Change • In 2011, CMS approved three health home state plan amendments in two states (Missouri and Rhode Island) and approved 13 health home planning requests from Alabama, Arizona, Arkansas, California, Idaho, Mississippi, New Mexico, New Jersey, Nevada, North Carolina, Washington, West Virginia, and Wisconsin (Smith et al. October 2011; New York State Department of Health December 2011; HHS.gov January 2012).

Implications • An HIV diagnosis alone is not sufficient to qualify for a health home—the enrollee for RWHAP must have two or more chronic conditions or one chronic condition and be at risk Grantees, for another. Providers, • Elected as a new Medicaid State Plan Option, health homes will provide an Clients, and enhanced FMAP (90 percent for the first eight fiscal quarters) for states that PLWHA enable Medicaid enrollees with two chronic conditions to choose a qualified provider as their medical home. • The new Medicaid health home benefit, for which HIV disease is identified as an eligible condition, provides an important opportunity for states to support comprehensive HIV care through chronic disease management or care coordination (Gallant et al. October 2011).

ACA = Affordable Care Act; FMAP = federal medical assistance percentage; FY = fiscal year; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Table E.3. Provider Capacity Issues*

Status Before • HIV disproportionately affects members of vulnerable population groups (for ACA example, members of racial/ethnic minority groups, gay men, and those living in poverty). • Many health plans and providers are unaware of how to provide care for PLWHA in a culturally competent manner.

ACA- Related • The ACA expands initiatives to increase racial and ethnic diversity in the health Change care professions and to strengthen cultural competency training for all health care providers [P.L. 111-148 & 111-152 SEC. 5307]. • The ACA requires comprehensive data collection of patients’ race, ethnicity, language, and other demographic factors in all federally supported health care programs [P.L. 111-148 & 111-152 SEC. 4302].

Implementation • An estimated 4,500 to 12,100 additional providers might be needed to care for Status of new Medicaid patients following the implementation of the ACA in 2014 (Sommers Change et al. October 2011). • In October 2011, the DHHS secretary announced $19.5 million in funding to enhance the primary care workforce through Primary Care Training and Enhancement grants, which prioritize training for members of underrepresented minority groups (HRSA October 2011). • The DHHS secretary must ensure that federally conducted or supported health care or public health programs, activities, or surveys collect data on race, ethnicity, sex, primary language, and disability status for applicants, recipients, or participants (Cartwright-Smith et al. March 2011). • DHHS released its first department-wide Action Plan to Reduce Health Disparities in 2011 (DHHS April 2011).

Implications • The ACA supplements the National HIV/AIDS Strategy goal of improving care and for RWHAP reducing disparities. Grantees, • Increases in the number of providers from underrepresented racial/ethnic minority Providers, groups will help to enhance care for PLWHA. Clients, and PLWHA • Improved data collection will assist in tracking the progress of the epidemic and focus resources on disproportionately affected communities.

ACA = Affordable Care Act; DHHS = U.S. Department of Health and Human Services; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Table E.4. Provider Reimbursement Rates*

Status Before • Low Medicaid primary care provider reimbursement rates create barriers to receipt ACA of HIV-related care for PLWHA (IOM January 2011).

ACA- Related • Temporary increases in 2013 and 2014 in Medicaid reimbursement rates for Change primary care providers to 100 percent of the Medicare payment level [P.L. 111-148 & 111-152 SEC. 1202] (IOM January 2011). • States will receive 100 percent federal financing for the difference in payments between the original Medicaid payment amount and the amount paid at the Medicare rate [P.L. 111-148 & 111-152 SEC. 1202].

Implementation • The issue of the adequacy of Medicaid reimbursement rates is being addressed in Status of a variety of public forums (Kaiser Family Foundation September 2011a). Change • New York’s Medicaid program has enhanced reimbursement rates for HIV care under FFS plans and has developed special capitated rates under managed care programs (IOM January 2011). • Beginning in October 2011, New York State plans to include pharmaceuticals and other services previously paid on an FFS basis into the managed care benefit package for HIV special needs plans and into other Medicaid managed care plans and to adjust the capitation rates accordingly (Gallant et al. October 2011).

Implications • With an increase in the number of people gaining Medicaid eligibility, there will be for RWHAP increasing costs to states. Because of maintenance of eligibility requirements, Grantees, states cannot cut eligibility criteria and have been cutting provider rates. If Providers, providers refuse to participate in Medicaid as a result of payment cuts, PLWHA Clients, and might lose access to providers. PLWHA • The ACA increases Medicaid primary care reimbursement rates, but the increase does not extend to infectious disease specialists who often provide primary care to their patients (Hauschild et al. January 2011; IOM January 2011). • Some HIV providers that are currently funded through RWHAP might refuse to participate in Medicaid because FFS rates are lower than those paid by RWHAP (McKay February 2011).

ACA = Affordable Care Act; FFS = fee-for-service; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Table E.5. Payment Reforms*

Status Before • FQHCs serve as safety net providers to members of vulnerable population groups, ACA including the uninsured, and offer a wide range of preventive and primary care services. • FQHCs and other safety net providers face financial strains as patient loads outpace spending (Taylor September 2010).

ACA- Related • The ACA provided $11 billion, over five years, to expand CHCs ($9.5 billion to Change expand operational capacity and $1.5 billion to fund capital improvements and construction of new centers) [P.L. 111-148 & 111-152 SEC. 5601]. • FQHCs’ significant role in preventive care and CHC expansions will help to increase access to preventive care (McKay February 2011). • FQHCs will receive a higher rate of reimbursement from Medicaid than most other health care entities do for similar services (National Association of Community Health Centers October 2010).

Implementation • Effective in FY 2010, the ACA was designed to double CHC/FQHCs capacity from Status of 20 to 40 million patients (McKay February 2011). Change • The discretionary (base program) of the Health Centers Program fund was reduced by approximately $600 million relative to FY 2010, resulting in a scaling back of the expansion (McColgan November 2011). • Current RWHAP grantees are partnering with existing health centers to become FQHCs, and the national AIDS Education and Training Center are expanding training to support HIV care and treatment in FQHCs without RWHAP funding.

Implications • Expansion of CHCs and FHQCs will increase access to care for vulnerable for RWHAP population groups, including those who remain uninsured following full Grantees, implementation of the ACA, and will enhance prevention efforts (McKay February Providers, 2011). Clients, and • FQHCs already engaged in HIV/AIDS care can continue to serve HIV clients under PLWHA enhanced reimbursement rates from both Medicaid and insurance companies (McKay February 2011).

ACA = Affordable Care Act; CHC = community health center; FQHC = federally qualified health center; FY = fiscal year; PLWHA = people living with HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program. * This table was updated through September 2012.

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Table E.6. Other Reforms: Section 1115 Waivers*

Status Before • Under Section 1115 of the Social Security Act, the Secretary may waive certain ACA provisions for experimental, pilot, or demonstration projects (National Health Care for the Homeless Council July 2011).

ACA- Related • The waiver approval process will become more transparent, allowing for increased Change public input. • Maintenance of effort requires that states uphold eligibility parameters that were in effect when health reform was enacted [P.L. 111-148 & 111-152 SEC. 2001] (National Health Care for the Homeless Council July 2011).

Implementation • As of June 2011, 30 states and the District of Columbia operate one or more Status of comprehensive Section 1115 Medicaid waivers (Smith et al. October 2011). Change • 17 states have indicated that they planned to implement a new Section 1115 waiver in FY 2012 (Smith et al. October 2011). • Most states with waiver plans intend significant delivery system and/or provider payment reforms for broad or targeted populations (including those with disabilities or special health care needs: Arizona, Alaska, Delaware, Florida, Iowa, New Jersey, New York, Oregon, Texas, Washington) (Smith et al. October 2011). • Several states have waiver amendments to implement cost containment measures including increased cost-sharing (Arizona, California, Florida); benefit changes (Arizona, Oklahoma, Oregon); and enrollment caps or eligibility cuts (Arizona, Hawaii) (Smith et al. October 2011). • Colorado and Minnesota reported using 1115 waivers to expand eligibility of childless adults (Smith et al. October 2011). • 33 states in FY 2011 and 22 states in FY 2012 expanded eligibility, many through 1115 waivers (Smith et al. October 2011) • Arizona, California, and Florida are requesting waiver authority to impose copayments beyond nominal levels and to exempt populations from eligibility requirements (Smith et al. October 2011) • A majority of states that plan waivers intend significant delivery system and/or provider payment reforms for broad or targeted populations, including dual eligibles or people with disabilities (Smith et al. October 2011). • California, as part of its “Bridge to Reform” Section 1115 Medicaid waiver, expanded coverage to low-income adults through the Low-Income Health Program Coverage Expansion, which builds upon coverage initiatives operating in 10 counties (Smith et al. October 2011). • Colorado plans to expand coverage to about 10,000 adults without dependent children through an 1115 waiver in early 2012 (Smith et al. October 2011). • Minnesota expanded coverage on August 1, 2011, for childless adults with incomes between 75 percent and 275 percent of FPL through an 1115 waiver, a changed expected to total 35,000 adults (Smith et al. October2011). • New York anticipates implementing continuous coverage for adults during FY 2012 through a Section 1115 waiver. The estimated number of people who would be affected is 61,000 (Smith et al. October 2011). • Vermont, California, and Iowa have incorporated outreach efforts into their Section 1115 waivers (National Health Care for the Homeless Council July 2011).

Implications • An 1115 waiver can act as a bridge to 2014 and give a state flexibility to for RWHAP immediately cover pre-disabled people living with HIV under its Medicaid program Grantees, (Harvard Law School Health Law and Policy Clinic November 2011a). Providers, • An HIV Section 1115 demonstration can allow states to cover people with HIV, Clients, and including those without an AIDS diagnosis (CMS June 2011). PLWHA

ACA = Affordable Care Act; FPL = federal poverty level; FY = fiscal year; PLWHA = people living with

HIV/AIDS; RWHAP = Ryan White HIV/AIDS Program.

* This table was updated through September 2012.

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