HIV/AIDS Bureau Division of State HIV/AIDS Program (DSHAP)

1. HIV/AIDS BureauDivision of State HIV/AIDS Program (DSHAP) Ryan White HIV/AIDS Part B Program Technical Assistance Webinar ADAP Updates June 18, 2014

2. DSHAP Mission: To provide leadership and support to States/Territories for developing and ensuring access to quality HIV prevention, health care, and support services. DSHAP Vision: Optimal HIV/AIDS Prevention, Care and Treatment for all.

3. Agenda

4. Objectives • To review Policy Clarification Notice 14-01, and updates to PCNs 13-05 and 13-06 • To provide an update on key issues related to ADAP, especially regarding implementation of the ACA • To provide a brief overview of CMS Final Rule for Exchange/Insurance Market Standards for 2015 and Beyond and how it may impact RWHAP grantees

5. Announcements & Updates

6. Announcements Announcements • New Ryan White Services Tracker Tool • CAREWare Survey Upcoming Webinars • ADR Town Hall: June 25 • Access to HIV Testing and Linkage to Care: June 26 • Ryan White Services Tracker: June 27 For more information, check the TARGET Center

7. ADR • Thanks for all the hard work that went into the CY 2013 ADR Submission • 41 States/Territories were able to submit on time • Data contractors are working with the remaining States/Territories to successfully submit ASAP • CY 2014 ADR • The data dictionary and ADR manual are scheduled to be released on 8/1/14 • The Division of Policy and Data (DPD) will be offering training webinars for the RSR and ADR in Fall 2014.

8. FFR Briefing for DSHAP April 2013 Updates on Policy Clarification Notices 13-05, 13-06 & 14-01 Yolonda Campbell Health Policy Analyst Office of Planning, Analysis and Evaluation Glenn Clark ADAP Advisor Division of State HIV/AIDS Program

9. FFR Overview Update on PCNs New Policy Clarification Notice (PCN) 14-01 on reconciliation of advance premium tax credits • On June 6th, HRSA released PCN 14-01, which clarifies HRSA policy regarding the use of Ryan White HIV/AIDS Program funds to purchase health insurance for clients in the Marketplace and the reconciliation of advance premium tax credits. • RWHAP grantees and sub-grantees must vigorously pursue any excess premium tax credit a client receives from the IRS upon submission of the client’s tax return. • Collect excess premium tax credit attributed to individual client

10. FFR Overview Update on PCNs PCN 14-01 continued • HRSA is considering allowing RWHAP grantees and sub-grantees to use RWHAP funds to pay the IRS any additional income tax liability a client may owe to the IRS solely based on reconciliation of the premium tax credit. • HRSA will be seeking comments from the public regarding this proposed policy in a forthcoming Federal Register Notice.

11. FFR Overview Update on PCNs Revised Policy Clarification Notice (PCN) 13-05 on formulary equivalency • On June 6th, HRSA released a revised PCN 13-05 that changes the formulary requirement be that it, at a minimum, includes at least one drug in each class of core antiretroviral therapeutics from the HHS Clinical Guidelines for the Treatment of HIV/AIDS as well as appropriate primary care services. • Please note that the ADAP still needs to do a cost effectiveness analysis.

12. FFR Overview Update on PCNs Revised Policy Clarification Notice (PCN) 13-06 on formulary equivalency • Revised PCN 13-06 that clarifies that when RWHAP Part A planning bodies, Part B, Part C and Part D grantees provide funding for Medicaid premium and cost-sharing assistance for low-income individuals, the grantee must also assure that they are buying health insurance that, at a minimum, includes at least one drug in each class of core antiretroviral therapeutics

13. Question and Answer Session

14. FFR Briefing for DSHAP April 2013 ACA Implementation-related Questions from ADAPs Glenn Clark and Heather Hauck Director Division of State HIV/AIDS Program

15. FFR Overview ADAP Clarifications Question: • While HRSA has clarified that an ADAP cannot pay for a combination drug when the components of the drug are covered by a client’s insurance but the combo drug is not, can ADAPs override this restriction if the physician writes a Dispense as Written (DAW) order for the combo medication? Answer: • No, the Dispense As Written does not override payer of last resort. The cost cannot be covered by the ADAP using RWHAP Funds.

16. FFR Overview ADAP Clarifications Question: • If an ADAP is paying for the premium for a client’s insurance, can the ADAP pay for a drug that is not covered on that insurance’s formulary? Answer: • Yes, if that drug is on the ADAP’s Formulary.

17. FFR Overview ADAP Clarifications Question: • With marijuana having been legalized in a few states, can ADAP be used to pay for medical marijuana? How about for marinol? Answer: • ADAP can only be used to pay for FDA approved medications. Marinolis FDA approved and can be covered by ADAP, but medical marijuana is not FDA approved, and cannot be covered.

18. FFR Overview ADAP Clarifications Question: • Will HRSA be providing further guidance on “vigorously pursue” and thoroughly document? Answer: • HRSA is working on identifying best practices for “vigorously pursue”. Grantees and sub-grantees should refer to the relevant Policy Clarification Notices and the National Monitoring Standards for existing guidance.

19. FFR Overview ADAP Clarifications Question: • Can ADAPs dis-enroll a client for non-compliance with enrolling in Medicaid or a QHP? Answer: • No. HRSA’s PCN 13-04 states that a client may continue to receive services through the RWHAP if the client remains unenrolled in health care coverage after extensive documented efforts on the part of the grantee. Our goal as a public health program is to ensure and enable coverage for all eligible PLWH.

20. Question and Answer Session

21. FFR Briefing for DSHAP April 2013 CMS Final Rule for Exchange/Insurance Market Standards for 2015 and Beyond Yolonda Campbell Health Policy Analyst Office of Planning, Analysis and Evaluation

22. FFR Overview CMS Final Rule Final Rule for Exchange/Insurance Market Standards for 2015 and Beyond • On May 16, the Department of Health and Human Services (DHHS), Centers for Medicaid & Medicare Services (CMS), issued the final rule for Exchange/Insurance Market Standards for 2015 and Beyond.  The rule promotes affordability, transparency and takes the first step toward providing additional quality related tools for consumers shopping in the Health Insurance Marketplace.

23. FFR Overview CMS Final Rule This rule will help to improve consumer protections, keep premiums affordable, and make additional information available to consumers in the future, such as quality ratings that will help them to better compare and choose plans.  Specifically, the rule finalizes policies to: • Strengthen the prescription drugs exceptions process, so consumers with an urgent medical issue have quicker access to needed drugs that aren’t already covered by their plan • Require health insurance issuers to provide standardized notices to their enrollees when issuers decide to discontinue or renew coverage

24. FFR Overview CMS Final Rule The rule finalizes policies to (continued): • Collect information from issuers to generate quality rating scores for plans on the Marketplace beginning in 2016 • Provide flexibility to states to ensure Small Business Health Options Program (SHOP) works in the best interest of consumers in 2015 • Strengthen standards for Navigators and other consumer assisters • Improve premium stabilization policies for 2015

25. Highlight: Consumer Assistance • “…in specific circumstances, certified application counselor (CAC) designated organizations can serve target populations without violating the broad non-discrimination requirement related to Exchange functions” • RWHAP providers may offer CAC services exclusively to their client populations (e.g. enrollment assistance, post-enrollment assistance, outreach and education about getting covered), so long as they do not discriminate based on race, color, national origin, disability, age sex or other prohibited factors

26. FFR Overview CMS Final Rule Highlight: 24 hour expedited review of formulary requests • Qualified Health Plans (QHPs) must have an expedited exceptions process for beneficiaries with exigent circumstances to seek a medication not covered under a plan • Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug • QHPs must decide within 24 hours of receiving the request • QHPs must provide coverage of any drug obtained through this expedited exceptions process for the duration of the exigency

27. Question and Answer Session

28. FFR Overview Coordination with State-Based Marketplaces DSHAP would like to hear from States with State-based marketplaces as to successes/best practices or challenges in working with your marketplace. If you would like to share your experiences, please contact your Project Officer or Glenn Clark.

29. Contact Information Glenn Clark ADAP Advisor, DSHAP Phone: (301) 443-3692 E-mail:GLClark@hrsa.gov

30. Thank You