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Updates on the. Open Enrollment for the Health Insurance Marketplace is ending soon…. Open enrollment ends on March 31 st , 2014. If you sign clients up for the marketplace from now until March 31 st , their coverage will begin on May 1 st , 2014.

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open enrollment for the health insurance marketplace is ending soon
Open Enrollment for the Health Insurance Marketplace is ending soon…
  • Open enrollment ends on March 31st, 2014.
  • If you sign clients up for the marketplace from now until March 31st, their coverage will begin on May 1st, 2014.
  • The next open enrollment period begins November 15th, 2014.
who is eligible to apply for the marketplace
Who is eligible to apply for the Marketplace?
  • Anyone who is a U.S. citizen or legal resident can apply for the marketplace no matter what income he/she earns.
  • A person’s income only determines what cost shares and/or tax credits he/she may be eligible for through the Marketplace.
    • Someone earning between 100%-250% FPL is eligible for cost-sharing assistance when enrolled in a Silver Plan.
    • Someone earning between 100%-400% FPL is eligible for tax credits in any marketplace plan.
    • All other incomes can still enroll in the marketplace, but just won’t benefit from cost-share assistance or tax credits.
  • As a reminder, people earning between 0%-300% FPL are eligible for the Louisiana Health Access Program (L-DAP and HIP).
third party payment issue
Third Party Payment Issue
  • In Louisiana, Ryan White ADAP funds (which are used to provide medication and insurance services to individuals with an HIV positive diagnosis) contract through HIP to assist clients with paying for their health insurance premiums and cost shares (copay, coinsurance, deductible).
  • In early 2014, some insurance companies in Louisiana decided NOT to accept premium payments from HIP.
  • Lambda Legal filed a lawsuit on 2/20/14, which resulted in a U.S. District Court hearing on 3/10/14.
  • As of 3/20/14:
      • BCBSLA and HMO of LA decided to continue accepting Ryan White funds as premium payments for individual policies for on-Marketplace and off-Marketplace plans until 11/15/14.
      • Louisiana Health Cooperative (LAHC) also confirmed that they will continue accepting Ryan White funds as premium payments until 11/15/14. LAHC only offers on-Marketplace plans.
      • AAA Vantage will also continue accepting Ryan White funds as premium payments until 11/15/14. AAA Vantage offers on-Marketplace and off-Marketplace plans.
      • Humana has been accepting Ryan White funds as premium payments and confirmed they have no plan to change this stance. Humana has both on-Marketplace and off-Marketplace plans. Humana on-Marketplace plans are only available to persons who live in Jefferson Parish.
third party payment issue1
Third Party Payment Issue
  • On 3/14/14 CMS released an interim final rule regarding third party payment. The rule went into effect immediately but will remain open for comment for 60 days.
  • The rule requires issuers of qualified health plans (QHPs), including stand-alone dental plans (SADPs), to accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program, other Federal and State government programs that provide premium and cost sharing support for specific individuals, and Indian tribes, tribal organizations, and urban Indian organizations.
third party payment issue2
Third Party Payment Issue
    • How do we know the insurance companies won’t change their minds and stop taking payment again?
      • BCBSLA, HMO of LA, LAHC, and AAA Vantage all individually consented on record at the hearing that they would continue accepting premium payments from third parties until 11/15/14.
      • If the insurers were to go back on their consent, they would receive heavy sanctions.
      • CMS released an interim final rule on 3/14/14 requiring QHP insurers to accept payments made on behalf of health plan enrollees by the Ryan White HIV/AIDS Program.
      • CMS says a failure to accept third-party payments as outlined in the rule would be considered substantial non-compliance with an exchange standard, and could also be considered a practice that would have the effect of denying or discouraging enrollment into a QHP by qualified individuals whose medical history suggests the need for a significant amount of services.
    • Continue to accept premium payments? I thought BCBSLA and LAHC stopped accepting premium payments from HIP.
  • While BCBSLA and LAHC internally stopped accepting premium checks from HIP, the only publicly produced written statements from either insurer stated they would continue accepting third party premium payments until 3/31/14.
  • As a result of this discrepancy, many clients dropped out of these plans or switched to another plan.
  • The bottom line: the most recent decision of these insurance companies gives clients more options (next slide).
client options
Client Options

Ryan White funded programs, including HIP, are not entitlement or required programs. If financially capable, individuals can choose to pay their own insurance premiums and/or cost shares. It may be helpful for these individuals to lower the metal level of their plan (e.g. from a platinum level to a bronze level) potentially making their premium costs more affordable.

Pay premiumthemselves

Individuals have until 3/31/14 to enroll in a Marketplace plan for 2014. If they cannot afford the premium and/or cost share costs themselves and have a household income < 300% FPL, they can apply for assistance through HIP.

With the 2014 Marketplace Open Enrollment period ending 3/31/14, providers are encouraged to assist clients in signing up for the Marketplace plan that best suits their needs.

HIP has received approval from SHP to resume issuing checks to BCBS and LAHC for the payment of premiums.

  • Enroll in a plan
  • and
  • apply for HIP
  • Switch Plans

If a client switched to another plan and would like to switch back to the plan they originally enrolled in, the client needs to check with the insurance company to find out if the plan has been effectuated yet. A plan can be effectuated whether or not payment was received.

Client can choose to become / remain uninsured with the understanding of the consequencesof being uninsured, suchas:

-Penaltyfor not obtaininghealth insurance*

-Being reliant on LDAP and the public health medical care system

-LDAP open enrollment is dependant on the availability of funding and is subject to the

possibility of restricted access, such as waiting lists.

Be uninsured

*The penalty in 2014 is calculated in 1 of 2 ways. You’ll pay whichever of these amounts is higher:

1. 1% of your yearly household income. The maximum penalty is the national average yearly premium for a bronze plan.

$95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.

The fee increases every year. In 2015, it’s 2% of income or $325 per person. In 2016, and later years it’s 2.5% of income or $695 per person. After that, it is adjusted for inflation.

If you would have qualified for expanded Medicaid (0%-138% FPL), you’re exempt from the law’s requirements to buy coverage because Louisiana declined expansion.

Therefore, you won’t pay a penalty this year for not buying it. HOWEVER, this exemption must be applied for and a Medicaid denial letter is required for application.

138% FPL = $15, 856 for a single person household.

More information on penalty exemptions are available at

what is effectuated
What is effectuated?

Effectuated is a term used by insurance companies that means a plan has become active or gone into effect.

  • If an individual’s plan has already been effectuated, or gone into effect, they do not have the option to switch plans until 2015 open enrollment unless they are eligible for a Special Enrollment Period (SEP).
  • If an individual’s plan has not yet been effectuated, they can terminate their coverage with their current insurer and switch to another plan.
  • The only way to know if a plan is effectuated is to contact the insurer directly.
information changes
Information changes!
  • While SHP will do our best to update you with new information, be on the look out for upcoming items:
    • The CMS interim final rule entitled “Patient Protection and Affordable Care Act; Third Party Payment of Qualified Health Plan (QHP) Premiums (CMS-9943-IFC)” was released on 3/14/14 and is open for public comment for the next 60 days. This rule requires that all QHPs accept premium payment from the Ryan White HIV/AIDS Program.
    • Legislation could be posed to bypass the governor and expand Louisiana Medicaid. If passed, Louisiana voters would decide whether to expand Medicaid on next November's election day ballot.
how to make an off formulary request
How to make an off-formulary request
  • Each insurance plan has a process for how to make an off-formulary request. Below are the processes for Louisiana Marketplace plans.
  • Blue Cross Blue Shield/HMO of Louisiana
    • Call Express Scripts at 1-866-781-7533 to make an off-formulary request
  • Louisiana Health Cooperative:
    • Contact LAHC. For more details use this link:
    • If approved, the drug will be covered at a “pre-determined cost-sharing level” and you will not be able to ask LAHC for a lower cost-sharing level.
    • Providers must complete a Coverage Determination Request Form and fax it to the Pharmacy Department available when providers log on to
  • AAA Vantage Health Plan:
    • File an “exception request” by calling AAA Vantage’s Member Service department at (318) 361-0900 or (888) 823-1910.
    • The insured and the physician must request the formulary exception.
  • Humana:
    • Off-formulary requests can be made by phone, mail, or fax.
    • Phone: The patient, provider, or appointed representative should call Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546), TTY: 711, Monday through Friday, 8 a.m. to 6 p.m. in your local time zone.
    • Mail/Fax form “Prior Authorization Request Form: Administrative Product – Nonformulary” available electronically -
      • Medicare: HCPR, Attn: Medicare Coverage Determination, P.O. Box 33008, Louisville, KY 40232
      • Commercial: HCPR, Attn: Prior Authorizations, P.O. Box 33008, Louisville, KY 40232
      • Fax: 1-877-486-2621
common hiv medications on louisiana marketplace plans
Common HIV Medications on Louisiana Marketplace plans

This information is available on

pcip extension through april 2014
PCIP Extension through April 2014
  • On March 14th, 2014 it was announced that the federally-run Pre-Existing Condition Insurance Plan (PCIP) will be extended through April 30th, 2014.
  • Individuals with active PCIP, who have not yet found new health insurance coverage through the Marketplace, can purchase an additional month of PCIP coverage through April 30, 2014, while they continue their search.
  • Eligible enrollees can purchase PCIP transitional coverage by sending in an April premium payment; which will be the same monthly rate that they paid for January-March 2014.
  • If you have clients that were on PCIP and have since obtained Medicaid, Medicare, or other currently active insurance coverage PLEASE contact Brandy Davis at HIP immediately.
  • Brandy can be reached at 225-927-1269.
special enrollment periods for pcip clients
Special Enrollment Periods for PCIP clients
  • On March 18th, The Center for Consumer Information & Insurance Oversight (CCIIO) clarified that if an individual selects PCIP transitional coverage for April 2014 and then loses that coverage before enrolling in a Marketplace plan, they would be eligible for a special enrollment period (SEP) outside of open enrollment.
  • This SEP it is NOT a mass PCIP special enrollment period, but a person specific one, which will need to be done on a case by case basis. 
  • Why a Special Enrollment Period?
    • PCIP is considered minimum essential health coverage and the loss of minimum essential health coverage is considered a qualifying life event that could result in an SEP outside of open enrollment.  
  • Most SEPs last 60 days from the date of the qualifying life event. 
  • SEPs are an option, but they are NOT ideal. SEPs require additional paper work, hoops to jump through, and may not be resolved quickly. 
  • The only way to help ensure that an individual with PCIP does not experience a coverage gap is to make sure they are enrolled in a Marketplace plan no later than March 31, 2014.
quick review what is adap
Quick review - What is ADAP?
  • ADAP stands for AIDS Drug Assistance Program.
  • ADAP is a federal Ryan White funding source awarded by the Health Resources and Services Administration (HRSA).
  • ADAP funds can be used to provide medication and insurance services to eligible individuals with a positive HIV diagnosis.
  • The State STD/HIV Program (SHP) gets ADAP funding from HRSA.
  • SHP uses ADAP funding to support medication and insurance services through our programs called L-DAP and HIP. 
    • covers drug costs for uninsured individuals only. Often referred to as Traditional ADAP.
    • covers insurance plan premiums as well as medical (non-drug) and drug copays, coinsurances, & deductibles (known as cost shares) for insured individuals.
  • LA HAP processes L-DAP enrollment through SHP.
  • HIP processes HIP enrollment through HAART.


Manage LDAP & HIP Contracts

Process LDAP Enrollment

  • Louisiana Health Insurance Program (HIP) Services
  • & Enrollment
  • Insured plan premium
  • Drug cost share assistance
  • Medical cost share assistance
  • Participating HIP Pharmacies
  • Louisiana Drug Assistance Program
  • (LDAP)
  • Drug costs for uninsured clients.
  • Previously through 10 LSU Medical Center Outpatient Pharmacies.
  • Currently central distribution through OPH Pharmacy.
coming soon
Coming soon…

To allow for better coordination of our programs you'll see a few more changes with LDAP and HIP.

    • Will continue to cover drug costs for uninsured individuals

and will soon cover drug copays, coinsurances, & deductibles

(known as cost shares) for insured individuals.

    • Will continue to cover insurance plan premiums as well as

medical (non-drug) cost shares for insured individuals.

  • LA HAP will soon process both L-DAP and HIP enrollment through a single application.
coming soon1
Coming soon…


Manage L-DAP & HIP Contracts

Process L-DAP & HIP Enrollment

  • Louisiana Health Insurance Program (HIP) Services
  • Insured plan premium
  • Medical cost share assistance

Coordinated through HAART.

  • Louisiana Drug Assistance Program (L-DAP)
  • Drug costs for uninsured clients
  • Drug cost shares for insured clients

Managed through Ramsell

okay but how do i apply for these programs now
Okay, but how do I apply for these programs NOW?
  • If you are uninsured and need assistance paying for your HIV medications, apply to LDAP using the new LA HAP application that was released in December 2013.
    • LA HAP application is available on
  • If you have any type of health insurance and need assistance with your premiums* and cost shares, apply to HIP using the HIP application
    • HIP application is available on under “services”  “HIP”

*If you need assistance paying for premiums, please double check that the insurance plan you sign up with will accept premium payments from HIP.

la hap application page 2 household information
LA HAP Application, Page 2, Household information
  • Carefully consider the definition of “household” for the purposes of this application. People in the same household MUST be related by blood, state legal marriage and/or state legal adoption.
  • Live-in boyfriends/girlfriends and/or same sex partners* are NOT considered part of the same household and should not be included in this section or included as contributing to household income.
  • Common law marriage is not recognized in Louisiana.
  • Louisiana does not recognize people as being “separated” in a marriage until they are legally divorced. However, LA HAP recognizes it is likely that if someone has been separated from his/her spouse for greater than six months, it may difficult for that person to obtain income documentation from his/her estranged spouse. Therefore, income eligibility can be determined on the separated individual’s income alone. Contact LA HAP at 504-568-7474 for more information.

*For the purposes of this application, only state legal marriages are considered. Therefore, even if a couple has a federally recognized marriage or was married in another state, they are not considered married unless the state of Louisiana recognizes their marriage.

la hap application page 2 income information
LA HAP Application, page 2, Income information
  • The client needs to provide proof of income for anyone listed in the “household” section that is 18 years of age or older and receives any source of income.
  • If the client’s household member(s) does not have any source of income, or the client cannot provide a household members’ income then the client needs to note that somewhere on the application. They can make a note in the household section, cover letter, in the comments section on page 3, etc.

Common mistakes when completing a LA HAP Application, Page 4

  • If you are a case manager/social worker/advocate helping a client complete this application, please remember to sign your name above “person obtaining consent” and date it.
  • Also print your name, agency, and phone number in the appropriate boxes so that LA HAP can help your agency track which referrals you have submitted.
hip s12 month recertification vs 6 month verification
HIP’s12 month recertification vs. 6 month verification

Clients must complete a 12 month recertification for HIP annually on their month of birth. This requires them to fill out an entire HIP application and check the

box on the HIP application.

Clients must also complete a 6 month verification on the month that falls 6 months after their birth month. This is a one page document that can be found by clicking the “6 month verification” link at

income eligibility for la hap hip
Income Eligibility for LA HAP & HIP
  • The new 2014 FPL guidelines have been released and are what LA HAP and HIP are currently using to determine income eligibility for their services.
contact information
Contact Information
  • My Contact Information:
    • Julia Frisk, Public Health Associate, 504-568-8387,
  • HIP: 225-927-1269

For assistance completing a HIP application ask for:

Brandy Davis (ext. 144)

For application status updates ask for:

    • Regions 1, 2, 3 new & recertification - Vena Lewis ext. 147 (
    • Regions 4, 5, 6, 8 new & recertification – Tanya Brown ext. 135 (
    • Regions 7, 9 new & recertification AND 6 month verification for all regions - Kne-KoleGibson ext. 126 (
    • ACA application for all Regions - Heather Farisext 124 (
  • LAHAP – for application status updates, the CSS are usually the easiest to contact.
    • Jennifer Carlos Gomez, ADAP Coordinator
      • 504-568-5448
    • Rosaline Morgan, Client Services Specialist (CSS)
      • 504-568-8746
    • Markham Bradburn, Client Services Specialist (CSS)
      • 504-568-3623
    • Heather Weaver, TAB Coordinator
      • 504-568-5489
  • This presentation is available on  “Links”  “Technical Assistance Resources” or the direct link at
  • under “services”
  • Enrollment Assistance:

Enroll Louisiana Inc. (

4664 Jamestown Ave, Suite 125

Baton Rouge, LA 70808

Office: 225-228-1515

Fax: 225-612-6395