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Affordable Care Act. What an HIV Provider Needs to Know Steve O’Brien, MD January 28, 2013. Pacific AIDS Education Training Center. Steve O’Brien, MD. Pacific AIDS Education Training Center. Steve O’Brien, MD. Agenda. What is ACA? What can Providers & Patients expect?

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affordable care act

Affordable Care Act

What an HIV Provider Needs to Know

Steve O’Brien, MD

January 28, 2013

agenda
Agenda
  • What is ACA?
  • What can Providers & Patients expect?
  • How will patients access care?
  • How do we prepare for ACA?
affordable care act aca
Affordable Care Act(ACA)
  • Goals:
    • Expand access to care
    • Reduce uninsured
    • Payment reform & innovation
  • Implement 2010-2014
affordable care act aca1
Affordable Care Act(ACA)
  • Goals:
    • Expand access to care
    • Reduce uninsured
    • Payment reform & innovation
  • Implement 2010-2014

Ryan White

HIV

ACA

affordable care act aca2
Affordable Care Act(ACA)
  • HIV treatment expansion
    • Individual Benefit
      • Early treatment
    • Community Benefit
      • Transmission VL related
      • 37% in treatment
affordable care act aca3
Affordable Care Act(ACA)
  • HIV treatment expansion
    • Individual Benefit
      • Early treatment
    • Community Benefit
      • Transmission VL related
      • 37% in treatment
national hiv aids strategy
National HIV/AIDS Strategy
  • Goals
    • Reduce new infections
    • Increase access to care
    • Reduce HIV health disparities
  • ACA key to achieving goals
access to healthcare before 2010
Access to HealthcareBefore 2010
  • Employer sponsored insurance
    • Most prominent source of insurance
    • Less with HIV pts
access to healthcare before 20101
Access to HealthcareBefore 2010
  • Employer sponsored insurance
    • Most prominent source of insurance
    • Less with HIV pts
  • Individual private insurance
    • mostly shut out HIV pts due to pre-existing condition or unaffordable
access to healthcare before 20102
Access to HealthcareBefore 2010
  • Employer sponsored insurance
    • Most prominent source of insurance
    • Less with HIV pts
  • Individual private insurance
    • mostly shut out HIV pts due to pre-existing condition or unaffordable
  • Medicaid/Medicare/RW
    • More important for HIV than general pop
    • Medicaid eligibility:
      • Before ACA, federal law excluded non-disabled adults w/o kids unless a waiver
      • Income & Categorical (kids, parent with kid, preg, disabled) : leaves out many men
    • Medicare – eligibility >65 or permanently disabled
    • State “high risk” pools
    • Ryan White
      • RW also wraps around other services
access to healthcare with aca coverage expansion 2010 2014
Access to Healthcare with ACACoverage Expansion: 2010-2014
  • Medicaid
    • Allows Coverage for Childless Adults
      • 138% FPL
      • Optional by state
    • Medical Homes
      • Now includes HIV
    • Primary Care Pay
      • 100% Medicare 2013-14
access to healthcare with aca coverage expansion 2010 20141
Access to Healthcare with ACA Coverage Expansion: 2010-2014
  • Medicaid
    • Allows Coverage for Childless Adults
      • 138% FPL
      • Optional by state
    • Medical Homes
      • Now includes HIV
    • Primary Care Pay
      • 100% Medicare 2013-14
  • Medicare
    • ADAP Counts towards TrOOP
    • Closes Drug Coverage Gap
      • Donut-hole rebate
      • Drug discounts
access to healthcare with aca coverage expansion 2010 20142
Access to Healthcare with ACACoverage Expansion: 2010-2014
  • Medicaid
    • Allows Coverage for Childless Adults
      • 138% FPL
      • Optional by state
    • Medical Homes
      • Now includes HIV
    • Primary Care Pay
      • 100% Medicare 2013-14
  • Medicare
    • ADAP Counts towards TrOOP
    • Closes Drug Coverage Gap
      • Donut-hole rebate
      • Drug discounts
  • Insurance Protections
    • No lifetime limits or rescissions
    • Pre-Existing Condition Insurance Plan (PCIP)
    • Dependents covered to 26
  • Small Business Coverage Subsidies
access to healthcare with aca coverage expansion 2014 and beyond
Access to Healthcare with ACACoverage Expansion: 2014 and Beyond
  • Medicaid up to 138% FPL
    • No categorical qualification
    • Enhanced Federal match (100% -> 90%)
    • States cannot be penalized for not enacting this part
  • Health Insurance Exchanges
    • Income based premium & cost-sharing subsidies
      • (via tax credits)
    • Individuals & businesses up to 100 employees
  • Basic Health Plan
    • Optional State plan 138-200% FPL
access to healthcare with aca coverage expansion 2014 and beyond1
Access to Healthcare with ACA Coverage Expansion: 2014 and Beyond
  • Medicaid up to 138% FPL
    • No categorical qualification
    • Enhanced Federal match (100% -> 90%)
    • States cannot be penalized for not enacting this part
  • Health Insurance Exchanges
    • Income based premium & cost-sharing subsidies
      • (via tax credits)
    • Individuals & businesses up to 100 employees
  • Basic Health Plan
    • Optional State plan 138-200% FPL
  • US citizens & legal residents must have insurance
    • Individual mandate
      • Up to 6mil may be penalized (avg $1200/yr)
  • No Pre-Existing Condition denial
    • PCIP dissolve
  • No annual limits
  • FQHC funding increase
  • New Insurance Regulations
    • Essential Health Benefits
access to healthcare with aca coverage expansion 2014 and beyond2
Access to Healthcare with ACA Coverage Expansion: 2014 and Beyond
  • Medicaid up to 138% FPL
    • No categorical qualification
    • Enhanced Federal match (100% -> 90%)
    • States cannot be penalized for not enacting this part
  • Health Insurance Exchanges
    • Income based premium & cost-sharing subsidies
      • (via tax credits)
    • Individuals & businesses up to 100 employees
  • Basic Health Plan
    • Optional State plan 138-200% FPL
access to healthcare with aca coverage expansion 2014 and beyond3
Access to Healthcare with ACA Coverage Expansion: 2014 and Beyond
  • Medicaid up to 138% FPL
    • No categorical qualification
    • Enhanced Federal match (100% -> 90%)
    • States cannot be penalized for not enacting this part
  • Health Insurance Exchanges
    • Income based premium & cost-sharing subsidies
      • (via tax credits)
    • Individuals & businesses up to 100 employees
  • Basic Health Plan
    • Optional State plan 138-200% FPL
  • US citizens & legal residents must have insurance
    • Individual mandate
      • Up to 6mil may be penalized (avg $1200/yr)
  • No Pre-Existing Condition denial
    • PCIP dissolve
  • No annual limits
  • FQHC funding increase
  • New Insurance Regulations
    • Essential Health Benefits
access to healthcare with aca coverage expansion 2014 and beyond4
Access to Healthcare with ACA Coverage Expansion: 2014 and Beyond
  • Medicaid up to 138% FPL
    • No categorical qualification
    • Enhanced Federal match (100% -> 90%)
    • States cannot be penalized for not enacting this part
  • Health Insurance Exchanges
    • Income based premium & cost-sharing subsidies
      • (via tax credits)
    • Individuals & businesses up to 100 employees
  • Basic Health Plan
    • Optional State plan 138-200% FPL
  • US citizens & legal residents must have insurance
    • Individual mandate
      • Up to 6mil may be penalized (avg $1200/yr)
  • No Pre-Existing Condition denial
    • PCIP dissolve
  • No annual limits
  • FQHC funding increase
  • New Insurance Regulations
    • Essential Health Benefits
access to healthcare with aca coverage expansion 2014 and beyond5
Access to Healthcare with ACA Coverage Expansion: 2014 and Beyond
  • Medicaid up to 138% FPL
    • No categorical qualification
    • Enhanced Federal match (100% -> 90%)
    • States cannot be penalized for not enacting this part
  • Health Insurance Exchanges
    • Income based premium & cost-sharing subsidies
      • (via tax credits)
    • Individuals & businesses up to 100 employees
  • Basic Health Plan
    • Optional State plan 138-200% FPL
  • US citizens & legal residents must have insurance
    • Individual mandate
      • Up to 6mil may be penalized (avg $1200/yr)
  • No Pre-Existing Condition denial
    • PCIP dissolve
  • No annual limits
  • FQHC funding increase
  • New Insurance Regulations
    • Essential Health Benefits
essential benefits package
Essential Benefits Package
  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care
what are the potential service gaps
What are the potential service gaps?

*Could be part of new structures for reaching “3 aims” such as PCMH

what are the potential service gaps cont
What are the potential service gaps? (cont.)

*Could be part of new structures for reaching “3 aims” such as PCMH

access to healthcare with aca quality financing
Access to Healthcare with ACA Quality & Financing
  • Delivery Systems Reform
    • Prevention
      • New Prevention/wellness fund
      • Free Prevention Services
        • USPSTF
        • HIV screening
    • Pt-centered outcome research
    • Community transformation grants
    • Value Based Purchasing
    • Medicare shared savings program (ACO’s)
    • Hospital readmission reduction
    • Bundled payment pilots
    • HACs payment reduction
  • Financing
    • Tanning salon tax
    • DRG adjustments
    • Medicare Advantage payment restructuring
    • Insurance industry fees
    • New taxes: Medicare, passive income, medical devices
    • Individual/Employer penalties
    • DSH payment adjustments
    • Excise tax on “Cadillac” health plans
access to healthcare with aca quality financing1
Access to Healthcare with ACA Quality & Financing
  • Delivery Systems Reform
    • Prevention
      • New Prevention/wellness fund
      • Free Prevention Services
        • USPSTF
        • HIV screening
    • Pt-centered outcome research
    • Community transformation grants
    • Value Based Purchasing
    • Medicare shared savings program (ACO’s)
    • Hospital readmission reduction
    • Bundled payment pilots
    • HACs payment reduction
  • Financing
    • Tanning salon tax
    • DRG adjustments
    • Medicare Advantage payment restructuring
    • Insurance industry fees
    • New taxes: Medicare, passive income, medical devices
    • Individual/Employer penalties
    • DSH payment adjustments
    • Excise tax on “Cadillac” health plans
bottom line reducing the number of uninsured
Bottom Line:Reducing the Number of Uninsured

Medicaid: 16 million

Income Under 138% FPL

Estimated 32 Million will gain coverage by 2019

Exchange: 16 million

Income 138%-400% FPL

supreme court aca
Supreme Court & ACA

Constitutional Discussion

  • Individual Mandate:
    • Can the Feds compel individuals to purchase health insurance?
  • Medicaid Expansion:
    • Is the ACA’s Medicaid expansion a violation of state’s rights?
  • Severability:
    • Should the remainder of the ACA stand if a portionis struck down?

Supreme Court Decision

Upheld

  • Under Congress’ power to impose taxes

Upheld but…

  • Feds can’t withhold existing Medicaid funds if states forgo expansion

The remainder of the law stands

aca hiv concerns
ACA: HIV Concerns
  • Exclusion of immigrants
  • Ryan White – What’s the future
    • Payer of last resort
    • Wrap-around services
  • Provider reimbursement rates
    • Hospitals hit hard….some will close
    • Medicaid & HIE vs RW
  • Cost containment
    • Critical Focus
  • Doesn’t cover dental, vision
slide35

Larry

Moe

Shirley

slide38

EmployerorPrivateInsurance?

Yes

Employer-based or Private

Insurance

Before 2010

slide39

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

No

Yes

Employer-based or Private

Insurance

Before 2010

slide40

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

No

Yes

Yes

Employer-based or Private

Insurance

Medicaid

Medicare

Before 2010

slide41

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

Other

Affordable

Coverage

Available?

No

No

Yes

Yes

Employer-based or Private

Insurance

Medicaid

Medicare

Before 2010

slide42

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

Other

Affordable

Coverage

Available?

No

No

Yes

Yes

Yes

Employer-based or Private

Insurance

Medicaid

Medicare

  • Other Coverage:
  • State High Risk Pools
  • State-only funded programs

Before 2010

slide43

Ryan

White

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

Other

Affordable

Coverage

Available?

No

No

No

Yes

Yes

Yes

Employer-based or Private

Insurance

Medicaid

Medicare

  • Other Coverage:
  • State High Risk Pools
  • State-only funded programs

Ryan White Wrap-Around Services

Before 2010

slide44

Ryan

White

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

Other

Affordable

Coverage

Available?

No

No

No

Yes

ACA allows State Medicaid expansion to 138% FPL

Yes

Yes

Employer-based or Private

Insurance

Medicaid

Medicare

  • Other Coverage:
  • State High Risk Pools
  • State-only funded programs
  • PCIP

Ryan White Wrap-Around Services

2010-2013

slide45

EmployerorPrivateInsurance?

Medicaid

Or

Medicare

Eligible?

Subsidy Eligible?

Or

Afford HIE?

RW??

No

No

No

ACA “mandates” State Medicaid expansion to 138% FPL w/ no penalty

Yes

Yes

Yes

Medicaid

Employer-based or Private

Insurance

Medicare

Health Insurance Exchanges

????? Ryan White Wrap-Around Services ?????

2014+

larry
Larry

PMD

Private Doctor’s Office

slide47
Moe

KC, MD

Ryan White Clinic

shirley
Shirley

SOB, MD

FQHC

winners losers
Winners &Losers

Private

RW

FQHC

winners losers1
Winners &Losers

Private

RW

FQHC

winners losers2
Winners &Losers

Private

RW

FQHC

winners losers3
Winners &Losers

Private

RW

FQHC

winners losers4
Winners &Losers

Private

RW

FQHC

winners losers5
Winners &Losers

Private

RW

FQHC

winners losers6
Winners &Losers

Private

RW

FQHC

winners losers7
Winners &Losers

Private

RW

FQHC

winners losers8
Winners &Losers

Private

RW

FQHC

winners losers9
Winners &Losers

Private

RW

FQHC

winners losers10
Winners &Losers

Private

RW

FQHC

winners losers11
Winners &Losers

Private

RW

FQHC

winners losers12
Winners &Losers

Private

RW

FQHC

worries
Worries
  • Managed Care
    • Private, Medicare, Medicaid
    • Are providers/patients ready?
      • Formulary issues
        • ADAP rebate heavy
        • Managed care – data driven & generic focused
      • Authorizations
      • Focus on Care Transitions & Cost-containment
      • Contracting
      • Auto-assignment
worries1
Worries
  • Managed Care
    • Private, Medicare, Medicaid
    • Are providers/patients ready?
      • Formulary issues
        • ADAP rebate heavy
        • Managed care – data driven & generic focused
      • Authorizations
      • Focus on Care Transitions & Cost-containment
      • Contracting
      • Auto-assignment
  • Who will help with complex transitions?
  • Ryan White
    • Reauthorized 4 times
    • Will it survive?
    • What will it look like
      • Unlikely to be undocumented immigrant, vision & dental program
  • Will RW Providers survive?
    • Medicaid expansion favors FQHC’s
    • RW Providers are expensive
    • With increased Insurance choices, patients may leave or at least healthiest may leave
what should you do clinics hospitals
What Should You Do?Clinics & Hospitals
  • FQHC alignment
    • Become an FQHC 
    • Align with an FQHC 
      • Co-manage patients
      • Disseminate care to specific FQHC’s and build expertise
  • Managed Care experience
    • Partner with Medicaid managed care providers
    • Are you part of Managed Care Network?
  • State-specific, enhanced reimbursement/chronic disease program (short term $$)
  • Demonstrate Cost Efdfectiveness
    • This means REAL data
what should you do emas counties
What Should You Do?EMAs & Counties
  • Collaborations!
  • Benefits Advocacy
  • Prepare for insured clients with choices
  • Strategize: Ryan White must fill gaps
    • Crosswalk area coverage
  • Policy Advocates
    • Expect many, rapid changes
reason to
Reason to…

Celebrate

Worry

Challenges to HIV exceptionalism

Focus on cost-containment

Will our HIV standards be compromised?

  • Expanded Healthcare for Americans
  • Focus on cost-containment
  • Focus on Quality
    • we have lots of experience with that in HIV