Title Date

“We Can Do It!” The New Basics of Health Reform for Frontline HIV Workers Webinar Series

Medicaid Expansion John Peller, AIDS Foundation of Chicago

Malinda Ellwood, Center for Health Law & Policy Innovation at Harvard Law School Anne Donnelly, Project Inform Tweet questions to @hivhealthreform

October 23, 2013 Download the slides & materials at www.HIVHealthReform.org

Follow us at @HIVHealthReform

Use the Question Feature to Ask Questions, or email questions • All attendees are in listenonly mode • Everyone can ask questions at any time using the questions feature • During Q & A segment, the moderators will read questions that have been submitted • You can also email questions to [email protected] • Tweet questions to @hivhealthreform Follow us at @HIVHealthReform

Can’t hear the audio? Use your telephone! • Click on the “audio” tab • Dial the telephone number, access code, and PIN you see on your computer


Download the slides & resources • Go to http://www.HIVHealthR eform.org to download the slides. • Resources and links to info on the ACA for immigrants, trans health coverage, videos, and links to related webinars


About the “We Can Do It!” series • Register at www.HIVHealthReform.org/webinars • Upcoming webinars: – Thurs. Nov. 14 Strategies for states not expanding Medicaid 3 p.m. ET (Cosponsored by Southern AIDS Coalition and NASTAD) – Thurs. Dec. 12 Marketplace In-Depth & How to Speak Insurance 3 p.m. ET

• Webinars & recordings will be archived at www.HIVHealthReform.org • This project is supported by an educational grant from Janssen Therapeutics, Division of Janssen Products, LP. Continuing education credits are not available. AND PLEASE NOTE • This is a 101! We won’t go in-depth. There may be some overlap with past webinars. • We wish we could provide state-specific info but we don’t have the resources. Follow us at @HIVHealthReform

Check out HIVHealthReform.org And watch recent webinars! • “We Can Do It!” Webinar 2: Marketplaces 101 – The New Basics of Health Reform for Frontline HIV Workers. • Health Reform Enrollment Begins on October 1st - Learn How to Pick a Plan! • “We Can Do It!” Webinar 1: Affordable Care Act Overview – The New Basics of Health Reform for Frontline HIV Workers • Health Care Reform Open Enrollment: What HIV/AIDS Housing Providers Need to Know • Get Ready to Enroll! Strategies to prepare your agency, staff & community for ACA open enrollment And many more…


And remember… Clients do not need to do anything if they are: • Are on Medicaid already • Are on Medicare already • Or have health insurance through work – Exception for costly employer-based insurance

AND: You can’t buy Medigap policies on the marketplace. Follow us at @HIVHealthReform

Today’s topics 1. Overview & Context for Medicaid Expansion 2. Benefits & drug coverage 3. The details 4. Payer of last resort


1. OVERVIEW & CONTEXT FOR MEDICAID EXPANSION

Tweet questions to @hivhealthreform


We’ve been fighting for health reform since 1981! • We’ve been fighting for 32 years • We’ll take a massive step forward January 1, 2014

• There WILL be problems and it’s not going to be easy • We need to keep working together to solve these problems and continue to improve health reform Follow us at @HIVHealthReform

Yes, there are bumps in the road! • Demand and interest are causing websites to be unavailable. • This is a good thing – shows how much demand there is • It will slow down! • The real deadline is Dec. 15 for coverage starting Jan. 1, and you can apply through 3/31 • State websites for Medicaid enrollment seem to be working pretty well.


Two major new health reform programs Medicaid expansion

• 26 states have already adopted • 0-138% of FPL • Cover low-income adults without children, even if they are not disabled

Private Insurance Marketplaces

• Website to browse, compare and select private insurance plans • All states • Any income level, but 100-400% get subsidies • The subject of this webinar


What Did the Supreme Court Say About the ACA? • The ACA is constitutional • The Medicaid expansion • Is constitutional… • …but the federal government cannot withdraw existing Medicaid funding from states that do not comply with the expansion • Essentially, this makes Medicaid expansion optional for states Follow us at @HIVHealthReform

States Expanding Medicaid (as of 10/22/13)

Statehealthfacts.org – http://is.gd/eayAGc


Medicaid is far from perfect • Medicaid expansion opponents say: – Concerns re provider access – States can’t afford the programs they have now – Feds could require the states to a higher share of the cost

BUT: • Temporary increase in primary care rates will help with network/provider adequacy • Having Medicaid is far better for enrollees than being uninsured • Once we get people covered, we can advocate for improvements to Medicaid. Follow us at @HIVHealthReform

Medicaid will revolutionize access to care for people with HIV • Traditional Medicaid has a cruel disability standard • Under old Medicaid rules, you have to be so sick you are totally disabled to get access to the health care services that could have prevented you from being sick and disabled in the first place.

• Now in expansion states, Medicaid will allow access to a full spectrum of prevention and treatment services that will help people with HIV to stay healthy before they become disabled Follow us at @HIVHealthReform

Who is eligible for expanded Medicaid? • Childless adults (includes parents with a child over 18, a married couple, etc.) • Ages 19-64 • Income below 138% FPL – $1,321/month or $15,586/year for a single person – Income is calculated using a new simplified MAGI standard

• Citizen or qualified immigrant • Resident of the state No more disability requirement! No more asset test! Follow us at @HIVHealthReform

Childless Adults: A New Medicaid “Door”

Low-income seniors

Low-income families

Low-income people with disabilities


Low-income childless adults

Housekeeping • Use the “questions” feature to ask questions. • Can’t hear? Click the “audio” tab and dial the number and code. • Download the slides at http://www.HIVHealthReform.org • Follow us and ask question live on Twitter @hivhealthreform


2. BENEFITS & DRUG COVERAGE


Medicaid Expansion States - How States Create Benefits Packages for the Newly Eligible •

States participating in the Medicaid expansion must create Alternative Benefit Packages (ABPs) for those who will become newly eligible

•

States choose from among several existing plans to serve as a benchmark for their new ABPs, or they can create a new plan

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ACA provisions allow states to create different ABPs for different populations

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Each ABP for the newly eligible must include services under each of the ten categories of Essential Health Benefits (EHB), and the state must supplement any missing benefits

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Some states are trying to mirror their standard Medicaid benefit as closely as possible

ACTION STEP: Every State must amend their state plans to create these new ABPs, and any state plan amendment must have a public comment period. Watch & weigh in! Follow us at @HIVHealthReform

What benefits are included? Essential Health Benefits • • • • • • • • • •

Federal Guidance/Regulations

Prescription drugs Mental health and substance use disorder services Hospitalization Maternity and newborn care Emergency services Ambulatory patients services Rehabilitative and habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

These are mandatory benefits that cannot be cut, unlike in the traditional Medicaid program. -Example: in traditional Medicaid, State are Implementation prescription drugs “optional”


Decisions

EHB + Medicaid Mandatory Benefits = New Medicaid Benefits Essential Health Benefits (EHB) • • • • • • •

• • •

Prescription drugs Mental health and substance use disorder services Hospitalization Maternity and newborn care Emergency services Ambulatory patients services Rehabilitative and habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

Additional Medicaid Requirements • • • • • • • • • • •

Prescription drugs Mental health services Family planning services Non-emergency transportation EPSDT Inpatient & outpatient hospital services Physicians’ surgical and medical services Laboratory and x-ray services Well-baby and well-child care Emergency services Access to rural health centers and federally qualified health centers (FQHCs)

State must supplement benchmark plan(s) to the extent the plan(s) falls short of EHB and the additional Medicaid Requirements Follow us at @HIVHealthReform

“Medically Frail” definition •

Newly eligible individuals considered to be “medically frail” must have the option to enroll in either the new ABP or the traditional Medicaid package in the state

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“Medically frail” individuals must at least include: – –

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individuals with a serious and complex medical condition, disability, or a physical, intellectual, or developmental disability that impairs daily life. Individuals with serious mental illness and chronic substance use disorders

States can include other populations, and or individuals living with specific chronic illnesses like HIV/AIDS or chronic viral hepatitis

•

Each state must have a way to identify new enrolled individuals who may be medically frail, and then provide them with information about choosing which plan they want (new ABP or the old Medicaid) ACTION STEP: Watch for a state plan amendment containing your state’s proposed definition and comment.


Prescription Drugs in New Medicaid • Must meet the benchmark plan prescription coverage standard (same as private plans on the marketplace): Provide at least the greater of: • •

1 drug in every USP category and class ; or, Same # drugs in each category and class as the EHB benchmark plan

• This is a LOWER standard that in traditional Medicaid, although it’s just a floor • States must have procedures in place that allow a Medicaid enrollee to request and gain access to clinically appropriate drugs not covered by the plan. • Advocates and clients should be aware of continuity of care provisions in their Medicaid program ACTION STEP: Monitor state plan amendments for prescription drug coverage definitions and weigh in. Follow us at @HIVHealthReform

Housekeeping • Use the “questions” feature to ask questions. • Can’t hear? Click the “audio” tab and dial the number and code. • Download the slides at http://www.HIVHealthReform.org • Follow us and ask question live on Twitter @hivhealthreform


3. THE DETAILS


New cost-sharing in Medicaid state option to apply to new & current recipients Inpatient Stay

Outpatient Services

Rx Drugs*

Income below 100% FPL

Maximum of $75

Up to $4

Income between 100150% FPL

Can charge up to 10% of the entire stay

Up to 10% of the visit

Up to $8 for $8 non-preferred drugs; $4 for preferred drugs

Income Can charge up between 150%- to 20% of the 200%FPL entire stay

Up to 20% of the visit

Up to 20% for non-preferred drugs, and $4 for preferred

Non-ER use of the ER

Unlimited costsharing

Total cost-sharing (including premiums) cannot exceed 5% of income on either a quarterly or monthly basis * There must be a way for beneficiaries to receive non -preferred drugs at the preferred level if the prescriber determines that it’s medically necessary Follow us at @HIVHealthReform

Enrollment Timeline

Enroll by December 15 to get coverage on January 1, 2014

Open Enrollment begins October 1, 2013 Runs through March 31, 2014

Plans are active January 1, 2014


There’s no Medicaid enrollment deadline Marketplace open enrollment ENDS MARCH 31, 2014.

BUT - clients can enroll in Medicaid any time.

Ryan White payer of last resort requirements apply.

Some states recently decided to expand Medicaid – coverage may begin later in 2014.


How is income calculated? MAGI Modified Adjusted Gross Income • Modified adjusted gross income • Aligns Medicaid and the marketplace with the tax system • Adjusted gross income from tax form PLUS things like foreign earned income excluded from taxes, taxexempt interest, tax-exempt Social Security income • Examples of income NOT INCLUDED in MAGI: child support, workers comp, and SSI benefits

ASSETS ARE NOT COUNTED under new Medicaid or the Marketplace!

More info: http://laborcenter.berkeley.edu/healthcare/MAGI_summary13.pdf NHELP Advocates Guide to MAGI: http://is.gd/daRXeo Follow us at @HIVHealthReform

What if income changes? • If a client’s income increases during the year: – They can ask to be switched to a marketplace plan (with tax credits and cost-sharing if new income is greater than 138% FPL and less than 250% FPL)

• If a client has private insurance through the marketplace and their income drops below 138% of FPL, they should contact the marketplace and apply for Medicaid – The client will most likely need to file taxes at the end of the year to reconcile the marketplace subsidy (may get money back)

• Watch for disruptions in care – e.g., find a plan that includes the client’s current providers Follow us at @HIVHealthReform

How will clients get medical care? • Many states are placing new enrollees in managed care (new or existing networks) • In most cases, client will choose a plan after their Medicaid application is approved – Make sure clients actively pick a plan and are not auto-assigned to a plan – Important to select a plan that includes their current providers in network and covers their medications

• Find out what your state is doing and educate clients Follow us at @HIVHealthReform

How can clients appeal and when should they appeal? • Can appeal eligibility decisions & coverage decisions • Learn your state’s process for eligibility and services appeals • Find out where you can refer clients for help • Know the timelines for appeals


Monitoring Access to Care and Enforcing ACA Anti-Discrimination Provisions •

Essential Health Benefits are a work in progress subject to review in 2016

•

The ACA prohibits discrimination based on health status and gender (including gender identity & stereotype)

•

If we don’t monitor and enforce our rights we can’t advocate for enhanced benefits and discrimination will be ongoing

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Advocates must document what is working and what isn’t working for people living with HIV – and let our federal and/or state ACA officials hear from us on a regular basis

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We must document & report all HIV-related discrimination and demand a strong response that protects our rights

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Get an HIV representative on state health reform committees


Arkansas & Iowa Medicaid Expansion • AR and IA have requested to use Medicaid expansion $ to help individuals who would ordinarily be eligible for ABPs in an expanded Medicaid program to purchase private health plans in the marketplaces • These individuals should have the same rights and protections as traditional Medicaid • As with ABPs, medically frail individuals must be identified and given the choice to enroll in traditional Medicaid Follow us at @HIVHealthReform

4. RYAN WHITE PAYER OF LAST RESORT

Ryan White Program Payer of Last Resort Requirement • RW funds cannot be used for items or services “for which payment has been made or can reasonably be expected to be made” by another source. (PHS Act) • Grantees must “vigorously pursue” enrollment, “make every effort” to enroll clients, etc. • HRSA enforces the requirement through audits; organization could be liable to repay those costs. Follow us at @HIVHealthReform

Coverage completion: What can Ryan White funds be used for? • Medicaid premiums, out-of-pocket costs for HIV drugs and medical visits (not all states have the capability to do this) • Any Ryan White service not covered by Medicaid or private insurance, such as: – Dental, legal services, case management, treatment adherence counseling, or medically necessary coverage that is limited by Medicaid

• See the policy clarifications: http://hab.hrsa.gov/affordablecareact Follow us at @HIVHealthReform

Payer of Last Resort Rqmt, continued • Ryan White programs will and must continue to serve clients who are not enrolled! • The priority must be to ensure clients don’t drop out of care and have access to appropriate high-quality care. • Be on the lookout for overly aggressive enforcement of payer of last resort and challenge denials of care. Follow us at @HIVHealthReform

Action Steps • Monitor state plan amendments for proposed benefits & drug coverage package & comment • Understand medically frail definition & comment • Learn appeals process (eligibility & services – including prescription drugs) • Monitor for discrimination & access problems and report Follow us at @HIVHealthReform

Get enrollment help • Federal marketplaces - Visit http://localhelp.healthcare.gov and enter your city and state. • Or visit your state marketplace. • Become a Certified Application Counselor (or state equivalent) – http://marketplace.cms.gov/help-us/cac.html

• Check out the Aug. 29 HIVHealthReform.org webinar and resources: Get ready to enroll! http://www.hivhealthreform.org/webinars/#8-29-13 Follow us at @HIVHealthReform

We’re here to help! John Peller AIDS Foundation of Chicago, [email protected] Malinda Ellwood Center for Health Law and Policy Innovation [email protected] Anne Donnelly Project Inform [email protected] Visit www.HIVHealthReform.org Check out the “resources” tab Follow us at @HIVHealthReform

What’s next? • Download & share the presentation and webinar recording (available in a few days) • We need your feedback! When you sign off, take the quick, five-question survey about the webinar • Register at www.HIVHealthReform.org/webinars • Thurs. Nov. 14 Strategies for states not expanding Medicaid 3 p.m. ET


Questions? • Ask your questions using the webinar chat feature. • Or email them to [email protected] • If we don’t get to your question it will be logged and we’ll do our best to follow up! Follow us at @HIVHealthReform

We’re here to help! John Peller AIDS Foundation of Chicago, [email protected] Malinda Ellwood Center for Health Law and Policy Innovation [email protected] Anne Donnelly Project Inform [email protected] Visit www.HIVHealthReform.org Check out the “resources” tab Follow us at @HIVHealthReform