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Amy Killelea, NASTAD North Dakota 2014 HIV/STD/TB/Viral Hepatitis Symposium September 18, 2014

ACA and Public Health: Successes, Challenges, and Priorities Moving Forward. Amy Killelea, NASTAD North Dakota 2014 HIV/STD/TB/Viral Hepatitis Symposium September 18, 2014. Presentation Overview. Part 1: ACA Opportunities: Where We Are and Where We’re Going

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Amy Killelea, NASTAD North Dakota 2014 HIV/STD/TB/Viral Hepatitis Symposium September 18, 2014

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  1. ACA and Public Health: Successes, Challenges, and Priorities Moving Forward Amy Killelea, NASTAD North Dakota 2014 HIV/STD/TB/Viral Hepatitis Symposium September 18, 2014

  2. Presentation Overview • Part 1: ACA Opportunities: Where We Are and Where We’re Going • Part 2: Implementation in Action: • Preparing for outreach and enrollment into new ACA coverage options • Assessing and filling coverage gaps • Assessing and filling affordability gaps • Preparing providers for a changing health care landscape • Questions/Discussion

  3. About NASTAD • NASTAD is an international non-profit 501(c)(3) association of U.S. state health department AIDS directors who administer HIV/AIDS and viral hepatitis programs funded by U.S. state and federal governments • NASTAD was established in 1992 as the voice of the states • NASTAD is governed by a 20 member, elected Executive Committee (EC) charged with making policy and program decisions on behalf of the full membership • NASTAD has a Washington, DC headquarters and field offices/programs in Bahamas, Botswana, Ethiopia, Haiti, Mozambique, South Africa, Trinidad, Uganda and Zambia

  4. Part 1 ACA Opportunities: Where We Are and Where We’re Going

  5. ACA: Three Prongs • Medicaid expansion • Medicare Part D reforms • Marketplaces • Prohibitions on discriminatory insurance practices • Investments in community health centers, health workforce, coordinated care, and prevention

  6. ACA Insurance Expansions Federal Poverty Level (FPL) 66% of Ryan White Clients had income below 100% FPL (in 2011) Current Medicaid/CHIP Eligibility

  7. Where States Stand on Medicaid Expansion Source: Kaiser Family Foundation, August 28, 2014

  8. Part 2: Implementation In Action

  9. ACA and Public Health ProgramsYear One: Redux

  10. Over 25,000 ADAP Clients Transitioned to Medicaid Expansion and Qualified Health Plans (as of May 2014) NH VT WA ME ND NY MT MN OR WI SD MI ID CT WY PA NJ OH IA NE IN DE NV IL CO WV UT KY VA MD KS MO CA NC DC TN OK AZ AR SC NM GA AL MS AK TX LA FL HI

  11. ACA Outreach and Enrollment Programs and Resources HIV/AIDS Care Programs and Providers HIV Prevention Programs ?

  12. Coordinating Enrollment to Ensure No Disruptions in Care

  13. Recap of 2014 Open Enrollment: Top Four Challenges and Solutions

  14. New Coverage Opportunities Laboratory services Prescription drugs Emergency services Hospitalization Mental health and substance use disorder services Preventive and wellness services Maternity and newborn care Pediatric services Rehabilitative and habilitative services Ambulatory services • Plans must cover 10 Essential Health Benefits (EHB) • Scope of coverage will vary – but clients and providers should look for THREE things: • Does the provider network include HIV providers? • Does the formulary include client’s treatment regimen? • How much does the plan cost?

  15. New Coverage Opportunities for Prevention

  16. Coordination Across Payers:Translating Coverage into Care and Treatment Adapted from West Virginia Ryan White Part B Program

  17. Example: Case Management Coverage

  18. Significant Coverage Gap: Prescription Drug Formulary Missing from USP classification system = combination therapies EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan

  19. Assessing Qualified Health Plan (QHP) Metal Tiers Lower premiums, but less generous Clients must enroll in a silver level plan to get cost-sharing reductions Higher premiums, but more generous • Premium tax credits to help offset cost of Qualified Health Plan premiums available for people with income up to 400% FPL • Cost-sharing reductions to reduce out-of-pocket costs available for people with income up to 250% FPL

  20. Assessing and Filling Gaps in Affordability • Other insurance purchasing considerations: • Does plan meet HRSA/HAB insurance purchasing requirements (cost-effectiveness and formulary adequacy) • Are providers and pharmacies in the plan network? • Which plans have co-pays instead of co-insurance? Affordability Gaps Will Remain…

  21. ADAP/Part B Programs Currently Purchasing Qualified Health Plans (QHPs) for Clients (June 2014) NH VT WA ME ND NY MT MA MN OR WI RI SD MI ID CT WY PA NJ OH IA NE IN DE NV IL CO WV UT KY VA MD KS MO CA NC DC TN OK AZ AR SC NM GA AL MS AK TX LA FL HI ADAP purchasing QHPs (premiums, Rx co-pays, or deductibles) ADAP piloting QHP purchase ADAP not currently purchasing QHPs (most are planning)

  22. Assessing the Gaps: Planning for Public Health Safety Net • Even after full ACA implementation, there will be populations left out of reform: • Low-income individuals in states that do not expand Medicaid • Undocumented populations • Hard-to-reach “eligible but not enrolled” populations

  23. HRSA/HAB ACA Policies • HRSA encourages state ADAP/Part B Programs to use their Ryan White funding to help clients access insurance, as long as: • Formulary includes at least one drug in each class of core ARVs from the HHS Clinical Guidelines • It is cost-effective in aggregate as compared to purchasing medications • Other Ryan White Program grantees may also use their funds to help clients with the cost of insurance • The Ryan White Program is the payer of last resort and grantees must “vigorously pursue” client eligibility for public and private insurance • Grantees may not dis-enroll clients from services for failure to enroll in public or private insurance coverage • Ryan White Program funds may be used to cover services not covered or inadequately covered by public and private insurance

  24. Preparing Providers for Health Reform

  25. Leveraging New Resources/Payers: It’s Complicated! Translate public health service into language of payers/insurance (e.g., CPT codes) Assess provider requirements (licensed provider; provider supervision; provider recommendation; setting) Compare reimbursement rate (within capitation or FFS) with cost of providing service Are privacy and confidentiality concerns addressed?

  26. A Changing Public Health Role • NHAS Goals • Reduce new infections • Increase access to care • Reduce health disparities ACCOUNTABILITY • State Health Departments • Prevention programs • Surveillance programs • Safety net care and treatment programs • Medical Providers • Private physicians • Community health centers • Hospitals • Specialty clinics • Community-Based Providers • Community-based organizations • Outreach workers • Peers • Payers • Private • Qualified Health Plans • Other private insurers • Public • Medicaid • Medicare

  27. Questions

  28. Resources • National Alliance of State & Territorial AIDS Directors (NASTAD), www.NASTAD.org • Amy Killelea, akillelea@nastad.org • HIV Health Reform, http://www.hivhealthreform.org/ • Treatment Access Expansion Project, www.taepusa.org • HIV Medicine Association, www.hivma.org • Health Care Reform Resources • State Refo(ru)m, www.statereforum.org • Kaiser Family Foundation, www.kff.org • Healthcare.gov, www.healthcare.gov

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