ADAP ADVOCACY ASSOCIATION PRESENTATION Monday August 4, 2014

1. ADAP ADVOCACY ASSOCIATION PRESENTATION Monday August 4, 2014 Denver Digital Photography

2. Transitioning ADAP Clients to Medicaid & Marketplace Plans: The Colorado Success Story Todd Grove Colorado Department of Public Health & Environment – AIDS Drug Assistance Program Rich Wolf Digital Photography

3. Other Federal and State Programs • Medicaid • Colorado Indigent Care Program (CICP) • Medicare • Tobacco class action lawsuit funds

4. Colorado AIDS Drug Assistance Program

5. Cost& Clients Served -2013 HMAP … 2,039 enrollees – 42,150 prescriptions $12,571,539.58* HIAP …690 – 10,887 prescriptions $1,022,003.61* $1,125,840 premiums, deductibles and co-pays BTGC … 869 enrollees - 26,189 prescriptions $1,320,628.07* Data provided by Colorado Department of Public Health & Environment

6. What makes Colorado unique, (and may make duplication difficult) • Allowed for innovative use of monies: • Creation of a Medicare State Pharmaceutical Assistance Program • Reimbursement of insurance premiums, as necessary • Payment of inpatient medical care • HIV incidence in Colorado is “moderate” and efforts would be extremely difficult to emulate in higher incidence states, particularly those without local funding of any sort / states that did not expand Medicaid • Colorado had the nation’s largest ADAP waitlist in 2004 • 315 people • Provided only 18 drugs (strictly ARV) • Advocacy resulted in over $1 million in General Funding and over $3 million in tobacco class action lawsuit funds per year • Legislation allowed for ADAP committee to direct $$, with approval of the Medical Director

7. Colorado’s decisions related to the Affordable Care Act • Expanded Medicaid (including AwDC) to 133% of Federal Poverty Level –MAGI • Created an effective state-based insurance marketplace w/ improved Medicaid interaction • Supportive environment for enrollment outreach • Democratic Governor • Democratic majorities in both State House and Senate Denver Digital Photography

8. Colorado’s efforts to transition enrollees to ACA plans • Became a non-funded partner of Health Coverage Guide network sanctioned by the marketplace “Connect for Health Colorado” • Paid for 14 individuals during open enrollment to enroll members in Medicaid, or ADAP-approved marketplace insurance plans with complete ADAP wrap-around • Identified Medicaid-eligible members on Health Insurance assistance to transition to Medicaid (waiver offered) • Co-located staff at larger HIV clinics to apply patients for Medicaid on-line • Purchased IT to allow Health Coverage Guides to patient homes or other locations to facilitate enrollment • Completed multiple attempts to outreach to members • Required a formal request to remain uninsured if they refused • Considering “off-marketplace” insurance options for undocumented patients next year

9. 25,000+ ACA-related Transitions Facilitated by State HIV Programs** NH VT WA ME ND NY MT MN OR WI SD MI ID CT WA WY PA NJ OH IA NE MT IN DE NV IL OR CO WV UT KY VA MD KS MO ID CA WY NC DC TN OK AZ NV AR SC NM GA CO AL UT MS AK CA TX LA FL AZ NM AK HI HI Source: NASTAD **Through end of March 2014

10. Colorado ADAP / Insurance Status after Implementation Uninsured using CICP and HMAP in 2013 Uninsured after HCR implementation – ryan WHITE 2,100 individuals 300 individuals 1,181 insured patients Insured after HCR implementation 400 new HIAP members 1,390 Medicaid /SWAP members 110 new HIAP members

11. Ryan White Case Management Roles and Duties CDPHE, DCAP, ADAP OFFICE AIDS Service Organizations & Social Service Entities CDPHE ADAP Office and Denver CAP for HIAP • Program management • Financial management • Eligibility and enrollment verification • Auditing/quality assurance Social Workers, Medical & Non- Medical Case Managers • All program areas • Eligibility and enrollment assistance • Trouble shooting and client support • Health Insurance Assistance Program Coordination • Located at BCAP, DCAP, NCAP, SCAP & West CAP • Coordination of premium, co-insurance, and co-payments • No requirement for case management (can remain with other ASOs) • Coordination of enrollment into marketplace by Health Coverage Guides HIAP Coordination Entities

12. Health Insurance Assistance Program (HIAP) • Wraps around employer, COBRA, and ACA marketplace insurance plans • Pays remaining costs of marketplace insurance after the APTC and Cost sharing assistance available has been applied • Pays premiums, medical and pharmaceutical deductibles, co-pays, and coinsurance • Up to $10,000 in aggregate per client • Works with providers who are willing to bill for services • Pays for prescriptions through a Medication Assistance Card. • Assistance in enrollment through Connect for Health Colorado marketplace

13. Insurance Enrollment Sites Boulder County AIDS Project Colorado AIDS Project Northern Colorado AIDS Project Southern Colorado AIDS Project Western Colorado AIDS Project

14. Supplemental Wrap Around Program (SWAP) • New ADAP program to cover all Medicaid-eligible clients with medication co-pay coverage for ADAP formulary • Members will be able to use many more pharmacies if they choose (rather than 4 previous ADAP pharmacies) • Recertification process easier (as member would have been screened eligible for Medicaid) = eliminates need for supporting documentation – income, residency. • ADAP suggests that patients continue to use HMAP network pharmacy at least at first - easy movement to HIAP, or to HMAP if “churning” is an issue – allows for back-billing.

15. The problem of “CHURN” Problems presented by loss of Medicaid Problems presented by loss of job/ eligibility for marketplace insurance • Loss of Medicaid may mean up to 45 days until access to insurance is established; • Enrollees can receive medication assistance for ADAP formulary drugs only through that time • May not qualify for CICP or the facility may not offer CICP • Enrollees often fail to notify ADAP of change in situation • Enrollees need to notify marketplace of change in income affecting eligibility; tax penalties and credits difficult to manage by the program • Enrollees may not be able to access same providers under Medicaid, or may have a waitlist

16. How to improve % of clients who recertify every six months Implications of not recertifying Benefits to enrollee • Can’t get medications, (missed doses, would have to pay own costs) • HIAP can’t pay premiums or pay medical co-pays until recertification is complete • Medicaid and marketplace may not be told of changes of income – affect eligibility and APTC/ cost sharing • Patients are used to being able to miss recertification and rectify the situation with relative ease • Colorado is working on a system where recertifying with ADAP would make individuals recertified for all Ryan White services • With a loss of Medicaid or insurance temporarily, enrollees can get medication through HMAP • Members can get assistance in enrolling in the proper assistance program • Instituting text message reminders

17. Significant financial effect already: UNINSURED PATIENTS INSURED PATIENTS • From an average of 1,300 patients provided direct medications in fall 2013, the average has dropped to 300 (largely categorically ineligible for Medicaid or insurance, or CHURN members) • From over $1.2 million in costs, estimates after back-billing to Medicaid are $300,000 in expenses per month. • Increased budget for Health Insurance by close to $2 million dollars • Much smaller investment required for Medicaid wrap -around Denver Digital Photography

18. Net effect & concerns: REBATE INCOME IMPLICATIONS of lost income • Robust application for partial pay rebates have provided significant program income • HRSA requires states to spend rebate income BEFORE Ryan White dollars • Results in large unexpended balance that may be “carried forward”, but will return to HRSA for redirection to other states if not spent in time • While morally correct to do so, any change in ability to apply for rebates would cause huge decrease in revenue…and lost Ryan White dollars would be desperately needed again • Successful management of Ryan White and funding offered by individual states will be redirected to states who refuse to expand Medicaid or invest in the epidemic in their own states

19. Innovations to “Get to Zero” PREVENTION and CARE • Prevention planning to include discussion of biomedical components such as nPEP and perhaps even PrEP • Prevention planning may include targeted $ resources to assist high risk HIV – individuals to seek behavioral health interventions and other preventative financial assistance Denver Digital Photography

21. Continuum of Care – Picture for ADAP Members

22. The post-ACA approach to HIV care: • Focus on services that are proven to help people move through the cascade toward viral suppression • If a person is eligible for Medicaid, Medicare, or commercial insurance, the Ryan White Program is required to “vigorously pursue enrollment“ of the person in these types of coverage • If there is a service that would help move people through the cascade but cannot be funded from a third party payer, Ryan White funding can be used to pay for that service. • Monitor how well the entire system of care is assisting with achievement of viral suppression, not just the long-standing Ryan White system.

23. Helping People Move Through the Cascade Achieve Viral Suppression Retained in Care Linked to Care First Diagnosis with HIV

24. The Process is NOT Linear Linked to Care Retained in Care First Diagnosis with HIV Re-Engaged Achieved Viral Suppression Lapsed in Care

25. Ryan White services are critical to engagement in care ADAP Advocacy Association Jeffrey S. Crowley Distinguished Scholar/ Program Director, National HIV/AIDS Initiative O’Neill Institute Georgetown Law

26. Innovation in the use of DIS, LTC and RTC personnel PROVIDE RESOURCES AS NECESSARY to ensure successful linkage to care and treatment • Disease Investigation Specialists – immediate linkage to enrollment services in ADAP, Medicaid, and Ryan White $$ when a patient has not enrolled in coverage • Linkage to Care – in addition to above, assessment of substance abuse, mental health issues, and access to resources through “Critical Event” pilot (described later) • Retention in Care personnel from State Health & partner agencies reviewing patients who appear to have dropped out of care, again, with $$ resources to assist – including housing, inpatient mental health and substance abuse treatment, medical transportation –

27. Critical Event Initiative What is a “critical event”? • An event that makes it much more likely a client will drop out of medical care or never seek medical care to begin with. • A “marker” for a destabilizing crisis. • A severe challenge to a client who wants to achieve and maintain viral suppression.

28. CE is an enhancement • Focused on short term stabilization (<90 days) • More structured approach to submitting and approving requests • Expedited and simplified for clients • Focused on clients at greatest risk of not achieving viral suppression • Uniform eligibility and assistance statewide • Coordinated across agencies and providers • Is not affected by funding shortages at local agencies

29. Two Targets for the Pilot • Newly diagnosed with HIV • (within the prior 90 days) • Recently lapsed in care • (within the prior year)

30. Critical Events for the Pilot • Recently homeless (within prior 90 days) • Recently unemployed (within prior 90 days) • Diagnosed with gonorrhea, syphilis, or chlamydia (within prior 180 days) • Worsening health status due to hepatitis C (within prior 180 days) • Named as a partner, potentially infected someone with HIV (within prior 180 days) • Domestic violence (within prior 180 days) • Diagnosed with another acute illness requiring complex medical treatment or hospitalization, such as cancer (within prior 180 days) • Evidence based screening shows potentially severe addiction or drug dependence. • Evidence based screening shows potentially severe mental illness.

31. Additional protocol provisions • Clients with multiple critical events prioritized higher than clients with a single critical event. • State health staff and community agencies use same data system to track requests, plans, budgets, client progress, and case closure • The process starts with a “CE Form” submitted by state health staff or contractor • Evaluation of requests coordinated by a state health staff person • Each request has a “sponsor” at state health

32. How is CE different from the support already available to clients? • Existing Public Health Order (PHO) Process • Only a small range of critical events are related to a PHO. • Enhanced services are offered in lieu of, or as part of, a public health order. • If the client is determined not to meet PHO criteria, no enhanced services are offered. • Less involvement of community contractors • Existing processes for housing, EFA, etc. • Clients experiencing critical events use the “standard” process to request assistance. • Different levels of assistance and FPL eligibility based on place of residence (TGA) • Data sharing issues being addressed by statewide taskforce – would those in need want to identify themselves to state health for fear of incrimination or disease investigation concerns?

33. Questions

34. Contact information: Todd Grove ADAP Coordinator Colorado Department of Public Health & Environment 303-692-2783 todd.grove@state.co.us www.colorado.gov/pacific/cdphe/services-people-hiv https://www.facebook.com/COADAP Rich Wolf Digital Photography

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