Affordable Care Act

1. Affordable Care Act What an HIV Provider Needs to Know Steve O’Brien, MD January 28, 2013

2. Pacific AIDS Education Training Center Steve O’Brien, MD

3. Pacific AIDS Education Training Center Steve O’Brien, MD

4. Agenda • What is ACA? • What can Providers & Patients expect? • How will patients access care? • How do we prepare for ACA?

5. Affordable Care Act(ACA) • Goals: • Expand access to care • Reduce uninsured • Payment reform & innovation • Implement 2010-2014

6. Affordable Care Act(ACA) • Goals: • Expand access to care • Reduce uninsured • Payment reform & innovation • Implement 2010-2014 Ryan White HIV ACA

7. Affordable Care Act(ACA) • HIV treatment expansion • Individual Benefit • Early treatment • Community Benefit • Transmission VL related • 37% in treatment

8. Affordable Care Act(ACA) • HIV treatment expansion • Individual Benefit • Early treatment • Community Benefit • Transmission VL related • 37% in treatment

9. National HIV/AIDS Strategy • Goals • Reduce new infections • Increase access to care • Reduce HIV health disparities • ACA key to achieving goals

10. How Does ACA Affect Access to Care ?

11. Access to HealthcareBefore 2010 • Employer sponsored insurance • Most prominent source of insurance • Less with HIV pts

12. 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

13. 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

14. HIV Patient’s Insurance Coverage2010

15. 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

16. 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

17. 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

18. Medicaid Childless Adult Coverage & ADAP Waiting List

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. What are the potential service gaps? *Could be part of new structures for reaching “3 aims” such as PCMH

27. What are the potential service gaps? (cont.) *Could be part of new structures for reaching “3 aims” such as PCMH

28. Huge Portions of Traditional RW Programs and Services are NOT Covered!!!!

29. 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

30. 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

31. 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

32. 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

33. 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

34. What are the practical implications of ACA implementation?

35. Larry Moe Shirley

36. Before 2010

37. EmployerorPrivateInsurance? Before 2010

38. EmployerorPrivateInsurance? Yes Employer-based or Private Insurance Before 2010

39. EmployerorPrivateInsurance? Medicaid Or Medicare Eligible? No Yes Employer-based or Private Insurance Before 2010

40. EmployerorPrivateInsurance? Medicaid Or Medicare Eligible? No Yes Yes Employer-based or Private Insurance Medicaid Medicare Before 2010

41. EmployerorPrivateInsurance? Medicaid Or Medicare Eligible? Other Affordable Coverage Available? No No Yes Yes Employer-based or Private Insurance Medicaid Medicare Before 2010

42. 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

43. 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

44. 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

45. 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+

46. Larry PMD Private Doctor’s Office

47. Moe KC, MD Ryan White Clinic

48. Shirley SOB, MD FQHC

49. Winners &Losers Private RW FQHC

50. Winners &Losers Private RW FQHC