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Amy KilleleaBritten PundXavior Robinson August 21, 2014 Plan Assessment and Enrollment: Considerations for HIV/AIDS Programs 1.

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Presentation on theme: "Amy KilleleaBritten PundXavior Robinson August 21, 2014 Plan Assessment and Enrollment: Considerations for HIV/AIDS Programs 1."— Presentation transcript:

1 Amy KilleleaBritten PundXavior Robinson August 21, 2014 Plan Assessment and Enrollment: Considerations for HIV/AIDS Programs 1

2 Webinar Etiquette  Phone lines – Lines will be muted until dedicated question time. – Please do not put your call on hold.  Verbal Questions – There will be dedicated time for questions. – Please wait until the Q & A section to ask questions on the phone. – Please identify yourself when asking a question or providing a comment.  Written Questions – Participants have the ability to submit written questions during the webinar using the “Chat” function  Evaluation – Following the webinar, participants will be taken to a website to complete a brief survey to provide feedback on the webinar. 2

3 Presentation Outline 1.Introduction 2.Plan Assessment Considerations – Cost – Formulary – Provider and pharmacy networks 3.ADAP Insurance Cost Effectiveness Model 4.Questions 3

4 HRSA/HAB Policies and ADAP Insurance Purchasing  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  HRSA is considering allowing ADAP insurance purchasing programs to cover client tax liabilities associated with an overpayment of the PTC 4

5 Top Three Plan Assessment Challenges in Year One ChallengesStrategies and some state- based Marketplaces experienced significant glitches CMS has invested significant resources into improving the performance A number of state- based Marketplaces are also trying to make improvements. Qualified Health Plan (QHP) information was unavailable, inaccurate, or incomplete Final QHP application submissions are due on 9/4/14. Certification notices and QHP agreements are scheduled to be signed by 11/3/14 QHP formulary, and provider and pharmacy networks information were not plan-specific Provider networks and formularies must be directly linked to in the Marketplace, and be plan-specific 5

6 Cost Considerations 6

7 Premiums Monthly payment to plan Out-of-pocket costs DeductiblesCopaymentsCoinsurance 7

8 Medicaid Qualified Health Plan (QHP) Federal Subsidies for Private Insurance: Premium Tax Credits Cost-sharing reductions Exchange/Marketplace Portal Federal Data Services Hub SSN verification via SSA Citizenship and immigration status via DHS Incarceration verification via SSA Title II benefits information via SSA MAGI income from IRS Navigating the Marketplace Web Portal Apply for coverage through Marketplace Screen for Medicaid and subsidy eligibility Evaluate QHP options Select QHP Pay first month’s premium 8

9 ACA Affordability Provisions  Three ACA provisions that make insurance more affordable: – Premium tax credits  Available to people with income 100-400% FPL who have no other public or affordable employer-based coverage – Cost-sharing reductions  Available to people with income 100-250% FPL who have no other public or affordable employer-based coverage – Out-of-pocket caps  2015 maximum amounts: $6,600 individual/$13,200 family  Applies to all Essential Health Benefits (medical AND pharmaceutical benefits)  Only applies to in-network services  Applies to ALL non-grandfathered private insurance plans 9

10 Premium Tax Credits: How They Work and Program Considerations  Premium Tax Credits for the vast majority people with income between 100 and 400% FPL  Tax credit = difference between benchmark premium and taxpayer’s expected contribution – Expected contribution based on annual income and increases from 2% of income to 9.5% as income increases – Consumer may choose to take credit in advance instead of as tax refund – Consumer responsible for overpayment at tax time  Programs should consider: – Requiring clients to take full amount of tax credit in advance – Directing clients to tax preparation resources – Aligning income criteria and verification with MAGI 10

11 201420152016 Premium Tax Credits: How They Work and Program Considerations Consumer earns income and generates a modified adjusted gross income (MAGI) for the 2014 tax year Consumer receives advance premium tax credit and cost sharing reductions based on 2014 MAGI Consumer files 2015 tax return and reconciles 2014 MAGI with 2015 MAGI – and under- /overpayment assessed by IRS Consumers must report changes in income to the Marketplace throughout the year! 11

12  Cost-sharing reductions (CSR) for people with income between 100 and 250% FPL – Increases actuarial value to reduce member contribution – Only available if person enrolls in a SILVER LEVEL plan Household Income AV Level (Silver Level Plans) AV Requirement w/CSR Reduced OOP Maximum Plan Designs 100-150% FPL70%94%~$2,250Deductible Copays Coinsurance 150-200% FPL70%87%~$2,250Deductible Copays Coinsurance 200-250% FPL70%73%~$5,200Deductible Copays Coinsurance Cost-Sharing Reductions 12

13 Assessing QHP Metal Tiers and OOP Plan Costs QHP Metal Tiers What It Means BronzePlan pays 60% of costs (on average)/enrollee pays 40% SilverPlan pays 70% of costs (on average)/enrollee pays 30% GoldPlan pays 80% of costs (on average)/enrollee pays 20% PlatinumPlan pays 90% of costs (on average)/enrollee pays 10% Lower premiums, but less generous Higher premiums, but more generous 13

14 OOP Costs In Action DeductibleOOP CapPrimary Care Visit Specialist Visit In-network$1,500$6,600$25$100 Out-of- network $5,500No cap50% Consumer pays 100% of costs until hit deductible Consumer pays co-pays, co-insurance Once consumer hits OOP cap (for in- network services) plan pays 100% of costs for rest of year 14

15 Client Archetypes: Meet Julie and Murray Julie Age:30 MAGI:$34,470 FPL:300% Resides in Camden, NJ Murray Age:30 MAGI:$17,235 FPL:150% Resides in Newark, NJ 15

16 Affordability Screenshot 16

17 17

18 18

19 The OOP Max for 2015 is $6,600 for individual coverage. Plans have the options of having a reduced OOP Max 19

20 So which plans are the best fit for Julie and Murray? Metal LevelMonthly Premium DeductibleOut-of- pocket Maximum Specialist Doctor Visit Silver$50$100/year$700$30 Gold$105$2,000/year$4,650$30 Platinum$294$0/year$4,500/year$25 Metal LevelMonthly Premium DeductibleOut-of- pocket Maximum Specialist Doctor Visit Silver$266$2,000/year$6,350$35 Gold$321$2,000/year$4,650$30 Platinum$510$0/year$4,500/year$25 20

21 Summary of Cost Considerations for HIV Programs  Require clients to take full amount of tax credit in advance  Direct clients to tax preparation resources  Align income criteria and verification with MAGI  Remind consumers to report changes in life circumstance throughout the year  Preference for silver level plans for clients eligible for cost-sharing reductions 21

22 Formulary Considerations 22

23 Evaluating Scope of Coverage: Prescription Drug Formulary  EHB Standard = same number of drugs per U.S. Pharmacopeia (USP) category/class as state’s benchmark plan USP Category USP Class Anti-viralNRTIs NNRTIs Protease inhibitors Anti-Cytomegalovirus (CMV) agents Anti-hepatitis agents Other Missing from USP classification system = combination therapies 23

24 Comparing Formularies Across Plans Julie Treatment regimen:  Prezista  Norvir  Truvada 24

25 Universal Formulary Utilization Management Techniques 25

26 Utilization Management Noun. set of techniques used by or on behalf of insurance carriers to manage the cost of health care before its provision by influencing patient-care decision making through case-by-case assessments and/or procedures of the appropriateness and cost of care based on accepted practices Examples Include: 1.Quantity Limit 2.Prior Authorization 3.Step Therapy 4.Provider Prescribing Limits 26

27 Assessing Formulary Affordability: Silver vs. Platinum Platinum Plan Silver Plan 27

28 Copayment vs. Coinsurance Copayment A copay is a fixed amount paid whenever a particular type of healthcare service or prescription drug. Coinsurance The consumer pays a percentage of the cost of a healthcare service or prescription drug. 28

29 Putting It Together: Premium Costs and Formulary Affordability Prescription Drug TierUtilization Management DeductibleCost-sharingMaximum Annual Cost Prezista2Prior Authorization, Quantity Limit, Specialty Formulary 0$40/month$480 Truvada20$40/month$480 Norvir30$50/month$600 Subtotal Drug Costs$1,560 Annual QHP Premium$3,528 Total Annual Premium and Drug Costs$5,088 Julie’s Platinum Plan Option 29

30 Putting It Together: Premium Costs and Formulary Affordability Prescription Drug TierUtilization Management DeductibleCost- sharing (50% after deductible) Maximum Unadjusted Annual Cost Prezista2Prior Authorization, Quantity Limit, Specialty Formulary $2,000$320/ Month $3,840 Truvada2$2,000$320/ Month $3,840 Norvir3$2,000$400/ month $4,800 Subtotal Drug Costs ( Adjusted for OOP Maximum)$6,350 Total Annual Premiums Costs$3,192 Total Annual Premium and Drug Costs$9,542 Julie’s Silver Plan Option REMINDER: Platinum Plan Costs = $5,088 30

31 Formulary Considerations  Prioritize plans that cover the consumer’s existing medications regimen – Including single-tablet regimens – Assess formulary exceptions processes  Investigate the utilization management techniques that are in place  Prioritize low-deductible plans with co-payments instead of co-insurance  Weigh premium cost against out-of-pocket maximums, deductibles, and cost-sharing 31

32 Provider and Pharmacy Network Considerations 32

33 Assessing Provider and Pharmacy Networks HIV/Ryan White Providers Must include “Essential Community Providers,” but plans still vary on coverage Pharmacy Network Are ADAP pharmacies (or pharmacies who will coordinate with ADAP) included? Do network pharmacies require mail order? 33

34 Mail-Order Pharmacy Considerations Some QHPs rely heavily on mail-order pharmacies to provide prescriptions. Mail-order pharmacies may have issues coordinating with third party payers such as ADAPs. Considerations Include: – Plan opt out provisions – State laws requiring an opt-out – Pending litigation (e.g. United settlement) 34

35 Dates to Consider for Plan Coverage  Coverage begins with initial on-time payment of premium by consumer – Marketplace plans must accept: paper check, Electronic Funds Transfer, cashier’s check, money order, and pre-paid debit card – Insurer sets deadline for payment of first premium – Insurance may be cancelled for failure to pay first premium by specified deadline set by plan  NOTE: unlike 90 day grace period once coverage begins, there is no initial grace period for late premium payments 35

36 ADAP Insurance Purchasing Checklist See NASTAD Assessment Tool: What is plan’s deductible? What is plan’s out-of-pocket cap (including cost- sharing reductions)? What is plan’s monthly premium (including premium tax credit)? What drugs are covered under plan’s formularies? Are their restrictions associated with drug coverage? What Ryan White services are covered by plan? What providers and pharmacies are included in plan network? 36

37 ADAP Insurance Cost-Effectiveness Model 37

38 How to use the ADAP Insurance Cost- effectiveness Model  Intended to assist in assessing if individual insurance plans are cost-effective. – Information inserted into the tool should be based on an individual insurance plan for an average client, not the total cost of providing insurance for all of your ADAP clients. – The cost-effectiveness model may be used and applied for any private insurance plan, including a qualified health plan (QHP) available through either a state- or federally-run Affordable Care Act (ACA) marketplace.  The tool has been built with two completion approaches: – The first aligned directly with HRSA guidelines outlined in HRSA policy notice 07-05 and 13-05. – The second providing a broader assessment of all costs associated with purchasing insurance. 38

39 HRSA Criteria: Step One 39

40 HRSA Criteria: Step Two 40

41 HRSA Criteria: Step Three 41

42 State Alternative: Step One 42

43 State Alternative: Step Two 43

44 State Alternative: Step Three 44

45 Questions 45

46 Resources  National Alliance of State & Territorial AIDS Directors (NASTAD), – Amy Killelea,  HIV Health Reform,  Treatment Access Expansion Project,  HIV Medicine Association,  HRSA/HAB ACA and Ryan White Resources,  Health Care Reform Resources – State Refo(ru)m, – Kaiser Family Foundation, –, 46

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