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Emily McCloskey National Alliance of State & Territorial AIDS Directors August 4, 2014 ADAPs and the First Open Enrollment Period.

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Presentation on theme: "Emily McCloskey National Alliance of State & Territorial AIDS Directors August 4, 2014 ADAPs and the First Open Enrollment Period."— Presentation transcript:

1 Emily McCloskey National Alliance of State & Territorial AIDS Directors August 4, 2014 ADAPs and the First Open Enrollment Period

2 Presentation Agenda  Inaugural Open Enrollment  ADAP Transitions  Looking Forward

3 Overview of NASTAD  NASTAD is an international non-profit association of U.S. state health department HIV/AIDS program 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 charged with making policy and program decisions on behalf of the full membership.  NASTAD has a Washington, DC headquarters with 38 staff and field offices/programs in Bahamas, Botswana, Ethiopia, Guyana, Haiti, Trinidad, South Africa and Zambia with 65 staff.

4 NASTAD Mission and Vision Mission NASTAD strengthens state and territory-based leadership, expertise and advocacy and brings them to bear on reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis. Vision NASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.

5 Inaugural Open Enrollment

6 Enrollment into Coverage: Where States stand on Medicaid Source: Kaiser Family Foundation Implementing Expansion in 2014 (27 States including DC) Open Debate (5 States) Not Moving Forward at this Time (19 States)

7 The Inaugural Open Enrollment Period  A multitude of challenges: – Healthcare.gov and state exchanges – 3 rd party payer issues – Limited coordination between Marketplaces and Medicaid – Availability of plan information – Formulary gaps – High cost sharing/co-insurance – Political environment in many states made it difficult for state employees to participate in ACA implementation activities – Many clients remain ineligible because their state has not expanded Medicaid

8 Insurance Assistance and Premiums: 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

9 ADAP Transitions

10 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

11 25,000 ADAP Clients Transitioned to Medicaid Expansion and Qualified Health Plans (QHPs) AL AR GA ID IL IN KY MO MT NV NH OH SC SD TX VA WY OK ME MD NJ NY OR AK CO LA UT CA KS MS FL HI NM AZ ND MN IA WI MI NE WA PA NC TN WV VT DE CT DC MedicaidQHPsTotal 12,00413,12925,133

12 Enrollments in the West ID MT NV WY OR AK CO UT CA HI NM AZ WA 11,063 Enrollments MedicaidQHPs 8,8372,226

13 Enrollments in the Midwest IL IN MO OH SD KS ND MN IA WI MI NE 7,508 Enrollments MedicaidQHPs 1,0136,495

14 Enrollments in the East NH OH ME MD NJ NY PA WV VT DE CT DC MA RI 1,866 Enrollments MedicaidQHPs 1,312554

15 Enrollments in the South MedicaidQHPsTotal 8423,8544,696 AL AR GA SC TX VA OK LA KY MS FL NC TN WV

16 Leveraging the ACA to Raise the Bars: Translating Coverage into Care and Treatment SERVICEQHPMEDICAIDRW/ ADAP/CDC HIV TestingContinue to cover in certain settings RXCost-sharing assistance MEDICAL CASE MANAGEMENT ORAL HEALTH LABSCost-sharing assistance MENTAL HEALTH SERVICES Cost-sharing assistance SUBSTANCE ABUSE TREATMENT Cost-sharing assistance HIV PRIMARY CARECost-sharing assistance MEDICAL TRANSPORTATIONLimited Coverage INPATIENT HOSPITAL SERVICES Adapted from West Virginia Ryan White Part B Program

17 Looking Forward

18 Enrollment into Coverage: Key Dates 15 th 31st Qualified Health Plans MARCH Enrollment Deadline for a Plan Effective Date of April 1 st Enrollment Deadline for a Plan Effective Date of May 1 st Deadline to switch plans Medicaid CONTINUOUS ENROLLMENT November 15, 2014 to February 15, 2015 Next open enrollment period pushed back 2015 QHP Open Enrollment Period 31 st PCIPs April 30 th PCIP coverage ends

19 Enrollment into Coverage: Mapping ACA Coverage Transitions Uninsured Lawfully present Income up to 138% FPL Medicaid Uninsured Lawfully present Income % FPL Subsidized private insurance through Marketplace Uninsured and in non-Medicaid expansion state Lawfully present Income below 100% FPL Unsubsidized private insurance through Marketplace Currently on MedicaidNo transition Currently on other government- sponsored insurance (e.g., Medicare, TRICARE) No transition Currently on or have access to employer-based coverage If plan is affordable and comprehensive, no transition Currently on PCIP or high risk poolMedicaid or Marketplace coverage Uninsured & categorically ineligible for federal programs No transition Grantees are defining how to“vigorously pursue” client eligibility for Medicaid and QHP coverage Churning

20 Addressing the “Medicaid Gap” in Non-Expansion States Ryan White Programs are:  Purchasing insurance for those in the “Medicaid Gap”  Providing safety net for those who cannot afford insurance or who are not otherwise eligible To help fill the gap…

21 Challenges and Priorities Challenges Availability of plan information Formulary gaps High cost sharing/co-insurance Political environment in many states made it difficult for state employees to participate in ACA implementation activities Many clients remain ineligible because their state has not expanded Medicaid Priorities/Solutions Advocate for Medicaid expansion Increase Ryan White capacity to assist clients with costs Identify work-arounds to obtaining insurance information Advocate with federal government, state government, and insurers about importance of formulary coverage for ALL ARVs Continue to educate clients about ACA and prepare for continued enrollment efforts in November

22 Questions and Answers

23 Contact Information Emily McCloskey Manager, Policy and Legislative Affairs NASTAD Phone: (202)


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