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The Patient Protection and Affordable Care Act Update and Implications Joseph Jefferson, MPH Director of Advocacy and Alliance Development.

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Presentation on theme: "The Patient Protection and Affordable Care Act Update and Implications Joseph Jefferson, MPH Director of Advocacy and Alliance Development."— Presentation transcript:

1 The Patient Protection and Affordable Care Act Update and Implications Joseph Jefferson, MPH Director of Advocacy and Alliance Development

2 1)Assessing the Landscape 2)ACA Implementation Update 3)ACA Patient Protections and Access 4)ACA and Ryan White 5)ACA and Implications for ADAP 6)Informing the Advocacy Agenda

3 Assessing the Landscape



6 HIV/Hep C Surveillance Comparison



9 Providers of HIV Care reported increasing numbers of HIV patients with co-occurring conditions like: – Cardiovascular disease (50%) – Renal disease (49%) – Mental health conditions (48%) – Substance abuse (38%) – Hepatitis C (36%) 58% of HIV Providers are seeing increasing number of HIV patients with sexually transmitted infections

10 Approximately 4,500 HIV providers (MD, DO, NP, PA) in US Fewer than 1/3 of physicians are in private practice – Movement to larger health systems The current HIV workforce composed of first generation providers who entered the field over 20 years ago. —50% of current HIV provider workforce retiring in next 5 to 10 years —Ryan White Part C-funded clinics report difficulty recruiting HIV clinicians



13 Healthy People 2020 (Dec 2010) – Goal: Increase immunization rates and reduce preventable infectious diseases National Viral Hepatitis Action Plan (May 2011) – Increase % of persons aware of HBV infection from 33% to 66% – Increase % of persons aware of HCV infection from 45% to 66% – Reduce number of new cases of HCV by 25% – Elimination of mother-to-child transmission of HBV CDC recommendations on HCV testing for baby boomers (August 2012) Patient Protection and Affordable Care Act (2014) – Focus on prevention

14 ACA Implementation Update

15 Implementation Benchmarks State Notification Regarding Exchanges Closing the Medicare Drug Coverage Gap Medicaid Coverage of Preventive Services Medicaid Payments for Primary Care Medicaid Expansion Individual Insurance Requirement Health Insurance Exchanges Guaranteed Availability of Insurance No Annual Limits on Coverage Essential Health Benefits January 2013January 2014

16 Center for American Progress, March 2013

17 Marketplace (Exchange) Decision Map

18 ACA Patient Protections and Access

19 Guaranteed availability of coverage, regardless of health status or pre-existing condition Prohibitions on discriminatory premium rates, ie. Gender and health status Prohibitions on pre-existing condition exclusions Coverage of “specified” preventive health services without cost-sharing Low-income PWLHs <64 may qualify for Medicaid in states that choose to expand

20 No lifetime or annual limits on coverage Health plans cannot drop people from coverage when they get sick Federal subsidies for people with incomes <400% FPL Plans have to contract with “community providers”, including Ryan White programs Plans must include EHB

21 Increased access to health insurance  HCV testing and treatment – 24% of HCV+ individuals without insurance had any knowledge of their chronic liver disease (compared with 50% among insured) 1 – Studies have found that of HCV-infected individuals in the US who are candidates for treatment, only half have any form of health insurance coverage and can, therefore, access treatment 2 Coverage of preventive services – USPSTF draft recommendations “C” grade for HCV screening among baby boomers (birth cohort) “B” grade for HCV screening among adults at high risk 1 Center for Liver Diseases at Inova Fairfax Hospital; John Cochran, VA Medical Center and Saint Louis University School of Medicine, St. Louis, MO; Michael E. DeBakey, Baylor College of Medicine; and Betty and Guy Beatty Center for Integrated Research 2 Brian Edlin, MD; Center for the Study of Hepatitis C, Weill Medical College of Cornell University


23 Very-low income individuals with income below $15,000 (133% FPL) (22 million by 2014) Eligible for Medicaid based on income alone, (250,000 PLWH -- 2011)* (+175,000 PLWH – 2014)* Ryan White Program will fill gaps not covered by Medicaid (529,000 PLWH – 2011)* (Approx. 80,000 PLWH – 2014*) Individuals earning between $15,000 and $44,000 (134% to 400% FPL) (61 million by 2014) Purchase private insurance with premium tax credits and cost-sharing subsidies Ryan While Program will fill gaps not covered by private insurance People who can never enroll in health care reform programs Ryan White Program will be a safety net for legal immigrants not eligible for Medicaid (5 year ban) or undocumented immigrants (Approx. 80,000 PLWH -- 2014

24 people-with-hiv.aspx

25 Contains $11B in new, dedicated funding for Health Centers Over 8,000 Health Centers currently serving 20 million people Health Centers will provide care and treatment of the vast majority of newly eligible Medicaid patients transferring from ADAP

26 ACA & Ryan White

27 Ryan White will likely not be reauthorized in 2013 – though 2009 reauthorization contains no sunset provision Programs will likely continue in FY 14 and beyond Final FY13 CR did not include $35M for ADAPs and $10M for PartC Sequester likely to result in 5.2% HHS funding reduction Obama FY14 budget provides $20M increase in RW – $10M ADAP; $10 for Part C clinics As Health Care Reform is implemented FQHCs are likely to see an influx of HIV patients

28 HRSA Justification Notes: “The Ryan White Program is authorized through September 30, 2013. However, the program will continue to operate. The 2009 reauthorization or the Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87, October 30, 2009) does not include an explicit sunset clause. In the absence of a sunset clause, the program will continue to operate without a Congressional reauthorization.”

29 HRSA/HAB Considerations: Identify issues as RW beneficiaries transfer to private insurance Reallocate RW dollars toward premium support Create flexible enrollment procedures/timelines Clarify effective coverage dates Network v. out-of-Network care Prior Authorization for both Medicaid and Marketplaces

30 Source: Andrea Weddle, HIV Medicine Association, HIV Medical Provider Experiences: Results of a Survey of Ryan White Part C Programs, Institute of Medicine Committee on HIV Screening and Access to Care, September

31 ACA & Implications for ADAP

32 HealthHIV HealthGram on Medicaid Expansion & HIV Incidence by State and Health Ranking


34 ADAP 2014 Population Estimates

35 Estimated % of ADAP Clients Newly Eligible for Medicaid in 2014: Top Quartile




39 ACA & Payor Shifts

40 Current Payor Current Service Venues Medicaid Private Practice Ryan White / ADAP RW Clinics CHCs

41 Current Payor Post-ACA Payor Current Service Venues Medicaid Private Practice Ryan White / ADAP Marketplaces FQHCs PCMHs

42 Informing the Advocacy Agenda

43 HHS/CMS must: Ensure “Alternative Benefit Plan” is similar to traditional Medicaid Give states flexibility to design multiple ABPs targeting specific populations Extend EHB non-discrimination mandates to ABPs Apply rules governing prescription drug coverage under Medicaid to ABP Apply non-disc protections to drug benefit Include preventive services, including routing HIV and HCV screening Mitigate burdensome cost-sharing proposals by adopting standard established in Medicare Part D low- income subsidy program 2. Advocates must press for Medicaid expansion in states leaning against expansion

44 Essential Health Benefits 1. CMS must: Evaluate and standardize “medical necessity” requirements Develop mechanisms to monitor utilization management techniques, exclusions, and service limits Ensure meaningful stakeholder engagement involvement at Federal and State level in the run-up to EHB framework reevaluation in 2016 – Goal: Higher and more clearly defined national standards Issue clarifying guidance to states to ensure reasonable, accessible, and expedited appeals process regarding benefit and service coverage decisions – including access to most appropriate and effective combination ARV therapy 2. Advocates need to work with CMS to overcome opposition by payers

45 1.Press for national data system and/or standards for hepatitis data collection 1.Press for increased funding for hepatitis prevention 1.Clarify EHB prescription drug coverage standards (given new HCV treatment opportunities in the pipeline) 1.Increase provider and consumer education HCV

46 Washington, DC 20009 202.232.6749 202.507.4727

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