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2 Purpose of Webinar  Educate Ryan White grantees about how the ACA helps people living with HIV/AIDS (PLWH) get health coverage  Review new Medicaid coverage options  CMS - Center for Medicaid and CHIP Services (CMCS)  Review new private coverage options  CMS – Center for Consumer Information and Insurance Oversight (CCIIO)  Outline new enrollment and eligibility verification process  CMS and CCIIO  Review what HIV providers need to know  HRSA – HIV/AIDS Bureau & Office of Policy Analysis and Evaluation

3 Health Coverage Options for PLWH BEFORE the Affordable Care Act Note: Data only reflective of Ryan White clients, not of entire HIV/AIDS population; Source: 2010 Preliminary Ryan White Services Report Data (RSR)

4 ACA: Increased Access to Coverage  Provides new opportunities for State Medicaid programs to cover additional adults with low incomes, and simplifies the eligibility rules for Medicaid and CHIP  Establishes Health Insurance Marketplaces to help individuals purchase health insurance coverage (major medical and stand- alone dental)  Provides for advance payments of the premium tax credit and cost-sharing reductions to help certain low-income individuals afford health insurance purchased through a Marketplace  Establishes one streamlined process for eligibility

5 Health Coverage Options for Individuals in 2014 133% FPL Adults 400% FPL 250% FPL Cost-Sharing Reductions Percent of Federal Poverty Level Advance Payment of the Premium Tax Credit CHIP FPL varies by State Qualified Health Plans without Financial Assistance 133% FPL 400% FPL 250% FPL Medicaid (optinal) Medicaid

6 Medicaid in 2014  Simplified Medicaid and CHIP eligibility and enrollment  Expanded Medicaid eligibility  Adult group  100% federal funding from 2014 – 2016; gradually moves to 90% in 2020 and beyond for new adult group  Move to MAGI for most individuals  Standards to ensure coordinated, accurate, and timely processing of eligibility determinations and data sharing to other agencies administering insurance affordability programs  Renewals every 12 months for many

7 Minimum Medicaid Eligibility Levels: Now and 2014 PopulationCurrent Minimum Eligibility Levels 2014 Minimum Eligibility Levels Children & Pregnant Women 100%/133% (Average =241%) ≥ 133% (Varies by state) Parents Varies by state (Average = 64%) 133% Disabled Adults 74% (SSI-related) 133% Other Adults 0%*133%** *Five states provide Medicaid or Medicaid look-alike coverage to certain childless adults; 15 states provide a limited benefit package to certain childless adults. **In states that cover new mandatory group.

8 Market Reforms: Overview Fair Health Insurance Premiums Health status and gender not used to set premiums; limits on age rating Single Risk Pool Issuers cannot use separate risk pools to charge certain customers higher rates Guaranteed Availability Coverage must be offered to all comers, with limited exceptions Guaranteed Renewability Coverage must be renewed for all policyholders, with limited exceptions Market Reforms The market reforms collectively ensure that individuals and employers will have a minimum set of protections with respect to access to health insurance coverage and greater premium stability in all States, both inside and outside the Marketplace.

9  “Marketplaces” were established by the Affordable Care Act (ACA)  New commercial insurance marketplace where eligible small businesses and qualified individuals can shop for private health insurance plans  Consumers will have  more choice and selection in health plans  access to assistance that will help make coverage more affordable What is the Health Insurance Marketplace?

10  Each State can choose to:  create and run its own Marketplace: State-Based Marketplace (SBM)  partner with the Federal government to run some Marketplace functions: State Partnership Marketplace (SPM)  have a Marketplace that’s operated by the Federal government: Federally-Facilitated Marketplace (FFM)  State grant funding to establish a SBM is available through 2014 State Marketplace Options

11 Financial Assistance - Individual Market  Advance premium tax credits:  Will reduce the premium amount an individual owes each month  Available to eligible individuals with household incomes between 100% and 400% of the FPL ($45,960 for an individual and $94,200 for a family of 4 in 2013), and who don’t qualify for other health insurance coverage providing “minimum essential coverage”  Based on household income and family size for the taxable year  Paid each month by the Federal government to the insurer  Reconciled on the taxpayer’s tax return after end of year

12 Financial Assistance - Individual Market  Cost-sharing reductions:  Reduces out-of-pocket costs (deductibles, coinsurance, copayments)  Generally available to those with income between 100% ($11,490 for an individual and $23,550 for a family of 4 in 2013) and 250% FPL ($28,725 for an individual and $58,875 for a family of 4 in 2013)  Also available to American Indians/Alaska Natives who meet the statutory definition of “Indian”  Based on household income and family size for the taxable year

13  Qualified Health Plans (QHPs) must be certified to be offered in a Marketplace. Must meet certain minimum standards.  QHPs will be standardized in 4 coverage tiers with varying actuarial values (percentage of the total allowed cost of benefits paid by an insurance plan) or be a catastrophic plan, available for certain eligible individuals: Insurers in the Marketplace: “Qualified Health Plans” Levels of CoverageActuarial Value Bronze60 percent Silver70 percent Gold80 percent Platinum90 percent

14 Qualified Health Plans and Essential Community Providers  Essential community provider (ECP) are providers who serve predominantly low-income, medically underserved individuals.*  “A QHP issuer must have a sufficient number and geographic distribution of essential community providers…”  On March 26, CMS/CCIIO posted a “non-exhaustive list” of ECPs to assist health insurance issuers in locating ECPs: *ECPs include health care providers defined in section 340(B)(a)(4) of the Public Health Service Act and described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act.

15 Essential Community Providers In 2014, CMS will use a tiered approach to ensure that QHP provider networks meet network adequacy requirements, including the integration of essential community providers:  Safe harbor standard: at least 20 percent of available ECPs in the plan’s service area participate in the issuer’s provider network(s). In addition, the issuer agrees to offer contracts before the coverage year to:  All available Indian providers; and  One ECP per type, per county (where available).  Minimum expectation: at least 10 percent of available ECPs in the plan’s service area participate in the issuer’s provider network(s). In addition, the issuer must submit a narrative justification as part of the QHP Application. Issuers that provide a majority of covered services through employed physicians or a single contracted medical group will be evaluated based on the same percentages, applied to the issuer’s provider locations in certain areas.

16 Essential Community Providers Potential Scenarios Issuers A, B, and C propose service areas in which 80 ECPs are available. Issuer A’s network includes 16 ECPs. Issuer A attests that it has offered contracts to available Indian providers and one ECP in each major ECP category. Issuer A meets the safe harbor standard; no additional documentation is required. Issuer B’s network includes 8 ECPs. Issuer B provides a narrative justification explaining why its network includes only 8 ECPs and how it will ensure service for low-income and medically underserved enrollees. Issuer B meets the minimum expectation. Issuer C’s network includes 10 ECPs. Issuer C fails to provide a narrative justification. Issuer C does not meet the minimum expectation and will receive a deficiency notice from CMS. For an issuer that does not meet either the safe harbor standard or the minimum expectation, CMS will expect the issuer’s application to include a narrative justification describing how the issuer’s provider network(s) will provide access for low-income and medically underserved enrollees and how the issuer plans to increase ECP participation in the issuer’s provider network(s) in future years.

17  Single, streamlined application for enrollment in a QHP through the Marketplace and all insurance affordability programs  Website that provides program information and accepts the single, streamlined application  Coordinated verification policies across Medicaid, CHIP and the Marketplaces (e.g. income, State residency, requesting SSNs)  Standards and guidelines for ensuring a coordinated, accurate and timely process for performing eligibility determinations and transferring information to other agencies administering insurance affordability programs How will PLWH apply for new coverage?

18 Online Phone Mail In Person Submit single, streamlined application to the Marketplace, Medicaid/CHIP Supported, in part, by the Federally-managed data services hub Eligibility for: Medicaid and CHIP Enrollment in a QHP Advance payments of the premium tax credit and cost-sharing reductions Eligibility is verified and determined Online plan comparison tool available to inform QHP selection Advance payment of the premium tax credit is transferred to the QHP Enrollment in Medicaid/CHIP or QHP Enroll in affordable coverage Streamlined Eligibility and Enrollment Process – Medicaid and Marketplace

19  Increased reliance on self-attestation  Primary reliance on electronic sources  A single electronic source for multiple verifications- “the Hub”  Local data sources will also be used  Decreased reliance on paper documentation  May not be the primary source of verification when electronic data sources exist, and may only be requested when electronic data is unavailable or not reasonably compatible A Streamlined Approach to Verification

20  Marketplace makes Medicaid/CHIP MAGI eligibility determinations using State Medicaid/CHIP eligibility rules and standards OR  Marketplace makes initial assessment of Medicaid/CHIP eligibility; State Medicaid and CHIP agencies make the final eligibility determination *For further information regarding options for conducting eligibility determinations, see 45 C.F.R. 155.302 Options for Coordinated Eligibility Determinations through Marketplaces

21 When Can Individuals Enroll?  First Open Enrollment  October 1, 2013 - March 31, 2014  First coverage date is January 1, 2014 for plan selections made by December 15, 2013  Annual Open Enrollment  October 15 - December 7  Coverage begins January 1 of the next year  Consumers eligible for Medicaid and CHIP can enroll at anytime

22 When Can Individuals Enroll?(cont’d) Certain events may allow eligible consumers to enroll during a Special Enrollment Period 1.Loss of minimum essential coverage 2.Marriage, birth, or adoption 3.Gain citizenship or qualifying immigration status 4.Enrollment errors 5.Plan violates their contract 6.Gain or lose eligibility for tax credits or cost- sharing reductions 7.Gain access to new plans as a result of a move 8.Status as an Indian 9.Exceptional circumstances 10.Enrolled in non-qualifying employer coverage

23 Ryan White HIV/AIDS Program - still the Payer of Last Resort  “funds received…will not be utilized to make payments for any item or service to the extent that payment has been made, or can reasonably be expected to be made…”  At the individual client level, this means that grantees are expected to make every reasonable effort to secure other funding instead of Ryan White HIV/AIDS Program funds whenever possible  The RWHAP will continue to pay for items or services received by individuals who remain uninsured or underinsured

24 Recap: Pathways of Coverage for PLWH Medicaid Medicare Employer- Based Insurance Health Insurance Marketplace Other Public Other Private Ryan White Program Cover comprehensive HIV medical and support services not covered by public programs or private insurance PLWH eligible for health coverage PLWH who remain uninsured

25 Premium Sponsorship: Aggregation of Premium Payments  State-based Marketplaces (SBM) have the flexibility to implement a process for premium payment aggregation  Organizations/entities are able to work with issuers or SBMs to establish a premium sponsorship process that facilitates the aggregation of premium payments for a group of individuals  The utilization of an organization’s/entity’s funds for such premium payments may be subject to federal and/or state laws, and/or agency procurement policies and may be used if permissible under law and in accordance with policy  The Federally-facilitated Marketplace (FFM) will not be able to establish a process that would facilitate premium sponsorship or facilitate the ability for organizations to pay premiums on behalf of individuals for Oct. 1, 2013; any third-party payments in the FFM will need to occur through direct work with individuals or issuers

26 What HIV Providers Need to Know  Many PLWH will move to new health coverage options  Marketplaces (private coverage):  QHPs are not required to contract with all HIV providers  Your practice must have appropriate IT and billing infrastructure to participate in plans  Open enrollment for Marketplaces begins October 1, 2013 - make sure you are in-network!  Medicaid:  RWHAP providers do not determine a client’s eligibility for Medicaid- only Medicaid makes final eligibility determinations for participation in Medicaid

27 To-Do List for HIV Providers  Get Involved in Planning  Research what’s going on in your state:  Participate in your local Ryan White Planning group:  Get regular updates from HRSA:

28 To-Do List for HIV Providers  Maximize Payer Options  Private Insurance / Marketplaces  Find out more about QHPs and provider credentialing requirements via your State Insurance Commissioner:  Contact the top three insurers in the small group market in your state to join new networks:  Medicaid Contact your state Medicaid office to join new networks: state.html state.html  Review third-party billing systems and seek TA as necessary

29 Where Can I Obtain Additional Information?  HHS   CMS – Medicaid   CMS – CCIIO   HRSA   For any questions related to RW and the ACA, please email: RWP- ACAQuestions@hrsa.govRWP-


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