1. Ryan White Part B Services The Impact of State Health Care Reform 2012 HRSA All Grantees Meeting Washington, D.C. November 28, 2012 H. Dawn Fukuda, Director Annette Rockwell, Federal Grants Coordinator Office of HIV/AIDS Massachusetts Department of Public Health

2. Background—Massachusetts  Small state (geographically), densely populated  High incidence jurisdiction  Adequate public transportation system (varies by region)  Early investment in community health centers and safety net hospitals (1990s)  ADAP Insurance Continuation Program (1999)  Medicaid expansion (2001)

3. Massachusetts Medicaid Expansion Lessons for Implementation of ACA  Expanded access to state Medicaid (MassHealth) for low income PLWHA up to 200% FPL irrespective of disability status  Required legislatively mandated allocation in state budget  The program enrolled 225 people under the expansion in 2001, and 1,314 are currently enrolled under the expansion component (2011)

4. Enrollment in HIV Waiver Medicaid (MassHealth) State Fiscal Year (FY)HIV Waiver—Average Enrollment FY04509 FY05675 FY06932 FY071,006 FY081,067 FY091,169 FY101,233 FY111,310

5. Massachusetts Health Care Reform Core Components Chapter 58, Laws of 2006 –Elimination of preexisting condition clauses –Expanded Medicaid eligibility for low income residents –Creation of Commonwealth Connector (“Exchange”) –Private health insurance Subsidies according to income level (<300% FPL) –Health Safety Net for “non-eligible” residents

6. Health Insurance Coverage PLWHA in Massachusetts HIV+ residents <200%FPL eligible for Medicaid HIV+ residents 200% - 300% FPL purchase subsidized health insurance plans— Commonwealth Care Over 300% FPL purchase non-subsidized plans via the Connector (<500% eligible for premium assistance through HDAP) Variety of coverage scopes, prescription medication formularies, deductibles, and co- pays PLWHA may require assistance to navigate coverage options

7. ADAP Role Post HCR Coverage completion services Determination of ADAP Structure –Premium continuation—plan selection –Medication co-payment assistance –Full-pay medication coverage Verification of eligibility as a component of ADAP application and 6-month recertification

8. HIV Drug Assistance Program Expenditures by Category Fiscal YearFull PayCo-PayPremiums FY03 $ 7,961,862.84 $ 963,205.88 $ 1,778,272.33 FY04 $11,174,879.98 $ 1,553,758.50 $ 3,159,200.01 FY05 $ 9,756,201.76 $ 1,839,807.23 $ 6,112,132.85 FY06 $ 4,634,683.35 $ 1,893,206.26 $ 7,015,306.89 FY07 $ 4,147,713.84 $ 2,071,118.94 $ 8,366,273.11 FY08 $ 4,184,279.93 $ 2,083,431.58 $ 9,323,821.42 FY09 $ 4,695,780.40 $ 2,567,789.28 $ 8,835,835.67 FY10 $ 4,635,751.00 $ 2,930,016.65 $ 9,320,425.00 FY11 $ 4,467,727.48 $ 3,175,917.00 $ 10,990,818.00

9. MA HIV Drug Assistance Program Enrollment & Expenditures by Year State Fiscal YearEnrolledTotal Expenditures FY022301 $ 9,716,375 FY032716 $ 10,703,342 FY044399 $ 15,887,838 FY054738 $ 17,708,142 FY064668 $ 13,543,197 FY075141 $ 14,585,106 FY085601 $ 15,591,533 FY095882 $ 16,099,405 FY106543 $ 16,886,192 FY117009 $ 18,634,462

10. Administration of ADAP Administered by third party, Community Research Initiative of New England (CRI) Allows for flexibility in responding to changes in payer environment Ease in processing both premium and full pay claims Expertise in working with different insurers Benefits counseling

11. Issues Related to Insurance Changes to major insurers’ eligibility documentation in the last year –Residency verification –Social Security Number submission Mandate of 90-day mail order Rx refills Increases in deductibles and other out-of-pocket costs

12. Other Ryan White Services Post HCR Ongoing importance of services that are not covered or adequately reimbursed by other payers –Case management –Housing search and advocacy –Benefits Coordination –Adherence counseling –Transportation –Non-traditional mental health –Peer support –Food and nutrition

13. HIV Outcomes Post HCR N= 1,004 Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc.

14. Source: R. Greenwald and M. Ellwood

15. Source: R. Greewald and M. Ellwood

16. Health Care Reform Planning Checklist # 1 Build connections with state Medicaid program Identify allies and formalize connections Review Medicaid application Understand plan types and coverage scopes Train providers about Medicaid eligibility, enrollment process, co-payment obligations, and recertification requirements Consider requiring Medicaid application as a component of ADAP recertification

17. Health Care Reform Planning Checklist—Continued #2 Anticipate cost shifting, realistically Eligibility determination/enrollment takes time Full impact of PPACA may not be fully apparent for years after 2014 Develop structural mechanisms to ensure coverage completion Transition to fund “essential enabling” services that are not 3 rd party reimbursed Calculate impact on collection of medication rebates

18. Health Care Reform Planning Checklist—Continued #3 Review ADAP coverage components Assess the need for premium continuation support for PLWHA over 133% FPL or ineligible for Medicaid Establish mechanism to administer medication co-pay coverage Preserve full-pay coverage during application submission and review period, or when clients lose coverage due to recertification gaps ADAP application process is opportunity to screen for eligibility across coverage options (Medicaid, Medicare, private insurance)

19. Health Care Reform Planning Checklist—Continued #4 Educate Providers and Consumers Develop fact sheets/literature about changing health care landscape Engage consumer advisory boards and planning bodies Identify expertise to support health insurance navigation for HIV+ residents Ensure readiness of the provider community— clinical and non-clinical Develop response plan for populations that will remain ineligible for coverage under HCR

20. Contact Information H. Dawn Fukuda, Director Office of HIV/AIDS Dawn.Fukuda@state.ma.us (617) 624-5303 Annette Rockwell, HDAP & Federal Grants Coordinator Office of HIV/AIDS Annette.Rockwell@state.ma.us (617) 624-5762