1. The AIDS Institute The Impact of Essential Health Benefits on People Living with HIV/AIDS Carl Schmid Deputy Executive Director ADAP Advocacy Association Annual Conference Washington DC July 8, 2013

2. The AIDS Institute Outline Essential Health Benefits Overview Private plans Expanded Medicaid Current Status Implementation

3. The AIDS Institute Established by ACA as core services health plans required to cover beginning 2014 Applies to: Plans in the individual and small group markets (inside and outside the Exchanges/Marketplaces) “grandfathered” plans exempt Medicaid Expansion plans (Alternative Benefit Plans) Basic Health Plans Estimated to impact 68 million people Essential Health Benefits

4. The AIDS Institute Essentials Health Benefits (EHB) Law outlines 10 broad categories of services that must be covered, leaves to Secretary of HHS to define: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive/wellness services; chronic disease management Pediatric services, including oral and vision care

5. The AIDS Institute CCIIO released bulletin outlining approach for defining EHB (December 2011) We expected Secretary to explicitly define the 10 categories Instead, a benchmark approach States chose benchmark from: 3 largest small group plans in the state 3 largest state employee plans in the state 3 largest federal employee plans Largest HMO in the state’s commercial market Default: Largest small group plan in the state EHB & the Private Market

6. The AIDS Institute Drug benefit: Only one drug in each class covered by benchmark Would be unworkable for certain conditions, such as HIV that require a full formulary Strong patient community opposition Concerns with: Benchmark approach Drug benefit EHB & the Private Market

7. The AIDS Institute Released February 2013 Maintains commitment to benchmark approach Moves away from one drug per class: Proposes the greater of: 1) One drug per US Pharmacopeia (USP) category & class; or 2) Same number of drugs in each category & class as benchmark Much better than initial proposal EHB Final Rule: Private Plans

8. The AIDS Institute

9. Plans in a significant majority of states will have to cover all medicines in two of the HIV/AIDS classes Plans in 48 states (including DC) will be required to cover all Protease Inhibitors Plans in 7 states would be permitted to cover fewer than 75% of therapies in the class of “other ARVs” (or antiretrovirals with different mechanisms of action that are currently not classified based on the USP classification system). ARV coverage in NM and WI especially concerning, other states with poor hepatitis drug coverage EHB Final Rule: Private Plans

10. The AIDS Institute FL selected its largest small group product Blue Cross and Blue Shield of Florida (PPO): BlueOptions 5462 Benchmark antiretroviral and hepatitis drug coverage by class (out of all FDA approved): Total HIV/AIDS Drugs (28/35) Non-nucleoside Reverse Transcriptase Inhibitors (5/6) Nucleoside & Nucleotide Reverse Transcriptase Inhibitors (11/12) Protease Inhibitors (9/11) Anti-HIV Agents, Other (3/6) Anti-hepatitis Agents (12) State Example: Florida

11. The AIDS Institute Did not address what to do with new drugs coming to market during plan year Concerns about using USP system to classify drugs: Updated only every 3 years Combination products not recognized Very broad Requires that plans have procedures to allow access to clinically appropriate drugs not covered by the health plan But no guidance on specific requirements Contains language allowing insurers to “appropriately utilizing reasonable medical management technique(s)” Problems with EHB: Private Plans

12. The AIDS Institute Proposed Rule - January 2013 Utilizes benchmark process Must contain all 10 benefit categories Applies to all enrolled through Medicaid Expansion States permitted to adopt separate benchmarks for special populations “Medically frail” can enroll in traditional Medicaid Medicaid

13. The AIDS Institute EHB Proposed Rule: Medicaid

14. The AIDS Institute Two step process: State selects alternative benefit plan (ABP) from existing Medicaid benchmark: Standard FEHBP BCBS State employee plan Largest commercial HMO plan in the state A Secretary approved plan (including traditional Medicaid) If ABP not a EHB option in private market, state selects a private EHB to backfill benefits missing from benchmark EHB Proposed Rule: Medicaid

15. The AIDS Institute Drug benefit Must cover all drugs made by companies participating in Medicaid drug rebate program States may incentivize use of generics and adopt utilization management techniques, including quantity limits Allows differential cost-sharing for preferred vs. non drugs Proposed co-pays: $8 for each non-preferred drug/$4 preferred Can deter usage/adherence EHB Proposed Rule: Medicaid

16. The AIDS Institute Waiting on Medicaid EHB final rule Coverage begins January 1 Do not know what benchmark states will use CMS and states reviewing adequacy of private plans Will not know what drugs covered until October 1 Will see an uneven coverage from state to state Patient costs also unknown Current Status

17. The AIDS Institute Enrollment for private plans begins October 1 Beneficiary should review plan for Drug adequacy and costs Use of quantity limits, tiers, prior authorizations, etc. Appeals process for medical necessity purposes If not working for patients with HIV/AIDS can appeal to CMS to change process or legislation CMS committed to this process for first two years HIV/AIDS Community needs to monitor Ryan White Program can provide coverage completion services Implementation

18. The AIDS Institute Resources Rules and Guidance EHB Final Rule (Private Plans): http://www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013- 04084.pdfhttp://www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013- 04084.pdf EHB Proposed rule (Medicaid): https://www.federalregister.gov/articles/2013/01/22/2013- 00659/medicaid-childrens-health-insurance-programs-and-exchanges-essential-health-benefits-in- alternativehttps://www.federalregister.gov/articles/2013/01/22/2013- 00659/medicaid-childrens-health-insurance-programs-and-exchanges-essential-health-benefits-in- alternative Essential Health Benefits Coalition Responses to Rulemaking: Proposed Rule (Private Plans): http://www.theaidsinstitute.org/sites/default/files/attachments/coalition%20comments%20on%20n prm%20ehb%20FINAL.pdf http://www.theaidsinstitute.org/sites/default/files/attachments/coalition%20comments%20on%20n prm%20ehb%20FINAL.pdf Proposed Rule (Medicaid): http://www.theaidsinstitute.org/sites/default/files/attachments/coalition%20comments%20on%20n prm%20ehb%20medicaid%20FINAL.pdf Other State benchmark EHB coverage summaries (incl. drug): http://www.cms.gov/CCIIO/Resources/Data- Resources/ehb.htmlhttp://www.cms.gov/CCIIO/Resources/Data- Resources/ehb.html Where states stand with benchmark selection: http://kff.org/health-reform/state-indicator/ehb- benchmark-plans/http://kff.org/health-reform/state-indicator/ehb- benchmark-plans/

19. The AIDS Institute THANK YOU Carl Schmid - cschmid@theaidsinstitute.org 202-462-3042 www.theaidsinstitute.org