ACA Implementation and the Border Focus on HIV, as well as STD, TB, Addiction & Family Planning Concerns

Alphabet Soup: ACA, HIV, SUD, TB, and HCV on the BorderJune 20, 2014

Tom Donohoe, MBAAssociate Professor of Family MedicineDirector, UCLA Pacific AIDS Education and Training CenterAssociate Director, UCLA Center for Health Promotion and Disease Prevention

David Geffen School of Medicine at UCLA

#

I have already seen you present on the ACA(in-person, webinar, etc)

TrueFalseI dont remember#

Yesb. Noc. Im not sure

Talking PointsAnswer: No. How many ACA-related trainings have you already attended (last 12 months)?

01-23-45 or more#

Declaration of DisclosureI do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter#

Read during opening.Educational Objectives 1State the importance of understanding ACA implementation for California and Arizona and how it will impact border communities & people living with HIV, TB, HCV, and SUD

Identify key dates for ACA roll-out and strategize to effectively implement the ACA locally#

At the end of this training participants will be able to(read objectives)Educational Objectives 2Explain how the ACA will extend new insurance benefits and patients rights and responsibilitiesImprove HIV patients engagement (linkage & retention) in high-quality HIV care as systems changeObtain further information and referral resources for ACA implementation in the border region as more patients become enrolled#

(read objectives)Which best describes WHERE you work?

ClinicCommunity-based organizationHealth departmentUniversityHospitalOther#

Which best describes WHAT you do?

Clinician (MD, PA, NP, nurse, dentist, etc)Case managerHealth education (peer educator, promotora)Medical AssistantOther#

What type of clinician?

MDNPPANurseDentistOther#

The Border#

So lets start our with some definitions.

What do we mean when we say the US/Mexico Border region?

There is a commonly accepted definition for the border region and its the same one the federal agency that funds our collaborative (the Health Services and Resources Administration or HRSA) uses.

So what do YOU think the US/Mexico Border region is?The HRSA/Federal definition of the U.S. border region is how many miles from Mexico?

5 miles 12 miles 62 miles 75 miles 100 miles#

The Border

#

The border between the United States and Mexico stretches approximately 2,000 miles (3,220 kilometers) from the southern border of Texas to California.

The La Paz Agreement of 1983 defines the United States-Mexico border region as the area extending 100 kilometers (or 62 miles) on either side of the border. The border region includes 4 U.S. and 6 Mexican states in total: Texas, New Mexico, Arizona and California in the U.S.; and Baja California, Sonora, Chihuahua, Coahuila, Nuevo Leon and Tamaulipas in Mexico. Additionally, there are approximately 25 Native AmericanNations located within the Border Region, creating a tri-national region (e.g., scroll across Arizona, Mexico, Tohono OOdham Tribal Nation).

The US border region includes the US communities that lie within 62 miles from the border with Mexico. (Scroll along the US side with the Adobe cursor.) This US border region has some of the poorest economic and health outcomes in the United States, some of which we will highlight in the next slide.U.S. Border Region ChallengesHealth Professional Shortage Area (HPSA)Higher incidence of infections diseases compared with the U.S. averageIf made a state, the border region would rank:1st in number of uninsured children2nd in death rates due to hepatitis3rd in deaths related to diabetesLast in access to health careLast in per capita income

Source: US/Mexico Border Health Commission#

The border region has increased health disparities, compared with the rest of the US. First it is designated a Health Professional Shortage Area (HPSA.) Most of the U.S.-Mexico border region is rural. Of the U.S. border counties, 73% are Medically Underserved Areas (MUAs) and (63%) are Health Professional Shortage Areas (HPSAs.) HPSAs are designated by HRSA as having shortages of primary medical care, dental or mental health providers. The Border Region has Higher incidence of infections diseases compared with the U.S. average.

If it were a separate US state, the border region would rank:1st in number of uninsured children2nd in death rates due to hepatitis3rd in deaths related to diabetesLast in access to health careLast in per capita income

Now Im going to turn it over to Kiesha who is going to talk about a theme for todays webinar: The need to test, link and keep people in high quality HIV care on the border.

Where the Poor and Uninsured Americans Live

#

HIV Treatment CascadeGardner, E., et al. (2010). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 52(6):793-800.#

A central goal of the Affordable Care Act is to significantly reduce the number of uninsured by providing a continuum of affordable coverage options through Medicaid and new health insurance exchanges. Strengthening health care also means reducing the growth of health care costs and promoting high-value effective care. This means getting people into care and keeping them in care.

One way we in the HIV world can go about this is to refer back to our HIV treatment cascade road map. Many of you are probably already familiar with Gardners article on the spectrum of engagement in HIV care. Clinical Trial HIV/Prevention Trials Network 052 (known as HPTN 052) demonstrated that if a person was virally suppressed to undetectable levels of HIV in the bloodstream, they are 96% less able to transmit the disease to their partner. That news means clearly treatment is prevention. So getting to zero or no new infections are part of the plan.If our ultimate goal is to increase the number of HIV positive individuals who are adherent with undetectable viral loads, we need to ensure that they get tested and know their HIV status, they get connected to---and stay in---high quality HIV care. Later we will illustrate through case discussions the conenctions between the treatment cascade and ACA implementation on the border.Affordable Care Act (ACA)#

So how does the Affordable Care Act help address these health disparities on the border? Although todays webinar is going to focus on people living with HIV on the border, lets first look at the impact of the affordable care act on US health disparities in general. Passage and implementation of the Patient Protection and Affordable Care Act is one of the biggest changes in US healthcare in 2 generations.Health Reform from the BeginningMedicare & Medicaid establishedAffordable Care Act (ACA) signed into lawSupreme Court upholds ACA#

So how did we get here? The last change this large in the US healthcare system occurred when Medicare and Medicaid were established. Medicare is a national social insurance program, administered by the U.S. federal government since 1965, that guarantees access to health insurance for Americans aged 65 and older and younger people with disabilities. Medicaid is the United States health program for families and individuals with low income and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states.[1] People served by Medicaid are U.S. citizens or legal permanent residents, including low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.

The Patient Protection and Affordable Care Act was signed into law in 2010 and was upheld by the Supreme Court in 2011, with the provision that states would not lose their exisiting Medicaid funding if they chose not to expand Medicaid.

Where We Are Now & Where We Are GoingOutreach/EducationAssistors/Navigators

MarketplacesSign-up starting October 1, 2013

Health Insurance (Marketplaces & Medicaid expansion) coverage begins January 1, 2014ACA fully implemented#

REMEMBER: Access to the health insurance market places begins October 1, 2013 when the market places open. Soon you will hear from a lot of outreach and education programs---from CBOs to the media-- describing the marketplaces in your state and pushing people who will need to get health insurance to learn more about the marketplaces. People who can use the marketplaces to sign up for Medicaid or to purchase insurance will be referred to Assisters and Navigators who will actually start enrolling people October 1.

This is when people can begin signing up for health insurance that begins January 1, 2014.

When the Patient Protection and Affordable Care Act is fully implemented in 2019, we will have millions of people with new health insurance coverage. We will still have millions without coverage, which we will describe more fully at the end of the webinar.I feel the ACA will make my job more secure

TrueFalseIm not sure/Dont know#

Yesb. Noc. Im not sure

Talking PointsAnswer: No.

What About HepC and ACA?Rachel McLean, MPHBrian Risley, Danny Jenkins..*MediCal expansion? Co-pays, Payment assistance, budget busters, reinfection rates, Costs costs costs costs sustainable? Undocumented?*Affordable Care Act (ACA) & HIV ServicesElimination of pre-existing condition exclusionsExpansion of Medicaid to non-disabled adults with incomes of up to 133% of FPLSubsidies to purchase insurance through exchanges for people with income up to 400% FPLMore PLWH are eligible for Medicaid/Marketplace exchanges

#

How does the Affordable Care Act improve access to coverage and protect people living with HIV/AIDS now? There are a few key provisions in the ACA that directly benefit people living with HIV/AIDS.

READ SLIDE

Health Reform will bring health insurance coverage to 32 million people over the next few years. Yet, there will still be about 23 million people in the country without health insurance. They will be outside the health care system. Some people will choose not to buy insurance and will have to pay a fee. And about 7 million will be undocumented immigrants.

Ryan White Funds: Payer of Last ResortRyan White Program funds may not be used for any item or service for which payment has been made or can reasonably be expected to be made by another payment source.

#

For those people living with HIV who still remain uninsured and have no other payer options for their care, remember Ryan White will remain the payer of last resort. Income status of individuals who receiveRyan White-funded services

FPL = Federal Poverty Level#

When we look at the income status of individuals who receive Ryan White services you can see that the majority make less than 100% of the federal poverty level. Remember is states that are expanding Medicaid, people earning less than 133% of the federal poverty level will qualify for Medicaid if they dont already have it. People making more than this amount and less than 400% of the federal poverty level, about 10-20% of Ryan White patients, will be required to purchase health insurance of or pay a penalty. However, they are very likely to qualify for additional assistance from their state or local AIDS program and/or ADAP (AIDS Drug Assistance Program.)

As people living with HIV move from Ryan White as payer of last resort to Medicaid or private insurance to pay for their medical needs, the ACA defines what essential health benefits they will receive.

So what is 100% FPL for a single person?What is 100% of the 2013 FPL for a single person

$5,025/year$7,110/year$11,490/year$13,170/yearI have no idea#

2013 Federal Poverty Level

CoverageforAll.org 138% FPL=$15,856The federal poverty level, or FPL, is the set minimum amount of gross income that an individual or family needs for food, transportation, shelter and other necessities. In the U.S. this level is determined by the Department of Health and Human Services (HHS). FPL varies according to family size, is adjusted for inflation and is reported annually.

Medicaid Expansion

JAMA. 2013;309(12):1219. doi:10.1001/jama.2013.2481#

Medicaid has been the countrys health coverage program for low-income individuals and families since 1965. It is jointly administered and funded by the federal government and the states. The federal government sets basic guidelines, and the states have broad authority to modify their Medicaid programs as they see fit, as long as they meet the federal guidelines.

Beginning in 2014, the Affordable Care Act (ACA) provides for the expansion of Medicaid eligibility to adults with incomes up to 138% FPL ($15,586 for an individual), which would make millions of currently uninsured adults newly eligible for the program. The 2011 Supreme Court ruling maintains the Medicaid expansion, but limits the Secretarys authority to enforce it. This means that states decide whether or not to adopt Medicaid expansion.

For most states that do not implement the ACA Medicaid expansion, there will be large gaps in coverage for low-income individuals because individuals with incomes below poverty are not able to access subsidies to purchase coverage in in the new health insurance exchanges. Individuals with incomes below 100% FPL ($11,490 annually in 2013) generally cannot receive subsidies to purchase coverage in the newly established health insurance exchanges and will not gain any new affordable coverage options and continue to face the consequences of being uninsured. This could leave individuals with higher incomes access to health coverage options while leaving those with lower incomes few or no options for affordable coverage. Which border state has said it will NOT expand Medicaid as part of ACA implementation?

Arizona California New Mexico Texas#

Ryan White Core Services vs. Essential Health Benefits (EHB)Ryan White Core ServicesAmbulatory & outpatient careAIDS pharmaceutical assistanceMental health servicesSubstance abuse outpatient careHome health careMedical nutrition therapyHospice servicesHome and community-based health servicesMedical case management, including treatment adherence servicesOral health care (not standard)

ACA Essential Health Benefits*Ambulatory patient servicesEmergency servicesHospitalizationMaternity & newborn careMental health & substance use disorder services, including behavioral health treatmentPrescription drugsRehabilitative & habilitative services & devicesLaboratory servicesPreventive and wellness services & chronic disease managementPediatric services, including oral & vision care

#

Under Ryan White, a person has access to Ryan White Core Services, which include (read red list) and others. Under the ACA, qualified health plans include the following Essential Health Benefits as part of coverage. It will be important for the Ryan White case managers, benefits counselors and others to understand the choices a transitioning patient may face, and understand what assistance may be offered to them to help them remain in high-quality HIV care. Health Insurance (Marketplace) Exchanges

Kaiser Family Foundation. State Decisions for Creating Health Insurance Marketplaces. http://www.kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/ #

The ACA creates health insurance marketplaces or exchanges in every state. These are online portals where people can shop for private insurance---with the potential for immediate tax credits or subsidies--or sign up for Medicaid. All states will have marketplaces, regardless of whether or not they expand Medicaid.

The Kaiser Family Foundation website has a helpful infographic mapping state decisions for creating their type of health insurance marketplaces.

California and New Mexico will both host state-based marketplaces. Both Arizona and Texas will host federally-facilitated marketplaces. State-Based Marketplace Exchanges:California & New Mexico

#

In California the body managing the state-based marketplace is called Covered California and in New Mexico it is called the New Mexico Health Insurance Alliance.

Federally Facilitated Marketplace Exchanges: Arizona & Texas

#

For updated information on federally-facilitated market places, like those in Arizona and Texas, you can visit healthcare.gov.ACA Implementation on the Border#

Now we will talk a little about each of the four border states and their progress towards ACA roll-out in Jan 2014. For each state we have developed a case study to highlight some of the key issues individuals living with HIV on the border may face beginning in October 2013, when the marketplaces open, for coverage that begins January 1, 2014..

The four cases we present are composites based on real-life situations that could occur to people living with HIV on the border as the Affordable Care Act is implemented. They do not depict any individuals and any similarities are purely coincidental. We wish to thank our expert reviewers in each state for their help in reviewing these demonstration cases.

ACA Implementation on the BorderExpanding health insurance coverage in every stateIncreasing access to MedicaidEstablishing Health Insurance MarketplacesCovering preventive services with no deductible or co-pay#

Overall, implementation of the Affordable Care Act will mean more people will have health insurance coverage in all 4 US border states (California, Arizona, New Mexico and Texas) starting January 1st, 2014. Much of this increased coverage will take place because of planned expansions of Medicaid in 3 of the 4 states (Texas currently is not planning an expansion of Medicaid)

Beginning Oct. 1, 2013, individuals in every state will be able to shop for health insurance and compare plans through the Marketplace. More people will be able to afford coverage because of tax credits and costs sharing to purchase insurance through these Health Insurance Marketplaces for those who make less than 400% of the federal poverty level.

Remember the Affordable Care Act also includes key provisions for expansion of preventive services and eliminates deductibles and co-pays for preventive services.

ACA Implementation in ArizonaExpanded MeidicadImplemented federally-run health insurance marketplace

#

Lets begin with Arizona. Since January the governor of Arizona, Jan Brewer, has stated her support to expand Medicaid and bring healthcare to an additional 350,000 Arizonans. The state senate has voted to approve Medicaid expansion. The state legislature, however, has not yet voted to make Medicaid expansion the law. Arizona has also decided not to run its own state health insurance marketplace. 947,880 or 18% of Arizonas non-elderly residents are uninsured, of whom 866,366 (91%) may qualify for either tax credits to purchase coverage in the Marketplace or for Medicaid if Arizona participates in Medicaid expansion.

For the purposes of todays case discussion we will assume Arizona moves forward with the intended Medicaid expansion.

Case Study: Arizona

Pedro is a 28 year old resident of Nogales, Arizona making ($12,065 or 105% FPL) who commutes to Tucson for HIV care at a Ryan White clinic. He has been in the U.S. legally for 7 years. He also receives HIV dental care and case management services through the Ryan White program in Tucson. He wants to stay at his HIV clinic.

#

Pedro is a 28 year old resident of Nogales, Arizona making ($12,065 or 105% of the federal poverty level) who commutes to Tucson for HIV care at a Ryan White clinic. He has been in the U.S. legally for 7 years. He also receives HIV dental care and case management services through the Ryan White program in Tucson. He wants to stay at his HIV clinic.

Under the ACA, will Pedro be required to purchase health insurance?

YesNoIm not sure.#

a,. Yesb. Noc. Im not sure

Talking PointsAnswer: No. Pedro earns less than 138% of the Federal Poverty Level under the ACA. Assuming Medicaid expansion, Pedro will now qualify for Medicaid. Medicaid will now be his payer and he will no longer need Ryan White to be his payer of last resort. If, however, Pedro made more than 138% of federal poverty level or $15,856 he would go the federally run Marketplace to purchase insurance on his own and would receive a government subsidy to help cover the cost.

Will Pedro be able to continue to receive HIV dental care through the Ryan White program?

YesNoI dont know.#

a. Yesb. Noc. I dont know

Talking PointsAnswer: Yes. Pedro will still qualify for Ryan White funded HIV wrap-around services not covered by Medicaid, like adult dental care.

Remember, the highest priority for Pedros health and public health is that he remain in high quality HIV care.

ACA Implementation in CaliforniaIncreasing access to MedicaidTransition to Medicaid expansion: Low Income Health Programs (LIHPs)Implementing state-run health insurance marketplace

#

California began expansion of Medicaid in 2011 through a federal Medicaid Waiver program called the Low-Income Health Program or LIHP. Through the LIHPswhich varied from county to county, people who were previously uninsured and were low income (or those who would now qualify for Medicaid expansion under the Affordable Care Act) were enrolled into transitional programs called LIHPs. For citizens and legal immigrants who have been here for more than 5 years but who make too much to qualify for Medicaid expansion, California will be running its own marketplace called Covered California. The same federal cost sharing and tax credits will apply in Covered California as in the federally run market places. Additionally, California is currently considering health coverage options for legal immigrants here less than 5 years.

We will now look at a case about Juan a person living with HIV, and how the affordable care act could impact him.

There are 13 QHPS in the state of California and 19 rating regions.39Border Rating Regions/PlansSan Diego Imperial HealthNet (HMO)/$269Kaiser Perm (HMO)Anthem (EPO)Blue Shield (PPO)Kaiser Permanente (HMO)Anthem (PPO)Molina Healthcare (HMO)SHARP Health Plan (HMO co-pay)Blue Shield (PPO)SHARP Health Plan (HMO co-insurance)Anthem (HMO)/$336

#

ACA, FPL, HIV, and OAHIPP Medicaid Expansion (MediCal) 138% of Federal Poverty Level (FPL) 100% 138% Immediate (or deferred) Premium Tax Credits 400% 500%

100 % 138% Subsidies 250% $15,856 (Individual)$32,500 (Household of 4)$11,490 (Individual)$23,550 (4)$45,960 (Individual)$94,200 (4)$11,490 (Individual)$23,550 (4)$28,725 (Individual)$58,875 (4) Silver PlanHIV-------OAHIPP400% FPL)HealthNet (HMO): $26940SilverWith Tax Credit (200% FPL)HealthNet (HMO): $81 (plus subsidies)40SilverWith Tax Credit (150% FPL)HealthNet (HMO): $18 (plus subsidies)

#

Case Study: AntonioSilver (eligible for Federal Subsidy) Premium: $41/month(of a $231/month premium--per Covered CA calculator)

Copays: Primary Care Visit: $15 Generic Drugs: $5Lab Test $15X-Ray: $20Deductible: $500Out of pocket maximum: $2250

#

If for example, Antonio learns his options and benefits to remain at his clinic and he choses the silver plan (double check these figures---show what these are for Platinum?) he would only have to pay $75/month premium and these other co-pays/deductibles.

But remember this does NOT include other assistance, like OAHIPP, so many of these expenses will be taken care of, including the remainder of his premium.

And remember he now has health insurance for his other medical needs or emergencies.

Case Study: CaliforniaJuan is a single construction worker with no children living with HIV. He lives in Imperial county and earns $15,512/year (135% FPL). He does not have health insurance and goes regularly to a Ryan White clinic for his HIV care. He has bonded with his HIV treatment team who he says saved my life. Juan has been in the United States legally for 5 years.

#

Juan is a single construction worker with no children living with HIV. He lives in San Diego and earns $15,512/year (135% of the federal poverty level). He goes regularly to a Ryan White clinic for his HIV care. He has bonded with his HIV treatment team who he says saved my life. Juan has been in the United States legally for 5 years.

He wants to remain at his HIV clinic.

Will Juan need to go to the Marketplace to purchase health insurance?

No, he will go to the Market Place and enroll in Medicaid (Medi-Cal)Yes, and he will could get his entire premium paid by OAHIPPYes, he will need to purchase health insurance in the Market Place, but he will get no subsidyI have no idea#

No, he will go to the Market Place and enroll in Medicaid (Medi-Cal)Yes, he will need to go to the Market Place and purchase health insurance, but he will get subsidiesYes, he will need to purchase health insurance in the Market Place, but he will get no subsidyI have no idea

Talking PointsThe correct answer is A.Juan will be able to enroll in Medicaid (called Medi-Cal in California) as California is expanding Medicaid for all those who earn less than 138% of the Federal Poverty Level ($15,856). He will now have Medi-Cal as his insurance and will likely be enrolled into a Medi-Cal Managed Care Plan. As he loves his HIV clinic and is doing well, he can remain there as long as they have a contract with, or participate as a member of the provider network of, the Medi-Cal Managed Care Plan in which he enrolls. However, just because Juan is eligible for Medi-Cal doesnt mean that transition process will be easy or that he wont require support and assistance in attaining (and maintaining) his benefits. Remember the highest priority for Juans health---and public health---is that he remain in high-quality HIV care.

Juan is in an auto accident and receives care in the emergency room. Does he have health insurance?

YesNoI dont know.#

Later in 2014 Juan is in a severe car accident and is admitted to the Emergency Room. Does he have health insurance to cover his expenses?

YesNoI dont know

Talking PointsThe correct answer is yes. Medi-Cal is health insurance that includes ER benefits.

Case Study: MariaMaria is a single 51 year old house/hotel cleaner living in Calexico who estimates she will make $21,027 in 2014 (183% FPL), but has no health insurance. She says she could never afford the rates for someone my age. She has not seen a doctor for years, but sometimes goes across the border for antibiotics, dental care, and back pain medicine. She wants health insurance as she has chronic back problems and owns a small house worth $200,000. She is afraid an ER trip could bankrupt her or cause her to lose the house.

#

48Mary is a single 62 year old hotel manager born and living in Las Cruces, New Mexico making $21,027 per year (183% FPL), but has no health insurance. She says she could never afford the rates for someone my age. She has not seen a doctor for years, but sometimes goes across the border for antibiotics and dental care. She would especially like health insurance now as she recently inherited a small ranch worth $250,000. She believes she is in good health and feels great. However, she does not know that she is living with HIV and hepatitis C. She would not report any risks for either if asked.

Maria (cont)Maria is a little worried that she is taking too much back pain medicine as she has to take more and more to get relief from pain and sometimes stress as she heard these pills could be addictive. Otherwise, she believes she is in good health and feels great.

However, she does not know that she is living with HIV and hepatitis C. She would not report any risks for either if asked.

#

49Mary is a single 62 year old hotel manager born and living in Las Cruces, New Mexico making $21,027 per year (183% FPL), but has no health insurance. She says she could never afford the rates for someone my age. She has not seen a doctor for years, but sometimes goes across the border for antibiotics and dental care. She would especially like health insurance now as she recently inherited a small ranch worth $250,000. She believes she is in good health and feels great. However, she does not know that she is living with HIV and hepatitis C. She would not report any risks for either if asked.

Under the Affordable Care Act, Maria will be required to purchase health insurance or face a tax penalty.

a. Trueb. Falsec. Im not sure#

I think Maria will sign up for health insurance (NOT pay the penalty)

a. Trueb. Falsec. Im not sure#

Maria signs up & chooses a qualified health plan primary care provider. Do you think she will be tested for HIV as part of her routine care with her provider in 2014?

a. Yesb. Noc. Im not sure#

Were YOU offered an HIV test the last time YOU saw your primary care provider?

a. YesI rememberb. Noc. Nowe already knew my HIV statusd. Im not sure I dont remember#

Do you think Maria will be tested for HCV as part of her routine care with her provider in 2014?

a. Yesb. Noc. Im not sure#

Remaining UninsuredMillions of individuals will remain uninsured after January 1, 2014, including:Individuals subject to the mandate who do not enroll Individuals who are eligible for Medicaid, but do not enrollIndividuals who are not lawfully present#

Despite the broad sweeping impact of the Affordable Care, many people will still remain uninsured. Often this group is referred to as the residually uninsured.

The UC Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research estimate that in California alone 3-4 million people will still remain uninsured in 2019. About of these are predicted to be individuals who are eligible for Medicaid expansion or subsidies to purchase health insurance in the marketplace, but who face barriers that prevent them from becoming insured. Predicted barriers to enrollment included lack of awareness about the programs, challenges in the enrollment process, or inability to afford subsidized coverage.

Additionally, an estimated 72 percent of these remaining uninsured in Californian will be exempt from paying tax penalties under the minimum coverage requirements of the ACA due to income, lack of an affordable offer of coverage (8% of income or less) or immigration status.

We know we have covered a lot of information so far in this webinar and we want to encourage you to continue to seek ACA implementation information on your own.Resources

DONOHOE@UCLA.EDU#

The next few slides will review what types of information are available right now, with a focus on information relevant for HIV providers, especially Ryan White providers.

#

Chart11106400HIV InfectedHIV Infected874056HIV DiagnosedHIV Diagnosed655542Linked to CareLinked to Care437028Retained in CareRetained in Care349622Need ARTNeed ART262217On ARTOn ART209773Viral SuppressedViral Suppressed

Number of Individuals

Sheet1State of EngagementNumber of IndividualsHIV Infected1,106,400HIV Diagnosed874,056Linked to Care655,542Retained in Care437,028Need ART349,622On ART262,217Viral Suppressed209,773To resize chart data range, drag lower right corner of range.

Chart10.70.210.060.03

HIV/AIDS Bureau. 2009 RDR. Household Income Data.Column1

Sheet1Column1100% FPL70%101-200% FPL21%201-300% FPL6%>300% FPL3%To resize chart data range, drag lower right corner of range.