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Ryan White Part B ServicesThe Impact of State Health Care Reform
2012 HRSA All Grantees MeetingWashington, D.C.
November 28, 2012
H. Dawn Fukuda, DirectorAnnette Rockwell, Federal Grants Coordinator
Office of HIV/AIDSMassachusetts Department of Public Health
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)
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)
Enrollment in HIV Waiver Medicaid (MassHealth)
State Fiscal Year (FY) HIV Waiver—Average Enrollment
FY04 509
FY05 675
FY06 932
FY07 1,006
FY08 1,067
FY09 1,169
FY10 1,233
FY11 1,310
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
Health Insurance CoveragePLWHA 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
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
HIV Drug Assistance Program Expenditures by Category
Fiscal Year Full Pay Co-Pay Premiums
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
MA HIV Drug Assistance Program Enrollment & Expenditures by Year
State Fiscal Year Enrolled Total Expenditures
FY02 2301 $ 9,716,375
FY03 2716 $ 10,703,342
FY04 4399 $ 15,887,838
FY05 4738 $ 17,708,142
FY06 4668 $ 13,543,197
FY07 5141 $ 14,585,106
FY08 5601 $ 15,591,533
FY09 5882 $ 16,099,405
FY10 6543 $ 16,886,192
FY11 7009 $ 18,634,462
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
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
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
HIV Outcomes Post HCRN= 1,004
0
10
20
30
40
50
60
70
80
90
100
In medicalcare
Taking HIVmedications
Virallysuppressed
Health goodto excellent
Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc.
Source: R. Greenwald and M. Ellwood
Source: R. Greewald and M. Ellwood
Health Care ReformPlanning 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
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 3rd party reimbursed• Calculate impact on collection of medication
rebates
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)
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
Contact Information
• H. Dawn Fukuda, Director
Office of HIV/AIDS
(617) 624-5303
• Annette Rockwell, HDAP & Federal Grants Coordinator
Office of HIV/AIDS
(617) 624-5762
