Slide 1

+ ADAP ADVOCACY ASSOCIATION PRESENTATION Monday August 4, 2014 Denver Digital Photography Slide 2 Transitioning ADAP Clients to Medicaid & Marketplace Plans: The Colorado Success Story Todd Grove Colorado Department of Public Health & Environment AIDS Drug Assistance Program Rich Wolf Digital Photography Slide 3 Medicaid Colorado Indigent Care Program (CICP) Medicare Tobacco class action lawsuit funds Other Federal and State Programs Slide 4 Colorado AIDS Drug Assistance Program Slide 5 Cost & Clients Served -2013 HMAP 2,039 enrollees 42,150 prescriptions $12,571,539.58* HIAP 690 10,887 prescriptions $1,022,003.61* $1,125,840 premiums, deductibles and co-pays BTGC 869 enrollees - 26,189 prescriptions $1,320,628.07* Data provided by Colorado Department of Public Health & Environment Slide 6 + What makes Colorado unique, (and may make duplication difficult) Colorado had the nations largest ADAP waitlist in 2004 315 people Provided only 18 drugs (strictly ARV) Advocacy resulted in over $1 million in General Funding and over $3 million in tobacco class action lawsuit funds per year Legislation allowed for ADAP committee to direct $$, with approval of the Medical Director Allowed for innovative use of monies: Creation of a Medicare State Pharmaceutical Assistance Program Reimbursement of insurance premiums, as necessary Payment of inpatient medical care HIV incidence in Colorado is moderate and efforts would be extremely difficult to emulate in higher incidence states, particularly those without local funding of any sort / states that did not expand Medicaid Slide 7 + Colorados decisions related to the Affordable Care Act Expanded Medicaid (including AwDC) to 133% of Federal Poverty Level MAGI Created an effective state-based insurance marketplace w/ improved Medicaid interaction Supportive environment for enrollment outreach Democratic Governor Democratic majorities in both State House and Senate Denver Digital Photography Slide 8 + Colorados efforts to transition enrollees to ACA plans Became a non-funded partner of Health Coverage Guide network sanctioned by the marketplace Connect for Health Colorado Paid for 14 individuals during open enrollment to enroll members in Medicaid, or ADAP-approved marketplace insurance plans with complete ADAP wrap-around Identified Medicaid-eligible members on Health Insurance assistance to transition to Medicaid (waiver offered) Co-located staff at larger HIV clinics to apply patients for Medicaid on- line Purchased IT to allow Health Coverage Guides to patient homes or other locations to facilitate enrollment Completed multiple attempts to outreach to members Required a formal request to remain uninsured if they refused Considering off-marketplace insurance options for undocumented patients next year Slide 9 + 25,000+ ACA-related Transitions Facilitated by State HIV Programs** ID MT NV WY OR AK CO UT CA HI NM AZ WA AL AR GA ID IL IN KY MO MT NV NH OH SC SD TX VA WY OK ME MD NJ NY OR AK CO LA UT CA KS MS FL HI NM AZ ND MN IA WI MI NE WA PA NC TN WV VT DE CT DC MedicaidQHPs 13,00012,500 Source: NASTAD **Through end of March 2014 Slide 10 Colorado ADAP / Insurance Status after Implementation 10 2,100 individuals 110 new HIAP members 400 new HIAP members 1,390 Medicaid /SWAP members 300 individuals 1,181 insured patients Slide 11 Ryan White Case Management Roles and Duties CDPHE ADAP Office and Denver CAP for HIAP Program management Financial management Eligibility and enrollment verification Auditing/quality assurance Social Workers, Medical & Non- Medical Case Managers All program areas Eligibility and enrollment assistance Trouble shooting and client support CDPHE, DCAP, ADAP OFFICE AIDS Service Organizations & Social Service Entities Health Insurance Assistance Program Coordination Located at BCAP, DCAP, NCAP, SCAP & West CAP Coordination of premium, co-insurance, and co-payments No requirement for case management (can remain with other ASOs) Coordination of enrollment into marketplace by Health Coverage Guides HIAP Coordination Entities Slide 12 + Health Insurance Assistance Program (HIAP) Wraps around employer, COBRA, and ACA marketplace insurance plans Pays remaining costs of marketplace insurance after the APTC and Cost sharing assistance available has been applied Pays premiums, medical and pharmaceutical deductibles, co-pays, and coinsurance Up to $10,000 in aggregate per client Works with providers who are willing to bill for services Pays for prescriptions through a Medication Assistance Card. Assistance in enrollment through Connect for Health Colorado marketplace Slide 13 Insurance Enrollment Sites Boulder County AIDS Project Colorado AIDS Project Northern Colorado AIDS Project Southern Colorado AIDS Project Western Colorado AIDS Project Slide 14 + Supplemental Wrap Around Program (SWAP) New ADAP program to cover all Medicaid-eligible clients with medication co-pay coverage for ADAP formulary Members will be able to use many more pharmacies if they choose (rather than 4 previous ADAP pharmacies) Recertification process easier (as member would have been screened eligible for Medicaid) = eliminates need for supporting documentation income, residency. ADAP suggests that patients continue to use HMAP network pharmacy at least at first - easy movement to HIAP, or to HMAP if churning is an issue allows for back-billing. Slide 15 + The problem of CHURN Loss of Medicaid may mean up to 45 days until access to insurance is established; Enrollees can receive medication assistance for ADAP formulary drugs only through that time May not qualify for CICP or the facility may not offer CICP Enrollees often fail to notify ADAP of change in situation Enrollees need to notify marketplace of change in income affecting eligibility; tax penalties and credits difficult to manage by the program Enrollees may not be able to access same providers under Medicaid, or may have a waitlist Problems presented by loss of Medicaid Problems presented by loss of job/ eligibility for marketplace insurance Slide 16 + How to improve % of clients who recertify every six months Cant get medications, (missed doses, would have to pay own costs) HIAP cant pay premiums or pay medical co-pays until recertification is complete Medicaid and marketplace may not be told of changes of income affect eligibility and APTC/ cost sharing Patients are used to being able to miss recertification and rectify the situation with relative ease Colorado is working on a system where recertifying with ADAP would make individuals recertified for all Ryan White services With a loss of Medicaid or insurance temporarily, enrollees can get medication through HMAP Members can get assistance in enrolling in the proper assistance program Instituting text message reminders Implications of not recertifyingBenefits to enrollee Slide 17 + Significant financial effect already: From an average of 1,300 patients provided direct medications in fall 2013, the average has dropped to 300 (largely categorically ineligible for Medicaid or insurance, or CHURN members) From over $1.2 million in costs, estimates after back-billing to Medicaid are $300,000 in expenses per month. Increased budget for Health Insurance by close to $2 million dollars Much smaller investment required for Medicaid wrap -around UNINSURED PATIENTSINSURED PATIENTS Denver Digital Photography Slide 18 + Net effect & concerns: Robust application for partial pay rebates have provided significant program income HRSA requires states to spend rebate income BEFORE Ryan White dollars Results in large unexpended balance that may be carried forward, but will return to HRSA for redirection to other states if not spent in time While morally correct to do so, any change in ability to apply for rebates would cause huge decrease in revenueand lost Ryan White dollars would be desperately needed again Successful management of Ryan White and funding offered by individual states will be redirected to states who refuse to expand Medicaid or invest in the epidemic in their own states REBATE INCOMEIMPLICATIONS of lost income Slide 19 + Innovations to Get to Zero Prevention planning to include discussion of biomedical components such as nPEP and perhaps even PrEP Prevention planning may include targeted $ resources to assist high risk HIV individuals to seek behavioral health interventions and other preventative financial assistance PREVENTION and CARE Denver Digital Photography Slide 20 Slide 21 Continuum of Care Picture for ADAP Members Slide 22 Focus on services that are proven to help people move through the cascade toward viral suppression If a person is eligible for Medicaid, Medicare, or commercial insurance, the Ryan White Program is required to vigorously pursue enrollment of the person in these types of coverage If there is a service that would help move people through the cascade but cannot be funded from a third party payer, Ryan White funding can be used to pay for that service. Monitor how well the entire system of care is assisting with achievement of viral suppression, not just the long-standing Ryan White system. The post-ACA approach to HIV care: Slide 23 Helping People Move Through the Cascade First Diagnosis with HIV Linked to Care Retained in Care Achieve Viral Suppression Slide 24 The Process is NOT Linear First Diagnosis with HIV Linked to Care Retained in Care Achieved Viral Suppression Lapsed in Care Re-Engaged Slide 25 ADAP Advocacy Association Jeffrey S. Crowley Distinguished Scholar/ Program Director, National HIV/AIDS Initiative ONeill Institute Georgetown Law Ryan White services are critical to engagement in care Slide 26 + Innovation in the use of DIS, LTC and RTC personnel PROVIDE RESOURCES AS NECESSARY to ensure successful linkage to care and treatment Disease Investigation Specialists immediate linkage to enrollment services in ADAP, Medicaid, and Ryan White $$ when a patient has not enrolled in coverage Linkage to Care in addition to above, assessment of substance abuse, mental health issues, and access to resources through Critical Event pilot (described later) Retention in Care personnel from State Health & partner agencies reviewing patients who appear to have dropped out of care, again, with $$ resources to assist including housing, inpatient mental health and substance abuse treatment, medical transportation Slide 27 + What is a critical event? An event that makes it much more likely a client will drop out of medical care or never seek medical care to begin with. A marker for a destabilizing crisis. A severe challenge to a client who wants to achieve and maintain viral suppression. Critical Event Initiative Slide 28 + Focused on short term stabilization (