Professional Documents
Culture Documents
What Will the ACA Mean for Addressing the HIV Epidemic?
14,266 11,698
5,755
49%
4,875 3,728
42% 32%
Re-Engaged
Lapsed in Care
insurance,
the
Ryan
Program
is
required
to
vigorously
pursue
enrollment
of
the
person
in
these
types
of
coverage
n 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. achievement of viral suppression, not just the long-standing Ryan White system.
NO
YES
Service
is
reasonably
accessible?
NO
YES
Provide the service and bill the 3rd party payer or refer to a provider who can do so
Services
HIV Testing Outreach Linkage Referral Retention Ambulatory care Case management Transportation Adherence Oral health Financial Assist ADAP Housing Nutrition/Food Psychosocial HE/RR Mental health tx Substance use tx
Diagnosed
Linked
Retained
Viral Supp
Re-engage
Both the CLIENT and the SERVICE NEEDED must be evaluated for potenIal 3rd party payment Eligibility criteria: Residence, ciIzenship, income level, household size Payers: Medicaid, Medicare, Plans through the Marketplace, Employer Based Plans Services they will pay for: the EssenIal Health Services (as interpreted by the payer) If the client is ELIGIBLE but not ENROLLED must vigorously pursue enrollment.
n n
Subsidized private insurance through Marketplace No transition No transition If plan is affordable and comprehensive, no transition Medicaid or Marketplace coverage No transition
HRSA Policy Notice13-01: Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services
n Grantees
and
their
subgrantees
are
expected
to:
n
Vigorously
pursue
Medicaid
enrollment
for
individuals
who
are
likely eligible for coverage, n Seek payment from Medicaid when they provide a Medicaid- covered service for Medicaid beneciaries n Back-bill Medicaid for RWHAP-funded services provided for all Medicaid-eligible clients upon determinaIon.
determinaIons with those for new coverage opIons, mainly modied adjusted gross income (MAGI) Marketplace eligibility and enrollment processes to reduce burden and increase coordinaIon Medicaid and/or Marketplace noIce of eligibility determinaIon when applying for or being recerIed for RWHAP
HRSA Policy Notice13-04: Eligibility for Private Health Insurance and Coverage by RWHAP
n Reiterates
that
RWHAP
grantees
must
make
every
eort
to
ensure
that eligible uninsured clients expediIously enroll in private health insurance when possible; this requirement will be monitored
n Grantees need to inform clients of the penalty for not enrolling n Clients who receive a cerIcate of exempIon from the Internal
+
HRSA Policy Notice13-04 (continued)
n Open
enrollment
into
private
health
plans
is
for
a
limited
If the client misses the open enrollment period, the grantee must make every eort to ensure the client enrolls in the next open enrollment period
process for pursuing enrollment for all clients, documentaIon of steps to pursue enrollment, and establishment of monitoring and enforcement of sub- grantee processes to ensure enrollment
+
HRSA Policy Notice13-04 (continued)
outside
of
their
insurance
network
unless
services
are
not
available
from
an
in-network
provider
n RWHAP
funds
may
be
used
to
pay
for
higher
co-pays
and
deducIbles within Iered networks but must consider availability of resources prior to making such allocaIons
Reasonably
accessible
n The
service
is
consistent
with
the
HIV
Care
and
Treatment
Program Standards of Care; n The service is available to the client within sixty calendar days or more promptly if needed to prevent death or substanIal, irreversible harm to the client; and, n The service is located within 70 miles of the client residence. n This is CDPHEs interpretaIon of HRSA rules and is subject to HRSA revision. Other Colorado HRSA Grantees (Part A, C, D) may have dierent interpretaIons.
+
RX
MEDICAL CASE MANAGEMENT ORAL HEALTH LABS MENTAL HEALTH SERVICES SUBSTANCE ABUSE TREATMENT HIV PRIMARY CARE MEDICAL TRANSPORTATION INPATIENT HOSPITAL SERVICES
X X
X
Limited Coverage Cost-sharing assistance Cost-sharing assistance Cost-sharing assistance Cost-sharing assistance
Limited Coverage
HRSA Policy Notice13-01: Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services
n Once
an
individual
is
enrolled
in
Medicaid,
RWHAP
funds
may
be used to pay for: n Any medically necessary services which Medicaid does not cover or where Medicaid coverage is limited in scope n Premiums, co-pays and deducIbles if required n Other core medical services as a part of primary care if those services are not covered or are limited under Medicaid, even when those services are provided at the same visit as Medicaid covered services.
HRSA Policy Notice13-04: Eligibility for Private Health Insurance and Coverage by RWHAP
n RWHAP
funds
may
be
used
to
pay
for
services
received
during the Ime between which a client enrolls in third party coverage and it becomes eecIve
only be used for services not covered or parIally covered by a clients plan
What are some other implicaIons of the Aordable Care Act for People Living with HIV or AIDS?
and STIs are highly concentrated among the poor and the uninsured. cost STI care for the uninsured is very limited in terms of geography and provider mental health or substance use issues are driving HIV risk, low cost counseling is also very limited health care providers are identifying most new HIV cases, but there is still a fear of becoming uninsurable due to HIV testing (even if negative)
n Low n If
n Private
HIV negative people will be eligible for Medicaid or some other form of coverage. they enroll, they should have new coverage that should reduce their vulnerability for HIV:
n STI
nIf
screening and treatment n HIV testing n Mental health care n Substance abuse treatment
IN MEDICAL CARE
US 41% MA 99%
HIV Diagnoses increased by 2% nationally between 2006 and 2009, there was a 25% DECREASE in HIV Diagnoses in Massachusetts. there was a significant decrease in HIV Deaths during this period (33%), Massachusetts beat this figure as well 44%)
nWhile
But the changes in Massachusecs were also very dramaIc for service providers
STD clinic closures were completed in June 2009. clinics maintained services, including a free clinic and a fee-for-service clinic. Clinic hours were reduced hours services were transferred to private doctor offices and clinics
nFour
nSTD
paIent care needs n Some public costs cannot be shieed in a health reform environment n Training needs for clinical providers may be signicant as specialized public health funcIons are pushed into primary care venues. n Establish baseline and future data needs, and variables to track impact
WHAT IS NEXT?
Next steps . . .
Providers
of
services
for
PLWH/A
should
adopt
the
new
triage
approach
to
their
clients
and
the
service
provided
Every
provider
should
build
their
capacity
to
screen
for
eligibility
and
vigorously
pursue
enrollment
Providers
are
WELL
ADVISED
to
build
their
capacity
to
bill
Medicaid
or
other
3rd
party
payers
for
at
least
some
of
the
services
they
provide
Current
Ryan
White
funded
services
will
need
to
be
parsed
between
those
that
are
reasonably
accessible
through
a
3rd
party
payer
and
those
that
are
not.
Next steps . . .
Ryan
White
will
con>nue
to
be
important
source
of
care
and
services
for
many
people
with
HIV
or
AIDS
Most
Ryan
White
clients
will
have
coverage
but
sIll
need
the
program
to
complete
their
care,
ll
in
gaps,
help
with
costs.
Ryan
White
provides
important
HIV-related
services
that
are
not
always
provided
by
insurance
plans
Those
who
are
undocumented
are
not
eligible
for
Medicaid
or
marketplaces;
Legal
residents
have
5
year
waiIng
period
for
Medicaid