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Colorado HIV Care & the Affordable Care Act: Making It Real!

Todays Presenters:

Colorado Department of Public Health & Environment Todd Grove, Colorado AIDS Drug Assistance Program Bob Bongiovanni Program Manager, HIV Care & Treatment Program

Where are we now??


Todd Grove, Colorado AIDS Drug Assistance Program

Colorado AIDS Drug Assistance Program

Colorado HIV Care before Implementation


1,600 people

900 people

57 PCIP members, 20 on Cover Colorado

600 people

HIV population already on Medicaid


An estimated 500- 600 people are currently on Colorado Medicaid Primarily those who have been declared medically disabled and receive Supplemental Security Benefits (SSI), or family Medicaid Will be able to join ADAPs new Supplemental Wrap Around Program (SWAP) in April

The Current System: Colorado Indigent Care Program (CICP) & Ryan White
Covers emergency medical, outpatient medical services (not specialty care) Some clinics (Denver Health) covers extra medications, and some dental services

Not Insurance

Ryan White dollars help wrap-around CICP services, including salaries, individuals over 250% of FPL, and the undocumented

I have CICP and HMAP, why do I need insurance?


CICP/HMAP
CICP is NOT health insurance, it is a discount program. Not comprehensive coverage Not all essential services covered Very limited network of providers Fills restricted to 3 pharmacies Only ADAP-formulary medications covered Requires recertification every year

Medicaid/ Health Insurance


All plans must offer Essential Health Benefits Comprehensive provider networks More drugs are covered Better laboratory and medical imaging coverage Better mental/behavioral health benefits Access to more services Expanded ADAP network of pharmacies, including all King Soopers, City Market and Walgreens pharmacies Emergency Services covered when traveling outside the state

WHERE ARE YOU ON THE FOLLOWING CHART?


Calculating Income & Defining a Household

Federal Poverty Levels - 2013


Persons in 100% of Household FPL 138% of FPL
(Medicaid max under Reform)

250% of FPL
(current max CICP)

400% of FPL
(current max ADAP programs)

1 2 3 4

$11,490 $15,510 $19,530 $23,550

$15,282 $21,404 $26,951 $32,499

$28,725 $38,775 $48,825 $58,875

$45,960 $62,040 $78,120 $94,200

Modified Adjusted Gross Income


Financial eligibility for the consolidated Medicaid and CHP+ programs will be determined using methodologies based on Modified Adjusted Gross Income (MAGI), MAGI for most taxpayers is equal to their Adjusted Gross Income as figured on their personal income tax return. It may also include: Any foreign earned income excluded from taxes Tax-exempt interest Tax-exempt Social Security income (SSDI), but not SSI.

Countable Income
MAGI CURRENT
Earned Employment Self-employment Unearned Alimony Child Support In-Kind Veterans Benefits Social Security Benefits Counts taxable income: Salaries, Wages, Tips Capital Gains Unemployment Benefits SSDI Minus allowable tax deductions: Retirement Plan Contributions Child Care Mortgage Interest Does not count non-taxable income: Social Security Title XVI (SSI) Child Support

Income Disregards
CURRENT
Medicaid:
$90 each working adult $50 Child support Childcare: Child under 2 years = $200 Child over 2 years = $175

MAGI

CHP+ attested amount for:


Daycare Child support Alimony Medical Expense

5% across the board disregard for both Medicaid and CHP+

Same sex marriage, income calculation & household size


Legal challenge of the Defense of Marriage Act triggers changes in income tax filing status:
The Internal Revenue Service (IRS) rules same-sex couples, legally married in jurisdictions that recognize their marriages, will be treated as married for federal tax purposes. The ruling applies regardless of whether the couple lives in a jurisdiction that recognizes samesex marriage or a jurisdiction that does not recognize same-sex marriage. Colorado ADAP will count all such marriages for the purposes of income and household size

Consider this:
If a couple is considered married, the maximum amount of earnings for the ADAP member only goes from $46,000 to $62,000 Colorado Civil Union does not count as marriage requiring that they be considered as a married couple for tax filing status.

Top 4 ways people with HIV will benefit from health care reform
1) Most low-income adults will get Medicaid (below $16k) 2) Above $16k, people will be able to buy more affordable private insurance 3) Private insurance companies will have to play by new rules 4) Medicare will get better

1) 2014: Most low-income people will get Medicaid


Expands eligibility: Starting in 2014, anyone who is low income can get Medicaid - no more requirement to be totally disabled Improves services: State will be required to provide benefits that cant be cut Improves payments to providers: Enhances reimbursement for primary care providers Allows people to earn money and not endanger their medical care Makes it easier to apply and enroll

The Expansion Population (Adults without Dependent Children - AwDC)


Age 19-64 Not pregnant Not receiving Medicare A or B Not mandatorily covered by Medicaid Income below 133% of federal poverty (138% after 5% income disregard Also allows parents access to Medicaid up to 138% of FPL (up from 60% of FPL)
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Essential Health Benefits under Medicaid


coverage later in 2014 under Emergency services Medicaid
Ambulatory patient services

Hospitalization Maternity and newborn care MH and SUD services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care (children only only) $1,000 dental benefit will likely be added later in 2014

Individuals who qualify for Standard Medicaid (not due to Medicaid Expansion)
Pregnant women Individuals who qualify for Medicaid based on being blind or disabled Dual eligible Medicaid Medicare Terminally ill hospice patients Inpatients in hospitals, nursing homes, and intermediate care facilities Former foster care children Individuals who qualify for long-term care services based on their medical condition Individuals who only qualify for emergency care Individuals who qualify based on spend down

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Single, Streamlined Application

1Pursuant

to the National Voter Registration Act of 1993, 42 USC Sec. 1973 GG-5

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Who is likely to help you enroll in Medicaid?


Clinical Based Social Work CICP enrollment Staff where you are seen Case Management / Social Worker through Peak or Insurance Marketplace CDPHE targeted enrollment

Who can help you apply for Medicaid


Schedule an appointment by calling your HIV Clinic (DH, CHIP, University, etc.). Some case managers are helping with enrollment Enroll yourself through Colorado PEAK website (PLEASE make sure to notify ADAP that you have enrolled in Medicaid by calling (303) 692-2716). If you are already receiving AND or SNAP, you can enroll using your PEAK account Meet with a County Social Service worker Applying for anything other than Medical will increase the time it takes for approval

Colorado http://coloradopeak.force.com/Medicaid Website

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I got this confusing letter


Medicaid in Colorado has started a program called the Accountable Care Collaborative / Regional Care Collaborative Model In this model, they attempt to coordinate care across all medical and behavioral care to increase efficiencies and decrease healthcare costs These RCCOs are attempting to create this system for ALL Medicaid clients (not just PLWH/A) You will likely get a letter from one of these RCCOs They will urge you to select a Primary Care Provider (PCP) an ID specialist cannot be considered as a PCP. It is important to know that participation in your RCCO is optional You do NOT have to change doctors for your care You should keep any scheduled appointment

Health Colorado Enrollment Letter


You DONT need to do anything if the letter indicates the correct PCMP Your RCCO and PCMP may not make the call to the Health Colorado on your behalf, but can assist you with making the call to select your doctor You can change PCMP selection at any time You can ask your RCCO to try and recruit your PCMP if not already contracted as an ACC primary care provider

Medicaid Service Co-Pays, 2013


Inpatient Hospital Services Outpatient Hospital Services Practitioner Services Psychiatric Services $10/ 50% $3 / visit $2 / visit 50 per 15 min service unit $2 per visit Rural health clinic/FQHC Laboratory $2 per service date $1 per service date

Prescriptions:

Generic drugs Brand name

$1 $3

Community mental health services

Supplemental Wrap Around Program (SWAP) ADAP has begun a new program to cover all Medicaideligible clients with medication co-pay coverage for ADAP formulary Members will be able to use many more pharmacies if they choose (King Soopers, Walgreens) Recertification process will become easier (as member would have been screened eligible for Medicaid) ADAP suggests that you continue to 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.

ADAP and the Benefits Exchange

2. More people will be able to buy affordable, private insurance


If your income is over the Medicaid limit, you can buy insurance through Connect for Health Colorado. You may qualify for a federal subsidy to pay a portion of your monthly plan premiums. If you are in ADAP, the program will cover the remainder of the monthly premium on select silverlevel plans. Deductibles, Coinsurance, and Copays for your ADAP HIAP -formulary medications will be covered at participating pharmacies Copays and coinsurance for office visits will be covered.

New Insurance Rules


Since July 2010, any new health insurance plans (with the exception of grandfathered plans*) are required to provide coverage for preventive services. Starting in 2014, all health insurers will have to sell coverage to everyone who applies, regardless of their medical history or health status. Starting in 2014, insurers are barred from charging more or excluding coverage for individuals with pre-existing conditions. And dont forget starting in 2014, you may have to pay a fine if you dont have health insurance.
* Grandfathered plans are employer insurance plans that were in place on March 23, 2010. These plans are subject to some of the new rules resulting from the health reform law, but exempt from others.

# 3 Current Insurers Have to play by new rules:

Health plans cannot drop people from coverage when they get sick (already in effect) No lifetime limits on coverage (already in effect); No annual limits on coverage (2014) Children under 26 may remain on parents insurance plan (in effect) If your employer plans premium costs more than 9.5% of your income, you can shop for another plan through the marketplace*
In most cases, Colorado ADAP will insist that you do.

How Much Will It Cost Me?


If you receive ADAP, your cost for your HIV care and prescriptions using private insurance and ADAP will be:

How Will It Work?


More benefits and services with no cost to the member, whats the catch?
Instead of paying the full cost of expensive HIV medication, ADAPs dollars can go further by paying the costs associated with insurance. Insurance pays a the majority of the costs of drugs and services, ADAP picks up the remainder ADAP saves money, members get comprehensive health coverage

http://www.connectforhealthco.com

Connect for Health Colorado Health Coverage Guide


Approximately 300-400 Colorado ADAP members would likely be newly eligible for the exchange Nearly all of these individuals have been receiving Medical Care through Ryan White and CICP Most will want / be able to stay with their current provider

CDPHE / ASO Collaborative for Connect for Health Colorado


CDPHE has worked with the local AIDS Service Organizations to hire a network of Health Coverage Guides to assist clients through the process of applying for coverage. Health Coverage Guides will work with clients and clinics through the Initial Enrollment Period of the Affordable Care Act to ensure that all members get the chance to enroll in comprehensive coverage. ADAPs initial goal was to have the majority of clients enrolled in Medicaid or Private Insurance to be effective January 1. We understand that not everyone may meet deadline, so we will continue to pursue Marketplace enrollment through March 31, 2014 and ongoing for Medicaid. There will be increasing pressure to enroll in programs that you qualify for.

Cost reduction for Individuals & Families


Financial help to reduce the cost of premiums Individual earning between $11,490 to $45,960/year Couple earning between $15,510 to $62,040/year Family of four earning $23,550 to $94,200/year
o Tax credit applied up-front by IRS o Tax credit is higher for older Coloradans, especially for those ages 55-64 o ADAP members MUST receive tax credit in advance (not applied at the end of the year o ADAP Members must report any change in income that might affect the amount due

Financial help to reduce out of pocket costs (co-pays and deductibles) Individuals earning $11,490 to $28,725/year Family of 4 earning $23,550 to $58,875/year
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Overestimating or underestimating income

At the enrollment date, it is important to estimate annual income carefully. If you underestimate your income they will receive too much premium subsidy. This could result in you owing money back to the IRS when you file your taxes. If you overestimate your income you will receive less premium subsidy than you are entitled to, imposing extra costs on ADAP. There will be a reconciliation with IRS, DHS, SSA, and other data systems.
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Process in a Nutshell
Health Coverage Guides (HCGs) are assigned to region, not necessarily ASO service area, to enroll clients. Through a one-on-one appointment arranged between the HCG and client or a walk-in clinic day, client is met with by an ADAP-specific HCG. The HCG will sit with the client and walk them through the enrollment process HCGs will report enrollment progress to the ADAP office to allow for a coordinated approach that avoids people falling through the cracks Clients will NOT be pressured into making immediate decisions. If they need time to think, HCG will make arrangements to complete process at future appointment. Clients will NOT be pressured into choosing plans that dont meet their needs. If they are not enrolled because they want a plan that has not been pre-approved by ADAP, they will be referred to the ADAP main office, who will work with the client to find a solution.

Members eligible for the Exchange

Assignment health coverage guide

Contact and enrollment through Connect for Health Colorado Portal

Plan choice, federal subsidy assigned, remaining balance to be paid by HIAP

Assignment to HIAP Enrollment Worker at Regional ASO

Set up new plan information, including premium and cost-sharing info for Jan 1 2014

Terminate HMAP plan @ 12/31/2013, send new HIAP card in December

Current HIAP Members enrolled by Region / area

Colorado Department of Public Health (CDPHE) HIV Care & Treatment Program

Colorado AIDS Project (Denver Colorado AIDS Project (510 enrollees)

Boulder County AIDS Project (BCAP) Boulder (51 enrollees)

Northern Colorado AIDS Project Ft. Collins/Greeley (32 enrollees)

Southern Colorado AIDS Project CO Springs/ Pueblo (71 enrollees)

Western Colorado AIDS Project Grand Jctn/ West Slope (29 enrollees)

Eligibility Screening done at these enrollment sites until January 2014, then performed by ADAP?

Map of AIDS Service Organization Service Areas with Insurance Rating Areas.
The following map shows the inconsistent overlaps between service areas and rating areas. Because of these inconsistencies, it makes sense to allow the client to choose the easiest location to enroll through. They would still be referred to their regional ASO to set up premium/co-pay assistance if enrolled in insurance.

Numbers indicate insurance rating area

Sample of ADAP-approved plans by area

Denver ADAP-Approved Plans


Insurer Plan Name Referral Deductible Medical Copays Required to see a specialist?
$0 Medical $0 Rx $1750 Medical Colorado Choice SilverChoice 1750/40 (HMO) $0 Rx Elevate Silver/Basic (Expanded Network Plan) $2500 Medical $0 Rx $1750 Medical $0 Rx Humana Connect Silver 4600/6300 Plan (HMO) $4600 Medical $1500 Rx $1500 Medical $250 Rx New Ventures Access Health CO Silver (PPO) $5000 Medical $500 Rx $1500 Medical $0 Rx $1500 Medical $0 Rx $30 primary care

Rx Copays

Cigna Life and Health Insurance Co.

myCigna Copay Assure Silver (OAP)

Denver Health Medical Plan

HMO Colorado (Anthem BCBS)

Silver DirectAccess (HMO)

Humana Health Plan, Inc.

Kaiser Permanente

KP CO Silver 1500/30 (HMO)

Rocky Mountain HMO Region-specific 1500/40 Plan(HMO) Rocky Mountain Health Plans Rocky Mountain HMO Statewide 1500/40 (PPO)

***Drug copays, plan formularies and provider networks are subject to change without regulatory approval. Make sure to verify with Connect for Health, coverage documents and/or provider at time of enrollment to ensure the plan covers clients preferred provider and medications.

$4 Preferred/$25 Non-preferred Generics $60 Preferred Brand No 50% Non-preferred Brand $60 Specialty care 40% Specialty Not required for $15 Generic $25 primary care consult with a $40 Preferred Brand specialist. Referral may $60 Non-preferred Brand be required for $45 Specialty care $60 Specialty procedures $8 Discount $40 primary care $40 Generic Yes $90 Preferred Brand $65 Specialty care $160 Non-preferred Brand $15 Tier 1 $35 primary care $40 Tier 2 No 20% Tier 3 20% Specialty care 20% Tier 4 $10 Preferred/$20 Non-preferred Generic $25 primary care $50 Preferred Brand Yes 50% Non-preferred Brand $35 Specialty care 50% Specialty $15 Generic $30 primary care $45 Preferred Brand No 30% Non-preferred Brand $50 Specialty care 30% Specialty $20 Generic $25 primary care $40 Preferred Brand Yes $80 Non-preferred Brand $50 Specialty care 30% Specialty $15 Tier 1 $40 primary care 30% Tier 2 Yes 40% Tier 3 $55 Specialty care 40% Tier 4 $15 Tier 1 $40 primary care 30% Tier 2 Yes 40% Tier 3 $55 Specialty care 40% Tier 4

ADAP Health Coverage Guides by Agency


2118 St. Boulder, CO 80302 (303) 444-6121 ADAP Health Coverage Guides: Amanda Heinrich Celeste LeBlanc Erin Dupuis

Boulder County AIDS Project


14th

Denver Colorado AIDS Project


2490 W. Ave. Suite A300 Denver, CO 80204 (303) 837-1501 ADAP Health Coverage Guides: Ashley Bruehl Dwayne Hickman Kate OMeara Stephen Pipal Tiffany Rosengrant 26th

Southern Colorado AIDS Project


1301 S. 8th St. Suite 200 Colorado Springs, CO 80906 (719) 578-9092 ADAP Health Coverage Guides: Ann Sulley Kelly DeMuth

Colorado ADAP

4300 Cherry Creek S Dr Denver, CO 80246 (303) 692-2716 ADAP Health Coverage Guides: Adam Brisnehan JoAnn Palma Todd Grove

805 Main Street Grand Junction, CO 81501 Northern Colorado AIDS Project (970) 243-2437 400 Remington St. ADAP Health Coverage Guides: Suite 100 Elizabeth Pertile Ft. Collins, CO 80524 (970) 484-4469 ADAP Health Coverage Guides: Emily Darrell Kelly Maycumber

Western Colorado AIDS Project

If you receive ADAP assistance and need to meet with someone to enroll in coverage, contact an area agency to speak with a Health Coverage Guide.

4) Medicare is Getting Better


54% discount on all brand-name prescription drugs paid by drug makers during Part D donut hole to be totally phased-out by 2020 Increased generic coverage as well More classes of drugs allowed Improved access to prevention & screening

DRUG FORMULARIES

HMAP
HMAP Formulary (9/15/2013)

HIAP
HIAP Formulary (9/15/2013) PCIP Formulary (ends 12/31/2013)

BTGC
Medicare Part D Plan Formulary through the coverage gap Then, HMAP Formulary (9/15/2013) only

SWAP
HMAP formulary

PHARMACIES

HMAP
Denver Health Walgreens at Childrens Hospital University of Colorado Walgreens at Rose Medical (Denver)

HIAP
Apothecary Walgreens King Soopers CHIP City Market Kaiser Denver Health University Rocky Mtn CARES Avella

BTGC
Apothecary

SWAP
Apothecary Walgreens King Soopers CHIP City Market Kaiser Denver Health University Rocky Mtn CARES Avella

Walgreens King Soopers CHIP City Market Kaiser Denver Health University Rocky Mtn CARES Avella

Lets Make Healthcare Reform Real:


1) Michael and Ross

Michael & Ross


Michael
Michael is on Medicare He has ADAP and Bridging the Gap, which pays his Medicare Part D premiums and his prescription Drugs In 2014, there are no changes to Michaels ADAP coverage he should expect his renewal application for BTGC in October

Ross
Ross has insurance through his employer, and earns about $30,000 a year It is a pretty good plan, and ADAPs Health Insurance Assistance Program (HIAP) pays his premiums, deductibles & co-pays Ross should also expect to have no changes to his HIAP coverage

Making it Real# 2: Aaron


Aaron, an uninsured man who makes $14,000 annually, is HIV-positive. Hes newly diagnosed and doesnt have any symptoms, although he does suffer from depression. He has a history of heart disease and diabetes in his family.

Aarons Situation Today


Aaron cant qualify for Medicaid because he is not totally disabled. Aaron can get HIV medications through ADAPs HIV Medication Assistance Program (HMAP). Aaron gets HIV primary care paid for by the Ryan White & CICP. However, if Aaron develops diabetes or heart disease, he may have to pay out-of-pocket for medical care or medications that will control these conditions Aaron has to pay out-of-pocket for medications to treat his depression.

Aarons Situation in 2014


FROM CICP, Ryan White & HMAP

Aaron will have access to Medicaid based only on his income* (<138% FPL) and will not need to wait for a disability determi-nation to access the program.

TO: Medicaid and SWAP Medicaid will pay for medical care, depression treatment, and medications for any condition that Aaron may have, which will help him to better manage his health and prevent costly hospitalizations.

Karyns Road to Health


Making it Real: Karyn, 40 year-old woman in Aurora, runs a small business and makes $40,000 per year (just under 400% of FPL). She just tested positive for HIV.

Karyns in trouble!
Karyns Situation Today:

Cant buy private insurance: HIV is a preexisting condition. She makes too much money for CICP Is able to get HIV meds ADAPs HMAP

Could possibly get business of one insurance expensive! Worst case: pay out of pocket for treatment, could very well file for medical bankruptcy, and would then need to wait until she became totally disabled until qualifying for Medicaid

Karyns Situation in 2014


Karyn has options! She can purchase private insurance through Connect for Health Colorado, the Colorado Marketplace Insurance companies will be required to sell policies to people with pre-existing conditions
Coverage will be more affordable:
Shell receive a sliding scale subsidy so her health care premiums are limited to 9.5% of her income. Insurance companies will be allowed to charge rates based only on age, geography and whether someone smokes or not (rates cant depend on gender or how sick someone is). Colorado ADAPs Health Insurance Assistance Program will help pay for the cost of insurance beyond what the federal government will pay

YOU HAVE RESPONSIBILITIES!!


Everyone will be required to have health insurance The requirement will be enforced by the IRS, you probably need to file taxes with few exceptions Employers must offer insurance or pay a tax in 2015* But there are lots of exceptions

The Clock is Ticking!!! October 1, 2013: Enrollment


began into Medicaid & health plans Apply ASAP! January 1, 2014: coverage begins March 31, 2014: open enrollment ends for insurance through the insurance marketplace. Medicaid is ongoing.

ADAP / Insurance Status after Implementation


1,800 individuals

200- 300 individuals 1,100 Medicaid /SWAP members 300 new HIAP members

100 new HIAP members

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Questions?
Todd Grove ADAP Coordinator Colorado Department of Public Health & Environment 303-692-2783 todd.grove@state.co.us Bob Bongiovanni Program Manager, HIV Care & Treatment Colorado Department of Public Health & Environment 303-692-2703 bob.bongiovanni@state.co.us

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