Professional Documents
Culture Documents
Todays Presenters:
Colorado Department of Public Health & Environment Todd Grove, Colorado AIDS Drug Assistance Program Bob Bongiovanni Program Manager, HIV Care & Treatment Program
900 people
600 people
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
250% of FPL
(current max CICP)
400% of FPL
(current max ADAP programs)
1 2 3 4
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
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
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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1Pursuant
to the National Voter Registration Act of 1993, 42 USC Sec. 1973 GG-5
20
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Prescriptions:
$1 $3
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.
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.
http://www.connectforhealthco.com
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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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.
Set up new plan information, including premium and cost-sharing info for Jan 1 2014
Colorado Department of Public Health (CDPHE) HIV Care & Treatment Program
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.
Rx Copays
Kaiser Permanente
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
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
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.
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
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
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 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
200- 300 individuals 1,100 Medicaid /SWAP members 300 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