Transcript The Affordable Care Act Individuals with Disabilities

THE INTERSECTION OF THE RYAN
WHITE HIV/AIDS PROGRAM
WITH THE ESSENTIAL HEALTH
BENEFITS IN PRIVATE HEALTH
INSURANCE AND MEDICAID
HIV/AIDS Bureau, Health Resources & Services Administration; Center for
Medicaid and CHIP Services; Center for Consumer Information and Insurance
Oversight
Purpose of Webinar
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Educate Ryan White grantees about potential new coverage options
and the essential health benefits available to PLWH through
Medicaid and the Health Insurance Marketplace
Review individual and small group commercial plan coverage of
essential health benefits inside and outside of the Health Insurance
Marketplace
 CMS – Center for Consumer Information and Insurance Oversight
(CCIIO)
Review Medicaid coverage of essential health benefits
 CMS - Center for Medicaid and CHIP Services (CMCS)
Review how essential health benefits offered in Medicaid and the
Marketplace intersect with the Ryan White HIV/AIDS Program
 HRSA – HIV/AIDS Bureau & Office of Policy Analysis and
Evaluation
Health Coverage Options for PLWH
BEFORE the Affordable Care Act
Note: Data only reflective of Ryan White clients, not of entire HIV/AIDS population; Source: 2010 Preliminary Ryan White Services Report Data (RSR)
Health Coverage Options for PLWH
AFTER the Affordable Care Act
PLWH eligible for health coverage
EmployerBased
Insurance
Medicaid
Cover comprehensive HIV medical
and support services not covered,
or partially covered, by public
programs or private insurance
Other
Public
Medicare
Ryan
White
Program
PLWH who remain uninsured
Health
Insurance
Marketplace
Other
Private
Cover comprehensive HIV medical
and support services not covered,
or partially covered, by public
programs or private insurance
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Private Health Plans & Essential
Health Benefits
Allison Wiley, Health Insurance Specialist
Lisa Cuozzo, Health Insurance Specialist
Helaine I. Fingold, Health Insurance Specialist
Center for Consumer Information and Insurance Oversight
(CCIIO)
Introduction
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
Under the Affordable Care Act: Non-grandfathered health plans
offered in the individual and small group markets (inside and
outside of the Exchanges) must cover the essential health benefits
package, which includes:
 Coverage of at least 10 categories of benefits and services
(EHB)
 Meeting certain actuarial value (AV) standards
 Meeting certain limits on cost sharing
Background on Essential Health
Benefits
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The ACA states that EHB must cover at least the following 10 categories of
benefits & services:
1. Ambulatory Patient Services
2. Emergency Services
3. Hospitalization
4. Maternity and Newborn Care
5. Mental Health and Substance Use Disorder Services, Including Behavioral
Health Treatment
6. Prescription Drugs
7. Rehabilitative and Habilitative Services and Devices
8. Laboratory Services
9. Preventive and Wellness Services and Chronic Disease Management
10. Pediatric Services Including Oral and Vision Care
Benchmark Plan Approach for
Essential Health Benefits
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Essential Health Benefits are based on a benchmark plan
selected by each state
 Benchmark options include plans typically offered by small
employers
 Preserves state flexibility
 Similar to the benchmark approach currently used in other
programs
 Benchmark plans were selected in March 2012, but must
conform to all ACA requirements in 2014
Supplementing the State Base-Benchmark
Plan to State’s EHB-Benchmark Plan
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The Benchmark plan serves as a reference plan:
 EHB plan benefits must be “substantially equal” to the
benchmark’s benefits
Benchmark plans must cover all 10 statutory categories
 A base-benchmark plan that lacks a statutory category must
supplement the entire category from another benchmark plan
option
A number of states’ base-benchmark plans did not include coverage
of pediatric oral & vision care
The final rule allows the state’s base-benchmark plan to be
supplemented with:
• The FEDVIP pediatric vision/dental plan; or
• The state’s separate CHIP plan benefit, if one exists
Supplementing Options for
Habilitative Services
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A number of state benchmark plans did not include habilitative
services
If a state’s benchmark plan does not include coverage of
habilitative services, the State may determine which services
are included
If a state’s benchmark plan does not include coverage of
habilitative services and the State did not define, insurers must:
• Provide parity by covering habilitative services benefits that
are similar in scope, amount, and duration to benefits
covered for rehabilitative services; or
• Decide what services to cover & report to HHS
EHB Prescription Drug Benefit
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Plans must cover at least the greater of:
• One drug in every USP category & class; or
• The same number of drugs in each USP category & class as
the EHB-benchmark plan
Requires an exceptions procedure so enrollee can gain access
to drug not on the plan’s list
Applies discrimination protections
Requires plans to report drug lists to the Exchange, state, or
OPM
Requirements for Mental Health and
Substance Abuse Benefits
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Plans must comply with parity standards for the mental health
& substance use disorder services
• Based on requirements in Mental Health Parity and
Addiction Equity Act of 2008
EHB rule extended parity to small group plans
Consumer Resource: Actuarial Value
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AV standards will help consumers compare health
plans by providing information about relative plan
generosity
 (Total
Overall Health Costs – Total Enrollee Cost
Sharing)/Total Overall Health Costs
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AV must be calculated based on the provision of
EHB to a standard population
AV is reflected as a percentage
AV Levels of Coverage
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AV determines a health plan’s metal level tier
ACA - directs that non-grandfathered individual &
small group plans inside & outside the Exchanges
meet particular AV targets (or be a catastrophic
plan1):
 Bronze
= 60% AV
 Silver = 70% AV
 Gold = 80% AV
 Platinum = 90% AV
1
Catastrophic plans are only available for certain eligible individuals
Consumer Protections: NonDiscrimination Standards
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The EHB rule prohibits discrimination in benefit design based
on:
 Age
 Expected length of life
 Disability
 Medical dependency
 Quality of life
 Other health conditions
Allows for reasonable medical management techniques
Consumer Protections: Cost-Sharing
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On or after January 1, 2014:
 Provides annual limits on maximum out-of-pocket (MOOP) for all
group health plans (including large and self-insured):
 $6,350 for self-only coverage; or
 $12,700 for other than self only coverage
 Provides deductible limits for small group market:
 $2,000 for self-only coverage
 $4,000 for other than self-only coverage
 For subsequent plan years:
 Will increase based on a premium adjustment %
Applies to in-network costs
Medicaid Alternative Benefit Plans
and Essential Health Benefits
Melissa Harris, Division Director
Christine Hinds, Technical Director, Division of Pharmacy
Centers for Medicaid and Chip Services (CMCS)
Background
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Intended to be an alternative benefit plan to the Medicaid
state plan
Comparability and statewideness are waivable
States define populations, benefit packages and identify
delivery systems within SPA
Cost sharing and payment methodology SPAs required if
applicable
May require changes to other authorities such as 1115s or
1915(b) waivers
Final Regulation Overview
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Section 1937 Medicaid Benchmark or Benchmark
Equivalent Plans are now called Alternative Benefit Plans
(ABPs)
ABPs must cover the 10 Essential Health Benefits (EHB) as
described in section 1302(b) of the Affordable Care Act,
whether the state uses an ABP for Medicaid expansion or
coverage of any other groups of individuals
Individuals in the new adult eligibility group will receive
benefits through an ABP
Ten Essential Health Benefits
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1. Ambulatory Patient Services
2. Emergency Services
3. Hospitalization
4. Maternity and Newborn Care
5. Mental Health and Substance Use Disorder Services Including
Behavioral Health Treatment
6. Prescription Drugs
7. Rehabilitative and Habilitative Services and Devices
8. Laboratory Services
9. Preventive and Wellness Services and Chronic Disease Management
10. Pediatric Services Including Oral and Vision Care
Steps for Designing a Medicaid ABP
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 Step
1: States must select a coverage option from the choices
found in section 1937 of the Act
• Four benchmark options
• (1) The Standard Blue Cross/Blue Shield Preferred
Provider Option offered through the Federal Employees
Health Benefit program
• (2) State employee coverage that is offered and
generally available to state employees
• (3) Commercial HMO with the largest insured
commercial, non-Medicaid enrollment in the state
• (4) Secretary-approved coverage, a benefit package
the Secretary has determined to provide coverage
appropriate to meet the needs of the population
Steps for Designing a Medicaid ABP
(continued)
22
 Step
2: States must determine if that coverage option is also one
of the base-benchmark plan options identified by the Secretary as
an option for defining EHBs
• If so, the standards for the provision of coverage, including
EHBs, would be met, as long as all EHB categories are covered
• If not, states must select one of the base-benchmark plan
options identified as defining EHBs.
Steps for Designing a Medicaid ABP
(continued)
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Step 3: Select a base benchmark plan to define the EHBs
• Any of the three largest small group market health
plans by enrollment
• Any of the three largest state employee health benefit
plans by enrollment
• Any of the three largest federal employee health
benefit plans by aggregate enrollment
• The largest insured commercial non-Medicaid health
maintenance organization operating in the state
Substitution Policy
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Aligns with the individual and small group market
Allows flexibility for states to align benefit packages with
their Medicaid state plan
Requires actuarial equivalence and placement in the same
essential health benefit category
;
Medicaid and Essential Health
Benefits
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Primarily Medicaid will align with EHB provisions in the
individual and small group market.
States may use more than one EHB base benchmark to
determine EHB coverage for Medicaid purposes
There are a few exceptions to address the specific needs
of the Medicaid population
Prescription Drugs
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The amount, duration, and scope of prescription drugs for an ABP is
governed by the requirements of section 1937.
EHB prescription coverage standard:
Provide at least the greater of:
• 1 drug in every USP category and class; or,
• Same # drugs in each category and class as EHB benchmark
plan.
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States must include sufficient prescription drug coverage to reflect the
EHB benchmark plan standards at 45 CFR 156.122, including procedures
in place that allow an enrollee to request and gain access to clinically
appropriate drugs not covered by the plan.
To the extent that a prescription drug is within the scope of the ABP
benefit as a covered outpatient drug, section 1927 and Federal rebates
apply.
Habilitative Services and Devices
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Coverage based on the habilitative services and devices that are
in the applicable base benchmark plan
If habilitative services and devices are not in the applicable base
benchmark plan, the state will define habilitative services and
devices either in parity with rehabilitative services and devices or
as determined by the state and reported to CMS in the ABP
template
Preventive Services
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EHB requirements for coverage of preventive services,
including the prohibition on cost sharing, will apply to
section 1937 ABPs
Medical Frailty
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Definition of “medically frail” is modified and includes the
addition of people with chronic substance use disorders
Individuals in the new adult group, if determined to be
medically frail, will receive the choice of ABP defined using
EHBs or ABP defined as state’s approved Medicaid state plan
Additional Items
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States may include other benefits outside of 1905(a) described
in sections 1915(i), 1915(j), 1915(k) and 1945 of the Social
Security Act
All children under 21 enrolled in an ABP must receive Early and
Periodic Screening, Diagnostic and Treatment (EPSDT), including
pediatric oral and vision services
ABPs must also comply with the requirements of the Mental
Health Parity and Addiction Equity Act (MHPAEA)
ABPs must include family planning services and supplies,
FQHC/RHC services, and an assurance of NEMT
Transition
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CMS is permitting transition time, if needed, as long as
states are working toward, but have not completed a
transition to the new ABPs on January 1, 2014.
1905(a) Preventive Services
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CMS has codified changes to the definition of preventive
services to be provided to the general Medicaid population
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These changes do not relate to the provision of preventive services as an
EHB
They relate to aligning the general 1905(a) definition of preventive
services with the statutory construct at 1905(a)(13) of the Social Security
Act
Services can be recommended by a physician or OLP
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The Ryan White HIV/AIDS Program
& Essential Health Benefits
Health Resources & Services Administration, HIV/AIDS
Bureau & Office of Planning, Analysis, and Evaluation
Yolonda Campbell, Health Policy Analyst
Ryan White HIV/AIDS Program - still the Payer
of Last Resort
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“funds received…will not be utilized to make payments for any item or
service to the extent that payment has been made, or can reasonably be
expected to be made…”
Grantees and their subgrantees are expected to vigorously pursue
enrollment in other funding sources (e.g., Medicaid, CHIP, Medicare, statefunded HIV/AIDS programs, employer-sponsored health insurance
coverage, and other private health insurance) to extend finite RWHAP
grant resources to new clients and/or needed services.
Once a client is enrolled in Medicaid or a private health plan, RWHAP
funds may only be used to pay for items or services not covered, or
partially covered, by Medicaid or the client’s private health plan (See PCN
13-01 & 13-04 at HAB’s Affordable Care Act website at
http://hab.hrsa.gov/affordablecareact/).
RWHAP funds may also be used to cover the cost of premiums, deductibles,
and co-payments for Medicaid and private health insurance (See PCN 1305 and 13-06 at HAB’s Affordable Care Act website at
http://hab.hrsa.gov/affordablecareact/).
RWHAP Core Medical and Support
Services & Essential Health Benefits
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Ryan
Ryan
White
White
Support
Core
Services
Medical
Services
Essential
Health
Benefits
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Some RWHAP core medical (e.g, prescription drugs, mental
health and substance abuse services) and support services
(e.g, rehabilitation services) will be covered benefits under
private health plans and Medicaid Alternative Benefit
Plans. However, scope of coverage will vary by plan.
Some RWHAP core medical (e.g. adult oral health care)
and many support services (e.g., treatment adherence
counseling, outreach, transportation) may not be covered
benefits under private health plans or Medicaid
Alternative Benefit Plans
Grantees should understand the different benefit
packages across private health plans and Medicaid
alternative benefit plans so they can help clients identify
and enroll in health coverage that best meets their
individual HIV care needs.
Don’t forget that RWHAP funds may be used to pay for
items or services not covered, or partially covered, by
Medicaid or the client’s private health insurance plan.
Grantee Essential Health Benefits
Package Resources
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To learn about your state’s EHB-benchmark plan
selection, please visit CCIIO’s EHB resource site at
http://www.cms.gov/CCIIO/Resources/DataResources/ehb.html
CMCS will be posting information about your state’s
EHB-benchmark plan for Medicaid Alternative Benefit
Plans at the Medicaid.gov site (http://medicaid.gov/)
Health Coverage Options for PLWH
AFTER the Affordable Care Act
PLWH eligible for health coverage
EmployerBased
Insurance
Medicaid
Cover comprehensive HIV medical
and support services not covered,
or partially covered, by public
programs or private insurance
Other
Public
Medicare
Ryan
White
Program
PLWH who remain uninsured
Health
Insurance
Marketplace
Other
Private
Cover comprehensive HIV medical
and support services not covered,
or partially covered, by public
programs or private insurance
Helpful Affordable Care Act Resources
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HealthCare.gov: https://www.healthcare.gov/
HRSA, HIV/AIDS Bureau Affordable Care Act
Website: http://hab.hrsa.gov/affordablecareact/
Target Center: https://careacttarget.org/
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Questions?
If you have additional questions that were not
answered in today’s webcast, please email
[email protected]