Transcript Cost-sharing reductions

Plan Assessment and Enrollment:
Considerations for HIV/AIDS Programs
Amy Killelea
Britten Pund
Xavior Robinson
August 21, 2014
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Presentation Outline
1. Introduction
2. Plan Assessment Considerations
– Cost
– Formulary
– Provider and pharmacy networks
3. ADAP Insurance Cost Effectiveness Model
4. Questions
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HRSA/HAB Policies and ADAP
Insurance Purchasing
 HRSA encourages state ADAP/Part B Programs to use their Ryan
White funding to help clients access insurance, as long as:
– Formulary includes at least one drug in each class of core ARVs
from the HHS Clinical Guidelines
– It is cost-effective in aggregate as compared to purchasing
medications
 Other Ryan White Program grantees may also use their funds to
help clients with the cost of insurance
 The Ryan White Program is the payer of last resort and grantees
must “vigorously pursue” client eligibility for public and private
insurance
– Grantees may not dis-enroll clients from services for failure to
enroll in public or private insurance coverage
 Ryan White Program funds may be used to cover services not
covered or inadequately covered by public and private insurance
 HRSA is considering allowing ADAP insurance purchasing programs
to cover client tax liabilities associated with an overpayment of the
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PTC
Top Three Plan Assessment
Challenges in Year One
Challenges
Strategies
Healthcare.gov and some statebased Marketplaces experienced
significant glitches
CMS has invested significant resources
into improving the performance
healthcare.gov. A number of statebased Marketplaces are also trying to
make improvements.
Qualified Health Plan (QHP)
information was unavailable,
inaccurate, or incomplete
Final QHP application submissions are
due on 9/4/14. Certification notices
and QHP agreements are scheduled to
be signed by 11/3/14
QHP formulary, and provider and
pharmacy networks information
were not plan-specific
Provider networks and formularies
must be directly linked to in the
Marketplace, and be plan-specific
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Cost Considerations
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Cost Considerations
Premiums
Out-of-pocket costs
Deductibles
Monthly
payment to plan
Copayments
Coinsurance
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Navigating the Marketplace
Web Portal
Exchange/Marketplace Portal
Medicaid
Qualified Health Plan (QHP)
Federal Subsidies for Private
Insurance:
• Premium Tax Credits
• Cost-sharing reductions
Federal Data Services Hub
•
•
•
•
•
SSN verification via SSA
Citizenship and immigration status via DHS
Incarceration verification via SSA
Title II benefits information via SSA
MAGI income from IRS
Apply for
coverage
through
Marketplace
Screen for
Medicaid and
subsidy
eligibility
Evaluate QHP
options
Select QHP
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Pay first
month’s
premium
ACA Affordability Provisions
 Three ACA provisions that make insurance more affordable:
– Premium tax credits
 Available to people with income 100-400% FPL who have
no other public or affordable employer-based coverage
– Cost-sharing reductions
 Available to people with income 100-250% FPL who have
no other public or affordable employer-based coverage
– Out-of-pocket caps
 2015 maximum amounts: $6,600 individual/$13,200
family
 Applies to all Essential Health Benefits (medical AND
pharmaceutical benefits)
 Only applies to in-network services
 Applies to ALL non-grandfathered private insurance plans
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Premium Tax Credits: How They Work
and Program Considerations
 Premium Tax Credits for the vast majority people with
income between 100 and 400% FPL
 Tax credit = difference between benchmark premium
and taxpayer’s expected contribution
– Expected contribution based on annual income and increases
from 2% of income to 9.5% as income increases
– Consumer may choose to take credit in advance instead of as
tax refund
– Consumer responsible for overpayment at tax time
 Programs should consider:
– Requiring clients to take full amount of tax credit in advance
– Directing clients to tax preparation resources
– Aligning income criteria and verification with MAGI
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Premium Tax Credits: How They Work
and Program Considerations
2014
Consumer earns
income and
generates a
modified
adjusted gross
income (MAGI)
for the 2014 tax
year
2015
Consumer
receives
advance
premium tax
credit and cost
sharing
reductions based
on 2014 MAGI
2016
Consumer files
2015 tax return
and reconciles
2014 MAGI with
2015 MAGI –
and under/overpayment
assessed by IRS
Consumers must report changes
in income to the Marketplace
throughout the year!
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Cost-Sharing Reductions
 Cost-sharing reductions (CSR) for people with income between
100 and 250% FPL
– Increases actuarial value to reduce member contribution
– Only available if person enrolls in a SILVER LEVEL plan
Household
Income
AV Level
(Silver Level
Plans)
AV
Requirement
w/CSR
Reduced OOP
Maximum
Plan Designs
100-150% FPL
70%
94%
~$2,250
Deductible
Copays
Coinsurance
150-200% FPL
70%
87%
~$2,250
Deductible
Copays
Coinsurance
200-250% FPL
70%
73%
~$5,200
Deductible
Copays
Coinsurance
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Assessing QHP Metal Tiers
and OOP Plan Costs
QHP Metal
Tiers
What It Means
Bronze
Plan pays 60% of costs (on
average)/enrollee pays 40%
Silver
Plan pays 70% of costs (on
average)/enrollee pays 30%
Gold
Plan pays 80% of costs (on
average)/enrollee pays 20%
Platinum
Plan pays 90% of costs (on
average)/enrollee pays 10%
Lower premiums,
but less generous
Higher premiums,
but more generous
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OOP Costs In Action
Consumer
pays 100%
of costs until
hit deductible
Once consumer hits
OOP cap (for innetwork services) plan
pays 100% of costs
for rest of year
Consumer
pays co-pays,
co-insurance
Deductible
OOP Cap
Primary
Care Visit
Specialist
Visit
In-network
$1,500
$6,600
$25
$100
Out-ofnetwork
$5,500
No cap
50%
50%
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Client Archetypes:
Meet Julie and Murray
Julie
Age: 30
MAGI: $34,470
FPL: 300%
Resides in Camden, NJ
Murray
Age: 30
MAGI: $17,235
FPL: 150%
Resides in Newark, NJ
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Affordability Screenshot
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The OOP Max for 2015 is
$6,600 for individual
coverage. Plans have the
options of having a
reduced OOP Max
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So which plans are the best
fit for Julie and Murray?
Metal Level Monthly
Premium
Deductible
Out-ofpocket
Maximum
Specialist
Doctor Visit
Silver
$50
$100/year
$700
$30
Gold
$105
$2,000/year $4,650
Platinum
$294
$0/year
$4,500/year $25
Metal Level Monthly
Premium
Deductible
Out-ofpocket
Maximum
Silver
$266
$2,000/year $6,350
$35
Gold
$321
$2,000/year $4,650
$30
Platinum
$510
$0/year
$30
Specialist
Doctor Visit
$4,500/year $25
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Summary of Cost Considerations
for HIV Programs
 Require clients to take full amount of tax
credit in advance
 Direct clients to tax preparation resources
 Align income criteria and verification with
MAGI
 Remind consumers to report changes in life
circumstance throughout the year
 Preference for silver level plans for clients
eligible for cost-sharing reductions
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Formulary Considerations
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Evaluating Scope of Coverage:
Prescription Drug Formulary
 EHB Standard = same number of drugs per U.S. Pharmacopeia
(USP) category/class as state’s benchmark plan
USP
Category
USP
Class
Anti-viral
NRTIs
NNRTIs
Protease inhibitors
Anti-Cytomegalovirus (CMV)
agents
Missing from USP
classification system =
combination therapies
Anti-hepatitis agents
Other
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Comparing Formularies Across Plans
Julie
• Treatment regimen:
 Prezista
 Norvir
 Truvada
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Universal Formulary
Utilization Management
Techniques
Utilization Management
Noun.
set of techniques used by or on behalf of insurance
carriers to manage the cost of health care before its
provision by influencing patient-care decision making
through case-by-case assessments and/or procedures
of the appropriateness and cost of care based on
accepted practices
Examples Include:
1. Quantity Limit
2. Prior Authorization
3. Step Therapy
4. Provider Prescribing Limits
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Assessing Formulary Affordability:
Silver vs. Platinum
Platinum Plan
Silver Plan
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Copayment vs. Coinsurance
Copayment
A copay is a fixed amount paid whenever a
particular type of healthcare service or prescription
drug.
Coinsurance
The consumer pays a percentage of the cost of a
healthcare service or prescription drug.
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Putting It Together:
Premium Costs and Formulary Affordability
Julie’s Platinum Plan Option
Prescription
Drug
Tier Utilization
Management
Deductible
Cost-sharing
Prezista
2
0
$40/month $480
Truvada
2
0
$40/month $480
Norvir
3
0
$50/month $600
Prior Authorization,
Quantity Limit,
Specialty Formulary
Maximum
Annual Cost
Subtotal Drug Costs
$1,560
Annual QHP Premium
$3,528
Total Annual Premium and Drug Costs
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$5,088
Putting It Together:
Premium Costs and Formulary Affordability
Julie’s Silver Plan Option
Prescription
Drug
Tier
Utilization
Management
Deductible
CostMaximum
sharing
Unadjusted
(50% after Annual Cost
deductible)
Prezista
2
Prior Authorization,
Quantity Limit,
Specialty Formulary
$2,000
$320/
Month
$3,840
Truvada
2
$2,000
$320/
Month
$3,840
Norvir
3
$2,000
$400/
month
Subtotal Drug Costs ( Adjusted for OOP Maximum)
Total Annual Premiums Costs
Total Annual Premium and Drug Costs
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$4,800
REMINDER:
Platinum
$6,350 Plan
Costs = $5,088
$3,192
$9,542
Formulary Considerations
 Prioritize plans that cover the consumer’s existing
medications regimen
– Including single-tablet regimens
– Assess formulary exceptions processes
 Investigate the utilization management
techniques that are in place
 Prioritize low-deductible plans with co-payments
instead of co-insurance
 Weigh premium cost against out-of-pocket
maximums, deductibles, and cost-sharing
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Provider and Pharmacy Network
Considerations
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Assessing Provider and
Pharmacy Networks
HIV/Ryan White
Providers
• Must include “Essential
Community Providers,”
but plans still vary on
coverage
Pharmacy Network
• Are ADAP pharmacies
(or pharmacies who
will coordinate with
ADAP) included?
• Do network pharmacies
require mail order?
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Mail-Order Pharmacy Considerations
Some QHPs rely heavily on mail-order pharmacies
to provide prescriptions. Mail-order pharmacies
may have issues coordinating with third party
payers such as ADAPs.
Considerations Include:
– Plan opt out provisions
– State laws requiring an opt-out
– Pending litigation (e.g. United settlement)
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Dates to Consider for Plan Coverage
 Coverage begins with initial on-time payment of
premium by consumer
– Marketplace plans must accept: paper check,
Electronic Funds Transfer, cashier’s check, money
order, and pre-paid debit card
– Insurer sets deadline for payment of first premium
– Insurance may be cancelled for failure to pay first
premium by specified deadline set by plan
 NOTE: unlike 90 day grace period once
coverage begins, there is no initial grace
period for late premium payments
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ADAP Insurance Purchasing Checklist
See NASTAD Assessment Tool:
 What is plan’s deductible?
 What is plan’s out-of-pocket cap (including costsharing reductions)?
 What is plan’s monthly premium (including
premium tax credit)?
 What drugs are covered under plan’s formularies?
 Are their restrictions associated with drug
coverage?
 What Ryan White services are covered by plan?
 What providers and pharmacies are included in
plan network?
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ADAP Insurance
Cost-Effectiveness Model
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How to use the ADAP Insurance Costeffectiveness Model
 Intended to assist in assessing if individual insurance plans are
cost-effective.
– Information inserted into the tool should be based on an
individual insurance plan for an average client, not the total
cost of providing insurance for all of your ADAP clients.
– The cost-effectiveness model may be used and applied for
any private insurance plan, including a qualified health plan
(QHP) available through either a state- or federally-run
Affordable Care Act (ACA) marketplace.
 The tool has been built with two completion approaches:
– The first aligned directly with HRSA guidelines outlined in
HRSA policy notice 07-05 and 13-05.
– The second providing a broader assessment of all costs
associated with purchasing insurance.
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HRSA Criteria: Step One
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HRSA Criteria: Step Two
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HRSA Criteria: Step Three
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State Alternative: Step One
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State Alternative: Step Two
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State Alternative: Step Three
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Questions
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Resources
 National Alliance of State & Territorial AIDS Directors
(NASTAD), www.NASTAD.org
– Amy Killelea, [email protected]
 HIV Health Reform, http://www.hivhealthreform.org/
 Treatment Access Expansion Project, www.taepusa.org
 HIV Medicine Association, www.hivma.org
 HRSA/HAB ACA and Ryan White Resources,
http://hab.hrsa.gov/affordablecareact/
 Health Care Reform Resources
– State Refo(ru)m, www.statereforum.org
– Kaiser Family Foundation, www.kff.org
– Healthcare.gov, www.healthcare.gov
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