Transcript Document
HIV Care Under the Affordable Care Act Addressing the Needs of HIV Clinics and Clinicians in Arizona May 2015 Julia Hidalgo, ScD, MSW, MPH Research Professor, George Washington University and CEO, Positive Outcomes, Inc. [email protected] Today We Will Address Key provisions of the Patient Protection and Affordable Care Act (ACA) Federal and State Medicaid policies Provider participation and covered benefit provisions Eligibility, service delivery, and payment systems Focus on challenges and opportunities for Arizona HIV clinical, social support, and prevention providers Maximizing third party reimbursement for HIV prevention, care, and support services through collaborative strategies ACA Marketplace From: Hidalgo J and Edelbrock E. Commercial Health Insurance Basics for HIV Prevention Programs Webinar. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-3-commercial-health-insurance-basics-for-hiv-prevention-programs/ US Census: Majority of Americans 19-64 Years Are Enrolled in Commercial Insurance Private Public Uninsured 70% 60% 50% 40% 30% 20% 10% 0% 19-25 26-34 35-44 Age Group 45-64 ACA Requirements: Essential Health Benefits (EHBs) Ambulatory patient services Hospitalization Emergency services Pregnancy, maternity, newborn care, and pediatric services (oral and vision care) Mental health and substance abuse disorder services (i.e., behavioral health treatment) Prescription drugs Rehab and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management ACA Requirements: Essential Community Providers (ECPs) ECP Category ECP Provider Type Federally Qualified Health Centers (FQHCs) FQHCs and other community health centers, and healthcare facilities operated by Indian tribes and other Indian organizations RWHAP Provider Ryan White HIV/AIDS Program-funded providers Family Planning Provider Title X family planning clinics and look alike family planning clinics Indian Health Provider Indian Health Service (HIS) providers, Indian tribes organizations, and urban organizations Hospital Disproportionate share hospitals (DSH) and eligible hospitals, children’s hospitals, sole community hospitals, and other similar facilities Other ECP Providers STD clinics, TB clinics, and other entities that serve predominantly low-income, medically underserved individuals ACA Requirements: ECPs CMS issued a letter to Federally-Facilitated Marketplaces in December 2014 QHPs must contract with at least 30% of ECPs in each QHP’s service area Offer contracts in good faith to all available Indian health providers in the service area Offer contracts in good faith to at least one ECP in each ECP category in each county in the service area Where an ECP in that category is available and provides medical or dental services that are covered by the issuer plan type (i.e., Individual or SHOP) To be in “good faith,” a contract should offer terms that a willing, similarlysituated, non-ECP provider would accept or has accepted Issuers must be able to provide verification of such offers if CMS chooses to review the offers for compliance ACA Requirements: Preventive Services DHHS US Preventive Services Task Force (USPSTF) recommends “A” grade for HIV infection screening Adolescents and adults ages 15 - 65 years Younger adolescents and older adults at increased risk All pregnant women, including those presenting in labor who are untested and whose HIV status is unknown “A” grade for syphilis for all pregnant women and other persons at increased risk for infection “B” grade for chlamydia screening for sexually active women age 24 or younger and in older women at increased risk for infection “B” grade for STD counseling for sexually active adolescents and for adults at increased risk for STDs ACA Marketplace Lessons Learned in 2014 Lack of health insurance “literacy” is a significant issue, with the need to educate clients about Share of cost: Co-pays, co-insurance, deductibles, premiums Newly insured individuals may be unaware of providers’ collection policies, resulting in high debt for unpaid medical bills Selection of primary providers, specialty referral requirements, prior authorization, and medical necessity Network adequacy: primary care physicians, specialists Health plan care management strategies present serious barriers to care for HIV+ individuals Arizona Marketplace QHPs Issuers Aetna Assurant Health Blue Cross Blue Shield of AZ, Inc. Cigna Healthcare Health Choice Insurance Health Net Health Net of AZ Humana Meritus Meritus Health Partners Meritus Mutual Health Partners Phoenix Health Plans, Inc. UnitedHealthcare University Healthcare Marketplace (UHM) ACA QHP Individual Individual Individual SHOP Individual Individual Individual SHOP SHOP Individual Individual SHOP SHOP Individual Individual Individual Impact of the ACA on State Medicaid Programs From: Hidalgo J and Edelbrock E. Medicaid Basics for HIV Prevention Program. ETR and University of Washington, Oct 2014. http://www.etr.org/CIS/webinars/webinar-2-medicaid-basics-for-hiv-prevention-programs/ Medicaid Overview Federal and state entitlement program Medical assistance for people with limited income and resources Covers 60 million adults and children Enrollment in “traditional” Medicaid is commonly via TANF, Aged, Blind, Disabled or other Categorical Programs Supplements Medicare benefits for 9 million low income aged and/or disabled individuals Beginning in 2014, the ACA permitted states to expand Medicaid optionally to non-disabled individuals Disability continues to be a common pathway to Medicaid and Medicare for HIV+ adults Anyone who is poor (include < $16,104 or 138% of the FPL) 4.8 million Americans enrolled in expanded Medicaid In AZ, Medicaid is operated by the AZ Health Care Cost Containment System (AHCCCS) Until ACA Medicaid expansion implementation, AZ HIV+ adults commonly enrolled in Medicaid through enrollment in Social Security Administration (SSA) disability or TANF benefits. In AZ, applications for SSA disability benefits are determined by the AZ Department of Economic Security Disability Determination Service Administration Social Security Administration Acceptance Rates in Arizona, By Month, October 2000 to March 2015 70.0 60.0 50.0 40.0 30.0 20.0 10.0 2015-02 2014-10 2014-06 2014-02 2013-10 2013-06 2013-02 2012-10 2012-06 2012-02 2011-10 2011-06 2011-02 2010-10 2010-06 2010-02 2009-10 2009-06 2009-02 2008-10 2008-06 2008-02 2007-10 2007-06 2007-02 2006-10 2006-06 2006-02 2005-10 2005-06 2005-02 2004-10 2004-06 2004-02 2003-10 2003-06 2003-02 2002-10 2002-06 2002-02 2001-10 2001-06 2001-02 2000-10 0.0 ACA-Related Medicaid Benefits EXPANSION STATES ACA requires adults enrolling through Medicaid expansion must receive “alternative benefit plans” (ABPs) Must include the ten “essential health benefits” (EHBs) required for Marketplace QHPs Must provide the full range of prevention services, including preventive services rated “A” or “B” by the USPSTF at no cost to beneficiaries Must cover family planning services and supplies (e.g., condoms), parity between physical health and behavioral health services, nonemergency transportation, and FQHC and Rural Health Center services New Opportunities for Medicaid Payment for Preventive Services CMS published a final rule effective in January 2014 Before the rule change: preventive services could only be provided by a physician or other licensed practitioner (OLPs) of the healing arts to be paid by Medicaid After the rule change: other practitioners, not just physicians and OLPs, can be paid to provide preventive services recommended by a physician or OLP Assigns authority to State Medicaid Programs to Define practitioner qualifications Ensure appropriate services are provided by qualified practitioners Define the preventive services to be provided Design the reimbursement methods Does not define the type of personnel to be covered AHCCS Acute Care Program Contractors Health Plan Name AZ DEPARTMENT OF CHILD SAFETY COMPREHENSIVE MEDICAL AND DENTAL PROGRAM CARE 1ST ARIZONA Telephone UNITEDHEALTHCARE 800-348-4058 CRS FULLY INTEGRATED (UNITED HEALTHCARE COMMUNITY PLAN) CRS PARTIAL ACUTE (UNITED HEALTHCARE COMMUNITY PLAN) HEALTH CHOICE AZ HEALTH NET ACCESS 800-348-4058 UNIVERSITY OF AZ HEALTH PLANS (MARICOPA HEALTH PLAN UNIVERSITY OF AZ HEALTH PLANS (UNIVERSITY FAMILY CARE) MERCY CARE PLAN PHOENIX HEALTH PLAN Provider Website Address 602-351-2245 https://www.azdes.gov/dcyf/provider/ 602-778-1800 https://www.care1st.com/az/providers/network_overview. asp http://www.uhccommunityplan.com/healthprofessionals.htm 800-348-4058 480-968-6866 http://www.healthchoiceaz.com/providers/ 888-788-4408 800-582-8686 https://www.healthnet.com/portal/provider/content/iwc/pro vider/unprotected/working_with_HN/content/provider_ahc ccs.action http://www.mhpaz.com/Providers.aspx 800-582-8686 http://www.ufcaz.com/Providers.aspx 602-263-3000 http://www.mercycareplan.com/providers/ 602-824-3700 https://www.phoenixhealthplan.com/providers AHCCCS Acute Care Program HIV Provisions Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention Contractor shall implement processes to assess, plan, implement, evaluate, and as mandated, report Medical Management monitoring activities Including an HIV Specialty Provider List Acute care performance measures including HIV/AIDS medical visits (2 visits with at least a 90-days separation) Contractor shall provide health care services through screening, diagnostic, and medically necessary treatment for members 21 years of age and older including STDs, TB, and HIV/AIDS Minimum performance standard = 75% and goal = 90% Contractor must develop and distribute, at a minimum, semi-annual newsletters during the contract year on HIV/AIDS testing for pregnant women Contractor shall report the number of pregnant women who have been identified as HIV/AIDS+ for each quarter in the contract year AHCCCS Acute Care Continuity and Coordination of Care Provisions Continuity and coordination of care Establish a process to ensure coordination of member care needs across the continuum based on early identification of health risk factors or special care needs Establish a process for timely and confidential communication of clinical information among providers Must proactively provide care coordination for members who have multiple complaints regarding services or the AHCCCS Program Meet with the Regional Behavioral Health Authorities to improve and address coordination of care issues Includes, but is not limited to, members who do not meet the Contractor's criteria for case management Meetings shall occur at least quarterly or more frequently if needed Contractor staff assigned these activities must reside in AZ Provisions Not Adequately Addressed in AHCCCS Acute Care RFP HIV and STD prevention, outreach, and education Access to HIV and STD screening in and out of network Waiver of co-payments for preventive services HIV treatment guidelines Care management for HIV, STDs, and other conditions Capitation adjustment for HIV+ beneficiaries Community health workers and promatores County health departments, including communicable disease and other reportable conditions There are important education and advocacy opportunities available for HIV providers and other stakeholders Arizona AHCCCS Regional and Tribal Regional Behavioral Health Authorities Telephone Regional Behavioral Health Authority CENPATICO (SERVICE AREA 2, 3, 4) 866-495-6738 800-564-5465 MERCY MARICOPA INTEGRATED Provider Website Address http://www.cenpaticoaz.com/providers/ http://www.mercymaricopa.org/providers/ COMMUNITY PARTNERSHIP OF SOUTHERN AZ SERVICE AREA 5 800-771-9889 http://www.cpsaarizona.org/providers/Pages/default.aspx NORTHERN AZ REG BEHAVIORAL SERVICES 800-640-2123 http://www.narbha.org/for-providers/ UNITEDHEALTHCARE COMMUNITY PLAN CHILDRENS REHAB 800-348-4058 http://www.uhccommunityplan.com/healthprofessionals.html Tribal Regional Behavioral Health Authority (TRBHA) GILA RIVER INDIAN TRIBE APACHE WHITE MOUNTAIN NAVAJO NATION PASCUA YAQUI TRIBE Telephone 800-259-3449 877-336-4811 866-841-0277 877-342-0912 Provider Website Address http://www.gilariverrbha.org/ http://www.wmat.nsn.us/ http://www.navajo-nsn.gov/ http://www.pascuayaqui-nsn.gov/ Opportunities for HIV Core Medical, Support, and Prevention Providers in the ACA and Medicaid Reform Contracting Opportunities in AZ QHP and Medicaid Acute Care Plan Markets Issuers AETNA ASSURANT HEALTH AZ DEPT OF CHILD SAFETY/ COMPREHENSIVE MEDICAL AND DENTAL PROGRAM BLUE CROSS BLUE SHIELD OF AZ CARE 1ST AZ CIGNA HEALTHCARE HEALTH CHOICE INSURANCE CO (Health Choice AZ) HEALTH NET (Health Net Access) HUMANA MERCY CARE PLAN MERITUS (Health Partners and Mutual Health Partners) PHOENIX HEALTH PLANS UNITEDHEALTHCARE UNITEDHEALTHCARE COMMUNITY PLAN- CRS FULLY INTEGRATED and CRS PARTIAL ACUTE UNIVERSITY HEALTHCARE MARKETPLACE (UHM) UNIVERSITY FAMILY CARE (UNIVERSITY OF AZ HEALTH PLANS) MARICOPA HEALTH PLAN (UNIVERSITY OF AZ HEALTH PLANS) ACA QHP AHCCCS Individual Individual Medicaid Individual SHOP Medicaid Individual Individual Individual Individual SHOP Medicaid Medicaid Medicaid Individual Individual Individual SHOP Medicaid Medicaid Medicaid Individual M(edicaid Medicaid Addressing Health Insurers’ Interests Via Services Offered by HIV Providers Health Insurers’ Interests Services That HIV Providers Might Offer Identify enrolled members that do not obtain preventive or other services Essential covered benefits Outreach, linkage, patient navigation RWHAP core medical providers Address members’ healthcare and health insurance literacy needs Prevent communicable diseases including HIV, STDs, TB, and HCV Non-MCM, patient navigation, health education nPEP and PrEP support, HIV/STD CTS, behavioral prevention, condom distribution and education, HERR Translation and health education Address members’ linguistic and numeracy needs to ensure that they can participate actively in health promotion, prevention, and care Culturally competent care coordination, disease Culturally competent workers with management, treatment education expertise in serving racial, ethnic, and sexual minority populations Addressing Health Insurers’ Interests Via Services Offered by HIV Providers Services That HIV Providers Might Offer Ensure access to physical, behavioral, MCM, navigation, behavioral and other outpatient services to promote health tx support, medical health, and prevent and treat disease transportation Ensure HIV+ clients receive and optimally MCM, navigation, tx education benefit from ARVs and other medications and adherence counseling, MCM Coordinate services provided by the care MCM team with the client, his/her family, and community resources Disease management MCM Discharge planning and readmission MCM prevention interventions for hospitalized patients Health Insurers’ Interests ACA Essential, RWHAP, and CDC-Covered Services ACA Essential Covered Benefits RWHAP Service Categories Ambulatory patient services Hospitalization Emergency services Pregnancy, maternity, newborn care Pediatric services Mental health (MH) services Substance abuse (SA) disorder services Prescription drugs OAMC, hospice care Rehab & habilitative services & devices Laboratory services Oral health services (peds)* Preventive & wellness services & chronic disease management Home health care, HCBHS CDC HIV High Impact Services OAMC visits for PrEP & PEP OAMC OAMC MH services, hospice care Outpt SA tx services, residential SA tx OAMC, ADAP, LAPA OAMC, EIS, lab tests Oral health services OAMC, MCM, EIS, HERR, tx adherence counseling HIV biomedical prevention: meds for PrEP & nPEP HIV & STD testing HIV test counseling, HIV behavioral prevention, HERR, PrEP and nPEP tx adherence, prevention case management Non-Essential ACA, RWHAP, and CDC-Covered Services RWHAP Service Categories ACA Non-essential Covered Benefits Medical nutrition therapy Medical transportation services Linguistic services Outreach services Rehabilitation services CDC HIV High Impact Services Outreach & linkage services Align With Your Organization Before Seeking New Opportunities Before moving forward, it is critical to Ensure your HIV program’s efforts are aligned with your organization’s overarching readiness efforts An important step for HIV practices in large integrated health systems, hospital-based or university-affiliated health systems, local health departments, large FQHCs Contracts may have been negotiated or are being negotiated QHP and Medicaid MCO contracts have probably been finalized for the current year Engage organizational leadership, including corporate board support Identify organizational resources that can be applied to your contracting and collaboration activities Medicaid Independent Contracting Model HospitalBased HIV Clinic MCO FQHCs CBOs Health Dept Collaborative Integration Strategies QHP or MCO Contract for services using “grant” type budget, FFS, sub-capitated arrangements Augment care management services provided by the insurer through contract Contract with provider networks to provide HIV and HIV services Hospital Provide subcontracted essential and other covered services Systems Coordinate and collaborate to serve HIV+ and non-HIV+ clients Subcontract with CBOs and handle their billing FQHCs & HIV Clinics CBOs Provide subcontracted essential and other covered services Coordinate and collaborate to serve HIV+ and non-HIV+ clients Subcontract with CBOs and handle their billing Provide subcontracted outreach, HIV and STD testing, linkage, home visits, MCM, preventive services On Our Own Virtual Integration Physical Integration Acquisitions & Mergers • Chart your own organizational course • Enhance your TPR capacity, join insurers’ FFS programs and networks • Crush the competition • Adopt a “trade association” model • Collaborate in information gathering, purchasing, and marketing • ASOs seek out and create formal relationships with HIV clinics, community health centers, or other core providers • Co-locate services but remain independent organizations • Share infrastructure costs • Identify agencies with services strengthening your capacity and “buy them” • Identify similar agencies but different service areas or populations and merge • Transfer clients to a fiscally solvent, culturally competent, and high quality agency; close HIV program Integrated Healthcare Facilities and Community-Based Organization (CBOs) Contracting Model Medicaid FFS MCO Hospitals FQHCs Hospitals FQHCs CBOs CBOs CBOs CBOs QHP Integrated Public Health Department and CBO Contracting Model State and County HDs Public HealthFunded HIV/STD Surveillance CBOs How to Learn More About ACA and MedicaidRelated Health Insurers in My State