Transcript The Affordable Care Act Implementation: A National Overview

American Academy of HIV Medicine
The Affordable Care Act Implementation:
A National Overview
Spring 2015
US Census: Majority of Americans 19-64 Years
Of Age 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 Medicaid
Expansion
Current Status of State Medicaid Expansion Decisions,
January 2015
Henry J. Kaiser Family Foundation, January 2015. http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
Medicaid Managed Care (MCOs)
ACA
Marketplace
ACA Marketplace/Exchange
Online one-stop virtual “marketplace,” where individuals, families,
and employees of small businesses can purchase health insurance
from Qualified Health Plans (QHPs)
• Individuals and families with incomes between 100-400% FPL
ineligible for other affordable employer-based or governmentbased may be eligible for premium tax credits and/or cost sharing
reductions
• Cannot charge higher premiums based on gender or health status
• Cannot deny coverage to individuals based on pre-existing
conditions
• Cannot set annual or lifetime limits on the amount of benefits paid
• Extends dependent coverage up to 26 years of age
• Prohibits imposing annual dollar limits on essential health benefits
• Cover specified preventive health services without cost-sharing
QHPs Offer Premiums Based on “Metal Levels” or Actuarial Value”
Bronze: Member pays 40%, QHP
pays 60%
Silver: Member pays 30%, QHP
pays 70%
Gold: Member pays 20%, QHP
pays 80%
Platinum: Member pays 10%,
QHP pays 90%
Impact of the ACA
Marketplace and
Medicaid on the
Ryan White
HIV/AIDS Program
Impact of the ACA and Medicaid Expansion on RWHAP
• The HRSA HIV/AIDS Bureau (HAB) administers RWHAP
• HAB determined that the RWHAP is the “payer of last
resort”
• Grantees must “vigorously pursue” client enrollment in
private or public insurance
– Some programs have been aggressive in enrolling clients without
adequate ongoing education and navigation assistance
• Grantees may not disenroll clients from services if they do
not enroll in health insurance
Impact of the ACA and Medicaid Expansion on RWHAP
• HAB encourages ADAPs to assist clients to enroll in insurance if
– Insurers’ formularies include at least one drug in each ARV class
– It is cost-effective to support premiums compared to purchasing
medications
• RWHAP-funded providers have variable experience with public
and commercial health insurance markets
–
–
–
–
Must enroll in QHP and Medicaid MCO provider networks
Credential their clinicians
Develop health insurance billing capacity
Undertake intensive “coordination of benefits” for clients enrolled ADAP
and QHPs or Medicaid MCOs
• The RWHAP’s future is unclear at the federal and state levels
Problem
Areas &
Trends
National Trends
Positive Side
• The number of Americans without health insurance has
been reduced by about 25 percent (8 to 11 million people)
– Will continue
• HIV Patients that could not get covered before are now
• Patient Protections under the law we never used to have
Issues: Patients
• Affordability Issues
– True Out-of-Pocket
• Formulary Issues
–
–
–
–
–
–
Tiering of HIV meds
Coverage of Single Tablet Regimens (STRs)
Formulary Changes (Additions/Drops) throughout coverage year
Requirements based of the USP categories
Formulary Appeals Process cumbersome
Success Rate?
• Non Discrimination Requirements
– Enforced?
Issues: Patients
• Loss of Case Management Services
– RWCA levels vs. Medicaid
• Pharmacy Issues
– Required use of Mail-Order Pharmacies
– Adherence disruptions
• Provider Networks
– Not Up-to-date Directories
– Access &Travel Burden
– Out-of-Network Standards
Issues: Patients – Premium Affordability
Issues: Patients – Formulary Tiering
Issues: Patients – Formulary Tiering
Issues: Patients - Gaps In Coverage
SERVICE
QHP
MEDICAID
RW/ ADAP/CDC
HIV Testing
Continue to cover in
certain settings
RX
Cost-sharing
assistance
MEDICAL CASE
MANAGEMENT
ORAL HEALTH
LABS
Cost-sharing
assistance
MENTAL HEALTH
SERVICES
Cost-sharing
assistance
SUBSTANCE ABUSE
TREATMENT
Cost-sharing
assistance
HIV PRIMARY CARE
Cost-sharing
assistance
MEDICAL
TRANSPORTATION
INPATIENT HOSPITAL
SERVICES
Adapted from West Virginia Ryan White Part B Program
Limited Coverage
Issues: Patients – Medication Affordability
Issues: Patients - Pharmacy
Requirements to use Mail-Order
Pharmacies:
• Patient Adherence Subject to
Shipping
• Loss of Adherence Counseling
Services
• Outsourced services with
different coverage
Issues: Providers
• Prior Authorization Burden
– Formulary not aligned with HIV Treatment Guidelines
• Step Therapy Requirements
• Required use of components / generics
– Utilization Management Restrictions
• Provider Networks
– Reports of closed networks
– Unfamiliarity with contracting
– Out of date Provider lists
• Reimbursement & Future Planning
Issues: Providers – Utilization Management
Issues: Providers – Formulary
vs. Treatment Guidelines
• EHB Standard = same number of drugs per U.S.
Pharmacopeia (USP) category/class as state’s
benchmark plan
Federal Advocacy Efforts
Federal Advocacy Efforts
Federal AIDS Policy Partnership & Health Care Access
Working Group
• Comments on proposed rules and regulations.
• Communications with federal law makers
– Administration- HHS, CMS, HRSA, etc.
– Congress – Oversight committees
Federal Advocacy Efforts
CMS Notice of Payment and Benefit Parameters for 2016
• Better definition of EHBs
• Stronger Prescription Drug Standard
– Replace Benefits Managers with P&T Committees
– Refer to National Treatment Guidelines as basis for coverage
– Review new meds within 30 days and determination by 90 days
Federal Advocacy Efforts
• Move from USP to American Hospital Formulary Services
(AHFS)
– More nuanced subclasses of ARVs
– Includes combination therapies
• Formulary Exceptions Process
– 24 hour appeal process
– Secondary external review process
• Formulary Transparency for Consumers
– Ability to view PA or UM
– Co-insurance & Cost-sharing
– No changes mid-year
Federal Advocacy Efforts
• Mail Order Pharmacy
– Optional brick & morter
– Additional costs count towards Out of Pocket Max
• Non-Discrimination
– Plan designs that impact HIV patients selection
• Network Adequacy
– Reasonable access standard in terms of time and distance
• HRSA Standards
– Exception for Out-of-Network Providers
– Transparency, Updated Lists, Identify ECPs
Changes in 2016
Final Rule – Changes to the 2016 plans
• P&T Committees
– plans must establish pharmacy and therapeutics committees that
will in turn develop drug formularies.
• Formularies
– have to provide appropriate access to drugs included in broadly
accepted treatment guidelines and be consistent with best practice
formularies
2016 Plans
• Exception Process
– plans must make a decision and notify the enrollee or physician
within 24 hours of a request
– New “standard exceptions process,”
• patient or physician can request coverage of a clinically appropriate
non-formulary drug and receive a decision within 72 hours of a
request.
• State regulators will be primarily responsible for enforcing
these requirements.
Florida precedent
The AIDS Institute & National Health Law Project
• Filed a complaint with the Office of Civil Right at HHS
(May 2014)
– CoventryOne, Cigna, Humana, Preferred Medical
– Allege discriminatory benefit design
• Aetna & Coventry voluntarily announced it will HIV
medications to a generic brand tier that will lower copayments to a range of $5-$100, after deductibles
(effective June 1, 2015)
Louisiana Precedent
2014 Lambda Legal filed law suit
• Blue Cross Blue Shield (BCBS) announced they would
not longer accept 3rd party payments
– Ryan White Premium Assistance
• CMS clarification that they expect insurers to accept 3rd
party payments
• The Louisiana Legislature passed, and Governor Jindal
signed, Louisiana Revised Statute 22:1080(June 2014)
– Forcing insurers to accept RW payments
Which cop is on the beat?
Federal Regulators
Federal Regulators
Federal Regulators
Advocacy on Your Behalf
The Most Important Thing:
Document and report discriminatory,
illegal, and medically inadvisable
practices & requirements!
AAHIVM Health Reform
Reporting Survey
www.aahivm.org
Project Speak Up!
• HIVHealthReform.org and the Center
for Health Law and Policy Innovation
Harvard Law School
http://www.hivhealthreform.org/speakup/
For more information contact:
Holly Kilness Packett
Director Public Policy
[email protected]