Medicaid Changes: Impact on HIV Care

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Medicaid Changes Impact on HIV Care

• August 28, 2006
• Christine Lubinski
• Executive Director
• HIV Medicine Association

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The U.S. Epidemic Snapshot of Key Data
Note Data are estimates. Sources CDC, 2005
Glynn, K. et al., CDC, "Estimated HIV prevalence
in the United States at the end of 2003",
Presentation at the National HIV Prevention
Conference, 2005 Fleming, P., et al., HIV
Prevalence in the United States 2000, 9th
Conference on Retroviruses and Opportunistic
Infections, 2002.
3
New AIDS Cases, Deaths, and People Living with
AIDS, 1985-2004
People Living with AIDS
New AIDS Cases
Deaths and New AIDS Diagnoses
People Living with AIDS
Deaths among People with AIDS
2004
Note Data are estimates. Source CDC, Data
Request, 2006.
4
Proportion of AIDS Cases, by Race/Ethnicity,
1985-2004
White, non-Hispanic
African American
Percent of AIDS Diagnoses
Latino
American Indian/ Alaska Native
Asian/Pacific Islander
2004
Note Data are estimates. Source CDC, Data
Request, 2006.
5
AIDS Case Rate per 100,000 Population by Region,
2004
Notes Case rates calculated by KFF data do not
include U.S. territories and possessions.
Sources CDC, HIV/AIDS Surveillance Report, Vol.
16, 2005 U.S. Census Bureau, Population
Estimates Program, 2004 Population Estimates.
6
Top 10 States by AIDS Case Rate per 100,000
Among Women, 2004
U.S. Rate 9.5
Source Kaiser Family Foundation, State Health
Facts (CDC, Special Data Request, November 2005).
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Major Federal Sources of Funding for HIV/AIDS Care

• Medicaid
• Medicare
• Ryan White CARE Act
• Others include Department of Veterans Affairs
  SAMHSA Community and Migrant Health Centers

Sources Kaiser Family Foundation, Financing
HIV/AIDS Care A Quilt with Many Holes, May 2004
DHHS, Office of Budget/ASBTF, 4/05.
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Persons with HIV/AIDS in US In Care

• 29 percent Medicaid only
• 12-13 percent dually eligible for Medicaid and
  Medicare
• 6 percent Medicare only
• 31 percent private insurance
• 20 percent uninsured
• Kaiser Family Foundation

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Medicaids Role in HIV/AIDS Care

• Provides health long-term care coverage for
  more than 52 M low-income people
• Largest source of coverage for people with
  HIV/AIDS
• 250,000 Medicaid beneficiaries with HIV/AIDS
• Reflects epidemics impact on low-income
  populations
• Many with HIV/AIDS qualify through
  disability-related pathway
• Mandatory and Optional Services
• All states cover Rx drugs

Federal Medicaid Spending on HIV/AIDS Care as
Percent of Federal Spending on HIV/AIDS Care FY
2005
Medicaid 49 (5.7B)
Medicare
All Other 51 (6.0B)
Total 11.7 B
Sources Kaiser Family Foundation, Medicare and
HIV/AIDS, 9/05 KCMU, The Medicaid Program at a
Glance, 1/05. Medicaid HIV/AIDS spending estimate
from CMS, Office of the Actuary, 2005, and HHS
Office of the Budget, 2005.
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Medicaid Enrollees and Expendituresby Enrollment
Group, 2003
Elderly
Elderly
9
26
People with Disabilities
16
27
People with Disabilities
Adults
43
48
Children
Adults
12
Children
19
Total 52.4 million
Total 252 billion
Note Total expenditures on benefits excludes DSH
payments. SOURCE KCMU estimates based on CBO
and OMB data, 2004.
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Qualifying for Medicaid on the Basis of Disability

• Medicaid is the health coverage program for
  low-income people who fall into certain
  eligibility categories (i.e. children, parents,
  seniors, and people with disabilities) and who
  meet income, resource (assets), citizenship, and
  state residency requirements
• People with disabilities must meet the same
  Social Security standard for disability as
  Medicare
• 78 of people with disabilities qualify as
  recipients of SSI
• States can cover people with disabilities up to
  the poverty level and use other options to extend
  coverage
• medically needy coverage in which individuals
  start out with too much income, but spend down
  by incurring substantial medical expenses is an
  important pathway to Medicaid coverage in some
  states

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Deficit Reduction Act of 2005

• Cuts Medicaid b y 4.8 billion over next 5 years
  and 26 billion over next 10 years.
• Cuts could have been averted with Senate
  provisions cutting excessive payments to Medicare
  managed care plans and securing better prices for
  Medicaid drugs from pharma.
• Savings are primarily being used to finance tax
  cuts not to reduce the deficit.
• Provisions will cause additional hardship for
  low-income families and individuals.

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Deficit Reduction Act - Medicaid

• States have the authority to deny health care or
  coverage to people who cannot afford the
  cost-sharing or premiums they are charged.
• Overall cost-sharing cannot exceed 5 of monthly
  or quarterly income.
• States may offer coverage in private plans in
  lieu of Medicaid package to certain beneficiaries
• States can use Medicaid/SCHIP funds to pay
  insurance premiums for employer-sponsored
  insurance.
• States can offer different benefit packages to
  different groups of beneficiaries flexibility
  instead of comparability
• States can impose premiums and increase
  cost-sharing on many groups of beneficiaries.
• New Medicaid applicants or those seeking
  recertification must prove citizenship.

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Deficit Reduction Act- Benefit Provisions

• Allows states to provide Medicaid to certain
  groups through enrollment in private health
  insurance plans. Plan coverage must include
  inpatient/outpatient hospital, physician visits,
  lab/x-ray, well baby/child care. Prescription
  drugs, mental health and other services could be
  excluded.
• Health plans must be comparable to BC/BS Federal
  Employee Health Benefits program, State employee
  coverage coverage of largest HMO in state
• The law prohibits states from requiring some
  groups of beneficiaries to enroll in such private
  plans, including those who qualify for Medicaid
  because they are blind or disabled, those that
  qualify as medically needy and dually eligible
  Medicare Medicaid beneficiaries.

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DRA- Benefit Provisions

• The mandatory enrollment will affect mostly
  children, working parents and pregnant women with
  income above 133 FPL.
• However, CMS regulations allow states to seek
  voluntary enrollment in such plans from any
  beneficiary, including assigning them to a plan
  with an opt out provision.
• Beneficiaries could find themselves in such a
  plan unaware of the ability to opt-out!

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Deficit Reduction Act Premiums/Cost-sharing

• Increase nominal co-payments for persons below
  the federal poverty level (FPL). States will be
  able to increase co-payments annually with the
  increase in the Medical consumer price index.
• For persons between 100 and 150 of FPL, states
  can charge 10 percent of cost of service.
• For persons will incomes above 150 FPL, states
  may charge 20 percent of cost of service.
• Prescription drugs States can establish lists of
  preferred and non-preferred drugs. Nominal
  co-payments for non-preferred drugs for persons
  under 150 FPL, and up to 20 of non-preferred
  drug cost for persons over 150 FPL.
• Allows states to charge cost-sharing for
  non-emergency use of emergency room. Nominal
  co-payments for exempt group, up to twice nominal
  co-payment for persons at or below poverty.
  Unlimited for those above poverty

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Exempt from Cost-Sharing/Premiums

• Children under age 6 up to 133 FPL
• Children ages 6-18 up to 100 FPL
• Foster children
• Hospice patients
• Institutionalized patients
• Women in breast/cervical cancer eligibility
  category
• SERVICES
• Preventive services for kids
• Pregnancy-related services
• Emergency services
• Family planning services
• Exempt groups still eligible for nominal
  co-payments

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Effective July 1 Application for Medicaid or
Recertification Requires Proof of Citizenship

• States can only accept affidavits in
  extraordinary circumstances
• Applicants have 45 days
• Providers dont get paid until documents go to
  state
• States can lose federal matching funds for
  failure to comply
• Policy likely to be implemented differently in
  different states
• Beneficiaries could lose coverage!

• Exemptions- persons eligible for Medicare, SSI
  beneficiaries
• Documentation- original/certified copies only
• Tier 1 passport, certificate of naturalization
• Tier 2 state and local birth certificates,
  military record for DOB
• Tier 3- documents showing place of birth- medical
  records, life and health insurance policies
• Tier 4- affidavit from 2 individuals- one
  unrelated

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What Can Advocates Do?

• Oppose cost-sharing, premiums and enrollment fees
  in Medicaid
• Enact special protections for prescription drugs.
• Make your state track out of pocket expenses of
  enrollees
• Join with other Medicaid advocates
• Ensure that Medicaid changes are evaluated when
  allocating Ryan White funds

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HIV Medicaid/Medicare Working Group

• Key Players
• NASTAD
• HIV Medicine Association
• Project Inform
• American Academy of HIV Medicine
• The AIDS Institute
• Network of 300 grass roots groups

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Working Group Activities

• Meetings with CMS officials
• Sign-on letters to Capitol Hill/Administration
• Grass Roots Alerts
• Analysis of legislation

• Participation in broader DC-based coalitions
• Meetings with Pharma on Medicare/Medicaid issues
• Monthly conference calls

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NJ Medicare Dual Eligibles Coalition

• Members- Hyacinth Foundation, NJ Legal Services,
  Epilepsy Foundation
• Dual eligibles in NJ pay no co-payments
• NJ Medicaid will pay for most non-formulary
  drugs.
• Best state policy for duals in the nation
• Coalition work matters!

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The Ryan White CARE Act

• Original intent relief to safety net (public
  hospitals)
• Important safety-net for uninsured and low-income
  individuals
• Discretionary program, not entitlement
• Only disease-specific discretionary grant program
  for care for people with HIV/AIDS
• Builds on Medicaid
• Gap filler in terms of eligibility AND services
• Services provided include comprehensive primary
  care support services, medications
• What you get depends on where you live
• 2.1 B in FY 2005

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Ryan White Reauthorization

• Creates new Title I structures
• Prioritizes medical care
• Phases out hold-harmless protections

• Authorization levels limit funding to under 4
  annually
• Mandates minimum formulary but does not guarantee
  funding
• Further fragments care system

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Institute of Medicine Recommendation for HIV
Entitlement ProgramMay 2004

• Eligibility All persons with HIV infection
  under 250 of federal poverty level
• Services primary medical care, prescription
  drugs, hospitalization, diagnostics, substance
  abuse, mental health, prevention, case management
• Reimbursement Medicare standard
• Ryan White medical services for non-citizens,
  ancillary and social services
• An estimated 58,000 additional individuals would
  receive HIV standard of care

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Early Treatment for HIV Act

• ETHA is the most comprehensive effort to date to
  address the early intervention health care and
  treatment needs of people living with HIV.
• ETHA would give states the option of readily
  amending their Medicaid eligibility requirements
  to include uninsured, non-disabled poor and low
  income people living with HIV and receive an
  increased federal match rate for doing so.
• ETHA is modeled after the successful Breast and
  Cervical Cancer Prevention and Treatment Act of
  2000, which allows states to provide early
  intervention access to Medicaid to women with
  breast and cervical cancer.

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Create a United Medicaid Front

• Potential allies and coalition partners-
• Mental health advocates
• Parents of special needs children
• Childrens advocates
• Nursing home advocates/ providers
• Senior advocates
• Physician groups

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What Can We expect from Federal Health Programs

• More privatization, more cost-shifting to states
• Fewer resources based on tax cuts, continuing
  defense outlays
• Ryan White- modest increases, likely only for ADAP

• Medicaid- more flexibility/diminishing federal
  support
• Medicare Part D- much more expensive than
  anticipated coverage retrenchment, inc.
  cost-sharing

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How do we Maintain and Expand Access to HIV Care
under These Conditions?

• Focus more advocacy on the big picture
  priorities of the federal budget
• Tax policy and spending priorities directly
  affect our ability to maintain or expand
  programs.
• Spending targets for discretionary and
  entitlement programs limit and possibly eliminate
  our ability to maintain or increase spending on
  AIDS
• Engage in efforts to protect Medicaid and to
  improve Medicare Drug benefit
• As citizens and leaders in HIV/AIDS,we must
  engage in a larger discussion about national
  priorities with others committed to affordable
  health care for all.

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Other Advocacy Considerations

• Challenge privatization as a strategy to expand
  access, improve quality, or save money in health
  care context
• Highlight the success of government programs-
  Ryan White, HIV research

• Underscore public health connection to HIV care
• Highlight Ryan White programs as integral to the
  public health, health care infrastructure of
  communities/states
• Use ETHA to demonstrate proactive and not simply
  defensive advocacy effort

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Stay Informed with Online Resources
Get Involved Join the HIV Medicare and
Medicaid Working Group, email contact information
and affiliation to Lei Chou at leichou_at_aol.com.
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66 Canal Center Plaza, Suite 600 Alexandria, VA
22314 [phone] www.hivma.org