The Promise of Health Care Reform Opportunities and Challenges for HIV/AIDS Care and Prevention (Or what we have learned so far in Massachusetts)

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The Promise of Health Care ReformOpportunities
and Challenges for HIV/AIDS Care and
Prevention(Or what we have learned so far in
Massachusetts)

• H. Dawn Fukuda, Director
• Office of HIV/AIDS
• Massachusetts Department of Public Health

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Core Health Reform Components

• Medicaid expansion (Massachusetts, 2001)
• PLWHA below 200 FPL
• Range of eligibility criteria (income,
  disability, age)
• Medicaid coverage scope/plan type
• Health insurance access (Massachusetts, 2006)
• Commonwealth Connector (Exchange)
• Subsidies according to income level and family
  size (lt300 FPL)
• Health Safety Net for non-eligible residents
• Increased access to clinical care providers
• Baseline CHC network, 50 agencies
• Hospitals, academic medical centers
• Workforce capacity (funding opportunities under
  ACA)

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Medicaid Expansion in Massachusetts

• Medicaid 1115 Waiver for HIV (2001)
• Expanded access to state Medicaid (Masshealth)
  for low income PLWHA up to 200 FPL irrespective
  of disability status
• The program enrolled 225 people under the
  expansion in 2001, and 1,314 are currently
  enrolled under the expansion component (2011)
• SFY 2011 spending on the HIV waiver population
  was 20 million.

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Enrollment and Costs for Members in MassHealth
HIV waiver, Massachusetts
State FY HIV Waiver Average Enrollment Total Cost
FY04 509 6,591,199
FY05 675 7,986,665
FY06 932 11,466,843
FY07 1,006 14,335,665
FY08 1,067 15,990,785
FY09 1,169 17,115,595
FY10 1,233 20,618,094
FY11 1,310 20,760,225
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Health Insurance Coverage Massachusetts

• HIV residents lt200FPL eligible for Medicaid
• HIV residents 200 - 300 FPL purchase
  subsidized health insurance plansCommonwealth
  Care
• Over 300 FPL purchase non-subsidized plans via
  the Connector (lt500 eligible for premium
  assistance through HDAP)
• Variety of coverage scopes, prescription
  medication formularies, deductibles, and co-pays
• PLWHA may require assistance to navigate coverage
  options

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HDAP Role Scope post HCR

• Verification of eligibility as a component of
  ADAP application and recertification
• Determination of HDAP support level
• Premium continuationplan selection
• Medication co-payment assistance
• Full-pay medication coverage
• Administered by third party, Community Research
  Initiative of New England (CRINE)

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HDAP Expenditures by Category
Fiscal Year Full Pay Co-Pay Premiums
FY03 7,961,862.84 963,205.88 1,778,272.33
FY04 11,174,879.98 1,553,758.50 3,159,200.01
FY05 9,756,201.76 1,839,807.23 6,112,132.85
FY06 4,634,683.35 1,893,206.26 7,015,306.89
FY07 4,147,713.84 2,071,118.94 8,366,273.11
FY08 4,184,279.93 2,083,431.58 9,323,821.42
FY09 4,695,780.40 2,567,789.28 8,835,835.67
FY10 4,635,751.00 2,930,016.65 9,320,425.00
FY11 4,467,727.48 3,175,917.00 10,990,818.00
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Massachusetts HIV Drug Assistance Program(HDAP)
Enrollment Expenditures by Year
State Fiscal Year Enrolled Total Expenditures
FY02 2301 9,716,375
FY03 2716 10,703,342
FY04 4399 15,887,838
FY05 4738 17,708,142
FY06 4668 13,543,197
FY07 5141 14,585,106
FY08 5601 15,591,533
FY09 5882 16,099,405
FY10 6543 16,886,192
FY11 7009 18,634,462
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Health Care ReformPlanning Checklist

• 1 Build connections with state Medicaid program
• Identify allies and formalize connections
• Review Medicaid application
• Understand plan types and coverage scopes
• Train providers about Medicaid eligibility,
  enrollment process, co-payment obligations, and
  recertification requirements
• Consider requiring Medicaid application as a
  component of ADAP recertification

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Health Care Reform Planning ChecklistContinued

• 2 Anticipate cost shifting, realistically
• Eligibility determination/enrollment takes time
• Full impact of ACA may not be fully apparent for
  years after 2014
• Consider mechanisms for Ryan White to sustain
  core health services until coverage is
  established
• Transition to fund integral service components
  that are not 3rd party reimbursed
• Calculate impact on collection of medication
  rebates

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Health Care Reform Planning ChecklistContinued

• 3 Review ADAP coverage components
• Assess the need for premium continuation support
  for PLWHA over 133 FPL or ineligible for
  Medicaid
• Establish mechanism to administer medication
  co-pay coverage
• Preserve full-pay coverage during application
  submission and review period, or when clients
  lose coverage due to recertification gaps
• ADAP application process is opportunity to screen
  for eligibility across coverage options
  (Medicaid, Medicare, private insurance)

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Health Care Reform Planning ChecklistContinued

• 4 Educate Providers and Consumers
• Develop fact sheets/literature about changing
  health care landscape
• Engage consumer advisory boards and planning
  bodies
• Identify expertise to support health insurance
  navigation for HIV residents
• Ensure readiness of the provider
  communityclinical and non-clinical
• Develop response plan for populations that will
  remain ineligible for coverage under HCR

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One Step at a Time

• H. Dawn Fukuda, Director
• Office of HIV/AIDS
• Massachusetts DPH
• Dawn.Fukuda_at_state.ma.us
• [phone]