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HIV Care Under the Affordable Care Act Addressing the Needs of HIV Clinics and Clinicians in Texas 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 Texas 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/ 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 QHPs in Texas Offering Coverage on the FFM QHPs Aetna Ambetter from Superior Health Plan Assurant Health Blue Cross and Blue Shield of TX Cigna Healthcare Community Health Choice CommunityFirst Firstcare Health Plans Humana Health Plan of TX, Inc. Humana Insurance Company IdealCare Molina Marketplace Scott and White Health Plan UnitedHealthcare Valley Baptist Health Plan Individual SHOP TX Department of Insurance Health Options http://www.texashealthoptions.com/index.html Information for consumers about commercial health insurance options: Information for providers about requirements for prompt payment of claims, the filing of complaints, and credentialing for fully insured health plans: http://www.tdi.texas.gov/hprovider/index.html 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 Disability continues to be a common pathway to Medicaid and Medicare for HIV+ adults Beginning in 2014, the ACA permitted states to expand Medicaid optionally to non-disabled individuals Anyone who is poor (include < $16,104 or 138% of the FPL) 4.8 million Americans enrolled in expanded Medicaid Until ACA Medicaid expansion implementation, TX HIV+ adults commonly enroll in Medicaid through enrollment in Social Security Administration (SSA) disability or TANF benefits. In TX, applications for SSA disability benefits are determined by the TX Department of Assistive and Rehabilitative Services (DARS) Division for Disability Determination Services Average SSA Initial SSI Allowance Rates in GA, LA, PA, TX, WA, By Year, 2001 to 2014 60.0 50.0 40.0 30.0 20.0 10.0 0.0 2001 2002 2003 2004 2005 GA 2006 LA 2007 PA 2008 TX 2009 WA 2010 Linear (TX) 2011 2012 2013 2014 ACA-Related Medicaid Benefits NON-EXPANSION STATES Can voluntarily cover EHBs under their traditional Medicaid benefit packages Coverage of preventive services in traditional Medicaid benefit packages is optional Some groups, such as the disabled, dual eligible, and medically frail individuals, are exempt from enrollment in ABPs and may choose to obtain traditional Medicaid 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 Identifying TX Medicaid STAR+ MCO Contracting Opportunities TX Health and Human Services Commission (HHSC) Uniform Medicaid Managed Care Contract requires MCOs Provide STD/HIV services- prevention, screening, counseling, diagnosis, and treatment Implement procedures to ensure members have prompt access to appropriate services for STDs/HIV Allow members access to STD/HIV diagnosis services without prior authorization or referral by a primary care provider Provide all covered services required for a diagnosis by the Provider, as well as the STD/HIV treatment plan Identifying TX Medicaid STAR+ MCO Contracting Opportunities HHSC Uniform Medicaid Managed Care Contract requires MCOs to Make education available to providers and members on the prevention, detection, and effective treatment of STDs/HIV Require providers to report all confirmed cases of STDs/HIV to the regional health authority using required forms and procedures for reporting Require the providers to coordinate with the HHSC regional health authority to ensure that members with confirmed cases of STDs/HIV receive risk reduction and partner elicitation/notification counseling Identifying Opportunities in the TX Medicaid 1115(a) Waiver Program Waiver approved through September 30, 2016 Expand Chronic Care Management (CM) Models in Regional Healthcare Partnerships (RHPs) coordinated by a public hospital or local governmental entity with the authority to make intergovernmental transfers Implement a plan that will accelerate meaningful delivery system reforms that improve patient care for low-income populations RHP Awardees With HIV-Related Projects Goals Improve access to care, quality of care, and health outcomes Improve health for the population Lower costs through improvements City of Houston Dept of Health and Human Services Bexar County Board of Trustees for Mental Health Mental Retardation Services Brazos County Health District City of Austin Health & Human Services Department Community Care Collaborative (CCC) San Antonio Metropolitan Health District Tarrant County Public Health Tenet Frisco, Ltd- Centennial Medical Center TX Center for Infectious Disease University of TX Health Science Center at San Antonio University of TX MD Anderson Cancer Center Identifying Opportunities in the TX Medicaid 1115(a) Waiver Program Expand Primary Care Workforce Increase the number of primary care providers and other clinicians/staff (e.g., health coaches, community health workers (CHW), promotoras) Chronic CM Models Goal: Develop and implement chronic disease management interventions geared to improve effective management of chronic conditions and ultimately improving patient clinical indicators, health outcomes and quality, and reducing unnecessary acute and emergency care use Chronic diseases addressed by chronic CM in RHP plans may include DM, HTN, heart failure, asthma, post-secondary stroke, community-acquired pneumonia, HIV/AIDS, and chronic pain Identifying Opportunities in the TX Medicaid 1115(a) Waiver Program Other required core Chronic CM Model components Care teams that are tailored to the patient’s health care needs, including non-physician health professionals such as pharmacists doing medication management, case managers, nutritionists, and health coaches helping patients to navigate the health care system Implement projects to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions Apply evidence-based CM model to patients with high-risk health care needs Redesign rehabilitation delivery models for persons with disabilities Develop a continuum of care in the community for persons with serious and persistent mental illness and co-occurring disorders Develop CM functions that integrate the primary and behavioral health needs of individuals Identifying Opportunities in the TX Medicaid 1115(a) Waiver Program Implement Evidence-based Health Promotion Programs Via CHWs Implement innovative evidence based health promotion strategies such as use of CHWs, innovations in social media, and messaging for targeted populations Engage CHWs in an evidence-based program to increase health literacy of a targeted population CHWs roles Increase access to care and facilitate appropriate use of health resources by providing outreach and cultural linkages between communities and delivery systems Reduce costs by providing health education, screening, detection, and basic emergency care Improve quality by contributing to patient-provider communication, continuity of care, and consumer protection Identifying Opportunities in the TX Medicaid 1115(a) Waiver Program Performance Type PA Required HIV and STD Measures Pay for Performance No Pay for Reporting Yes Chlamydia screening and follow-up in adolescents Chlamydia screening in women Follow-up after treatment for primary or secondary syphilis Follow-up testing for N. gonorrhoeae among recently infected men and women Gonorrhea + screening rates HIV screening: Patients at high risk of HIV HIV/AIDS TB screening HIV/AIDS: STD screening for Chlamydia, Gonorrhea, and Syphilis Prescription of ARVs Syphilis + screening rates Follow-up testing for C. trachomatis among recently infected men and women Gonorrhea screening rates High intensity behavioral counseling to prevent STDs for all sexually active adolescents and for adults at increased risk for STDs Syphilis screening Opportunities for HIV Core Medical, Support, and Prevention Providers in the ACA and Medicaid Reform 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 Resources for Contracting for HIV Prevention and Care Services HealthHIV. Health Insurance Contracting for HIV Prevention and Wrap-around Service Providers. 2015. Available at: http://www.healthhiv.org HIV Medicine Association. Strategies for HIV Medical Providers Contracting With Health Insurers. 2013. Available at: http://www.hivma.org/uploadedFiles/HIVMA/Policy_and_Advoca cy/Policy_Priorities/Healthcare_Reform_Implementation/Resour ces/Strategies%20for%20HIV%20Medical%20Providers.pdf 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 TX Services, Populations, and Delivery Model: An Example Target Populations Insured individuals without an HIV test in the last year Pregnant woman HIV+ insured individuals identified by MCO as lost to care MCO Contract MCOs HIV/STD screening, location, home visits, jail and prison in-reach, outreach, and linkage services using public health model Behavioral prevention Provider education State and Subcontract to CBOs in counties with insufficient LHD resources County HDs LHD HIV/STD clinical services Linkage and relinkage services HIV/STD Partner services CBOs Services Communicable disease reporting From: Hidalgo J and Ruiz B. Creating New Opportunities for Community-Based HIV Prevention Services to Insured Populations. Nov 2014. http://www.etr.org/CIS/webinars/webinar-4-creating-new-opportunities/ TX Marketing Strategy: An Example TX Medicaid and Dept of State Health Services (DSHS) HIV/STD program meet with State and local HDs and MCOs Before meeting, TX Medicaid calculates rates of HIV/STD testing by MCOs, treatment rates, HIV expenditures, results of the Medicaid HIV linkage projects, and return on investment (ROI) if MCOs fund HIV services Before meeting, LHDs prepare epi profiles documenting rates of community viral load and STDs, services offered by LHDs and CBOs Include the MCOs’ care cascades DSHS, LHDs, and CBOs identify key marketing messages for inclusion in meeting presentations From: Hidalgo J and Ruiz B. Creating New Opportunities for Community-Based HIV Prevention Services to Insured Populations. Nov 2014. http://www.etr.org/CIS/webinars/webinar-4-creating-new-opportunities/ TX Marketing Strategy: An Example Brief presentations made at the meeting by Medicaid, DSHS, LHDs, and CBOs to MCO staff Follow-up regional meetings to discuss contracting and services to be provided via Medicaid and QHP contracting On-going quarterly meetings with MCO staff to identify ongoing areas of collaboration and address challenges TX Medicaid provides annual HIV and STD quality reports to MCOs to document improvement in their performance Continue to promote state-level communication between TX Medicaid and DSHS HIV/STD staff to keep up the momentum From: Hidalgo J and Ruiz B. Creating New Opportunities for Community-Based HIV Prevention Services to Insured Populations. Nov 2014. http://www.etr.org/CIS/webinars/webinar-4creating-new-opportunities/ TX Payment Model: An Example Sub-capitated monthly payment model LHDs will be paid fixed amount per Medicaid or QHP member assigned for prevention services Invoicing to request monthly payment, no service-level claims No financial risk is borne by the LHDs and CBOs Down-side LHD staffing may be not be nimble to meet new demands The number of referrals per month may vary throughout the year, making staff hard to plan From: Hidalgo J and Ruiz B. Creating New Opportunities for Community-Based HIV Prevention Services to Insured Populations. Nov 2014. http://www.etr.org/CIS/webinars/webinar-4creating-new-opportunities/ How to Learn More About ACA and MedicaidRelated Health Insurers in My State