Download HIV/AIDS - American Academy of HIV Medicine

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
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Key provisions of the Patient Protection and Affordable Care
Act (ACA)
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Federal and State Medicaid policies
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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
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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)
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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
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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
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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
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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
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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
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SHOP  TX Department of
Insurance Health Options
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http://www.texashealthoptions.com/index.html
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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
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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
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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
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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
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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
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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
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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
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Expand Primary Care Workforce
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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
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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
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Other required core Chronic CM Model components
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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
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Implement Evidence-based Health Promotion Programs Via CHWs
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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
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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
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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
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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
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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
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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