AIDS Care Group

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AIDS Service Organization Blog

The Health Insurance Marketplace Is Simple

by Kevin Moore, PsyD

Have you heard about the Health Insurance Marketplace recently? Did you see on television how it caused the government to shut down? Did you read in the newspaper a long list of abstract information? Did you hear on the radio the speculation that this or that will be changing? Are you unsure if the Marketplace applies to you or not?

I’m pleased to write this blog and tell you: the Health Insurance Marketplace is simple. I’m going to tell you how to find real information. If you are living with HIV/AIDS or work with people who do, I highly recommend you spend a few hours of your time and get direct answers rather than spending your time on second or third-hand media coverage. Beyond being complex, a lot of media coverage is inaccurate, sometimes wildly (e.g. I saw on Fox News that Obamacare is a Congressional Bill) or subtly (e.g. I read the ACA Wikipedia page and counted 3 small factual mistakes in the Overview of Provisions.)

So here is the deal, and it can be said in just one sentence: If you don’t have medical insurance (or you feel you pay too much for insurance) and you file taxes for $11,490 or more as a single person (or add $420 per person in your family), go to healthcare.gov and thoroughly read your options. That’s it. It is honestly that simple. Plus, its the only way to know for sure.

Just like picking a cell phone plan, you will be walked through coverage options and payment information. You will learn about co-pays, co-insurance, deductibles, and spending limits. It will explain the benefits that are covered. You can stop reading and come back later to read more. If you are someone who has relied on Ryan White clinics for your medical care, this might be your first opportunity to receive coverage for emergency care, hospital stays, and rehabilitation services that Ryan White does not cover. You can not be discriminated against and denied healthcare because you have HIV. The only health condition that can increase your costs is if you smoke. But don’t take it from me, go to healthcare.gov and see.

You may have heard the website is down. It has been difficult to access in its first week, but it has never been down. You might want to wait a week or two after the posting of this blog to check out the website, but don’t take too much time. I’d recommend you check it out before December 7th to insure you have coverage starting January 1.

If you work with uninsured people with HIV/AIDS, I recommend you offer to sit down with them at the computer and walk through the options with them. There are Patient Navigators and Certified Application Counselors who can assist them, but,  really, even they can be confused and only healthcare.gov has the complete and accurate information. When you are sitting and helping, there is an option on the website for the patient to name you as a “non-navigator patient assister.” This means you aren’t claiming to have any knowledge but are acting in a professional capacity to try to help. Yes, it will take several hours to move through all the information, but you can reassure them that they can do it.

The Health Insurance Marketplace is simple.

AIDS Service Organizations transitioning into the Affordable Care Act, Part Two: Medicaid Expansion and Health Insurance Marketplace

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By Kevin Moore and Erica Goldberg

The majority of people with HIV are poor and uninsured. This can be attributed to the fact that most people living with HIV are unemployed, which is in turn due to a myriad of factors including social, psychological, and medical factors surrounding the disease. Because the pre-ACA United States primarily tied insurance to employment (rather than insurance to citizenship), the largest group of people with HIV have always had to turn to disability benefits such as Medicaid and Medicare and/or the Ryan White system of care. According to a recent Kaiser Healthcare Report, Americans living with HIV accessed care through the following coverage:

42% Medicaid (including dual Medicaid/Medicare)
13% private insurance
24% no coverage
(The reason this percentage does not equal 100% is because not all people with HIV are accessing care, a topic of a future blog.)

One main tenant of the ACA was to get as many people insured as possible. In order to achieve this, Medicaid expansion was made a top priority. In states that are expanding Medicaid, the federal-state insurance program for low-income Americans, will be available without restriction to people up to 138% of the federal poverty level, which for single adults is $15,856 in 2013. We note “without restriction” because in states that do not expand Medicaid, not everyone who makes less than 100% of federal poverty level (i.e. $11,489) is eligible because they are not disabled, pregnant, or one of the other allowable categories.

For those who do not know, we think it is important to understand that in America today you can make less than $31 a day and not be able to see a doctor.

Pre-ACA requirements dictate that after you have attained Medicaid, you have to keep re-enrolling in Medicaid or lose your coverage. Here in Pennsylvania, the Department of Public Welfare adopted new rules in 2012 which allowed lots of people to be kicked off of Medicaid because of heightened re-enrollment requirements. One of the many benefits of expanding Medicaid is re-enrollment wouldn’t be an issue unless you started making significantly more money.

The second way the ACA gets more people insured is the creation of the Health Insurance Marketplace, which allows individuals from 138%-400% of the federal poverty level to purchase insurance with assistance of a significant tax credit. The Health Insurance Marketplace is an internet website, www.healthcare.gov, which provides a single application for both the Marketplace and or Medicaid. There is also a paper version. The Marketplace will open on October 1st and the plans will become active January 1, 2014.
There is a new “live chat” feature on www.healthcare.gov , a small black rectangle with the words “Questions? Live Chat” pops up in the bottom right-hand corner of pages as you navigate through the site. Click on it to chat online with trained professionals and ask questions. If you prefer to talk in-person, a new hotline was also recently launched. It offers 24/7 access via telephone to trained representatives who can also help answer your questions about the Marketplaces. The toll-free number is 1-800-318-2596 and the TTY line is 1-855-889-4325.

A marketing campaign is currently underway to raise public awareness about these options. Please be part of it. These changes are very complex and require multiple exposures and explanations to effectively communicate the information to those it will assist. These are our patients, our friends, and ourselves as providers, who are affected by these changes. You can help by talking about these changes with your friends and family.

If you don’t know what your state is doing about expanding Medicaid, you can find out here: http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

If you are in a state that is not expanding, please use the following tool that was prepared by the Duke AIDS Legal Project to understand your options for the Health Insurance Marketplace.
INSURANCE MARKETPLACE PRE-SCREENING

Can you prove US citizenship or legal residence? ☐ NO. Stop here. You CAN’T buy insurance in the marketplace

☐ YES. Go to the next question

Do you have Medicaid or Medicare? ☐ YES. Stop here. You CAN’T buy insurance in the marketplace

☐ NO. Go to the next question

Does your employer offer insurance that
a) Is affordable (costs less than 9.5% of household income to cover you)
b) Has decent benefits (eg “mini-med” doesn’t count) ☐ YES. Stop here. You CAN’T buy insurance in the marketplace

☐ NO or you’re unsure. Go to the next question

Does your spouse’s employer offer insurance that
a) Is affordable (costs less than 9.5% of household income to cover your spouse)
b) Has decent benefits (eg “mini-med” doesn’t count)

☐ YES. Stop here. You CAN’T buy insurance in the marketplace

☐ NO or you’re unsure. Go to the next question.

Is your income lower than column A in the Income Table on the table below? (Use your best guess for your income.) ☐ YES. Stop here.
• You CAN buy insurance, but can’t get help with the cost
• You are exempt from the requirement to have insurance

☐ NO. You CAN buy insurance in the marketplace. Go to the next question to find out about help with costs.

Is your income higher than column C in the Income Table below? ☐ YES. Stop here. You MUST to buy insurance or pay a tax penalty. You can’t get help with the cost.

☐ NO. You CAN buy insurance in the marketplace AND get help with the cost. Go to the next question.

Is your income higher than column B in the Income Table on the next page? ☐ NO. You SHOULD apply for insurance and financial help, but won’t owe a tax penalty if you don’t buy.

☐ YES. You MUST apply for insurance, and will owe a tax penalty if you don’t buy (unless you qualify for an exemption).

INSURANCE MARKETPLACE PRE-SCREENING
Instructions
• Use the above form to identify ADAP clients who may be
 able to buy health insurance through the Insurance Marketplace
 able to get financial help with costs, and/or
 required to obtain coverage

• Clients who may be eligible should be encouraged to enroll in insurance and find out how much financial help they can get. Clients will be able to shop online and compare cost, coverage, and providers. Financial help will include reduced or free premiums and reduced cost sharing.

• Open enrollment runs October 1, 2013 to March 31, 2014. Coverage starts January 1, 2014.

NOTE: This form attempts to simplify complicated rules so you can identify clients who should be prioritized for enrollment assistance after October 1. For questions about specific circumstances, clients should turn to consumer assistance resources that will be coming available over the summer of 2013, including:
• healthcare.gov
• health insurance navigators (beginning mid to late August)
• Marketplace 24/7 call center – 1-800-318-2596
• Online enrollment portal for the marketplace (available at healthcare.gov, going live October 1)

Marketplace Insurance Benefit Table

Numbers in the far left hand column are number in household Eligible for Financial Help with Costs Required to
Have Coverage Upper Limit for Help with Costs.

Lettered Income thresholds are the columns:
A. Eligible for financial help with costs: income over 100% of federal poverty level. People under this income level can buy insurance in the marketplace, but won’t qualify for financial help
B. Required to have coverage: income over 133% of federal poverty level (some exemptions apply). Coverage can come from employer, marketplace, government, or private market
C. Upper limit for help with costs: 400% of federal poverty level. People with incomes above this level can buy insurance, but won’t financial help (tax credit)

A                 B                C
1     12,065     15,856     46,535
2     16,286     21,404     62,816
3     20,507    26,951     79,097
4     24,728     32,499     95,378
5     28,949     38,047     111,659
6     33,170     43,594      127,940
7     37,391     49,142      144,221
8     41,612      54,689      160,502

Incomes listed above are increased to account for a 5% income disregard.

AIDS Service Organizations transitioning into the Affordable Care Act, Part One

By Erica Goldberg and Kevin Moore

The implementation of the Affordable Care Act promises to bring about many beneficial changes to our health care system. For people living with HIV/AIDS, there are a significant number of enhancements that will increase access to healthcare, most importantly access to health insurance through Medicaid expansion and the Health Insurance Marketplace. This is the first in a series of blogs that will seek to better understand the impact that the Affordable Care Act will have on AIDS Service Organizations.

HIV is a special disease, not merely because of its enormous mortality when untreated, but because of how it disproportionately affects stigmatized social groups: African Americans, Latino Americans, people in the LGBTQ community, injection drug users, ex-offenders, the severely mentally ill, and others. HIV is special in that to effectively provide medical care to people living with HIV/AIDS, medical and social service providers come to understand the social issues each stigmatized group struggles to manage. The Ryan White Care Act has successfully funded an array of providers nation-wide that comprehend the social issues surrounding HIV. Thus, Ryan White funded AIDS Service Organizations provide culturally competent medical providers and services and create safe spaces for these communities to receive care. This array of providers has developed a unique position in the current healthcare system. This series of blogs will attempt to define this unique position and show how the Affordable Care Act fundamentally alters how AIDS Service Organizations must function.

The Ryan White Care Act is the payer of last resort, i.e. it funds care for people without insurance. With Medicaid expansion and the introduction of the Health Insurance Marketplace, many more people should theoretically become insured. While there will remain some people without insurance, this will drastically reduce the number of people eligible for Ryan White services. The logic follows that funding for Ryan White can be dramatically reduced. This is not necessarily a decrease in funding for AIDS Service Organizations because there is the ability to bill the insurance of the newly insured patients. But will it work this way? Will Ryan White funded agencies most used to paying a lot of attention to performance measures, population based health management, and fulfilling grant award deliverables be able to maximize fee-for-service billing? Will the constraints of what you can or cannot bill erode the specialized care born from understanding the social issues around HIV?

If Ryan White is significantly reduced, how can we ensure that people with specialized needs receive the care that they deserve? Expansion of health insurance does not equal access to health care or a guarantee of receiving quality care. We already know that there is significant drop off between the number of people living with HIV/AIDS who initiate HIV medical treatment and those who stay engaged in medical care. Do we know that Medicaid expansion and the Health Insurance Marketplace would retain the same percentage of patients in care? How can we ensure that we do not lose the special skills acquired by providers due to Ryan White?

Those of you who have been following the possibility of Medicaid expansion in Pennsylvania may be wondering why AIDS Care Group, who has offices in Chester, Sharon Hill, and Reading, PA, is concerned with Medicaid expansion at all. Pennsylvania Governor Tom Corbett has decidedly and repeatedly declined Medicaid expansion, typically citing the reason that he would be forced to cut other social service programs. My take is that PA will ultimately accept Medicaid expansion because it is clearly in the state’s interest to do so. The tide is turning nationally: a growing number of Republican governors have accepted expansion, who had initially refused. The tide is turning on the state level: PA’s general assembly came close to forcing Corbett to accept expansion when the PA Senate passed a bill backing expansion that was defeated by only a narrow margin in the House. While Corbett will surely appease his base and continue to say he will refuse, I expect he will accept expansion, probably at the last minute or even in 2014. The Obama Administration has said it will honor Medicaid expansion at any time. Thus, Medicaid expansion will be relevant to planning ASO activities in an ACA environment both in and outside of Pennsylvania. Much more on this topic will appear in a future blog.

Save Health Care: Avoid Waste, Part II

By Kevin Moore, PsyD

As an alternative to rationing, avoiding waste is an organizing logic, policy strategy, and professional ethic.  In Part I of this blog, I named many things normally cited as avoiding waste as well as argued that effective care coordination is most important.  I mentioned – but did not explain- how effective care coordination was built into the ACA and what you could do to avoid waste.

The ACA promotes at least two major innovations that support care coordination: Accountable Care Organizations (ACOs) and Medical Homes.  ACOs are groups of medical providers who are responsible for a large group of patients for a set price and they determine what care is given based on certain quality markers.  There have been some early missteps with ACOs, but the idea is sound: have doctors to talk to each other so they give the best care they can.  By unhooking doctors from only charging for the time a patient is sitting on an exam table, the whole patient can be treated and quality management is no longer “extra work” but the work itself.

Medical homes are a family of related concepts: Health Homes in Medicaid, Patient Centered Medical Homes (PCMHs), and others.  PCMHs are perhaps the very best ACA-promoted program for care coordination. They are the future of health care.  They are primary care practices which closely monitor the processes and outcomes of their patients in return for enhanced payments.   A practice’s only way to improve processes and measure outcomes is to efficiently coordinate care.  Simple.  Powerful.

My first recommendation is that your AIDS Service Organization explore becoming a PCMH.  There are many PCMH credentialing bodies, but the National Committee on Quality Assurance (NCQA) is dominant.  A place to start: http://www.ncqa.org/Programs/Accreditation/HealthPlanHP.aspx?gclid=CLvagcjdsrcCFcF9Ogod1XYAQA

My second recommendation is that you consider avoiding waste to be a professional ethic of yours.  Think about your own practice and how you can more efficiently coordinate care with those who also treat your patients.  Avoid practicing defensive medicine. Consider open access scheduling so re-admissions can be avoided.  Collaborate with mental health professionals to help reduce obesity, poor diabetes management, smoking, non-adherence to medications, and excessive substance use.  Educate yourself about treatment variations that are often regional.  Resist overprescribing antibiotics, narcotics, and benzodiazepines, while aggressively treating pain.  Embrace – not just tolerate- an Electronic Medical Record with e-prescription functionality.  Use the ACA’s new preventive medicine codes.  Save health care one patient at a time.

If we can keep our own house clean, we are in a position to win an argument against those who would defund us.  Voluntarily striving for the highest professional ethics has always been the best policy strategy.

The ACA includes many waste-avoiding ideas: reduce fraud and insurance overpayments, reduce behavioral/clinical/organizational waste, and efficiently coordinate care.  These ideas have the potential to make health care reform successful.  These ideas can benefit ASOs just as much as they can benefit all of health care.  At no point do these ideas incorporate funding restrictions.  Avoiding waste – and not rationing- is the logic that can lead to health.

Save Health Care: Avoid Waste, Part I

By Kevin Moore, PsyD

In my last blog, sequestration had just begun and I questioned the moral and economic justifications of rationing. In the two subsequent months, our AIDS Service Organization (ASO) has suffered a sequestration-related cut of 11% to our primary funding.   We have heard about ASOs in other cities receiving as much as 30% cuts.  The logic of ration is impairing ASOs and harming the clients that we serve.  There is an alternative to rationing: avoiding waste.

During his 2012 re-election campaign, Obama highlighted reducing waste, fraud, and insurance overpayments as goals of his reforms.   Unfortunately, fraud and insurance overpayments together only account for a small amount of money (though these are important goals).   But what about the larger – and far more abstract- concept of reducing waste?  What does reducing waste mean?

A recent PricewaterhouseCoopers study places the dollar value of identified waste at $1.2 trillion dollars.  They specified three types of identified waste:

Behavioral – obesity, smoking, non-adherence to medications, and excessive alcohol use.

Clinical- defensive medicine, re-admissions, poor diabetes management, medical errors, unnecessary ER visits, treatment variations, hospital acquired infections, and overprescribing antibiotics.

Operational – claims processing, ineffective use of information technology, staffing turnover, and paper prescriptions.

Clearly these are all important areas to improve and the Affordable Care Act (ACA) has elements that address essentially all of them.  However, even $1.2 trillion will not fully correct our sky-rocketing health care costs and improve quality (though it would help).   Fortunately, there is an even more powerful waste avoidance measure built into the ACA.  It is so simple and so straightforward that it is routinely underestimated by even health care professionals: effective care coordination.

Allow me to illuminate effective care coordination by using a sports analogy.  Imagine a professional sports team with a head coach, assistant coaches, and a star player.   The coaches talk to each other and with the player individually and as a group so that everyone is on the same page.  Important information is repeated so clarity is achieved.  The work of the head coach is to insure the entire team is communicating so that the player can maximally perform.

Now let’s imagine the antithesis of this analogy.  What if the head coach didn’t think it was important to coordinate the input of the assistant coaches?   What if the coaches rarely talked to each other?  What if they typically only spoke individually to the player and often asked the player to relay what the other coaches said?  This is the state of much of this nation’s health care system.   Let me give a real world example of what the current lack of care coordination looks like.

A person living with HIV sees both his primary care provider, who is an HIV specialist, and a psychologist for psychotherapy for depression.   The CDC estimates that half of those living with HIV screen positive for depression.  The primary care provider is prescribing a “standard of care” anti-retroviral medication that combines several medications into one pill a day.  The psychologist is assisting the person cope with seemingly intractable depression.  The primary care provider occasionally asks the patient how therapy is going and the psychologist occasionally asks the patient how he is doing medically.  The two health care providers never speak directly, though the patient has signed releases to consent to this communication.

Were they to communicate, the primary care provider would hear that the depression was not resolving as expected and might wonder if the side effect of depression from the anti-retroviral medication might be a factor.  The psychologist would be surprised to learn that a strictly “biological” cause of depression could account for the patient’s continued pain.  A different medication could be prescribed and the depression might lift just as quickly.   Simple care coordination could improve the life of this patient and improve the outcome of both of these providers.  Care coordination might be boring to talk about, but it is intensely powerful in healing the sick.   It is wasteful not to coordinate care.

In Part II of this blog, I will explain how the ACA enhances care coordination and what you can do to help.

Does the United States treat the poor poorly? The terrible logic of rationing and sequestration.

By Kevin Moore, Psy.D.

Let’s take the beginning of sequestration as a time to reflect on the funding of healthcare for poor people in the United States.

Medicaid, the health program for certain people and families with low income and resources, has long paid the lowest fees to medical providers anywhere in the United States. The Medicaid fees are so low that no medical practice can survive on these fees alone.  All safety net medical providers, such as AIDS Service Organizations, combine grant funding with Medicaid reimbursement to survive. Medicaid fees are so low because the government uses the logic of rationing.

Rationing assumes the management of scarce resources.  If we only have x dollars to spend on y services, we should reduce fees until x=y.  Rationing is the standard and accepted logic of public healthcare funding in the United States.  Sequestration applies the logic of rationing to the entire Federal budget.

But is it the right logic?  The problem is that y services is the health of our citizens, which is both an ethical good and impacts the x dollars generated.  Even if the logic is sound, does legislation based on rationing work?

The Affordable Care Act tries to address the ridiculously low Medicaid fees by increasing the Medicaid rates to the same level as Medicare rates.  Medicare, the health program for the elderly and disabled, has higher reimbursement than Medicaid even though Medicare rates are less than standard medical fees.  Plus, Medicare has its own problems.

For the last twenty years, Congress has tried rationing Medicare by calculating something called a Sustainable Growth Rate (SGR).  The SGR is a kind of “bad cop” who tries to keep medical costs low by threatening a cut in Medicare rates.  In only one of the last twenty years did the SGR follow through with its threat and actually decrease Medicare rates.  Year after year, Congress makes a last minute “Doc Fix” to the budget, suspends the SGR for another year, and sporadically allows extremely modest increases to Medicare rates.

The difference between the SGR and Congress’ actual behavior in setting Medicare rates is a telling example that rationing is a failed logic.   Despite enacting the SGR, Congress doesn’t actually think rationing Medicare will fix the problem.  Similarly, few believe sequestration will actually achieve its aims, and I suspect fewer will think so as sequestration’s effects begin to be felt.

Both SGR and sequestration are laws built on the logic of rationing.  Both SGR and sequestration are failsafe devices to control government spending when nothing else worked.   Neither are regarded as helpful or good laws, but – at best – necessary evils intended to stimulate actual answers to problems.

Answers to Medicaid spending, Medicare spending, and the Federal deficit have yet to materialize.  Even if rationing has a moral and economic justification, it has yet to work as legislation.

On top of the long standing problems with Medicaid and Medicare, sequestration will compound difficulties for people seeking access to healthcare.  Rationing treats the poor poorly by saying “sorry, we don’t have money for your care” to sick and dying Americans.

Perhaps the logic of rationing is itself the problem.  In my next blog, I will propose an alternative to the terrible logic of rationing: avoiding waste.

Are AIDS Service Organizations Preparing for Health Insurance Exchanges?

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By Fungisai Nota, PhD

            One of the key components of the Patient Protection and Affordable Care Act (ACA) is the creation of health insurance exchanges. Health exchanges are new organizations that are being set up to create a more organized and competitive market for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and provide information to help consumers better understand their options. States are expected to establish Exchanges–which can be a government agency or a non-profit organization–with the federal government stepping in if a state does not set them up. States can create multiple Exchanges, so long as only one serves each geographic area, and can work together to form regional Exchanges. The federal government will offer technical assistance to help states set up Exchanges. More than half of the states have opted for Federally Facilitated Exchanges (FFEs) putting the burden of designing the health exchange systems and enrolling patients to the federal government.

For states, like Pennsylvania that opted for Federally Facilitated Exchanges there are several implications on the management, financing, and operation of these exchanges:

i)    The federal government would design and operate customer services, which may be provided from a location outside of the state and centralized with customer services for other states participating in the federal exchange.

ii)    The federal government would conduct exchange-related consultations with stakeholders. AIDS Service Organizations need to be part of these consulted stakeholders.

iii)    The federal government would within the confines of Pennsylvania, provide customer service separately from the State Department of Human Services. This may increase administrative complexity particularly for families with members enrolled in public and private coverage, compared to the state exchange providing these services directly.

iv)    The federal government would conduct an outreach and education program to promote enrollment in the exchange. Current AIDS Service Organizations can play a pivotal role in educating and enrolling not only their patients but other individuals without insurance in the exchange.

v)    The federal government would determine the criteria for certifying Qualified Health Plans (QHP), the certification process, which plans are eligible to participate in the exchange, and provide oversight for QHP issuers. Account management for QHP issuers would be provided by federal “Account Managers.”

vi)    The federal government would, similarly as the above, review rates, rate increase justifications, policy forms, benefit levels, actuarial plan values, and compliance with market reforms. The federal government would also assess accreditation, market conduct, adequacy of plan-level rate and benefit data, and proposed changes in services/networks, ownership, mergers, or acquisitions.

Besides understanding and taking part in the design of health insurance exchanges, ASOs need to prepare for the potential reduction in Ryan White grant funding as their current patients get insurance. One of the ways ASOs can survive and even thrive under the health insurance exchange system would be to retain and grow their strength in numbers. They should use their patients’ networks to find and link those HIV positive that are lost to care. In addition, they should create mergers and partnerships with other ASOs. The bigger the communities of patients they represent and serve, the more influence they will have in the design of exchanges that take into account the unique needs of people living with HIV/AIDS.

When ASOs start increasing the number of patients they serve, creating lasting mergers and partnership with organizations that share their strategic goals, then they will have the strength in numbers to argue for and ensure that sure health insurance exchanges are HIV/AIDS friendly. In addition, a community of ASOs can approach insurance providers in the exchange and negotiate a carve-out for HIV care. Given ASOs experience with the HIV/AIDS patients who mostly have complex co-morbid conditions they should convince insurance providers to give them “preferred provider status” for treating HIV/AIDS and related ailments.

Instead of crying victim that Ryan White funding is going away, ASOs should buckle-up and start creating powerful, targeted and positive strategies to change through affiliated and collaborative networks. To avoid facing extinction, ASOs should take a stand and demand being part of the decision making process, and being a major player in the world of the Affordable Care Act.

Medicaid Eligibility Will Be Easier, And Why That Matters

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By Kevin Moore, Psy.D.  11/28/12

Healthcare reform is extremely complicated and has an enormous number of changes and interlocking parts, some of which are not fully explained or even exist yet.  Imagine healthcare as an airplane and we are expanding the fuselage at the same time as replacing the engine.  And the engine is still being invented as it is being installed.  And the plane is in the air.

This blog will bull’s-eye specific segments of ACA changes and how it will affect AIDS Service Organizations and the people they serve.  Under current Medicaid law a single person without dependents is only eligible for Medical Assistance if they are disabled, i.e. if the person’s medical provider signs a form.  In addition to having a chronic condition such as HIV/AIDS, a person needs to meet criteria including very few financial assets.  You can own one car and one home, but otherwise have extremely little savings or items of value of any kind.  This financial evaluation is called an asset test.

An asset test may seem like it is a reasonable bar to keep people with resources out of publically funded health insurance.  It is often not.  Consider a person with zero income, zero savings, but has, say, $14K in a 401K retirement account.  The asset test will deny this person Medicaid until such a time as they cash in the retirement account, paying both penalty and taxes, and spend down the remaining devalued asset.   As a healthcare provider, I’m not sure why utterly broke sick people are supposed to be better patients than broke sick people.

For states that accept the Medicaid Expansion option of the ACA, Medicaid eligibility will be easier as of 2014. The ACA “[r]equires states to use a net income standard (no asset or resource test, no income disregards) to determine [Medicaid] eligibility.”  Thus, the asset test will be eliminated, as will the criteria of being disabled, plus other simplifications.  This matters to people living with HIV/AIDS because they won’t have to navigate as many complexities and be better able to retain their scarce resources.  I see it as the job of AIDS Service Organizations’ staff to pass this information along.  We are all in this airplane together.  (Thanks to Mimi McNichol, Director of Client Services at Philadelphia FIGHT, for passing this information to me.)

How will healthcare reform change health insurance for people living with HIV/AIDS?

By Kevin Moore, Psy.D. on 11/16/12

Even though current Ryan White services fund a complete spectrum of medical services from medical and dental care to receiving HIV medications, it is always a good idea to get health insurance. One never knows when she or he might need to go to the emergency room. Besides, the current way that Ryan White services are certified in the Commonwealth of Pennsylvania and other States, Ryan White recipients are required to apply for benefits such as Medicaid, if they are eligible. Given this state of things, what will change?

First of all, about 50% of people who are currently eligible for Medicaid are not receiving this entitled benefit, primarily because they have not applied but also because of bureaucratic difficulties.  This percentage should go down.  While a high percentage of people living with HIV/AIDS are receiving the Medicaid coverage, also called Medical Assistance or MA, they are sometimes kicked off of their coverage because the state declares that they have failed to keep current documentation or have exceeded the income limits or other eligibility criteria.  One of the aims of the Medicaid expansion is to reduce the sometimes adversarial nature of public benefits.  This change will be a tricky one as it will depend on each states’ Medicaid administration to conform to a yet to be determined standard.  Pennsylvania’s Department of Public Welfare has dropped hundreds of thousands of enrollees for new technicalities since the Corbett Administration, though many of these were able to regain coverage with additional documentation.  Healthcare reform should reduce the amount of gaps of Medicaid coverage by current recipients.

Second of all, for states that accept Medicaid expansion from the federal government, people up to 133% of the Federal Poverty Level (FPL) will be eligible to receive Medicaid.  This will be a significant benefit to a group sometimes called “the working poor.”  For states, such as Pennsylvania, who have indicated they will not accept the Medicaid expansion, this 100-to-133% FPL group are in danger of not being eligible for Medicaid but still being mandated to have health insurance.  It is extremely unclear how this will play out, and this may be the single most fractious, partisan, hot-button issue of healthcare reform implementation.  This should be a primary target of advocacy for people living with HIV/AIDS as they could end up in the worst case scenario of having neither Medicaid nor the current Ryan White care system and face a penalty for not having health insurance.

Third, for people above 133% and up to 400% FPL, state health care exchanges will be established so they can have both access to new groups of insurance pools and assistance in deciding which plan is right for them.  Depending of level of income, there are maximum percentages of the cost of insurance that can be charged.  To be clear, a working class American in 2014 will be able to individually purchase health insurance whose coverage far exceeds what the individual must contribute.  Curious how this might work out for you or your loved ones?  Try this easy to use subsidy calculator:http://healthreform.kff.org/en/SubsidyCalculator.aspx. Some states, like Pennsylvania, will not choose to set up healthcare exchanges themselves and thus an arm of the federal government, the Department of Health and Human Services, will set it up for that state.  In either case, each health exchange will have to decide how they will cover people living with HIV/AIDS.  As they cost on average about five times as much per year as the average Medicaid recipient, it will require massive advocacy on a state level to ensure that people living with HIV/AIDS are well cared for in the state exchanges.

Finally, people above 400% of the FPL will not receive subsidies for their insurance, but they will enjoy other benefits of healthcare reform such as not being rejected for insurance because of a pre-existing condition such as HIV/AIDS, no lifetime caps on insurance spending, and other protections previously unavailable.  Whatever your income, healthcare reform will directly benefit you in multiple ways.

Act like a non-profit, and think like a for profit organization

By Fungisai Nota, PhD

The Patient Protection and Affordable Care Act (ACA) brings a wealth of good news for those living with HIV/AIDS in the United States:

  • 1. Insurance companies will no longer be able to deny coverage based on pre-existing conditions.
  • 2. Insurers can no longer rescind coverage for adults or children because of changes in health status.
  • 3. The proposed expansion of Medicaid will insure some coverage of the estimated 25% of those living with HIV/AIDS without insurance.
  • 4. And, by 2014 there will no longer be lifetime spending caps from insurance companies.

These upcoming changes imply the need for well managed “organizational change” within AIDS Service Organizations (ASOs). With the expansion of medical insurance coverage, Ryan White funding is likely to be reduced to cover wrap-around services – about 25 percent of the current funding. Therefore, the leadership of ASOs should start asking themselves the following questions:

  • i) If most of our patients gain insurance coverage will they be asked to be treated by someone other than ourselves?
  • ii) If all of our patients have Medicaid insurance, and Ryan White funding goes down to 25 percent, can we survive financially?
  • iii) What do we do best (comparative advantage in economics), and can we scale it up in a fee for service framework to create financial sustainability?
  • iv) How can ASOs optimize their current services, human capital skills, and infrastructure to remain relevant and keep providing the much needed HIV/AIDS services?

These are tough questions that will challenge the leadership of ASOs to marry their public service vision with business acumen. For the first time in a long time, ASOs have to examine their strengths, weaknesses, opportunities and threats – knowing full well that if they do not strategically adapt to the changing health care environment, they may lose their patients and potentially cease to exist.

As one public health expert rightly said to HIV providers, “Don’t expect anything to be handed to you on a silver platter. Don’t wait to be invited. Get Involved”. And I would add: develop your strategic plan; learn the required essential health benefits for private insurance plans in your state; ensure that your provider team is informed about ACA changes that will affect your patients, and understand the process of enrolling your newly eligible patients in Medicaid.

Look deep, and identify for-profit ventures within your non-profit organization. The sustainability of your organization depends not only on your ability to manage the organizational change, but also creativity in replacing potential loses in Ryan White funding.