ACA Presentation for Community Forum Dec 10 2013

8/13/2019 ACA Presentation for Community Forum Dec 10 2013

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Colorado HIV Care & theAffordable Care Act: Making It

Real!


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Todays Presenters:

Colorado Department of Public Health &Environment

Todd Grove, Colorado AIDS Drug AssistanceProgram

Bob Bongiovanni Program Manager, HIV Care& Treatment Program


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Colorado AIDS Drug AssistanceProgram


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HIV population already onMedicaid

An estimated 500- 600 people are currently onColorado Medicaid

Primarily those who have been declared

medically disabled and receive SupplementalSecurity Benefits (SSI), or family Medicaid

Will be able to join ADAPs new SupplementalWrap Around Program (SWAP) in April


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I have CICP and HMAP, why do Ineed insurance?

CICP is NOT health insurance, it

is a discount program.Not comprehensive coverageNot all essential services covered

Very limited network ofprovidersFills restricted to 3 pharmacies

Only ADAP-formularymedications coveredRequires recertification every

year

All plans must offer Essential HealthBenefitsComprehensive provider networksMore drugs are coveredBetter laboratory and medical imagingcoverageBetter mental/behavioral health

benefitsAccess to more servicesExpanded ADAP network ofpharmacies, including all KingSoopers, City Market and WalgreenspharmaciesEmergency Services covered whentraveling outside the state

CICP/HMAP Medicaid/ HealthInsurance


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WHERE ARE YOU ON THE FOLLOWING CHART?

Calculating Income & Defining a Household


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Federal Poverty Levels - 2013

Persons inHousehold

100% ofFPL

138% ofFPL(Medicaid maxunder Reform)

250% ofFPL(current maxCICP)

400% ofFPL(current maxADAPprograms)

1 $11,490 $15,282 $28,725 $45,960

2 $15,510 $21,404 $38,775 $62,040

3 $19,530 $26,951 $48,825 $78,120

4 $23,550 $32,499 $58,875 $94,200


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Modified Adjusted Gross Income

Financial eligibility for the consolidated Medicaid andCHP+ programs will be determined usingmethodologies based on Modified Adjusted GrossIncome (MAGI),

MAGI for most taxpayers is equal to their AdjustedGross Income as figured on their personal income taxreturn. It may also include:

Any foreign earned income excluded from taxes Tax-exempt interest

Tax-exempt Social Security income (SSDI), but notSSI.


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Countable Income

Earned

Employment

Self-employmentUnearned

Alimony

Child Support

In-Kind

Veterans Benefits

Social Security Benefits

Counts taxable income:

Salaries, Wages, Tips

Capital Gains

Unemployment Benefits

SSDIMinus allowable taxdeductions:

Retirement Plan Contributions

Child Care

Mortgage InterestDoes not count non-taxableincome:

Social Security Title XVI (SSI)

Child Support

MAGI

CURRENT


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1) 2014: Most low-income people will

get Medicaid Expands eligibility: Starting in 2014, anyone who

is low income can get Medicaid - no morerequirement to be totally disabled

Improves services: State will be required toprovide benefits that cant be cut

Improves payments to providers: Enhancesreimbursement for primary care providers

Allows people to earn money and not endangertheir medical care Makes it easier to apply and enroll


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The Expansion Population (Adultswithout Dependent Children - AwDC)

Age 19-64

Not pregnant

Not receiving Medicare A or B

Not mandatorily covered by Medicaid

Income below 133% of federal poverty (138%after 5% income disregard

Also allows parents access to Medicaid upto 138% of FPL (up from 60% of FPL)

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Pregnant women

Individuals who qualify forMedicaid based on being blind

or disabled Dual eligible Medicaid

Medicare

Terminally ill hospice patients

Inpatients in hospitals, nursinghomes, and intermediate carefacilities

Former foster care children

Individuals who qualify forlong-term care services based

on their medical condition Individuals who only qualify

for emergency care

Individuals who qualifybased on spend down

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Individuals who qualify for StandardMedicaid (not due to Medicaid Expansion)


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Clinical Based Social Work CICP

enrollment Staff where you are seen

Case Management / SocialWorker through Peak or

Insurance Marketplace

CDPHE targetedenrollment

Who is likely to help you enroll in

Medicaid?


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Who can help you apply forMedicaid

Schedule an appointment by calling your HIV Clinic(DH, CHIP, University, etc.).

Some case managers are helping with enrollment

Enroll yourself through Colorado PEAK website(PLEASEmake sure to notify ADAP that you haveenrolled in Medicaid by calling (303) 692-2716).

If you are already receiving AND or SNAP, you can enrollusing your PEAK account

Meet with a County Social Service worker

Applying for anything other than Medical will increasethe time it takes for approval


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Coloradohttp://coloradopeak.force.com/Medicaid

Website
http://coloradopeak.force.com/http://coloradopeak.force.com/http://coloradopeak.force.com/


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Health Colorado Enrollment Letter

You DONT need to do anything

if the letter indicates the

correct PCMP

Your RCCO and PCMP may not

make the call to the Health

Colorado on your behalf, but

can assist you with making the

call to select your doctor

You can change PCMP

selection at any time

You can ask your RCCO to try

and recruit your PCMP if not

already contracted as an ACC

primary care provider


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Medicaid Service Co-Pays,2013

Inpatient HospitalServices

$10/50%

Rural healthclinic/FQHC

$2 perservicedate

Outpatient HospitalServices $3 /visit Laboratory $1 perservicedate

Practitioner Services $2 /visit

Prescriptions:

Psychiatric Services 50 per15 minserviceunit

Generic drugs Brand name

$1$3

Community mental healthservices

$2 pervisit


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Supplemental Wrap Around Program(SWAP)

ADAP has begun a new program to cover all Medicaid-eligible clients with medication co-pay coverage forADAPformulary

Members will be able to use many more pharmacies if

they choose (King Soopers, Walgreens) Recertification process will become easier (as member

would have been screened eligible for Medicaid)

ADAP suggests that you continue to to use HMAP

network pharmacy at least at first - easy movement toHIAP, or to HMAP if churning is an issue allows forback-billing.


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ADAP and theBenefits Exchange


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# 3 Current InsurersHave to play by newrules:

Health plans cannot drop peoplefrom coverage when they get sick

(already in effect)

No lifetime limits on coverage(already in effect); No annual limitson coverage (2014)

Children under 26 may remain onparents insurance plan (in effect)

If your employer plans premiumcosts more than 9.5% of yourincome, you can shop for anotherplan through the marketplace*

In most cases, Colorado ADAP will insist that you do.


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How Much Will It Cost Me?

If you receive ADAP, your cost for your HIV careand prescriptions using private insurance andADAP will be:


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How Will It Work?

Instead of paying the full cost of expensive HIV

medication, ADAPs dollars can go further by payingthe costs associated with insurance.

Insurance pays a the majority of the costs of drugs andservices, ADAP picks up the remainder

ADAP saves money, members get comprehensivehealth coverage

More benefits and services with no costto the member, whats the catch?


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http://www.connectforhealthco.com
http://www.connectforhealthco.com/http://www.connectforhealthco.com/


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Approximately 300-400Colorado ADAP memberswould likely be newly eligible

for the exchange Nearly all of these individuals

have been receiving MedicalCare through Ryan White

and CICP Most will want / be able tostay with their currentprovider

Connect for Health Colorado HealthCoverage Guide


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CDPHE has worked with the local AIDS Service Organizations to hire anetwork of Health Coverage Guides to assist clients through the process ofapplying for coverage.

Health Coverage Guides will work with clients and clinics through the InitialEnrollment Period of the Affordable Care Act to ensure that all members getthe chance to enroll in comprehensive coverage.

ADAPs initial goal was to have the majority of clients enrolled in Medicaid or

Private Insurance to be effective January 1. We understand that noteveryone may meet deadline, so we will continue to pursue Marketplaceenrollment through March 31, 2014 and ongoing for Medicaid.

There will be increasing pressure to enroll in programs that you qualify for.

CDPHE / ASO Collaborative forConnect for Health Colorado


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Cost reduction for Individuals & Families

Financial help to reduce the cost of premiums

Individual earning between $11,490 to $45,960/year

Couple earning between $15,510to $62,040/year

Family of four earning $23,550 to $94,200/yearo Tax credit applied up-front by IRS

o Tax credit is higher for older Coloradans, especially for those ages 55-64o ADAP members MUST receive tax credit in advance (not applied at the end

of the year

o ADAP Members must report any change in income that might affect theamount due

Financial help to reduce out of pocket costs (co-pays anddeductibles)

Individuals earning $11,490 to $28,725/year

Family of 4 earning $23,550 to $58,875/year


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Overestimating or underestimating income

At the enrollment date, it is important to estimateannual income carefully.

If you underestimate your income they will receivetoo much premium subsidy. This could result inyou owing money back to the IRS when you fileyour taxes.

If you overestimate your income you will receiveless premium subsidy than you are entitled to,

imposing extra costs on ADAP.

There will be a reconciliation with IRS, DHS, SSA,and other data systems.


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Process in a Nutshell

Health Coverage Guides (HCGs) are assigned to region, not necessarilyASO service area, to enroll clients.

Through a one-on-one appointment arranged between the HCG and clientor a walk-in clinic day, client is met with by an ADAP-specific HCG.

The HCG will sit with the client and walk them through the enrollmentprocess

HCGs will report enrollment progress to the ADAP office to allow for acoordinated approach that avoids people falling through the cracks

Clients will NOT be pressured into making immediate decisions. If theyneed time to think, HCG will make arrangements to complete process atfuture appointment.

Clients will NOT be pressured into choosing plans that dont meet theirneeds. If they are not enrolled because they want a plan that has not beenpre-approved by ADAP, they will be referred to the ADAP main office, whowill work with the client to find a solution.


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Members eligible for the Exchange

Assignment healthcoverage guide

Contact andenrollment throughConnect for Health

Colorado Portal

Plan choice, federalsubsidy assigned,remaining balanceto be paid by HIAP

Assignment to

HIAP EnrollmentWorker at RegionalASO

Set up new planinformation,

including premiumand cost-sharing

info for Jan 1 2014

Terminate HMAP

plan @ 12/31/2013,send new HIAPcard in December


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Colorado Department of Public Health(CDPHE) HIV Care & Treatment Program

Boulder County AIDSProject (BCAP) Boulder

(51 enrollees)

Northern Colorado AIDSProject

Ft. Collins/Greeley

(32 enrollees)

Southern Colorado AIDSProject

CO Springs/ Pueblo

(71 enrollees)

Western Colorado AIDSProject

Grand Jctn/ West Slope

(29 enrollees)

Colorado AIDS Project(Denver Colorado AIDSProject (510 enrollees)

Current HIAP Members enrolled by Region/ area

Eligibility Screening done at these enrollment sites until January 2014, then performed by ADAP?


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Map of AIDS Service

Organization Service Areas withInsurance Rating Areas.

The following map shows the inconsistent

overlaps between service areas and rating areas.Because of these inconsistencies, it makes senseto allow the client to choose the easiest locationto enroll through. They would still be referred to

their regional ASO to set up premium/co-payassistance if enrolled in insurance.

Numbers indicate insurance rating area


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Numbers indicate insurance rating area


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Sample of ADAP-approved

plans by area

Denver ADAP-Approved Plans


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Insurer Plan Name Deductible Medical Copays

Referral

Required to see

a specialist?

Rx Copays

Cigna Life and Health Insurance Co. myCigna Copay Assure Silver (OAP)

$0 Medical $30 primary care

No

$4 Preferred/$25 Non-preferred Generics

$60 Preferred Brand

$0 Rx $60 Specialty care50% Non-preferred Brand

40% Specialty

Colorado Choice SilverChoice 1750/40 (HMO)

$1750 Medical $25 primary careNot required for

consult with a

specialist. Referral may

be required for

procedures

$15 Generic$40 Preferred Brand

$0 Rx $45 Specialty care$60 Non-preferred Brand

$60 Specialty

Denver Health Medical PlanElevate Silver/Basic

(Expanded Network Plan)


Yes

$8 Discount

$40 Generic

$0 Rx $65 Specialty care$90 Preferred Brand

$160 Non-preferred Brand

HMO Colorado (Anthem BCBS) Silver DirectAccess (HMO)


No

$15 Tier 1

$40 Tier 2

$0 Rx 20% Specialty care

20% Tier 3

20% Tier 4

Humana Health Plan, Inc.Humana Connect Silver 4600/6300 Plan

(HMO)


Yes

$10 Preferred/$20 Non-preferred Generic

$50 Preferred Brand


50% Specialty

Kaiser Permanente KP CO Silver 1500/30 (HMO)


No

$15 Generic

$45 Preferred Brand


30% Specialty

New Ventures Access Health CO Silver (PPO)


Yes

$20 Generic

$40 Preferred Brand

$500 Rx $50 Specialty care$80 Non-preferred Brand30% Specialty

Rocky Mountain Health Plans

Rocky Mountain HMO Region-specific

1500/40 Plan(HMO)


Yes

$15 Tier 1

30% Tier 2

$0 Rx $55 Specialty care40% Tier 3

40% Tier 4

Rocky Mountain HMO Statewide 1500/40

(PPO)


Yes

$15 Tier 1

30% Tier 2

$0 Rx $55 Specialty care40% Tier 3

40% Tier 4

***Drug copays, plan formularies and provider networks are subject to change without regulatory approval. Make sure to

verify with Connect for Health, coverage documents and/or provider at time of enrollment to ensure the plan coversclients preferred provider and medications.

ADAP Health Co erage Guides b Agenc


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Boulder County AIDS Project2118 14thSt.Boulder, CO 80302

(303) 444-6121ADAP Health Coverage Guides:Amanda HeinrichCeleste LeBlancErin Dupuis

Colorado ADAP4300 Cherry Creek S DrDenver, CO 80246

(303) 692-2716ADAP Health Coverage Guides:Adam BrisnehanJoAnn PalmaTodd Grove

Denver Colorado AIDS Project2490 W. 26thAve.Suite A300

Denver, CO 80204(303) 837-1501ADAP Health Coverage Guides:Ashley BruehlDwayne HickmanKate OMearaStephen PipalTiffany Rosengrant

Northern Colorado AIDS Project400 Remington St.Suite 100Ft. Collins, CO 80524(970) 484-4469ADAP Health Coverage Guides:Emily DarrellKelly Maycumber

Southern Colorado AIDS Project1301 S. 8thSt.Suite 200

Colorado Springs, CO 80906(719) 578-9092ADAP Health Coverage Guides:Ann SulleyKelly DeMuth

Western Colorado AIDS Project805 Main StreetGrand Junction, CO 81501

(970) 243-2437ADAP Health Coverage Guides:Elizabeth Pertile

If you receive ADAP assistance and need to meet with someone to enroll incoverage, contact an area agency to speak with a Health Coverage Guide.

ADAP Health Coverage Guides by Agency


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4) Medicare isGetting Better

54% discount on all brand-nameprescription drugs paid by drugmakers during Part D donut hole to be totally phased-out by 2020

Increased generic coverage as well More classes of drugs allowed

Improved access to prevention &

screening


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DRUG FORMULARIES

PHARMACIES

HMAP

HMAP Formulary(9/15/2013)

HIAP

HIAP Formulary(9/15/2013)

PCIP Formulary(ends 12/31/2013)

SWAP

HMAP formulary

BTGC

Medicare Part D PlanFormulary throughthe coverage gap

Then, HMAPFormulary(9/15/2013) only

HMAPDenver Health

Walgreens at Childrens

Hospital

University of Colorado

Walgreens at RoseMedical (Denver)

HIAP Apothecary

Walgreens

King Soopers

CHIP City Market

Kaiser

Denver Health

University

Rocky Mtn CARES

Avella

SWAP Apothecary

Walgreens

King Soopers

CHIP City Market

Kaiser

Denver Health

University

Rocky Mtn CARES

Avella

BTGCApothecary

Walgreens

King Soopers

CHIP City Market

Kaiser

Denver Health

University

Rocky Mtn CARES

Avella

L M k H l h R f


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Lets Make Healthcare ReformReal:

1) Michael and Ross


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Michael & Ross

Michael

Michael is on Medicare

He has ADAP and Bridgingthe Gap, which pays hisMedicare Part D premiumsand his prescription Drugs

In 2014, there are nochangesto Michaels

ADAP coverage he shouldexpect his renewalapplication for BTGC inOctober

Ross

Ross has insurance throughhis employer, and earnsabout $30,000 a year

It is a pretty good plan, andADAPs Health InsuranceAssistance Program (HIAP)pays his premiums,

deductibles & co-pays Ross should also expect to

have no changesto hisHIAP coverage


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Making it Real# 2: Aaron

Aaron, an uninsured man who makes$14,000 annually, is HIV-positive. Hesnewly diagnosed and doesnt have any

symptoms, although he does suffer fromdepression. He has a history of heartdisease and diabetes in his family.


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Aarons Situation Today

Aaron cant qualify for Medicaid because he is not totallydisabled.

Aaron can get HIV medications through ADAPs HIVMedication Assistance Program (HMAP).

Aaron gets HIV primary care paid for by the Ryan White &CICP. However, if Aaron develops diabetes or heartdisease, he may have to pay out-of-pocket for medical

care or medications that will control these conditions Aaron has to pay out-of-pocket for medications to treat

his depression.


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Aarons Situation in 2014

FROM CICP, Ryan White& HMAP

Aaron will have access toMedicaid based only on his

income* (


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Karyns Road to Health

Making it Real:

Karyn, 40 year-oldwoman in Aurora, runs asmall business andmakes $40,000 per year(just under 400% ofFPL). She just testedpositive for HIV.


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Karyns in trouble!

Karyns Situation Today:

Cant buy privateinsurance: HIV is a pre-existing condition.

She makes too muchmoney for CICP

Is able to get HIV medsADAPs HMAP

Could possibly getbusiness of one insurance

expensive!

Worst case: pay out ofpocket for treatment, could

very well file for medical

bankruptcy, and would then

need to wait until she

became totally disabled until

qualifying for Medicaid


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Karyns Situation in 2014

Karyn has options!

She can purchase privateinsurance through Connect

for Health Colorado, the

Colorado Marketplace

Insurance companies willbe required to sell policies

to people with pre-existing

conditions

Coverage will be moreaffordable:

Shell receive a sliding scale subsidyso her health care premiums are

limited to 9.5% of her income.

Insurance companies will be allowedto charge rates based only on age,geography and whether someone

smokes or not (rates cant depend on

gender or how sick someone is).

Colorado ADAPs Health Insurance

Assistance Program will help pay forthe cost of insurance beyond what

the federal government will pay


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YOU HAVE RESPONSIBILITIES!!

Everyone will be required tohave health insurance

The requirement will beenforced by the IRS, you

probably need to file taxeswith few exceptions

Employers must offerinsurance or pay a tax in2015*

But there are lots ofexceptions

Th Cl k i


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The Clock isTicking!!! October 1, 2013: Enrollment

began into Medicaid &health plans Apply ASAP!

January 1, 2014: coverage

begins March 31, 2014: open

enrollment ends for

insurance through theinsurance marketplace.

Medicaid is ongoing.

ADAP / I St t ft I l t ti


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ADAP / Insurance Status after Implementation

59

1,800 individuals

100 new HIAP members300 new HIAP members1,100 Medicaid /SWAP members

200- 300 individuals


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Like us on facebook!www.facebook.com/COADAP


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Questions?

Todd Grove

ADAP Coordinator ColoradoDepartment of Public Health &Environment

[email protected]

Bob Bongiovanni

Program Manager, HIV Care &

Treatment Colorado Department ofPublic Health & Environment

303-692-2703

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]

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ACA Presentation for Community Forum Dec 10 2013

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