Health Insurance Premium & Co-Pay Assistance

J:\Committees\Quality Assurance\FY16 How To Best\Workgroups\Workgroup 2\TOC - WG2.doc

Health Insurance Premium & Co-Pay Assistance

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Service Category Definition – Part B/DSHS State Services

1

Service Category Definition – Part A

4

Feasibility of a Pilot Project Using Ryan White Health Insurance

Funding to Assist Consumers Below 100% FPL with Purchasing

Health Insurance – RWPC, February 2015

7

Pilot Project Addendum: Impact of Co-Pay Assistance Programs

(CAPs) on Pilot Project Cost

18

Pilot Project Addendum: Cost of Care for Hepatitis C

19

Health Insurance Assistance Satellite Program – The Resource

Group, October 2014

20

Interim Guidance to Texas Administrative Agents on Health

Insurance Assistance Services – DSHS, December 2014

39

Houston EMA Health Insurance Assistance & Advance Premium

Tax Credit (APTC) Reconciliation – RWGA, March 2015

52

86% of Health Law Enrollees Receive Subsidies, White House

Says – NY Times, March 2015

54

Local Service Category:

Health Insurance Premium and Cost Sharing Assistance

Amount Available

:

To be determined

Budget Requirements or

Restrictions

(TRG

Only)

:

Contractor must spend no more than 20% of funds on disbursement

transactions. The remaining 80% of funds must be expended on the actual

cost of the payment(s) disbursed. ADAP dispensing fees are not allowable

under this service category.

Local Service Category

Definition:

Health Insurance Premium and Cost Sharing Assistance:

The Health

Insurance Premium and Cost Sharing Assistance service category is

intended to help HIV positive individuals continue medical care without

gaps in health insurance coverage or discretion of treatment. A program of

financial assistance for the payment of health insurance premiums and

co-pays, co-insurance and deductibles to enable eligible individuals with HIV

disease to utilize their existing third party or public assistance (e.g.

Medicare) medical insurance. Agency may provide help with client

co-payments, co-insurance, deductibles, and Medicare Part D premiums in

amounts up to $650.00 per month.

Co-Payment: A cost-sharing requirement that requires the insured to pay a

specific dollar amount for each unit of service.

Co-Insurance: A cost-sharing requirement that requires the insured to pay a

percentage of costs for covered services/prescription

Deductible: A cost-sharing requirement that requires the insured pay a

certain amount for health care or prescription, before the prescription drug

plan or other insurance begins to pay.

Premium: The amount paid by the insured to an insurance company to

obtain or maintain and insurance policy.

Target Population (age,

gender, geographic,

race, ethnicity, etc.):

All Ryan White eligible clients with 3

rd

party insurance coverage

(COBRA, private policies, Qualified Health Plans, CHIP, Medicaid, and

Medicare) within the Houston HSDA.

Services to be Provided:

Contractor may provide assistance with:

•

Insurance premiums up to the DSHS annual cap (HIV/STD Policy

260.002),

•

And deductibles, co-insurance and/or co-payments up to $650.00 per

month.

Service Unit Definition

(TRG Only)

:

A unit of service will consist of payment of health insurance premiums,

co-payments, co-insurance, deductible, or a combination.

Financial Eligibility:

At or below 500% of federal poverty guidelines.

Client Eligibility:

HIV positive resident of HSDA, and have insurance or be eligible to

purchase a Qualified Health Plan through the Marketplace.

Agency Requirements

(TRG Only)

:

Agency must:

•

Provide a comprehensive financial intake/application to determine

client eligibility for this program to insure that these funds are used as

a last resort in order for the client to utilize his/her existing insurance

or be eligible to purchase a qualified health plan through the

Marketplace.

•

Must comply with DSHS policy 206.002 including tracking of annual

caps. This policy states that, for Premium Assistance, an individual

cannot receive assistance greater than the annualized Texas Health

Insurance Risk Pool Monthly premium total. Please refer to the table

at

http://www.txhealthpool.org/rates.html

.

•

Clients will not be put on wait lists nor will Health Insurance Premium

and Cost Sharing Assistance services be postponed or denied due to

funding without notifying the Administrative Agency.

•

Conduct marketing in-services with Houston area HIV/AIDS service

providers to inform them of this program and how the client referral

and enrollment processes function.

•

Establish formal written agreements with all Houston HSDA Ryan

White-funded (Part A, B, C, D) primary care, mental health and

substance abuse provider agencies to enable clients of these agencies

to enroll in Health Insurance assistance at his/her primary care, mental

health or substance abuse provider site. (i.e. No need for client to

physically present to Health Insurance provider.)

•

Utilizes the RW Planning Council-approved prioritization of cost

sharing assistance when limited funds warrant it.

o

Priority Ranking of Requests (in descending order)

:



HIV medication co-pays and deductibles (medications on

the Texas ADAP formulary)



Non-HIV medication co-pays and deductibles



Co-payments for provider visits (eg. physician visit and/or

lab copayments)



Medicare Part D (Rx) premiums

•

Utilizes the RW Planning council –approved consumer

out-of-pocket methodology.

Special Requirements

(TRG Only)

:

Must comply with the Houston EMA/HSDA Standards of Care and,

pending the most current DSHS guidance, client must:

•

Purchase Silver Level Plan with formulary equivalency

•

Take advance premium credit

•

No assistance for Out of Network Out of Pocket expenses without

prior approval of the Administrative Agent.

Must comply with DSHS Interim Guidance.

Must comply with updated guidance from DSHS.

FY 2016 RWPC “How to Best Meet the Need” Decision Process

Step in Process:

Council

Date:

06/11/2015

Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______

If approved with changes list

changes below:

1.

2.

3.

Step in Process:

Steering Committee

Date:

06/07/2015

Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______

If approved with changes list

changes below:

1.

2.

3.

Step in Process:

Quality Assurance Committee

Date:

05/21/2015

Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______

If approved with changes list

changes below:

1.

2.

3.

Step in Process:

HTBMTN Workgroup #2

Date:

04/14/2015

Recommendations:

_{Financial Eligibility:}

1.

2.

3.

FY 2015 Houston EMA/HSDA Ryan White Part A/MAI Service Definition

Health Insurance Co-Payments and Co-Insurance Assistance

(Revision Date: 03/27/15)

HRSA Service Category

Title:

Health Insurance Premium and Cost Sharing Assistance

Local Service Category

Title:

Health Insurance Co-Payments and Co-Insurance

Budget Type

:

Hybrid Fee for Service

Budget Requirements or

Restrictions:

Agency must spend no more than 20% of funds on disbursement

transactions. The remaining 80% of funds must be expended on the

actual cost of the payment(s) disbursed.

HRSA Service Category

Definition

:

Health Insurance Premium & Cost Sharing Assistance

is the

provision of financial assistance for eligible individuals living with

HIV to maintain a continuity of health insurance or to receive

medical benefits under a health insurance program. This includes

premium payments, risk pools, co-payments, and deductibles.

Local Service Category

Definition:

A program of financial assistance for the payment of health

insurance premiums, deductibles, co-insurance and co-payments to

enable eligible individuals with HIV disease to utilize their existing

third party or public assistance (e.g. Medicare) medical insurance.

Agency may provide help with client premium, payments,

co-insurance and deductibles in amounts up to $650.00 per month.

Co-Payment: A cost-sharing requirement that requires the insured to

pay a specific dollar amount for each unit of service.

Co-Insurance: A cost-sharing requirement that requires the insured

to pay a percentage of costs for covered services/prescription

Deductible: A cost-sharing requirement that requires the insured to

pay a certain amount for health care or prescription, before the

prescription drug plan or other insurance begins to pay.

Premium: The amount paid by the insured to an insurance company

to obtain or maintain and insurance policy.

Target Population (age,

gender, geographic, race,

ethnicity, etc.):

All Ryan White eligible clients with 3

rd

party insurance coverage

(COBRA, private policies, Qualified Health Plans, CHIP, Medicaid

and Medicare) within the Houston EMA.

Services to be Provided:

Provision of financial assistance with co-payments, co-insurance

and deductibles up to $650.00 per month per client.

Service Unit Definition(s):

(RWGA only)

1 unit of service = A payment of a premium, co-payment or

deductible for an HIV-infected person with insurance coverage.

Financial Eligibility:

Refer to the RWPC’s approved

Financial Eligibility for Houston

EMA Services

.

Client Eligibility:

HIV-infected individuals residing in the Houston EMA meeting

financial eligibility requirements and have insurance or be eligible to

purchase a Qualified Health Plan through the Marketplace.

Agency Requirements:

Agency must:

•

Currently administer a HIV/AIDS insurance assistance

program utilizing Ryan White Program funding in the Houston

EMA/HSDA.

•

Provide a comprehensive financial intake/application to

determine client eligibility for this program to insure that these

funds are used as a last resort in order for the client to utilize

his/her existing insurance or be eligible to purchase a qualified

health plan through the Marketplace.

•

Ensure that assistance provided to clients does not duplicate

services already being provided through Ryan White Part B or

State Services. The process for ensuring this requirement must

be fully documented.

•

Have mechanisms to vigorously pursue any excess premium

tax credit a client receives from the IRS upon submission of

the client’s tax return for those clients that receive financial

assistance for eligible out of pocket costs associated with the

purchase and use of Qualified Health Plans obtained through

the Marketplace.

•

Conduct marketing with Houston area HIV/AIDS service

providers to inform such entities of this program and how the

client referral and enrollment processes function. Marketing

efforts must be documented and are subject to review by

RWGA.

•

Clients will not be put on wait lists nor will Health Insurance

Premium and Cost Sharing Assistance services be postponed

or denied without notifying the Administrative Agency.

•

Establish formal written agreements with all Houston HSDA

Ryan White-funded (Part A, B, C, D) primary care, mental

health and substance abuse provider agencies to enable clients

of these agencies to enroll in Health Insurance assistance at

his/her primary care, mental health or substance abuse provider

site. (i.e. No need for client to physically present to Health

Insurance provider.)

•

Utilize RWGA approved prioritization of cost sharing

assistance, when limited funds warrant it.

•

Utilize consumer out-of-pocket methodology approved by

RWGA.

Staff Requirements:

None

Special Requirements:

Agency must:

•

Comply with the Houston EMA/HSDA Standards of Care

FY 2016 RWPC “How to Best Meet the Need” Decision Process

Step in Process:

Council

Date:

06/11/2015

Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______

If approved with changes list

changes below:

1.

2.

3.

Step in Process:

Steering Committee

Date:

06/07/2015

Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______

If approved with changes list

changes below:

1.

2.

3.

Step in Process:

Quality Assurance Committee

Date:

05/21/2015

Recommendations: Approved: Y:_____ No: ______

Approved With Changes:______

If approved with changes list

changes below:

1.

2.

3.

Step in Process:

HTBMTN Workgroup

Date:

04/14/2015

Recommendations:

_{Financial Eligibility:}

1.

2.

3.

Approved

Feasibility of a Pilot Project Using Ryan White

Health Insurance Funding to Assist Consumers

Below 100% FPL with Purchasing Health

Insurance

A Special Study of the Houston Area Ryan White Planning Council

Approved February 12, 2015

Approved

Acknowledgments

The Houston Area HIV Services Ryan White Planning Council would like to thank the following individuals and agencies for their contribution to this Special Study.

Comprehensive HIV Planning Committee Members

Ted Artiaga

Patient Navigator, Legacy Community Health Services Curtis Bellard

Former Security Operations Manager, Omni Hotels David Benson

Director of Programs & Special Programs, Harris County Precinct One

Evelio Salinas Escamilla

Research Administrator University of Houston School of Social Work; and Co-Chair, Comprehensive HIV Planning Committee

Herman Finley

Health Education Risk Reduction Coordinator, St. Hope Foundation, Inc.; and Vice-Chair, Houston Area HIV Services Ryan White Planning Council

Morenike Giwa

Founder, Advocacy without Borders Tam Kiehnhoff

Former Case Management Coordinator, Triangle Area Network

John Lazo

Producer, Standing Room Only Productions Osaro Mgbere, PhD

Epidemiologist, Houston Department of Health and Human Services

Nancy Miertschin

HIV Projects Manager, Thomas Street Health Center; and Co-Chair, Comprehensive HIV Planning Committee Allen Murray

External Member, Comprehensive HIV Planning Committee

Shital Patel, MD

Assistant Professor, Baylor College of Medicine L. Bunny Woods

Counseling, Testing, and Referral Coordinator, St. Hope Foundation

Amana Turner

Program Coordinator, Change Happens Staff

Ryan White Planning Council Office of Support Tori Williams Amber Alvarez Diane Beck Georgette L. Monaghan Key Informants Katy Caldwell

Executive Director, Legacy Community Health Services Orlando Dawson

Nurse, St. Hope Foundation Joseph Fuentes, Jr.

CEO, Houston Area Community Services, Inc. Melisa Garcia

Vice President of Clinical Business Services, Legacy Community Health Services

Sandra Longoria

Director of Financial Services, Legacy Community Health Services

Kenneth Malone

HIV Project Analyst, HIV Services Administration, Thomas Street Health Center

Jack Parker

Vice President of Pharmacy Operations, Legacy Community Health Services

Ann Robbins, PhD

Senior Public Health Advisor, TB/ HIV/STD Unit, Texas Department of State Health Services

Shannon Schrader, MD

Concierge Physician, MDVIP; and Volunteer Physician, Legacy Community Health Services

Janina Vazquez

Manager, HIV Care Services Group, Texas Department of State Health Services

Funding acknowledgment:

The development of this document was made possible by funding from the Ryan White

HIV/AIDS Treatment Extension Act of 2009.

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Page 3 of 11

Background

The Houston Area Ryan White Planning Council (RWPC) is a volunteer planning group

comprised of 38 appointed community members charged with planning, designing, and

allocating funding for HIV medical care and support services for people living with HIV/AIDS in

the six-county Houston Eligible Metropolitan Area (EMA). To inform these processes, the RWPC

conducts a community needs assessment every three years that measures and describes the HIV

medical care and support service needs of the local HIV-positive community. In addition to

capturing data related to service needs and barriers, the 2014 Houston Area HIV/AIDS Needs

Assessment serves as a tool to evaluate consumer knowledge about services, engagement along

the HIV Care Continuum (including a profile of those with unmet need), and co-occurring

medical conditions and social determinants of health.

The RWPC’s Comprehensive HIV Planning Committee commissions Special Studies to

complement and contextualize the wealth of information gathered through the community

needs assessment process, and to bridge the gap in data between community needs

assessments. Past Special Studies have examined service needs among special demographic

populations such as people living with HIV/AIDS in the Houston EMA who are

transgender/gender non-conforming, youth, or incarcerated/recently released. Following the

first Affordable Care Act Health Insurance Marketplace Open Enrollment period, the

Comprehensive HIV Planning Committee directed the RWPC Office of Support to conduct two

Special Studies in 2014 pertaining to health insurance. This report details the key findings from

the Special Study “Feasibility of a Pilot Project Using Ryan White Health Insurance Funding to

Assist Consumers Below 100% FPL with Purchasing Health Insurance.”

Introduction

The Patient Protection and Affordable Care Act (ACA) brought about extensive changes for

uninsured and under-insured people living with HIV/AIDS (PLWHA). Guaranteed issue prevented

insurers from denying coverage for people with a pre-existing condition like HIV. Community

rating prohibited insurers from charging people with pre-existing conditions more for health

coverage. The ACA also eliminated lifetime and annual coverage limits on essential health

benefits. More recent changes like the Health Insurance Marketplace and Medicaid expansion

have altered the PLWHA in many states access health care.

State health insurance exchanges and the federal Health Insurance Marketplace provide

locations for people to shop for qualified health plans (QHPs) that meet their needs and budgets.

People with annual incomes between 100% and 400% of the Federal Poverty Level (FPL) who

have no existing coverage can qualify for an advance premium tax credit (subsidy) to help cover

their monthly insurance premium payments. In states that have chosen to expand their Medicaid

programs, people with annual incomes at 133% and below are now eligible to apply for Medicaid

coverage. However, in states that have not expanded their Medicaid programs, uninsured

individuals with incomes too low to qualify for subsidies to purchase Health Insurance

Marketplace QHPs and who do not meet other eligibility requirements for Medicaid have limited

options for obtaining health coverage. In Texas, an estimated 948,000 individuals (including

PLWHA) fall into this Medicaid coverage gap, and Ryan White programs throughout the state

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often provide care and support services to PLWHA in the Medicaid coverage gap as the payer of

last resort.

1

Between March 2013 and February 2014, nearly 70% of Ryan White consumers in the

Houston Area had annual incomes below 100% FPL.

2

Of these consumers, only 32% had health

coverage. This means that 5,562 local Ryan White consumers (48% of all local Ryan White

consumers) were uninsured, and not eligible for a Health Insurance Marketplace subsidy due to

low income. In addition to relying on Ryan White funded care and support services to treat their

HIV, these consumers have limited access to medical care for other co-occurring conditions.

Amid questions of whether the Texas HIV Medication Program (THMP), the AIDS Drug Assistance

Program (ADAP) for the state of Texas, would offer reimbursement to local programs for

purchasing QHPs for uninsured consumers below 100% FPL, this Special Study was

commissioned to evaluate whether a pilot project to purchase Health Insurance Marketplace

QHPs and cover cost-sharing expenses such as co-pays, co-insurance and deductibles for 100

uninsured consumers below 100% FPL for one year would be feasible and cost-effective.

Methodology

Unlike past studies, this Special Study did not include client-level data collection. The

feasibility of the proposed pilot project was evaluated using a brief literature review,

semi-structured key informant interviews with 10 stakeholders conducted in October 2014, and cost

analyses using unsubsidized 2015 Marketplace Silver plans accessed through the federal Health

Insurance Marketplace website to populate a feasibility framework.

3

The TELOS feasibility

framework was used to develop key informant interview questions, and to categorize findings

into specific domains. The acronym TELOS describes Technical/Technological, Economic, Legal,

Operational, and Schedule considerations for project feasibility. To determine likelihood that the

proposed pilot project will result in cost-neutrality or cost-savings, greater emphasis has been

placed on assessing economic feasibility.

Limitations

In general, feasibility studies are not intended to determine whether a particular program or

project should be implemented, or forecast program or project outputs and outcomes. The

function of feasibility studies is to inform the decision-making and planning processes through

describing the components that must be present to initiate and complete a proposed program

or project. As such, this Special Study is only one of many tools to be used in determining

whether and how the proposed pilot project should be implemented.

Though the cost analyses presented in this report were conducted across four distinct QHPs,

the cost variability between plans and consumers is another limitation of this Study. For

example, premium and cost-sharing assistance within the same QHP can vary greatly depending

on the formulary tiers of the consumer’s medications. The actual cost of the pilot could vary

considerably, which accounts for the wide cumulative estimated cost range for the pilot

provided in the findings of this report.

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Finally, the impact of ADAP was not included in the calculations of the local Ryan White

program costs for covered service categories, the estimated cost of the pilot per consumer, and

for the project as a whole. In the event that ADAP offers reimbursement to local programs for

premium and cost-sharing assistance for unsubsidized Health Insurance Marketplace QHPs

future, the total cost of the pilot project would be substantially reduced. At the time of this

report was created, ADAP has not offered reimbursement to local programs for premium and

cost-sharing assistance for Health Insurance Marketplace QHPs.

Findings

Technical/Technological Feasibility

No technical/technological barriers to pilot project implementation were found in the Study.

A benefit to the current activities of Ryan White-funded providers to assist subsidy-eligible

consumers with purchasing and sustaining health insurance is that no additional

technical/technological infrastructure or resources would be required to implement the

proposed pilot project. Computers with reliable internet access and phone lines are already

available and used to assist consumers with the enrollment process. Moreover, current software

used for billing and statement processing can be applied to premium and cost-sharing assistance

for consumers with unsubsidized Health Insurance Marketplace QHPs.

Economic Feasibility

Many factors were considered in evaluating the economic feasibility of the pilot project,

including current costs to the local Ryan White program for covered services, premium and

cost-sharing assistance estimates for individual participants across a variety of QHPs, estimated

cumulative premium and cost-sharing assistance for the pilot, considerations for funding the

administrative processes of the pilot project, and project sustainability.

Under the ACA, all Health Insurance Marketplace QHPs must provide coverage for essential

health benefits, which include “ambulatory patient services; emergency services; hospitalization;

maternity and newborn care; mental health and substance use disorder services, including

behavioral health treatment; prescription drugs; rehabilitative and habilitative services and

devices; laboratory services; preventive and wellness services and chronic disease management;

and pediatric services, including oral and vision care.”

4

To evaluate the potential for

cost-neutrality or cost-savings as a result of the pilot project, the average cost per unduplicated client

(UDC) for covered services in the local Ryan White program were calculated in Table 1. These

costs include services funded under Ryan White Parts A and B, MAI, and State Services, and

exclude ADAP (See Limitations).

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Table 1: Ryan White Program Average Costs per UDC by Covered Service Category in 20132

Primary Care $1,176

Local Pharmacy Assistance Program (LPAP) $722 Medical Nutrition Therapy (supplements) $582 Mental Health Therapy and Counseling $803 Substance Abuse Treatment (outpatient) $2,179

Total average cost per UDC for all covered services $5,462

The total average cost per UDC to the local Ryan White program in 2013 for services that would

be covered as essential health benefits under Health Insurance Marketplace QHPs was $5,462. It

is important to note that actual cost and service utilization for individual consumers varied in

relation to the needs of the consumer.

Two key informants interviewed for this Study estimated the total premium and cost-sharing

assistance for a consumer below 100% FPL to range between $10,000 and $11,000 annually for

unsubsidized 2014 Health Insurance Marketplace QHPs. To assess estimated costs using 2015

QHPs available locally, cost analyses were conducted for four unsubsidized QHPs available in the

Houston area. According to the Texas Department of State Health Services, the greatest

proportion of PLWHA in the Houston EMA in 2013 were male and between the ages of 45 and

54, and it is estimated that between 50% and 70% of PLWHA smoke.

5, 6

For these reasons,

premium and cost-sharing assistance estimates for the QHPs evaluated in this Study were

calculated using cases in which the pilot participant was a 54 year-old male smoker who required

either a low tier or a high tier medication. Unsubsidized Health Insurance Marketplace QHPs

compared in this Study were categorized as High/Low Premium and High/Low Medication

Co-Pay or Co-insurance. (For the full comparison of unsubsidized Health Insurance Marketplace

QHPs evaluated in this Study, see Appendix.)

The total annual premium and cost-sharing assistance amount per participant was calculated

for: 12 months of premium payments, four infectious disease specialist visits, 4 lab tests, and 12

months of medications. Comparisons were also made for high and low tier medications

according to each plan’s formulary. Excluding multiple medications and non-HIV related care,

the estimated total annual premium and cost-sharing amount per participant ranged between

$6,636 and $15,134. Health Insurance Marketplace health maintenance organization (HMO)

QHPs tended to have lower premiums and lower total annual costs, even for cases in which the

participant required a higher tier medication. The formularies for these QHPs listed most

commonly prescribed antiretroviral (ARV) medications, including single-tab regimens, as mid-tier

or low tier. However, the HMO QHPs examined greatly restricted the number of in-network

infectious disease specialists that would be accessible to the pilot participants. For example,

participants receiving assistance with purchasing the lower cost HMO QHPs would not be able to

access providers through Harris Health System, including providers at Thomas Street Health

Center.

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Plans with higher premiums with both low and high medication co-pays/co-insurance were

also examined. These QHPS tended to be preferred provider organization (PPO) plans, which

would allow the pilot participant to access a larger network of infectious disease specialists.

However, the PPO plans examined also had much higher premium payments, and one listed

most commonly prescribed ARV medications as specialty tier, which require a very high

co-insurance of 40%. The PPO QHP with the highest premium examined also had the lowest

out-of-pocket limit, which included the prescription drug out-of-out-of-pocket limit.

Based on the estimated total annual premium and cost-sharing assistance cost per

participant, the cumulative estimated cost for the pilot to provide premium and cost-sharing

assistance to 100 consumers by purchasing and sustaining unsubsidized Health Insurance

Marketplace QHPs could range between $663,600 and $1,513,400 for one year. Excluding

ADAP, the cumulative cost to the local Ryan White program to provide similar services covered

under the plans would be $546,200 or lower, depending on service utilization. It is important to

note that participants with unsubsidized Health Insurance Marketplace QHPs could access care

for medical concerns beyond HIV care. Considering the cost of uncompensated care and

avoidable hospitalization, there may be cost-neutrality or cost-savings outside the local Ryan

White program for pilot participants. Further study is necessary to determine whether local

partnerships with facilities that would benefit from reduced uncompensated care and avoidable

hospitalization costs, including partnerships with facilities receiving funding through the 1115

Waiver Texas Healthcare Transformation and Quality Improvement Program, would result in

lower costs for the pilot project through cost-sharing.

In addition to the estimated cumulative annual premium and cost-sharing assistance cost for

the pilot project, funding for administrative processes may be required. In the event that the

pilot is scheduled to begin during an Open Enrollment period, additional personnel may be

required to assist the 100 pilot participants with Health Insurance Marketplace enrollment.

Funding for personnel to communicate with participants, process statements, and issue

payments would also be needed to carry out the pilot project may be difficult to obtain, as

restrictions may prevent the use of Ryan White funds for “any administrative costs outside of the

premium payment of the health plans.”

7

The final consideration for economic feasibility is project sustainability. The function of the

proposed pilot project is to determine whether providing premium and cost-sharing assistance

for unsubsidized Health Insurance Marketplace plans to consumers below 100% FPL provides

enough cost-neutrality or cost-savings and benefit to the consumers to warrant program-wide

implementation. Should the outcomes of the pilot project indicate that program-wide

implementation is not beneficial, pilot participants would experience a loss of health coverage at

the conclusion of the project (see Legal Feasibility). If project outcomes indicate program-wide

implementation would be beneficial, the present level of funding is unlikely to accommodate

premium and cost-sharing assistance to the over 5,500 local consumers who potentially fall in

the “Medicaid gap”.

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Legal Feasibility

The Study found no legal or policy barriers to implementation of the pilot project. Policy

guidance from Health Resource Service Administration’s (HRSA) HIV/AIDS Bureau (HAB) supports

the use of Ryan White funding for premium and cost-sharing assistance for individuals who are

ineligible for subsidy when doing so would be cost-effective. According to a HAB Policy

Clarification Notice released in 2013 and revised in 2014:

If resources are available, [Ryan White HIV/AIDS Program (RWHAP)] grantees and

subgrantees are strongly encouraged to use RWHAP funds for premium and cost-sharing

assistance for [clients not eligible for premium tax credits and cost-sharing reductions in a

Health Insurance Marketplace] when it is cost-effective, as appropriate. The grantee and

subgrantee must ensure that use of RWHAP funds for premium and cost-sharing

assistance for these clients is cost-effective.

7

Though there are no legal or policy barriers to implementation of the pilot project, consideration

must be made to ensure informed consent is obtained from participants before acceptance into

the pilot. In the event that the pilot project is not cost-effective, pilot participants would lose

health coverage at the conclusion of the project. While this may have a minimal impact for

participants’ HIV care among participants that retain their providers when beginning their Health

Insurance Marketplace QHPs, loss of coverage may present a substantial barrier to accessing

providers for non-HIV related medical conditions.

Operational Feasibility

Certified Application Counselors at Ryan White funded sites currently assist subsidy-eligible

consumers with enrollment in the Health Insurance Marketplace. While the process of assisting

100 consumers below 100% FPL with enrollment would not differ from the current method, an

additional Certified Application Counselor could be required to assist with enrollment if the pilot

project takes place during an Open Enrollment period (see Schedule Feasibility).

Additional administrative needs for premium and cost-sharing assistance processing may present

a challenge to implementing the pilot project. Personnel would be needed for communication

with pilot participants, receiving and processing statements, and issuing payments to insurers.

One key informant that currently issues premium payments to insurers noted that the current

process entails issuing individual payments for each consumer because most insurers will not

accept mass third-party payments. Funding may not be available to provide additional

administrative personnel (see Economic Feasibility).

Schedule Feasibility

While this Study yielded no barriers to schedule feasibility, there were certain aspects of

scheduling the pilot project’s implementation and funding that require consideration. As

purchase of Health Insurance Marketplace QHPs can only occur during an Open Enrollment

period, the pilot project would need to be scheduled to begin during an Open Enrollment period,

or be limited to consumers with life-changing events that qualify the participants for a Special

Enrollment Period, such as loss of health coverage, marriage or divorce, birth or adoption, a

Approved

Page 9 of 11

death in the household, change in income, moving outside the current plan’s coverage area,

gaining citizenship, or release from incarceration. If the pilot is scheduled to begin during an

Open Enrollment period, funding for the project could span multiple fiscal years, and the earliest

opportunity to begin the pilot project would be the Health Insurance Marketplace Open

Enrollment period for coverage beginning in 2016. The pilot would also require sufficient

funding to cover high deductible cost-sharing assistance during the first quarter of the calendar

year.

Alternate Pilot Project

Though barriers to technical/technological, legal, operational, and schedule feasibility

discovered in the course of this Study are minimal, substantial barriers to the economic

feasibility of the pilot project may prevent implementation of the pilot project unless some

amount of cost-sharing is obtained through a partnership or ADAP reimbursement. However, an

unanticipated finding of this Study is that purchasing add-on dental plans for consumers already

enrolled in subsidized Health Insurance Marketplace QHPs may result in cost-savings for the local

Ryan White program in Oral Health services, clear system capacity, and expand consumer

accessibility to a larger network of dental providers.

In 2013, the local Ryan White program average cost per UDC for Oral Health services was

$604. A query of subsidized Health Insurance Marketplace plans for a 54 year-old male who

smokes yielded 30 available add-on dental plans with monthly premiums ranging from $9 to $51.

A brief cost analysis was conducted for a high coverage dental HMO with a $15 monthly

premium.

Plan: Alpha Dental Individual & Family DeltaCare® USA Preferred Plan for Families Dental HMO

Monthly Premium: $15 x 12 payments $180

Deductible: $0

Out of Pocket Maximum: None for adults age 19 and over

2 annual cleanings ($5 Office Visit Co-Pay; $5 Prophylaxis (Cleaning) Co-Pay): $10 x 2 cleanings  $20

Annual X-rays ($5 Panoramic X-ray (Every 2-5 Years); No Cost for Bitewing X-rays): $5 x 1 X-ray  $5

3 Amalgam Fillings: $25/1 Surface; $30/2 Surface; $40/3 Surface x 3 Fillings + $5 Office Visit  $80-$125

1 Extraction ($18): $18 + $5 Office Visit $23

Total Cost: $308 -$353

Though the proposed alternate pilot project would not address access to health coverage for

consumers in the “Medicaid gap”, purchasing add-on dental plans for consumers enrolled in

subsidized Health Insurance Marketplace QHPs could provide cost-savings and added benefits

for consumers. Further study is needed to develop a more detailed estimate of potential

cost-savings, identify plans that cover commonly utilized dental services within the Oral Health

service category and have Ryan White-funded providers in-network , and assess whether

providers in the community that are not funded through the local Ryan White program could

adequately address the unique dental care needs of PLWHA.

Approved

Page 10 of 11

References

1.

Garfield, R et al., “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand

Medicaid – An Update”, The Henry J. Kaiser Family Foundation, (November 12, 2014)

http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/

2.

Ryan White Grant Administration and The HIV Resource Group, “FY15 How to Best Meet the

Need Service Utilization Presentation”, (Presented April 7, 2014)

3.

http://www.healthcare.gov/see-plans

4.

https://www.healthcare.gov/glossary/essential-health-benefits/

5.

Texas Department of State Health Services HIV/STD Prevention and Care Branch, Planning

and Program Evaluation Group Data Team, “HIV Prevalence 2004-2013”, (Received July 31,

2014)

6.

U.S. Department of Health and Human Services, Health Resources and Services

Administration, Guide for HIV/AIDS Clinical Care – 2014 Edition. Rockville, MD: U.S.

Department of Health and Human Services, (2014)

http://hab.hrsa.gov/deliverhivaidscare/2014guide.pdf

7.

HRSA/HAB, “Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for

Premium and Cost-Sharing Assistance for Private Health Insurance Policy Clarification Notice

(PCN) #13-05”, (Revised June 6, 2014)

Approved

_{Page 11 of 11}

* Annual Out of Pocket Maximum

Appendix

Annual To

tal Pre

m

iu

m

an

d Cos

t-S

haring Assistance Estimate

Pl an 1: M o lin a M arketp lace · M o lin a Ma rk etplace Silv er 250 Plan HMO Low premi u m, high m ed icatio n co-pay /co-insuran ce

Plan 2: Blue Cross and Blue Sh

ield of Te xas · Blu e A d van tage Silver H M O ℠ 004 Low pr emi u m, low m ed ica tio n co-p ay/ co-i ns ur an ce Plan 3: Cigna Healthcare · my Cigna Copay Assur e S ilver Plan

High premium, high

medic ation co-pay /co-insuran ce Plan 4: Assur an t Health · Assurant Health Silve r Plan 001 High p rem ium, low medic atio n co-pay /co-insuran ce Month ly Pr emi um: $4 53 x 12 pay m ents  $5,436 Month ly Pr emi um: $5 75 x 12 pay m ents  $6,900 Month ly Pr emi um: $7 32 x 12 pay m ents  $8,784 Month ly Pr emi um: $8 66 x 12 pay m ents  $10,392 Deduc tib le: $0 Deduc tib le: $3,000 Deduc tib le: $0 Deduc tib le: $3,500 OOP * Maximum: $6,600 OOP * Maximum: $6,350 OOP * Maximum: $6,350 OOP * Maximum: $3,500 4 ID Sp eci ali st Co-Pay s: $7 5 x 4 vis its  $300 4 ID Sp eci ali st Co-Pay s: $5 0 x 4 vis its  $200 4 ID Sp eci ali st Co-Pay s: $7 5 x 4 vis its  $300 4 ID Sp eci ali st Co-Pay s: N/A 4 La b Co-Pay s ($ 30 ): $3 0 x 4 la bs  $120 4 L ab Co-Ins ur anc e ( 2 0% ): $2 00 x 4 lab s at 20%  $160 4 L ab Co-Insuranc e ( 40% ): $2 00 x 4 lab s at 40%  $320 4 L ab Co-Pa ys: N/A

Low Tier Medication (Atri

p la) ( $ 65): $6 5 x 1 2 mo nt hs  $780 High Tie r Medication: (Intelence )( 40%): $1, 02 0 x 1 2 months at 40%  $4,896

Low Tier Medication (St

ribi ld) ($50): $5 0 x 1 2 mo nt hs  $600 High Tie r Medication (Fuzeo n)($150) : $1 50 x 12 months  $1,800

Low Tier Medication ($25):

N/A High Tie r Medication (Atri p la)(40%) : $1, 80 0 x 1 2 months at 50% $8,640 Low Tier Medication:

N/A High Tie r Medication: N/A Total Cost: $6,636 Total Cost: $10,752 Total Cost: $7,860 Total Cost: $9,060 Total Cost: N/A Total Cost: $15,134 Total Cost: $13,892 Total Cost: $13,892 Not es: P re scr ip tion dr ug OOP maxim u m included in OOP maximum; limit ed provi d er n et w ork wit h HMO (ex: p art icip an t wou ld not be abl e to se e a p rov id er at Thom as St re et Health C

enter); most comm

o n ly pre scr ibed ARV s ar e mid-tier or lowe r Presc rip tion d rug OOP m axi m u m included in OO P maximum; limited provider network with HMO (ex: partici p ant wo uld not be abl e to see a provider at Thomas St re et H eal th Cent er) ; mo st commonl y prescri b ed

ARVs are mid-tier or lo

wer Presc rip tion d rug OOP m axi m u m included in OO P maximum; all commonl y prescri b ed A RVs speci alt y tier m edicat ions according to plan formu lary No c h arge on medications, PCP/ Sp eci ali st visits , o r l ab s af ter d edu ct ib le is me t; p res cr ip ti on dr u g OOP maximum incl ud ed in O O P maxim u m; formulary covers most ARVs. Page 17 of 59

J:\Committees\Comprehensive HIV Planning\old files\2014 Files\2014

Special Studies\Addendum - Impa

ct of CAPs - 02-13-15.docx Adden dum: Im pact of Co-P ay Assistance Programs (CAPs)

on Pilot Project Cost

Plan 1: Molina Ma rk etplace · M o lin a M arket p lace Silver 25 0 Pl an HMO Low premi u m, high medicat ion co-p ay/co-insuranc e

Plan 2: Blue Cross and Blue Shield

of T exas · Blu e Advantage Silv er HMO ℠ 00 4 Low pr emi um, low medicat ion co-p ay/ co-insuranc e

Plan 3: Cigna Healthcare · myCigna

Copay

Assure Silve

r

Pl

an

High premium, high medicat

ion co-p ay/co-insuranc e Plan 4: Assur an t Health · As sur ant Health Silver Plan 001 High p rem ium, low medicat ion co-p ay/co-insuranc e

Total Cost with

out CAP s: $6,636 - $10,752 $7,860-$9,060 $15,134 $13,892

Total Cost with

CAPs: $5,856-$6,030 $7,260-$8,460 All HI V m edi cat ions are sp eci alty ti er ( 40% co-insuranc e). Th ough unli kely , CAP s cou ld br in g t h e an n u al cost as lo w as $6,494. No c h ar ge for medi cat ion once $3,500 d edu ctib le is met, w h ich co uld bring t h e ann ua l co st as lo w as $10,392 with CAP s. Plan do es not co ve r: Tybo st; E d u ra n t; Combivi r; Ret rovir; Tivic ay; T ri u meq N/A Tybo st; Combi vir; T ivica y; Tri zivir; T riu meq; Ziag en Tri zivir; T riu meq; Ziag en Plan P ros: Mos t commonly pr es cr ib ed HI V me di ca ti on s a re mi d -ti er or lo wer Mos t commonly pr es cr ib ed HI V me di ca ti on s a re mi d -ti er or lo wer N/A No c h arge on medications, PCP/ Sp eci ali st visits , o r l ab s af te r de d uct ible is me t; formu la ry cov ers most commonl y prescri b ed HI V medications Plan Con s: Limit ed provi d er n etwo rk with HMO ( ex: partici p ant woul d n o t b e able to see a

provider at Thomas Street He

alth C enter) Limit ed provi d er n etwo rk with HMO ( ex: partici p ant woul d n o t b e able to see a

provider at Thomas Street He

alth C enter) All commo nl y presc rib ed HI V medi cat ion s ar e sp ecia lty ti er medicat ions ac cording to plan formu lary High prem ium

may make plan

J: \C o m m it te es \C o m p rehen siv e H IV P lan n in g\ o ld files \2 01 4 Fil es \2 0 1 4 Sp ecial S tud ies \2 0 1 4 F easib ility \Ad d en d u m H ep C Co st o f Car e - 3 -16 -1 5 .d o cx Ad d end u m : C o st o f Care f o r Hep atitis C Pl an 1 : M ol in a M ar ket pl ac e · M ol ina M ar ke tpl ac e Si lv er 2 50 Pl an HM O Low pr em ium , hi gh m e di cat io n co -pa y/c o -ins uran ce Pl an 2 : B lu e Cr o ss a nd Bl u e Shi el d of T ex as · Bl u e A dv an tag e S ilv er HM O ℠ 0 04 Low pr em ium , lo w m edi cat ion co -pa y/ co -ins uran ce Pl an 3 : C ig na H eal thc ar e · m yC ig na C op ay A ssu re Si lv er Pl an H igh pr em ium, h igh m ed ic at io n co -pa y/c o -ins uran ce Pl an 4 : A ss ur an t H eal th · A ssu ran t H eal th S ilv er Pl an 0 01 H igh pr em ium, low m e di cat io n co -pa y/c o -ins uran ce D edu ct ibl e: $0 D edu ct ibl e: $3, 000 D edu ct ibl e: $0 D edu ct ibl e: $3, 500 OOP * Maxi m um: $6, 60 0 OOP * Maxi m um: $6, 35 0 OOP * Maxi m um: $6, 35 0 OOP * Maxi m um: $3, 50 0 To ta l C os t of HI V C ar e wi th ou t C A Ps ** : $6, 63 6 $ 10, 75 2 $7, 86 0 - $9, 06 0 $ 15, 134 $ 13, 892 To ta l C os t of HI V C ar e wi th C A Ps : $5, 85 6 -$ 6, 030 $7, 26 0 -$ 8, 460 A ll H IV m edi cat io ns ar e spe ci al ty ti er ( 40% co -ins uran ce). Th o ugh un lik el y, C A Ps co ul d br ing th e an nu al co st as low a s $6, 49 4 , dep en di ng on m edi ca ti on . No ch ar ge for m edi cat ion on ce $3, 50 0 ded uc ti bl e is m et , w hi ch c ou ld br ing t he an nu al co st as low as $ 10, 39 2 wi th C A Ps . Regi m en s C over ed U nd er Pl an F orm ul ar y? H ar von i – S pec ial ty ( 40% C o -I n s. ) Sovald i – S pec ial ty ( 40% C o -I n s. ) Ri ba vi ri n – Spe ci al ty ( 40% C o -I ns .) Pegi n ter fer on a lfa – S pe ci al ty (40% Co -I n s. ) H ar von S pec ial ty ( $150 C o -P ay ) Sovald i – S pec ial ty ( $1 50 C o -P ay ) Ri ba vi ri n – Spe ci al ty ( $150 C o -Pa y) Pegi n ter fer on a lfa – Spe ci al ty ($150 C o -Pa y) H ar von i – S pec ial ty ( 40% C o -I n s. ) Sovald i – S pec ial ty (40% C o -I n s. ) Ri ba vi ri n – N on -pref er red Gen er ic ( $25 Co -Pa y) Pegi n ter fer on a lfa – S pe ci al ty (40% Co -I n s. ) Sovald i – C over ed 100% after ded u ct ibl e Ri ba vi ri n – C over ed 10 0% afte r deduc ti b le Pegi n ter fer on a lfa – C over ed 1 00% after ded u ct ibl e Wi th o u t h ep C CA Ps Wi th h ep C CAP s Wi th o u t h ep C CAPs Wi th h ep C CAP s Wi th o u t h ep C CAPs Wi th h ep C CAP S: W it ho ut hep C C A Ps W it h hep C C A Ps C os t f or Gen ot ype s 1, 4, & 6 $1, 28 4 -$ 5, 4 00 to me et OOP Ma x. $ 15 $ 600 $20 $0 (OOP Ma x. m et th ro u gh H IV m ed .) $0 (OOP Ma x. m et th ro u gh H IV m ed .) N /A N /A C os t f or Gen ot ype 2 $ 1 ,28 4 -$ 5, 4 00 to me et OOP Ma x. $ 154 $1, 20 0 $475 $0 (OOP Ma x. m et th ro u gh H IV m ed .) $0 (OOP Ma x. m et th ro u gh H IV m ed .) N /A N /A C os t f or Gen ot ype 3 $ 1 ,28 4 -$ 5, 4 00 to me et OOP Ma x. $1, 28 4 -$ 5, 4 00 to m e et OOP Ma x. $2, 40 0 $1, 09 5 $0 (OOP Ma x. m et th ro u gh H IV m ed .) $0 (OOP Ma x. m et th ro u gh H IV m ed .) N /A N /A C os t f or Gen ot ype 5 $ 1 ,28 4 -$ 5, 4 00 to me et OOP Ma x. $1114 $1, 80 0 $620 $0 (OOP Ma x. m et th ro u gh H IV m ed .) $0 (OOP Ma x. m et th ro u gh H IV m ed .) N /A N /A D edu ct ibl e / O O P* m e t throug h H IV m eds ? Yes / No Yes / No Yes / Yes Yes / Ye s Co m b in atio n therap y re gi m ens : G en o ty p es 1 , 4, 6: 1 2 we eks 1. H ar vo n i d aily ( $94, 5 00 ) G en o ty p e 2: 12 w e eks 1. Sov ald i d aily ( $84 ,000 ) 2. Rib av irin d aily ( $550 -$8 50 ) G en o ty p e 3: 24 w e eks 1. Sov ald i d aily ( $168 ,00 0 ) 2. Rib av irin d aily ( $1, 100 -$1 ,700 ) G en o ty p e 5: 1 2 w e eks 1. Sov ald i d aily ( $84 ,000 ) 2. Rib av irin d aily ( $550 -$8 50 ) 3. Peg in ter fe ro n a lf a w ee kly ( $ 8, 400 ) H arvo n i CA P : P ays up to 2 5% o f c atal o g pri ce (o r $ 23 , 6 25 ) u p t o 6 m o n ths; Cli ent m u st pay $ 5 c o -p ay p er fill So vald i CA P : P ay s up to 2 5% o f c atal o g pri ce (o r $ 21 ,0 0 0 ) up t o 6 m o n ths ; Client m u st p ay $ 5 co -p ay per fill Rib asp h ere (rib av iri n ): P ay s up t o $ 1 50 ; Cli ent m u st p ay $ 5 c o -p ay per fill P egas ys (peg in terfer o n alfa ): P ays 8 0 % o f co -p ay up t o $ 2 ,4 0 0 ; Client m u st p ay t h e fir st $ 2 5 and 2 0 % o f c o -p ay *O u t o f P o cke t M axi m u m ** Co -p ay Assis tance P ro gr am s Page 19 of 59

1

Interim Guidance to Texas Administrative Agents on

Health Insurance Assistance Services

December 2014

Table of Contents

Purpose ... 2 Health Insurance Assistance in the ACA Era ... 2 Understanding local insurance and clinical services costs ... 2 Calculating the per client allocations for clinical services at an HSDA or Service Area ... 2 Understanding local insurance costs ... 2 Comparing the per client costs for covered clinical services to the costs for insurance ... 3 Making Decisions about Health Insurance Assistance Services at the Client Level ... 3 Special Enrollment Periods and COBRA ... 3 Supporting Marketplace Plans ... 3 Making Allocating and Budgeting Decisions for Insurance Assistance Services ... 4 Components of Insurance Costs ... 4 Ryan White Health Insurance Assistance Best Practice Recommendations ... 5 Appendix A: Recommended Method for Calculating per Client Expected Direct Costs of Covered Clinical Services ... 6 Appendix B: Average Health Insurance Costs in Texas, 2015 Plan Year ... 8 Keep in Mind... 8 Reading the Tables ... 8 Rating Area: Austin ... 9 Rating Area: Dallas and Fort Worth ... 9 Rating Area: El Paso ... 10 Rating Area: Houston ... 10 Rating Area: San Antonio ... 11 Rating Area: Rest of Texas ... 11 Comparisons of Rating Areas within Income Levels ... 12

2

Purpose

This interim guidance is provided while comprehensive DSHS policy and guidance on health insurance

assistance, including guidance on allocations and budgeting for this category, is being prepared. This guidance applies to use of Ryan White Program(RWP) Part B funds and State Services (SS) funds contracted by the Department of State Health Services (DSHS).

Health Insurance Assistance in the ACA Era

Federal law and policy and state policy require that RWP Part B and SS funds be used as payment of last resort for eligible HIV-related services. Care standards currently require that each client be carefully assessed for eligibility for other health-related programs, including eligibility for Medicaid, Medicare, employer-based health insurance, and commercial insurance. This last group includes health plans available on through the Texas Marketplace. HRSA policy requires that enrollment in health insurance be vigorously pursued. This includes strong consideration of paying some or all of the costs of health insurance (including payment of premiums and/or copays and coinsurance) as an alternative to using RWP funds to pay directly for client service.

Health insurance can offer a cost advantage for some clients, but it is not automatically the best alternative for every client. The changes in the availability of affordable insurance has implications for both

allocations/budgeting for health insurance assistance services, and whether or not insurance is the best choice for an individual client.

The information in this guidance should be considered when making allocations and budgeting for health insurance assistance at an administrative level. At the client level, when considering a client request for health insurance continuation services, staff must carefully consider the information in this guidance to help decide if paying health insurance costs though the RWP is an affordable and feasible alternative.

Understanding local insurance and clinical services costs

Insurance is preferred when it provides a cost advantage to delivering direct services. Understanding your expenditures for clinical services typically covered by insurance is critical for making allocations and for decisions about individual client coverage. You should not support requests for health insurance assistance if providing the assistance would result in a greater expenditure for the clinical services needed by the client.

Calculating the per client allocations for clinical services at an HSDA or Service Area

Health insurance will cover some but not all of the eligible RWP/SS services. It is a best practice to develop a local figure of the per client expected expenditures for covered clinical services. This gives an idea of the clinical costs that would be avoided by providing insurance assistance. We have attached a workbook to help with this calculation. You can calculate these costs for each HSDA or for your service area as whole. Instructions for the worksheet are in Attachment A.

Understanding local insurance costs

We have pulled information from the Texas Marketplace plans, and it is attached for your use. It provides the average premiums and maximum out of pocket costs for primarily Silver plans in the five health insurance rating areas where 85% of the persons with HIV live. We also include averages that can be used to estimate insurance

3 costs for persons outside those areas - labeled "Area 26" in the attached materials. These average costs are adjusted for age and smoking status (which can increase premiums), and are shown for five different household income levels. These figures are explained in more detail in Appendix B.

Comparing the per client costs for covered clinical services to the costs for insurance

The workbook with your direct cost estimates also provides a format to compare the average costs for clinical services to the average insurance costs for an area. The worksheet for this comparison integrates ADAP costs with your local costs, and also provides a option to include an estimate of uncompensated care costs in your area. In state fiscal year 2014, the average ADAP expenditure on dispensed drugs was $5,790.93. Your local hospital district or agency that coordinates indigent care may have estimates of uncompensated care costs associated with HIV.

Making Decisions about Health Insurance Assistance Services at the Client Level

Until last year, our insurance assistance funds supported premiums and co-payments primarily for employer-based plans, which includes COBRA. Before extending assistance for employer-employer-based insurance, please continue to consider not only the level of premium, but the cost-sharing and copayment requirements. Many employer-based plans have very high caps on out of pocket expenditures, meaning that even after the client fulfills her deductible, office visits and prescriptions will continue to require co-payments from the client. Understanding the requirements for co-payments and how those fit with local policies on caps and the client's ability to pay will help assure that there is an appropriate amount of money budgeted for that client.

Special Enrollment Periods and COBRA

The loss of employer-based insurance triggers a special enrollment period for the Marketplace, and your client will have 90 from the loss of her employer-based insurance to enroll on a Marketplace plan as an alternative to COBRA. When assistance is requested for a COBRA plan, a comparison must be made to available Marketplace coverage before making a commitment to support the costs of the COBRA plan.

Supporting Marketplace Plans

There are many resources available to help clients select plans that are appropriate for their needs. This guidance considers only the financial and policy aspects of health insurance assistance decisions.

Creating the cost comparisons described above can give you an idea when insurance assistances looks like the best alternative for a client. There are some special features of Marketplace plans that will help decide if insurance is the best choice for a client, and will help predict the total costs of assisting a client with a Marketplace plan.

Persons between 100 and 200% FPL qualify for premium reductions and reduced cost sharing that can make Marketplace insurance costs comparable to or lower than direct service costs, especially when ADAP costs are considered. Unlike some employer-based plans, plans sold on the Marketplace caps on out of pocket costs such as co-pays and prescription co-insurance payments. Persons with household incomes between 100% and 250% FPL are eligible for reduced out of pocket maximums (OOP) when they buy Silver plans. The average out of pocket maximums for plans in the different rating areas of Texas are shown in the attachments. This helps estimate the maximum charges that you could expect for a client's insurance coverage.

4 Persons under 100% FPL do not qualify for reduced insurancecosts on the Marketplace. Please carefully

consider the possible maximum expenditure on insurance (1 year of premiums plus the maximum out of pocket costs) before making a commitment to assist with insurance costs for clients under 100%. You can decline to provide insurance assistance if plan costs greatly exceed costs of directly delivered care. If a client is under 100% FPL or over 250% FPL, Gold or Platinum plans may actually provide a cost advantage for clients with high clinical costs such as co-morbidities or complex treatments. Silver is not always the best choice in this situation. The average insurance costs for this group are shown in Attachment B.

If you will provide insurance assistance for a Marketplace plan, you must comply with the following:

• the client must take the advance premium credit.

• if client is between 100 and 250% FPL, the client must select a Silver Plan.

• Clients must report changes in income, family size, tobacco use or residence promptly through Healthcare.gov. You should have processes in place to review financial eligibility information on a regular basis (i.e. no less often than every 6 months).

Making Allocating and Budgeting Decisions for Insurance Assistance Services

The information Appendix B shows the average premiums and out of pocket maximums for single member households with varying levels of income. This information is from Healthcare.gov. Please keep the following in mind.

Components of Insurance Costs

Insurance costs have two basic components: the premium and the out of pocket maximum. Premiums

The cost of Marketplace premiums depend on the age and income of clients, and whether or not they smoke. Premiums are higher for older people and smokers compared to younger people and those who do not use tobacco. The average premiums in the tables are adjusted for age. The effect of smoking on premiums is also shown in the averages; the weighted average column will give you an overall average of the total costs you should expect without knowing the smoking status of your clients. Use this figure to estimate overall insurance costs. People with household incomes between 100% and 400% of FPL are eligible for tax credits that lower the cost of premiums. Clients that are income-eligible for tax credits must take them as advance premium tax credits. This means the federal government pays the insurance company and not the client. Premiums have to be paid every month, and will not vary in cost as long as client income does not change.

Out of Pocket Maximums

The ACA Marketplace plans have caps on the amount of money that a person must pay out of their pocket. Out of pocket costs include co-pays and co-insurance fees for drugs and medical services. Once someone reaches an out of pocket limit, the insurance pays for 100% of the medical service costs. Out of pocket maximums are much lower for persons between 100% and 200% of FPL who purchase Silver level plans compared to costs for other plans for people at this income level.

5 When a coverage period starts, your insured clients may have very high copayments/co insurance charges, especially for HIV treatment drugs or other "4th tier" or "specialty drugs". Please remember that

copayment/coinsurance charges will stop once the client reaches the OOP maximum for the plan. If a plan has a $2,500 out of pocket maximum, once the out of pocket payments total that amount, there are no more

copayments/co-insurance charges. It may be shocking for a client to be told that they owe $500 or more for prescription, but these high copayments mean that out of pocket maximums are reached very quickly, and then the co-pays or coinsurance charges stop.

This means that OOP charges are "front loaded" - theyare much higher at the beginning of a coverage year

than at the end. Don't give up on insurance due to high initial copayment charges - they will decrease as clients

hit their out of pocket maximums.

The out of pocket maximums do not include premium payments. Copayments/Co-insurance payments made for out of network services do not count - if the doctors and pharmacies used by your clients are not in the health plan's network, and the client continues to see doctors and use pharmacies outside the network, the client will continue to pay high levels of co-pay throughout the year.

If your area uses a monthly cap to control costs for Health Insurance Assistance services, these policies must be re-considered in light of the Marketplace provisions that cap OOP expenses for persons between 100% and 250% FPL. Your policy may make a Marketplace plan unaffordable if it caps maximum monthly payments for a client. Since OOP payments are front loaded, you should expect much higher requests for co-payment assistance at the beginning of a plan year, but these payments will stop completely once the maximum is reached. For example, your current policy may limit co-payment support to no more than $500 a month. A client on a Marketplace plan with a $2000 OOP maximum may have initial monthly co-payments totaling much more than this, but the annual total will not exceed $2000. While this may create complications related to budgeting and cash flow, the overall cost of the insurance is still reasonable.

Monthly caps may still make sense for employer based plans with continuing co-payments, but these policies may put affordable Marketplace coverage out of reach for clients. Please examine your cost-containment policies to assure that they will work for Marketplace plans.

Ryan White Health Insurance Assistance Best Practice Recommendations

1. Implement local Health Insurance Assistance Program (HIAP) policies that encourage uninsured

RW-eligible clients transition to Qualified Health Plans (QHP) offered through the Marketplace.

a. Local HIAP policy must be consistent with RWHAP and DSHS requirements

b. Ensure cost effectiveness compared to direct (traditional) funding of providers of 3rd party eligible services (e.g. primary medical care, pharmacy, behavioral health services)

c. Ensure consistency with HIAP policies in other Texas Part A/B jurisdictions to enable HIAP recipients to maintain coverage when relocating to other areas in the State

d. Ensure HIAP sustainability and maintenance of care for PLWHA enrolled in QHPs

i. Ensure funding allocations are sufficient to sustain HIAP program costs on an ongoing basis