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Debbie Cestaro Seifer, MS, RN


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HIV Case Conference:

The U.S. Territories Healthcare Reform

Debbie Cestaro‐Seifer, MS, RN

Clinical Trainer and  Faculty Member, Florida/Caribbean AIDS Education and Training Center

2010 Rate of Uninsured 

U.S. Territories 

With the exception of  Puerto Rico, which has a  popular locally funded  health coverage program,  the rate of uninsured in  U.S. territories far exceeds 


The Territories and the Affordable 

Care Act

The ACA’s design created a problem to the  territories: • It required insurers there to comply with the law's major  market reforms — guaranteed coverage, mandated  benefits, limits on profits, etc. — • Without requiring residents to get coverage or providing  subsidies to help them afford coverage. (Puerto Rico, the  U.S. Virgin Islands, American Samoa, Guam, & Northern  Mariana Islands)

Health Reform in the 

U.S. Virgin Islands


The USVI and PR are NOT REQUIRED under the  Affordable Care Act to participate in a heath  insurance exchange


Health Reform in

Puerto Rico

1. Continue to financially support “Mi‐Salud” a free state run health insurance  program that is very popular and continues to provide health care to  approximately 1.7 residents of the island (currently PR has very low uninsured  rate, 2ndonly to Massachusetts) 2.  Expand Medicaid Program   What the Government of Puerto Rico Did

Health Reform in the 

U.S. Virgin Islands

What the USVI Government Did 1. Created a Healthcare Reform Implementation Task Force 1. Decision made to expand  its Medicaid Program and as a result, the number of  local beneficiaries is expected to increase from approximately 8,500 to more than  20,000


Medicaid Expansion USVI

Phase I  August 2013: pregnant women and children only with  an income eligibility level of $6500/year Phase 2 January 2014: children, seniors, disabled residents  and former foster children ages 18‐26

Health Reform in the 

U.S. Virgin Islands

Question:  Is expanded Medicaid the “perfect fix” for  the health care challenges facing the USVI? Response:  Does not solve the challenges for the  following groups of individuals:  • many uninsured people ages 50‐64 will not qualify  • 30% of the workforce are not insured by their  employers, but will not qualify 


Long‐term Care:  Additional Healthcare  Challenge for the USVI Border patients at the two  government  hospitals are  often not covered by  Medicare during their  extended hospital stay OPTIONS: • pursue certification &  expansion of Herbert Grigg  Home for the Aged • Develop a Program of All‐ Inclusive Care for the  Elderly (PACE)  (comprehensive home care) Additional Vulnerable Populations and  Medicaid Expansion Efforts Non pregnant, childless  adults who may be:   homeless  mentally ill


Questions and Comments About Healthcare  Reform in the U.S. Territories What questions and/or comments do you have  about healthcare reform in Puerto Rico and the U.  S. Virgin Islands? 

Healthcare Reform Resources 


• http://www.dhs.gov.vi/contact/index.html • J Public Health Manag Pract. 2013 Sep‐Oct; 19(5):393‐ 401.doi:  10.1097/PHH.0b013e31826d8020 • http://donnachristensen.house.gov/press‐ release/christensen‐questions‐secretary‐sebelius‐ec‐ hearing‐aca‐rollout • http://states.aarp.org/aarp‐virgin‐islands/ • http://www.kaiserhealthnews.org/daily‐ reports/2014/july/18/reform‐implementation.aspx


Question & Answer


F/C AETC Faculty

Session Type 

Wednesday, October 8, 2014, 2:00 pm – 3:00 pm Didactic Presenter Suzanne Stevens, MSW University of South Florida Case Discussant(s) Debbie Cestaro‐Seifer, MS,RN University of South Florida

HIV Case Conference:

ACA, Ryan White and Managing Your Patients

Suzanne Stevens, MSW

Program Coordinator Faculty Member, Florida/Caribbean AIDS Education and Training Center


Participant Learning 


Upon completion of this program, participants 

will be able to


–Identify patients who need to transition into an ACA  market plan. –Recognize steps and processes needed to transition  patients. –Describe the role of ADAP in assisting patients who  enroll in an ACA plan.

What Additional Information 

Do You Want to Know?

Please share any additional questions you may 

have about the ACA, Ryan White and managing 

your patients using these resources.


Federal ACA Requirements

Be a US Citizen or lawful resident of U.S. 

Have established state residency 

Not incarcerated (does not include individuals 

waiting for disposition of charges) 

Not have or be eligible for any other form of 

“acceptable coverage” that would fulfill the 

individual mandate 

Pay income taxes

Federal ACA Requirements

Individuals who are offered employer‐

sponsored insurance may be eligible to 

purchase insurance through the Marketplace 

if either of the following conditions apply: 

–Plan does not meet minimum essential coverage  (defined as an actuarial value less than 60% of  estimated health costs)  The cost of the plan exceeds 9.5% of gross income 


Open Enrollment

The next 

Marketplace open enrollment period 

is from November 15, 2014 to February 15, 


It’s around the corner!!!

Prepare NOW!

ADAP and the ACA

• As a medication program, when ADAP purchases  insurance for a client, ensuring that the client’s  medication needs are met is the main priority.  • ADAP will only purchase insurance plans that cover  medications on the ADAP formulary. 


ADAP Plan Selection

HRSA requires ADAPs to document the cost  effectiveness and formulary compatibility of the  plans purchased.  • To maximize dollars and ensure cost‐effectiveness,  ADAP will purchase Marketplace plans that offer  advanced premium tax credits and cost sharing  reductions. • At this time, only plans in the silver metal level offer  those added benefits. 

ADAP Plan Selection 


• Plans will also be purchased based on their readiness  to coordinate benefits with the ADAP contracted  Pharmacy Benefits Manager (PBM), currently CVS  Caremark.  • For clients that transition into the Marketplace,  ADAP formulary medications will ONLY be provided  through ADAP’s contracted Pharmacy Benefits  Manager, CVS/Caremark.


Transitioning ADAP Clients

• In order to meet grant requirements with limited  funding, Florida ADAP will transition persons with  household incomes between 100% and less than 250%  of the FPL ($11,670‐$29,175 for a single individual). • Clients to be transitioned must also meet the following criteria: – Be in the ADAP Uninsured Program – Have up‐to‐date (less than six months old) core eligibility  letter – Be eligible to purchase insurance and receive assistance  through the Marketplace

ADAP Plan Selection 


ADAP will only purchase plans for clients 

selected to transition (talk to the ADAP or 

worker or case manager).

ADAP limited plan coverage will only cover 

plans that are approved by the ADAP program 


Premium Tax Credit

The premium tax credit is an advanced and/or 

refundable tax credit designed to help eligible 

individuals afford health insurance purchased 

through the Marketplace by reducing premium 


The Marketplace will estimate the amount of the 

premium tax credit that an individual may be able 

to claim for the tax year, using information 

provided about family composition and projected 

household income. 

How tax credit impacts 

ADAP clients

ADAP clients selected for transition MUST 

elect to have 100% of any premium tax credit 

for which they are eligible, paid in advance 

directly to their insurance company, to be 

applied to their monthly premiums, in order 

to receive help with the remainder of 

premium costs from ADAP. 


Who is Eligible for Tax Credit

• Individuals between 100%‐400% of the FPL ($11,670‐ $46,680 for a single individual)  • An individual who is part of a Tax Filing Unit (either as  individual or as family)  • Individuals who can not be claimed as a dependent by  another person  • Married couples who file a joint return at end of the  tax year.  • An individual who purchases an insurance policy  through the Marketplace  D8

Applying for an Exemption

• Clients between 100% and 138% FPL MUST apply for  an exemption. • Clients MUST apply for Medicaid first.  


ADAP and the ACA

• The ACA requires that all individuals acquire health  insurance coverage with minimal essential benefits.  • The Ryan White Care Act requires ADAP to remain the  payer of last resort (HRSA PCNs 13‐01 through 13‐08).  • ADAP will shift from the primary medication provider to  a secondary provider, offering wrap‐around coverage for  qualified health plans.  • A benefit of getting insurance is expanded access to  other services such as medical care. 

ADAP and Clients who DO 

NOT Transition

• ADAP has limited resources that govern how many  persons can be transitioned during the upcoming  Marketplace open enrollment period.  • ADAP clients outside of the 100%‐250% FPL range  being transitioned to the Marketplace will see no  change to the manner in which they have historically  received ADAP services. 


Final Reminders

Case managers need to keep in contact with 

local ADAP staff as changes will occur due to 

transition year and unknown factors.

Case managers and ADAP should coordinate 

and collaborate with the patients to ensure a 

smooth enrollment process for the patient.

Communicate problems with central ADAP 

staff and medical team at HIV/AIDS section to 

assist in problem solving for future.











Question & Answer


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