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

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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

REQUIREMENTS

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

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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, 2nd_{only 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

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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

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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

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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

USVI & PR

• 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

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Question & Answer

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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

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Participant Learning

Opportunities

• 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.

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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‐

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

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Open Enrollment

• The next

Marketplace open enrollment period

is from November 15, 2014 to February 15,

2015.

• 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.

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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

(Continued)

• 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.

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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

(continued)

• 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

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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

costs.

• 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.

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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.

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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.

Debbie Cestaro Seifer, MS, RN

HIV Case Conference:

The U.S. Territories Healthcare Reform