ACA Update Part 1: New Rules and Regulations Federal AIDS Policy Partnership August 7, 2013 Andrea Weddle, Co-chair HIV Health Care Access Working Group

Medicaid Expansion Benefits Referred to as “Alternative Benefits Package” Regulation sets minimum standard – state flexibility to develop robust package Can develop different benefits packages for different populations “Medically Frail” population can choose traditional Medicaid benefits Definition broad - should include PWA See Final Rule at http://www.ofr.gov/(X(1)S(le1fsc4mockmw1tkuddol4r5))/OFRUpload/OFRData/2013-16271_PI.pdf

Complicated Process State selects benchmark plan Add EHB service if not covered Add required Medicaid services Option to submit Secretary-approved coverage States use if want traditional Medicaid benefits Learn More: http://www.medicaid.gov/State-Resource-Center/Eligibility-Enrollment-Final-Rule/Alternative-Benefit-Plans-and-Essential-Health-Benefits.pdf

Retreat on Drug Coverage Requirement Minimum coverage = number of drugs covered by the benchmark for a drug class or at least one drug in a class, whichever greater Traditional Medicaid requires coverage of nearly all drugs Monthly drug limits and prior authorization allowed Must have process for accessing drugs not on formulary

Coverage for Antiretrovirals USP ARV Drug Classes USP Drug Count Typical Drug Count for Benchmark Plans Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors 4 5 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors 11 8 Anti-HIV Agents, Protease Inhibitors 9 Anti-HIV Agents, Other 3 Will Combination ARVs be Covered? See US Pharmacopia Drug Classification at: http://www.usp.org/usp-healthcare-professionals/medicare-model-guidelines

New Medicaid Cost Sharing Rules Income Under 150% FPL: Up to $8 for non-preferred drugs; $4 for preferred drugs Physician can request non-preferred drug as preferred with justification Up to $4 for office visits Up to $8 for nonemergency of the ER Up to $75 for inpatient stays

Medicaid Cost Sharing II New rules apply to everyone – not just expansion population Under 100% not denied for failure to pay (still) New HAB Guidance – Ryan White A B C D can assist with Medicaid premiums & cost sharing depending on coverage adequacy and cost effectiveness

Take Away: State Advocacy Critical Educate state Medicaid on importance of comprehensive coverage for people with HIV Urge coverage of ARVs according to federal treatment guidelines, including combination ARVs Comment on proposed Alternative Benefits Package

For Details… www.nastad.org Click on “Health Reform” in the feature box www.hivhealthreform.org

More Regulations/Guidance Certified Application Counselor Guidance: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CAC-guidance-7-12-2013.pdf Employer Mandate Delay Announcement:  http://www.treasury.gov/connect/blog/Pages/Continuing-to-Implement-the-ACA-in-a-Careful-Thoughtful-Manner-.aspx Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions http://www.ofr.gov/OFRUpload/OFRData/2013-15530_PI.pdf Eligibility for Minimum Essential Coverage for Purposes of the Premium Tax Credit http://www.irs.gov/pub/irs-drop/n-13-41.pdf For a translation of latest rules and policies – check out Timothy Jost’s Health Affairs Blog: http://healthaffairs.org/blog/author/jost/

Enrollment - Training Resources http://marketplace.cms.gov

New & Improved: Tool to Evaluate Potential New Coverage Options State-specific Information Coverage Information

55 Days Until Open Enrollment Next HHCAWG Call: August 14th – 4 pm ET HIV/AIDS Bureau Call on ACA Guidance: August 14th – 2:30 pm ET