HRSA Policy Updates NASTAD AIDS Drug Assistance Program (ADAP) Technical Assistance Meeting July 31, 2014 Heather Hauck, Director Division of State HIV/AIDS Programs (DSHAP) HIV/AIDS Bureau Health Resources and Services Administration

HIV/AIDS Bureau’s Framework Highlight components of the RW program that are transpaeent to many Tx as prevention PLWH a key component

HIV/AIDS Bureau’s Framework Zero New Infections The Ryan White HIV/AIDS Program (RWHAP) supports the goals of the National HIV/AIDS Strategy (NHAS) by: Funding a comprehensive care systems for low-income people living with HIV (PLWH) that: Reduces new HIV infections Improves health outcomes and increases quality of life for PLWH Decreases HIV-related health disparities Including PLWH in the planning of services Employing a public health approach to care and treatment HAB facilitates improvements in HIV care through a continuum of quality HIV care for low-income individuals and families to reduce new HIV infections, to improve health outcomes for PLWH from diagnosis to achieve optimal treatment, and to reduce HIV-related health disparities. HAB leadership and staff continually assess the HIV care and service needs of PLWH via grantee/provider monitoring and oversight, client feedback, implementation of special studies and collaborative activities within HHS OPDVIS and other federal agencies. HAB leadership and staff provide expertise regarding HIV policy and consideration for the medically underserved on Federal care and treatment guidelines. In conjunction with Ryan White grantees and providers, HAB assesses models of care and services required for care completion with insight from the implementation of Special Projects of National Significance. Targeted training of the health care workforce through curriculum development, mini-residency experience to promote the adoption of HIV/AIDS care as a chronic illness. Training, dissemination and replication of effective models of care inclusive of medical homes to Ryan White and other clinical providers HAB staff provides leadership on national HIV/AIDS quality measures by the development, alignment among HHS OPDIVS and other federal agencies and adoption of these measures Ryan White clinical providers.

DSHAP Mission and Vision Division of State HIV/AIDS Program (DSHAP) Mission: To provide leadership and support to States/Territories for developing and ensuring access to quality HIV prevention, health care, and support services. DSHAP Vision: Optimal HIV/AIDS prevention, care, and treatment for all.

HIV/AIDS Bureau (HAB) Initiatives

Improved Availability of Ryan White HIV/AIDS Program (RWHAP) Data: HAB Initiatives Improved Availability of Ryan White HIV/AIDS Program (RWHAP) Data: RSR- moving from a 12-18 month cleaning-to-dissemination process to a 6-9 month process ADR – moved to new calendar year data collection period; 3-6 month cleaning-to-dissemination process State Profiles – eliminating the backlog of data (currently 2011 data is posted on the HAB website); 2012 data will available in fall 2014 Let’s get started with our program overview of the FOA. Here on Slide #2 we begin with the purpose of the Cooperative Agreement divided into the program focus for Year 1 and Year 2. Our following slides will examine program activities in more detail.

HAB Initiatives Innovative Uses of Data to Improve Prevention and Care Outcomes HAB continues to work with CDC/DHAP on the Continuum of Care initiatives (e.g., CAPUS, SMAIF, communication campaigns) HAB continues to invest in health information technology initiatives through the Special Projects of National Significance (SPNS) (e.g., facilitate exchange, examine staffing) HAB and CDC/DHAP worked with NASTAD to convene a meeting to discuss opportunities and challenges for surveillance and program data integration and utilization to improve continuum of care analysis and related activities

HAB Initiatives HIV Care Continuum Cross-Part Collaborative A quality collaborative of 5 states involving RWHAP grantees to increase access to HIV care and viral load suppression. Aim 1: Build regional capacity for closing gaps across the HIV Care Continuum to ultimately increase viral load suppression rates for individuals living with HIV Aim 2: Align quality management goals across all Ryan White HIV/AIDS Program Parts to jointly meet legislative quality management mandates Aim 3: Implement joint quality improvement activities to advance the quality of care for people living with HIV within a state and to coordinate HIV services seamlessly across Parts All grantees within the state form a team. Arkansas Mississippi Missouri New Jersey Ohio All HIV providers must be engaged to keep individuals living with HIV involved in ongoing HIV care and to achieve high viral load suppression rates, both of which are necessary to maintain long-term health and reduce the risk of transmission to others.

HAB Initiatives Black MSM Cooperative Agreement (14-106) Black MSM in the Ryan White HIV/AIDS Program: Black MSM: 32.4% of all MSM 29.4% are ages 45-54 Represent 66.4% of the MSM are ages 13-18 Represent 61% of the MSM are ages 19-24 68.5% of Black MSM are 100% below FPL 48.7% of Black MSM had no insurance at some time during the year Source: 2012 RSR (preliminary)

MSM & IDU Retained in Care & Virally Suppressed HAB Initiatives MSM & IDU Retained in Care & Virally Suppressed Retained in care: had at least one OAMC visit before September 1, 2012, and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200 Source: 2012 RSR data (preliminary)

HAB Initiatives Black MSM Cooperative Agreement (14-106) Purpose of Cooperative Agreement Compiling, distributing, and replicating effective models for HIV clinical care and treatment for adult and young Black Men who have Sex with Men (Black MSM). Specifically, the intent of this cooperative agreement program is: For Year 1: To inventory existing evidence-based interventions for HIV care and prevention strategies For Year 2: To identify and disseminate best practices and effective models of care for Black men who have sex with men (Black MSM), including young Black MSM ages 13-24 Let’s get started with our program overview of the FOA. Here on Slide #2 we begin with the purpose of the Cooperative Agreement divided into the program focus for Year 1 and Year 2. Our following slides will examine program activities in more detail.

HAB Initiatives Collaborating Across Federal Government RWHAP legislation specifically references coordination across U.S. Department of Health and Human Services NHAS/HIV Care Continuum: http://hab.hrsa.gov/nationalstrategy/index.html Collaborate and coordinate to: Align across Federal programs to reduce reporting burden on grantees Partner to advance evidence base and develop interventions to improve care and treatment across the HIV Care Continuum Share resources and expertise to build capacity at the grantee level 1. SEC. 2681. COORDINATION. (a) Requirement- The Secretary shall ensure that the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, and the Centers for Medicare & Medicaid Services coordinate the planning, funding, and implementation of Federal HIV programs (including all minority AIDS initiatives of the Public Health Service, including under section 2693) to enhance the continuity of care and prevention services for individuals with HIV/AIDS or those at risk of such disease. The Secretary shall consult with other Federal agencies, including the Department of Veterans Affairs, as needed and utilize planning information submitted to such agencies by the States and entities eligible for assistance under this title. 3 Goals of the NHAS: Reducing new HIV infections Increasing access to care and improving health outcomes for people living with HIV Reducing HIV-related health disparities 3. Collaborate and coordinate to: Align across programs- example quality measures, data reduction, aligning definitions with HUD and age groups with CDC, testing, policy work, integrated planning Advance evidence base/interventions- NIH on Adolescent treatment network, building on work on AHRQ for text messaging, CDC/NIH on PWP, CDC/SAMSHA on CAPUS Share resources and expertise- CMS with our webinars, HOPWA with housing issues, testing funds from CDC to AETCs

ACA-Related Updates

PCN 14-01 New Policy Clarification Notice (PCN) 14-01 on reconciliation of advance premium tax credits On June 6th, HRSA released PCN 14-01, which clarifies HRSA policy regarding the use of Ryan White HIV/AIDS Program funds to purchase health insurance for clients in the Marketplace and the reconciliation of advance premium tax credits RWHAP grantees and sub-grantees must vigorously pursue any excess premium tax credit a client receives from the Internal Revenue Service (IRS) upon submission of the client’s tax return Collect excess premium tax credit attributed to individual client FFR Overview

PCN 14-01 PCN 14-01 continued HRSA is considering allowing RWHAP grantees and sub-grantees to use RWHAP funds to pay the IRS any additional income tax liability a client may owe to the IRS solely based on reconciliation of the premium tax credit. A Federal Register Notice was published on July 14, 2014 in which HRSA seeks comments from the public regarding this proposed policy, with a closing date of August 13, 2014. The Federal Register Notice can be found at: http://www.gpo.gov/fdsys/pkg/FR-2014-07-14/pdf/2014-16406.pdf FFR Overview

ACA Technical Assistance HAB currently has three cooperative agreements that provide technical assistance to grantees regarding the Affordable Care Act: Engaging in Marketplace Insurance Plans under the Affordable Care Act (Cicatelli Associates) Establishing AIDS Service Organization (ASO) Service Models (Fenway Community Health) Supporting the Continuum of Care: Building Ryan White Program Grantee Capacity to Enroll Eligible Clients in ACA Health Coverage Programs (ACE Project)(John Snow, Inc.) 17

Affordable Care Enrollment (ACE) TA Center ACE Outreach & Enrollment Survey 231 Ryan White HIV/AIDS Program Part A, B, C, and D grantees were surveyed in fall 2013 to determine grantee needs to facilitate outreach and enrollment assistance to minority clients seeking private insurance through the Marketplace About a third of respondents (31%) received resources other than RWHAP grant funds to support outreach and enrollment efforts Just over half of respondents (51%) reported that they have staff with outreach and enrollment certifications within their organizations Source: JSI presentation The John Snow Institute (JSI) was funded by the HIV/AIDS Bureau in late summer 2013 to develop Technical Assistance to support increased outreach and enrollment to minority clients eligible for private insurance through the Marketplace. A needs assessment was conducted Fall 2013 that surveyed 231 Ryan White Part A, B, C, and D grantees. As you see here, about a third of respondents (31%) received resources other than RWHAP grant funds to support outreach and enrollment efforts. Just over half of respondents (51%) reported that they have staff with outreach and enrollment certifications within their organizations.

ACE TA Center Outreach & Enrollment Survey Key Findings Limited Knowledge and Experience Many direct service providers faced general outreach and enrollment challenges related to lack of knowledge of new coverage options Communication and Coordination RWHAP grantees and providers want more local guidance about policies and best practices. Gaps in coordination may have implications for how clients experience care Many direct service providers faced general Outreach and Enrollment challenges related to lack of knowledge of new coverage options in their area. Barriers to care for minority clients still exist. RWHAP providers are working with minority clients who have historically faced barriers to accessing care and who may not be comfortable enrolling in new ACA coverage options. Clients were particularly concerned about plan affordability, and the possibility of needing to change providers. RWHAP providers needed support to build consumer confidence in the enrollment process, and to assure clients that they will be supported in their care in a culturally competent care setting. Community-based providers that have already built credibility in their local communities needed to develop O&E capacity. These organizations may be able to help other organizations learn to build community-level trust. 193

ACE TA Center Outreach & Enrollment Survey Key Findings Barriers to Care RWHAP providers are working with minority clients who have historically faced barriers to accessing care and who may not be comfortable enrolling in new ACA coverage options Clients are particularly concerned about plan affordability, as well as the possibility of needing to change providers Both outreach and enrollment capacity and cultural competency are critical to enrolling and retaining minority RWHAP clients in ACA coverage options Many direct service providers faced general Outreach and Enrollment challenges related to lack of knowledge of new coverage options in their area. Barriers to care for minority clients still exist. RWHAP providers are working with minority clients who have historically faced barriers to accessing care and who may not be comfortable enrolling in new ACA coverage options. Clients were particularly concerned about plan affordability, and the possibility of needing to change providers. RWHAP providers needed support to build consumer confidence in the enrollment process, and to assure clients that they will be supported in their care in a culturally competent care setting. Community-based providers that have already built credibility in their local communities needed to develop O&E capacity. These organizations may be able to help other organizations learn to build community-level trust. 193

ACE TA Center July Webinar Series The ACE TA Center is presenting a series of webinars to introduce practical new tools and resources to support culturally competent enrollment of RWHAP clients in health insurance July 10: Introducing new tools and resources to help enroll people of color living with HIV in health care coverage July 17: Ready for the next open enrollment period? A new Online Resource Guide to help enroll PLWH in health insurance July 24: Are we speaking the same language? Tools to assist with complicated conversations about enrolling in health insurance July 31: Trouble keeping track of your clients in the enrollment process? A worksheet to assist them through every step The webinars and presentation slides are archived on the TARGET Center website Here is a link for you to sign up for updates on this TA project. JSI will then email you when the needs assessment report, other tools, and TA will be available.

ACE TA Center Additional Assistance for Grantees Subscribe to the ACE TA Center list for updates about strategies, tools and training, and to get a copy of the Needs Assessment report: http://eepurl.com/JPUVj Contact the ACE TA Center with questions: acetacenter@jsi.com Look for the ACE TA Center on the TARGET Center website, which will include new resources and existing tools that are tailored, adapted, and translated for RWHAP providers (https://careacttarget.org/ace) Here is a link for you to sign up for updates on this TA project. JSI will then email you when the needs assessment report, other tools, and TA will be available.

HAB’s ACA-Related Studies Study Description Contractor/ Awardee Emerging Issues Related to ACA Implementation: The Future of Ryan White Services: A Snapshot of Outpatient Ambulatory Medical Care Assess current status of Ryan White HIV/AIDS Program medical services during the first year of ACA implementation and how well the RWHAP is positioned to improve clinical outcomes including viral suppression, retention in care, and linkage to care services in 30 sites across the country Abt Associates Evaluating the Impact of 1115 Medicaid Waivers on the Ryan White HIV/AIDS Program and Its Clients and Providers Understand how Medicaid expansion and the 1115 Medicaid waivers will affect the Ryan White HIV/AIDS Program as well as PLWH, and how the waivers have prepared states for implementation of the Affordable Care Act JSI Understanding and Monitoring Funding Streams in Ryan White Clinics Identify the types of medical and support services that are not covered or not fully covered by Medicaid, Medicare, and private insurance in RWHAP clinics Provide information on how grantees monitor changes in patient healthcare coverage (e.g., payer source, type of insurance) and the cost of care Development of a technical assistance tracker to assist grantees/providers in monitoring and assessing changes in the mix of funding sources used to pay for client services as the ACA is fully implemented Walter R. McDonald & Assoc., Inc. Mission Analytics  

ACA Post-Enrollment Role of HRSA Continue to engage with colleagues in CMS and CCIIO on key issues such as monitoring third party payment, mail order pharmacy, prior authorization, and ECP implementation Develop and co-host webinars to relevant topics, including best practices http://hab.hrsa.gov/affordablecareact/webinars/index.html Respond to and post FAQs http://hab.hrsa.gov/affordablecareact/faqs.html

ACA Post-Enrollment Role of Grantees Assist clients in applying for and enrolling in health care coverage Role of assisters: http://marketplace.cms.gov/help-us/assisters-after-enrollment.pdf Educate patients about what it means to have health insurance Coverage to Care: http://marketplace.cms.gov/help-us/c2c-roadmap.pdf

Role of Grantees (cont.) ACA Post-Enrollment Role of Grantees (cont.) Get “in-network” with Qualified Health Plans and Medicaid Managed Care Organizations as soon as possible TARGET Center Provider Network Resources: https://careacttarget.org/library/contracting-health-plans-and-provider-networks “Answers About Health Plan Contracting” Webinar Archive: http://www.fpntc.org/training-and-resources/webinar-recording-answers-about-health-plan-contracting

Final Rule for Exchange/Insurance Market Standards for 2015 and Beyond CMS Final Rule Final Rule for Exchange/Insurance Market Standards for 2015 and Beyond On May 16, the Department of Health and Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS), issued the final rule for Exchange/Insurance Market Standards for 2015 and Beyond The rule promotes affordability, transparency and takes the first step toward providing additional quality related tools for consumers shopping in the Health Insurance Marketplace FFR Overview

Highlight: Consumer Assistance CMS Final Rule Highlight: Consumer Assistance “…in specific circumstances, certified application counselor (CAC) designated organizations can serve target populations without violating the broad non-discrimination requirement related to Exchange functions” RWHAP providers may offer CAC services exclusively to their client populations (e.g., enrollment assistance, post-enrollment assistance, outreach and education about getting covered), so long as they do not discriminate based on race, color, national origin, disability, age sex or other prohibited factors

Highlight: 24 hour expedited review CMS Final Rule Highlight: 24 hour expedited review of formulary requests Qualified Health Plans (QHPs) must have an expedited exceptions process for beneficiaries with exigent circumstances to seek a medication not covered under a plan Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug QHPs must decide within 24 hours of receiving the request QHPs must provide coverage of any drug obtained through this expedited exceptions process for the duration of the exigency FFR Overview

Integrated Planning

Integrated Planning with CDC HAB and DHAP released a joint letter indicating our ongoing support for integrated planning and the alignment of the RWHAP Comprehensive Plan/Statewide Coordinated Statement of Need and the HIV Jurisdictional Prevention Plan due dates HAB and DHAP are continuing to work on the guidance(s) for these plans and anticipate releasing guidance in 2015

Other HAB Updates

ADR Thanks for all the hard work that went into the CY 2013 ADR submission 41 States/Territories were able to submit on time Data contractors worked with the remaining States/Territories to successfully submit CY 2014 ADR The 2014 ADR Client Data Dictionary is now available on the TARGET Center website as part of the ADAP Data Report (ADR) Download Package. This resource has been updated to reflect reporting requirements for the 2014 ADAP Data Report (ADR)

ADR CY 2014 ADR (cont.) Thank-you to ADAPs that submitted comments on the draft 2014 ADR Manual. The manual will be posted on TARGET in early August DART is planning a webinar with ADAPs on August 20 at 2 pm ET to go over the 2014 ADR changes. Check the Events tab on the TARGET Center website to register

Contact Information Heather Hauck Phone: (301) 443-3613 Email: HHauck@hrsa.gov Glenn Clark Phone: (301) 443-3692 Email: GLClark@hrsa.gov