1. 1115 Medicaid Waivers: A Bridge to 2014 for People Living with HIV Prepared by: Harvard Law School Health Law and Policy Clinic, the Treatment Access Expansion Project, & AIDS Foundation of Chicago November 2010

2. Acknowledgments Speakers – Cindy Mann, Director of the Center for Medicaid and State Operations (CMSO) – Amy Killelea, Harvard Law School/TAEP – Robert Greenwald, Harvard Law School/TAEP – Annette Rockwell, Commonwealth of Massachusetts Moderator – David Ernesto Munar, AIDS Foundation of Chicago You! One of many groups supporting the Coalition’s efforts, Bristol-Myers Squibb has generously sponsored this teleconference, with no review or editorial discretion as to topics or content discussed.

3. Presentation Agenda Welcome and Introduction Moderator David Munar Opening Remarks from CMS Cindy Mann Part 1: What is an 1115 Waiver? Amy Killelea Part 2: How Will an 1115 Waiver Help My State? Robert Greenwald Part 3: What Does an 1115 Waiver Look Like? Case Study: Massachusetts Annette Rockwell Part 4: Where Do We Go From Here? Robert Greenwald Q and A 3

4. Instructions for Submitting a Question You may submit a question at anytime online during the presentation by entering your question in the space provided on the bottom right of your screen in the Chat box. Clicking the SEND button will send your question directly to the speakers and will be addressed during the Q&A session. If you require assistance or are in need of technical support during the presentation, please press star, then zero at any time. This session is being recorded and will be made available at www.nationalaidsstrategy.org next week.

5. 1115 Waivers and the National HIV/AIDS Strategy The Federal Implementation Plan calls on Centers for Medicare and Medicaid Services (CMS), by the end of 2010, to: “promote and support the development and expedient review of Medicaid 1115 waivers to allow States to expand their Medicaid programs to cover pre-disabled people living with HIV.” 5

6. Opening Remarks from CMS

7. Part 1 What is an 1115 Waiver? 7

8. 1115 Waiver = A “Demonstration Project” to Expand Coverage States have flexibility in designing and running Medicaid programs, but have to meet federal laws and regulations: – E.g., categories of eligibility – E.g., benefits package – E.g., statewideness Section 1115 of the Social Security Act: – Secretary of HHS can waive compliance with requirements of federal Medicaid laws for: “experimental, pilot, or demonstration project[s] which,” in her judgment, are “likely to assist in promoting the objectives of [the Act]” 8

9. An 1115 Waiver: What It Looks Like Traditionally, successful waivers must demonstrate “budget neutrality”: Federal & state governments share coverage costs o Federal share (FMAP) varies by state and is based on per capita income 1115 waivers are time-limited o Must be re-approved after a five-year period 9 Federal Costs w/ Waiver ≤ Federal Costs w/out Waiver

10. Examples of 1115 Waivers Response to public health emergency Expansion to childless adults Cost-effective early intervention to people living with HIV 10

11. Part 2 How Will an 1115 Waiver Help My State? 11

12. Early Expansion Helps States Address the ADAP & Broader Access to Care Crisis Waiting lists for ADAP have grown to over 4,000 individuals nationwide 60% of those living with HIV/AIDS are not in regular care Ryan White care, treatment and service demands far outpace current funding 12  An 1115 Waiver Provides Access to Comprehensive Medicaid Coverage with Ryan White Wrap Around to Fill Gaps

13. Early Expansion Helps States Leverage Federal Matching Funds North Carolina 13 State Response1115 State/Federal Response $14 million out of state budget to address ADAP crisis $14 million from state leverages $26 million in federal matching funds (65% FMAP or 75% EFMAP) State Response1115 State/Federal Response $5 million out of state budget to address ADAP crisis $5 million from state leverages $11 million in federal matching funds (69% FMAP or 78% EFMAP) Alabama  An 1115 Waiver Maximizes Effectiveness of State Dollars

14. Early Expansion Helps States Provide Cost-effective Early Intervention Early intervention is a cost-effective way to improve individual and public health o Reduces costly hospitalizations & other treatments o Reduces transmission rates/ community viral load o Reduces unreimbursed care and expenditures by disproportionate share hospitals o Reduces Social Security disability and other costs o Increases productivity and employment 14  An 1115 Waiver = Cost Effective Investment in Health

15. Early Expansion Helps States Prepare for 2014 Medicaid Expansion Under health care reform, states will be required to cover most individuals up to 133% FPL ($14,000 indiv./$28,000 family of four) o Incremental expansion allows for a smooth transition to full Medicaid expansion in 2014 o Phases-in integration of providers and consumers into new coverage options o Provides opportunity to effectively integrate Ryan White model of care into broader reforms 15  An 1115 Waiver = Test Run for 2014 Expansion

16. Part 3 What Does an 1115 Waiver Look Like? Case Study: Massachusetts 16

17. Massachusetts Case Study: Timeline April 2000 HIV Waiver Expansion Application Submitted ↓ January 2001 HIV Waiver Approved ↓ January – June 2001 Outreach/Social Marketing Campaign (e.g., “Get Tested, Get Care”) ↓ April 2001 HIV Waiver Implemented

18. Eligibility Requirements Clinical HIV Diagnosis Income at or below 200% of the FPL No Asset Limit/No Enrollment Cap Under 65 Years of Age and Not Institutionalized Benefits Package Primary Care Diagnostic Care Hospital Care Prescription Drug Coverage Substance Abuse and Mental Health Treatment Massachusetts Waiver: Eligibility Requirements and Benefits Package

19. Massachusetts ADAP: Who Pays? YearEnrolled State CostFederal Cost Total Cost (including rebates) FY022301$ 699,700$ 7,816,675 $ 9,716,375 FY032716$ 1,011,873$ 8,491,468 $ 10,703,342 FY044399$ 4,635,821$ 9,352,017 $ 15,887,838 FY054738$ 4,216,175$ 11,591,967 $ 17,708,142 FY064668$ 4,216,175$ 7,427,022 $ 13,543,197 FY075141$ 1,958,523$ 10,726,583 $ 14,585,106 FY085601$ 1,958,523$ 11,733,010 $ 15,591,533 FY095882$ 1,958,523$ 12,640,882 $ 16,099,405

20. Massachusetts ADAP Expenditures by Category YearFull PayCo-PayPremiums FY02 $ 7,947,832 $ 648,030 $ 1,120,512 FY03 $ 7,961,862 $ 963,205 $ 1,778,272 FY04 $11,174,879 $ 1,553,758 $ 3,159,200 FY05 $ 9,756,201 $ 1,839,807 $ 6,112,132 FY06 $ 4,634,683 $ 1,893,206 $ 7,015,306 FY07 $ 4,147,713 $ 2,071,118 $ 8,366,273 FY08 $ 4,184,279 $ 2,083,431 $ 9,323,821 FY09 $ 4,695,780 $ 2,567,789 $ 8,835,835

21. Massachusetts ADAP Eligibility (Sept. 2009) IncomeEnrolledPercentage < 100% FPL271152% 100 - 200% FPL125124% 200 - 300% FPL61812% 300 - 400% FPL4028% > 400% FPL2495% 21

22. Massachusetts ADAP 2010 ADAP income eligibility 500% of FPL “Open formulary” since 2001 Implementation of insurance continuation program Allows for flexibility to provide gap coverage in a multi-payer environment (good preparation for state healthcare reform in 2006)

23. Part 4 Where Do We Go from Here? 23

24. What Do We Want CMS to Do? 24 The HIV/AIDS community is asking CMS to: Appoint a senior advisor on HIV to coordinate NHAS implementation Appoint a CMS representative to provide T/A and outreach to states Send letter to State Medicaid and AIDS Directors Promote the waiver option on the CMS website Hold conference calls to discuss the waiver option with state officials Develop guidance to help states submit successful waiver applications

25. What Has CMS Done So Far? So far, we have had a series of communications/ discussions with CMS: o We have received numerous assurances of their commitment to “promote and support” an expedited waiver process o T/A and outreach will be provided o Unclear if CMS will appoint a senior advisor on HIV o Biggest ongoing hurdle is what guidance will look like 25

26. What You Can Do: The Federal Ask Advocates can help ensure that the federal government fulfills its obligation under NHAS  Send letter to HHS Secretary Sebelius and CMS and White House officials, urging them to quickly act to make the 1115 waiver option a reality for states  Message: Federal support of early expansion is crucial to addressing the current HIV health care access and public health crisis 26

27. What You Can Do: The State Ask Advocates can start conversations with state officials about 1115 waiver and how it will help your state What you can do:  Let your state Medicaid officials, AIDS director, and governor know about the 1115 waiver  Provide state officials with your state’s story: What does the access to care crisis look like in your state and how will a waiver help? 27

28. Stay Tuned Next Steps:  Ongoing updates on what CMS will do to support waiver applications  Advocacy alerts as needed  Follow-up webinar when the CMS guidance is finalized to ensure advocates can promote and support successful state applications 28

29. For More Information Treatment Access Expansion Project  Taepusa.org Coalition for a National AIDS Strategy  Nationalaidsstrategy.org Dose of Change  Doseofchange.org 29