1. 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

2. 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

3. 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:

4. 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

5. 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:

6. 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

7. 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

8. 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

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

10. More Regulations/Guidance
Certified Application Counselor Guidance:
Employer Mandate Delay Announcement: 
Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions; Miscellaneous Minimum Essential Coverage Provisions
Eligibility for Minimum Essential Coverage for Purposes of the Premium Tax Credit
For a translation of latest rules and policies – check out Timothy Jost’s Health Affairs Blog:

11. Enrollment - Training Resources

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

13. 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