1. The Affordable Care Act and Ryan White 2013 United Conference on AIDS (USCA) New Orleans September 10, 2013 Jen Kates, Kaiser Family Foundation

2. What Will the ACA Mean for Addressing the HIV Epidemic?

3. Private Insurance Expansions & Consumer Protections Benefit Standards Medicare Fixes Prevention Medicaid Expansion Key ACA Provisions for People with HIV

4. Expansion of Private Coverage & Consumer Protections Medicaid Expansion Medicare Fixes Benefit Standards Private Market End to lifetime and annual coverage limits Elimination of pre-existing conditions exclusions Dependent coverage to age 26 Non-discrimination protections State-based health insurance marketplaces, with subsidies based on income To Follow: State decisions on exchanges, network adequacy and inclusion of essential community providers

5. Benefit Standards Medicaid Expansion Medicare Fixes Benefit Standards Benefits Essential Health Benefits (EHB) - must provide comprehensive set of services across 10 categories, including Rx EHB required for plans in individual and small group markets in and outside of marketplaces, Medicaid benchmark and benchmark- equivalent, Basic Health Plan, Alternate benefit Plan To Follow: State flexibility means benefits will vary by state; service limits could still be used

6. Medicare Fixes Medicaid Expansion Medicare Fixes Benefit Standards Medicare As of 2011, ADAP prescription expenses count towards True out of pocket costs (TrOOP), to reach catastrophic coverage level for drug coverage Closing the Part D coverage gap for all, starting in 2010 and fully by 2020

7. Prevention Medicaid Expansion Medicare Fixes Benefit Standards Prevention Prevention & Public Health Fund Free preventive services: USPSTF A and B rated services, including routine HIV screening, must be provided for free in new health plans, Medicaid expansion benefits; financial incentive to provide in traditional Medicaid Additional preventive services for free for women To Follow: State decisions on coverage of routine HIV screening in traditional Medicaid; Will Medicare cover routine HIV screening

8. Medicaid Expansion Medicare Fixes Benefit Standards Medicaid In 2014, Medicaid eligibility expanded to nearly all low-income individuals (state option as of 2010): Eliminates Catch-22 for people with HIV, sets floor of eligibility Supreme Court decision effectively makes this a state option Today, Medicaid coverage of childless, non- disabled adults very limited; without mandatory expansion, will lead to new coverage gap, uneven access Note: other Medicaid provisions include Medicaid health home option To Follow: State decisions on expansion; benefits package for expansion population; Use of Medicaid for premium assistance in marketplace in non-expansion states?

9. NOTE: MN /VT also offer waiver coverage more limited than Medicaid. OR/UT also offer premium assistance with open enrollment. IL/ LA/MO offer coverage for adults residing in a single county/area. SOURCES: KCMU/Georgetown University, survey of states, as of January 2013. KFF Analysis of data from the CDC Atlas Current Medicaid Coverage of Low-Income Adults is Limited More Limited than Medicaid (16 states) – 30% PLWH Medicaid Benefits (9 states, including DC) – 22% PLWH No Coverage (26 states) – 48% PLWH Closed = enrollment closed to new applicants

10. Just Over Half of People with HIV are in States that Plan to Expand Medicaid; Almost 4 in 10 are not NOTE: As of September 3, 2013 SOURCES: KCMU analysis of recent news reports, executive activity and legislative activity in states. KFF analysis of data from the CDC Atlas. Debate Ongoing (4 States) – 8% PLWH Moving Forward at this Time (25 States including DC) – 55% PLWH Not Moving Forward at this Time (22 States) – 38% PLWH

11. What Will the ACA Mean for Ryan White?

12. Ryan White is the Third Largest Source of Federal Funding for HIV Care in the U.S. SOURCE: Kaiser Family Foundation analysis of data from OMB, CBJs, and appropriations bills.

13. NOTES: The Consumer Price Index (CPI) from the Bureau of Labor Statistics (BLS) was used to adjust for inflation. HIV prevalence data are estimates based on analysis of data from CDC. SOURCES: Funding amounts based on Kaiser Family Foundation analysis of data from OMB, CBJs, appropriations bills, and CRS; Prevalence based on data from CDC; U.S. Department of Labor, Bureau of Labor Statistics. Federal Ryan White Funding (adjusted for inflation) and HIV Prevalence, 1991-2012

14. NOTES: Based on those with reported insurance status (duplicated number of clients, N=764,163) in 2010. SOURCE: HRSA, HAB, http://hab.hrsa.gov/stateprofiles/index.htm. Most Ryan White Clients Are Insured, And Rely on the Program Because They Face Limits in Their Coverage

15. SOURCES: Adapted from CDC "HIV in the United States–The Stages of Care" July 2012; Service Definitions from HRSA, HAB, 2012 Annual Ryan White HIV/AIDS Program Services Report (Rsr) Instruction Manual. Select Examples of Ryan White Services That Support Clients Along The HIV Treatment Cascade Treatment Adherence Health Insurance Premium Assistance & Cost- Sharing

16. Key Messages on Ryan White & the ACA State-level decisions, particularly on Medicaid, will have significant implications for Ryan White More Ryan White clients will gain insurance coverage through Medicaid and private insurance coverage through the marketplace Greater share of Ryan White funding can shift to cover services not covered in private sector or by Medicaid, or those with limits Ryan White providers can join Medicaid and Marketplace provider networks – Marketplaces required to include essential community providers – Ryan White providers will need to proactively engage with marketplaces and Medicaid managed care networks Ryan White providers can assist clients with enrollment in new coverage options (including as Navigators & Assistors)

17. Key Messages, continued Ryan White will continue to be important source of care and services for many people with HIV: – Most Ryan White clients already have coverage but still need the program to complete their care, fill in gaps, help with costs. Even as more gain coverage, they may still need help – Ryan White provides important HIV-related services that are not always provided by insurance plans – Current Medicaid coverage of low income adults (who are not disabled) is very limited – Not all states will expand Medicaid, at least not in 2014 – Those who are undocumented are not eligible for Medicaid or marketplaces; Legal residents have 5 year waiting period for Medicaid