1. Ryan White Moving Forward and ACA Implementation San Francisco Provides Access to Healthcare – SF PATH Celinda Cantú Data Administrator San Francisco Department of Public Health HIV Health Services

2. Low Income Health Program (LIHP) San Francisco ‘s LIHP program is called SF PATH (“San Francisco Provides Access To Healthcare”) San Francisco’s LIHP is under the Department of Public Health Provider network for SF PATH is Department of Public Health – same network as Health Care Coverage Initiative under previous 1115 Waiver: 16 primary care clinics (all FQHcs) 12 community oriented primary care clinics, including Tom Waddell, Castro Mission, Maxine Hall 4 hospital-based primary care clinics, including Ward 86:Positive Health Practice San Francisco General Hospital Community Behavioral Health Services Laguna Honda Hospital (short-term rehabilitation) SF PATH was approved by State and CMS, and implemented on July 1, 2011 – currently  10,000 enrollees in SF PATH 2 10/2/2014

3. Eligibility Criteria Ryan White SF PATH Ryan White (formally RW clients) Ryan White SF PATH (formally RW clients) Income: 0-400% FPLIncome: 0% -133% FPL SF Resident Legal Residency not considered Documented citizenship or permanent legal resident (at least 5 years) Government and other types of identification accepted Government issued identification No insurance or limited coverageIneligible for Medi-Cal HIV diagnosisNo medical condition needed No age restrictionsAge: 19 – 64 years old 3 10/2/2014

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5. HIV/AIDS Client Services Comparison for RW Eligible Clients Who Become/Are SF PATH or ACA Enrollee ACA Services may include:Enrollee may become ineligible for these RW Core Service Categories: Enrollee: Remains eligible for these RW Service Categories: Ambulance Services Diagnostic and Laboratory Durable Medical Equipment Emergency & Post-Stabilization Services Family Planning Home Health Care Hospital Care Mental Health Care (outpatient and acute inpatient services) Non-Emergency Medical Transportation Outpatient Alcohol and Drug Treatment Podiatry Care Prescriptions (including ADAP/HIV medications)* Preventive and Primary Care Services Radiology Short-term Rehabilitation Specialty Care Therapy (Occupational, Physical, Speech) Urgent Care *Disenrollment from ADAP is required for clients Outpatient/Ambulatory Medical Care Home Health Care Medical Case Management (including Treatment Adherence)** Outpatient Mental Health Services** Outpatient Substance Abuse Services** **Level of service provision and frequency TBD by state of CA Ryan White Core Services: Oral Health Care – (Dental Services)*** Facility-based Care (not acute hospital care) Hospice Ryan White Support Services: Housing Services Food Bank/Delivered Meals Psychosocial Services Legal Services Case Management (Non-Medical): Benefits Counseling Money Management Outreach Services Emergency Financial Assistance Residential Substance Abuse Services ***Oral Health Care may be reinstated as covered service with level & frequency TBD by state of CA 5 10/2/2014

6. LIHP Transition Milestones TopicMilestone Continue Stakeholder EngagementJune – July 2013 Initial SF PATH Transition Notice to Enrollees July 2013 Complete Data Transitions for Medi-Cal Managed Care October 2013 Transition Health Care Coverage Initiative enrollee contact information to Covered California for Outreach October 2013 Medi-Cal Managed Care Initial Plan Assignment Notice November 2013 Administrative move of LIHP (SF PATH) Medi-Cal Coverage Expansion to Medi-Cal December 2013 Covered California Open Enrollment Period Completed December 2013 Medi-Cal Managed Care Plans & Covered California Qualified Health Plans Initiate Coverage January 2014 6 10/2/2014

7. State ADAP Screening for LIHP On March 1, 2012, the ADAP enrollment/recertification process, accomplished through Ramsell (the ADAP statewide pharmacy benefits manager), began tracking client eligibility for SF PATH New enrollment forms that include SF PATH-related questions have been activated on the Ramsell ADAP enrollment website for San Francisco These forms require the ADAP Enrollment Worker to determine if the client may be eligible for SF PATH and track the client’s SF PATH application process Any ADAP applicant who may qualify for LIHP must be referred to apply to LIHP Access to the updated application can be obtained in the “Forms” section of the Ramsell secure website at: www.publichealthrx.com 7 10/2/2014

8. Post ACA Implementation populations that will continue to receive medical services through Ryan White Funding Residually ineligible individuals (undocumented and those documented with resident status of less than five years) Other HIV populations at-risk to be under- served in capitated care systems: Patients with significant behavioral health issues At high risk for falling out of care Often are 86-ed out of multiple programs At higher risk for depression, chaotic substance use, violence and suicide than general population Have limited insight to modify behavior Don’t meet criteria for “mental disability” DSM5 Axis II “Personality Disorder” fixed traits or diagnosis Important to move beyond labels to see what is needed both for patient and system Borderline is often over diagnosed and underdiagnosed Often described as “low threshold patients” HIV elders 8 10/2/2014

9. Continuing Challenges Given uncertainty of RWPA funding in future years Focus on sustainability- if RWP does decrease which services could be integrated into emerging primary care system? Which services categories of service have funding streams in addition to RWP? Use Gardner Cascade as a tool to assist in determining service funding priorities Federal government is placing increased importance on clinical health care outcomes what does the data show for what are considered “support service categories”? 9 10/2/2014

10. Conclusions and Opportunities CY 2014 is a unique opportunity to determine the best way for RWP services and funding can wrap around ACA services HHS can help ensure successful payer transitions while maintaining continuity of care both of which will be a more immediate and on- going need HHS will focus on reviewing and potentially expanding services within a given service category as well as expanded and new uses of existing RW service categories HHSPC should sustain and improve the strength and coordination of multiple partnerships : HIV Care and Prevention Services. Consumer, Provider, Council and SF DPH 10 10/2/2014