1. Challenges and Opportunities: Caring for People With HIV/AIDS in Managed Care °Financing °Movement To Managed Care °Challenges/Opportunities

2. FINANCING CARE: FEDERAL PROGRAMS J MEDICAID P Largest payer of direct medical services for PLWH/A P FY 1998: $3.5 billion (est) on HIV/AIDS medical services P 53% of all people with HIV/AIDS are on Medicaid. 90% of all children with AIDS are on Medicaid P PWA are fewer than 1% of beneficiaries, 2% of total cost J MEDICARE P FY 1997: 1.4 billion- est. 6-20% of PWA (excludes RX) J RYAN WHITE CARE ACT PROGRAMS P FY 1998: $1.15 billion J OTHER FEDERAL - SAMSHA, NIH, federal prison, VA, IHS, HUD

3. MOVEMENT TOWARD MANAGED CARE J Growth in Medicaid Managed Care P As of June, 1997, approximately 47.5% Medicaid recipients in managed care (vs 12% in 1995) ; majority increase in fully capitated plans J States shifting risk from State to MCOs J Focus shifting from TANF(AFDC) to SSI (65% of expenditures) J WHY? P Control Costs/ Predict Medicaid budget P Get out of insurance business- fewer staff?; negotiate with few MCOs vs all constituent groups P Increase Quality & Access- fragmented FFS system; low provider participation; coordinated care J HOW?- 1915(b)/1115 waivers, State plans(BBA)

4. BALANCED BUDGET ACT (BBA) J Section 1932(a) of SSA - States submit State Plan amendment to enroll beneficiaries into managed care w/o waivers P exceptions: dually eligibles; special needs children; tribes J REQUIREMENTS: P choice of 2 managed care entities (MCEs) P disenroll any time for cause in first 90 days; 12 months thereafter P HCFA approval of model contracts I subject to new quality assurance, timely payments provisions I default enrollment based on prior provider-patient verification of access to providers I info on providers, enrollee, rights, grievances etc in readable format

5. TRENDS J Nearly half of all enrollees in Medicaid dominated plans (more than 75% membership is Medicaid) number of plans serving Medicaid market increased from 166 to 355 b/n 1993-96 J Medicaid dominated plans more likely to serve SSI/disabled population J 87% enrollees in 16 states: AZ, CA, CT, FL, IL, MI, MN, MO, NJ, NY, OH, OR, PA TN, VA & WA J Newly formed plans dominate new Medicaid plans

6. CHALLENGES AND OPPORTUNITIES J PEOPLE LIVING WITH HIV/AIDS J HIV SERVICE AND MEDICAL PROVIDERS J MANAGED CARE ORGANIZATIONS J STATE MEDICAID AGENCIES J ACCESS J COST J CONTINUITY OF CARE J QUALITY

7. Challenges/Opportunities for: People Living With HIV/AIDS J Understanding & navigating the system J Enrollment P Choice of MCO P Disclosure of provider network J Access to experienced HIV providers P primary care P timely & appropriate referrals to specialists P access to clinical trials P out of network providers

8. PLWH (continued) J Access to Pharmaceuticals P Restrictive health plan formularies P location of pharmacies J Coordination with Social Services J Confidentiality of medical & enrollment information J Discrimination J Grievance process Opportunity to receive coordinated care with an emphasis on prevention & early diagnosis

9. HIV PROVIDERS J Understanding the system J Potential Loss of Patients/Revenue P Increase Uninsured J Adapting to Change P defining Strategic position P changing their mission/repackaging services P Using “business” principles J Upgrading MIS P ability to obtain cost & utilization info P limited resources

10. HIV PROVIDERS (continued) J Development of networks P Protecting their “turf” J Fair Reimbursement P Risk Adjusted Capitation Opportunity to diversify revenue streams & increase patient base

11. MANAGED CARE ORGANIZATIONS J Understanding the needs of PLWH J Maintain profitability P risk adjusted rates J Meeting contractual obligations J Turnover of Medicaid population J Develop delivery networks for PLWH P # of PLWH members vs actual membership J Confidentiality vs assuring care Opportunity to diversify membership & provide quality care

12. STATE MEDICAID AGENCIES J Shift from FFS to managed care P limited resources & staff P antiquated MIS P negotiating contracts J Internal/External Pressure P control costs/budgets P growth of eligible populations P assuring quality care J Incentives to MCOs to provide care P reimbursement rates Opportunity to improve access to care for eligibles

13. HAB MANAGED CARE STRATEGIC PLAN J Enhance the capabilities of HIV providers to participate in managed care J Improve HAB’s knowledge base about MC and HIV, especially with regard to various financing and reimbursement methodologies J Educate people with HIV/AIDS about managed care to improve their ability to access services J Assure quality care for HIV/AIDS members enrolled in managed care J Collaborate Efforts with HCFA, States and Other Key Stakeholders

14. HAB’s TRAINING AND TECHNICAL ASSISTANCE J Strengthen the infrastructure within individual states for RW programs to participate in managed care by providing customized, state based training & TA J Build collaborative relationships between key stakeholders including MCOs, State Medicaid agencies, HCFA and RW funded programs J Up to $20,000 in JSI TA monies can be used for training, TA from individuals/groups of consultants, facilitated meetings between key stakeholders, data analysis, or other activities requested by the State J 7 States participated in pilot: CT, NJ, PA, MD, FL, IL, WA 9 States currently funded: OR, VA, WV, AL, AZ, RI, NM, TX, OK J HAB Staff training, Project Officer Guide, Resource List

15. HAB TA: EXPAND KNOWLEDGE BASE J Expert Panel on Risk Adjustment P addressed policy, development and implementation; proceedings published as TA document J 1115 Waiver Study P examined capitation rates, benefits, eligibility & enrollment requirements related to HIV service delivery in 9 States (OSE) J Evaluation Studies (Center for Managed Care) P impact on Medicaid Managed Care on providers (Mathmatica) & safety net providers (IOM) J Managed Care SPNS Grantees J Updated Medicaid Guide (AIDS Action)

16. HAB TA: CONSUMER EDUCATION J Joint Project with National Association of People with AIDS P consumer resource guide to help PWH/A navigate the system-diary to record information and “what to ask for” P Spanish & English P Will be tested in several markets in March, 1999 J Train the Trainers P plan to identify consumers to become trainers of managed care in key states

17. HAB TA: QUALITY J Purchasing Specifications P contract with GWU Center for Health Policy Research P modules for contracts between State Medicaid agency & MCOs to assure access to care for PLWH P coordination with CDC P available in February 1999

18. HAB TA: RELATIONSHIP WITH STAKEHOLDERS J Federal Agencies P HCFA - cross trainings, waiver reviews, review guidelines J National Association of State Medicaid Directors P 4 regional meetings- Chicago, Sante Fe, Austin, Boston P HRSA program directors (MCH, PCA, AIDS) & Medicaid Directors J American Association of Health Plans J National Association of State Health Policy Officials J National Association of Insurance Commissioners