1. Slide 1 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. IAS–USA Jennifer Kates, PhD Vice President and Director, Global Health and HIV Policy Kaiser Family Foundation Implications of the Patient Protection and Affordable Care Act and the Status of the Ryan White HIV/AIDS Program: What Does the Future Hold? From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA.

2. Slide 2 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. The Challenge 21 years into the AIDS Epidemic –More than one million living with HIV –New infections stable for more than a decade (50,000/year) –New infections rising among gay and bisexual men People with HIV more likely to be low-income, uninsured than U.S. population overall; heavy reliance on Medicaid Most not on treatment Yet new science shows “Treatment as Prevention” (TasP) & Possibility of an AIDS Free Generation

3. Slide 3 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. SOURCE: Adapted from CDC "HIV in the United States–The Stages of Care" July 2012. The HIV Treatment Cascade 2/3 not in regular care Only 33% on ART Only 25% virally suppressed

4. Slide 4 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. NOTES: Based on Patients with HIV Attending Medical Offices Participating in HIVRN in 2010; N=19,235. Medicaid includes those with Medicare coverage. SOURCES: Data from K. Gebo and J. Fleishman, in Institute of Medicine, HIV Screening and Access to Care: Exploring the Impact of Policies on Access to and Provision of HIV Care, 2011. Insurance Coverage of People with HIV in Care in the U.S. 78% Rely on Public Sector

5. Slide 5 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. CONSUMER PROTECTIONS & PRIVATE INSURANCE REFORMS HEALTH CARE MARKETPLACES (EXCHANGES) BENEFIT STANDARDS MEDICARE FIXES PREVENTION ENHANCEMENTS MEDICAID EXPANSION HEALTH SYSTEM IMPROVEMENTS Key PPACA Provisions for People with HIV

6. Slide 6 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Consumer Protections/ Private Insurance Reforms Consumer Protections/ Private Insurance Reforms Medicaid Expansion Medicare Fixes Benefit Standards Consumer Protections & Private Insurance Reforms End to lifetime and annual coverage limits Elimination of pre-existing conditions exclusions Health plans can no longer rescind coverage or charge higher premiums for those with pre-existing conditions Health plans cannot discriminate on the basis of sexual orientation and gender identity Dependent coverage up to age 26

7. Slide 7 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. The Marketplace (Exchanges) The Marketplace (Exchanges) Medicaid Expansion Medicare Fixes Benefit Standards Health Care Marketplaces Most individuals required to have health insurance by 2014 State marketplaces designed to create more organized, competitive insurance market Choice of health plans (“Qualified Health Plans”) Tax credits and cost-sharing subsidies based on income Network “adequacy” and essential community providers State options for exchange: State run, partnership with federal government, or default to federal exchange

8. Slide 8 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Partnership Marketplace (7 states) – 7% PLWH State-based Marketplace (16 states and DC) – 43% PLWH Default to Federal (27 states) – 51% PLWH * In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or SHOP, marketplace. SOURCES: KFF review of state legislation and other exchange documents, as of May 28, 2013; KFF analysis of data from the CDC NCHHSTP Atlas. Where are the States on Marketplace Decisions?

9. Slide 9 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Benefit Standards Medicaid Expansion Medicare Fixes Benefit Standards Essential Health Benefits (EHB): must provide comprehensive set of services across 10 categories, including Rx Applies to non-grandfathered plans in individual and small group markets in and outside of Exchanges, Medicaid Alternative Benefit Plan, and Basic Health Plan

10. Slide 10 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. The 10 EHB Categories 1.Ambulatory patient services 2.Emergency services 3.Hospitalization 4.Maternity and newborn care 5.Mental health and substance use disorder services, including behavioral health treatment 6.Prescription drugs 7.Rehabilitative and habilitative services and devices 8.Laboratory services 9.Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision care Final Rule: RX category: plans must cover “at least the greater of” one drug in every U.S. Pharmacopeia category and class or same number of prescription drugs in each category and class as the EHB benchmark; must have procedure in place “to allow enrollee to request and gain access to clinically appropriate drugs not covered by the health plan.”

11. Slide 11 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Medicare Fixes Medicaid Expansion Medicare Fixes Benefit Standards Medicare Fixes 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

12. Slide 12 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Prevention Medicaid Expansion Medicare Fixes Benefit Standards Prevention Enhancements New health plans must provide preventive services at no cost Those rated “A” and “B” by the USPSTF: Routine HIV screening received “A” rating on 4/29/13 Free annual HIV counseling and testing for sexually active women Medicare must provide these at no cost as well State Medicaid programs that cover these services receive one percentage point increase in FMAP New Prevention and Public Health Fund (CDC HIV Prevention funding)

13. Slide 13 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Medicaid Expansion Medicare Fixes Benefit Standards Medicaid In 2014, Medicaid eligibility expanded to nearly all low-income individuals (state option as of 2010) Medicaid eligibility “floor” of 133% FPL ($15,000 for individual, $27,000 for family of three) Eliminates “Catch-22” for people with HIV – eligibility solely based on income Enhanced FMAP for states Enhanced provider reimbursement rates Supreme Court decision effectively makes this a state option

14. Slide 14 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Where are the States on Medicaid Expansion? NOTES: 1-Exploring an approach to Medicaid expansion likely to require waiver approval. 2- Discussion of special session being called on Medicaid expansion. SOURCES: KCMU analysis of recent news reports, executive activity and legislative activity in states as of May 21, 2013. KFF analysis of data from the CDC NCHHSTP Atlas. Debate Ongoing (8 States) – 12% PLWH Moving Forward at this Time (23 States including DC) – 52% PLWH Not Moving Forward at this Time (20 States) – 37% PLWH

15. Slide 15 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Health Systems Health Systems Medicaid Expansion Medicare Fixes Benefit Standards Health System Improvements Medicaid Health Homes, including for people with HIV Increased Medicaid payments for primary care physicians, including subspecialists Integrated care for dual eligibles Health center investments, national health service corps Health disparities data collection

16. Slide 16 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. The Ryan White HIV/AIDS Program Insurance coverage alone ≠ access to or receipt of care Ryan White is nation’s safety net for people with HIV Fills gaps in care for PLWHA not covered by other resources or payers and serves as payer of last resort Most Ryan White clients are insured, and rely on the program to supplement limits in their coverage Will need to change, but continue to be critical; impact will depend on state decisions on Medicaid expansion and benefit packages in the health care marketplace

17. Slide 17 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Notes: Based on those with reported insurance status (duplicated number of clients, N=764,163). Source: HRSA, HAB, http://hab.hrsa.gov/stateprofiles/index.htm. Most Ryan White Clients Are Insured; Use Program to Supplement Coverage

18. Slide 18 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Source: HRSA.gov, Grantee Allocations & Expenditures, 2009, accessed August 2012. Ryan White Program Pays for Medical Care and Support Services

19. Slide 19 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Looking Ahead More Ryan White clients will gain insurance coverage through Medicaid and exchanges 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 assist clients with enrollment in new coverage options –Navigators and Assistors Timing of reauthorization is complicated

20. Slide 20 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. 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. Ryan White Supports Clients Along the Treatment Cascade Treatment Adherence Health Insurance Premium Assistance & Cost-Sharing

21. Slide 21 of 21 From J Kates, MD, at New York, NY: May 3, 2013, IAS-USA. Looking Ahead, continued Ryan White will continue to be important source of care and services for immigrants with HIV –Undocumented not eligible for Medicaid or exchanges –Legal residents have 5 year waiting period for Medicaid Payer of last resort requirement still applies –Ryan White funds may not be used “for any item or service to the extent that payment has been made, or can reasonably be expected to be made” Ryan White providers can join Medicaid and Exchange provider networks –Exchanges required to include some “essential community providers” but not all safety net providers –Ryan White providers will need to proactively engage with exchanges and Medicaid managed care networks