Marketplace Health Plan Options for People with HIV Under the ACA: An Approach to More Comprehensive Cost Assessment

Executive Summary
  1. Kates, J., et al. (2014.) Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV. Washington, DC. Available at: https://www.kff.org/hivaids/issue-brief/assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv/view/footnotes/

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  2. Dawson, L. and Kates, J. (2015.) The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States. Kaiser Family Foundation. Available at: https://www.kff.org/hivaids/issue-brief/the-ryan-white-program-and-insurance-purchasing-in-the-aca-era/.

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  3. Marketplace plans have an out-of-pocket limit capped at $6,850 (for an individual) in 2016 but plans may opt to set that cap at a lower level.

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Issue Brief
  1. Kates, J., et al. (2014.) Assessing the Impact of the Affordable Care Act on Health Insurance Coverage of People with HIV. Washington, DC. Available at: https://www.kff.org/hivaids/issue-brief/assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv/view/footnotes/

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  2. Hamel, L., et al. (2015) Survey of Non-Group Health Insurance Enrollees, Wave 2. Kaiser Family Foundation. Washington, DC. Available at: https://www.kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-2/

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  3. U.S. Department of Health and Human Service (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE). Premium Affordability, Competition, and Choice in the Health Insurance Marketplace. (2014.) Available at http://aspe.hhs.gov/health/reports/2014/premiums/2014mktplaceprembrf.pdf and HHS, ASPE. Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period. (2014.) Available at: http://aspe.hhs.gov/health/reports/2014/marketplaceenrollment/apr2014/ib_2014apr_enrollment.pdf

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  4. Identical statistics were not readily available for California and New York, operating State-Based-Marketplaces. However, in New York 55% of those who enrolled in marketplace plans in the first open-enrollment period, did so through silver plans. (See: NY State of Health: The Official Health Plan Marketplace 2014 Open Enrollment Report (2014.) Available at: http://info.nystateofhealth.ny.gov/sites/default/files/NYSOH%202014%20Open%20Enrollment%20Report_0.pdf.) In California, 62% of enrollees did so. (See, Covered California Open Enrollment 2013–2014: Lessons Learned. (2014.) Available at https://www.coveredca.com/PDFs/10-14-2014-Lessons-Learned-final.pdf.)

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  5. See for example, Eaddy, M., et al. (2012) How Patient Cost-Sharing Trends Affect Adherence and Outcomes: A Literature Review.

    Pharmacy and Therapeutics. 37(1): 45–55.

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  6. Centers for Disease Control and Prevention. (2015.) HIV Surveillance Report- Special Report: Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection Medical Monitoring Project United States, 2012. No. 12. Available at: http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-HSSR_MMP_2012.pdf.

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  7. 67% of Ryan white clients are at or below the poverty level. Source: Ryan White HIV/AIDS Program 2012 State Profiles. Available at: http://hab.hrsa.gov/stateprofiles/Client-Characteristics.aspx#chart6).

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  8. While grantees of the program have been permitted to use funds to help clients with the cost of purchasing coverage since the program’s enactment in 1990, under the ACA this practice has become increasingly common with grantees being “strongly encouraged” by the federal government to adopt such a program (See: Health Resources and Services Administration, HIV/AIDS Bureau. Clarifications Regarding Clients Eligible for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program. Policy notice: 13-04. Revised 6/6/14. Available at: http://hab.hrsa.gov/manageyourgrant/pinspals/pcn1304privateinsurance.pdf and Dawson, L. and Kates, J. (2015.) The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States. Kaiser Family Foundation. Available at: https://www.kff.org/hivaids/issue-brief/the-ryan-white-program-and-insurance-purchasing-in-the-aca-era/).

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  9. Marketplace plans have an out-of-pocket limit capped at $6,850 (for an individual) in 2016 but plans may opt to set that cap at a lower level.

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  10. CMS, June 30, 2015 Effectuated Enrollment Snapshot, accessed September 8, 2015. Available at https://www.kff.org/health-reform/state-indicator/total-marketplace-enrollment-and-financial-assistance/

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  11. National Association of State and Territorial AIDS Directors. (2015.) ADAP Supports Expanded Access to Care. Available at https://www.nastad.org/sites/default/files/ADAP-Supports-Access-to-Care-July-2015.pdf

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  12. U.S. Department of Health and Human Service (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE). Premium Affordability, Competition, and Choice in the Health Insurance Marketplace. (2014.) Available at http://aspe.hhs.gov/health/reports/2014/premiums/2014mktplaceprembrf.pdf and HHS, ASPE. Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period. (2014.) Available at: http://aspe.hhs.gov/health/reports/2014/marketplaceenrollment/apr2014/ib_2014apr_enrollment.pdf

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  13. Center for Medicare and Medicaid Services. (2015.) March 31, 2015 Effectuated Enrollment Snapshot. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-02.html

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  14. Department of Health and Human Service, Health Resources Services Administration. FY 2015 Congressional Budget Justification. Available at http://www.hrsa.gov/about/budget/budgetjustification2015.pdf

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  15. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed 12/17/15.

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  16. Among silver plans providing the lowest expected health costs, about half the time that plan was the lowest premium silver plan (16 out of 31 times) and about half the time (15 out of the 31 times) the silver plan with the second lowest cost premiums would provide the lowest expected health expenses. While silver plans were over represented in this sample, if the silver plans with the second lowest cost premiums had been excluded, on each occasion where the 2nd lowest premium silver plan provided the lowest cost, the silver plan with the lowest premium provided the next lowest costs. Therefore, the overall frequency of silver plans having the lowest OOP costs would be the same.

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  17. If the silver plans with the second lowest premiums had been excluded from this analysis, in all but one case the silver plan with the lowest premium would then have had the least liability. In the case of the New York City, the plan with the least liability at the $25,000 income level, would have been found in the platinum plan.

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  18. In 6 of 11 occasions the silver plan with the least liability for a potential enrollee, was the silver plan with the lowest premiums. In 5 of 11 occasions, the silver plan with the lowest liability was plan with the second lowest cost premiums. In all but one case, (NY at the $25,000 income level), if the silver plan with the second lowest premium had been excluded, the silver level plan with lowest premium would have provided the least liability.

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  19. HIV Surveillance Report- Special Report: Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection Medical Monitoring Project United States, 2012. No. 12. Available at: http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-HSSR_MMP_2012.pdf

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  20. See for example, Eaddy, M., et al. (2012) How Patient Cost-Sharing Trends Affect Adherence and Outcomes: A Literature Review.

    Pharmacy and Therapeutics. 37(1): 45–55.

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  21. Dawson, L. and Kates, J. (2015.) The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States. Kaiser Family Foundation. Available at: https://www.kff.org/hivaids/issue-brief/the-ryan-white-program-and-insurance-purchasing-in-the-aca-era/).

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  22. Health Resources and Services Administration, HIV/AIDS Bureau. (2014.) Clarifications Regarding Clients Eligible for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program. Policy notice: 13-04. Available at: http://hab.hrsa.gov/manageyourgrant/pinspals/pcn1304privateinsurance.pdf

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Appendix
  1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed 12/17/15.

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  2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2014; vol. 26 November 2015. http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf

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  3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed 12/17/15.

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  4. Hauschild BC1, Weddle A2, Lubinski C2, Tegelvik JT1, Miller V1, & Saag MS3. HIV Clinic Capacity and Medical Workforce Challenges: Results of a Survey of Ryan White Part C-funded Programs. Ann Forum Collab HIV Res. Volume (13): 2011; 1-9.

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  5. Prices in the average were excluded when a membership program is required. Prices of flat generic rate of $4 or $5 offered exclusively through a big box store (e.g. Walmart) were also excluded. Extreme outliers are also not included in averages. Warehouse pricing was also excluded (e.g. Costco).

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  6. Gilead Sciences. (2015). Presentation from, Third Quarter 2015, Gilead Sciences Earnings Conference Call. Call held October 27, 2015. Presentation accessed 1/1/16, available at: http://investors.gilead.com/phoenix.zhtml?c=69964&p=irol-earnings.

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  7. Pollitz, K. (2016.) Surprise Medical Bills. Kaiser Family Foundation. Available at: https://www.kff.org/private-insurance/issue-brief/surprise-medical-bills/

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