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The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States

Introduction
  1. 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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  2. See: Amanda Bowes, Ann Lefert, and Britten Pund. National Alliance of State and Territorial AIDS Directors (NASTAD). National ADAP Monitoring Project Annual Report. February 2014. Available at:  http://www.nastad.org/docs/NASTAD%20National%20ADAP%20Monitoring%20Project%20Annual%20Report%20-%20February%202014.pdf and Fakuda, Dawn. “‘Fitting the Ryan White Program & Health Care Reform Together, Experience in Massachusetts.” Presented for HIVHealthreform.org webinar, Working together, The Ryan White Program and Health Care Reform. 5/20/12. Presentation available at: http://www.hivhealthreform.org/webinars/webinar-archive/

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  3. 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

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Background
  1. Part A of the Ryan White Program funds the urban areas most significantly impacted by the HIV/AIDS epidemic. Part B funds all 50 states and U.S. Territories and includes, the AIDS Drug Assistance Program (ADAP) as well as other base and supplemental awards. Part C provides funds directly to public and private organizations to provide primary care and support services to people with HIV. Part D funds public and private organizations to provide family-centered and community-based services to children, youth, and women living with HIV and their families. For more detail see the Kaiser Family Foundation factsheet on the Ryan White Program: https://www.kff.org/hivaids/fact-sheet/the-ryan-white-program/

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  2. M. Danielle Davis, et al. National ADAP Monitoring Project Annual Report. May 2004. Available at: https://www.kff.org/wp-content/uploads/2013/01/national-adap-monitoring-project-2004-annual-report.pdf;

    [ii] Amanda Bowes, Ann Lefert, and Britten Pund. National Alliance of State and Territorial AIDS Directors (NASTAD). National ADAP Monitoring Project Annual Report. February 2014. Available at:  http://www.nastad.org/docs/NASTAD%20National%20ADAP%20Monitoring%20Project%20Annual%20Report%20-%20February%202014.pdf

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  3. Under the ACA states were required to expand their Medicaid programs to all eligible adults up to 138% of the federal poverty level. However, a Supreme Court decision effectively made Medicaid expansion a state option by taking away the federal enforcement mechanism. While most low-income adults are eligible for this program in expansion states, beneficiaries must meet citizenship requirements, not be incarcerated, and be ineligible for Medicare, along with meeting the income requirements.

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  4. See Sections 2605(a)(6), 2617(b)(7)(F), 2664(f)(1), and 2671(i) of the Public Health Service Act.

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  5. 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

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  6. CMS Interim Final Rule “Patient Protection and Affordable Care Act; Third Party Payment of Qualified Health Plan Premiums.” CMS–9943–IFC.  (March 2014)

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  7. Lambda Legal. Press Release: Lambda Legal Files Federal Lawsuit Against Louisiana Insurers for Dumping People With HIV. September 20, 2014. August 29, 2014:  http://www.lambdalegal.org/news/20140220_la_lambda-legal-files-federal-lawsuit-against-insurers

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  8. Sharon Begley. “Louisiana insurers to accept funds from federal AIDS program for Obamacare premiums.” Reuters, March 10, 2014. Accessed August 29, 2014: http://www.reuters.com/article/2014/03/10/obamacare-aids-idUSL2N0M71Y220140310

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  9. In addition to pursuing enrollment in the private market, ADAPs have also worked to enroll eligible clients in Medicaid expansion programs, in states expanding their programs. In addition, ADAPs in all states are able to enroll clients who were previously eligible but not enrolled in the traditional Medicaid program.

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  10. One reason that ADAPs were particularly interested providing assistance for QHPs, rather than other forms of private coverage, is because many Ryan White clients would be eligible to receive subsidized coverage based on their incomes which is only available through coverage purchased on the health insurance marketplaces.

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  11. KFF NASTAD Correspondence

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  12. Amy Killelea. Ryan White Part B Services The Impact of State Health Care Reform. HIVHealthrefom.org Webinar Series. June 24, 2014. Available at: http://www.hivhealthreform.org/wp-content/uploads/2014/06/6_Month_ACA_Checkup_slides.pdf

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Findings
  1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2013; vol. 25. February 2015.

    http://www.cdc.gov/hiv/pdf/g-l/hiv_surveillance_report_vol_25.pdf.

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  2. Pre-Existing Condition Insurance Plans (PCIPs) are high risk pools created through the ACA as a precursor to the marketplaces for those denied access to the private insurance market

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  3. In 2012, almost 90% of Ryan White clients were below 200% of the Federal Poverty Level, (Ryan White HIV/AIDS Program 2012 State Profiles http://hab.hrsa.gov/stateprofiles/Client-Characteristics.aspx#chart6).

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  4. Discussion of Part A activities are provided as examples. Insurance purchasing activities in all Part As in each state are not recounted.

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  5. Correspondence with Patient Access Network Foundation.

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  6. While not the case in the states examined here, early numbers indicate that overall QHP premium assistance has played a more significant role in states not expanding their Medicaid programs.

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  7. 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

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  8. Since the first open enrollment period, HRSA has provided additional information on what is meant by vigorously pursing enrollment, including in disseminating information to grantees through webinars. See http://hab.hrsa.gov/affordablecareact/webinars/ryanwhiteprogramaffordable.pdf and https://careacttarget.org/calendar/ryan-white-grantees-and-advanced-premium-tax-credits.

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Appendix
  1. LIHPs were county run and LIHP eligibility limits varied by county of residence. In addition a few counties in the state did not participate in the program at all.

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  2. Bowes, Lefert, and Pund. National ADAP Monitoring Project Annual Report. February 2014.

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  3. Bowes, Lefert, and Pund. National ADAP Monitoring Project Annual Report. February 2014.

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  4. California State Budget 2015-2015. Available at http://www.ebudget.ca.gov/

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  5. Florida Department of Health and Health Council of South Florida, Inc. presentation. AIDS Insurance Continuation Program (AICP). Accessed 10/27/14 available at: http://www.theaidsinstitute.org/sites/default/files/attachments/AICP.pdf

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  6. Bowes, Lefert, and Pund. National ADAP Monitoring Project Annual Report. February 2014.

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  7. Florida Department of Health, Division of Disease Control and Health Protection, Bureau of Communicable Diseases.  Ryan White Part B AIDS Drug Assistance Program (ADAP). March 2014. Available at: http://www.floridahealth.gov/%5C/diseases-and-conditions/aids/adap/_documents/ryan-white%20part-B-ADAP-march.pdf

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  8. Cost-sharing for HIV drugs can be as much as 50% of the cost of a drug costing more than $2,000 and deductibles, especially for bronze level plans, were sometimes upwards of $6,000.

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  9. Bowes, Lefert, and Pund. National ADAP Monitoring Project Annual Report. February 2014.

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  10. Bowes, Lefert, and Pund. National ADAP Monitoring Project Annual Report. February 2014.

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