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

These state case studies provide a closer look at how each of the five states covered in this report – California, Florida, Georgia, New York and Texas – have elected to use Ryan White funds for insurance purchasing in the ACA era. Findings are based on early experiences during the first open enrollment period and focus on ADAP premium assistance for QHPs, although assistance provided by other entities is also examined where appropriate. Past and ACA era experiences and decision making around insurance purchasing are summarized in each state case study below.


California’s ADAP had relatively robust health insurance purchasing experience prior to the ACA, including in assisting with private insurance. This experience, coupled with new insurance options available in the state-run health insurance marketplace, provided a solid foundation to pursue insurance purchasing of QHPs in the ACA era. However, despite this experience, challenges arose. These were largely related to the process of aligning the existing purchasing system with the realities of the new health insurance landscape, utilizing older systems for larger scale enrollment, and the ADAP’s relationship as a third party payer to insurance companies.  While most insurance purchasing occurred via the state’s ADAP, Ryan White Part As and ASOs played an important role in easing some of the transition challenges faced by the ADAP, including providing assistance when coverage might have otherwise lapsed. Despite these obstacles, which caused significant problems for some, once enrolled and were premiums paid, clients reported satisfaction with the ability of ADAP to provide assistance with coverage. While some clients continue to face high out-of-pocket costs, others are paying significantly less than in the past and have expressed relief at the protections afforded with insurance coverage offered through the ACA. Specific details that emerged from the research include:

Key ACA Decisions with Implications for Ryan White Insurance Purchasing

California created its own state-run health insurance marketplace called Covered California, and elected to expand its Medicaid program to eligible adults under 138% FPL. In addition, as of 2011, many in the state had access to expanded Medicaid coverage prior to the ACA through an 1115 Medicaid Demonstration Waiver. This demonstration project, known as the Low Income Health Program (LIHP), allowed counties to expand eligibility to up to 200% FPL and aimed to serve as a “bridge” to full Medicaid expansion under the ACA. Stakeholders believed that having clients enrolled in this early expansion made for easier transitions to both Medicaid expansion under the ACA (for those up to 138% FPL) and to QHPs with premium support (for those above 138% FPL).  Given that most Ryan White clients have relatively low incomes and because the payer of last resort requirement means that clients must enroll in other coverage if it is available, many were thought to have been enrolled in the LIHP programs leading up to 2014.1

Pre-ACA Experience with Insurance Purchasing

California’s Ryan White Program had an insurance purchasing infrastructure through its ADAP in place prior to the ACA.  As of June 2013, 8,973 individuals, or 40% of ADAP clients in the state, were being served through insurance purchasing, including for private insurance.2  California had a greater number of ADAP clients engaged in premium support than any other state at this time.3

ADAP Role in Premium Support Under the ACA

Ahead of the 2013-2014 open enrollment period, California prepared to move eligible Ryan White clients into QHP coverage and provide insurance purchasing assistance. However, understanding that engagement of clients in new systems sometimes takes time, knowing many clients would gain Medicaid coverage, and because the ADAP could not assist with all out-of-pocket costs, the initial wave of enrollees was expected to be modest.

The state Office of AIDS’-Health Insurance Purchasing Program (OA-HIPP) uses ADAP funds to manage insurance purchasing efforts. OA-HIPP encouraged eligible clients, including those who had been in the LIHP and had incomes higher than Medicaid eligibility level (some LIHP enrollees had incomes up to 200% FPL), to enroll in QHPs. In addition to providing access to more comprehensive health coverage, stakeholders reported that encouraging enrollment met the “vigorously pursue” policy and fulfilled the payer of last resort requirement.

OA-HIPP provided assistance with premiums and cost-sharing for HIV prescription medications. Other cost-sharing assistance however, such as for physician visits, laboratory tests, and non-HIV medications, was not provided. Despite the fact that insurance in the state of California had lower caps on out-of-pocket spending than federally required, stakeholders worried that costs not supported through the state program would be unaffordable for some clients and result in clients not enrolling or using their QHP coverage once enrolled. In an effort to address these concerns, California Governor Jerry Brown included a proposal to provide comprehensive support for premiums and all cost-sharing for ADAP clients in the revised May 2014 state budget, signed into law in June 2014.4 While this will likely provide financial relief for clients in the future, this more comprehensive assistance does not go into effect until January 2016.

Despite a clear interest in fostering an ADAP that could wrap around QHPs, some stakeholders questioned whether the state was capable of meeting increased demand, even at the low levels projected for the first year. Going into the 2013-2014 open enrollment period there were concerns that the system was still manual and paper-based rather than online and synched with other electronic eligibility and enrollment systems. Stakeholders reported that the state struggled with administrative issues and that current systems need updating in order to handle the increase in client load as new individuals gained coverage and leveraged insurance purchasing support. These updates include enhancing mechanisms for enrollment and getting checks out to issuers in time to meet premium payment due dates. While the state has future plans to update these systems, stakeholders reported that these adaptations had been incremental and did not immediately address problems.

As a result of these challenges, stakeholders reported that some clients faced significant problems in enrolling in coverage with OA-HIPP assistance, including experiencing long enrollment delays and not having premium payments get to issuers in time to meet payment due dates. Some stakeholders reported three to four month enrollment delays. In some cases, clients reported having to front the first several months of premiums in order to retain coverage. In other situations, clients were dis-enrolled from their insurance when the OA-HIPP payment did not make it to the issuer in time. Stakeholders explained that it was sometimes difficult to assess whether complications were a result of enrollment and processing delays on the ADAP end or because of problems at the issuer end (e.g. not knowing how to process third party payments or accurately attributing them to client’s accounts).

Despite these sometimes significant challenges, stakeholders believed that the early Medicaid expansion along with the ADAP’s previous experience with premium assistance helped the state prepare for the transition of clients into QHP coverage in 2014.

Non-ADAP Cost-sharing Assistance

In some instances, county Part A programs and AIDS Service Organizations (ASOs), funded through parts of Ryan White (Part A and non-ADAP Part B) helped address the initial enrollment delays and other hurdles to ensure that coverage was maintained and interruptions minimized, often temporarily assisting with payments. For instance, the Orange County Part A stepped in to help clients with premiums as a stop-gap measure while third party payment delays were resolved with ADAP


Despite getting off to a late and challenging start, Florida did get a very limited pilot program off the ground at the close of the first open-enrollment period. Prior to the ACA, the Florida ADAP had more experience in continuing COBRA or PCIP coverage for clients than in purchasing new private coverage. In addition, the state did not choose to expand Medicaid, which meant coverage options for clients overall were fairly limited during the first open enrollment. Stakeholders explained that overarching state resistance to ACA implementation, at levels above that of the ADAP office, initially made pursuing widespread insurance purchasing more challenging. However, stakeholders described the pilot program as a first step and anticipated greater engagement with insurance purchasing in the future. Specific details that emerged from the research include:

Key ACA Decisions with Implications for Ryan White Insurance Purchasing

Florida did not create its own health insurance marketplace and thus defaulted to the federal-facilitated marketplace, In addition, Florida did not expand its Medicaid program to eligible adults under 138% FPL.

Pre-ACA Experience with Insurance Purchasing

Florida first began using Ryan White funding for insurance purchasing in 1989 through a limited demonstration project, the AIDS Insurance Demonstration Project. This was expanded to serve individuals statewide in 1994 and later rebranded as the AIDS Insurance Continuation Program (AICP), now part of ADAP.5 AICP assists enrollees who already have insurance with maintaining their private health coverage, including those with COBRA policies. It is also not available to all those with HIV served by ADAP as it requires that an individual have an AIDS diagnosis or be HIV symptomatic. As of June 2013, 2,745 ADAP clients, or 20% of all state ADAP clients,6 were served through insurance purchasing or continuation, the majority of who were enrolled in AICP. The state had far less experience with supporting client enrollment directly into the private market.

ADAP Role in Premium Support Under the ACA

According to stakeholders, the state ADAP was not fully prepared to assist Ryan White clients with their QHP premiums during the first open enrollment season. At the start of the open-enrollment period, there was considerable confusion among ASOs, advocates, and, in some cases, Ryan White Part As, as to whether the ADAP office would offer insurance purchasing assistance for clients enrolling in QHPs. Stakeholders explained that the ADAP faced significant constraints as to what information could be released about their plans to pursue insurance purchasing given the resistance to ACA implementation at the state level. Many had heard that the ADAP had plans to cover premiums, but had little idea of a timeline or an implementation agenda. As a result, some stakeholders were frustrated by a lack of communication from the ADAP office and perceived inaction. Further, some worried about how grantees and sub-grantees could comply with the need to “vigorously pursue” enrollment into QHPs if there was no premium support available through the state’s ADAP office.

On March 7, 2014, just shy of when the first open enrollment period was expected to close, the ADAP released a memo announcing pilot project for approximately 500 clients meeting certain criteria for enrollment into QHPs with premium support.7  About 60 clients ultimately enrolled in QHPs through the pilot and were supported with premium assistance and cost-sharing assistance for HIV medications. Most of those taking part had prior coverage, many transferring from the AICP and the state PCIP. Only a small handful of those clients enrolled in QHPs through the pilot were previously without another other form of coverage.

The existing AICP provider was enlisted to coordinate enrollment and third party payments. Stakeholders expressed concern about the ability of the AICP provider to handle QHP enrollment and third party payments in the future when enrollment was expected to increase. Similar to the frustrations expressed in California, some stakeholders noted that the current system for enrollment and third party payments relied on manual processes and out-of-date technology with limited capacity.

Lastly, stakeholders expressed concerns about the level of communications about the pilot project. For instance, the ADAP selected certain QHPs it determined to be cost-effective and would support with premium assistance, but that information was not clearly communicated externally. As a result, some clients enrolled in plans the ADAP was unable to support. It was expected that many clients who enrolled in these unsupported plans would be unable to maintain coverage as a result of high out-of-pocket costs, particularly those associated with drug cost-sharing (i.e. coinsurance and copayments) and deductibles.8

Non-ADAP Cost-sharing Assistance

Over the course of the first open-enrollment period, Part As in the state were concerned with whether and when the ADAP would establish a QHP insurance purchasing program and what their role should be as they attempted to plan for their clients’ needs. Some wrestled with whether it was feasible to provide insurance purchasing out of their own budgets as a stopgap measure to help clients enroll in QHPs. Ultimately, Part As made different decisions. Broward County, for instance, decided not to pursue premium assistance because they were unable to find such a program to be cost-effective, as required by HRSA. The Miami-Dade program did elect to pursue insurance purchasing for clients, using an ASO to enroll a small number of individuals into coverage and assisting with premiums and cost-sharing. However, stakeholders report that they approached premium assistance cautiously in view of finite funding and there have been reports of limited success in light of the difficulty in assessing overall costs to the program.  In addition, some clients who enrolled in plans without ADAP assistance sometimes relied on industry Patient Assistance Programs (PAPs) and other non-profit assistance programs to help meet out-of-pocket costs.


At the close of the first open enrollment period, insurance coverage remained limited for Ryan White clients in Georgia. The state did not choose to expand Medicaid and QHP premium support through the state’s ADAP did not take hold until after the first open enrollment period opened. Once the program got off the ground, the majority of those enrolled had previous coverage through the state PCIP. Additionally, stakeholders explained that state resistance to ACA implementation made pursuing insurance purchasing more challenging for Ryan White grantees, including the state’s ADAP program.  Specific details that emerged from the research include:

Key ACA Decisions with Implications for Ryan White Insurance Purchasing

Georgia did not create its own health insurance marketplace and thus defaulted to the federal-facilitated marketplace, In addition, Georgia did not expand its Medicaid program to eligible adults under 138% FPL.

Pre-ACA Experience with Insurance Purchasing

Prior to the ACA, Georgia’s ADAP program had little capacity to assist with premiums, doing so mainly for PCIP and COBRA clients. The ADAP was not experienced with enrolling clients into private insurance.

ADAP Role in Premium Support Under the ACA

Both the ADAP and the Atlanta metro region, Fulton County, Part A (the only Part A in the state) shared a commitment to develop an insurance purchasing infrastructure for QHP assistance by allocating funds to the program. However, there were delays in implementing insurance purchasing in the state. Stakeholders explained that ADAP was constrained by a state policy environment that made planning related to the ACA highly sensitive, including making it challenging for some Ryan White grantees to discuss implementation openly, which complicated their ability to meet the requirement to “vigorously pursue” coverage. Others felt that expectations around the requirement to “vigorously pursue” enrollment lacked clarity and highlighted this as an additional obstacle.

Stakeholders also noted that delays in contracting with the pharmacy benefits manager (PBM) that would administer the program, contributed to the slow implementation of the insurance purchasing program. QHP insurance purchasing did not begin until after enrollment opened during the first season and was relatively modest in scope. During the first open enrollment period, between 200-300 individuals with HIV enrolled in QHPs with ADAP premium support but without other cost-sharing assistance. Many of these clients were brought in from the state pool of about 190 Ryan White PCIP enrollees.  Stakeholders believed that with the PBM in place, QHP insurance purchasing would be rolled out to a greater number of ADAP clients in future open enrollments.

Stakeholders across the state have had some concerns about the affordability of plans once clients were enrolled. In particular, the high-level of cost sharing associated with HIV drugs in some plans raised questions about whether clients would be able to afford treatment even when premiums are covered through the insurance purchasing program.

Non-ADAP Cost-sharing Assistance

Some stakeholders reported hearing that clients were going without drugs as a result of the limited cost-sharing assistance, but that, in most cases, clients and ASOs were able to take measures, such as linking clients to PAPs and foundations, to provide financial assistance to prevent gaps in treatment. In addition, in August 2014, the Part A, which serves approximately 80% of the state’s Ryan White clients, established a program for clients to access cost-sharing assistance by awarding funds to three of their 15 partner agencies to distribute. However, it was unclear at the time how many people could be served.

New York

New York’s ADAP had an insurance purchasing system in place with the ability to enroll clients into the private market in advance of the ACA. As a result, many clients were able to transition into marketplace coverage with insurance assistance with relative ease. While challenges did arise and had real implications for individual enrollees, stakeholders reported that systems within the state appeared ready to enroll ADAP clients in QHPs with premium and cost-sharing support. The initial barriers experienced in New York related to coordinating third party payments when enrolling Ryan White clients into QHPs with premium support, but in most-cases these were surmountable obstacles. Specific details that emerged from the research include:

Key ACA Decisions with Implications for Ryan White Insurance Purchasing

New York established a state-based marketplace called New York State of Health and elected to expand its Medicaid program to eligible adults under 138% FPL. In addition to expanding its Medicaid program, prior to 2014, New York’s state Medicaid included eligibility for parents up to 150% FPL and up to 100% FPL for childless adults. Under the ACA, like in California, stakeholders saw this early expansion as contributing to smoother enrollment into ACA-era Medicaid and QHP coverage, for those 138% FPL to 150% FPL.

Pre-ACA Experience with Insurance Purchasing

In June 2013, 28% of ADAP clients were served through insurance purchasing or continuation.9  Because the state had gone through an early Medicaid expansion, a large number of ADAP clients received coverage through that program, which is why despite having a fairly robust insurance purchasing program ahead of the ACA, the share of clients relying on that support might be lower than expected.

ADAP Role in Premium Support Under the ACA

During the 2013-2014 open enrollment period, approximately 2,800 new clients gained access to QHP coverage with premium and full cost-sharing support, including about 1,200 individuals transitioning off of PCIP coverage. Many ADAP clients were enrolled in New York’s expanded Medicaid program prior to the 2014 open enrollment period. Those who had incomes above 138% FPL were encouraged to move into QHP coverage. The state Part B program conducted outreach to providers and clients regarding QHP enrollment and plan selection to help this process go more smoothly. Those below 138% FPL retained Medicaid coverage, most moving into the Medicaid expansion population at recertification. A range of stakeholders report that the early Medicaid expansion program coupled with an existing insurance purchasing infrastructure in advance of open enrollment allowed for a fairly smooth transition of clients into QHP coverage in 2014.

While New York ADAP clients had access to the premium assistance program and enrollment was fairly straightforward, process issues surfaced in getting the first premium payments to plans on time. Stakeholders also reported challenges in making sure that ADAP premium payments were credited to the right client accounts. They explained that issuers typically do not provide a policy number to an enrollee until a first premium is paid, but that ADAP needs a policy number to ensure premium payments were applied to enrollee accounts accurately. In some cases this “catch-22” caused confusion and enrollment delays. Stakeholders also reported instances of enrolled clients receiving bills from insurance companies that would be due with very little notice, making timely third party payment difficult. Despite ADAP efforts to turn payments over quickly, occasionally the timeframe would be too short and an enrollee would be terminated. Although stakeholders reported that the ADAP office and case-workers moved quickly to resolve these issues, fixes became more challenging after open-enrollment closed.

Non-ADAP Cost-sharing Assistance

Stakeholders spoken to for this study report that the ADAP insurance purchasing systems is working smoothly enough in New York so that ASOs and Part As have not needed to commit funds to provide this type of assistance.


In Texas, health insurance coverage options for Ryan White clients remain limited in the ACA era. Texas did not expand its Medicaid program, nor has its ADAP been able to provide insurance purchasing for QHPs. Stakeholders surmise that ADAP has been unable to provide insurance purchasing support as a result of a larger state policy environment that has been resistant to ACA implementation rather than as a result of decision making out of the ADAP office. ASOs and Part As have played an important role in making insurance coverage possible in the regions they serve when ADAP could not. Specific details that emerged from stakeholder interviews and other research include:

Key ACA Decisions with Implications for Ryan White Insurance Purchasing

Texas did not create its own health insurance marketplace and thus defaulted to the federal-facilitated marketplace, In addition, Texas elected not to expand its Medicaid program to eligible adults under 138% FPL.

Pre-ACA Experience with Insurance Purchasing

Texas has had limited experience using Ryan White funding for insurance purchasing. As of June 2013, about 1,500, or 14%, of ADAP clients received premium support or continuation assistance.10 Most of this support assisted Medicare beneficiaries with Part-D costs. In addition, the state had a small pre-ACA pilot program for insurance purchasing, unrelated to QHPs, which reached about 150 ADAP clients, primarily focused on supporting client’s COBRA coverage and high-cost employer plans.

ADAP Role in Premium Support Under the ACA

Beyond the limited activities described above, there is no other Ryan White insurance purchasing within the ADAP, including for QHPs. Stakeholders throughout Texas described state opposition to ACA implementation has as having impacted ADAP’s ability to move forward with developing a premium assistance program that supports QHP purchasing. The ADAP has not yet received permission from the state to use funds for QHP premium assistance, despite stakeholder expectations that such a program would be cost-effective. Similarly, stakeholders surmise that the inability of the ADAP office and Part B to be more communicative with sub-grantees, Part As, and community members, about aligning Ryan White programs with the ACA, including around the requirement to vigorously pursue enrollment, is a result of the larger state policy environment.

Non-ADAP Cost-sharing Assistance

Because the state did not actively use ADAP funds to support enrollment in QHPs through insurance purchasing, some Part As, which appear to have faced less restrictions, have stepped in to provide assistance where possible, typically through ASOs. Access, however was often dependent on living within particular service areas. For instance, the Houston area Part A (Harris County) is using Ryan White dollars to assist clients with insurance premiums and cost sharing. The Part A partnered with a local ASO to deliver these services. Approximately 90-95% of the Part A clients enrolled in QHPs reportedly received some kind of financial assistance to help with the costs of coverage.

The Dallas Part A reallocated some of their funds from their outpatient medical services category to their health insurance services category as a result of the ACA and anticipate that more funding will be needed for insurance purchasing in the future. The Dallas Part A funds a handful of programs to provide insurance assistance and has done so historically, prior to the ACA. The largest funded program is an ASO that has offered premium assistance for approximately 20 years and had nearly 400 clients enrolled in the program in 2013. This ASO continues to provide insurance purchasing assistance for local clients through QHPs. However, stakeholders note that funding is limited and dependent on grant cycles, which has meant that, on occasion, the program has put new enrollment on hold as it waits for funding.



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