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


First enacted in 1990, the Ryan White Program – the largest federal grant program designed specifically for people with HIV – has grown to become a critical part of the HIV health care delivery system in the U.S., providing care, treatment, and support services to more than half a million low-income people with HIV each year.1 The program is administered by the Health Resource Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) and functions as a safety net, filling in gaps in care for people with HIV. The Ryan White Program is a “payer of last resort,” meaning that whenever possible, services must first be reimbursed by other available payers (e.g., public or private health insurance) before Ryan White funds can be used.

Ryan White funds primarily pay for medical and support services and for the direct cost of medications for those who are uninsured or underinsured. Additionally, the federal government has authorized the use of program funds to assist clients in purchasing new health insurance or continuing existing insurance coverage, which includes paying for premiums, deductibles, co-payments, and co-insurance (see Table 1).  Using funds this way, compared to directly purchasing care and medications, can provide clients with more comprehensive health coverage than they might have been able to obtain on their own and has been shown to be cost effective for the program compared to the cost of directly purchasing medications.2

Table 1: Key Insurance Terms
Insurance Term Definition
Premium The amount owed to an issuer (health insurance company) on a monthly basis to keep a policy active, typically paid by an individual or a third party, such as an employer or the Ryan White Program.
Deductible The set dollar amount an individual enrolled in a plan must pay before the health plan starts to pay for services. Depending on the plan, an issuer may pay for certain services before meeting the deductible. Deductibles are sometimes covered by a third party, such as the Ryan White Program.
Co-payment A fixed amount an individual enrolled in a health plan pays “out-of-pocket” toward the cost of a covered health service such as a doctor’s visit, laboratory test, hospital visit, or a prescription drug. These may vary by type of service. Co-payments are sometimes covered by a third party, such as the Ryan White Program.
Co-insurance A fixed percentage of the total cost of a health service, such as a doctor visit, laboratory test, hospital visit, or a prescription drug that an individual enrolled in a health plan pays “out-of-pocket” towards that service. Co-insurance is sometimes covered by a third party, such as the Ryan White Program.

While insurance purchasing, also referred to as premium assistance or premium support, has been a permissible use of Ryan White funds since the program’s inception, its role has become both more important and more complex with the implementation of the Affordable Care Act (ACA). Because of the ACA, tens of thousands of people with HIV have new insurance options, with some accessing insurance coverage for the first time. Therefore, Ryan White grantees and sub-grantees – states, territories, cities, providers, and other organizations providing services to people with HIV (collectively referred to as AIDS Service Organizations or ASOs in this brief) – have new opportunities to assist clients with the costs of private health insurance. In fact, federal policy guidance has encouraged Ryan White grantees to provide this assistance where appropriate.3

While some Ryan White grantees have substantial experience using their funds for premium assistance, others are newer to this arena. Moreover, because the ACA has made significant changes to the health care environments in all states, even grantees with experience in insurance purchasing are facing new challenges and decisions. How Ryan White grantees at the state and local levels elect to move forward with insurance purchasing in the ACA era has key implications for the program and for clients’ access to coverage.

As such, it is important to examine the decisions around insurance purchasing that Ryan White grantees are making in the ACA era. Doing so will help provide an understanding of the various ways insurance purchasing programs are being implemented and allow for analysis of how these programs impact insurance coverage and ultimately health outcomes for people with HIV. This policy brief provides an early look at the insurance purchasing experiences of Ryan White-funded entities in five states – California, Florida, Georgia, New York, and Texas – during the first open enrollment period (October 2013 through April 2014). While Ryan White can assist with insurance purchasing and cost-sharing related to both public and private insurance, this report examines private insurance purchased through the health insurance marketplaces established under the ACA.

The report is based on interviews with more than 60 stakeholders across the five states (7-12 per state) 10 focus groups conducted with people with HIV (two per state), and a review of federal, state, and other documents. Stakeholders held a range of public and private positions in fields related to HIV service delivery and policy development. Interviews and focus groups were conducted between March and September of 2014, so may not reflect more recent decisions made within states with respect to insurance purchasing, particularly those occurring during subsequent open enrollment periods. In addition, the experiences of these five states and of those interviewed are not meant to be representative of all states or all people living with HIV.

Executive Summary Background

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