Here you will find answers to frequently asked questions about the Ryan White Program and the Affordable Care Act. To learn more about Ryan White and the Affordable Care Act, including resources, guidance, and policy notices, check out Ryan White & the Affordable Care Act: What You Need to Know.
How should AIDS Drug Assistance Program (ADAP) deal with transitioning patients into the new insurance options created under the Affordable Care Act? How can they address key challenges such as increased cost-sharing in the Health Insurance Marketplace as compared to ADAPs?
The HIV/AIDS Bureau expects grantees to aquire knowledge and expertise regarding the Affordable Care Act and the key components being implemented in their states. Grantees should be familiar with the different Medicaid, Medicare, and private insurance plans available to assist their clients in choosing the best option for their health care coverage needs such as ensuring that medications they will need are available to them at a cost they can afford and an HIV/AIDS provider is included in their plan’s provider network.
ADAP funds may be used to cover costs associated with a health insurance policy, including co-payments, deductibles, or premiums to purchase or maintain health insurance coverage. See policy notices 13-05 and 13-06 for additional information. Grantees should inform their clients if ADAP will provide insurance premium assistance and/or copayment and deductible assistance and if there are specific plans that the ADAP will be working with. For patients eligible for coverage through private insurance in the Marketplace, navigators, non-navigator assistance personnel, certified application counselors and insurance brokers can also assist in understanding the different options available, premium tax credits and other mechanisms available to make purchasing insurance affordable.
Will the State ADAP funding still be available for persons enrolled in a Health Insurance Marketplace or will their medications need to come under the new health insurance coverage options?
Ryan White HIV/AIDS Program (RWHAP) Part B ADAP funds will continue to provide completeness of coverage for needed pharmaceutical services. If a patient has health insurance with pharmacy benefits through the Health Insurance Marketplace or other private insurance, that insurance should pay for medication. ADAP may assist clients with the co-pays and deductibles for medications. If an HIV-related medication is not covered, then RWHAP ADAP may pay. Further, ADAP funds may be used to cover any costs associated with a health insurance policy, including co-payments, deductibles, or premiums to purchase or maintain health insurance coverage as outlined in. Policy Notices 07-05 and 13-05.
Will ADAP monies be available past January 1, 2014 for those have not yet enrolled in a health plan for which they are eligible?
The HIV/AIDS Bureau expects that all grantees will comply with payer of last resort, and vigorously pursue enrollment of eligible clients. Each State ADAP makes determinations regarding support for health coverage depending on the availability of funds and other program administration factors. Please contact your State ADAP for more information.
Some states or counties will be offering extra subsidies/incentives to enroll low-income individuals into private insurance. How will these subsidies affect ADAP enrollment and RWHAP participation?
These subsidies/incentives do not affect ADAP enrollment and RWHAP participation. RWHAP legislation requires that RWHAP funds only be used as a payer of last resort and clients eligible for health insurance should be enrolled in private coverage. Clients may still continue to be eligible for ADAP and RWHAP services and receive assistance with premiums, copayments, deductibles and receive RWHAP services that are not covered or are partially covered by other payer sources.
Should clients be advised to stay with their COBRA policies until they expire and then enroll in the Marketplace?
The RWHAP expects grantees to conduct a cost-effectiveness analysis to determine whether an insurance plan may be paid for the RWHAP. Policy Clarification Notice #13-05 states that “The grantee must determine how to operationalize the health insurance premium and cost-sharing assistance program, including the methodology used by the grantee to: (1) assure they are buying health insurance that, at a minimum, includes pharmaceutical benefits equivalent to the HIV antiretroviral and opportunistic infection-related medications on the Part B ADAP formulary as well as coverage for other essential medical benefits; and (2) assess and compare the aggregate cost of paying for the health insurance option versus paying for the full cost for medications and other essential medical services.”
It is my understanding that since my State will have a federally run Marketplace, the only insurance options will be the 'silver' level plan for anyone with a pre-existing condition like HIV/AIDS. Is this correct?
Clients have the option of selecting and purchasing the insurance plan at any level that suits their needs. The Health Insurance Marketplace insurance group plans are categorized into four levels: Bronze, Silver, Gold, and Platinum, based on cost sharing. All Marketplace insurance plan categories must include essential health benefits, but the Silver Plan will be the benchmark for premium tax credits and cost-sharing reductions. People living with HIV/AIDS (PLWH) will have to weigh their new insurance options carefully. They need to consider the availability of appropriate specialists, pharmacy formularies, other insurance options, and the availability of health care and pharmacy assistance, as well as the cost associated with co-pays, premiums, and other cost sharing options. For more information click here.
For PLWH, especially those who make more than 133 percent of the Federal Poverty Level (FPL), will their decisions be more complex (and require more input) than the insurance information offered through a Health Insurance Marketplace? Should RWHAP providers explain the extra benefits the new insurance coverage options will have over Ryan White (i.e., emergency room and inpatient care)?
Making decisions about health insurance is difficult for everyone. For PLWH, the decision about which insurance to buy in the Marketplace is especially important because their decision must be based on the type of coverage needed for things like prescription drug coverage and expenses the client is able to afford, and if the plan's network includes an HIV/AIDS provider. RWHAP providers should make every effort to educate their clients about the changes the Affordable Care Act brings, to inform clients of coverage options, and to help them make educated decisions about their choice of health plans. There are several sources of information that are available now and more will become available as we approach 2014. The primary public source for information pertaining to the Affordable Care Act and health insurance coverage is www.HealthCare.gov. HealthCare.gov provides individuals seeking assistance with applying for health insurance coverage with a 24/7 toll-free call center (1-900-318-2597) and 24/7 website chat. In-person assistance in the form of navigators, non-navigator assistance personnel, certified application counselors, and insurance agents and brokers will also available to provide important information on health care coverage options, health care access points, and enrollment. More information on where to find in-person assistance will be forthcoming on HealthCare.gov.
Should PLWH who currently receive services through RWHAP talk to their ADAP enroller before going to the State-based Health Insurance Marketplace to purchase health insurance?
Yes, RWHAP clients should work with their ADAP eligibility specialist to discuss the most appropriate coverage options.
If a plan does not include any RWHAP or HIV providers can a person with HIV switch plans or is there any recourse to access HIV care?
It is critical that PLWH carefully weigh all of their options when choosing a health plan to ensure the HIV and other services they require are included in the plans they are considering. If you wish to continue seeing your current RWHAP provider, you must confirm that they are considered an in-network provider with your new insurer. Once a person enrolls in a health insurance plan, he or she cannot switch plans unless he or she qualifies for a special enrollment period based on a qualifying life event, such as moving to a new state, eligibility changes for premium tax credits and/or cost-sharing reductions, or loss of employer-sponsored coverage. Once a client is enrolled in a private health plan, RWHAP funds may only be used to pay for any services not covered, or partially covered, by the client’s private health plan. PLWH cannot utilize RWHAP funded services solely because their current provider is not in-network with their new plan. If they are eligible for coverage through the Marketplace, they must find coverage to meet their needs.
Is it suggested that a client take the premium tax credit upfront when enrolling in the Marketplace?
Every client must review their individual circumstances to decide on the best choice. Advance payments of the tax credits can be used right away to lower the client’s monthly premium costs. If a client qualifies for a tax credit, he or she may choose how much advance credit payments to apply to his or her premiums each month, up to a maximum amount. When clients apply for coverage in the Marketplace, it is important for them to double check the information they put on their application. If the amount of their expected annual income they report is not accurate, they may not get the right amount of savings. If they wind up making more money than they predicted on their application, they could have to pay back some or all of the savings they received. Learn more about premium tax credits and how clients can estimate income for their Marketplace application.
Will the help with Marketplace and Medicaid enrollment end after March 31, 2014, or could a grantee build this activity into their program long term?
RWHAP grantees are encouraged to continue to assist clients with Marketplace and Medicaid enrollment throughout the year. Although the initial open enrollment period closes on March 31, 2014, some individuals may qualify for special enrollment periods. Further, annual open enrollment in the Marketplace will begin on October 15 and close on December 7 each year. In addition, Medicaid enrollment will continue throughout the year and is not confined to the Marketplace’s open enrollment periods. Building outreach and enrollment activities into their program long-term can further ensure RWHAP funds are used by grantees in a cost-effective way.
Can you explain how out-of-network service affects RWHAP?
RWHAP funds may NOT be used to pay for services a client receives out-of-network, unless they are services that a client could NOT have obtained from an in-network provider. For example, Mr. Sanchez needs resistance testing. He has ABC insurance, which will pay for the test, and he is also a RWHAP client. Lab A is in-network, but it is across town from Mr. Sanchez. Mr. Sanchez chooses to go to Lab B because it is closer, but it is not in-network with ABC insurance. Thus, RWHAP funds may NOT be used to cover Mr. Sanchez’s test because he could have received that test from an in-network provider and had the service paid for by ABC insurance.
In Part A, can RWHAP funds be used to pay for higher “tiered” copayments in “tiered” networks (networks that require individuals to pay more to see some providers)?
Yes, RWHAP funds may be used to pay for higher copays and deductibles within “tiered” networks, since providers in any covered tier are not considered out-of-network. Grantees must consider availability of resources prior to making such allocations. Specific to RWHAP Part A grantees, this determination will be made by the Planning Council as part of its priority setting/resource allocation processes and implemented by the grantee.
Can RWHAP Part B ADAP rebates be used to pay for premiums, copayments, and deductibles?
Yes. ADAPs can use rebate dollars to pay for premiums, copayments, and deductibles. If an ADAP chooses to pay Medicaid prescription copays and prescription deductibles for an ADAP-eligible person, the ADAP cannot collect the 340B rebate as that would be double-dipping.
For PLWH, including those who are below 400 percent of FPL (but above 133 percent of FPL) who receive insurance through the Health Insurance Marketplace at a discounted rate, can RWHAP dollars be used to pay for insurance premium, deductibles, and co-pays?
Yes, Parts A, B, C, and D of the RWHAP will still be able to assist clients with co-pays, insurance premiums, and deductibles in allowable circumstances and as part of core medical services. Please see Policy Notice 13-01 for more information on using RWHAP funds for this purpose. The HIV/AIDS Bureau projects that this core medical service will increasingly be a priority. This is based on a review of the need, circumstance, and cost-effectiveness of assisting with full insurance coverage. While the HIV/AIDS Bureau will not require that RWHAP Part A jurisdictions or Part C or D grantees use criteria identical to RWHAP Part B, we recommend that discussions occur to explore the possibility of common criteria, as well as the possible integration of RWHAP Part A and B funds into a single effort, similar to allocations that EMAs/TGAs currently make to the State ADAP.
My state will use the Federally-facilitated Marketplace and will not expand Medicaid. We currently use RWHAP dollars for premium assistance. Will we still work directly with the insurance companies to pay for premiums following the Affordable Care Act implementation?
Yes, you will continue to work directly with the health insurance companies, including making direct payments to the health insurance company for premiums, co-payments, and deductibles.
If a client receives assistance with premiums through the Marketplace, can he or she also request additional assistance with premiums through RWHAP's Health Insurance Continuation services program?
Yes, RWHAP is able to assist clients who receives assistance with health insurance premiums (premium assistance, tax subsidies, etc.). Clients should check with their RWHAP Part to determine if such support is available. See Policy Notice 13-01 for more information on using RWHAP funds for this purpose.
How will premium assistance payments occur in both the State-based Marketplace and the Federal Marketplace?
State-based marketplaces have the flexibility to implement a process for premium aggregation. Any entity including a RWHAP grantee that wants to be able to pay premiums on behalf of an individual would need to work with the State-based marketplaces to develop or establish a process that will facilitate the aggregation of premium payments.
For at least the first year, the Federally-facilitated Marketplace will not establish a process that facilitates premium sponsorship or allows organizations to pay premiums on behalf of enrolled individuals. Any organization that wants to make such payments will need to work directly with the issuers (health insurer) or with the individuals to help pay these premium payments. As always, cash payments to individuals are not allowable.
If a client’s recertification would normally occur at the end of August, could the grantee push that client’s recertification process forward to October to align with the Affordable Care Act enrollment process?
We encourage grantees to seek opportunities to align existing RWHAP recertification processes with their Affordable Care Act outreach and enrollment activities.
Could you please provide guidance regarding the tax credits associated with the Affordable Care Act? If I understand this section of the Affordable Care Act correctly, premium tax credits will be both refundable and “advanceable.” So, if a RWHAP client chooses the reimbursement in a “lump sum” after they file their Federal income tax, with the assumption that RWHAP will pick up the costs during the year. If the client receives a reimbursement on their taxes, will RWHAP Part A be eligible for the reimbursement from that client? Some RWHAP clients have Federal debt, and, therefore, the Federal government keeps their “refund.” Is HRSA going to make it a requirement that clients must elect to receive an “advanceable” tax credit in order to participate in the program?
A refundable tax credit is one that is available to a person if he or she has no tax liability. An “advanceable” tax credit allows a person to receive assistance at the time that he or she purchases insurance rather than paying his or her premium out of pocket and waiting to be reimbursed after filing his or her annual income tax return. Advance premium tax credits will reduce the premium amount an individual owes each month for health insurance coverage. They are available to eligible individuals with household incomes between 100% and 400% of the FPL (400% FPL is $45,960 for an individual and $94,200 for a family of four in 2013), and individuals who don’t qualify for other health insurance coverage providing “minimum essential coverage.” Premium tax credits are paid each month by the Federal government to the insurer and reconciled on the taxpayer’s tax return after end of year. The HIV/AIDS Bureau Policy Clarification Notice #13-05 addresses advance premium tax credits and states that many RWHAP clients with incomes between 100% to 400% of the FPL without access to certain types of minimum essential coverage may be eligible for premium tax credits to offset the cost of purchasing a qualified health plan through their State’s Marketplace. Individuals who qualify may choose how much advance credit payments to apply to their premiums each month, up to a maximum amount. If the amount of advance credit payments they get for the year is less than the tax credit they're due, they'll get the difference as a refundable credit when they file their Federal income tax return. If a client’s advance payments for the year are more than the amount of his or her credit, he or she must repay the excess advance payments with his or her tax return.
HRSA/HIV/AIDS Bureau will be issuing more information on the question related to both reconciliation and debt in the future.
Does HRSA require a Notice of Eligibility Determination to be placed in all client files?
Policy Clarification Notice (PCN) #13-03 encourages RWHAP grantees to consider requiring proof of the Medicaid/Marketplace notice of eligibility determination; however, it will be a Program decision on whether and how to do this. Regardless, HRSA still requires the RWHAP eligibility documentation outlined in PCN #13-02.
Our State is working hard to prepare for getting our uninsured clients enrolled in coverage under the Affordable Care Act, but we can't guarantee 100% success in this effort given factors outside of our control. What expectations does HRSA have for how quickly grantees must transition uninsured patients into new coverage either through Marketplace or expanded Medicaid (in applicable states)?
We understand that there will be a great deal of effort put forth by all grantees to assist clients’ enrollment into new health insurance options. As stated in PCN #13-03, all grantees need to work vigorously to enroll all eligible clients. The HIV/AIDS Bureau is requiring grantees to develop policies and standard operating procedures to accomplish this and to document the steps which they will utilize to enroll clients. This process will be reviewed by HRSA during future site visits to RWHAP grantees.
What does the HIV/AIDS Bureau mean by “vigorously pursue” enrollment?
The HIV/AIDS Bureau’s expectation is that RWHAP grantees and subgrantees will make every reasonable effort to ensure all uninsured clients are assessed for all options in both public and private health care coverage. This includes Medicaid, Medicare, and any other private health insurance options. Clients must be informed about consequences of not enrolling in either public or private health insurance coverage options. Also, grantees are expected to maintain policies regarding their required process for the pursuit of enrollment in health care coverage for all clients. These policies must include how the process will be documented by the grantee. If a grantee has subgrantees, this policy must also include steps that will be taken to monitor subgrantee implementation of the policy. If after extensive efforts, a client remains unenrolled in health care coverage, the client may be served by RWHAP. The expectation is that grantees have established these policies to ensure they are vigorously pursuing client enrollment in health care options and can document this process in way that the HIV/AIDS Bureau would be able to monitor when a site visit is conducted. RWHAP remains the payer of last resort, and grantees are expected to maximize all resources and health care dollars in order to serve the most patients/clients.
Can RWHAP Parts/ADAPs require that American Indians (AIs) and Alaska Natives (ANs) utilize the Marketplace to purchase insurance? How does the payer of last resort statutory provision apply to AI/ANs?
RWHAP can inform all eligible clients, including AIs and ANs, of all sources of health care available to them, including the Marketplace and Medicaid expansion. RWHAP Parts/ADAPs cannot require AIs and ANs who are eligible for RWHAP/ADAP and the Medicare Part D to receive their HIV prescription drugs from the Medicare program.
The Ryan White HIV/AIDS Program statute was amended in 2006 to specifically exclude AI/ANs from the payer of last resort provision. See § 2617(b)(7)(F) of the Public Health Service Act. The HIV/AIDS Bureau Policy Notice #07-01: "The Use of Ryan White Program Funds for American Indians and Alaska Natives and the Indian Health Service Programs" states that American Indians and Alaska Natives can utilize RWHAP services for which they are eligible where they choose, regardless of the availability of services that may also be available to them (e.g., through Indian Health Service, tribal, or urban Indian health programs and services).
What will happen to RWHAP when the Affordable Care Act is implemented? Is RWHAP going to disappear?
RWHAP is currently authorized through September 30, 2013. After that date, the Program will not sunset and can continue to operate through Congressional appropriations with or without subsequent legislation. The decision of whether or not to pursue reauthorization of RWHAP rests with Congress.
Will Part A grantees have flexibility this year (FY 2013) to assist clients with enrollment into health plans in the Marketplace? For example, can we change our Medical Case Management to Non-Medical Case Management services and reduce the amount of funding directed toward core medical services? The EMA does not have a core medical services waiver currently in place and the earliest would be for the FY 2014 funding cycle.
RWHAP Part A grantees are encouraged, working with their Planning Council, to modify their system of care to meet needs identified in the jurisdiction. Please refer here for guidance on the flexible utilization of RWHAP funds for outreach and enrollment activities. EMAs/TGAs that do not have an approved core medical services waiver for FY 2013 must adhere to the 75/25 requirement. We recommend that you submit a request for FY 2014, which if approved, would become effective with the start of the FY 2014 budget period on March 1, 2014.
Will HRSA consider lining up with the Medicaid annual eligibility determination instead of the currently required six month eligibility determination?
To maintain eligibility for RWHAP services, clients must continue to recertify at least every six months. The primary purpose of the recertification process is to ensure that an individual’s residency, income, and insurance status continues to meet the grantee eligibility requirements and to verify that RWHAP is the payer of last resort.
Grantees have flexibility with regard to timing and process, especially in consideration of Health Insurance Marketplace enrollment periods, but all RWHAP Parts must engage in eligibility determination and recertification. Grantees have the option of allowing client's six month recertification, however it is the expectation of the HIV/AIDS Bureau that at least once a year (whether defined as a 12-month period or calendar year), the recertification procedures include the collection of more in-depth supporting documentation, similar to that collected at the initial eligibility determination. Please see Policy Clarification Notice 13-02 for additional details.
Does HRSA expect that RWHAP funds for case management will continue to be available once the Affordable Care Act is fully implemented? If funds will be available to continue this work, will there be any changes to the way it is implemented?
RWHAP Program funding will continue to be issued based on the current legislation. Under current law, RWHAP funds for Medical Case Management services (including treatment adherence) and Non- Medical Case Management will continue to be available after the implementation of the Affordable Care Act.
I missed one of the Affordable Care Act webinars the HIV/AIDS Bureau offered. Are the slides posted online?
Webinars and the corresponding slides are recorded and available on the HIV/AIDS Bureau webpage, “Ryan White and the Affordable Care Act: What You Need to Know:”.
If my private non-profit Part C clinic contracts with our local Federally Qualified Health Center (FQHC), will they still be eligible for the 340B program if they no longer receive Part C grant funds?
Yes, FQHC entities are eligible for participation in the 340B program. Please visit here.
Will individuals who are exempt from purchasing insurance in the Marketplace or are considered exempt by the Internal Revenue Service (IRS) be eligible for RWHAP services?
Under the Affordable Care Act, starting in 2014, most individuals who do not enroll in minimum essential coverage will be required to pay an individual responsibility penalty. Some individuals may be exempt from the Affordable Care Act’s requirement to enroll in health coverage. In these circumstances, the Health Insurance Marketplace or the IRS will provide individuals with certificates of exemption if they meet certain criteria. Individuals who receive an exemption from the Marketplace or IRS will be considered uninsured and therefore if eligible, RWHAP would be the payer of last resort. Click here for a list of criteria that may qualify individuals for an exemption.
Where can I find technical assistance related to the Affordable Care Act?
Since November, the HIV/AIDS Bureau has hosted four Affordable Care Act webinars targeting RWHAP grantees and stakeholders, including a webinar targeting HIV providers and network participation. Visit here to review the archived webinars. In January, the HIV/AIDS Bureau launched an Affordable Care Act webpage on the HIV/AIDS Bureau website where RWHAP grantees may find recently posted Affordable Care Act related guidance including letters, policy clarification notices and links to Affordable Care Act educational tools.
Additionally, there are a significant number of technical assistance resources found on the TARGET Center website. You may also visit the Centers for Medicare & Medicaid Services (CMS) training website. We anticipate additional opportunities for technical assistance in the coming months.
If a client is already enrolled in Medicaid, must he or she still fill out the application for the Marketplace to make sure he or she is still eligible for the same benefits?
If a client is already enrolled in Medicaid and continues to be eligible for Medicaid, he or she may remain in Medicaid. No further action is required.
What allowable expenses can RWHAP grantees provide to patients?
In addition to providing the core medical Services necessary for eligible individuals to treat their HIV infection, the RWHAP also allows for the provision of support services to help clients remain in care. RWHAP only pays for services that are not covered by other public and private insurance. Please see Policy Clarification Notice 13-01 for more information on allowable costs. Also, the Outreach, Enrollment, and Benefits Counseling letter on the HIV/AIDS Bureau’s Affordable Care Act webpage has more information on these allowable services in the context of Affordable Care Act implementation.
How will RWHAP deal with persons who are categorically ineligible for coverage under the Affordable Care Act?
RWHAP provider will ask eligibility determination questions and will follow their established procedure to assess the client’s eligibility for other health care coverage options. The RWHAP remains the payer of last resort and RWHAP providers must assist the client to vigorously pursue all other health care coverage options.
Should grantees become Champions for Coverage?
HRSA encourages grantees to become Champions for Coverage. Becoming a Champion for Coverage is a pledge that your organization supports getting clients insured. More information about how your organization can become a Champion for Coverage.
Will the Affordable Care Act affect RWHAP client caps or discounted sliding scale fees?
No, when RWHAP is the primary payer, client caps and discounted sliding scale fees will not be affected by the Affordable Care Act.
In a small Part D clinic where about 50% the HIV positive youth are uninsured, can funds that were budgeted to cover lab tests be allocated to assist with premiums for uninsured HIV positive youth in the Marketplace?
Yes, this is allowable. HRSA suggests the grantee carefully review its Part D budget to ensure the full range of services can be delivered, given the limited amount of RWHAP funds available for most Part D clinics, and to determine if this use of RWHAP funds is cost effective. The cost-effectiveness analysis should include an analysis of the formulary’s adequacy, what other essential medical benefits the plan covers, the cost of the plan’s premium, and the effect of any cost-sharing reductions that may be available on the overall cost of the qualified health plan. If the grantee decides to revise its budget, this change should be reviewed with the grantee’s Project Officer.
In Policy Clarification Notice #13-04, what does partially covered mean in the phrase, “Once enrolled in a private health plan, RWHAP funds may only be used for services not covered or partially covered by a client’s plan.”
It means that RWHAP can cover eligible costs not covered by the health plan. For example, if a client needs 12 treatment adherence visits, and his or her insurance only covers four treatment adherence visits, RWHAP funds can be used to pay for the remaining eight visits.
Would RWHAP Part A be able to fund additional staff to process insurance payments or would that need to come from administrative funds?
RWHAP grantees are allowed to use funds for insurance premiums and cost sharing, which includes co-pays and deductibles. In providing this assistance, the direct service to a client would be considered an allowable program expense. This would not be part of the administrative cap. The cost of administering the overall program is considered administrative, and is subject to the cap.
Can RWHAP funds be used to pay Medicare Part B premiums?
Yes. The same requirements apply for using RWHAP funds to pay for Medicare premiums, deductibles, and co-payments as for Medicaid or private insurance premiums, deductibles, and co-payments. If resources are available, Part A planning bodies and RWHAP Part B, C, and D grantees may choose to prioritize and allocate funding to Medicaid premium and cost-sharing assistance for low-income individuals in accordance with Section 2615 of the Public Health Service Act. Please see Policy Clarification Notices 13-05 and 13-06 for more information on using RWHAP funds for premium assistance.
We provide RWHAP Part B services specific to medical and non-medical case management. How can we obtain a list of covered Part B benefits under the Affordable Care Act to know what will still be covered by the Ryan White HIV/AIDS Program?
While the exact benefits that will be covered will vary by health insurance plan and by State, all plans offered through the Marketplace must provide the essential health benefits, which include at least: ambulatory patient services (outpatient care you get without being admitted to a hospital); emergency services; hospitalization, maternity, and newborn care (care before and after your baby is born); mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy); prescription drugs; rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills); laboratory services; preventive and wellness services and chronic disease management; and pediatric services. You can find out more about what plans cover at www.HealthCare.gov.
You will need to review the specific health coverage plans in your State to determine which specific services are not covered or partially covered as each health coverage plan may have a different level of coverage.
For more information about the Essential Health Benefits and RWHAP, you can also access the archived webinar at http://hab.hrsa.gov/affordablecareact/webinars/index.html
If case managers are performing enrollment and benefits counseling, do we have to allocate dollars for case managers under both core medical services and support services?
If the service is being provided as a component of medical case management, it should be captured and reported as medical case management, which is a core medical service. If it is being provided as non-medical case management, it should be documented as a support service.
What about case management in states where there is no Medicaid expansion at this time? How will we provide those services and also ensure RWHAP is the payer of last resort? Will case management be considered a specialty service?
In states where Medicaid is not expanding, RWHAP will continue to operate as it does today. Case management will continue to be important to ensure that people who are eligible for public or private health insurance plans are enrolled in health insurance and that RWHAP continues to be the payer of last resort.
RWHAP has a cap on charges for its clients based on their income. For clients who are below 100% of Federal Poverty Level, they are not allowed to be charged for services. For individuals who have plans that require a co-pay, who is responsible for paying that co-pay, CMS or the service provider?
The cap on charges applies only to services provided to clients when RWHAP is the payer. Individuals who have a health insurance plan (Medicaid or private insurance) must use their health insurance to pay for services that the health insurance plan covers. The individual receiving care paid for by the health insurance plan is responsible for the required co-pay; however, it is allowable for RWHAP to assist the client in paying his or her co-pay. See Policy Clarification Notices 13-05 and 13-06 for more information on using RWHAP funds for co-pays, deductibles, and other cost-sharing.
If a patient who receives services through the RWHAP is eligible for enrollment in a health insurance plan in the Marketplace or through Medicaid, but chooses not to enroll, thereby incurring the penalty, will they be eligible then for RWHAP services again, even though that is the payer of last resort?
Because the Ryan White HIV/AIDS Program is the payer of last resort, RWHAP grantees and subgrantees must make every reasonable effort to ensure all uninsured RWHAP clients enroll in any health coverage options for which they may be eligible. Grantees are required to maintain policies regarding the required process for the pursuit of enrollment for all clients, to document the steps during their pursuit of enrollment for all clients, and to establish stronger monitoring and enforcement of subgrantee processes to ensure that clients are enrolled in coverage options for which they qualify. If after extensive documented efforts on the part of the grantee, the client remains unenrolled in health care coverage, the client may continue to receive services through RWHAP. See Policy Clarification Notices 13-01 and 13-04 for more information.
Please clarify whether it is individual or household income for eligibility determination.
The RWHAP grantee establishes the income guidelines for eligibility. The HIV/AIDS Bureau Policy Clarification Notice 13-03 recommends that RWHAP grantees consider updating financial eligibility to use Modified Adjusted Gross Income (MAGI), which is based on household income.
My State is not expanding Medicaid. When RWHAP sunsets in September 2013, will there be special provisions for States where PLWH will not have access to the expanded Medicaid option?
RWHAP will not sunset in September 2013. It can continue to operate through Congressional appropriations with or without subsequent legislation. The decision of whether or not to pursue reauthorization of RWHAP lies with Congress. In States that choose not to expand Medicaid, the RWHAP will continue to provide medical and support services to those uninsured and underinsured individuals living with HIV. For more information, see also Policy Notice 13-01.
What if our State is NOT accepting the Medicaid expansion funds? Will RWHAP be the only option for those patients? That will stretch our already flat RWHAP funds.
RWHAP is the payer of last resort for HIV-related services and will continue to serve uninsured and underinsured individuals living with HIV. RWHAP-funded providers/case managers need to continue to enroll potentially eligible clients in regular Medicaid as before. Individuals who are ineligible for Medicaid will be able to enroll in a private health plan offered in the Marketplace. Many of these individuals may qualify for Federal financial assistance (e.g. premium tax credits and cost-sharing reductions) to help them afford enrolling in a private plan in the Marketplace, which will reduce the burden placed on RWHAP. Those ineligible for federal assistance may remain uninsured and will continue to rely primarily on RWHAP. However, if resources are available, grantees and subgrantees may use RWHAP funds to pay for premiums and cost-sharing to help these individuals gain private coverage in the Marketplace when it is cost-effective and in accordance with RWHAP policy.
May RWHAP funds be utilized for Medicaid spend down?
Medicaid regulations indicates that there is no spend down when a third party, including RWHAP, pays for services. See 42 CFR § 435.831 (d).
Can a client enroll into expanded Medicaid coverage (up to 138% of FPL) outside of the Marketplace?
Yes. The Affordable Care Act has a “no wrong door” approach to enrollment such that individuals should only have to fill out one streamlined application to learn if they are eligible for Medicaid, CHIP, or a private health plan offered in the Marketplace, including eligibility for premium tax credits. Eligibility determinations will be coordinated between Medicaid and the Marketplace. If an individual applies for Medicaid outside of the Marketplace, the Medicaid agency will coordinate with the Marketplace to ensure that any individual determined ineligible for Medicaid is also assessed for eligibility for the Marketplace, including premium tax credits.
Where can I find state-specific information about Medicaid if my state is not expanding Medicaid?
In cases where there is more than one RWHAP-funded provider in the area, what strategies should RWHAP-funded providers use to become part of Qualified Health Plans (QHP)? In other words, what might motivate QHPs to contract with RWHAP-funded providers given the cost of HIV care?
The best strategy for joining a QHP network as a new provider is to begin negotiating with health plans as quickly as possible. Joining a network can be a lengthy process QHPs are not required to contract with all HIV/AIDS providers. Getting started as soon as possible is your best strategy. For more information on contracting with health plans and provider networks please visit here.
A center has one or more satellite offices. If the main site is on the Essential Community Providers (ECP) list, does the agency also need to have the satellite offices on the list?
That depends on the nature of the network membership. In some cases, the clinical provider must be listed, and in others, only the corporate entity needs to be listed. As your agency becomes a member of a network, be sure you know what is required.
Do we need to become ECPs for each insurance network we participate in?
We encourage you to become an ECP, although you are not required to do so for each network you participate in. However, it is important to ensure that you are “in network” for the insurance plans most used in your area in order to avoid losing access to your RWHAP clients who will shift to new coverage beginning in January 2014.
We are a RWHAP provider but we are not on the ECP list posted by CMS. How can we either get on the list or notify our availability to the QHPs?
Qualified Health Insurance Plans (QHPs or Issuer) will be permitted to write in ECPs not on the CMS-developed list for consideration as part of CMS certification review - that is, allowable write-ins will count toward the satisfaction of the minimum expectation or safe harbor standard.
The U.S. Department of Health and Human Services expects to monitor inclusion of ECPs in QHP provider network(s) over time, including providers that issuers write in, and will update this list in future years. Questions about the list may be directed to firstname.lastname@example.org.
Can you talk a little more about the Essential Community Provider “write in” option? How does that work?
The current list of Essential Community Providers is non-exhaustive, and issuers may identify and write in other providers who meet the regulatory standard. View a list of current Essential Community Providers. If you have questions, please direct them to email@example.com. You may also read CMS’ frequently asked questions about essential community providers.
I have tried to update our information several times; could you send the link to update the information for Essential Community Providers?
CCIIO released a non-exhaustive list of Essential Community Providers. However, RWHAP providers should email CCIIO at EssentialCommunityProviders@cms.hhs.gov if they are not on the list or if their contact information is incorrect.
Our Ryan White HIV/AIDS Program (RWHAP) has clients who are enrolled in the state's high risk insurance pool, which will continue to provide coverage in 2014. If a RWHAP client currently enrolled in the state's high risk insurance pool is newly eligible for Medicaid, what then happens with the client’s coverage?
Since state high risk pools are credible coverage, RWHAP grantees and subgrantees are not required to move clients, but they are strongly encouraged to assess the difference in cost to the program between continuing enrollment in the state high risk pool and enrollment in Medicaid. If Medicaid is more cost-effective, RWHAP grantees and subgrantees should transition clients into Medicaid. See Policy Clarification Notice #13-01: Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services by the Ryan White HIV/AIDS Program.
If the RWHAP grantee or subgrantee determines that it is more cost-effective for clients to receive health care coverage through Medicaid, how can the RWHAP grantee transition clients currently enrolled in a state high risk pool into Medicaid?
Clients should apply for Medicaid through the Marketplace or their state Medicaid agency. Clients who are determined eligible for Medicaid by the Marketplace or state Medicaid agency application process will be enrolled into Medicaid. The client will receive a notice of eligibility and the state Medicaid program will send the client more information on how to access his or her Medicaid benefits.
Our RWHAP has clients who are enrolled in the state's high risk insurance pool which will continue to provide coverage in 2014. If a RWHAP client currently enrolled in the state's high risk insurance pool is determined to be eligible for a private insurance plan, including advanced premium tax credits, through the Marketplace application process, what should RWHAP do?
RWHAP may currently pay the premium for clients to be enrolled in coverage through a state high risk insurance pool. Starting October 1, 2013, it may be more cost-effective for these clients to be enrolled in a private health plan in the Marketplace, especially if the client is eligible for advanced payment of premium tax credits. Since state high risk pools are credible coverage, RWHAP grantees and subgrantees are not required to move clients, but they are strongly encouraged to assess the difference in cost to the program between continuing enrollment in the state high risk pool and enrollment in a private health plan in the Marketplace. If the Marketplace plans with or without the advanced payment of premium tax credits are more cost-effective, RWHAP grantees and subgrantees should transition clients into a Marketplace plan.
If the RWHAP grantee or subgrantee determines that it is more cost-effective for clients to receive health care coverage through the Marketplace, how can the RWHAP grantee seamlessly transition clients currently enrolled in a state high risk pool into a private insurance plan offered in the Marketplace?
The Marketplace provides one streamlined application where individuals can learn about their health care coverage options and enroll. Individuals with health care coverage who file an electronic application with the Marketplace will be prompted to answer questions related to when they expect their existing coverage to end.
In some states, including those operating under the federally-facilitated Marketplace, individuals will be able to receive an eligibility determination for advanced payment of premium tax credits up to 60 days prior to the loss of their current coverage. Individuals who are determined eligible for advanced payment of premium tax credits may enroll in a health plan in the Marketplace, but enrollment is contingent upon the actual termination of their current coverage as indicated in their electronic Marketplace application. RWHAP grantees and subgrantees should provide clients with written confirmation of the date by which the RWHAP will no longer make payments for the state high risk pool coverage, in order to facilitate the accurate completion of their electronic Marketplace application.
It is also important for RWHAP grantees and subgrantees to understand that the effective date of coverage for a private health plan in the Marketplace is contingent upon the issuer receiving the client’s premium payment by the issuer’s specified due date. If RWHAP will be assisting that client with any portion of the premium payments for the private plan, ensuring that the payment to the issuer is received by the specified due date will be critical to prevent both a lapse in coverage and a discrepancy in the tax reconciliation at the end of the year. RWHAP grantees and subgrantees are reminded that while states operating under the Federally-facilitated Marketplace will redirect grantees and subgrantees to issuers to facilitate premium payments by the RWHAP for individual clients, State-based Marketplaces have flexibility to implement a process for premium payment aggregation. Grantees and subgrantees should work with health insurance issuers and/or the State-based Marketplace to establish a coordinated process that facilitates premium payments by RWHAP for individual clients.
I am a RWHAP grantee who currently pays for clients to be enrolled in a state high risk pool. I would like to ensure that my clients transition to a plan offered in the Marketplace with coverage effective on January 1, 2014. What do I need to do to ensure that my clients have a seamless transition into their private health plan coverage by January 1, 2014?
Since state high risk pools are credible coverage, RWHAP grantees and subgrantees are not required to move clients, but they are strongly encouraged to assess the difference in cost to the program between continuing enrollment in the state high risk pool and enrollment in a private insurance plan in the Marketplace. If the Marketplace plans with or without the advanced payment of premium tax credits are more cost-effective, RWHAP grantees and subgrantees should transition clients into a Marketplace plan. The earliest date that coverage in the Marketplace can begin is January 1, 2014. The timeline below assumes that enrollment in the state high risk pool will end on December 31, 2013.
In order to transition clients from a state high risk pool to a Marketplace plan with coverage effective on January 1, 2014, the RWHAP grantee should:
What happens if a client’s state high risk pool coverage ends outside of the Marketplace’s open enrollment periods?
The initial open enrollment period for the Marketplace runs from October 1, 2013, through March 31, 2014. Additionally, the annual open enrollment period for the Marketplace is October 15 through December 7 each year. It is possible that a client’s state high risk pool coverage may end outside of the Marketplace open enrollment period. Termination of a client’s state high risk pool coverage is considered a “qualifying life event” that triggers eligibility for a special enrollment period.
During the special enrollment period, clients will have 60 days from the date their state high risk pool coverage ends to enroll in a plan offered in the Marketplace. However, it is important for grantees and subgrantees to assist clients in identifying as early as possible if, and when, the client’s state high risk pool coverage may end to ensure a seamless transition into a private health insurance plan or Medicaid. In some states, including those operating under the federally-facilitated Marketplace, individuals may receive an eligibility determination for advanced payment of premium tax credits up to 60 days prior to the loss of their state high risk pool coverage. Eligible individuals may enroll in a health plan in the Marketplace, but enrollment is contingent upon the actual termination of their current coverage as indicated in their electronic Marketplace application. RWHAP grantees and subgrantees should provide clients with written confirmation of the date by which the RWHAP will no longer cover the premiums for the client’s state high risk pool coverage in order to facilitate the accurate completion of their electronic Marketplace application.
Please refer to the other frequently asked questions in this section for more information on how grantees can ensure a seamless transition for clients currently enrolled in a state high risk pool into a private health insurance plan offered in the Marketplace.