Chapter 1
Coordination of Payers and Programs  TOP

Introduction

For CARE Act programs, the goal of coordination is to enhance access to a range of services in order to both achieve better client health outcomes and use CARE Act resources wisely. Coordination within the CARE Act community occurs through specific efforts of grantees to work together, such as joint planning under Titles I and II and through the Statewide Coordinated Statement of Need (SCSN).

The CARE Act Amendments of 2000 expand requirements for coordination with non-CARE Act programs and payers from multiple sectors. Driving these changes are not only the dollars represented by these entities but also the potential to coordinate planning and service delivery. The anticipated outcome is better services for people living with HIV disease (PLWH) with complex care demands, such as substance abusers and PLWH who are not in care.

Among the non-CARE Act programs where coordination is required are Medicaid and Medicare. Both are much larger public sources of funding than the CARE Act. Others—defined by their services as well as their payer status—include Veterans Affairs, substance abuse prevention and treatment services (funded extensively through State block grants and other public and private mechanisms), maternal and child health care, and HIV prevention. The latter includes Centers for Disease Control and Prevention (CDC) HIV prevention. CDC also funds outreach and early intervention services, both of which are also fundable under the CARE Act but distinguishable because the CARE Act must target PLWH.

Private health insurance is yet another payer that has great potential to cover some of the service needs of CARE Act clients. While not apparent given that many CARE Act primary care clients are unlikely to have private health insurance, insurance mechanisms that are potential payers of care include, for example, health insurance continuity payments and special insurance programs like risk pools.

Coordination—with both programs and payers—can occur in the following areas:

• Planning. Coordination in CARE Act planning involves consideration of other programs in such critical areas as assessment of needs, priority setting, and resource allocation. Required representation of other Federal programs on CARE Act planning bodies is designed to ensure their participation in CARE Act planning. To illustrate, needs assessments should determine existing resources, regardless of funding stream, as part of efforts to identify areas of unmet need. In setting priorities, other resources must be considered in terms of how they help meet service demands so that CARE Act resources can be used to fill gaps.
• Funding of Services. CARE Act grantees, including Title II programs, are required to coordinate their services and seek payment from other sources before CARE Act funds are used. This makes the CARE Act the “payer of last resort,” meaning that funds are to fill gaps in care not covered by other resources. Major payers include, for example, Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and private health insurance.
• Service Delivery. The CARE Act requires coordination with specific services (i.e., outreach, substance abuse prevention and treatment, HIV counseling and testing, and early intervention services). Many are funded primarily by other Federal, State, and local sources. For example, HIV prevention is funded through the CDC, while State substance abuse programs are supported partially through block grants from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Legislative Background  TOP

Planning body requirements for States are outlined in Section 2617(b)(6). States are required to engage in “a public advisory planning process” to secure broad input in the development and implementation of the comprehensive plan from PLWH, providers, other CARE Act entities, and other agencies, similar to those outlined for Title I planning councils (e.g., PLWH, health and social service providers, other payers).

Title II planning body requirements are also outlined for consortia. Section 2613 requires the consortium membership to be inclusive in terms of (1) agencies with experience in HIV/AIDS service delivery and (2) populations and subpopulations of persons living with HIV disease (PLWH), who are reflective of the local incidence of HIV. Such consortia are also to be located in areas where such populations reside.

Section 2613(c)(2) also provides for additional involvement by diverse perspectives by requiring consortia, in establishing their service plans, to demonstrate that they have consulted with PLWH, the public health agency or other entity(ies) providing HIV-related health care in the area, at least one community-based AIDS service provider, Title II grantee, Title IV grantees or organizations with a history of serving children, youth, women, and families with HIV, and entities such as those required to be represented on Title I planning councils (e.g., PLWH, health and social service providers, other payers).

Section 2617(b)(4)(A) calls for States to “establish priorities for the allocation of funds within the State based on, in part: “ii) availability of other governmental and non-governmental resources, including the State medicaid plan under title XIX of the Social Security Act and the State Children’s Health Insurance Program under title XXI of such Act to cover health care costs of eligible individuals and families with HIV disease;”

Section 2617(B)(4)(c) requires States to “develop a comprehensive plan for the organization and delivery of health and support services” to be funded under Title II that, in part— “(C) includes a strategy to coordinate the provision of such services with programs for HIV prevention (including outreach and early intervention) and for the prevention and treatment of substance abuse (including programs that provide comprehensive treatment services for such abuse); (E) provides a description of the manner in which services funded with assistance provided under this part will be coordinated with other available related services for individuals with HIV disease; and (F) provides a description of how the allocation and utilization of resources are consistent with the statewide coordinated statement of need (including traditionally underserved populations and subpopulations) developed in partnership with other grantees in the State that receive funding under this title….”

Section 2611(b) discusses the provision of funds “for the purpose of providing health and support services to infants, children, youth, and women with HIV disease, including treatment measures to prevent the perinatal transmission of HIV.” Such funds must total “not less than the percentage constituted by the ratio of the population involved (infants, children, youth, or women in such area) with acquired immune deficiency syndrome to the general population in the State of individuals with such syndrome.”

Section 2611(b)(2) suggests coordination in determining use of Title II funds for these populations in allowing for a waiver of this requirement if “the population is receiving HIV-related health services through the State Medicaid program under title XIX of the Social Security Act, the State children’s health insurance program under title XXI of such Act, or other Federal or State programs.”

Section 2612(c) permits the use of Title II funds for “early intervention services” for individuals with HIV disease. It specifies entities “through which such services may be provided,” which include an array of substance abuse, mental health, homeless services, and other providers.

Section 2617(b)(6)(G) requires that a Title II application include assurances that entities that receive funds under a Title II grant “will maintain appropriate relationships with entities in the eligible area served that constitute key points of access to the health care system for individuals with HIV disease.” These entities include an array of substance abuse, mental health, homeless services, and other providers.

HAB/DSS Expectations  TOP

The objective of coordination is to enhance access to the continuum of services. CARE Act grantees are required to build relationships with other Federal and State agencies, including State Medicaid agencies, CHIP, providers of HIV prevention and substance abuse prevention and treatment services, and incarceration facilities. Areas for coordination include planning, payment of services, and service delivery, as described below.

Planning with Other Programs

Grantees are required to collaborate with other publicly funded programs in the assessment of need, priority setting and resource allocation, and development of their comprehensive plans. Among the most important are Medicaid (by far the largest public payer of HIV care), Medicare (the second largest public payer of HIV care), CHIP, and private health insurance (a source of payment accessible to PLWH through the CARE Act by way of health insurance continuity payments, which can cover both continuation of existing policies and purchase of new ones). Also important are community health centers and providers of services to the homeless and substance abusers. Planning coordination is evident in the following requirements, each of which is covered in greater detail in other chapters in this manual.

• Planning Body Membership. Title II requirements related to planning bodies are outlined for both States and consortia. The legislation requires States to engage in “a public advisory planning process” in the development and implementation of the comprehensive plan from PLWH, providers, other CARE Act entities, and other agencies, similar to those outlined for Title I planning councils (e.g., PLWH, health and social service providers, other payers).

For consortia, the CARE Act requires the consortium membership to be inclusive in terms of (1) agencies with experience in HIV/AIDS service delivery and (2) populations and subpopulations of persons living with HIV disease (PLWH), who are reflective of the local incidence of HIV. Such consortia are also to be located in areas where such populations reside. The legislation also provides for additional involvement by diverse perspectives by requiring consortia, in establishing their service plans, to demonstrate that they have consulted with PLWH, the public health agency or other entity(ies) providing HIV-related health care in the area, at least one community-based AIDS service provider, Title II grantee, Title IV grantees or organizations with a history of serving children, youth, women, and families with HIV, and entities such as those required to be represented on Title I planning councils.

• Needs Assessment. In order to adequately address priority setting and resource allocation and comprehensive plan requirements, needs assessments must address coordination with HIV prevention and substance abuse prevention and treatment. Coordination with these services can enhance efforts to identify individuals with HIV who know their status but are not receiving HIV-related services and result in better attention to the range of their care needs.
• Priority Setting and Resource Allocation. States are required to conduct priority setting with consideration to multiple factors, including the availability of other governmental and non-governmental resources, including State Medicaid and CHIP programs, to cover health care costs of eligible individuals and families with HIV diseases.
• Comprehensive Plan. The comprehensive plan must include strategies to coordinate services with HIV prevention programs (including outreach and early intervention services) and substance abuse prevention and treatment programs. In addition, the comprehensive plan must be compatible with State or local plans for the delivery of HIV services.

Coordination of Payers

All CARE Act grantees are required to coordinate their services and seek payment from other sources before CARE Act funds are used, making the CARE Act the “payer of last resort,” meaning that funds are used to fill gaps in care not covered by other resources. 

One specific area of payer coordination is services for women, youth, children, and infants. Each State must allocate funds for each group in an amount no less than the proportion that each is represented in the total AIDS cases in the State. A waiver is provided when States can demonstrate that the needs of these populations are being met through other sources, such as Medicaid and CHIP.

Private health insurance can also be coordinated in various ways with CARE Act funding, such as covering services not paid for by private insurance or paying health insurance premiums, if cost effective. For example, Title II grantees may purchase health insurance for clients as part of their AIDS Drug Assistance Programs (ADAPs) under the Health Insurance Continuity Program (HICP). HICP funds may only be used to purchase health insurance that includes the full range of HIV treatments and access to comprehensive primary care services and provides prescription coverage that is equivalent to the Title II ADAP formulary. The total amount spent on insurance premiums cannot be greater than the annual cost of maintaining that same population on ADAP. Clients covered under HICP may continue to qualify for some Title I services that are not covered by their health insurance.

Each State has different insurance laws and regulations. For example, some States have existing insurance programs, like risk pools, and CARE Act dollars might be used to pay premiums. If qualified HIV providers are on the preferred provider list for these insurance policies, such pools may offer opportunities for payer coordination.

Service Coordination

EIS and outreach services are intended to increase access to primary care services for PLWH. In funding EIS, Title II grantees must demonstrate that other sources of funds for EIS are insufficient before spending CARE Act funds on EIS and must make this determination in their needs assessment (particularly the resource inventory). For outreach services, CARE Act outreach programs must focus on reaching PLWH who are not in care.

CARE Act providers are required to maintain appropriate relationships with entities providing “key points of access” to both identify and link PLWH into care. These include, for example, providers of early intervention services, family planning clinics, substance abuse treatment providers, sexually transmitted disease clinics, community organizations, and correctional institutions.

Understanding Other Payers and Programs  TOP

In order to work more effectively with other health programs, particularly Federal programs that provide services for PLWH, CARE Act grantees should learn more about these payers. Among the most significant Federal programs that provide services for PLWH are Medicaid, Medicare, CHIP, and private health insurance. Each of these programs and several other HHS programs are briefly summarized below.

Medicaid

Medicaid, the joint Federal/State health program for low-income and disabled Americans, is the largest single public payer of health care services for people living with HIV/AIDS. The Medicaid program is administered by the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA). To be eligible for Medicaid, a person must either be very poor, have children, and/or be disabled (based on the Social Security definition of “disabled”). Thus, most people with HIV disease are not eligible for Medicaid until they become impoverished and disabled. HIV-infected women and children covered by Medicaid are often eligible for reasons other than their HIV disease.

Medicaid programs vary from State to State. While there are basic eligibility rules and a core benefits package (such as hospital, physician, and nursing services), each State may elect to provide optional services (prescription drug benefits, clinic services), modify eligibility rules above the minimum and place beneficiaries in fee-for-services or managed care arrangements. CARE Act funds can be used to fill service and population gaps not covered by Medicaid. When a State’s Medicaid program does not cover a specific service, CARE Act funds can be used for payment.

Medicaid Managed Care

In the 1990’s, many States began enrolling Medicaid beneficiaries in managed care. Managed care is designed to reduce costs by eliminating inappropriate and unnecessary services and relying more heavily on primary care and coordination of care. Managed care is characterized by formal enrollment of individuals in a managed care organization, contractual agreements between the provider and a payer, and some gatekeeping and utilization control.

For PLWH, managed care systems can present some challenges to the receipt of appropriate services. These include:

• Access to primary care providers and specialists experienced in the treatment of HIV disease, and
  
• Adequate coordination between medical and social services.

Additionally, HIV/AIDS and other high-cost conditions present challenges to managed care plans and providers that contract with them where capitation rates do not reflect the real costs of treating HIV disease.

Medicare

Medicare is the second largest source of Federal financing of HIV/AIDS care. Most people 65 and older are entitled to Medicare because they are eligible for Social Security payments. Disabled persons who receive Social Security Disability Insurance (SSDI) cash payments (because they have sufficient work history to qualify) become eligible for Medicare after a two-year waiting period. It is estimated that Medicare covers as many as one in five PLWH in care.

Medicare covers such services as inpatient hospitalization, skilled nursing and home health visits, and physician and outpatient hospital services. However, it does not cover outpatient prescription drugs, has deductible payments, and has no cap on out-of-pocket spending. These factors are particularly problematic for PLWH, especially given the high cost of drugs. Many beneficiaries purchase supplemental insurance to help with Medicare’s cost-sharing requirements and fill gaps in the benefit package. Some opt to enroll in managed care organizations that typically have lower cost-sharing benefits.

An estimated one in six PLWH is dually eligible for both Medicare and Medicaid. Despite coverage by both sources of public insurance, gaps in care may exist. They include, for example, PLWH who live in States whose Medicaid programs have limited drug coverage and provisions that disallow dual eligible persons from enrolling in managed care plans (which precludes access to the potential benefit of access to plan services like prescription drugs).

State Child Health Insurance Program

CHIP, administered by the CMS Center on Medicaid and State Operations, was enacted in 1997 and allows States to expand health insurance coverage for low-income children through three options:

• Expand Medicaid,
• Create or expand their own children’s health insurance program, or
• A combination of the two.

Children up to age 19 are eligible if they:

• Meet eligibility standards set by the State
  
• Have family incomes below 200 percent of poverty or 50 percent above the State’s Medicaid eligibility limit, whichever is greater, and
  
• Are not eligible for Medicaid or other health insurance.

Children cannot be excluded from eligibility due to a disability or pre-existing condition.

States have great discretion in the design of their CHIP programs. For example, States can choose how they will determine family income and have flexibility in determining which groups of low-income children to cover (e.g., based upon age, disability status, where they live in the State). States also have flexibility to revise their child health plans over time.

Maternal and Child Health Bureau Programs

The Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) addresses the health of mothers, infants, children and adolescents. A focus is on families with low income levels, those with diverse racial and ethnic heritages, and those living in rural or isolated areas without access to care. MCHB administers four major programs:

• Maternal and Child Health Services Block Grant (Title V)
• Healthy Start Initiative (Public Health Service Act)
• Emergency Medical Services for Children Program (Public Health Service Act), and
• Abstinence Education Program (Title V)

Projects funded through these programs are operating in many States.

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Substance Abuse and Mental Health Services Administration (SAMHSA) supports programs in substance abuse prevention, substance abuse treatment, and mental health services. It oversees State block grants that support HIV early intervention services in substance abuse or mental health treatment settings. In addition, SAMHSA provides HIV/AIDS grants to cities to enhance the effectiveness of outreach in urban areas highly impacted by substance abuse and HIV infection.

HIV/AIDS Prevention/Counseling and Testing

Publicly funded HIV counseling and testing services have been provided under grants from CDC through 65 local and State health departments since March of 1985. Both anonymous and confidential voluntary HIV counseling, testing and referral services are available and have evolved to focus on individual, client-centered risk reduction counseling models. Recently revised CDC Guidelines for HIV Counseling Testing and Referral include many recommendations to ensure that HIV-infected individuals (as well as those at risk) have access to appropriate medical, prevention, and psychosocial support services.

Resources  TOP

Resources on CDC

Centers for Disease Control and Prevention (CDC).

CDC, National Center for HIV, STD, and TB Prevention.

CDC National Prevention Information Network.

Resources and Medicaid

Centers for Medicare and Medicaid Services (formerly Health Care Finance Administration).

Kaiser Family Foundation. A source of research and policy reports on Medicaid available on their website.

Managed Care Resources of HRSA’s HIV/AIDS Bureau. This page on the HRSA/HAB website includes managed care-related resources developed by HRSA/HAB and other organizations.

Medicaid Managed Care and HIV/AIDS: A Guide for CBOs. A managed care primer for CARE Act and other community agencies, this document was developed for HRSA/HAB by the AIDS Action Foundation (AAF). Chapters include an overview of Medicaid, trends in managed care and persons living with HIV, recent Federal Medicaid activities, challenges and solutions in moving toward Medicaid managed care, and resources such as a managed care glossary and key State Medicaid contacts. The Guide can be obtained from AAF by calling (202) 530-8030.

New Rules, New Roles: How Title V/Maternal and Child Health and Ryan White CARE Act Programs and Providers are Adapting to Medicaid Managed Care. This report provides insight into how managed care has affected HIV/AIDS service and maternal and child health programs and providers supported by HRSA. The report draws on data from telephone interviews and site visits to HRSA-funded organizations in Oregon, Pennsylvania, Tennessee, and Virginia. The document identifies many resources and ways that HRSA can help grantees overcome these challenges.

Making Medicaid Managed Care Work: An Action Plan for People Living With HIV. Action steps for serving people living with HIV disease under Medicaid managed care are outlined in this report, an update of an earlier National Association of People with AIDS (NAPWA) report produced with support from the Kaiser Family Foundation. This report updates information on the policy and regulatory environment and discusses nine key consensus points. Contact the Kaiser Foundation at (800) 656-4553.

Medicaid Policy Resources from the Center for HIV Quality Care. The Center for HIV Quality Care’s web site is the main vehicle for disseminating information on findings from the Center's Medicaid policy research. Resources available include:

• State Health Care Medicaid and AIDS Profiles for selected States
• Resources for providers including an updated list of “HIV Experienced Provider” definitions and links to websites of related HIV/AIDS organizations
• Updates on State and Federal actions, and
• An archive of the bimonthly newsletter, HIV Quality Care Network News.

To access the Center's home page, go to Infectious Diseases Society of America’s web site and click on HIV Quality Care Network.

Your Passport to Managed Care. Designed to assist PLWH with the transition from traditional health insurance to managed care, the passport was developed by the National Association of People with AIDS in partnership with HAB. The guide is designed to help PLWH understand managed care and develop the skills necessary to ensure that they receive appropriate care. Contact NAPWA at (202) 898-0414 or go to their website.

Resources on Medicare

Health Care Financing Administration, an agency of the U.S. Department of Health and Human Services.

Kaiser Family Foundation - State profiles, information on various populations served, and survey results.

Resources on the HRSA Maternal and Child Health Bureau

Maternal and Child Health Bureau, HRSA.

Resources on State Children’s Health Insurance Programs

Centers for Medicare and Medicaid. Status reports, State contact information, plan information, estimated enrollment reports, and links to other sources of information.

Outreach/Enrolling in CHIP.

Express Lane Eligibility: How to Enroll Large Groups of Eligible Children in Medicaid and CHIP. Kaiser Family Foundation (KFF). Additional resources on CHIP are also available at this website.

American Academy of Pediatrics. Summary of CHIP provisions, information on State programs, statistics and outreach information.

Children’s Defense Fund. Reports, key facts, frequently asked questions, and outreach information.

Families USA. Information on state programs and implementation issues.

National Governor’s Association. Reports, issue briefs and fact sheets.

Why is Rural Important? Enrolling Rural Children in CHIP and Medicaid. Office of Rural Health Policy, HRSA. Available on their website.

CHIP and Access for Children in Immigrant Families. National Conference of State Legislatures. Available on their website.