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

Background

Insurance Purchasing Under Ryan White Pre-ACA

The federal government has authorized the use of Ryan White funds to assist with insurance purchasing since the program was first enacted in 1990. While most parts of the Ryan White Program are authorized to use funds for this purpose (Parts A, B, C, and D)¹, the primary source of Ryan White funding for insurance purchasing is the AIDS Drug Assistance Program (ADAP), a component of Part B funding which is provided by the federal governments directly to states to help pay for HIV care and treatment services (states may also contribute their own funds for services).

ADAP was initially created to directly purchase HIV medications for infected individuals and this is still its dominant function in most states. Insurance purchasing, however, has grown rapidly over time given its cost-effectiveness and ability to provide clients with more comprehensive care (covering services not provided through Ryan White, such as non-HIV drugs, emergency room visits, and hospital stays), compared with purchasing medications directly. Insurance purchasing under ADAP has grown from supporting coverage for 6% of ADAP clients nationwide in 2003 to 35% in 2013.²

Over time, Ryan White reauthorizations and policy guidance have put greater emphasis on grantees’ ability to use Ryan White funds to help clients obtain insurance coverage. Policy notices have clarified aspects of the law related to insurance purchasing, emphasized the permissibility of this function, and to provided implementation guidance to grantees (see Tables 2 and 3). For example, while the initial authorization of The Program and subsequent guidance focused on insurance continuation (assisting clients in maintaining existing coverage), later policies specified that funds could also be used for purchasing new coverage (emphasized in notice 99-01 and explicitly affirmed in the 2006 reauthorization legislation). Further, the 2006 reauthorization of the program stipulated that 75% of grant awards must be spent on “core medical services,” identifying insurance purchasing as one such service.

Table 2: Law & Policies Related to Use of Ryan White Funds for Insurance Purchasing
Policy	Significance
Ryan White Comprehensive AIDS Resources Emergency Act of 1990	First authorizes the Ryan White Program. Sections 2612(a)(3) and 2615(a) permit Title II program funds (funding provided to states, now called Part B) to be used for “maintaining a continuity of health insurance” and ensuring  eligible individuals receive “medical benefits under a health insurance program.” Further, Sec. 2616(a) and (c)(4) specify that “a state may use [their]…grant…to establish a program…to provide treatments that have been determined to prolong life or prevent the serious deterioration of health arising from HIV” and that the state shall “facilitate access to treatment for such individuals.”
Ryan White CARE Act Amendments of 1996	First reauthorization of the Ryan White Program. Given advances in HIV antiretroviral therapy, Sec. 2616(a) is modified to permit states to “establish a program…to provide therapeutics to treat HIV disease or prevent the serious deterioration of health arising from HIV disease”…and the state shall “facilitate access to treatment for such individuals.”
HRSA HIV/AIDS Bureau (HAB) Program Policy Notice 97-01 (1997)	Policy clarifies eligibility for services provided by Ryan White. It states that funds awarded under Title I and II (now called Parts A and B) are permitted to cover the cost of continuing family health insurance, including for non-infected individuals, to ensure coverage continuation of a family member with HIV. Along with 97-02, this policy gives explicit permission to use Ryan White funds for insurance continuation to Title I (Part A grantees, in addition to Title II (Part B) grantees (as stipulated in legislation). (Later replaced by DSS Program Policy Guidance No. 1, June 2000 and later included in Policy Notice 10-02)
HRSA HAB Program Policy Notice 97-02 (1997)	Permits Title I and II (now called Pars A and B) grantees to cover the cost “of public or private health insurance co-payments and deductibles for low-income individuals.” Policy states that grantees must “make reasonable efforts to secure other funding…whenever possible” and that “aggressively and consistently” pursuing other payment sources is an appropriate use of funds.” Along with 97-01, this policy gives explicit permission to use Ryan White funds for insurance continuation to Title I (Part A) grantees (in addition to Title II grantees as stipulated in legislation). (Later replaced by DSS Program Policy Guidance No. 2, June 2000 and later included in Policy Notice 10-02)
HRSA HAB Policy 99-01 (1999):The Use of Title II AIDS Drug Assistance Program (ADAP)Funds to Purchase Health Insurance	Policy states that ADAP funds may be used to assist with insurance costs (e.g. premiums, co-payments, and deductibles). It also makes clear that funds may be used for both purchasing new and continuing existing insurance, and lays out specific guidelines for using ADAP funds this way, including through a cost effectiveness requirement. (Available at: ftp://ftp.hrsa.gov/HAB/ADAPTitleII.pdf) (Later replaced by HRSA HAB Policy Notice 7-05, 2007)
Ryan White CARE Act Amendments of 2000	Second reauthorization of the Ryan White Program. Sec. 2616 (e)(1)(a) codifies policy 99-01 in statute, making clear in the law that ADAP funds can be used to assist with both insurance purchasing and continuation, stating that funds may be used “to provide the therapeutics described…by paying on behalf of individuals with HIV disease the costs of purchasing or maintaining health insurance…whose coverage includes a full range of such therapeutics and appropriate primary care services.” Includes the requirement that insurance coverage must be cost effective compared to the direct purchase of drugs.
Ryan White Treatment Modernization Act of 2006	Third reauthorization of the Ryan White Program. Requires Part A, B, and C grantees to “use not less than 75% [of grant award] to provide core medical services” and identifies “health insurance premium and cost sharing assistance” as one such core service (see Sections 2604(c), 2612 (b), and 2651(c)). This reauthorization marked the first time Part C grantees were given explicit permission in legislation to provide premium and cost-sharing support.
Ryan White HIV/AIDS Treatment Extension Act of 2009	Fourth reauthorization of the Ryan White Program. No changes made to insurance purchasing authority.
HRSA HAB Policy Notice 10-02 (Reissued 2010):Eligible Individuals & Allowable Uses of Funds for Discretely Defined Categories of Services	Replaces DSS Program Policy Guidances No. 1 and No. 2 (were previously issued as policies 97-01 and 97-02). Consolidates policies and updates to reflect technical changes in 2006 reauthorization and extends authority to Part C grantees. Policy states that funds through Parts A, B, and C may be used for insurance premiums (and related cost-sharing such as co-payments and deductibles) and that such expenses are an allowable service category and are a core medical service. States that funds may be used to cover the cost of continuing family health insurance, including for non-infected individuals, to ensure coverage continuation of a family member with HIV. In reference to the payer of last resort requirement, policy states “grantees must assure that funded providers make reasonable efforts to secure non-Ryan White HIV/AIDS Program funds whenever possible.”
*Unless otherwise noted, legislation and current policies can be found at http://hab.hrsa.gov/manageyourgrant/policiesletters.html and http://hab.hrsa.gov/abouthab/legislation.html

The Affordable Care Act & Insurance Purchasing Under Ryan White

The Patient Protection and Affordable Care Act (ACA), signed into law by President Obama in 2010, provided for comprehensive health reform, expanding health insurance options – among other provisions – for millions of people in the U.S., including tens of thousands of people with HIV. The most significant coverage expansions began in 2014, when individuals were able to obtain subsidized coverage by enrolling in Qualified Health Plans (QHPs), private insurance sold through state and federally-run health insurance marketplaces. In addition, Medicaid coverage in states that chose to expand their programs was extended to eligible adults up to 138% of the federal poverty level (FPL).³ These developments, coupled with other key provisions of the ACA, including an end to pre-existing condition exclusions, prohibition on insurance rate setting tied to health status, and a ban on annual and lifetime caps on coverage, meant that many more uninsured and underinsured people with HIV, including Ryan White clients, would have access to more comprehensive health insurance.

Beginning in 2013, HRSA issued guidance through a series of policy notices to help clarify requirements and expectations related to enrollment in these new forms of coverage. Guidance discussed the use of Ryan White funds in the context of the ACA, both generally and specifically related to insurance purchasing through the new health insurance marketplaces (see Table 3). Since, as a payer of last resort, Ryan White funds cannot be used for services when “payment has been made or can reasonably be expected to be made” by another payer, it was expected that grantees would help ensure that clients enrolled in the new forms of coverage for which they were eligible.⁴ Policy notices 13-01 and 13-04 addressed the need for grantees to secure non-Ryan White funds wherever possible, including by enrolling eligible clients in Medicaid and marketplace plans, noting that grantees should “vigorously pursue” enrollment. In addition, guidance moved beyond simply permitting grantees to use funds for insurance purchasing. HRSA now “strongly encouraged” grantees “to use RWHAP [Ryan White HIV/AIDS Program] funds to help clients purchase and maintain health insurance coverage, if cost-effective and in accordance with…policy.”⁵

Table 3: Law & Policies Related to Use of Ryan White Funds for Insurance Purchasing and the Affordable Care Act
Policy	Significance
HRSA HAB Policy Clarification Notice 13-01 (Revised 12/13):Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services by the Ryan White HIV/AIDS Program	Reiterates that grantees are expected to secure non-program funds for services whenever possible and enroll clients in available coverage options including, Medicaid, specifically applying this policy to the Medicaid expansion population through the ACA.  If a client is currently enrolled in private coverage with premium assistance, the client may remain in that coverage only if it is more cost-effective. Ryan White can cover the cost of services not covered or partially covered by Medicaid. This is a revised policy.
HRSA HAB Policy Clarification Notice 13-04 (Revised 9/13): Clarifications Regarding Clients Eligible for PrivateHealth Insurance and Coverage of Services by Ryan White HIV/AIDS Program	Specific to the ACA, lays out the expectation that grantees will “vigorously pursue” enrollment of eligible clients into eligible coverage, including into marketplace plans (QHPs) and includes broad documentation requirements.  Policy states that “grantees are strongly encouraged to use [program]…funds to help clients purchase and maintain health insurance coverage, if cost-effective…” This is a revised policy.
HRSA HAB Policy Clarification Notice 13-05 (Revised 6/14):Clarifications Regarding Use of Ryan White  HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Private Health Insurance	Reiterates HAB policy regarding use of funds to assist with purchasing private insurance. In addition to addressing Part A, B, and C grantees, policy also extends authority to purchase insurance to Part D grantees. Specifically considers the role the ACA will have on insurance options for people with HIV and lays out specific conditions plans must meet before Ryan White funds can be used for insurance purchasing, including cost-effectiveness and that any policy purchased covers at minimum “one drug in each class of core antiretroviral therapeutics from the HHS” HIV Treatment Guidelines, along with appropriate primary care services. A previously issued version of this policy included a more stringent formulary requirement. This is a revised policy.
HRSA HAB Policy Clarification Notice 13-06 (Revised 6/14):Clarifications Regarding Use of Ryan White  HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance Medicaid	Reiterates HAB policy regarding use of funds to assist with costs associated with Medicaid plans. In addition to addressing Part A, B, and C grantees, policy also extends authority to purchase insurance to Part D grantees. Specifically considers the role the ACA will have on insurance options for people with HIV and lays out specific conditions plans must meet before Ryan White funds can be used for insurance purchasing, including cost-effectiveness and that any policy purchased covers at minimum “one drug in each class of core antiretroviral therapeutics from the HHS” HIV Treatment Guidelines, along with appropriate primary care services. A previously issued version of this policy included a more stringent formulary requirement. This is a revised policy.
CMS Interim Final Rule “Patient Protection and Affordable Care Act; Third Party Payment of Qualified Health Plan Premiums.” CMS–9943–IFC.  (March 2014)	In wake of legal challenge, requires qualified health plan (QHP) issuers to accept premium and/or cost-sharing payments made by the Ryan White Program (and other federal, state, and tribal programs) on behalf of enrollees (i.e. 3rd party payments). (Available at:https://www.federalregister.gov/articles/2014/03/19/2014-06031/patient-protection-and-affordable-care-act-third-party-payment-of-qualified-health-plan-premiums)
HRSA HAB Policy Clarification Notice 14-01 (2014):Clarifications Regarding the Ryan White HIV/AIDS Program and Reconciliation of Advance Premium Tax Credits under the Affordable Care Act	Builds on policy 13-05, states that clients between 100%-400% of the Federal Poverty Level (FPL) and enrolled in QHPs with premium support may be eligible for premium tax credits. Explains that grantees should relay to clients covered with premium support the importance of accurately reporting income and that grantees must have procedures in place to recoup tax credits paid back to clients in cases of over payment of premiums (if premiums were paid for by the program). It also announced a public comment period (closed Aug. 2014) to consider allowing programs to pay funds back to IRS on client’s behalf, if original tax credit was overestimated and premium underpaid.
* Unless otherwise noted, policies can be found at: http://hab.hrsa.gov/manageyourgrant/policiesletters.html

In addition to the guidance released by HRSA, the Centers for Medicare and Medicaid Services (CMS), which has promulgated private insurance regulations under the ACA, released an interim final rule requiring QHP issuers to accept premium and cost-sharing payments made by the Ryan White Program, and other entities, on behalf of enrollees, also known as third party payments.⁶ This rule was issued in response to a lawsuit in Louisiana in which an issuer in that state refused to accept premium payments from the Ryan White Program made on behalf of enrollees. While the issuer stipulated the intent of their policy was to prevent fraud, advocacy groups filed the lawsuit against the issuer claiming that the policy served to deter those with HIV from enrolling in the company’s marketplace plans and as such violated non-discrimination provisions in the ACA.⁷⁸ The interim final rule served to settle the lawsuit.

Given the new insurance opportunities provided by the ACA, the guidance from HRSA encouraging grantees to pursue new coverage options, and the payer of last resort requirement, most grantees are working to help ensure Ryan White clients enroll in coverage for which they qualify, including in the private market.⁹ In particular, many ADAPs worked to ready their systems to assist with marketplace insurance purchasing for the 2013-2014 open enrollment period.¹⁰ While the majority of ADAPs had some form of insurance purchasing infrastructure in advance of the ACA, states needed to decide if they would use their existing systems to purchase QHPs, and, if so, if those systems had the capacity. Data from the National Alliance of State and Territorial AIDS Directors (NASTAD) indicates that, as of June 2014, most states had moved to use ADAP funds to assist with QHP coverage, enrolling at least 16,000 ADAP clients into QHPs in the 2013-2014 open enrollment season.¹¹  Only six states (Texas, Alabama, Mississippi, Idaho, Pennsylvania, and North Carolina) had not done so, though, most were planning to do so in the future. Additionally, Florida was operating a pilot insurance purchasing program for a limited number of clients (details included in the Florida case study, see Appendix).¹²