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

Findings

To provide a closer look at how grantees have elected to use Ryan White funds and ready systems for insurance purchasing in the ACA era, this analysis explores the early experiences of five states – California, Florida, Georgia, New York, and Texas – during the first open enrollment period (October 2013 through April 2014). The analysis focuses on ADAP activities related to the purchase of QHPs through the health insurance marketplaces. In addition, insurance purchasing that occurred at local levels is also explored, particularly when it supplemented ADAPs’ provision of insurance assistance to clients. Local level insurance purchasing occurs in many cases when Part As (Ryan White funded urban areas with a high burden of HIV/AIDS) award funding to ASOs (sub-grantees of the program) to assist with this support.

The states examined here were chosen for several reasons. First, together, they account for half of all people living with an HIV diagnosis in the United States (see Table 4).¹ Similarly, about half of all Ryan White clients live in these five states (see Table 4). Second, each state has made different decisions regarding ACA implementation. Two of the states, California and New York, expanded their Medicaid programs and established their own state-based insurance marketplaces where residents can shop for private coverage. The other three states – Florida, Georgia and Texas – have not expanded their Medicaid programs and are relying on the federal insurance marketplace. Lastly, the ADAPs in these states had varying experiences with insurance purchasing prior to the ACA. While ADAPs in California and New York had substantial insurance purchasing experience prior to the ACA, programs were more limited in Florida, Georgia and Texas.

Table 4: Case Study States: Select Characteristics and Status of Insurance Purchasing in the First Open Enrollment Season
State	Medicaid Expansion Decision1	Type of Marketplace2	No. of People with an HIV Diagnosis3	No. of Ryan White Clients Served4	Ryan White  Clients <100% FPL4	Percent UninsuredRyan White Clients4	ADAP QHP Insurance Purchasing	Part A QHP Insurance Purchasing*
California	Yes	State	117,814	58,177	64%	27%	Yes	Yes
Florida	No	Federal	98,650	55,325	62%	32%	Pilot	Yes
Georgia	No	Federal	39,102	20,683	69%	48%	Yes	Yes
New York	Yes	State	129,379	75,001	66%	15%	Yes	No
Texas	No	Federal	72,010	36,502	70%	38%	No	Yes
United States	–	–	912,308	536,219	67%	28%	–	–
SOURCES: 1KFF State Health Facts: State Decisions on Health Insurance Marketplaces and the Medicaid Expansion; 2KFF State Health Facts: Health Insurance Marketplace Types; 3CDC. (2015) HIV Surveillance Report Vol. 25, Diagnoses of HIV Infection in the United States and Dependent Areas, 2013 (US total does not include dependent areas); 4HRSA HAB. Ryan White HIV/AIDS Program 2012 State Profiles; *Not all Part As in state necessarily participating.

Cross-cutting observations related to state approaches to insurance purchasing are discussed below. Detailed analyses of approaches to insurance purchasing in the first open enrollment period for the five states can be found in the Appendix.

Prior Insurance Purchasing Experience Facilitated ACA Era Arrangements, But Challenges Persist

State ADAPs varied significantly in the degree to which they participated in insurance purchasing in advance of the ACA and this often paralleled the degree to which they were prepared to offer insurance purchasing through the marketplaces. For instance, ADAPs in California and New York had relatively robust insurance purchasing infrastructures in advance of the ACA and were capable of working with private insurance. These programs were able to better align processes with the new ACA era coverage opportunities and enroll clients in QHPs though their existing infrastructures.

However, enrolling clients was not without challenges for California and New York. In particular, stakeholders in both states cited challenges pertaining to technical or process issues encountered when enrolling clients. Navigating relationships with insurance companies who had had limited experience with ADAP as a third-party payer was also sometimes difficult. For instance, both states faced challenges meeting initial premium due dates. Sometimes the challenge was obtaining bills from clients, creating accounts in their own systems, and getting payments out the door to issuers in time. In other cases, challenges surfaced related to accurately attributing ADAP payments to client policies with the issuer.

In both states, but especially in California, these challenges sometimes led to significant delays in the enrollment and payment for clients. In California, some clients were dis-enrolled from coverage due to long delays in getting payments to issuers. Additionally, in California, clients and other stakeholders reported that, in some cases, clients needed to front premium payments for several months before ADAP insurance assistance became effective. Some believed these delays resulted because the systems in place to handle premium payments were “out-of-date” and “manual.” Stakeholder described a state infrastructure in need of updating in order to handle the surge of new enrollees. In New York, stakeholders described some similar process problems as those in California, although they seemed to occur to a lesser degree and stakeholders appeared to more quickly identify solutions when facing a barrier, such as re-enrolling clients that were dropped from coverage.

Florida and Georgia ADAPs had less experience with insurance purchasing compared with California and New York, so had less robust infrastructures from which to build upon going into open enrollment. Coming into the first open enrollment season, the insurance purchasing experience of these ADAPs was mostly limited to coordinating payments with Medicare Part D, COBRA and the state Pre-Existing Condition Insurance Plan (PCIP).² Therefore, they were less experienced with the private insurance market. While both attempted to get some QHP insurance purchasing off the ground, systems were not prepared to engage all clients at the beginning of the open enrollment period. In addition, it was not clear to stakeholders at the outset if or how the ADAPs would handle QHP purchasing, which made it challenging for Part As and local ASOs to prepare to assist in insurance purchasing and enrollment.

Stakeholders also described concerns regarding the contractors needed to run insurance purchasing systems. In Georgia, it took several months to iron out negotiations with their Pharmacy Benefits Manager (PBM), delaying the roll out of premium support. In Florida, stakeholders were unsure the third party organization assigned to assist with premium payments in the past could handle the increased capacity if a surge of new clients enrolled into QHPs.

However, by the end of the first open enrollment period in 2014, both states were operating small or pilot QHP insurance purchasing systems for a limited number of clients. According to stakeholders in both states, the enrollees consisted primarily of clients who were previously being served by insurance purchasing through PCIP and COBRA plans and, for the most part, were not those who were previously uninsured. During the first enrollment season, Florida enrolled about 60 clients, almost all of whom had previous coverage, and Georgia enrolled 200-300 clients, 190 of whom had previously been served through the state PCIP. Stakeholders in both states reported planning was underway to expand programs to provide more QHP premium and enrollment assistance in 2015.

The Texas ADAP had a very limited insurance purchasing program in advance of 2014, which was largely focused on assisting Medicare beneficiaries. Unlike the other four states examined, Texas was unable enroll clients into QHPs with insurance purchasing support. While lack of prior insurance purchasing experience was certainly the case in Texas, stakeholders also highlighted that the ADAP was not given the necessary authority at the state level to assist clients with enrollment in such coverage (discussed in more depth below).

State-Level Approaches to ACA Implementation Impacted the Scope of QHP Insurance Purchasing

While prior insurance purchasing arrangements impacted an ADAPs’ ability to move ahead with QHP purchasing, stakeholders also cited state political atmospheres around ACA implementation as an important factor. According to stakeholders in Florida, Georgia, and Texas, state ADAPs had difficulty operationalizing insurance purchasing through the marketplaces in part due to opposition to ACA implementation at levels of the state government above that of the ADAP office. Stakeholders in a range of positions in all three states spoke of informal “gag orders“ that made it challenging for state employees to engage in activities that could be perceived as helping to implement ACA or drive enrollment. While Florida and Georgia were ultimately able to move forward with insurance purchasing in the first open enrollment period to some extent, stakeholders across both states explained that it was challenge to ready systems for even small scale enrollment within atmosphere opposed to ACA-related activities. In Texas, the resistance to ACA implementation was felt most sharply. Stakeholders explained that larger state decisions surrounding ACA implementation prevented the ADAP from leveraging funds to assist with insurance premiums and that the ADAP was not permitted to facilitate any enrollment through the health insurance marketplace.

While stakeholders in these states commented that ADAP programs recognized the benefits of enrolling clients into QHPs with premium support, efforts in states with environments resistant to ACA implementation focused on getting programs off the ground, rather than addressing new system readiness issues, as was the case in California and New York. Indeed, conversations with stakeholders in Florida, Georgia, and Texas were starkly different than those in California and New York. ADAPs in the latter two states could pursue coverage options available under the law openly, with support of other state offices, and communicate their plans with the clients and community members without constraint.

Cost-Sharing Assistance Beyond Premium Support Varied by State

Stakeholders explained that for people with HIV, access to cost-sharing assistance can play an important role in helping clients meet out-of-pocket obligations associated with insurance, which can be significant. Stakeholders were especially concerned with costs related to prescription medications and deductibles and believed that access to cost-sharing assistance could ultimately determine whether an individual remains covered and stays engaged in care and treatment. In the states examined, ADAPs differed in their ability to offer cost-sharing assistance beyond premium support, including for deductibles, co-payments, and co-insurance. While enrollees receive some protection as a result of the annual out-of-pocket limit under the ACA ($6,350 in 2014), paying out-of-pocket to reach that limit could be challenging for Ryan White clients, many of whom live on limited incomes.³ During the first open enrollment period:

• New York’s ADAP offered full cost-sharing assistance to those enrolled in their insurance purchasing program and, of these five states examined, was the only ADAP to do so (e.g. for deductibles and co-payments and co-insurance for laboratory tests, provider visits, and prescription drugs).
• California’s ADAP offered support for a limited number of costs, including those associated with HIV drugs (such as co-payments and co-insurance), and has plans to expand this assistance in 2016.
• Georgia‘s ADAP program was not able to offer cost-sharing assistance in 2014 but worked closely with the Atlanta Region Part A, which was able to step in and assist with these costs for some (see below for more detail). Additionally, the ADAP has plans to include cost-sharing assistance as part of their program in the future.
• Florida’s pilot ADAP insurance purchasing program offered partial cost-sharing assistance for HIV medications (such as co-insurance, and co-payments) to the limited number of enrollees in the program.
• Texas did not provide cost-sharing assistance (the state ADAP did not offer premium support).

States Sought Alternative Options When ADAPs Faced Challenges Providing Premium and Cost-sharing Assistance

In some cases where ADAPs have played a less active role in providing premium support or cost-sharing assistance, and in cases where there have been challenges implementing premium support, other Ryan White grantees and sub-grantees, such as Ryan White Part As, ASOs, and external entities, have stepped in to provide assistance.

In California, Florida, Georgia, and Texas, some Part A programs worked to help fill in gaps.⁴ In Florida, the Miami-Dade Part A helped some clients pay premiums when it was unclear if the ADAP would establish an insurance purchasing program. Similarly, in Texas, the Dallas and Harris County Part As helped clients gain QHP coverage when it became clear to stakeholders that premium assistance would not be available through the ADAP. In Georgia, the Fulton County Part A, which includes about 80 percent of the state’s Ryan White population, contributed to the pool of ADAP funds set aside for insurance purchasing and was also helping with some cost-sharing not available through ADAP. In California, the Orange County Part A stepped in to help clients with premiums as a stop-gap measure while third party payment delays were resolved with ADAP.

Part As often worked in collaboration with local ASOs to deliver these premium and cost-sharing support services. Some ASOs have historically used Part A funds to deliver premium assistance, although in the past, this assistance has primarily supported those with COBRA, PCIP or employer coverage. In the ACA era some ASOs also used these funds to support QHP coverage. For instance, one Dallas ASO that has been providing premium support for clients for over 20 years using Part A funding began providing premium support for QHPs from the start of the first open-enrollment.

Some Part As, however, found determining cost-effectiveness, which is a HRSA requirement, challenging and were anxious about their ability to assist with these costs. ADAPs could demonstrate cost-effectiveness fairly easily by comparing the cost of paying for prescription drugs directly to purchasing insurance and providing cost-sharing support, which often provided an overall cost-savings to the program. As Part As do not pay for prescription drugs (which is an ADAP function), some worried about being able to demonstrate cost-effectiveness as clearly. In addition, noting the variability across plans and between enrollees, some Part As and funded ASOs found it difficult to estimate out-of-pocket costs and know how many clients they would be able serve at the beginning of the first open enrollment with their limited funds before plan benefit designs were understood and utilization patterns established.

Pharmaceutical assistance programs (PAPs) sponsored by pharmaceutical companies and other non-Ryan White entities were also tapped to help clients meet out-of-pocket obligations, such as deductibles, co-insurance, and co-payments.  For instance, one such program, the Patient Access Network (PAN) Foundation, had assisted 2,500 people with HIV with premiums and other cost-sharing across the country as of June 2014.⁵

Lastly, Stakeholders and clients reported that case managers played an important role in helping clients navigate access to these various insurance purchasing and assistance opportunities both within and outside of ADAP.

Among These States, Insurance Purchasing Programs Were Less Robust in States Not Expanding Medicaid Programs

As a safety-net provider Ryan White plays a particularly important role in maintaining clients in HIV care and treatment. Stakeholders described that this is especially true in states not expanding their Medicaid programs. QHP premium assistance can potentially offer clients access to comprehensive health insurance coverage, helping to meet both their HIV and non-HIV care needs. This could be especially important for those low-income clients in non-expansion states without access to Medicaid. However, in the states examined in this study, those in non-expansion states (Florida, Georgia, and Texas) who might most benefit from marketplace coverage with premium assistance, in many cases had the most limited access, at least via ADAP programs during the first year of marketplace coverage.⁶ Conversely, those states in this study that had the most robust QHP premium assistance programs enrollment also expanded their Medicaid programs (California and New York).

For Some Stakeholders the “Vigorously Pursue” Policy Supported Insurance Purchasing, but for Others it Posed Challenges

HRSA encouraged grantees to “use RWHAP [Ryan White HIV/AIDS Program] funds to help clients purchase and maintain health insurance coverage, if cost-effective…”⁷ and to “vigorously pursue” enrollment into available coverage, including private insurance, in order to meet the payer of last resort requirement. As a result, grantees looked to premium assistance to facilitate access to QHP coverage through the health insurance marketplaces. While some grantees and sub-grantees found it very difficult to interpret HRSA’s guidance to “vigorously pursue” client enrollment into QHPs, others assumed that nothing had changed in terms of their grant requirements and noted that HRSA was reiterating past policy. The push to “vigorously pursue” coverage may have helped encourage some grantees to engage more actively in premium support, particularly for grantees that felt comfortable with this requirement and who lived in states actively implementing the ACA.

For those that had more difficulty with the directive, which in this case happened to be those in states with an overall environment that was resistant to ACA implementation, stakeholders felt they were receiving conflicting instructions. On the one hand, stakeholders explained that grantees wanted to comply with the HRSA requirement, but on the other hand they explained grantees felt unable to move forward given the inability to launch a widespread insurance purchasing effort due to resistance to ACA implementation at the state-level. More broadly, several stakeholders discussed experiencing significant confusion while trying to figure out what it meant to define and document vigorous pursuit of enrollment. Some felt they were unable to gain clarity in conversations with federal officials. While HRSA has since provided greater detail on the policy, many grantees and sub-grantees felt that additional and uniform guidance on meeting and documenting this requirement would have been useful during the first open enrollment period.⁸