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Health Reform and HIV Providers: Part 2

Health Reform and HIV Providers: Part 2

by Nicole Johns

June 20, 2013

The presentation referenced below was given by Ann Ricksecker (Planning Council member and PA/MidAtlantic AETC staff) and myself at the PA HIV Provider Capacity Building Training on June 18, 2013. The purpose of the presentation was to provide some basic background on the ACA and  practical steps for organizations to prepare for the future of the Ryan White Program. Thanks to the  TARGET Center for providing some great materials to work from, especially the 6 steps.

If this is your first visit to our blog, you may want to check out my previous posts on some of the important issues covered in this presentation like: payer of last resort, providers' roles in health reform, and health reform resources.  I will be creating a web-based presentation with audio for these steps as well, so stay tuned.

During this presentation a few questions came up that I needed to do some more research before I could answer. I decided to share those questions and my answers here. If you have questions, let me know in the comments and I'll post a follow up ASAP.

Question 1: Contracting with an insurance company is sometimes difficult and time consuming. What steps can an organization take to make it easier/more efficient?

Here's a good example from Kevin Moore of the AIDS Care Group about the difficulties some will face in dealing with health insurance companies. Here are some ways you may get some help if you run into a dead end:

1. Call your state insurance department and see what assistance they can provide. (PA, NJ)

2. Call your state's insurance marketplace to get some help facilitating the relationship with the insurer. At this time I couldn't find any contacts for either NJ or PA's marketplaces.  (Both PA and NJ will have federally-facilitated Marketplaces.)

3. Call a provider who is on the insurance plan and ask for a contact person in that agency's contract office. Then ask for a contact with the insurer who will actually help. 

I'm sure there are other options. Anybody have another option that worked?

Question 2:  Will case managers be expected to help consumers pick a health plan? Do case managers have a role in the state insurance marketplaces?

Short answer: Yes! 

Case managers already help people get enrolled in health insurance. Enrolling in a Marketplace plan is just another option. HRSA has been very clear that Ryan White providers are expected and encouraged to help consumers with eligibility and enrollment, including consumer education about health insurance and health reform. In the end, consumers are responsible for picking the appropriate health plan for their individual needs, but case managers and other providers will need to be available to help with those decisions. If the Ryan White provider is not staffed or resourced to provide this assistance, then a referral should be made to a local resource that can provide the required level of support and guidance.

The 4 E's are the latest buzzwords: education (about health reform), eligibility (for public and private insurance options), enrollment (in public and private insurance) and engagement (in care). Consumers will be looking to their case managers and medical providers for answers about insurance and eligibility. To learn more about consumer outreach and enrollment check out the resources at Enroll, America.

Question 3: What opportunities are there for community-based organizations in the era of coordinated care and health homes? 

There are opportunities for CBOs in this new world. CBOs have skills and services that support and promote whole-person care like cultural competency and care coordination (case management).  You can become a Federally Qualified Health Center (FQHC) or form a cooperative agreement with a FQHC. Either option would allow for the possibility of either becoming a Primary Care Medical Home or a Medicaid Health Home (which are essentially the same thing. Primary Care Medical Home (PCMH) is the general term and the Medicaid Health Home is a type of PCMH.).  

Here is a great step-by-step guide for CBOs to integrate with health homes.

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