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Policy Update for Providers

Policy Update for Providers

by Nicole Johns

May 6, 2013

There has been so much going on in health policy over the last several weeks, especially concerning how Ryan White service providers are going to be doing business in the era of health reform. I pulled together several (but certainly not all) of the  developments and resources in order to help providers know where to start in preparing to meet the challenges that are sure to come, as well as to take advantage of all the opportunities for growth and sustainability. Last time, I wrote about what community planners need to know. Next up, I'll focus on what all of these changes mean to individuals.

But First

Before you do anything go here and sign up to receive bulletins from HRSA about Ryan White and Affordable Care Act (ACA) news. This is also the place to read all the latest developments and get copies of documents related to Ryan White and ACA.

Also HRSA will host a webcast on Tuesday, May 7th at 1pm EST on the Potential Impacts of the Affordable Care Act on Safety Net Providers in 2014

Eligibility for Ryan White services

In the era of health reform and the ACA, there are so many questions about the role of Ryan White funds and what impact health reform will have on consumers' eligibility for Ryan White services. HRSA released a policy clarification last month that lays out expectations and requirements for client re-certification and eligibility for Ryan White services:
Clarifications on Ryan White Program Client Eligibility Determinations and Recertifications Requirements

Re-certification is still required and important to determine eligibility of individuals. Providers and grantees are responsible to make sure that only eligible individuals receive Ryan White services, meaning all Ryan White clients must be HIV-positive and have low income, in order to be re-certified every six months. The policy statement includes the types of documentation needed and where individual declaration or self-reported status will be accepted for re-certification purposes.

HRSA also held a webinar on April 5th called Eligibility 101: The Affordable Care Act and Ryan White Program - New Opportunities for People Living with HIV/AIDS. You can watch the webinar at the link and download slides.

Essential Community Providers

Starting in 2014, the Affordable Care Act (ACA) will result in over 20 million people enrolling in private insurance coverage through health insurance marketplaces (or exchanges). These private plans, called “Qualified Health Plans” (QHP) must meet standards for inclusion of “Essential Community Providers” (ECPs) in their provider networks. ECPs serve predominantly low-income, medically underserved populations and include, but are not limited to, safety net providers who are eligible to participate in the 340B drug purchase program in these six categories: Federally Qualified Health Centers (FQHCs), Ryan White providers, family planning providers, Indian providers, specified hospitals*, and others. But inclusion in Qualified Health Plans’ provider networks is not automatic. Safety net providers must identify insurers offering plans on their state’s ACA marketplace and negotiate to be included. Keep in mind that ACA implementation is just beginning, and relationships that begin now can be built on in future years--  Essential Community Providers:Tips to Connect with Marketplace Plans from National Academy for State Health Policy

Official deadline for health plans on the federal-facilitated exchanges is Friday, May 3rd, but plans can add providers after that as well.  You can check out the list of Essential Community Providers and determine if your organization is included. Follow the steps in the fact sheet quoted above to work with marketplace plans.

Enrollment Assistance

Ryan White providers are expected to make every effort to assist clients in enrolling in appropriate health insurance, whether Medicaid, a health plan through the state marketplace, or through other public or private programs. 

A joint letter from Center for Medicaid and Medicare Services (CMS) and the Health Services and Resources Administration (HRSA) was released on May 1,2013 clarifying the importance of coordination between Medicaid and Ryan White programs.

HRSA also has a chart detailing how Ryan White providers and grantees can provide benefit enrollment and counseling to clients through  Outreach Services, Early Intervention Services, Medical Case Management, Non-medical Case Management, Health Education and Risk Reduction, and Referral for Health Care or Supportive Services under Parts A, B, and the Minority AIDS Initiative. 

On April 18th, there was an informative panel discussion with national experts on enrollment assistance, thanks to the Kaiser Family Foundation for the video.

You can also use a subsidy calculator to figure out what (if any) amount of federal subsidy you (or a client) might be eligible for in order to make purchasing health insurance on the exchange affordable for you.  

As you probably remember, most individuals will be required to purchase health insurance provided they meet these requirements:

Exchange Applications

Enrollment for the state insurance marketplaces (sometimes called exchanges) will be open on October 1, 2013 and coverage will begin on January 1, 2014 for those plans. The federal government just released the applications that individuals and families will use to apply for coverage on those exchanges. They have been simplified to 3 pages for individuals not offered affordable coverage by employers and 12 pages for families and individuals with employer coverage.  

The individual and small group insurance marketplaces for New Jersey and Pennsylvania will be federally-run, because New Jersey and Pennsylvania did not choose to run their own marketplaces. You can read more about the development of these exchanges at the links for each state.


More general information about eligibility and enrollment can be found at Enroll America.

New Jersey and Pennsylvania also have websites to help consumers nad providers navigate insurance options:
New Jersey Department of Banking and Insurance
PA Health Options

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