1. What Do You Need to Know
about Health Care Reform?
Anne Donnelly, Project Inform
Courtney Mulhern-Pearson, San Francisco AIDS
Foundation

2. Presentation Outline
• Part 1: What does Health Care Reform Do?
• Part 2: What’s Up in California?

3. HCR is Vital For People with HIV:
Status Quo = Access to Care Crisis
Few on employer
insurance;
17% PLWH
compared to 54%
general population

4. What Does Health Care Reform Do?
US (Federal)
CA (State)
Individual Mandate
US citizens and legal residents must
maintain health coverage or face a tax
penalty unless exempted.
CA residents must obtain healthcare
coverage in 2014 or face a tax penalty,
unless exempted.
Expanded Coverage:
Focus on the
Uninsured
State option to expand Medicaid
Medi-Cal expansion < 138% FPL;
Insurance Marketplace in all states –
federal or state run
Covered California (California’s state run
marketplace) > 138% FPL
Affordability
Subsidies for lower income people – in
marketplace;
Exemptions for hardships, Out of
pocket caps on coverage – for all
Same in California
Reforms Private
Insurance: Creates
New Protections
Eliminates denials and increased
premiums for pre-existing conditions;
no annual or lifetime limits on coverage
Same in California
Strengthens medical work force;
Improves Care Coordination
Strengthens medical work force;
Improves Care Coordination
Other
4

5. Makes Comprehensive Insurance a Right
ACA Essential Health Benefits
•
•
•
•
•
•
•
•
•
•
Ambulatory services
Emergency services
Hospitalization
Maternity/newborn care
Mental health and substance use
disorder services – to parity
Prescription drugs
Rehabilitative and habilitative services
Laboratory services
Preventive and wellness services and
chronic disease management
Pediatric services
* Vision and dental remain a gap
In California
“Benchmark” Plan
for
Covered CA:
Kaiser Small Group
Employer Plan
“Alternative
Benefits Package”
Basically the same as
traditional Medi-Cal
5

6. Strengthens Prevention: Some Examples
• STI prevention counseling (high risk adults only; sexually active
adolescents)
• HPV vaccination (all women)
• Syphilis screening (high risk adults and pregnant women)
• HIV screening ( everyone age 15-65)
• Hepatitis C screening (for high risk adults)
• Hepatitis B Screening (pregnant women)
• Chlamydia screening (young & high risk women)
• Gonorrhea screening (high risk and pregnant women)
• Gonorrhea preventive Rx (all newborns)
• HPV DNA testing (30+ women)
• Tobacco cessation counseling
CDC. HIV Surveillance Supplemental Report. U.S. Department of Health & Human Services, 2012, Vol. 17, No. 4 CDC. HIV Cost-Effectiveness. U.S. Department of
Health and Human Services, 2012 -13
6

7. Reforms Private Insurance
• Can’t be denied insurance because of pre-existing health
condition, even if you don’t currently have coverage (2014)
• Health plans cannot drop people from coverage when they
get sick (in effect)
• No lifetime limits on coverage (in effect)
• No annual limits on coverage (2014)
• Allows young adults to stay on their parents’ health care plan
until age 26

8. Expands Coverage
Estimated 32 Million
will gain coverage by
2019
Medicaid
Income Under 138% FPL
Marketplace
Income above 138% FPL

9. Expanding and Improving Medicaid
(State Option)
• Everyone at or below 138% FPL (about $16,000 annually )
regardless of disability status
• Removes asset test
• Provides essential health benefits (EHB)
• Allows for standard covered preventive services
– State option for cost sharing
• Increases primary care reimbursement for 2013/2014
• Provides option for a medical home

10. Private Insurance Marketplaces
• All states will have a Marketplace
•
– Either state run or federally run
Marketplaces must provide assistance with coverage
– Assisters, Enrollment Counselors, Navigators
• Assistance with costs
•
•
Out-of-pocket subsidies for those between 100 – 250% FPL ( ~29K for
an individual)
Premium tax credits for those between 100-400% FPL
( ~$46K for an
individual)

11. Who’s Left Out?
Undocumented immigrants left out:
•Barred from Marketplace plans
•Not eligible for non-emergency Medicaid
•Eligible for restricted “emergency” Medicaid
•Eligible for services through community health centers
and/or safety-net providers
Legally present immigrants:
•5 year waiting period for Medicaid services continues
•Can purchase with subsidies in Marketplace

12. Who Provides HIV Care in the Future?
Individuals with income up to 138% FPL –
State Option
Eligible for Medicaid based on income
alone (Ryan White still needed to fill in gaps
not covered by Medicaid)
Individuals with incomes above 138% FPL
Eligible to buy in Marketplace
Income between 100% and 250% FPL
Eligible for premium tax credits and costsharing subsidies
Income between 250% FPL and 400% FPL
Eligible for premium tax credits
(Ryan White still needed to fill gaps )
Individuals with unmet care and treatment Ryan White Program still a safety net for:
needs
insured people with unmet need and gaps
in services legal immigrants not eligible for
Medicaid, and undocumented immigrants

13. The Challenge for People with HIV and their
Providers
• Medicaid expansion not in every state
• Ryan White program (RW) – patient centered comprehensive HIV
care – providers funded by grants
• Ryan White: Payer of last resort
• HCR expanded coverage means transitions
– PWH: Transitions to new plans, providers, pharmacies
• Once in new coverage, may need continued access to some RW services
– HIV Providers – to new payers
• Once in new plans they may not cover all services – continued RW funding

14. PART 2:
WHAT’S UP CALIFORNIA?

15. “A Bridge to Health Care Reform”
July 2011
• Low Income Health Program (LIHP) Partial and temporary county
– based Medicaid expansion: called SF Path in San Francisco
– Ends December 31, 2013
– SF Path eligibility has recently changed from 25% to 133% FPL
• Medi-Cal managed care expansion: moved most from fee-forservice into Medi-Cal managed care plans
– Must get care in your managed care “network”

16. What Will Health Care Reform Bring in CA in
2014?
• People with employer coverage, Medicare and traditional
Medi-Cal will see few changes
– Employers could extend coverage to more full time employees
– Insurance reforms apply to employer coverage
– Small employers will have some tax credits and access to the
Marketplace
– All covered people, including Medi-Cal and Medicare, will have access
to certain free preventative services
– Medicare recipients will get more help with prescription drugs
• Medi-Cal (California’s Medicaid program) expansion
• A state run Marketplace - Covered California

17. How to enroll
• You should be able to enroll in Medi-Cal and Covered
California at the same location
– Not clear yet which enrollment locations will have HIV expertise
– Several HIV clinics will assist but have not yet been certified
• Medi-Cal
–
–
–
–
Can enroll in Medi-Cal at any time during the year
If eligible, you need to enroll
Important to choose your provider and your “network”
Will have to do provider choice on paper form

18. How to enroll
• Covered California
– Open enrollment October, 2013 - March 31, 2014
– If eligible, you should consider enrollment
– Advising people to wait until more details and assistance are available
• Covered California website doesn’t yet have adequate information to
make informed decisions
– No information on provider networks
– No formulary information
• Currently very few helpers have been certified

19. A closer look at Covered California
• Five plans offered in San Francisco
– Anthem – Exclusive Provider Organization (EPO)
– Blue Shield – Preferred Provider Organization (PPO)
– Chinese Community Health Plan – Health Maintenance Organization
(HMO)
– Kaiser Permanente (HMO)
– Health Net (PPO)

20. Plans available at four different “tiers” or cost levels

21. Covered California – Cost Assistance Available
Two kinds of cost assistance available:
1.
Cost sharing subsidies
• For people between 100% and 250% FPL (about $16,000 annually)
• must take a Silver plan to receive help with out of pocket costs
1.
Premium tax credits
• For people between 100% and 400% FPL (about $46,000 annually)

22. Remember!
Remember!
•
The income figure we use to
calculate extra help is based on MAGI
but must consider PROJECTED
INCOME FOR 2014.
•
If you underestimate this figure now,
you may end up owing money back
to the Federal government when you
report 2014 taxes (in 2015.)

23. Additional cost assistance for people with HIV
• Premium help:
– State Office of AIDS is planning to assist with premium costs in
Covered California
– Program is call Office of AIDS Health Insurance Premium Payment
Program
• Eligibility is the same as ADAP
• Cost sharing for prescription drugs
– Pay co-pays etc. for ADAP drugs only
• Currently no assistance available for other out of pocket costs
including primary medical co-pays or lab co-pays

24. Transitions for people with HIV/AIDS
• Transitions for uninsured people with HIV, if eligible:
– From SF Path to Medi-Cal expansion (mandatory movement)
• Administrative move; will receive letter notice from DHCS; should ensure
that you get the providers you want
– From Ryan White to Medi-Cal expansion (mandatory movement)
• Will happen with Ryan White recertification; ensure that you choose the
providers you want; believe you will need to see someone at your clinic
for help
– From Ryan White to Covered California (not mandatory but RW doesn’t meet
individual mandate)
• Complex choices, open enrollment until March 31, 2014
• From PCIP to Covered California
– Mandatory in order to maintain coverage, PCIP ends December 31, 2013

25. What do you need to know before you make
any decisions
• Big and complex change
– Don’t go it alone!
• Read and keep all documents that are sent to you regarding
your health care
• Reach out for help
–
–
–
–
Your current provider
HIV experienced benefits counselor
Tax consultant
A certified enrollment counselor
• But know that they may not have HIV specific information

26. Some important considerations – Covered
California
• You don’t need to sign up for Covered California immediately
– Must sign up for Covered California by December 15 th if you need your
coverage to start on January 1, 2014
– Must sign up prior to February 15, 2014, in order to avoid the
individual mandate tax penalty
• Do your homework in order to make sure you pick the best
plan for you
– If you want to stay with your provider check with them to see what
plans they are contracted with
– If possible, see an HIV experienced benefits counselor to understand
how your plan will work with OA-HIPP/ADAP
• Don’t expect the Covered California enrollment counselors to understand
HIV programs
• Ask for a bridge supply of medications from your provider
before you transition to Medi-Cal

27. Some Important Considerations – Medi-Cal
• Make sure you don’t get defaulted into a plan – choose a plan
• Consider which plan includes your provider as well as which
networks are available (hospitals, etc.)
• Make sure to sign up with a paper application if you want to
choose your provider
• Medi-Cal has consumer protections available – if you have
problems with coverage you should seek help to exercise
those rights
• Ask for a bridge supply of medications from your provider
before you transition to Medi-Cal

29. Resources
 State HCR Information
-www.statereforum.org
 Enroll America
www.enrollamerica.org
 Center for Budget and Policy
Priorities - www.cbpp.org
 Treatment Access Expansion
Project – www.taepusa.org
 Kaiser Family Foundation –
www.kff.org
 Families USA –
www.familiesusa.org
 National Health Law Program
– www.nhelp.org
 NASTAD – www.nastad.org
 Health Resources and
Services Administration –
www.habhrsa.gov

30. CA Resources
 Covered California – www.coveredca.com
 Health Access - www.health-access.org
 Western Center on Law and Poverty –
www.wclp.org
 National Senior Citizens Law Center –
www.nsclc.org
 Health Consumer Alliance –
www.healthconsumer.org

31. Contact
Anne Donnelly, Project Inform
415.558.8669x208 adonnelly@projectinform.org
Courtney Mulhern-Pearson, San Francisco AIDS Foundation
415.487-8008 cpearson@sfaf.org
San Francisco HIV Health Care Reform Task Force
sfhivhealthreform@gmail.com