Ryan White: Where are we with ACA?

A health care reform “to do” list was presented about six months ago at the November 2012 Ryan White Grantee Meeting. You may have missed it. In a sea of hundreds of sessions at the biennial conference were 11 grantee workshops on ideas and recommendations for Ryan White agencies to take in 2013 and beyond to implement the Affordable Care Act (ACA). Contract with health plans, revitalize benefits counseling, collaborate with state Medicaid officials on HIV/AIDS care issues - the TARGET Center sorted and captured all these ideas in one place: the ACA and Ryan White Learning Modules. There are just four categories but lots of details under each. They are:

  • Learn about Reform
  • Engage in Marketplace Planning
  • Educate and Assist Clients
  • Adjust Systems

Learning about Reform

When it comes to learning the ACA basics, you might be ready to check off item one on the list, Learn about Reform, which pulls liberally from HealthCare.Gov and national partners like The Henry J. Kaiser Family Foundation, National Alliance of State & Territorial AIDS Directors (NASTAD), Project Inform, HIV Health Reform, and others. In recent months we have seen a notable uptick in ACA webinars, calls, reports, and webpages. It seems that, every day, a new piece of information is released about the law, key provisions, pending and final regulations, and key steps to take.  People have been tuning in, according to select interviews with grantees around the country.  The learning will of course be ongoing given the complexities of health insurance, health care, and service systems.

Beyond learning about ACA, what is the Ryan White community doing to get ready for full implementation of ACA?  That’s hard to summarize as work is going on in multiple national groups and federal agencies, several hundred grantees and planning bodies at the local and state level, hundreds of community agencies, and thousands of providers.  

From HRSA, for example, the TARGET Center is building its repository of ACA TA tools, drawing upon resources developed by Ryan White agencies. HRSA’s HIV/AIDS Bureau has issued guidance materials and webcasts for grantees and is in the process of developing tips for planning, educating consumers, and strategic restructuring.  The AETC National Resource Center is developing a toolkit that will include information about contracting and connecting to Medicaid Managed Care Organizations and commercial insurance plans, blogs on integrating HIV care within ACA programs, and a webinar on clinical fiscal review (payer-mix evaluation).

Much is also going on at the state and local level. For a sampling of resources that have been developed based upon select outreach to Ryan White agencies, visit the TARGET Center website to see ACA tools compiled to date and share your ACA resources. Also, stay tuned for insights from NASTAD, which is also collecting insights in regional meetings.

Engaging in Marketplace Planning

Planning is taking place at many levels: in Marketplaces, with Medicaid agencies, in Ryan White planning groups, and within clinics.

Within Marketplaces, an unknown and perhaps unknowable number of Ryan White consumers and grantees have been taking part in Marketplace planning tasks like ACA regulations governing Qualified Health Plans and consumer portals to review and select insurance. Case in point: Us Helping Us, a Ryan White provider in Washington, DC, gave input to the DC Exchange in key areas like guidance on network adequacy standards. Similarly, various states like Washington, Tennessee, and Colorado, have ramped up their collaboration with state Medicaid programs as described in a NASTAD session on ACA in late May. Washington State, for example, has raised the question of whether the Ryan White definition of case management could be used in the state’s Medicaid Health Home program. Alabama Ryan White agencies are also working with their state on the design of their Medicaid Health Home model.

As for Ryan White-specific planning, various Part A and B grantees are spinning multiple plates in the air. Resource allocation adjustments are underway in response to sequestration budget cuts as grantees simultaneously prepare for ACA-driven adjustments, like projecting what proportion of clients might transition to Medicaid or commercial insurance. (See the Modeling reports, which provide relevant data for ADAPs to consider). These payer transitions might lead to shifts in funding towards premium support and cost assistance. Massachusetts certainly experienced this when implementing health care reform several years ago.

One way that Ryan White agencies can gather information about possible shifts in coverage is to undertake insurance eligibility screening as part of their Ryan White 6-month recertification processes.  The results can also help programs pre-identify clients to target for Marketplace enrollment.

Educating and Assisting Clients

In the coming months, multiple programs (Health Centers, Ryan White Part C, federally-facilitated and state partnership Marketplaces, and state Marketplaces) are being established to help clients understand their new insurance options under Medicaid and private insurance. They go by different names—outreach and education, assisters, navigators—but share a mission of driving consumers to Marketplaces to review and select public and private health insurance coverage. (See state-by-state enrollment activities).

Navigating the world of health insurance is not new to many Ryan White front-line staff. Case mangers across the country are used to talking with clients about their insurance coverage issues, as some are already covered by Medicaid or private coverage.

Many Ryan White agencies are applying for these grant funds, although many seem to be waiting for the release of federal and state-specific training resources being developed under these initiatives. In the meantime, some agencies are taking initial steps at training case managers and benefits counselors by participating in national and state webinars. Colorado is conducting a multi-day “boot camp” for case managers. A Part C agency in North Carolina is using a CQI process to improve eligibility screening in their clinic.

As for preparing consumers, San Francisco’s HIV Health Reform Task Force released an FAQ document to help clients prepare for change, while the TARGET Center offers a downloadable resource entitled “6 Ways to Prepare: Consumers.”

Adjusting Systems

The category “systems” is a big category that largely relates to agency infrastructure. The primary focus this spring has been to urge Ryan White agencies to expand contracting with health plans so they are positioned to serve clients who transition to new Medicaid and commercial coverage. However, there’s much more: enhancing third party billing systems; enhancing health information technology and Electronic Medical Records (EMR); and securing new credentials and status as an FQHC, FQHC-look alike, or Primary Care Medical Home.

Some agencies are responding through internal strategic planning and exploring changes in their organizational structure.  Meanwhile, the phones and emails are undoubtedly pouring in as agencies hear from armies of firms calling up to offer specialized services in billing, coding, contracting, and EMR systems design. What follows are just a few examples of what grantees have shared:

  • The Texas Part B grantee is pulling together a technical assistance and training strategy to build agency capacity in key areas like third party billing and reimbursement.
  • On the agency level, a Ryan White agency in South Carolina has several years under its belt working with the board on ACA planning, including consideration of becoming an FQHC.
  • Safety net providers with limited back-office infrastructure are probably the most vulnerable to ACA changes as the market shifts toward third-party payers and new service delivery models.  TA resources produced under a foundation project for Washington, DC metro area agencies are available to help these agencies self-assess and make changes.
  • Some Part A grantees have, for several years, issued Part A service delivery contracts that promote more integrated care delivery and require funded agencies to establish back office capacity in managing data and third party reimbursement. Agencies that meet these requirements will be better positioned to adjust to ACA. 

HoweImage of ACA Posterver, many HIV health clinics are still in assessment mode. There are plenty of directions they can take. See HIV Health Clinics and Health Reform: Getting Ready for 2014 and the TARGET Center’s 6 Ways to Prepare: Providers for additional information.

Share Your ACA Insights

What is shared above is just a taste of what we’ve learned so far in select calls with Ryan White agencies. Not mentioned? Let us know so we can share your insights.

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