The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States The Ryan White Program, enacted in 1990, is the nation’s safety net program for HIV care and treatment and serves about half a million people with the disease in the United States. The federal government has authorized the use of Ryan White funds for purchasing health insurance on behalf of clients since the enactment of the program and using funds this way has increased over time. While insurance purchasing has always been a permissible use of Ryan White funds, its role has become both more important and more complex with the implementation of the Affordable Care Act (ACA), as many more people with HIV have become newly eligible for insurance coverage. How Ryan White grantees at the state and local levels elect to move forward with insurance purchasing in the ACA era has key implications for the program and for the clients it serves. This brief discusses the historic role the Ryan White Program has played in helping clients purchase insurance coverage and provides an early look how grantees have elected to use Ryan White funds and ready systems for insurance purchasing in the ACA era, in five states – California, Florida, Georgia, New York, and Texas. The focus of this brief is on the first open enrollment period (lasting from October 2013 through April 2014) and on insurance purchasing activities conducted through the health insurance marketplaces for qualified health plans (QHPs). The findings of this brief are based on stakeholder interviews, focus groups with HIV positive individuals, and reviews of federal, state, and local documents. Key findings from the state studies include:  Most insurance purchasing in the Ryan White Program occurs through AIDS Drug Assistance Programs (ADAPs), a component of the state (Part B) program. ADAPs approached the first open enrollment period with different degrees of insurance purchasing experience and this often paralleled the degree to which they were prepared to offer insurance purchasing through the marketplaces. Among the states in this analysis, two ADAPs moved ahead with larger scale insurance purchasing programs (California and New York), two (Florida and Georgia) operated small-scale or pilot programs, and one (Texas) did not pursue an insurance purchasing program that could support QHP coverage.  All ADAPs examined here, including those more proactively pursuing QHP premium assistance, faced challenges. For those embracing QHP premium support, stakeholders described technical and/or process issues related to leveraging existing systems – which in some cases needed to be updated – for larger scale enrollment and challenges in orchestrating third party payments.  In the states that less aggressively pursued QHP insurance purchasing, stakeholders explained that challenges ran deeper and were often related to operating programs in states that were, overall, resistant to ACA implementation. As a result, stakeholders in these states reported that ADAPs were unable to sufficiently prepare for client enrollment through the marketplaces, were only able to conduct limited insurance purchasing, or, in the case of one state, were not able to start a QHP insurance purchasing program altogether.  States also varied in their ability to assist with cost-sharing assistance beyond premiums. While one state was able to provide complete cost-sharing assistance, other states provided only limited support beyond paying premiums. Stakeholders worried that without full cost-sharing assistance, clients would find insurance expenses unaffordable and may not be able to maintain their coverage, jeopardizing their care and treatment.  Part As, often by funding AIDS Service Organizations (ASOs), frequently stepped in to fill gaps in coverage and assist with costs not met through ADAP program insurance purchasing. This included covering premiums in states whose ADAPs had no or limited QHP insurance purchasing programs, helping with cost- sharing not supported by ADAPs, and preventing gaps in care and treatment during bumpy enrollment processes or coverage transitions. In some cases additional support was obtained through private foundations and pharmaceutical assistance programs.  The ADAPs that had the most limited QHP insurance purchasing programs in this study operated in states that did not expand Medicaid. Conversely, the states that embraced premium support for QHPs through their ADAP programs early on also expanded Medicaid, offering clients more robust coverage options.  The federal government encouraged Ryan White Program grantees to “vigorously pursue” client enrollment into available coverage, including QHPs. While this directive was clear to some grantees and helped to underpin efforts to enroll clients in QHPs with insurance purchasing assistance, others found the directive difficult to interpret. Some stakeholders trying to operate programs in states that were more resistant to ACA implementation overall reported a conflict between what was being asked of them by the federal government with regard to enrollment under the Ryan White Program and state-level decisions opposing to ACA implementation which lead to limited insurance purchasing opportunities. First enacted in 1990, the Ryan White Program – the largest federal grant program designed specifically for people with HIV – has grown to become a critical part of the HIV health care delivery system in the U.S., providing care, treatment, and support services to more than half a million low-income people with HIV each year.1 The program is administered by the Health Resource Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) and functions as a safety net, filling in gaps in care for people with HIV. The Ryan White Program is a “payer of last resort,” meaning that whenever possible, services must first be reimbursed by other available payers (e.g., public or private health insurance) before Ryan White funds can be used. Ryan White funds primarily pay for medical and support services and for the direct cost of medications for those who are uninsured or underinsured. Additionally, the federal government has authorized the use of program funds to assist clients in purchasing new health insurance or continuing existing insurance coverage, which includes paying for premiums, deductibles, co-payments, and co-insurance (see Table 1). Using funds this way, compared to directly purchasing care and medications, can provide clients with more comprehensive health coverage than they might have been able to obtain on their own and has been shown to be cost effective for the program compared to the cost of directly purchasing medications.2 While insurance purchasing, also referred to as premium assistance or premium support, has been a permissible use of Ryan White funds since the program’s inception, its role has become both more important and more complex with the implementation of the Affordable Care Act (ACA). Because of the ACA, tens of thousands of people with HIV have new insurance options, with some accessing insurance coverage for the first time. Therefore, Ryan White grantees and sub-grantees – states, territories, cities, providers, and other organizations providing services to people with HIV (collectively referred to as AIDS Service Organizations or ASOs in this brief) – have new opportunities to assist clients with the costs of private health insurance. In fact, federal policy guidance has encouraged Ryan White grantees to provide this assistance where appropriate.3 While some Ryan White grantees have substantial experience using their funds for premium assistance, others are newer to this arena. Moreover, because the ACA has made significant changes to the health care environments in all states, even grantees with experience in insurance purchasing are facing new challenges and decisions. How Ryan White grantees at the state and local levels elect to move forward with insurance purchasing in the ACA era has key implications for the program and for clients’ access to coverage. As such, it is important to examine the decisions around insurance purchasing that Ryan White grantees are making in the ACA era. Doing so will help provide an understanding of the various ways insurance purchasing programs are being implemented and allow for analysis of how these programs impact insurance coverage and ultimately health outcomes for people with HIV. This policy brief provides an early look at the insurance purchasing experiences of Ryan White-funded entities in five states – California, Florida, Georgia, New York, and Texas – during the first open enrollment period (October 2013 through April 2014). While Ryan White can assist with insurance purchasing and cost-sharing related to both public and private insurance, this report examines private insurance purchased through the health insurance marketplaces established under the ACA. The report is based on interviews with more than 60 stakeholders across the five states (7-12 per state) 10 focus groups conducted with people with HIV (two per state), and a review of federal, state, and other documents. Stakeholders held a range of public and private positions in fields related to HIV service delivery and policy development. Interviews and focus groups were conducted between March and September of 2014, so may not reflect more recent decisions made within states with respect to insurance purchasing, particularly those occurring during subsequent open enrollment periods. In addition, the experiences of these five states and of those interviewed are not meant to be representative of all states or all people living with HIV. The federal government has authorized the use of Ryan White funds to assist with insurance purchasing since the program was first enacted in 1990. While most parts of the Ryan White Program are authorized to use funds for this purpose (Parts A, B, C, and D)4, the primary source of Ryan White funding for insurance purchasing is the AIDS Drug Assistance Program (ADAP), a component of Part B funding which is provided by the federal governments directly to states to help pay for HIV care and treatment services (states may also contribute their own funds for services). ADAP was initially created to directly purchase HIV medications for infected individuals and this is still its dominant function in most states. Insurance purchasing, however, has grown rapidly over time given its cost- effectiveness and ability to provide clients with more comprehensive care (covering services not provided through Ryan White, such as non-HIV drugs, emergency room visits, and hospital stays), compared with purchasing medications directly. Insurance purchasing under ADAP has grown from supporting coverage for 6% of ADAP clients nationwide in 2003 to 35% in 2013.5 Over time, Ryan White reauthorizations and policy guidance have put greater emphasis on grantees’ ability to use Ryan White funds to help clients obtain insurance coverage. Policy notices have clarified aspects of the law related to insurance purchasing, emphasized the permissibility of this function, and to provided implementation guidance to grantees (see Tables 2 and 3). For example, while the initial authorization of The Program and subsequent guidance focused on insurance continuation (assisting clients in maintaining existing coverage), later policies specified that funds could also be used for purchasing new coverage (emphasized in notice 99-01 and explicitly affirmed in the 2006 reauthorization legislation). Further, the 2006 reauthorization of the program stipulated that 75% of grant awards must be spent on “core medical services,” identifying insurance purchasing as one such service. The Patient Protection and Affordable Care Act (ACA), signed into law by President Obama in 2010, provided for comprehensive health reform, expanding health insurance options – among other provisions – for millions of people in the U.S., including tens of thousands of people with HIV. The most significant coverage expansions began in 2014, when individuals were able to obtain subsidized coverage by enrolling in Qualified Health Plans (QHPs), private insurance sold through state and federally-run health insurance marketplaces. In addition, Medicaid coverage in states that chose to expand their programs was extended to eligible adults up to 138% of the federal poverty level (FPL).6 These developments, coupled with other key provisions of the ACA, including an end to pre-existing condition exclusions, prohibition on insurance rate setting tied to health status, and a ban on annual and lifetime caps on coverage, meant that many more uninsured and underinsured people with HIV, including Ryan White clients, would have access to more comprehensive health insurance. Beginning in 2013, HRSA issued guidance through a series of policy notices to help clarify requirements and expectations related to enrollment in these new forms of coverage. Guidance discussed the use of Ryan White funds in the context of the ACA, both generally and specifically related to insurance purchasing through the new health insurance marketplaces (see Table 3). Since, as a payer of last resort, Ryan White funds cannot be used for services when “payment has been made or can reasonably be expected to be made” by another payer, it was expected that grantees would help ensure that clients enrolled in the new forms of coverage for which they were eligible.7 Policy notices 13-01 and 13-04 addressed the need for grantees to secure non-Ryan White funds wherever possible, including by enrolling eligible clients in Medicaid and marketplace plans, noting that grantees should “vigorously pursue” enrollment. In addition, guidance moved beyond simply permitting grantees to use funds for insurance purchasing. HRSA now “strongly encouraged” grantees “to use RWHAP [Ryan White HIV/AIDS Program] funds to help clients purchase and maintain health insurance coverage, if cost-effective and in accordance with…policy.” In addition to the guidance released by HRSA, the Centers for Medicare and Medicaid Services (CMS), which has promulgated private insurance regulations under the ACA, released an interim final rule requiring QHP issuers to accept premium and cost-sharing payments made by the Ryan White Program, and other entities, on behalf of enrollees, also known as third party payments.9 This rule was issued in response to a lawsuit in Louisiana in which an issuer in that state refused to accept premium payments from the Ryan White Program made on behalf of enrollees. While the issuer stipulated the intent of their policy was to prevent fraud, advocacy groups filed the lawsuit against the issuer claiming that the policy served to deter those with HIV from enrolling in the company’s marketplace plans and as such violated non-discrimination provisions in the ACA.1011 The interim final rule served to settle the lawsuit. Given the new insurance opportunities provided by the ACA, the guidance from HRSA encouraging grantees to pursue new coverage options, and the payer of last resort requirement, most grantees are working to help ensure Ryan White clients enroll in coverage for which they qualify, including in the private market.12 In particular, many ADAPs worked to ready their systems to assist with marketplace insurance purchasing for the 2013-2014 open enrollment period.13 While the majority of ADAPs had some form of insurance purchasing infrastructure in advance of the ACA, states needed to decide if they would use their existing systems to purchase QHPs, and, if so, if those systems had the capacity. Data from the National Alliance of State and Territorial AIDS Directors (NASTAD) indicates that, as of June 2014, most states had moved to use ADAP funds to assist with QHP coverage, enrolling at least 16,000 ADAP clients into QHPs in the 2013-2014 open enrollment season.14 Only six states (Texas, Alabama, Mississippi, Idaho, Pennsylvania, and North Carolina) had not done so, though, most were planning to do so in the future. Additionally, Florida was operating a pilot insurance purchasing program for a limited number of clients (details included in the Florida case study, see Appendix).15 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).16 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. Sources: State Decisions on Health Insurance Marketplaces and the Medicaid Expansion; , Diagnoses of HIV Infection in the United States and Dependent Areas, 2013. HRSA Ryan White HIV/AIDS Program 2012 State Profiles; 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. 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).17 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). 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