Friday, February 21, 2014

Tarnished Blue

By Anna Meghan Nunn

Hundreds of patients living with HIV/AIDS in Louisiana and North Dakota are facing uncertain futures in their search for health insurance through the Marketplace Exchange under the Affordable Care Act (ACA). At the end of last year, Blue Cross and Blue Shield of Louisiana announced that they would no longer be accepting insurance premium payments from third party payers. On the surface, this decision might not seem like such a big deal, but digging deeper it reveals the potentially troubling reality for patients living with HIV/AIDS receiving supports and services under the Ryan White CARE Act, which in this scenario would be one of those third party payers.

Breaking News

Reuters reported in its recent article, "Exclusive: AIDS Patients in Obamacare Limbo as Insurers Reject Checks," that Blue Cross and Blue Shield of Louisiana spokesman John Maginnis told them, "In no event will coverage be provided to any subscriber, as of March 1, 2014, unless the premiums are paid by the subscriber (or a relative) unless otherwise required by law."

Another report, "More Obamacare Insurers in Louisiana Reject AIDS Patients," published online by News Daily quoted Maginnis as saying that the policy is, "a safeguard against…patient steering and other fraudulent activity," adding that it knows "from experience that there are people who want to game the system." Two smaller insurance companies (The Louisiana Health Cooperative and Vantage Health Plan) in Louisiana followed suit days later, as did the Blue Cross and Blue Shield of North Dakota.

This statement from the Blue Cross and Blue Shield of Louisiana comes on the heels of a November announcement by the Centers for Medicare and Medicaid Services (CMS) in which they warned, "hospitals, other healthcare providers, and other commercial entities" that it has "significant concerns" about their accepting premium payments from third party payers, citing the risk of fraud. The interesting thing about this November statement is that it somewhat contradicts an earlier statement made by the CMS in September 2013, whereby they informed insurers that Ryan White funds "may be used to cover the cost of private health insurance premiums, deductibles, and co-payments" for ACA insurance plans.

The ambiguity of these conflicting messages allowed Blue Cross and Blue Shield of Louisiana to justify their rejection of the third party payments from Ryan White. In an attempt to clarify their position, CMS released a new statement on February 7th, in which spokeswoman Tasha Bradley told Reuters, "Ryan White grantees may use funds to pay for premiums on behalf of eligible enrollees in Marketplace plans, when it is cost-effective for the Ryan White program." Reuters maintains that this means that having people with HIV/AIDS enroll in insurance under Obamacare could save the government money. Bradley went on to say that, "the third-party payer guidance CMS released (in November) does not apply to Ryan White programs."

The drama didn't end there!

According to The Advocate in its recent post, "Blue Cross Decision Affects Some HIV/AIDS Enrollees," CMS further refined this point, explaining that the November statement was in response to isolated cases of hospital staff attempting to enroll it’s chronic emergency room patients (its most expensive patients) in online Marketplace Exchange plans. Unfortunately this clarification came too late; Louisiana insurance companies and Blue Cross and Blue Shield of North Dakota had already began rejecting checks and informing previously enrolled patients that they will be dropped from their plans.

Many healthcare advocates are accusing these two Blue Plans and the other smaller insurance companies of attempting to side step the ACA mandate that patients cannot be denied access to care based on pre-existing conditions. Since HIV/AIDS is a chronic condition that tends to encompass some of the most expensive policy holders, some advocates are calling it blatant discrimination. These companies are now being accused of avoiding adverse selection, a term used to define the practice of insurance companies attracting patients with chronic conditions and expensive care (Reuters, 02/08/14).

The Advocate quotes Ged Kinslea, communications director for the AIDS Healthcare Foundation in Los Angeles as saying, "It looks as if Blue Cross is deliberately misunderstanding CMS…it seems like they are trying to weasel out of covering high-acuity patients." Several recent articles have noted that this maneuver flies directly in the face of the fundamental intent of the ACA, to expand comprehensive and affordable healthcare to all citizens, especially the most economically and physically vulnerable.

Noel Twilbeck, Chief Executive Officer of the New Orleans AIDS Task Force, claims that there are currently 19,000 people in Louisiana living with HIV/AIDS and that NO/AIDS has registered approximately 200 people in Marketplace Exchange insurance plans, but that number may be even higher. Twilbeck says that it is unclear how many people will ultimately be effected by this recent development.

This is an especially pertinent issue for Louisiana residents as the state has chosen not to accept the Medicaid Eligibility expansion offered under the ACA. This means that many patients living with HIV/AIDS who earn too much to qualify for Medicaid but not enough to qualify for federal subsidies for insurance plans will fall into a coverage gap.

The concern is best summarized by Twilbeck, "Our biggest fear is that if we stand by and do nothing, and Blue Cross gets away with this, a lot of others will try to do the same" (The Advocate, 02/20/14).

So, what is being done to remedy this situation?

According Lambda Legal's blog, the nonprofit has filed an administrative complaint with the U.S. Department of Health and Human Services Office of Civil Rights against Blue Cross and Blue Shield of Louisiana. Scott Schoettes, HIV Project Director at Lambda Legal, said:

"The situation is urgent. Refusing federal funds that provide life-saving care to people living with HIV could potentially affect thousands of low-income Louisiana residents, and if BCBS does not recognize the error of its ways and reverse course, the only logical explanation for its conduct is discrimination. This strategy keeps people living with HIV off BCBS's insurance rolls, and smacks of the sordid legacy of years of insurance industry practices designed to deny coverage to those living with HIV."

Days later, Lambda Legal filed complaints against the other two insurance companies, The Louisiana Health Cooperative and Vantage Health Plan. The NO/AIDS joined them in filing (The Advocate, 02/20/14). Lambda Legal contends that they sent a written request to Blue Cross and Blue Shield of Louisiana on January 27th with regard to this new policy. They requested a response by January 30, 2014, but state that they have not received a response as of February 10th.

One of the defendants was obviously paying attention, evidenced by the following Tweet: "@LambdaLegal @VOCALNYAction @Vantage_Health is currently accepting 3rd party payments."

That hasn't stopped some powerful players inside the Beltway. Senator Mary Landrieu (D-LA) is putting pressure on Blue Cross and Blue Shield of Louisiana. According to Jessica Stone, Senator Landrieu’s health staffer, "BCBS LA told me their decision was not due to the CMS guidance or any confusion (as we thought before) but was in fact due to adverse selection concerns. I have also recently learned North Dakota’s BCBS plan has implemented the same policy" (Reuters, 02/08/14). Reuters insists that Stone declined to further discuss the details of her interactions between Senator Landrieu’s office and Blue Cross and Blue Shield of Louisiana.

Local Baton Rouge, LA news station WAFB-9 published a story last week, claiming to have received an email from CMS which read:

"Federal rules do not prevent the use of Ryan White funds to pay for health care plans.  In fact, CMS issued guidance last week making this clear and encouraging issuers and Marketplaces to accept such payments.  Given the importance of access to care for people with HIV/AIDS, CMS is considering amending those the rules to require issuers to accept these payments."

In response Blue Cross and Blue Shield of Louisiana spokesman John Maginnis emailed WAFB stating, "we are reviewing and considering this new information to decide whether it is helpful in addressing our concerns about taking third-party payments" (WAFB-9, 02/10/14).

Blue Cross and Blue Shield of Louisiana maintains that they, "welcome all Louisiana residents who chose Blue Cross and Blue Shield of Louisiana" (News Daily, 02/13/14). Unfortunately Louisiana residents who chose Blue Cross and Blue Shield of Louisiana, and who are dependent on Ryan White funding for premium payment assistance are not able to participate in the insurance plans.

According to CMS, Blue Cross and Blue Shield of North Dakota is the only other carrier refusing to accept third-party payments, so far. Blue Cross and Blue Shield of North Dakota spokeswoman Andrea Dinneen recently stated that they are, "currently reviewing its eligibility policies with respect to recipients of Ryan White Program funding" (Reuters, 02/08/14).

But a recent Tweet by Blue Cross and Blue Shield of North Dakota's was less ambiguous, stating they are enforcing North Dakota’s century code that forbids them accepting third party payments.

Blue Cross and Blue Shield of North Dakota Twitter Account

Healthcare advocates and HIV/AIDS advocacy groups are hopeful that this issue will be favorably resolved in the coming weeks. In the meantime, they advise patients living with HIV/AIDS effected by this policy in Louisiana and North Dakota to reach out to local AIDS resource groups for guidance. Other groups are asking patients who are effected to put pressure on their legislators and insurance companies by participating in an online petition that are currently being circulated by

Thursday, February 13, 2014

Keeping a Watchful Eye on ACA Implementation, and ADAPs

By Anna Meghan Nunn
Intern from the University of North Carolina at Wilmington, Department of Public and International Affairs

The Patient Protection and Affordable Care Act (PPACA), or the Affordable Care Act (ACA) – also known as "Obamacare" – is in the early stages of implementation, but there are emerging uncertainties in the public health community about certain aspects of the law. Specifically, some advocacy groups, nonprofit organizations, advocacy coalitions, and policy institutes have voiced concern over the potential threat the ACA may pose to the HIV/AIDS community. While most in the public health community view the new healthcare law favorably with respect to HIV/AIDS care, there are some unintended consequences that have many worried. Specifically there are five areas of concern about the new law and its potential impact on HIV/AIDS supports and services:

Gaps and barriers in access to comprehensive care and treatment
Unintended consequences
Uncertainties in treatment/coverage
Future of the Ryan White CARE Act
ADAP’s role in the distribution of allocated funds

Affordable Care Act: Millions of Americans Benefiting from the Law

Gaps and Barriers in Access to Comprehensive Care and Treatment
A recent Kaiser Health News article estimated that there are nearly 1 million patients living HIV/AIDS, and whereas the ACA will bring new opportunities for health care coverage to those patients, there will be some gaps in coverage. For example, the Henry J. Kaiser Family Foundation in its recent study, "Status of State Action on the Medicaid Expansion Decision, 2014," indicates that there are currently 19 states opting out of the Medicaid Eligibility expansion offered through the ACA, with 6 states still openly debating the decision. This includes, but are not limited to, the majority of the states in the Southeastern portion of the country. The Southeast also accounts for 8 of the top ten states with the highest HIV/AIDS rates. Patients in these states will see significant gaps in their healthcare coverage, as many of them will not qualify for Medicaid or tax exemptions for private insurance in the Marketplace Exchange. In total it is estimated that 4 million of the lowest income Americans will suffer gaps in coverage due to the states choosing to opt out of the expansion. Further, because the ACA will impact states differently there is concern that some states will suffer more than others. An article published by the Virginian-Pilot entitled, HIV Patients Wade Warily Into the Health Marketplace (2014), emphasizes a major concern in their state. They contend that, “… because of Ryan White funding rules, patients in the drug-assistance program can sign up only for plans that cover all HIV medications included on the program's formulary. Plans from Anthem Blue Cross and Blue Shield of Virginia don't include them all. That means none of the program's clients can sign up for an Anthem policy.” These state-by state cases are causing confusion for programs like the AIDS Drug Assistance Program (ADAP) that are ensured with helping clients find affordable health care coverage and medications.

An additional concern of some advocates is the fact that undocumented aliens will not be covered by ACA insurance and will therefore not benefit from the comprehensive care that would otherwise be available to them. This has considerable negative implications for public health, public clinics, and already over-burdened emergency rooms where these patients will likely be forced to receive their care.

Unintended Consequences 
The unintended consequences of the implementation of the ACA relates to the financial burden it will place on low-income patients living with HIV/AIDS. While many patients are enthusiastic about the potential of more comprehensive coverage, many are concerned about the out of pocket expenses that they may incur through co-pays, deductibles, and further costs associated with laboratory tests and associated costs related to HIV/AIDS care. Currently, ADAP assists with some of these costs including medications. The implementation of the ACA may force many patients to pay these costs until they reach an “out of pocket maximum,” which will potentially take months to reach and place a sizeable financial burden on patients, many of whom are living below the poverty level or on fixed incomes. A New York Times article entitled, On Health Exchanges, Premiums May Be Low, but Other Costs Can Be High (2013), states that, “For policies offered in the federal exchange, as in many states, the annual deductible often tops $5,000 for an individual and $10,000 for a couple.” It is still unknown how many HIV/AIDS patients will be impacted by these large deductibles and co-pays.

Uncertainties in Coverage/Treatment
With the rollout of the ACA still in the early stages there is a great deal of uncertainty in the future of coverage and care for patients living with HIV/AIDS. The ambiguity of the law and the reaction of the states has many worried that certain medications will not be covered. The previously mentioned Kaiser Health Network article also highlights these concerns saying that, “advocacy groups have criticized some health plans in the insurance exchanges for failing to cover key HIV medications, charging high amounts for necessary drugs or failing to tell consumers which doctors and medications are included.”  While this benefits these insurance companies, as they will not be covering the expenses related to patients living with HIV/AIDS, it puts the burden back on public clinics and leaves patients without access to crucial drugs that they need. Further still, many are concerned as to whether or not they will be able to continue seeing their current medical professionals and continue on their healthcare regimens. This is a notable concern due to the importance of the healthcare regimen and could have serious consequences to public health.

The Future of the Ryan White CARE Act
While the ACA will be beneficial for many patients in the country, there is unease among many as to how the law will affect the Ryan White CARE Act. The Ryan White program is funded through federal dollars and some are worried that increased access to healthcare may have inadvertent effects on funding. There may be a political pushback against funding programs like ADAP through federal grants like the Ryan White program. This was recently witnessed in the case of the Farm Bill with Republicans pushing to separate the legislation into two separate Bills in an effort to cut funding to food stamps and lower the price tag of the $939 billion proposal. Some worry that the same may occur with decreased funding for Ryan White or a loss of funding all together. We argue that these funds are still vital and necessary to providing access to medications, insurance plans, supplemental insurance, and associated costs of HIV/AIDS related treatment.

ADAP’s Role in the Distribution of Allocated Funds 
A final concern is the role ADAP will play in the distribution of the Ryan White program funds. It is ultimately going to be up to local programs and health departments receiving Ryan White funds as to how they will be allocated with regard to costs not associated with medications. These costs include co-pays, laboratory tests, and other cost sharing expenditures. There is a great deal of concern as to how ADAP will be able to administer these funds. A similar situation arose a few years ago when many ADAP programs in the southern states had to take drastic measures to reduce their extensive waiting lists. Many of these states were forced to cap enrollment, reduce formularies, discontinue reimbursements of laboratory expenses, and use emergency ADAP funds to reduce the number of patients living with HIV/AIDS on their waiting lists (NASTAD, 2012). It is the concern of ADAP that a parallel incidence will occur with the rollout of the ACA.

It is crucial that the public health community continue to monitor these glitches with the Affordable Care Act and collaborate on solutions to better assist the recipients of ADAP funds.