Affordable Care Act & Ryan White: Adjust Your Systems

Affordable Care Act & Ryan White: Adjust Your Systems

March 2014
Adjust Your Systems

Outreach, Benefits Counseling, Enrollment, Eligibility/Recertification | Provider Contracts/Relationships (Essential Community Providers) | Certification, Payer Status, Quality | HIV Finance Systems/Third Party Payers | Health IT/Electronic Health Records | Assess Organizational Position

ACA is making an array of broad changes to the U.S. system of health insurance coverage. Care systems are evolving under new delivery and payment approaches. Administrative operations involving data and information are expanding to better monitor quality and costs.

To keep pace, Ryan White agencies need to undertake corresponding adjustments in multiple areas. The types of changes required will be highly variable for any given agency, as they are contingent upon the agency’s current situation. Key factors include the type of services provided by the agency (eg, medical services that are reimbursable versus support services that are less likely to be covered by health plans or Medicaid); existing third-party reimbursement systems and other agency operations like electronic medical records; contracting mechanisms with Medicaid, provider networks, and health insurance plans. 

Below is an overview of key areas. See the Health Care Reform topic page for technical assistance and training resources as well as the links below. Ryan White programs are encouraged to share their resources here.

Outreach, Benefits Counseling, Enrollment, Eligibility/Recertification

Many Ryan White clients will be eligible for coverage under new ACA insurance options (both individual coverage in the private market and Medicaid). At the same time, Ryan White agencies must conduct eligibility determinations and periodic recertifications to determine ongoing eligibility for Ryan White services.  Below are key considerations in helping clients with enrollment and eligibility. 

Consumer Assistance

Ryan White grantees can use grant funds to educate clients about benefits and assist them with enrollment. Those eligible for new coverage should be referred to the Marketplace for enrollment help. A key part of helping clients is to maintain continuity of care as clients transition to new coverage. Thus, providers should explain to patients that Medicaid and private insurance plans usually require participants to get services from the provider networks set up by these plans. A patient will have to get HIV/AIDS medical services from another doctor or clinic if their current Ryan White provider is not part of the chosen plan. 

Ryan White programs also have opportunities to participate in consumer assistance programs in Marketplaces (formerly called Exchanges). All state Marketplaces (state-run, federally facilitated, and state partnerships) offer assistance to consumers in understanding and selecting health insurance plans through in-person assister and Navigator programs. ACA mandates that community agencies be part of these programs as they are implemented at the state and federal level. 

Eligibility Determinations/Recertifications

Ryan White programs are required to conduct eligibility determinations and recertifications, in accordance with the Ryan White payer of last resort provision.

Provider Contracts/Relationships (Essential Community Providers)

Under ACA, many Ryan White clients will be securing new coverage under Medicaid or approved private health plans known as Qualified Health Plans (QHPs). Clients will get their HIV/AIDS care from providers that have contracts with QHPs. Some Ryan White providers--especially larger agencies--already have contracts in place. However, many HIV/AIDS providers will need to establish new contracts with health insurance plans and Medicaid (including Medicaid Managed Care Organizations, MCOs) so that their clients can continue to receive care from skilled Ryan White providers. Providers also can focus energy on joining provider networks that, in turn, establish contracts with health insurers.

Contracting and Essential Community Providers

QHPs and Medicaid plans establish contracts with providers on an ongoing basis as they update their provider networks. Plans must comply with ACA provisions like the requirement for QHPs to include some, but not all, Essential Community Providers (ECPs) in their networks. ECPs are defined as providers (including Ryan White providers) that serve predominantly low-income medically underserved individuals. Learn more about the importance of being listed as an ECP for purposes of contracting with QHPs in the HRSA HIV/AIDS Bureau ECP resources pageAlso, keep in mind that states operating their own Marketplaces may have further defined ECP rules for QHPs, reflecting the traditional role of states as health insurance regulators.

With these ECP requirements in mind, providers should consider the following steps in establishing contracts with health plans, which are also presented in this tool: 4 Steps to Contracting with Health Insurers & Provider Networks.

Step 1: Start with Current Contracts

Some agencies already may have one or multiple contracts with private health plans and may have status as a certified Medicaid provider (a designation secured through the state Medicaid agency). Agencies with existing contractual arrangements with health plans and Medicaid MCOs should approach these plans to determine what coverage they will be offering in the Marketplaces. Also, ask these health plans whether the agency’s contracts are up to date and what changes need to be implemented.

Step 2: Identify Potential New Partners

Identify the potential universe of contracting partners. They include health plans and Medicaid MCOs that are currently, or will be, offering coverage in your target area. In addition, identify provider networks that you may want to join, as those networks will carry out the contract negotiation process. Although an individual agency can carry out this time-consuming information collection process, an existing network of Ryan White agencies (or even a planning body) might want to take on that task as a project, sharing information will all interested parties. Regardless, much of this information is readily available online.

Step 3: Determine the Process for Establishing Contracts

Each plan, MCO, and provider network has its own process for contracting with providers. Thus, you will need to do some legwork to identify their specific processes. To determine what process to follow in order to become a contracted provider or a member of a network:

  • Contact health plans. Go to the websites of health plans you identified in the step above and download their provider contracting materials.
  • Contact major provider networks in your area and express your interest in joining their network.
  • Contact your State Medicaid office to determine the process for becoming an enrolled provider
  • Contact current Medicaid contractors (especially Medicaid MCOs), express your interest in joining their network, and ask what process to follow. 

When making the above contacts, you may want to provide some basic information about your agency (eg, current number of clients, their insurance/Medicaid status, the services you provide). However, this information will be more relevant to share when you actually engage in the next step, conducting contractual negotiations.

Step 4: Secure Contractual Status/Relationships

Establishing a contractual relationship is a process of assessing the contracting partner (eg, the financial viability of the prospective partner, and nature of its presence in your target area), providing information (usually a form or set of forms and related documentation, such as an agency’s accreditation) and subsequent negotiations (eg, reimbursement rates). Contracts can be established with:

  • Health Insurance Plans as part of a network of providers.
  • Health Insurance Plans directly as an individual provider.
  • Medicaid as an enrolled provider under Medicaid Managed Care.
  • Medicaid as an enrolled/certified provider in fee-for-service Medicaid. 

In securing contracts, information is crucial (eg, your expertise and accreditations, your status as an ECP, number of clients you serve and their current coverage status under Medicaid, Medicaid eligibility under expansion, and coverage under private insurance).

Certification, Payer Status, Quality

Health care providers secure accreditation from multiple entities, attesting to their qualifications and standards for delivering high-quality care. These certifications are essential as they are required by insurance and health care laws and regulations and health plans.

There are several certification, status, and clinic operational considerations that are particularly relevant and useful for Ryan White agencies in adopting new care delivery innovations and positioning themselves for enhanced reimbursement.

  • Health Centers. HRSA’s Health Centers Program delivers care to medically undeserved individuals. Health Centers take on various forms of designation, including Federally Qualified Health Center Status (FQHC) and FQHC Look-Alikes. Learn more from HRSA, including how to achieve FQHC and Look-Alike designation. See this slide set on What Does it Take to Become an FQHC?
  • 340B Status. ECPs include those agencies defined in Section 340B(a)(4) of the Public Health Services Act and section 1927(c)(1)(D)(i)(IV) of the Social Security Act (safety-net providers that the Secretary of HHS determines would benefit from nominal drug pricing under Medicaid). Section 340B eligibility for Ryan White grantees is outlined on HRSA's Office of Pharmacy Affairs website. 
  • Patient-Centered Medical Home (PCMH). PCMH is an accreditation program that requires compliance with multiple criteria in order to be recognized as such under new health care reform and reimbursement policies. See the Medical Homes topic page for resources. 
  • Quality Management. HRSA’s HIV/AIDS Bureau has many quality management training and technical assistance resources to build the capacity of Ryan White programs to monitor and improve the quality of services. Quality management is necessary for achieving certification/recognition under the above Health Centers and PCMH efforts, and it is an essential component in establishing contractual relationships with Medicaid, health plans, and provider networks. 

HIV Finance Systems/Third Party Payers

As an increasing number of Ryan White clients transition to public and private health insurance plans, Ryan White agencies will need to adjust HIV finance systems that are focused on grant-based reimbursement.

Third Party Billing/Reimbursement

Ryan White agencies should review and enhance their third-party billing systems to make sure they are maximizing reimbursement by other payers (Medicaid, health plans, Medicare).

Measuring the Cost of Care

Ryan White agencies will also need to enhance their capacity to monitor and measure the cost of care. This information is necessary in establishing contracts with provider networks and health insurers in order to help ensure that third party payments cover the cost of delivering care.

Health IT/Electronic Health Records

Health information technology is comprised of the software, hardware, and processes to help providers manage patient care. Known as Health IT, this infrastructure includes use of electronic health records (EHRs), or electronic medical records, for maintaining health information that can then be used to improve care delivery and monitor outcomes. Agencies should enhance their Health IT/EHR systems in order to:

  • Improve the monitoring of the quality of care, service utilization, and costs.
  • Enhance information sharing among providers and payers.
  • Provide for a seamless interface with Marketplace eligibility and enrollment systems, which will evolve over time to enhance information systems communications in order to help consumers access health coverage and services.

Learn more about Health IT. Access these Health IT resources and videos for patients and families explaining the benefits of information technology in health care, protection of privacy and security, and more.

Assess Organizational Position

Health care agencies are witnessing multiple changes in terms of insurance, care models, payers, and care needs. Medicaid eligibility and marketplaces are expanding and creating new payer options for Ryan White clients. Health Centers have been expanding for over a decade, creating new venues for care for low-income populations. HIV/AIDS care and treatment has evolved and improved but remains challenging. Although antiretroviral therapies are increasingly effective, agencies are faced with continued challenges to do a better job of engaging infected people in care in order to achieve full viral suppression, which will benefit the health of individuals and that of the community in terms of reduced viral transmission.

This ever-shifting environment suggests the need for corresponding moves by agencies to assess the need to make changes within their own operations. Adjustments might include assessments of current and anticipated positions in the community with strategic restructuring (eg, adjustments in the agency’s mission, new collaborative ventures, specialization, merger). See Agency Readiness for ACA resources to help guide agencies in assessing their organizational position.

Add a Comment

Log in or register to post comments