Affordable Care Act & Ryan White: Learn about Reform

Affordable Care Act & Ryan White: Learn about Reform

July 2014
ACA and Ryan White Learn About Reform

Overview  |  Ryan White & ACA  |  Health Benefits and Access to Providers  |  Changes in Medicaid and Medicare  |  Changes in Medicaid Eligibility  |  Tax Credits and Cost Sharing Subsidies  |  Accessing Health Insurance: Marketplaces  |  Changes in Care Systems  |  Changes in Financing

The first step for anyone seeking to engage in ACA implementation is to become informed. Multiple activities are under way and many resources are available to guide states, agencies, and consumers. The starting point for everything about ACA is (sign up for updates). A number of nongovernmental websites (see Key Websites) also explain ACA and present various implementation resources.

ACA is complex, so getting up to speed on everything is quite a challenge. Thus, decide what is most relevant and focus on those key areas. For example, you might be most interested in learning what benefits will be provided in health insurance plans. Alternatively, you may want to learn about new eligibility screening processes. Regardless of the topic, be aware that information contained here and on the referenced websites can provide you with the basic facts and portals for digging deeper into the intricate details, such as federal implementation rules. 


ACA is changing the nature of health insurance and health care delivery. Many changes are taking place at the federal and state level, although state changes are variable as some jurisdictions have moved more rapidly to implement reforms.

In 2013 and early 2014, much attention has been directed to changes in the health insurance Marketplace, which opened for enrollment on October 1, 2013, and started offering coverage on January 1, 2014. Every state has a Marketplace wherein eligible individuals and small businesses can shop for and purchase private health insurance plans or enroll in Medicaid and CHIP if eligible.  Almost everyone will be required to have health insurance or pay a penalty if they do not. This is called the individual mandate (see the final rule on shared responsibility and exemptions and the IRS's Affordable Care Act Tax Provisions web pages). Subsidies and tax credits will be available to help lower income individuals afford health insurance (see below).

Health care delivery reforms have been in progress since passage of ACA in 2010 and will continue for decades to come. 

Here are key examples on health insurance market reforms, including provisions of particular importance to people living with HIV/AIDS.

  • Insurers can no longer deny coverage based on preexisting conditions.
  • Higher premiums cannot be charged based on preexisting conditions.
  • Insurers must cover "Essential Health Benefits" (EHBs, described below).
  • Lifetime dollar limits on coverage have ended.
  • Annual limits on EHBs will be phased out in 2014.
  • Insurers cannot drop policyholders from coverage simply because they become sick or make mistakes on their applications.
  • Certain preventive health services are covered at no charge.
  • Premium variations based on age (age rating) are limited to 3:1.

In addition, as discussed below, ACA expands Medicaid eligibility (at state option) to all adults with incomes up to 138% of the federal poverty level.

On the health care delivery front, changes include new ways to fund and deliver care (eg, moving away from the fee-for-service mechanism traditionally found in the U.S. health care system).

The above ACA reforms support the goals of the National HIV/AIDS Strategy to reduce new HIV infections, increase access to care/improve outcomes, reduce disparities, and improve coordination of the nation's response to the U.S. HIV epidemic.  Ryan White agencies and consumers can support ACA and National Strategy implementation by learning about ACA, getting involved in implementation activities, working to further improve HIV/AIDS services.

Learn more:

Ryan White and ACA

ACA has many implications for Ryan White programs.

  • A significant number of clients will be enrolled in public and private health insurance, providing them with a new source of coverage. Many will be eligible for assistance to help pay for the cost of coverage. Ryan White may be able to continue to provide support for necessary services that are not covered by other insurance.
  • Payments from AIDS Drug Assistance Programs (ADAPs) are considered true out-of-pocket expenses under Medicare Part D.
  • Issuers of Qualified Health Plans (QHPs) must "accept premium and cost-sharing payments made on behalf of enrollees by the Ryan White HIV/AIDS Program, other Federal and State government programs that provide premium and cost sharing support for specific individuals, and Indian tribes, tribal organizations, and urban Indian organizations."
  • Service delivery systems are undergoing many changes to improve outcomes and cut costs. 

HRSA's HIV/AIDS Bureau has prepared Ryan White & the Affordable Care Act: What You Need to Know, highlighting ACA issues with particular relevance to Ryan White grantees and people living with HIV/AIDS. 

Health Benefits and Access to Providers

HHS has issued ACA regulations defining the benefits that must be covered in most health insurance plans. These Essential Health Benefits (EHBs) comprise a core set of services that must be provided under Medicaid and under health insurance plans that are approved for offering (Qualified Health Plans [QHPs]) in the individual and small-group markets both inside and outside Marketplaces. QHPs must be equal in scope to a typical employer health plan, which each state has defined in its "benchmark" EHB (ie, a plan currently being offered in that state). Certification of QHPs is by the state (if the state is operating its own Marketplace - see this chart of state QHP certification standards by State Reforum) or by CMS (in states participating in the federally facilitated or partnership Marketplace model).

Plans also must be at 1 of 4 actuarial value (AV) levels. These levels are defined as the percentage of health care costs that a plan will cover. For example, a plan with an AV of 80% would pay 80% of costs for covered benefits and the beneficiary would be responsible for 20% of the costs.

In order to maximize access to coverage for low-income individuals, ACA requires plans to contract with some, but not all, Essential Community Providers (ECPs)--providers that serve predominately low-income medically underserved individuals. ACA provides examples of ECPs (eg, entities defined in Section 340B(a)(4) of the Public Health Services [PHS] Act). Plans also are required to cap the maximum out-of-pocket costs for enrollees.

Learn more:

  • See State Reforum for insights on how state Marketplaces are further defining, refining, and implementing ACA requirements on plan design. 
  • HHS final rule on EHBs, AV, and accreditation. 
  • HHS QHP resources for states and prospective QHP issuers in preparing and submitting a QHP application for the Marketplace.
  • NASTAD analysis of how EHB rules apply to private health insurance plans and Medicaid expansion plans for (1) prescription drugs, (2) preventive services, (3) chronic disease management, and (4) mental health and substance abuse services--benefits particularly important to people living with HIV/AIDS and viral hepatitis.

Changes in Medicaid and Medicare

A significant proporation of people living with HIV/AIDS are covered by Medicaid, Medicare, or both (dually eligible). ACA changes are underway in each of these areas.

  • Medicaid. The most well-known Medicaid change is the state option to expand eligibility (see below). ACA is also changing Medicare eligibility and enrollment processes (eg, streamlined applications through Marketplaces; verification of eligibility primarily via electronic means; new and varied income eligibility procedures, depending on one's eligibility category). Other changes include benefits (eg, alternative benefit plans for states that expand eligibilty for the adult population with incomes less than 138% of the federal poverty level), enhanced reimbursement for providers, and financing of IT systems updates. Finally, new approaches to delivery of care under Medicaid are being explored (eg, Medicaid Health Homes). Keep abreast of the technical aspects of Medicaid and ACA on the HHS/CMS Medicaid and ACA webpages and Kaiser's Medicaid pages.
  • MedicareMedicare Part D change under ACA include, for example, the eventual phase out (by 2020) of the "donut hole" and (effective 2011) lower cost brand name drugs for individuals in the "donut hole." For Ryan White, a key change, also implemented in 2011, allows ADAP expenditures to count as True Out of Pocket (TrOOP) costs. This means that ADAP expenditures for a Ryan White client count as incurred out-of-pocket expenses, allowing the person to move more rapidly through the "donut hole" cost phase and into the next Medicare Part D phase--catastrophic coverage--where Medicare Part D drugs are available at nominal cost. 
  • Medicaid-Medicare. ACA changes for the dually eligible include enhanced coordination of Medicaid and Medicare

Changes in Medicaid Eligibility

States have the option of deciding whether to expand Medicaid eligibility to cover all individuals earning up to 138% of the federal poverty level.

  • In states that expand Medicaid eligibility, low-income individuals at or below 138% (including persons living with HIV/AIDS) will no longer have to become disabled in order to be Medicaid eligible. 
  • In states that do not expand Medicaid eligibility, existing state Medicaid eligibility rules will continue to apply.

See this Kaiser chart on the status of Medicaid expansion and current eligibility levels in the states. See Medicaid.Gov for information on your state's Medicaid program.

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

Tax Credits & Cost Sharing Subsidies

Federal tax credits and cost-sharing subsidies are available to certain individuals who purchase insurance on the Marketplace. The goal is to make health insurance affordable to lower income individuals and families. Tax credits/subsidies:

  • Are available to individuals who have incomes between 100% and 400% of the federal poverty level. (More specifically, premium tax credits are available for eligible individuals with household incomes between 100-400% of the federal poverty level, while cost-sharing assistance is available for eligible individuals between 100-250% of the federal poverty level. Tax credits and subsidies are calculated in relation to silver level policies.)
  • Are available to individuals whose employer-provided coverage is not affordable (defined as costing more than 9.5% of income) or does not have an Actuarial Value (AV) of at least 60%.
  • Are not available to persons who are eligible for public insurance programs (Medicaid, Medicare, CHIP, TriCare).

Learn more:

Accessing Health Insurance: Marketplaces

Marketplaces are where individuals and small businesses shop for health insurance coverage from private insurers and from public insurers such as Medicaid. Here are some specifics:

  • Each state has the option of deciding whether to operate its own state Marketplace, to partner with the federal government, or default to a federally facilitated Marketplace.
  • People looking for insurance can shop from a menu of QHPs. These QHPs must provide EHBs and meet other requirements, such as including ECPs in their network of service agencies. ECPs include many types of safety-net providers, such as those agencies defined in Section 340B(a)(4) of the PHS 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). (See HHS information on ECPs.) Other requirements pertain to network adequacy, marketing, quality reporting and improvement, and accreditation. Because states regulate health insurance, QHPs also must comply with state licensure requirements. State Marketplaces may stipulate additional requirements for QHPs.
  • Marketplaces present a "no wrong door" approach by offering one-stop, comprehensive screening to determine eligibility for various public and private health insurance programs. Marketplaces help individuals apply for coverage via website portals, call centers, and enrollment assisters (personnel/agencies that provide education and assistance with enrolling in a plan). HRSA's HIV/AIDS Bureau issued guidance explaining how Ryan White service categories can be used to support Marketplace outreach, benefits counseling, and enrollment activities for Ryan White clients who are enrolling in private health insurance plans or Medicaid.

Learn more about Marketplaces from  See what's going on in your state.

Changes in Care Systems

Reforms are under way to improve the health care infrastructure and develop new care delivery approaches that can improve quality and lower costs.

  • New funding has gone toward expansion of the Health Centers program, administered by HRSA's Bureau of Primary Health Care.
  • Prevention enhancements include, for example, little to no cost sharing for various preventive services
  • Regarding IT, under the Office of the National Coordinator for Health Information Technology (HealthIT), significant resources have also gone into enhancing health information technology systems to enable providers to manage care and share data through Electronic Health Records. Those efforts are continuing under ACAimplementation activities to enhance monitoring of care quality, service use, and costs; sharing of information among providers and payers; and interfacing Marketplace eligibility and enrollment systems.
  • Payment and care delivery innovations (e.g., managed care, primary care medical homes, accountable care organizations, bundled payments, global payments) are largely happening through CMS's Center for Medicare and Medicaid Innovation (CMMI). Key areas for Ryan White agencies include securing status as a Primary Care Medical Home and delivering services under the care/financing model of the HRSA Health Center program (as an FQHC or FQHC Look Alike). Under Medicaid, most states deliver care to eligible individuals through Medicaid managed care. ACA allows states the option to create Health Homes to provide coordinated care for persons with chronic conditions at enhanced reimbursement rates.
  • There is increased attention to program integrity (i.e., fraud and abuse).
  • Payments to disproportionate share hospitals (which serve a significantly disproportionate number of underserved/uninsured patients) are being reduced, starting in 2014, as more people are expected to gain insurance coverage. 

Changes in Financing

Under ACA, Marketplaces will offer individuals a number of coverage options through Medicaid (in states that expand eligibility) and private health insurance plans. As a result, an increasing proportion of HIV/AIDS care will be covered by these payers. In order to be well positioned to continue serving their clients--who will be making choices from among these options--Ryan White agencies need to enhance their third-party billing systems and establish new relationships with multiple provider networks and health insurance plans.

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