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Affordable Care Act & Ryan White: Participate in the Marketplace Process

Affordable Care Act & Ryan White: Participate in the Marketplace Process

March 2014
TARGET Center
ACA and Ryan White Marketplace

What to Ask  |   Who to Contact to Get Involved  |   See What’s Going On in Your State  |   Resources to Use

ACA implementation is a complex process that is changing both the health insurance Marketplace and the care delivery system. 

  • Health insurance companies have implemented many new insurance protections (eg, health insurers cannot deny coverage or charge more because an individual has a preexisting condition).
  • At the federal level, rules and regulations have been issued (and are periodically updated) with guidance for individuals, states and insurance companies. 
  • Federal and state activities to investigate and create new care delivery systems are under way.
  • Every state has implemented ACA in some manner and has engaged in some type of planning. That’s because ACA calls for reforms in health insurance that apply to all states (eg, prohibition of exclusions based on preexisting conditions). The work is ongoing. States operating their own Marketplaces have undertaken further refinement of ACA rules and regulations (eg, defining Essential Health Benefits, network adequacy standards, Essential Community Providers) and designed outreach and enrollment (eg, website portals, staff to assist consumers). Planning is also taking place in states that are not expanding Medicaid and are not setting up their own Marketplaces, although the type of planning work varies considerably. 
  • Individuals have new responsibilities to have health insurance, which entails being informed about health insurance, selecting a coverage plan, and keeping track of its use. Consumers also need to be more informed and involved in their own care under new delivery models.

Although preparations are well underway, there are still opportunities to become engaged in ACA implementation.

  • Marketplaces will be making adjustments, refinements, and additional implementation steps that will present new opportunities for participation.
  • In addition to Marketplace implementation, there will be opportunities for involvement in reform of the care delivery system through HHS initiatives and countless other activities that have been in progress for decades through initiatives being undertaken by, for example, individual states and foundations. Agencies also can make internal adjustments to their operations in terms of certifications and practices (see Adjust Your Systems). 

What to Ask

Planning and Regulations

  • What advisory activities and decision-making processes are under way and how can I get involved? In particular, what actions are taking place regarding implementation of ACA requirements around Essential Health Benefits, Essential Community Providers, and other provisions that affect access to care for underserved individuals? See these ACA planning tools. Importantly, bring your insights on how Ryan White planning has been carried out in terms of planning processes and use of data and informed perspectives to guide decision-making about setting up Marketplaces.

Medicaid

  • Medicaid/Ryan White Coordination. What are the key Medicaid and Ryan White coordination issues?  See this May 1, 2013 HRSA/CMS letter on Medicaid and Ryan White coordination, which discusses the following issues. First, Ryan White agencies need to maximize efforts to enroll eligible clients in Medicaid coverage that is available to them. Second, Ryan White agencies also need to fulfill the legislative mandate of Ryan White as payer of last resort through eligibility/recertification processes and coordination with third party payers. Third, Ryan White agencies need to manage clients who experience transitional coverage issues (e.g., clients whose Medicaid and Ryan White eligibility changes over time; the role of Ryan White to fill gaps in Medicaid services; billing issues like cases of retroactive Medicaid eligibility for Ryan White clients and back billing). Please note: CMS and HRSA are providing ongoing webinars to discuss key coordination topics. See these ideas for Medicaid/Ryan White collaboration.
  • Medicaid Changes and Innovations. What actions are taking place regarding Medicaid--Medicaid expansion, assistance to individuals with enrollment, Medicaid Managed Care, Medicaid Health Homes, etc.? Getting answers to questions about Medicaid can best happen by developing connections with the state Medicaid program by: identifying allies and formalizing connections; reviewing the state Medicaid application; understanding plan types and scope of coverage; and training providers about Medicaid eligibility, enrollment processes, co-payment obligations, and recertification requirements (ideas shared by Massachusetts Part B). In addition to asking about Medicaid issues, find out what state Mediciaid officials know about HIV/AIDS service models and issues and fill their knowledge gaps by providing them with briefings. Note: State Medicaid programs can access technical assistance from CMS on Medicaid Managed Care. Work with state Medicaid staff to determine if a technical assistance request can be submitted to CMS to advise the state Medicaid agency on strategies to assure access to services, adequate provider networks, and other strategies for Medicaid managed care organizations to adopt in order to meet the needs of people living with HIV/AIDS. 

Help for Clients

Changing Provider Systems

  • How should health care providers go about setting up relationships with provider networks and health insurance plans so that their services can be part of new coverage options? How should agencies adjust their systems (eg, third party billing, health information technology and Electronic Medical Records)?  See the health care reform topic page for resources. 

Ryan White Issues

  • How will ACA impact Ryan White activities--services and shifts in costs? What changes are being undertaken to revise Ryan White activities? See the health care reform topic page for resources. 

Who to Contact to Get Involved

  • Ryan White. Part A Planning Councils and Part B Programs. Many groups are convening learning sessions on ACA, and many planning body members are participating in ACA planning work. National groups such as NASTAD (for Part B/ADAP) also are keeping track of ACA and developing implementation tips and tools.
  • State Marketplaces. See below. 

See What’s Going On in Your State

State Marketplaces (Exchanges)

Multiple sites are tracking implementation:

  • State Refo(r)m also has links to state Marketplace websites.
  • See State Reforum to find detailed information on the status of implementation and to access resources being shared by various states.
  • See State Network for technical resources on state implementation.  
  • The Kaiser Family Foundation site has several links. Select a state for a descriptive update and a link to the state’s ACA work or click on the map to see the status of implementation.
  • The Commonwealth Fund has a map with the status of state Marketplace activities (state, state partnership, federally facilitated).
  • A listing of state ACA websites, reports, and research are listed on this map-based page by the National Conference of State Legislatures.

Insurance Reform (State Departments of Insurance). Ryan White or Marketplace planning groups are the best place to start when learning about health insurance reforms in your state. However, you can reach out directly to your state’s insurance department as well. Some state insurance websites have pages devoted to ACA implementation.  

Resources to Use

The Health Care Reform topic page presents tools from grantees, HRSA, and key partners as well as links to key websites. Check frequently as resources are being added over time.

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