This characterization is intended to depict the possible journey of a patient living with HIV under the implementation of ACA. It shows the various risks and practice considerations necessary to try to prevent patients from slipping through the cracks as they transition from Ryan White/ ADAP to Medicaid or the Marketplace or remain in ADAP depending on eligibility within each state.
This December 2013 map indicates which states are expanding Medicaid, which are not and which ones are seeking to expand. This information is dynamic in nature and there may be changes over time. Anytime there is a change in care ( Provider, Insurance Plan, Pharmacy) there is a risk that it may disrupt care provided currently to a person living with HIV.
Based on the January 2013 NASTAD ADAP Monitoring Report, the National ADAP population that was eligible by financial criteria alone to shift to Medicaid was 59% . Based on actual Medicaid expansion the percent likely to transition to Medicaid is more likely to be in the 20-25% range of the National total. That number can vary significantly from State to State depending on eligibility criteria.
Unlike other disease areas where ACA implementation is expected to bring more people in to care, within the HIV Arena there is the possibility for disruption in care as patients are forced from the Ryan White/ ADAP care and treatment system to one they are less familiar with. 1) Transition to Medicaid – Those eligible for Medicaid must move to Medicaid since Ryan White/ ADAP is payor of last resort. 2) Transition to Marketplace Plans – Those eligible for the Marketplace must chose a Qualified Health Plan and move to a plan. 3) Patients who are ineligible for Medicaid or the Marketplace will likely remain in Ryan White/ ADAP.
A key component of the Ryan White program has been case management for individuals living with HIV. Will new Marketplace Plans continue to offer this service and support to patients living with HIV who sign up for this new insurance? It will vary from State to State. If case management is not provided there is the potential to create added challenges to patients living with HIV that could result in them dropping out of care.
Another key question is whether the Expanded Medicaid programs will include comprehensive support for some of the complex health needs of people living with HIV.
In states throughout the South and Mid West that are not expanding Medicaid there is a risk that if Federal or State funding for ADAP is reduced, there could be a return of HIV Patient Wait Lists. Wait lists can result in disruption of care for patients living with HIV who depend on ADAP for their medications.
Of considerable concern to patients living with HIV currently getting their medications through ADAP is whether the Marketplace plans and Managed Medicaid plans will cover all ARVs. Will new drugs be added to formularies in a timely manner? The protections afforded to the ARVs in Medicare Part D are not present in the Marketplace Plans or in Managed Medicaid.
Within the Medicaid space with multiple Managed Medicaid Plans there are concerns that formularies will not be consistent or match the Fee for Service formulary previously used within the state. If a physician chooses not to participate in Medicaid, it may force patients to make a provider change that could have impact on their ability to successfully transition and remain engaged in their care.
Within the Medicaid space with multiple Managed Medicaid Plans there are concerns that formularies will not be consistent or match the Fee for Service formulary previously used within the state. If a physician chooses not to participate in Medicaid, it may force patients to make a provider change that could have impact on their ability to successfully transition and remain engaged in their care.