HIV Network News
A periodic publication to keep Network members informed 
about developments in HIV care and managed care
June 2000

• HIV Quality Care Network Joins Local HIV Providers in Meeting
  with New Jersey Medicaid Director
  

• Definitions of Experienced HIV Providers – A Correction and
  a Call for Other Examples
  

• IDSA's Redesigned Website Includes Enhanced Network and Center Pages
  

• House and Senate Committees Vote on Fiscal Year 2001 Funding Levels
  for Federal HIV/AIDS Programs
  

• HCFA Creates HIV Home Page
  

• NAPWA Offers Consumer Managed Care Tool Online
  

• State Action:

  • Michigan

  • Massachusetts

  • New York

  • Tennessee  

  • Indiana and Illinois Expand Disability Coverage Under Medicaid  

  • New Jersey

NAPWA Offers Consumer Managed Care Tool Online

The National Association of People with AIDS (NAPWA) is offering its publication Your Passport to Managed Care on the NAPWA website.  The passport was developed by NAPWA, in partnership with HRSA’s HIV/AIDS Bureau.  Print versions of the publication are available in English and Spanish to organizations for distribution to clients.

STATE ACTION 
Michigan

Eight members of Michigan’s Congressional delegation have called on the federal government to audit Michigan’s Medicaid program.  Members of the state delegation have sent a letter to both the inspector general of the Department of Health and Human Services and the HCFA Administrator expressing concern that the state’s Medicaid recipients are losing access to health care under the state’s managed care system.

Michigan’s Department of Community Health, the agency that houses the state’s Medicaid program, has finally distributed the $891,000 appropriated by the state legislature last year to provide some relief for health plans for the high costs of treating HIV/AIDS patients.  By September 30, 2000, plans have been asked to document the use of the money, which is designated for patient costs only.

Meanwhile, Dr. Douglas Mayers, Chief of Infectious Diseases for the Henry Ford Hospital Systems met with senior Medicaid staff, other leading HIV physicians in the state and medical directors from some of the Medicaid HMOs to discuss improving access to experienced providers for HIV/AIDS patients as well as ensuring adequate reimbursement for HIV providers.  The state is currently involved in a competitive bidding process with health plans for the state’s Medicaid managed care program.  It remains to be seen whether new HMO contracts will reflect changes in HIV care delivery and reimbursement under the program.

Massachusetts  

Massachusetts has submitted its request to HCFA to modify the state's current Medicaid managed care waiver to include people with HIV disease with incomes up to 200 percent of the Federal Poverty Level (FPL) ($16,700 for a one-person household based on 2000 poverty guidelines).  The state’s proposal includes insurance assistance for those with access to private insurance and coverage to supplement benefits of some private insurance packages.  The program would include full Medicaid coverage for eligible individuals without private insurance.  The state asserts that the proposal would allow them to provide services to 400 people with AIDS, and 800 people in the earlier stages of HIV disease.  The state is using some of its tobacco settlement money to finance the expansion and is arguing that they have room within the budget neutrality cap of their current Section 1115 waiver to fund the program.

The District of Columbia has also sent HCFA a letter of intent to submit a proposal to expand Medicaid eligibility to low-income individuals with HIV disease who are not now eligible for Medicaid.         

New York

On April 26, Governor George Pataki (R) announced the selection of 8 HIV/AIDS special needs health care plans (SNPs) as components of the state's Medicaid managed care system.  The plans were selected through competitive procurement to proceed to be licensed as special needs plans to provide a medical home for HIV-positive Medicaid recipients and their children under age 19.  The selected plans will now go through a process to be licensed as special needs plans.  Part of the $12 million in funding allocated for the 8 SNPs will be awarded immediately for developmental costs in the licensing process.

New York also has its first mental health special needs plan.  The western New York special needs plan will serve adult Medicaid recipients with serious psychiatric illnesses.

Tennessee

Blue Cross/Blue Shield of Tennessee, which covers about half of all TennCare enrollees, will continue to participate in the TennCare program until June 30, 2001.  Blue Cross/Blue Shield of Tennessee had announced its intention to leave TennCare in June 2000.  The state invoked a provision of their contract that required the insurer to stay for another year, but also transfers much of the risk to the state.  Blue Cross/Blue Shield will not be a TennCare HMO after June 30 but, rather, will become an administrator of services for its 630,000 TennCare members.  Tennessee officials are also reporting that they have 8 new health plans interested in participating in TennCare, and that each of these plans has signed a letter of intent.

In the meantime, the Acting TennCare Director John Tighe has presented a TennCare overhaul plan to leaders of the state legislature that would require a $264 million infusion from the state.  Components of the program redesign include: 

• Several regional MCOs, each with no more than 300,000 members.

• New payment system that accounts for risk and utilization.

• Three-year contracting system to allow MCOs to choose one of three risk-sharing options with the state.  

• Stop-loss reinsurance program funded by all participating insurers to pay for “extraordinarily high” medical claims.  

• Requirement that health providers receive at least 85 percent of all    funds paid to MCOs.  

• Monthly financial reporting by MCOs.  

• “Direct state payment” for prescription drugs for Medicare-eligible patients.  

• Co-payments and increased premiums for beneficiaries with incomes above 200 percent of the Federal Poverty Level (FPL).  

• Annual open enrollment to allow beneficiaries to choose their new MCOs.  

Indiana and Illinois Expand Disability Coverage Under Medicaid  

Currently, Indiana limits Medicaid disability coverage to individuals with permanently debilitating medical conditions.  On January 1, 2001, low-income individuals (73 percent of the FPL) with severe medical conditions that are expected to last 4 years or more would qualify.  The state estimates that 5,500 new people will qualify as a result.

Illinois currently caps Medicaid eligibility for seniors and disabled individuals at 41 percent of the FPL or $308 per month.  A new law passed by the legislature in the spring session will raise the income threshold to 100 percent of FPL, which is currently set at $695 per month for a single individual.  When the new law takes effect on July 1, 2000, seniors and disabled individuals with incomes at or below 70 percent of the FPL will become newly eligible for Medicaid.  On July 1, 2001 and 2002, those with incomes at 85 percent and 100 percent of FPL, respectively, will become eligible.  An estimated 1,500 people with AIDS will qualify for Medicaid for the first time under these eligibility changes.

Most states automatically extend full Medicaid coverage to individuals who receive Supplemental Security Income (SSI), but states are allowed to use more restrictive standards for disability eligibility.  These states are called 209(b) states because section 209(b) of the Social Security Act allows states this option.  These more restrictive standards may include more restrictive definitions of disability and/or lower income and asset standards.  SSI eligibility is available to individuals earning no more than 75 percent of the federal poverty level—currently $512 a month, with countable assets not exceeding $2,000 for individuals and $3,000 for couples.  Nine states still exercise the 209(b) option:  Connecticut, Hawaii, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia.

New Jersey

Following is a summary of HIV-specific and HIV-relevant provisions in the New Jersey contract to implement mandatory managed care for SSI beneficiaries in the state Medicaid program:

Rates

The rates paid to health plans for plan members with AIDS in the contract are as follows:

Patient Category	Rate
AIDS- ABD with Medicare	$1,241.01 PM/PM
AIDS & DDD - ABD with Medicare	$1,273.41 PM/PM
AFDC- AIDS   (Includes pregnant women and NJ KidCare  Parts A, B, C and D)	$1,788.90 PM/PM
AFDC- AIDS & DDD	$1,854.11 PM/PM
ABD (including AIDS) without Medicare	$475.26 PM/PM
ABD with AIDS	$1331 PM/PM

Please note:

• PM/PM = Per Member/Per Month
• ABD = Aged, Blind and Disabled/SSI eligible
• DDD=Developmentally Disabled

Explanation

The rates listed for the ABD population with Medicare and the AFDC population are statewide rates.  The ABD without Medicare rates will be individually determined using the Disability Payment System (DPS) grouper to create a unique case mix rate for each individual.  (Colorado uses such a system.)  Weights are developed for diagnostic categories, and the sum of those weights are multiplied against the base rate—$475.26—to determine the individual case rate for each individual. The average rate for a SSI beneficiary with AIDS without Medicare eligibility would be approximately $1,331 (PMPM).  This assumes no additional complicating diagnoses.  It is important to note that substance abuse and mental illness would not be additional diagnoses for the purposes of calculating the capitation rate because those services are carved out of the capitation.

Carve-outs (services not included in the capitation rates)

• Payment for protease inhibitors and Factor VIII and IX blood clotting factors.  
  Payment for protease inhibitors shall be made by the Department of Medical Assistance and Health Services (DMAHS) to the health plan based on:  (1) submission of appropriate encounter data; and (2) prior notification from the contractor to DMAHS of identification of individuals with HIV/AIDS.
• Mental health and substance abuse services.  
  Included in rates for developmentally disabled, but carved out for all other populations.  Note:  Organic brain conditions are included in the capitation rate.  Services not provided by the plan or included in the capitation rate include substance abuse diagnosis, treatment and detoxification, and costs for methadone and its administration.
• The following drugs will be paid fee-for-service by the Medicaid program:  clozapine, risperidone, olanzapine, quetiapine, methadone.
• Pregnancy.  
  Lump sum payments are made to plans outside capitation.  
• Home health services.  
  Not included in capitation for ABD only, but are included in capitation for ABD Medicare with AIDS and AFDC-AIDS.  
• Abortions and related services.
• Family planning services and supplies when provided by
  non-participating provider.  
• Hospice services.

Mental Health and Substance Abuse Services (MH/SA) 

• Lab tests associated with mental health treatment are carved out.
• Plans must develop a referral process to be used by providers for MH services and sharing findings of physical exams and lab tests within 24 hours of receipt for urgent cases and 5 days in non-urgent.
• Pharmacy services are covered by the contractor except for those drugs noted above.
• Plans can require preauthorization for mental health drugs under certain conditions including if number of scripts is greater than four.
• Inpatient treatment paid by state if not developmentally disabled.

Enrollees with Special Needs  

• "Special needs" is defined as "complex chronic medical conditions requiring special health care services."  
• Contractor shall have method for identifying enrollees with special needs.
• Contractor shall have method for determining needs of enrollee.
• Contractor shall provide care management to ensure all required services are provided on a timely basis.
• Contractor shall have policies to allow enrollees to continue seeing non-participating providers if appropriate provider is not in network or considered in the best interest of the enrollee with special needs by the contractor.
• New enrollees should receive immediate transition planning within 10 business days for those who are identified at time of plan selection or 30 days after special needs identified by provider (plan includes assurance of continuous care during transfer to contractor's network).
• Contractor shall have procedure for referring to specialist who can serve as primary care provider (PCP) if approved by contractor so that specialist can then treat enrollee without referral.
• If specialist is not serving as PCP then rules for referral apply but standing referrals can be considered when ongoing specialty care is required.

Provider Network Requirements

• Provider network shall include primary care and specialists "trained and experienced in treating individuals with special needs." 
• Network shall include PCPs and dentists with experience in treating people with complex and chronic disabling conditions; "to extent possible" in care of board certified pediatricians or internists and subspecialists as appropriate.  
• Network shall include adult and pediatric subspecialists for cardiology, hematology/oncology, gastroenterology, emergency medicine, endocrinology, infectious diseases, orthopedics, neurology, neurosurgery, ophthalmology, pulmonology, surgery and urology and those with knowledge in behavioral developmental pediatrics, adolescent health, geriatrics and chronic illness management.  
• Network shall include Special Health Services Network Agencies including Pediatric AIDS/HIV Network.  
• As part of its credentialing process shall collect information from licensed practitioners including pediatricians and pediatric sub-specialists about nature and extent of experience in serving children with special needs.  

Care Management for People with Special Needs

• Plan shall provide coordination of care to "actively link" to providers, medical services, residential, social and other support services as needed and should be provided at higher intensity as determined by Complex Needs Assessment.  
• Complex Needs Assessment shall be done within 30 days of enrollment or 30 days of the date enrollee is identified as having special needs.  
• Care mangers for higher levels of care management shall include, but is not limited to, individuals with undergraduate or graduate degree in nursing or social work.  
• Caseloads shall be adjusted as needed to accommodate work load and intensity of management needed by all manager's cases.  
• Enrollees have right to decline coordination of care services, but contractor can still case manage enrollees' care.  

Children with Special Health Care Needs

• Plans are responsible for care management of children with serious, chronic and rare disorders. 

• Plans are responsible for ensuring access to specialty centers in and out of New Jersey for diagnosis and treatment of rare disorders.  

• Plans are responsible for developing policies for continuing care with existing out-of-network providers when considered in best medical interest of enrollee.

• Plans shall have methods for coordinating care and linking with schools, child protective agencies, early intervention agencies, and behavioral and developmental disabilities service organizations.  

Persons with HIV/AIDS 

The contractor shall:    

• Develop program to treat pregnant women.  HIV testing done with consent and noted if refused.  Counseling and education on perinatal transmission of HIV and available treatment options shall be made available during pregnancy.
• Address HIV/AIDS prevention needs including methods for promoting HIV prevention consistent with age, sex and risk factors.
• Have method for accommodating self-referral and early treatment.
• Have process to facilitate access to specialists and/or include HIV/AIDS specialists as PCPs.
• Include traditional HIV/AIDS providers in networks including HIV/AIDS specialty centers and establish links with AIDS clinical educational programs to keep current on up-to-date treatment guidelines and standards.
• Establish policies and procedures for providers to assure use of most current diagnosis and treatment protocols and standards established by DHSS and medical community.
• Develop and implement HIV/AIDS care management program with capacity to provide services to all enrollees who benefit from HIV/AIDS care management services. 
• Establish links with Ryan White CARE Act grantees for these services either through a contract, MOA, or other cooperative working agreement approved by the Department.

Note:  The contract's appendices include a list of Pediatric HIV/AIDS Specialty Centers and a list of Title II consortia contacts across the state.

Americans with Disabilities Act (ADA) Compliance

This summary highlights only those parts of the section language especially pertinent to people with HIV/AIDS.  The plan shall address policies and procedures regarding ADA compliance in the following areas:

• Provider refusal to treat qualified individuals with disabilities including, but not limited to, individuals with HIV/AIDS.
• Holding community events and part of its provider and consumer education responsibilities in places readily accessible to and useable by qualified individuals with disabilities.
• How the contractor will ensure it will link qualified individuals with disabilities with the providers/specialists with the knowledge and expertise in treating the illness, condition, and special needs of the enrollees.

Access to HIV Testing/Treatment for Pregnant Women

Plans shall report access to HIV testing and AZT therapy every quarter with the following data elements:

1. Number of pregnant women.
2. Number of pregnant women receiving HIV testing within the HMO.
3. Number of pregnant women who test positive for HIV.
4. Number of pregnant women treated with AZT.
5. Number of births involving AZT treatment in utero.
6. Number of newborns receiving full AZT treatments.