supportive service care and prescription drug assistance through the Ryan White HIV/AIDS Program (>500,000) will become eligible for Medicaid in 2014 (KFF, 2011b; NASTAD, 2012b; Project Inform, 2012). The implications of this coverage shift are discussed later in this chapter.
Health Insurance Exchanges
The ACA also mandates the establishment of state or regional health insurance exchanges by January 2014 (Figure 2-3). The exchanges are meant to provide a marketplace in which eligible individuals and small businesses (less than 100 employees) can easily obtain and compare information on different health insurance options and purchase insurance coverage (KFF, 2011a). Individuals and families with incomes between 100 and 400 percent of the FPL will be eligible for federal subsidies to help cover insurance premiums and out-of-pocket health care costs (KFF, 2011a).
Medicare Part D Drug Coverage Gap
Medicare Part D prescription drug plans currently contain a coverage gap (“donut hole”) that can impose significant financial burdens on enrollees. Prior to the enactment of the ACA, Medicare Part D beneficiaries were required to pay the full cost of their prescription drugs while in the coverage gap between the time they and their drug plans spent a specified dollar amount on covered drugs and the time beneficiaries’ “true out-of-pocket” (TrOOP) costs reached the threshold catastrophic coverage. Of importance specifically for people with HIV, AIDS Drug Assistance Program (ADAP) benefits now count toward Medicare Part D recipients’ TrOOP costs for medications, allowing them to move through the coverage gap more quickly. Additional ACA provisions will ease the burden of out-of-pocket drug costs for all individuals in the donut hole. Currently, pharmaceutical manufacturers are required to provide a 50 percent discount on prescriptions of brand name medications filled in the gap, and the beneficiary coinsurance rate will be reduced from 100 percent to 25 percent by 2020 (KFF, 2011a).
Essential Health Benefits Package and Preventive Care
The ACA charges HHS with establishing an “essential health benefits package” within specified parameters whose scope “is equal to the scope of benefits provided under a typical employer plan, as determined by the [HHS] Secretary” (P.L. 111-148, Sec. 1302 [42 U.S.C. 18022]). At a minimum, the essential health benefits package must include items and services in 10 areas of care: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use