3 RW Part B and ADAP

Evaluating the Impact of 1115 Medicaid Waivers

on Ryan White HIV/AIDS Program and Its Clients and Providers

Discussion Guide

Ryan White HIV/AIDS Program, Part B/ADAP

Step 1: Welcome and Introduce Participants

Convene the group, welcome everyone, and ask participants and JSI staff to introduce themselves.

Step 2: Read Introductory Script (below)

Thank you for joining us today for this discussion. Before we begin, I have some important information that I need to share with you. I will then answer any questions you have, and then we will start the discussion.

“The US Department of Health and Human Services, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau has asked John Snow, Inc. to study the implementation of 1115 Medicaid waivers that have expanded Medicaid eligibility for people living with HIV/AIDS (PLWH). These waivers are part of Section 1115 of the Social Security Act that allows states to develop, test, and implement new approaches to providing Medicaid coverage outside of federal program rules, leading up to full implementation of the Affordable Care Act.

“The purpose of our discussion today is to learn more about the waiver in place here in [STATE]. The case study is not an evaluation of your program/agency, but a study to learn more about the waivers in practice. The goal is to understand how Medicaid expansion and the 1115 Medicaid waivers will affect the Ryan White HIV/AIDS Program (hereafter, Ryan White Program) as well as PLWH, and how the waivers have prepared states for implementation of the Affordable Care Act.

“Specifically, we hope to learn more about your experience with the waiver process, from application to implementation, and practice. We would like to hear about any notable successes or challenges [STATE] has had as well as anything that you think could have been done differently. We will be holding similar discussion groups with Medicaid and Ryan White Program staff in a total of eight states that have established these waivers.

“Participation in this study, including taking part in today’s discussion, is completely voluntary and will not affect your relationship with any federal funder. Any information that you share with us today will not be attributed to you by name. However, the final report will include the names of all individuals who participated in this study, and may include examples of the waivers’ impact in specific locations.

“As facilitator, I have a series of questions that I want to cover with you. A similar set of questions will be asked in each discussion group with Medicaid and Ryan White Program staff. These questions are the same at each of the eight sites we will be visiting across the country. Please note that for any question in which we refer to the 1115 Medicaid waiver, we are primarily interested in how it relates to PLWH and Ryan White Programs, not in the overall waiver or broader populations affected.

“It is possible that during our conversation, we will cover many of the questions without prompting; in other cases, we may need to ask you more pointed questions or probes. We encourage you to share your thoughts and opinions openly and freely, but we also ask that you be respectful of the other participants’ opinions and time. At no time should you feel you have to answer a question.

“We will be taking notes and recording this discussion to help ensure that we gather all of the information you share with us. The recording will only be listened to by JSI staff in order to ensure that our notes are accurate and compete. We are not recording your names.

“We anticipate that our discussion will last no longer than two hours. If you feel uncomfortable or decide you no longer want to participate, you may leave at any time.

“The results of this discussion and others held at here in [STATE] will be used to develop individual case studies for each jurisdiction. All case studies will then be analyzed as a group. A final report will be prepared that identifies key themes across the sites, unique challenges and successes, and any lessons learned that could affect the Affordable Care Act implementation as well as help to understand how Medicaid expansion will affect the Ryan White Program and PLWH in the future.

“Before we begin, are there any questions about what I’ve said, why we’re here, or what we are going to do?”

Step 3: Answer Questions from Participants

Step 4: Obtain Consent to Record

“Does anyone have any objections to us recording the conversation? If not, I’ll turn on the digital recorder.”

Step 5: Turn on the Recorder

Step 6: Confirm Consent to Participate

“Based on what you’ve heard so far, I want to confirm that each of you consents to participate in today’s discussion. Please say “YES” if you understand and wish to participate.”

Step 7: Begin Discussion with Questions on the Next Page

Discussion Questions

1. Were HIV/AIDS program staff involved in development of the 1115 waiver proposal and application?

2. From what entity/office did you receive information about the waiver and changes to client eligibility? (e.g., HIV/AIDS office, Medicaid office, other?)

3. Describe the relationship between the HIV/AIDS program and the Medicaid office.

4. What has the impact of the Medicaid expansion been on insurance status of Ryan White Program clients? On ADAP clients?

5. How long did it take to transition clients to Medicaid coverage through the waiver?

6. In addition to the 1115 waiver, what other public or private insurance programs have had the greatest impact on the HIV/AIDS program in your state recently?

7. Did you make any programmatic changes in the following processes as the result of the waiver and increased Medicaid coverage of your clients? If so, describe.

• Eligibility screening

• Client outreach and enrollment assistance

• ADAP application and recertification

• Case manager training standards

8. Do you require Ryan White providers of core services to enroll with the Medicaid program? What proof do you require to ensure that Medicaid is billed first?

9. Since enactment of the waiver, have you made any changes in Ryan White Program “payer of last resort” compliance processes? If yes, describe.

10. How do you pay for core services – through grants (cost reimbursement) or unit rates (fee for service)? Are there issues with this arrangement?

11. Do the Medicaid provider networks (both medical and pharmacy) include all Ryan White Program-funded providers and ADAP pharmacies? If not, describe those who are left out and the impact of this on clients and providers.

12. For Ryan White Program clients who transitioned to Medicaid coverage through the waiver, what services did the Ryan White Program continue to provide?

13. What services are not covered by the Medicaid waiver?

• Probe: Explore the following services:

  • Prescription drugs (is full ADAP formulary covered?)

  • Case management

  • Mental health services

  • Substance abuse services

  • Support services

  • Transportation

  • Dental care for adults

• Probe: How have you adjusted Part B or other funding allocations to respond to these gaps? Have these adjustments been successful?

14. What populations are not covered by the Medicaid waiver (e.g., undocumented immigrants and legal immigrants within the five-year Medicaid ban)? How large are these groups in your state?

15. What are the differences in the benefits package that Ryan White Program clients are able to access through traditional Medicaid and the benefits package accessed through the waiver?

16. How have ADAP expenditures changed as a result of the waiver?

17. What three aspects of the waiver development and implementation do you feel were the most beneficial for maintaining quality and access to care for Ryan White patients?

18. If the State were to do a waiver like this again, what three recommendations would you make to improve the process?

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DISCUSSION GUIDE: RYAN WHITE PROGRAM, PART B/ADAP

DRAFT, OMB No. 0915-xxxx