The AIDS Insurance Continuation Program (AICP) has begun to move some of its clients to Affordable Care Act (ACA) Marketplace plans or to AIDS Drug Assistance Program (ADAP) and Ryan White Care (RWC) programs. AICP provides assistance with payments for comprehensive health insurance to low income people infected with HIV. This program is moving only those clients with plans terminating December 31, 2014. All AICP clients should maintain HIV coverage throughout this transition, but some AICP clients may be losing coverage for conditions other than HIV. Those clients eligible for the federal ACA subsidies are moving to comprehensive ACA marketplace plans. Those clients ineligible for Federal ACA subsidies are moving to ADAP and Ryan White Care program and loosing insurance coverage for non-HIV conditions.
As of press time, the Florida Department of Health has not provided an estimate for the number of clients involved in this process. Based on reports from 2013 and 2014, active AICP enrollment in Florida can be estimated to average about 1,500 clients, not all of whom will have plans ending on December 31, 2015. At the end of 2013, Florida had 106,335 people diagnosed and living with HIV. The AICP program covers less than 2% of the known HIV infected in Florida.
Those AICP clients ineligible for federal subsidies include both those making too little to qualify for the subsidies and those making too much. In the original act authorizing the ACA, people making too little to qualify for federal ACA subsidies would have become eligible for an expanded federally funded Medicaid. ACA resistant states like Florida, however, have refused to expand Medicaid. If Florida had expanded Medicaid, these very low-income AICP clients would now be moving from one comprehensive insurance system into another, instead of losing coverage for non-HIV conditions.
Managing payment for health care has become even more complicated than managing health care. This transition has provided many opportunities for miscommunication and bureaucratic “screw-ups.” These process problems differ from policy disagreements about whether these transitions are a good idea or not. Process problems are also somewhat easier to prevent and fix, if people report them.
One such “screw-up” concerns an AICP client, Frank Smith (not his real name). AICP failed to inform him about these upcoming changes. Instead, he found out about this transition during a visit to his doctor in early December.
As his income made him eligible for federal ACA subsidies, Smith set about choosing an ACA plan. No one from the Health Department or AICP informed him which plans ADAP had pre-approved. He found out the names of these plans through an insurance broker and selected an approved plan on www.Healthcare.gov.
When he received a bill for the non-subsidized part of the premium, he contacted the local Health Department about payment. They said the bill would be paid by the end of December. The Health Department asked for Smith’s www.healthcare.gov User ID and password in order to process his payment. The payment was due the first week in January, but by January 6, the insurer still had not received payment. Fortunately, Smith had the resources to pay the bill himself.
The Health Department claims that they processed the payment between December 26 and December 31, but as of January 13, the insurer still had not received the payment. The Health Department told Smith that electronic processing could take 10 to 15 days, which would make it slower than “snail” mail. Smith does not know what he will do about February’s payment. Smith emphasized that the people with whom he spoke, all tried to help. He found the problem somewhere else. “It’s not the people at the bottom who are the problem. It’s the people at the top. Everyone I’ve spoken to has tried to help me”.
Smith’s story may be a fluke or it may be typical. Other people may not have had the resources to cover the failure of the Florida’s check to reach the insurer in time. People prone to depression may have just given up. The system should have worked for Smith, a pro-active "go-getter". Good planning and communication could have minimized these problems, which will inevitably occur in any complex process. Minimally a feedback loop can be set up to respond to problems that clients and external customers report. Unfortunately, this does not appear to have happened.