Priority Setting & Resource Allocation Committee Minutes April 10, 2023

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Meeting of the Priority Setting & Resource Allocation Committee

Monday, February 6, 2023

By Zoom Videoconference

3:00 – 4:00

Members Present: Marya Gilborn (Co-chair), Jeff Natt (Co-chair), Matt Baney, Kyron Banks, Joan Edwards, Billy Fields, Graham Harriman, Steve Hemraj, Matthew Lesieur, Scott Spiegler (for Guadalupe Dominguez Plummer), John Schoepp, Claire Simon, Terry Troia

Members Absent: Fulvia Alvelo, Dorella Walters

Staff Present: David Klotz, Johanna Acosta, PhD, Doienne Saab, Karen Miller, Deb Noble, Roland Torres, Ilana Newman, Kimbirly Mack, Patrick Chan, Jimmy Jaramillo (NYC DOHMH); Gemma Barclay (Public Health Solutions)

Guests Present: Julie Vara (NYSDOH AIDS Institute)

Agenda Item #1: Welcome/Introductions/Minutes

Ms. Gilborn and Mr. Natt opened the meeting, followed by a roll call and a moment of silence.  The minutes of the February 6, 2023 meeting were approved with no changes.  

Agenda Item #2: Public Comment

Mr. Lesieur reported that on April 1st, the NYS Medicaid program changed its prescription reimbursement from a managed care to a fee-for-service model.  While the State has assured the public that there will be no interruption in services, there have been reports of pharmacies asking for prior authorization for some medications.  Mr. Lesieur is collecting information about prior authorizations to ask the State to address any issues that are impacting Medicaid recipients. 

Agenda Item #3: GY 2023 Reprogramming Plan

Mr. Klotz explained that the PSRA develops a reprogramming plan each year to spend funds that become uncommitted during the course of the year.  The plan gives the Recipient the latitude to shift funds between service categories in order to enhance overperforming contracts.  No service category will be enhanced by more than 20% of its original allocation in the spending plan without Council approval, and categories are enhanced internally before funds are shifted between categories.  ADAP will be included as a category for enhancement after all other service categories have been considered, but will not be subject to the 20% cap.  The plan will allow the EMA to maximize spending during the year and reduce the levels of carryover.

A motion was made, seconded and approved 11Y-0N to approve the GY2023 reprogramming plan.

Agenda Item #4: NYS Uninsured Care Program Update

Ms. Vara presented an update on the NYS HIV Uninsured Care Program (UCP), which includes four components: ADAP (prescription coverage), ADAP Plus (outpatient medical care), Home Care, and Insurance Continuation (APIC).  The ADAP formulary (covered drugs) has over 500 medications, including all ARVs, medications for opportunistic infections, hep C and diabetes, psychotropic and cardiac medications, antibiotics and vitamins/nutritional supplements.  The program is working on adding a new injectable, Sunlenca.  Injectables are covered under both ADAP and ADAP Plus.  ADAP Plus covers primary care and specialty clinic visits, viral load and genotype tests, dental and oral surgery, mental health visits and nutritional assessment and counseling.  The Home Care program includes up to $30K of lifetime home health care, skilled nursing and homemaker services, IV infusion care, durable medical equipment, and direct payment for Medicaid spenddown.  APIC can pay for commercial health insurance premiums for ADAP eligible clients.  Policies considered for payment must be comprehensive and provide full prescription and primary care coverage without annual coverage caps.  APIC does not pay for Medicare Part B, as plans have to include prescription coverage.  APIC can pay for out-of-pocket costs on a case-by-case basis.  APIC creates substantial savings what would otherwise be expenditures through ADAP and ADAP Plus.

To be eligible for UCP, clients must live in NY State and have an income below 500% of federal poverty level (currently $72,900 for an individual).  As of GY 2022-23, there are currently about 23,000 people enrolled in ADAP statewide, of whom 73% are from NYC.  ADAP Plus has similar numbers.  About 5200 people are enrolled in APIC (63% from NYC).  Enrollment in Home Care is very low.  Over 77% of enrollees are male, and 54% are over the age of 50. 35% are Black, and about 39% Hispanic.  

84% of UCP costs are spent on the ADAP program, 9.6% on APIC, 4.6% of ADAP Plus, only 0.2% of home care and only 1.5% is used for program operations.  The largest source of money for the program’s budget (64%) is from recoveries (340B program rebates, retroactive billing to insurance).  There is no impact on the program yet from the changes in the Medicaid pharmacy benefit.  Twenty-nine percent of revenue comes from the state’s Ryan White Part B grant, 4.3% from the NYS budget, and 2.8% from the NY EMA’s Part A allocation.  

Potential challenges for the program include that the UCP has seen a decline in its total enrollment of about 2500 since 2020 due to the COVID-19 Public Health Emergency continuous coverage requirements.  The UCP anticipates increases in new enrollment and service utilization due to the Medicaid Unwinding for GY 2023-24.  A multi-faceted approach continues to be refined to balance expenditures with available revenues. Ongoing reductions in available resources and increases in demand are ongoing. The most productive cost-saving and cost-avoidance activity is coordinating benefits with other health care coverage. ADAP fully participates in rebate collections and back billing Medicaid.  New York State ADAP will continue to refine drug and service coverage to address emerging HIV-related conditions and the approvals of new antiretroviral agents.  There are no anticipated shortfalls for GY 2023-24.

Future goals for the program include: Enhance UCP covered services to meet the needs of people aging with HIV; Ensure that PWH are involved in designing the program; Leverage the UCP MAI contracts and other community resources; and Develop outreach strategies and printed materials.  The program will also seek to expand its primary and home care networks, expand portal functionality to be more interactive, and increase use of technology.  Ms. Vara added that the program’s online portal and hotline are prepared for any anticipated uptick in enrolment.  

Mr. Harriman thanked Ms. Vara for her presentation, for the exemplary work of the UCP and for the State’s collaboration with the Council.  

Mr. Klotz reported that the Committee has two more tasks this planning cycle: the GY 2024 application spending plan, and the GY 2023 carryover plan.  The next PSRA meeting will be on Monday, May 8th. There being no further business, the meeting was adjourned.