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Project Inform et al.: Letter to Cindy Mann, Deputy Administrator and Director, Centers for Medicare and Medicaid Services

letter to Cindy Mann
Deputy Administrator and Director
Center for Medicaid, CHIP and Survey & Certification
Centers for Medicare and Medicaid Services
U.S. Department of Health & Human Services

from Project Inform, American Academy of HIV Medicine, AIDS Project Los Angeles, LA Gay and Lesbian Center, Desert AIDS Project, San Francisco AIDS Foundation, August 10, 2011

Re: Reject California’s Department of Health Care Services State Plan Amendment Requests

Dear Ms. Mann:

On March 24, 2011 California Governor Jerry Brown signed into law AB 97, the health care budget trailer bill. We, the undersigned organizations, are writing to express our grave concerns about the unaffordable and potentially illegal cost-sharing provisions imposed on California Medi-Cal beneficiaries through AB 97. We urge the Centers for Medicare and Medicaid Services (CMS) to decline the state’s request to impose any mandatory cost-sharing provisions or caps on essential services, such as physician visits, on people living with HIV/AIDS and all vulnerable Medi-Cal beneficiaries.

We believe AB 97 violates the Medicaid Act by implementing mandatory copayments on doctor and clinic visits ($5), prescription medications ($3 for preferred generic prescriptions / $5 for all others), emergency room visits ($50 regardless of circumstances) and inpatient hospital stays ($100 per day and up to $200 per admission) and does not include any out-of-pocket maximum. Thus, if implemented, AB 97 will impose untenable cost-sharing on the sickest and the poorest Californians, including people with HIV/AIDS and other chronic conditions.  These copays will be mandatory and providers permitted to turn away beneficiaries if they are not able to make the required payment. The imposition of cost-sharing on Medi-Cal beneficiaries, who are among the poorest and sickest Californians, undermines Medi-Cal’s primary objective: to provide health care to low-income families and persons with disabilities.

The amounts of cost-sharing proposed by the Department are plainly unaffordable to Medi-Cal beneficiaries – the vast majority of whom live below the poverty line.  Five dollar copays are out of reach for people living at this income level who already cannot afford the basic necessities of life and will force people to choose between essential health care and food and housing. Many studies have shown that even the smallest amounts of cost sharing are dramatic barriers to care for this low-income population. Five dollar copays on doctor’s visits and brand name prescription drugs disproportionately affects people with HIV/AIDS and other beneficiaries with complicated, chronic health conditions who rely on careful clinical monitoring and combination therapies to maintain their health and achieve positive health outcomes.

The impact of cost sharing is exacerbated by State budget cuts to cash assistance to families.   At the same time that Governor Brown signed AB 97, he also approved an 8% grant cut to all CalWORKs (TANF) households and a $15 monthly cut to the Supplemental Security Program, which provides cash assistance to low-income elderly and disabled individuals, including people living with HIV. Individuals on SSI will have their assistance reduced from $845 to $830 a month while an average CalWORKs household will see their monthly grant reduced from $509 to $468 a month. One night in the hospital at $100 would be more than one-fifth of a CalWORKs’ family’s monthly income.

AB 97 further harms Medi-Cal beneficiaries by capping physician visits at seven per year. In order to get additional visits a physician must indicate need and Medi-cal must agree.  The caps would be enacted for all Medi-Cal beneficiaries, including people with HIV/AIDS and other disabilities, seniors and low income beneficiaries who need the highest and most frequent levels of care.  One recent UCLA study indicated that Medi-Cal beneficiaries with HIV/AIDS needed an average of 15 provider visits annually. These visits are often time sensitive clinical monitoring visits. Health outcomes for people with HIV/AIDS would be negatively impacted by waits for approvals for additional visits. The same is true for other Medi-Cal beneficiaries.

This policy would create a significant barrier to effective HIV care. It is being entertained at a time when the Obama administration has authored a National HIV/AIDS Strategy that emphasizes linking more people with HIV to quality care and improving engagement and retention in care. It also comes at a time when studies have demonstrated that people with HIV who are in care and on effective, uninterrupted treatment are highly unlikely to spread HIV to their partners.

Finally, the waiver submitted by CMS lists the AIDS Healthcare Foundation (AHF) as one of the groups that would be exempted from the imposition of cost-sharing should it be implemented.  We assume AHF was exempted because it serves Medi-Cal beneficiaries living with HIV/AIDS; however, it is only one entity serving this Medi-Cal population. If those living with HIV/AIDS served by AHF are to be exempted, clearly no California Medi-Cal beneficiary should be subject to this misguided policy.

For the reasons outlined above, we urge CMS to reject any request by the state to impose cost-sharing or to cap physician visits. We look forward to meeting with you by phone or in person to further discuss these matters.


American Academy of HIV Medicine
AIDS Project Los Angeles
LA Gay and Lesbian Center
Desert AIDS Project
Project Inform


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