1. ADAP Eligibility
Purpose: To provide clear parameters for eligibility and program enrollment.
Objective: To ensure AIDS Drug Assistance Program (ADAP) eligible clients are referred to the appropriate service option.
To be eligible for one of the programs supported by Virginia ADAP applicants/clients must:
- Live in Virginia.
- Have an individual or family income at or below 500% of the Federal Poverty Level (FPL)
- Have a documented HIV diagnosis.
- Not qualify or have Medicaid.
- Provide proof of income, changes in insurance coverage, or any changes in residency every six months for recertification. Failure to report changes in factors impacting eligibility may result in discontinuation of ADAP services.
2. Covered vs. Non-covered Medications
Purpose: To specify which medications and medication copayments will be supported with ADAP funds.
Objective: To ensure medication assistance through Direct ADAP, the Health Insurance Marketplace Assistance Program (HIMAP), Insurance Continuation Assistance Program (ICAP), and Medicare Part D Assistance Program (MPAP) complies with federal policies.
Virginia ADAP operates under three formularies:
- Virginia Direct ADAP Formulary
2. Virginia Ryan White (RW) Part B Formulary
3. Virginia ADAP Formulary for Insured Clients
a) Direct ADAP: Clients enrolled in Direct ADAP will receive medication assistance for medications on the Virginia Direct ADAP Formulary.
b) ICAP: Clients enrolled in ICAP will receive copayment assistance for medications only on the Virginia Direct ADAP Formulary and the Virginia RW Part B Formulary.
c) HIMAP & MPAP: The Virginia ADAP Formulary for Insured Clients is a replica of each formulary of an insurance plan that is paid for by Virginia ADAP for clients enrolled in HIMAP and MPAP. Clients enrolled in a VDH-approved HIMAP plan and enrolled in MPAP will receive copayment assistance for all medications on the plan’s formulary. Coverage of medications through Direct ADAP that are not covered by the insurance plan’s formulary will be assessed on a case-by-case basis.
3. ICAP Coverage
Purpose: To provide medication copayments for ADAP eligible clients with private insurance (health insurance from a source other than the Affordable Care Act [ACA]).
Objective: To expand medication access to insured ADAP clients requiring assistance with medication co-payments, while maximizing rebates on medication copayments used to sustain ADAP.
Policy: ADAP eligible clients who have private insurance may receive assistance with medication co-payments for medications only on the Virginia ADAP and RW Part B formularies.
Clients transitioning from Direct ADAP to ICAP will no longer access medications through Direct ADAP beginning 60 days after successful transition. The client, pharmacy, medication distribution site (where the client obtained Direct ADAP medications) and the client’s medical provider will be notified of ICAP enrollment.
4. MPAP Coverage
Purpose: To provide premium assistance and medication copayments for ADAP eligible clients with Medicare Part D.
Objective: To expand medication access and ensure medication assistance through MPAP complies with federal policies.
All ADAP applicants who have Medicare Part D coverage must enroll in MPAP. Clients may not remain enrolled in HIMAP if eligible for MPAP.
Clients may enroll into Direct ADAP only while applying for a Medicare Part D plan.
ADAP clients with household incomes less than 150% of the FPL must apply for Low Income Subsidy (LIS).
Clients who qualify for full LIS are not eligible for MPAP. Those with partial LIS coverage or no LIS qualify for MPAP.
When approved for MPAP, the client, their provider and LHD or alternate medication access site will be sent a letter (or fax), and the client will no longer access medications through Direct ADAP.
5. HIMAP Coverage
Purpose: To provide premium assistance and medication copayments for ADAP eligible clients for VDH approved ACA insurance plans.
Objective: To expand medication access and ensure medication assistance through HIMAP complies with federal policies.
a) Plan Selection
Clients seeking assistance with costs for policies obtained through the Federal Insurance Marketplace under the ACA may only receive assistance with ADAP-approved plans.
b) Individual vs. Family Plan Coverage
VDH will only enroll and make payments toward individual coverage plans. An exception may be made if all covered persons in a family are ADAP clients.
c) Premium Tax Credits
If an ADAP client is eligible for a premium tax credit when applying for Federal Marketplace Insurance, the client must request the tax credit be applied to the premium payment at the time of application (instead of receiving it in the form of a tax return or refund at the end of the calendar year).
d) Transition from Direct ADAP to HIMAP
Clients enrolled in insurance plans will no longer access medications through Direct ADAP beginning 60 days after successful insurance plan enrollment. The client, pharmacy, medication distribution site (where the client obtained Direct ADAP medications) and the client’s medical provider will be notified of HIMAP enrollment.
e) Medication Exception Requirement
When a drug is not covered by an ACA insurance company’s published formulary, the provider must complete a Medication Exception request through the insurance company providing all required information. The ACA provides for expedited review (within 24 hours) in exigent circumstances, which is when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or the ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a non-formulary drug.
As part of the request for an expedited review based on exigent circumstances, the prescribing physician or other prescriber should support the request by including an oral or written statement that:
1. An exigency exists and the basis for the exigency (that is, the harm that could reasonably come to the enrollee if the requested drug were not provided within the timeframes specified by the issuer’s standard drug exceptions process), and
2. A justification supporting the need for the non-formulary drug to treat the enrollee’s condition, including a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
If the Medication Exception request is denied, the provider must file an appeal within 24 hours and follow up with the insurance company. VDH requests in all cases where a drug exception has been denied that the Bureau of Insurance Ombudsman be contacted:
• By Toll free phone at: (877) 310-6560, select option 1
• By fax at: (804) 371-9944
• By letter at: Office of the Managed Care Ombudsman, Bureau of Insurance, P.O. Box 1157, Richmond, Virginia 23218
• By email: email@example.com
f) Medicare Enrollment
Clients who are currently enrolled in an approved VDH insurance plan through ACA and become eligible to enroll in a Medicare Part A or Medicare Part B plan may remain enrolled in their current ACA insurance plan. Per Centers for Medicare and Medicaid Services (CMS) guidance (Publication No. CMS-10050), clients who do not enroll in Medicare during their Initial Enrollment Period (either for Medicare Part B or Premium Part A) will only be able to enroll in Medicare during the Medicare General Enrollment Period and may be subject to the late enrollment penalties. The Medicare Part B penalty applies for as long as the individual has Medicare Part B.
VA ADAP will cover premium costs for either the approved VDH insurance plan or the Medicare Part D plan if client chooses to enroll.
6. Incarcerated Clients
Purpose: To ensure ADAP remains the payer of last resort for incarcerated clients.
Objectives: To remove incarcerated clients from Direct ADAP; to expedite ADAP enrollment for incarcerated clients upon release; and to remove incarcerated clients from HIMAP based on disposition of charges.
a) Upon receiving notification that a Direct ADAP client has been incarcerated, the client will no longer be eligible for ADAP services.
b) Before or upon release from incarceration, the client will be referred to VDH Care Coordination by calling 1-804-864-7919. An ADAP application may be completed prior to release to help expedite enrollment; however, the application will not be approved until after the client is released. Upon release from a local/regional jail that is participating with the Expedited Enrollment Program (EEP), client should receive a 7-day supply of medications from the jail. Upon release from the Department of Corrections (DOC), client should receive a 30-day supply of medication from the DOC. Once released, a client ADAP application will be processed through the EEP within 48 hours. Clients will be enrolled to Direct ADAP or MPAP, depending on eligibility. During the ACA open enrollment period, all eligible clients will be referred for ACA insurance enrollment.
c) If a client is enrolled in an ACA insurance plan and ADAP Central Office staff is notified that the client is incarcerated, ineligibility or eligibility for services will be determined when the legal disposition of charges against the client are finalized. This will be determined on a case-by-case basis.
7. Conditions for Authorizing Premium Payments
Purpose: To ensure cost effectiveness for premium costs being covered for approved clients.
Objective: To ensure clients are utilizing Ramsell pharmacies to access medications and to remain cost effective according to federal policy.
Policy: HIMAP clients, whose monthly premium is being paid by VDH, must access medications through in-network, non 340B Ramsell pharmacies.
8. Vigorously Pursue Health Care Coverage
Purpose: To ensure ADAP remains the payer of last resort.
Objective: To comply with Health Resources and Services Administration (HRSA)/HIV/AIDS Bureau (HAB) requirement to vigorously pursue other sources of health coverage for enrolled clients.
Virginia (VA) ADAP will vigorously pursue enrollment into health care coverage for individuals who may be eligible for Medicaid, Medicare, employer-sponsored health insurance coverage, Qualified Health Plans through the Marketplace and/or other private health insurance and will document efforts in client file. Documentation that VA ADAP has vigorously pursued other health coverage will include copies of or notes in the client’s file about:
- Screening for coverage eligibility for other health coverage.
- Proof that the client is not eligible to obtain other health coverage, including but not limited to proof of an exemption.
- Detailed efforts to educate the client about other health coverage options including Medicaid, Medicare, employer-sponsored health insurance coverage, Qualified Health Plans through the Marketplace and/or other private health insurance, etc.
- Informational letters, brochures, or other materials provided to the client to educate about other health coverage options.
- Client’s acknowledgement of education and their decision about enrollment.
- Detailed efforts to enroll/apply or referral for assistance with enrollment/applications for other health coverage options including Medicaid, Medicare, employer-sponsored health insurance coverage, Qualified Health Plans through the Marketplace and/or other private health insurance, etc.Clients will be screened during the annual and semi-annual eligibility recertification process for eligibility for other types of health coverage (or any other alternative payment source). All clients must be informed about all possible health coverage available and the consequences (including possible penalties and financial impact) for not applying/pursuing health coverage.
9. Inactive Status
a) Clients on Direct ADAP
Purpose: To ensure Direct ADAP clients are accessing medications on a consistent basis.
Objective: To properly oversee program utilization and maximize resources for clients utilizing medications.
Policy: Clients who have not accessed medications at the Local Health Department (LHD), Virginia Commonwealth University Health System (VCUHS), or other medication distribution site (where the client obtained Direct ADAP medications) within six months will be considered inactive and will no longer be eligible for ADAP services. Clients may reapply for eligibility if they need to access medications.
b) Clients enrolled in ICAP, HIMAP or MPAP
Purpose: To ensure ICAP, HIMAP or MPAP clients receiving support for medication copayments are accessing medications on a consistent basis.
Objective: To properly oversee clients enrolled in insurance plans who received support with ADAP funds and maximize resources for clients utilizing medications.
Policy: Clients who have not accessed medications at a retail pharmacy within six months will be considered inactive and will no longer be eligible for ADAP services. Clients may reapply for eligibility if they need to access medications.
10. Proof of Income
Purpose: To simplify proof of income documentation for ADAP applicants.
Objective: To ensure financial eligibility documentation can assist clients with both ADAP and Affordable Care Act (ACA) enrollment.
If a client files taxes, the client is required to submit their most recent tax return to Virginia ADAP as proof of income.
11. Tax Credit Liability
Purpose: To clarify that the use of Ryan White funds may be used to pay any tax credit liability that a VA ADAP client may owe to the Internal Revenue Service (IRS) based on the reconciliation of the premium tax credit.
Objective: To assist VA ADAP clients with this liability as VA ADAP pays the monthly premiums for their insurance plans.
Policy: VA ADAP may pay the tax credit liability if the criteria listed below are met:
- Client was eligible for VA ADAP the entire tax filing year.
- The client will complete the Request to Pay Tax Credit Liability Form and submit along with a copy of the client’s 1095-A form, 1040 form, and 8962 form.
- A refund is not owed to the individual by the IRS. In this case the tax credit liability would be deducted from the total refund.
No payment will be made to the client directly.
VA ADAP will not pay any IRS late fees.
VA ADAP will not pay any penalty the client may have incurred due to failure to enroll in a Qualified Health Plan (QHP) through the Health Insurance Marketplace.
VA ADAP’s ability to pay tax credit liability is dependent upon the availability of funding.
12. Grievance Policy
Purpose: The purpose of this document is to provide a grievance policy and procedure that will ensure there is due process and fair treatment for clients receiving services under ADAP.
Policy: Clients receiving services under ADAP may file a grievance, or complaint, if services provided are different than what he or she believes should be offered under ADAP. Grievances should be submitted in writing on a Client Grievance Form. VDH will respond to client within 5 business days of the grievance.