Purpose: To provide clear parameters for eligibility and program enrollment.
Objective: To ensure ADAP eligible clients are referred to the appropriate service option.
To be eligible for one of the programs supported by Virginia AIDS Drug Assistance Program (ADAP) applicants/clients must:
- Live in Virginia
- Apply through Virginia Department of Health (VDH) Central Office or through Virginia Commonwealth University Health Systems (VCUHS) Financial Services.
- Have an individual or family income at or below 400% of the Federal Poverty Level
- Have documented CD4 count(s) and Viral Load(s) within the last six months
- Not qualify or have Medicaid
- Provide proof of income, changes in insurance coverage or any changes in residency every six months for recertification
- Agree to participate in the service option that best meets the client's needs and resources, and for which the applicant/client is eligible.
Central Office Staff will determine the program for which an applicant/client is eligible based on review of the application and submitted documentation.
The following programs are available through Virginia ADAP:
- Health Insurance Marketplace Program (HIMAP) – If a client has insurance through a VDH approved Affordable Care Act (ACA) plan, he/she must access
medications through Ramsell. This program is used to purchase insurance for clients who are eligible to enroll into specific VDH approved plans via the
Health Insurance Marketplace. VDH will pay for monthly insurance premiums, as well as all medication copayments and deductibles approved by the primary
insurance. Clients access medications at retail pharmacies within an approved network.
- Insurance Continuation Assistance Program (ICAP) – If a client has private insurance, that has approved program medication benefits, he/she must access
medications through ICAP. This program assists clients with certain private insurance with medication benefits. The program allows ADAP to assist those
with limited income to access medication at retail pharmacies within an approved network. VDH will pay for medication copayments and deductibles on the
ADAP and Ryan White Part B non-ADAP formularies.
- Medicare Part D Assistance Program (MPAP) – If a client has Medicare they must enroll in a Part D prescription drug plan and, he/she must access
medications through MPAP. This program assists clients who are on, or eligible for, Medicare Part D. VDH will pay for monthly Medicare Part D premiums, as
well as all medication copayments and deductibles for medications that are approved by the Part D plan. Clients access medications at retail pharmacies
within an approved network.
- Direct ADAP – This program assists clients who are not eligible for any other coverage (including insurance or Medicare Part D) for HIV/AIDS
medications. Medications on the ADAP formulary are ordered and picked up through any Local Health Department or other medication access site.
Covered vs. Non-Covered Medications
Purpose: To specify which medication copayments will be supported with ADAP funds.
Objective: To ensure ADAP medication assistance through the Health Insurance Marketplace Assistance Program (HIMAP), Insurance Continuation Assistance
Program (ICAP), and Medicare Part D Assistance Program (MPAP) complies with federal policies.
Clients enrolled in a VDH-approved HIMAP plan will receive copayment assistance for all medications on the plan's formulary.
Clients enrolled in ICAP will receive copayment assistance for medications only on the Virginia ADAP and non-ADAP formularies.
Clients enrolled in a MPAP will receive copayment assistance for all medications on the client's Medicare Part D formulary.
Purpose: To provide medication copayments for ADAP eligible clients with private insurance (health insurance from a source other than the Affordable Care
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
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
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.
Clients seeking assistance with costs for policies obtained through the Federal Insurance Marketplace under the ACA may only receive assistance with
ADAP-approved plans. Information about those plans is located here:
- 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.
- 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).
- 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
- 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
Medication Exception and Prior Authorization Guidance
- 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.
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.
- Upon receiving notification that a Direct ADAP client has been incarcerated, the client will no longer be eligible for ADAP services.
- 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.
- 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.
Conditions for Authorizing Premium Payments
Purpose: To ensure cost effectiveness for premium costs being covered for approved clients.
Objective: To streamline the process for enrolling clients to insurance plans who are not currently on ARVs and to remain cost effective according to
Policy: ADAP clients must be prescribed ARVs within 3 months of insurance enrollment process.
- ADAP application is received at VDH.
- If no ARVs are listed on the medical certification form, VDH will contact the medical provider to verify client medication regimen.
- To be approved for ADAP, the client must be prescribed ARVs within three months of ADAP approval. The medical provider must send medical record
documentation (progress note, chart note and genotype/lab results) explaining reason(s) for non-prescribing ARVs at the time of the ADAP application.
- Once approved for ADAP and/or during open enrollment, client will be transitioned to HIMAP or MPAP, if eligible.
- Once ARVs are prescribed, an updated medical certification form will be required from the medical provider listing ARVs.
- If a client is on a clinical trial, the medical provider must contact the VDH Medication Assistance Hotline at 855-362-0658 to discuss individual
situations with a projected end date of the clinical trial.
- Consistent with ADAP policy, clients who do not access medications within 6 months are no longer eligible for ADAP services.
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.
ACA Exception Process
Purpose: To allow Ryan White funds to be used for Direct ADAP clients who have no VDH approved ACA health insurance options available due to their
Objective: To ensure uninterrupted access to medications through Direct ADAP.
Policy: Clients will be issued an exception to remain on Direct ADAP if no VDH approved ACA insurance options are available based on geographic location of
- Client completes the ACA application through the health insurance marketplace.
- If it is confirmed that no VDH-approved ACA insurance options are available based on client's geographic location, this information is communicated to VDH
and an exception request is submitted.
- The exception request is reviewed by the ADAP Coordinator and, if approved, is documented in the client's file.
- The approved exception for the client to remain on Direct ADAP is forwarded to the client, medication distribution site (where the client obtained Direct
ADAP medications), medical provider, and the VDH Central Pharmacy.
NOTE: Clients may be fined under the ACA if they fail to enroll in an insurance plan prior to the end of the open enrollment period. The client will be
notified in writing that under no circumstances may Ryan White HIV/AIDS Program funds be used to pay the fee for a client's failure to enroll in
minimum essential coverageï¿½ according to
Clarifications Regarding Clients Eligible for Private Health Insurance and Coverage of Services by Ryan White HIV/AIDS Program
Policy Clarification Notice (PCN) #13-04
, available at
Please refer to the Healthcare.gov website (
) for more information about tax penalties and exemptions from penalties
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
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.
Proof of Income Policy
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.
Policy: If a client files taxes, the client is required to submit their most recent tax return to Virginia ADAP as proof of income. Clients who do not file taxes may submit other forms of income documentation as explained here.
Tax Credit Liability Policy
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 Penalty 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 a