Eligibility

Please visit ADAP Updates to view policy memos.

• Eligible applicants must reside in Virginia.

• ADAP enrollment is currently closed unless you are
  1. A new client with a CD4 at or below 350, or a previously wait-listed client with a reported CD4 count less than 350
  2. Pregnant
  3. 18 years old or younger (includes perinatally-exposed newborns)
  4. Currently receiving treatment for an active opportunistic infection.  People who are currently being treated for opportunistic infections may sign up for ADAP, if their doctors complete an Enrollment Exception Request and send it to the ADAP Central office at (804) 864-8050.
  5. Clients on the wait list with CD4 counts from 351-500 are being enrolled through a first-on-first-off process over time to ensure sustainability on ADAP.

  Applicants who do not meet one of these criteria will be put on a wait list.

• All client eligibility for ADAP is determined at local health departments or through Virginia Commonwealth University Health Systems Financial Counseling and Governmental Services. Centralized ADAP eligibility, managed by Patient Services, Inc. (PSI), is being launched regionally. Regional launches will continue through the 2010 and 2011 calendar years.

• As of November 1, 2010 PSI will determine eligibility for all new and returning clients. An application can be started by calling PSI's toll-free number 1-866-392-1309. This number will connect the caller directly to an ADAP representative at PSI. Virginia Commonwealth University Health System/Financial Services will continue to manage ADAP eligibility for clients obtaining ADAP medications through ACC Pharmacy and Hayes E. Willis.

• Applicants referred to PSI will be allowed thirty days (30) to respond to first attempt by PSI to initiate the application process. PSI will follow-up seven (7) days with applicant. On 30th day, if PSI has not heard from the applicant, the applicant shall be considered ineligible and the application will be closed. Applicants who do respond to PSI will be given a total of sixty (60) days, inclusive of the initial 30, to complete an application. Applicants may reapply at any time.

• The client will need to provide written prescriptions for all requested medications. Documentation of CD4 and viral load counts are required for some medications.

• Clients must have no third party insurance coverage for the prescribed medication(s).

• Federal policy gives Veterans (who meet all other ADAP eligibility criteria) the option of accessing covered medications through ADAP.

• The client must be ineligible for Medicaid. The Medicaid Referral Assessment Form provides a means to screen ADAP clients to determine whether referral to Department of Social Services to submit a Medicaid application is indicated. If client is referred, verification of application submission must be provided within 14 days of entry into ADAP. The local health department will provide the client with medications through ADAP until Medicaid is approved. To remain eligible for ADAP, clients must submit proof of Medicaid ineligibility within 90 days of Medicaid application. If a client loses Medicaid coverage, medications will again be provided through ADAP.

• Yearly family income cannot be more than 400% of the federal poverty level (FPL).   

• Individuals without income must bring either a signed letter of support or evidence of employment status to the local health department. It is no longer required that this documentation be notarized.

• ADAP eligibility must be recertified every 6 months.Clients are required to report changes in income, insurance or Medicaid status when they occur. Failure to report changes in factors impacting eligibility may result in discontinuation of ADAP services. Clients managed by PSI will be recertified every 6 months with a 12 month re-apply.

• Clients shall be considered ineligible for ADAP after two documented attempts by local health department staff to obtain proof of income, insurance or Medicaid status.

• Clients are not required to live in the heath district where they receive ADAP.

• HIV-infected pregnant women or newborn infants of HIV-infected mothers are eligible for antiretrovirals regardless of the CD4 count or viral load.

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ADAP and Medicare Part D Eligibility

POLICY ON ADAP-ELIGIBLE CLIENTS WITH MEDICARE PART D

BACKGROUND:

Serving clients through the Medicare Part D Patient Assistant Program (MPAP) results in substantial cost-savings to the AIDS Drug Assistant Program (ADAP). Because there is a limit on out of pocket costs for clients (which MPAP pays on their behalf), approximately 3 clients are able to be served for every 1 client served through traditional ADAP. This allows ADAP to serve more clients who have no other coverage for medications.

Medicare eligibility status for ADAP-eligible clients is assessed at initial eligibility determination and every six months. ADAP-eligible clients who are also eligible for Medicare are instructed to enroll in a Medicare Part D plan. ADAP clients with household incomes less than 150% of the Federal Poverty level (FPL) must apply for the low-income subsidy (LIS) or “extra-help” component of the Part D benefit to assist with out-of-pocket costs. Medications can be accessed through the MPAP under ADAP until LIS eligibility determination is received. Clients who qualify for the full LIS are not eligible for MPAP/ADAP assistance.

POLICY:

• Effective immediately, all ADAP-eligible clients who have Medicare Part D must be enrolled in MPAP.
• Clients with Medicare Part D will not be served through the more costly traditional ADAP. If a client with Medicare Part D declines enrollment to MPAP, that client will be disenrolled from all ADAP services.
• ADAP-eligible clients who are also eligible for Medicare will be instructed to obtain a Medicare Part D plan. If a client declines enrollment into a Medicare Part D plan, that client will be disenrolled from all ADAP services. Clients may be supported on ADAP (as funding allows) while applying for a Medicare Part D plan, and may be supported on MPAP while applying for LIS (if indicated).

DOCUMENTATION:

Clients and their HIV providers will be notified by letter if disenrolled from ADAP due to declining MPAP services or declining to apply for Medicare Part D. A copy of the letter will be maintained in the closed client file.

EXCEPTIONS: NONE

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Requirements for the NRTI, NNRTI, PIs, and Multi-Class medications (unless otherwise noted):

1. Eligible clients will have access to medications covered on the formulary. Such clients will meet all of the above requirements.

2. New prescriptions, CD4 and viral load counts are required every 6 months.

Requirements for Opportunistic Infection Protection/Treatment (unless otherwise noted):

1. New prescriptions, CD4 and viral load counts every 12 months.
2. If a client presents to the provider with an extremely low CD4 count, medications for opportunistic infections can be initiated while waiting for test results.
3. Local health departments are responsible for verification of CD4 and viral load counts.

Additional ADAP Program Requirements:

1. All pregnant women seen at prenatal clinics must be counseled about HIV infection and offered HIV testing. Women testing positive must be informed they could transmit HIV infection to their newborn baby and about the potential benefits of antiretroviral therapy and other measures in reducing prenatal transmission. They must be informed about the other measures in reducing prenatal transmission. They must also be informed about unknown long-term effects of antiretroviral therapy during pregnancy. The most recent guidelines published for preventing perinatal transmission of HIV can be accessed at www.aidsinfo.nih.gov.
2. Periodic site visits to all local health departments will be made by the VDH ADAP Coordinator to assure quality administration of ADAP.

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Questions or comments?

Contact HIV/STD/Viral Hepatitis Hotline