1. All client eligibility for ADAP is determined at local health departments or through Virginia Commonwealth University Health Systems Financial Counseling and Governmental Services.
2. The client will need to provide written prescriptions for all requested medications. Documentation of CD4 and viral load counts are required for some medications.
3. Clients must have no third party insurance coverage for the prescribed medication(s).
4. A change in federal policy now gives Veterans (who meet all other ADAP eligibility criteria) the option of accessing covered medications through ADAP.
5. 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.
6. Yearly family income cannot be more than 300% of the federal poverty level (FPL); for Northern Virginia the number is slightly higher at 333%. ADAP and Ryan White Part B eligibility scale 2008
7. 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.
8. ADAP eligibility must be recertified every 12 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.
9. 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.
10. Clients are not required to live in the heath district where they recieve ADAP.
11. HIV-infected pregnant women or newborn infants of HIV-infected mothers are eligible for antiretrovirals regardless of the CD4 count or viral load.
12. New ADAP clients currently on antiretroviral therapy are not required to meet the CD4 and viral load requirements. A statement documenting current antiretroviral treatment and previous source of funding must be reported to the ADAP coordinator.
ADAP and Medicare Part D Eligibility
1. Medicare eligibility status must be assessed at initial enrollment and annually.
2. Federal policy requires that ADAP clients who are eligible for Medicare enroll in the Medicare Part D benefit. However, if a client refuses enrollment after extensive counseling about this benefit and has no other viable option for obtaining medications other than ADAP, please document the reason for not enrolling on the CHS-1 or equivalent eligibility form and allow the client to access medications through ADAP. Please fax the documentation of refusal to the VDH ADAP Coordinator at 804 864-8050.
3. Medicare eligible clients with incomes less than 150% of the FPL must apply for the low-income subsidy (LIS) or “extra-help” component of the Part D benefit to assist with the client’s share of out-of-pocket costs. Medications can be accessed through ADAP until LIS eligibility determination is received. The ADAP Medicare Assessment Form is to be utilized to track application outcome.
4. Medicare Part D enrolled ADAP clients with incomes above 150% of FPL and those who do not qualify for the LIS will be allowed to continue to receive medications through ADAP. This is to be documented on the Medicare Part D Assessment Form. Clients who qualify for the LIS will need to utilize their Medicare Part D Plan for their medications.
5. Medicare eligible clients who qualify for the low income subsidy, with incomes 135% to 150% FPL, and are unable to obtain assistance with Part D cost sharing may request an ADAP eligibility exception through the local health department. The local health department will complete the ADAP Medicare Part D Eligibility Exception Form and submit to the VDH ADAP Coordinator. These requests will be reviewed on a case-by-case basis. ADAP Medicare Part D Eligibility Exception form
6. ADAP clients with Medicare coverage who are on a Medicaid “spend down” will be automatically enrolled in a Part D plan as a dual eligible when their “spend down” is met. They will no longer be eligible for ADAP and will need to utilize their Part D plan.
Requirements for the NRTI, NNRTI, PIs, and Multi-Class medications (unless otherwise noted):
1. CD4 count currently or previously below 500 or CD over 500 with a detectable viral load.
2. New ADAP clients currently on antiretroviral therapy are not required to meet the CD4 and viral load requirements for these medications. A statement documenting that the client has been receiving antiretroviral therapy and identifying the previous source of funding must be submitted to the ADAP Coordinator by fax to (804) 864-8050 for consideration on an individual basis.
3. 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 presets 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.
Questions or comments?
Contact HIV/STD/Viral Hepatitis Hotline