1. VA MAP Eligibility
Purpose: To provide clear parameters for eligibility and program enrollment.
Objective: To ensure Virginia Medication Assistance Program (VA MAP) eligible clients are referred to the appropriate service option.
To be eligible for one of the programs supported by VA MAP 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 VA MAP services.
2. Covered vs. Non-covered Medications
Purpose: To specify which medications and medication co-payments will be supported with VA MAP funds.
Objective: To ensure medication assistance through any of the VA MAP Service Options (Direct Medication Assistance Program; Health Insurance Marketplace Assistance Program; Insurance Continuation Assistance Program; and Medicare Prescription Assistance Program) complies with federal policies and regulations.
The Virginia Medication Assistance Program (VA MAP) operates under three formularies:
1. Virginia Direct Medication Assistance Program Formulary
2. Virginia Ryan White (RW) Part B Formulary
3. VA MAP Formulary for Insured Clients
a) Direct Medication Assistance Program: Enrolled clients will receive medication assistance for medications on the Virginia VA MAP Formulary.
b) Insurance Continuation Assistance Program: Enrolled clients will receive co-payment assistance for medications only on the Virginia VA MAP Formulary and the Virginia RW Part B Formulary.
c) Health Insurance Marketplace Assistance Program and Medicare Prescription Drug Assistance Program: The Virginia VA MAP Formulary for Insured Clients is a replica of each formulary of an insurance plan that is paid for by VA MAP for clients with private insurance (through the Affordable Care Act, or ACA, Marketplace) or Medicare. Clients enrolled in a VDH-approved private insurance plan, and those enrolled Medicare will receive copayment assistance for all medications on the plan’s formulary. Coverage of medications through VA MAP that are not covered by the insurance plan’s formulary will be assessed on a case-by-case basis.
3. Insurance Continuation Assistance Program Coverage
Purpose: To provide medication co-payments for VA MAP eligible clients with private insurance (health insurance from a source other than the Affordable Care Act [ACA]).
Objective: To expand medication access to insured VA MAP clients requiring assistance with medication co-payments, while maximizing rebates on medication co-payments used to sustain VA MAP.
Policy: VA MAP eligible clients who have private insurance may receive assistance with medication co-payments for medications only on the Virginia VA MAP and RW Part B formularies.
Direct Assistance clients who obtained employer-based insurance will no longer access medications through Direct Assistance beginning 60 days after successful transition. The client, pharmacy, medication distribution site (where the client obtained their medications) and the client’s medical provider will be notified of any enrollment transitions.
4. Medicare Prescription Assistance Program Coverage
Purpose: To provide premium assistance and medication co-payments for VA MAP eligible clients with Medicare.
Objective: To expand medication access and ensure medication assistance for clients with Medicare complies with federal policies and regulations.
All VA MAP applicants who have Medicare coverage must enroll in the Medicare Prescription Assistance Program. Clients may not remain enrolled in private insurance assistance plans through VA MAP if they are eligible for Medicare.
Clients may enroll into Direct Assistance only while applying for a Medicare plan.
VA MAP 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 Medicare Prescription Drug Assistance through VA MAP. Those with partial LIS coverage or no LIS, however, do qualify.
When approved for Medicare Prescription Assistance Program, 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 Assistance.
5. Health Insurance Marketplace Assistance Program Coverage
Purpose: To provide premium assistance and medication co-payments for VA MAP eligible clients for VDH approved ACA insurance plans.
Objective: To expand medication access and ensure medication assistance for clients with ACA insurance plans complies with federal policies and regulation.
a) Plan Selection
Clients seeking assistance with costs for policies obtained through the Federal Insurance Marketplace under the ACA may only receive assistance with VA MAP-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 VA MAP clients.
c) Premium Tax Credits
If an VA MAP 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 Assistance to ACA plan assistance
Clients enrolled in insurance plans will no longer access medications through Direct Assistance beginning 60 days after successful insurance plan enrollment. The client, pharmacy, medication distribution site (where the client obtained their medications) and the client’s medical provider will be notified of any enrollment transitions.
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: firstname.lastname@example.org
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 MAP 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 VA MAP remains the payer of last resort for incarcerated clients.
Objectives: To remove incarcerated clients from Direct Assistance; to expedite VA MAP enrollment for incarcerated clients upon release; and to remove incarcerated clients from ACA plan assistance based on disposition of charges.
a) Upon receiving notification that a VA MAP client has been incarcerated, the client will no longer be eligible for VA MAP services.
b) Before or upon release from incarceration, a qualifying applicant is referred to VDH Care Coordination (1-804-864-7919). Upon release from a local/regional jail that is participating with the Expedited Enrollment Program (EEP), a client should receive a 7-day supply of medications from the jail. Upon release from the Department of Corrections (DOC), a client should receive a 30-day supply of medication from the DOC. Applications to VA MAP may be completed prior to release to help expedite enrollment. A submitted VA MAP application is processed for non-incarcerated applicants within 48 hours. During the ACA open enrollment period, all eligible applicants are referred for ACA insurance enrollment. The applicant may also be eligible for health insurance through the ACA Marketplace Special Enrollment period if ACA open enrollment has ended. Eligible applicants may also qualify for medication assistance through Direct VA MAP, private insurance including employer based or Medicare through VA MAP or through VA Medicaid.
c) If a client is enrolled in VA MAP and is incarcerated, the client is no longer eligible to continue to receive services. A client may reapply before or upon release from incarceration.
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: ACA plan-assisted 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 VA MAP 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.
The Virginia Medication Assistance Program (VA MAP) 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 MAP 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. Proof of Income
Purpose: To simplify proof of income documentation for VA MAP applicants.
Objective: To ensure financial eligibility documentation can assist clients with both VA MAP and Affordable Care Act (ACA) enrollment.
If a client files taxes, the client is required to submit their most recent tax return to VA MAP as proof of income.
10. 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 MAP client may owe to the Internal Revenue Service (IRS) based on the reconciliation of the premium tax credit.
Objective: To assist VA MAP clients with this liability as VA MAP pays the monthly premiums for their insurance plans.
Policy: VA MAP may pay the tax credit liability if the criteria listed below are met:
- Client was eligible for VA MAP 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 MAP will not pay any IRS late fees.
VA MAP 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 MAP’s ability to pay tax credit liability is dependent upon the availability of funding.
11. 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 VA MAP.
Policy: Clients receiving services under VA MAP may file a grievance, or complaint, if services provided are different than what he or she believes should be offered under VA MAP. Grievances should be submitted in writing on a Client Grievance Form. VDH will respond to client within 5 business days of the grievance.