Texas HIV Medication Program THMP 101 with a Focus on Special Populations Eligibility Presented by: Marivel Cantu-Ressler, BSW

Presentation Outline Overview of the Texas HIV Medication Program (THMP) including ADAP, SPAP and TIAP THMP Application Process and Enrollment Identification and discussion of challenging areas on the THMP application.

HIV Medication Resources Private Insurance Patient Assistance Programs Medicare Medicaid Local Assistance Programs THMP as the payer of last resort

Texas HIV Medication Program Program established in 1987 Provides life-sustaining medications used for the treatment of HIV disease and its related complications to eligible low income Texans Key Philosophies –Access to care and Retention in care Administered by the HIV/STD Prevention and Care Branch within the Texas Department of State Health Services (DSHS) Mandated under Chapter 85 of the Health and Safety Code Authorized by the Federal Ryan White CARE Act, 42 USC, Section 300 Consists of two programs and a pilot program AIDS Drug Assistance Program (ADAP) State Pharmacy Assistance Program (SPAP) Texas Insurance Assistance Program (TIAP)

Current Enrollment 19,597 unique clients served in State FY15 17,364 ADAP 2,182 SPAP and 300 TIAP Pilot Programs are open to new enrollment/No waiting list Clients served has increased significantly from 5,106 in 1996 to the 19,597 in 2015

THMP Eligibility Proof of Texas residency HIV Diagnosis Uninsured or underinsured for prescription drugs Low income – *Adjusted gross income less than 200% of the Federal Poverty Level (adjusted annually) $23,540/year for a single person $ 8,320/year for each + family member * A spend-down calculation is applied to applicants’ gross income to determine an adjusted gross income for eligibility screening

THMP Application Processing Applications are completed by clients, often with the assistance of a case manager, and reviewed by eligibility staff. A Medical Certification Form (MCF) must be filled out by the doctor The applicant and/or their designated authorized person will be contacted if further information is needed, including information for SPAP or TIAP Pilot enrollment. Once the application is processed, the applicant will be notified of the decision by mail. If denied by the THMP, the denial letter can be used to access other assistance programs

Expedited Processing for Special Populations In some instances applications can be expedited. The program will allow faxing for applications that meet the following requirements: Pregnant Women Children Under 18 Years of Age Post-Incarcerated/Recently Released CD4 Count Under 100 Insured or Recently Insured Medicare Recertification Applications Urgent Situations (Identified by Staff) Note: In order for an expedited application to be approved it must be complete and the applicant must meet all eligibility guidelines. Expedited Processing for Special Populations

Texas HIV Medication Program AIDS Drug Assistance Program (ADAP) Clients not eligible for Medicare Texas HIV State Pharmacy Assistance Program (SPAP) Clients eligible for Medicare 17th HIV/STD Conference May 2010

Texas ADAP Funded by Federal Ryan White and State General Revenue Provides ADAP formulary medications to eligible individuals 50 drugs on Formulary All ARV’s on the formulary are FDA approved Limits on the number of antiretroviral medications a client can receive (4 per month)

Accessing Medications Medications are distributed through a network of over 500 pharmacies located throughout the state Mail order option is available Pharmacies may charge a dispensing fee per prescription A pharmacy cannot refuse service if a client is unable to pay A list of participating ADAP pharmacies can be found at: www.dshs.state.tx.us/hivstd/med s/pdf/pharlist.pdf

Accessing Medications Each client approved to receive medication from the program will receive a letter containing: A unique 6-digit client code number The name and address of his/her assigned pharmacy List of approved medications Instructions for receiving medications from the program

ADAP Participating Pharmacies Medications are dispensed in full bottle amounts Pharmacies may charge a $5.00 dispensing fee per prescription Clients concurrently approved for Medicaid must first utilize their Medicaid prescription benefits in order to receive THMP medications Dispensing fees are not charged to a client concurrently approved for Medicaid

Texas HIV SPAP and TIAP Pilot Developed to assist eligible clients with Medicare following the creation of the prescription drug benefit, Medicare Part D in 2006 Implemented January 1, 2008 Provides assistance with Medicare Part D out of pocket costs The client must be enrolled in a Medicare Part D plan or a Medicare Advantage Plan w/drug coverage to participate in the program TIAP Pilot Developed to assist clients who lost insurance coverage to transition to COBRA and to help clients with unaffordable medication copayments with copayment assistance Implemented July 1, 2013 Provides assistance with COBRA premiums, medication copayments, and medication deductibles Client must be eligible for COBRA or have a current insurance plan for program participation.

Texas HIV SPAP/TIAP Benefit The SPAP and TIAP will cover the out-of- pocket costs for an enrollee for medications covered on the enrollees’ Part D plan formulary or health insurance plan formulary – Excludes meds not covered by Medicare Out-of-pocket costs include: Deductibles, Co-payments Medications during the coverage gap/donut hole Co-payments/coinsurance after reaching catastrophic coverage Enrollees are not responsible for the plan premiums under COBRA, but are under SPAP and participation in plans with unaffordable prescription copayments (usually employer-sponsored health plans) Participants use a network pharmacy – a network of over 2,000 pharmacies in TX Texas HIV SPAP/TIAP Benefit

Recertification Purpose: To ensure that program enrollees continue to meet eligibility criteria Required by our federal Ryan White funder, the Health Resources and Services Administration (HRSA) Recertification is required every six months for ADAP and SPAP

Application Processing MAI Clients Post-incarceration TDCJ clients contact THMP upon release and apps are generally processed within a few days. Note: In order for an app to be approved it must be complete and the applicant must meet all eligibility guidelines. Once approved, THMP contacts assigned pharmacy to request transfer of TDCJ prescriptions. Faxed medication orders are processed, pharmacy receives order shipment in 3- 4 business days Clients are recertified 6 months after THMP approval

Application Processing Post-incarceration Fill out the THMP application Application can be downloaded from the web: www.dshs.state.tx.us/hivstd/meds or contact the THMP to have a packet sent Have the Medical Certification Form (MCF) filled out by doctor Mail or fax the application and supporting documentation to the THMP Be sure to indicate recently released on application ( fully complete question #12 on application) Once the application is processed, the applicant will be notified of the decision by mail.

THMP Application Processing Challenges Incomplete application, missing pages or has blanks Application NOT signed Missing or inadequate verification of income Unclear, incomplete, inconsistent representation of household situation, family members, and/or marital status Inadequate proof of Texas residency Insurance/prescription status issues Missing Supporter Statement Missing or incomplete Medical Certification Form (MCF)

What Can Be Done? The client is encouraged to explain in writing as much as possible to clarify any part of the application pertaining to them, especially: Household information Marital status (if separated, give detailed information about how long, where spouse is, etc.) Employment situation, especially if not employed (written explanation of when/where last employed) Support documentation, if zero income a completed THMP Supporter Statement is preferable or any other written support document or statement

What Can Be Done? Note that additional documentation from Social Workers, Case Managers, LVN’s, RN’s will continue to be needed to clarify any unusual or complicated situations a client may be in Applications must be completed fully, no blank spaces or marks across pages or areas, questions must be answered completely If the client is uncertain about what the THMP requires in a given situation, they can call and request clarification from our eligibility staff

Questions? Comments?

Train Texas https://tx.train.org State employees and non-state employees can create an account Email address is used as the Login Name Once on site Course Title: Texas HIV Medication 2013 update Couse ID Number:1033734

Phone: 1-800-255-1090 Eligibility Fax: 512-533-3178 Website: www. dshs Phone: 1-800-255-1090 Eligibility Fax: 512-533-3178 Website: www.dshs.state.tx.us/hivstd/meds Email: Marivel.Cantu-Ressler@dshs.state.tx.us THMP Contact Information Staff Area of Expertise Contact Number Becky Spanish, Insurance 512-533-3006 Christine Insurance, Post- Incarcerated 512-533-3003 Eric Recertification Lead 512-533-3013 Heather Data Manager 512-533-3083 Imelda Spanish, Eligibility 512-533-3007 Juliet SPAP Coordinator 512-533-3004 Krystal Eligibility 512-533-3009 Marivel Spanish, Post-Incarcerated 512-533-3011 Mary Pharmacy Coordinator 512-533-3014 Rachel Program Manager 512-533-3002