1. Texas HIV Medication Program
Becky Ruiz, BSW
Katherine Wells, MPH

2. Presentation Outline HIV Medication Assistance in Texas
Overview of the Texas HIV Medication Program (THMP)
Application Process
Discussion of problem areas on the THMP application
TA Conference Call
March 6, 2009

3. Help with Medications in Texas
Private Insurance
Patient Assistance Programs
Texas High Risk Pool
City and County Assistance Programs
Medicare
Medicaid
Texas HIV Medication Program
AIDS Drug Assistance Program (ADAP)
State Pharmacy Assistance Program (SPAP)
TA Conference Call
March 6, 2009

4. Patient Assistance Programs
Run by the individual drug manufacturers
Provides free and/or reduced cost medications to eligible individuals
These programs cover HIV Medications as well as medications used to treat side effects and other complications
Some of the major HIV manufacturers are planning to start assisting with insurance co-pays
Helpful websites:
TA Conference Call
March 6, 2009

5. Local Drug Assistance Programs
Ryan White Funding, Parts A, B, C & D
State Services
County Funds
Local Programs: Carelink (San Antonio), MAP Card (Travis County), Gold Card (Harris County)
TA Conference Call
March 6, 2009

6. Medicare
Federal program that provides medical care for the elderly and disabled
Medicare includes 4 different programs
Part A – Hospital Insurance
Part B – Medical Insurance, individuals must select the program and pay a monthly premium ($96.40)
Part C – Medicare Advantage Plan, provides Part A and Part B benefits through a private company, may provide prescription coverage
Part D – Prescription Drug Benefit, individuals must enroll in an approved plan and pay a monthly premium (avg. $25)
Additional information: or
TA Conference Call
March 6, 2009

7. Medicaid
A state program that provides medical assistance to low income individuals
Medicaid can provide:
Medical Care
Prescription Drugs
Health Insurance Premium Payments
Assistance with the Medicare Part B premium – QMB/SLMB
Income limits are higher for children and pregnant women
For more information call or or online at
TA Conference Call
March 6, 2009

8. Texas HIV Medication Program
Administered by the HIV/STD Comprehensive Services Branch within the 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
TA Conference Call
March 6, 2009

9. Texas HIV Medication Program
Program established in 1987
Provides life-sustaining medications used for the treatment of HIV disease and its related complications to low income Texans
Key philosophies –Access to care and Retention in care
Consists of two programs
AIDS Drug Assistance Program (ADAP)
State Pharmacy Assistance Program (SPAP)
4th Largest ADAP (NY, CA, FL)
TA Conference Call
March 6, 2009

10. Current Enrollment 11,651 currently enrolled clients
10,738 enrolled in the ADAP
913 enrolled in the SPAP
13,108 clients served in State FY08
Program is open to new enrollment/No waiting list
Clients served has increased significantly from 5,106 in 1996 to the 13,108 in 2008
The THMP dispensed over $75 million in medications to eligible clients in SFY2008
TA Conference Call
March 6, 2009

11. THMP Eligibility Texas resident HIV-positive
Uninsured or underinsured for prescription drugs
Low income – Adjusted gross income less than 200% of the Federal Poverty Level (2009)
$21,660/year for a single person
$ 7,480/year for each + family member
TA Conference Call
March 6, 2009

12. Application Process Fill out the THMP application
Application and Instructions can be downloaded from the web: or contact the THMP to have packet sent
Have the Medical Certification Form (MCF) filled out by doctor
Mail the application and supporting documentation to the THMP
TA Conference Call
March 6, 2009

13. Application Process
Applications are typically processed within 2 to 3 business days of receipt
The applicant and/or their designated authorized person will be contacted by THMP staff if further information is needed.
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
Clients are required to recertify for the program (ADAP: every 3 years, SPAP: every other year)
TA Conference Call
March 6, 2009

14. Expediting Applications
In some instances applications can be expedited. This means the application can be faxed instead of mailed.
Pregnant Women
Children under 18 years of age
Recently Incarcerated
Special Situations – call the program to discuss the situation before faxing
Note: In order for an expedited application to be approved it must be complete and the applicant must meet all eligibility guidelines.
TA Conference Call
March 6, 2009

15. 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
TA Conference Call
March 6, 2009

16. Texas ADAP Funded by Ryan White and State General Revenue
Provides ADAP formulary medications to eligible individuals
Medications are distributed through a network of pharmacies
TA Conference Call
March 6, 2009

17. Texas ADAP Formulary 42 drugs/80 different formulations
All FDA approved ARVs on formulary
Limited scope-includes 10 of the 14 PHS recommend drugs for the treatment & prevention of OIs – no drugs to treat side effects of toxicities
Medical criteria for the majority of drugs
Limits on the number of antiretroviral medications a client can receive (4 per month)
TA Conference Call
March 6, 2009

18. Accessing Medications
Medications are distributed through a network of community pharmacies
Pharmacies may charge a $5.00 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:
TA Conference Call
March 6, 2009

19. Approved on ADAP – What happens now?
The ADAP enrollee receives an approval letter that includes
Name and Address of Assigned Pharmacy
List of approved medications
Client ID number
The assigned pharmacy receives the same letter
ADAP client takes their prescriptions to the assigned pharmacy and lets the pharmacy know they are part of the Texas HIV Medication Program
Pharmacy will verify prescriptions and order medications from the THMP
TA Conference Call
March 6, 2009

20. What happens now?
THMP receives medications order via fax and phone at the office in Austin
THMP order staff verify the client is enrolled in the program, approved for the medications and if the client has active Medicaid
If the order is denied the pharmacy is notified, common reasons for denial include:
Client not approved for the Medication
Client has open Medicaid slots
Client is on HOLD
TA Conference Call
March 6, 2009

21. What happens now?
If the order is approved, the medication orders are batched and sent to the DSHS pharmacy.
The DSHS pharmacy packs the medications ordered from the local pharmacy and ships the medications via UPS
The medications arrive at the pharmacy, the pharmacist labels the medications and dispenses them to the client
The process can take 3 to 5 business days, therefore it is important for clients to reorder medications before they run out of medications
TA Conference Call
March 6, 2009

22. Texas HIV SPAP State funded program
Developed to assist clients with Medicare following the creation of Medicare Part D in 2006
Started 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
TA Conference Call
March 6, 2009

23. Texas HIV SPAP Benefit
The SPAP will cover the out-of-pocket costs for an enrollee for medications covered on the enrollees’ Part D plan formulary
Out-of-pocket costs include:
Deductible
Co-payments
Medications during the coverage gap
Co-payments/coinsurance after reaching catastrophic coverage
TA Conference Call
March 6, 2009

24. Texas HIV SPAP Benefit
SPAP enrollees can enroll in any Medicare Part D plan offered in Texas
SPAP enrollees will be responsible for paying monthly Prescription Drug Plan Premiums
The SPAP will assist with all medications covered on the individual’s Part D formulary
The beneficiary must maintain enrollment in a Part D plan in order to access services from the THMP
TA Conference Call
March 6, 2009

25. Texas HIV SPAP Benefit
Annual allowable amount per SPAP enrollee for 2009: $10,995
High End Risk Example:
Retail Cost
Part D Coverage Period
Out-of-Pocket
Month 1
$10,000
$4,522
Deductible, Initial Coverage, Coverage Gap, Catastrophic
Month 2
$500
Catastrophic Coverage
Month 3 -12
$100,000
$5,000
(10 months)
Total
$120,000
$10,022
TA Conference Call
March 6, 2009

26. Medicare Part D Plan Enrollment
Medicare open enrollment is from Nov 15 to Dec 31 each year
A one time Special Enrollment Period (SEP) will be available for newly enrolled SPAP clients
Must give official SPAP name (THMP SPAP) and ID# (SS028) to Medicare/prescription drug plan to successfully enroll the client during the SEP
Clients can enroll by:
Calling the plan directly
Calling MEDICARE ( )
Online at
TA Conference Call
March 6, 2009

27. Late Enrollment Penalty
Medicare will assess a late enrollment penalty if a person with Medicare
does not join a Medicare Part D plan when first eligible or
does not have creditable coverage (THMP is not creditable coverage)
The penalty is 1% of the national Medicare premium ($30.36 in 2009) for every month without creditable coverage
The penalty is added to the monthly drug premium
The penalty is permanent and recalculated each year
TA Conference Call
March 6, 2009

28. Example
Bob became eligible for Medicare on April 1, 2008 but did not enroll in a Medicare Part D plan
He later decides to enroll in a plan during the open enrollment period. His plan will be effective on January 1, 2009.
Since Bob is without creditable drug coverage from April 2008 through December 2008 he will be assessed a 9% penalty (1% for each of the 9 months he did not enroll)
In addition to the plan premium Bob will pay an extra $2.73 each month (National Average Premium $30.36 x 9%)
If Bob waits 24 months to enroll in a plan he will have to pay an extra $7.28 per month
TA Conference Call
March 6, 2009

29. How to Enroll in the SPAP
SPAP eligibility is determined by THMP staff
Complete the Texas HIV SPAP Enrollment form
Submit a copy of the LIS partial approval or denial letter from SSA (all pages of the letter)
If not currently enrolled in the THMP, a complete THMP application must also be submitted
Applications can be printed from the THMP website:
TA Conference Call
March 6, 2009

30. Accessing Medications
All SPAP enrollees will receive a welcome packet from Ramsell Holding Corp (Ramsell Public Health Rx) in Oakland, CA, which will include an ID Card
Enrollee will take their ID cards (Part D Plan and SPAP) and prescriptions to a participating pharmacy
Pharmacist will process prescriptions through the Medicare Part D Plan first
If medications are approved, remaining out-of-pocket costs will be billed to SPAP as the secondary payer
TA Conference Call
March 6, 2009

31. Low Income Subsidy/Extra Help
Applications are processed by Social Security
apply online at fill out a paper application or call
To qualify for LIS the beneficiary must meet income and asset guidelines
All THMP Clients with Medicare are required to apply for this assistance and submit a copy of the Social Security Determination Letter to the THMP
TA Conference Call
March 6, 2009

32. Full Low Income Subsidy (LIS)
100% assistance w/ premium, drug costs are reduced to $6.00 per prescription
No coverage gap (donut hole) or deductible
To qualify must have resources below $6,120 and income below $13,784 (135% FPL)
Income and resource limits are adjusted annually and are higher for couples and families
All people with Medicare & Medicaid or are a qualified Medicare beneficiary (receive QMB or SLMB) automatically qualify for full LIS
- Not eligible for SPAP
TA Conference Call
March 6, 2009

33. Partial Low Income Subsidy
25% to 100% assistance w/premium
Drug costs are reduced to 15% co-pays
No coverage gap or donut hole
Reduced drug deductible ($0 – $60)
To qualify resources below $10,210 and income below $15,315 (150% FPL) for a single person
Income and resource limits are adjusted annually and are higher for couples and families
- Eligible for SPAP
TA Conference Call
March 6, 2009

34. Helpful Websites Texas HIV Medication Program Website:
Low Income Subsidy Application or
Medicare, including Part D Plan finder and enrollment information
Ramsell Public Health Rx TX Pharmacy List (searchable by city, zip, or county)
TA Conference Call
March 6, 2009

35. Problem Areas on the THMP Application
Missing or inadequate verification of income
Unclear or incomplete representation of household situation, family members, and/or marital status
Invalid proof of Texas residency
Insurance/prescription coverage issues
Missing or incomplete Medical Certification Form (MCF)
TA Conference Call
March 6, 2009

36. What You Can Do To Help
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
TA Conference Call
March 6, 2009

37. What You Can Do To Help
Note that additional documentation from YOU (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, please answer each question completely
If either you or the client is uncertain about what the THMP requires in a given situation, please call and request clarification from our eligibility staff
TA Conference Call
March 6, 2009

38. THMP Contact Information
Phone: or
Website:
Staff
Extension
Area of Expertise
Becky
3006
Case Management, Eligibility, Medicare
Christine
3003
Recertification Lead
Juliet
3004
SPAP Lead
Jack
3012
Incarcerated Populations
Katherine
3008
SPAP
Kelley
3011
Order Processing Lead
Krystal
3009
Eligibility
Stacy
3007
TA Conference Call
March 6, 2009