Transcript AA_200903_THMP - Texas Department of State Health Services

Texas HIV Medication Program
Becky Ruiz, BSW
Katherine Wells, MPH
Presentation Outline
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HIV Medication Assistance in Texas
Overview of the Texas HIV Medication
Program (THMP)
Application Process
Discussion of problem areas on the THMP
application
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March 6, 2009
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Help with Medications in Texas
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Private Insurance
Patient Assistance Programs
Texas High Risk Pool
City and County Assistance Programs
Medicare
Medicaid
Texas HIV Medication Program
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AIDS Drug Assistance Program (ADAP)
State Pharmacy Assistance Program (SPAP)
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Patient Assistance Programs
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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: www.needymeds.com;
www.RxAssist.org
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March 6, 2009
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Local Drug Assistance
Programs
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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)
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Medicare
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Federal program that provides medical care for the
elderly and disabled
Medicare includes 4 different programs
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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: www.medicare.gov or 1-800633-4227
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Medicaid
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A state program that provides medical assistance to
low income individuals
Medicaid can provide:
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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 2-1-1 or 1-877-541-7905
or online at www.YourTexasBenefits.com
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Texas HIV Medication Program
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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
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Texas HIV Medication Program
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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
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AIDS Drug Assistance Program (ADAP)
State Pharmacy Assistance Program (SPAP)
4th Largest ADAP (NY, CA, FL)
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Current Enrollment
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11,651 currently enrolled clients
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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
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THMP Eligibility
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Texas resident
HIV-positive
Uninsured or underinsured for prescription drugs
Low income – Adjusted gross income less than
200% of the Federal Poverty Level (2009)
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$21,660/year for a single person
$ 7,480/year for each + family member
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Application Process
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Fill out the THMP application
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Application and Instructions can be downloaded
from the web: www.dshs.state.tx.us/hivstd/meds
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
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Application Process
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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)
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Expediting Applications
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In some instances applications can be expedited.
This means the application can be faxed instead of
mailed.
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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.
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Texas HIV Medication Program
AIDS Drug
Assistance Program
(ADAP)
Clients not eligible
for Medicare
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Texas HIV
State Pharmacy
Assistance Program
(SPAP)
Clients eligible
for Medicare
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Texas ADAP
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Funded by Ryan White and State General
Revenue
Provides ADAP formulary medications to
eligible individuals
Medications are distributed through a network
of pharmacies
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Texas ADAP Formulary
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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)
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Accessing Medications
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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:
www.dshs.state.tx.us/hivstd/meds/pdf/pharlist.pdf
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Approved on ADAP –
What happens now?
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The ADAP enrollee receives an approval letter that
includes
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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
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What happens now?
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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:
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Client not approved for the Medication
Client has open Medicaid slots
Client is on HOLD
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What happens now?
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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
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Texas HIV SPAP
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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
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Texas HIV SPAP Benefit
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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:
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Deductible
Co-payments
Medications during the coverage gap
Co-payments/coinsurance after reaching catastrophic
coverage
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Texas HIV SPAP Benefit
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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
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Texas HIV SPAP Benefit
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Annual allowable amount per SPAP enrollee for
2009: $10,995
High End Risk Example:
Retail
Cost
Month 1
$10,000
Month 2
$10,000
Out-of-Pocket
Deductible, Initial Coverage,
$4,522 Coverage Gap, Catastrophic
$500 Catastrophic Coverage
Month 3 -12
$100,000
$5,000
Total
$120,000
$10,022
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Part D Coverage Period
Catastrophic Coverage
(10 months)
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Medicare Part D Plan
Enrollment
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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
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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:
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Calling the plan directly
Calling 1-800-MEDICARE (633-4227)
Online at www.Medicare.gov
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Late Enrollment Penalty
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Medicare will assess a late enrollment penalty if a
person with Medicare
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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
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Example
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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
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How to Enroll in the SPAP
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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:
www.dshs.state.tx.us/hivstd/meds
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Accessing Medications
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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-ofpocket costs will be billed to SPAP as the secondary
payer
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Low Income Subsidy/Extra Help
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Applications are processed by Social Security
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apply online at www.ssa.gov, fill out a paper
application or call 1-800-772-1213
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
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Full Low Income Subsidy (LIS)
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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
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Partial Low Income Subsidy
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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
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Helpful Websites
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Texas HIV Medication Program Website:
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Low Income Subsidy Application
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www.ssa.gov or 1-800-772-1213
Medicare, including Part D Plan finder and
enrollment information
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www.dshs.state.tx.us/hivstd/meds
www.medicare.gov
Ramsell Public Health Rx TX Pharmacy List
(searchable by city, zip, or county)
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www.publichealthrx.com/tx_spap.html
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Problem Areas
on the THMP Application
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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)
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What You Can Do To Help
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The client is encouraged to explain in writing as
much as possible to clarify any part of the
application pertaining to them, especially:
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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
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What You Can Do To Help
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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 1800-255-1090 and request clarification from our
eligibility staff
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THMP Contact Information
Phone: 1-800-255-1090 or 512-533-3000
Website: www.dshs.state.tx.us/hivstd/meds
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
Eligibility
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