VDH Affordable Care Act Implementation Weekly Update
Pre-Existing Condition Insurance Plan (PCIP) Update
The Virginia Department of Health has received notification from PCIP representatives of issues with enrollment. These issues are affecting enrollees nationwide, including Virginia’s ADAP clients that are enrolled in the insurance program. Please direct clients to contact the Eligibility Hotline, 1-855-362-0658, if they have received letters or other communications from PCIP. If clients are encountering problems when using their PCIP cards when picking up medications or visiting a medical provider, please direct them to call the hotline, 1-855-362-0658.
Reasons for disenrollment from PCIP—
PCIP may disenroll clients from the insurance for various reasons. It is case-specific. Some of the reasons for disenrollments have included the following:
As VDH is made aware of PCIP disenrollment (by clients mainly), VDH is working to validate the reason for removal from the program. If VDH agrees with the disenrollment, the client, health department and provider should receive a follow-up letter from VDH. VDH works with PCIP to resolve any disenrollment VDH considers to be in error.
Additionally, Virginia ADAP has established a confidential toll-free fax line 1-877-837-2853 for use by consumers, providers and Local Health Departments. Documents sent to the existing fax number of 804-864-8050 will still be received.
ADAP Data Dashboards-April 22, 2013:
The ADAP Data Dashboards with client characteristics and program data for 2012 as well as enrollment data by program through 4/4/2013 by region and Part A area are posted here http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/HCS/. Quarterly updates of these updates will be posted in the future.
Effective 10/01/2012:
ADAP Central Office will begin conducting 6 month recertification during client’s birth month and every 6 months thereafter. VCU-HS will conduct recertification according to this model as well.
Effective 8/30/2012:
The ADAP Wait List has been eliminated. All financially eligible clients regardless of CD4 count may enroll into ADAP.
Effective 7/16/2012:
All individuals on the waitlist with a CD4 count above 500 will be enrolled into ADAP. New clients with a CD4 count above 500 will be temporarily placed on the wait list until all wait listed clients are enrolled to ADAP. All new clients, regardless of CD4 count, will be enrolled directly to ADAP by September 10. Please contact ADAP toll free at (855) 362-0658 for information about medication access resources for new clients.
Expansion of ADAP Enrollment Criteria Talking Points
Effective 4/2/2012:
All individuals on the waitlist with a CD4 count at or below 500 and those newly presenting to Virginia ADAP with a CD4 at or below 500 may enroll directly into ADAP. In December 2011, VDH began enrolling individuals from the waitlist with CD4 counts between 351 and 500 by the date they were put on the waitlist.
As of April 2, 2012 ADAP enrollment criteria includes the following:
Update to Policy on ADAP-Eligible Clients with Medicare Part D - March 29, 2012
BACKGROUND:
Serving clients through the Medicare Part D Patient Assistant Program (MPAP) results in substantial cost-savings to the AIDS Drug Assistant Program (ADAP). Because there is a limit on out of pocket costs for clients (which MPAP pays on their behalf), approximately 3 clients are able to be served for every 1 client served through traditional ADAP. This allows ADAP to serve more clients who have no other coverage for medications.
Medicare eligibility status for ADAP-eligible clients is assessed at initial eligibility determination and every six months. ADAP-eligible clients who are also eligible for Medicare are instructed to enroll in a Medicare Part D plan. ADAP clients with household incomes less than 150% of the Federal Poverty level (FPL) must apply for the low-income subsidy (LIS) or “extra-help” component of the Part D benefit to assist with out-of-pocket costs. Medications can be accessed through the MPAP under ADAP until LIS eligibility determination is received. Clients who qualify for the full LIS are not eligible for MPAP/ADAP assistance.
POLICY:
DOCUMENTATION:
Clients and their HIV providers will be notified by letter if disenrolled from ADAP due to declining MPAP services or declining to apply for Medicare Part D. A copy of the letter will be maintained in the closed client file.
EXCEPTIONS: NONE
As of December 22, 2011, ADAP enrollment criteria includes the following:
Applicants who do not meet one of these criteria will be put on a wait list.
Update to Dispensing Policy - Dec. 17, 2010
Effective immediately, all ADAP prescriptions will be dispensed for a supply not to exceed 30 days. The LHS-181 will still be completed by the local ADAP coordinator or designated staff but cannot exceed a 30-day supply. Please keep in mind that antiretroviral prescriptions will have a refill maximum of six months and prescriptions for greater than 30 days will not be dispensed.
This change is necessary due to the current ADAP funding shortfall which has necessitated the need to transition some clients to pharmaceutical manufacturers'' patient assistance programs. Limiting the supply to 30 days provides tighter inventory control, reduced medication wastage if regimens change, and ensures clients are receiving equitable access to medications. Historically, about 20% of ADAP prescriptions were for a 90-day supply, but we have seen a recent increase in 90-day prescriptions. If you have any questions about this change, please contact Pharmacy Services at 804 786-4326.
Program Changes Effective November 2010
More Information About These Changes
Library of Policy Updates & Program Memos
Changes to Eligibility Criteria & Formulary - Power Point Summary (Nov. 2010)
New and Returning ADAP Clients - Patient Services, Inc. to Determine Eligibility (Nov. 2010)
Dispensing Medications at the Time of Disenrollment (April 2010)
Notification: State Pharmaceutical Assistance Co-Pay Assistance Wait List (February 2010)
ADAP Data Reports
ADAP Evacuee Policies and Application
In the event a disaster necessitates that Virginia assists evacuees from other states, please follow and utilize the following documents: (1) Virginia’s ADAP Evacuee Policy and (2) the Virginia ADAP Emergency Relief Application.
Questions or comments?
Medication Eligibility Hotline 1-855-362-0658