Health and Wellness for all Arizonans azdhs.gov 2015 ADAP Overview Lisa Fuentes Ryan White Part B Program Manager Jimmy Borders, ADAP Operations Manager.

Health and Wellness for all Arizonansazdhs.gov

2015 ADAP Overview

Lisa FuentesRyan White Part B Program Manager

Jimmy Borders,ADAP Operations Manager

Health and Wellness for all Arizonansazdhs.gov

Ryan White Part B/ADAP Team

Lisa Fuentes HIV/AIDS Care Services Manager

Lora AndrikopoulosRW Fiscal Monitor

Jimmy Borders ADAP Operations Manager John Lick

RW Quality Manager

David BalkcomRW Data Manager

VacantReengagement in Care Specialist

Laura KrogerRetention Coordinator

LisaMarie Bates

ADAP Admin Assistant

Louisa VelaADAP Eligibility Coordinator

Claudia CardielADAP Eligibility Coordinator

Jessica AlvidrezADAP Eligibility Coordinator

Lynelle Dorsey-BrooksRW Data Manager

Greg RomeroADAP Eligibility Coordinator

Megan SwansonHIV Surveillance Epidemiologist

Health and Wellness for all Arizonansazdhs.gov

ADHS RWPB & ADAP• The RWPB Care & Services Program Manager, Lisa Fuentes,

is responsible for the oversight and management of the RWPB Program and is the direct supervisor of the ADAP Program Manager.

• The ADAP Program Manager, Jimmy Borders, is responsible for the day to day operations of the ADAP Program which includes ADAP Assist, MTM, MBM, PBM and 340B pharmacy.

Health and Wellness for all Arizonansazdhs.gov

ADAP Eligibility • Client must be diagnosed as HIV-positive • Client must be a resident of Arizona with acceptable documentation

provided. • Client’s Modified Adjusted Gross Income (MAGI) cannot exceed 400%

of federal poverty level (FPL) with acceptable documentation provided. – For example, in 2015 a client cannot have an annual income of more than

$47,080 for a household size of one.• Client cannot be eligible for AHCCCS (Arizona’s Medicaid agency)

Acute care coverage only. – To ensure that Ryan White Part B is the payer of last resort for ADAP, all

individuals applying, not deemed FFM eligible, will need to screen for AHCCCS eligibility and submit an AHCCCS denial, if applicable.

Health and Wellness for all Arizonansazdhs.gov

ADAP Enrollment Process • For initial application and/or birthday renewals, the client and/or Case

Manager must submit the most current version of the ADAP application found at – English version at

http://www.azdhs.gov/phs/hiv/documents/adap/ADAP-application-english.pdf

– Spanish version at http://www.azdhs.gov/phs/hiv/documents/adap/adap-application-es.pdf

• For ½ birthday renewals, the client and/or Case Manager must submit the ½ birthday renewal notice along with Medical Provider Page (MPP) found in CAREWare under the client’s forms.

Health and Wellness for all Arizonansazdhs.gov

ADAP

• The Arizona Department of Health Services (ADHS) is responsible for the administration of ADAP for the State of Arizona.

• ADAP (a.k.a. “Straight ADAP”) provides access to 340B medications used to treat HIV and prevent the onset of related opportunistic infections to low-income individuals who have limited or no coverage from private insurance or Medicaid.

Health and Wellness for all Arizonansazdhs.gov

ADAP 340B Pharmacy

• ADAP 340B medications are dispensed through Avella Specialty Pharmacy in Central Phoenix. – The headquarters of Avella Specialty Pharmacy is in

Phoenix.

• Medication can be picked up in person or shipped directly to ADAP-eligible clients' homes.

• There is also the option to pick up medications shipped to any other Avella Specialty Pharmacy locations throughout Arizona.

Health and Wellness for all Arizonansazdhs.gov

ADAP Assist• ADAP Assist is prescription (Rx) co-pay assistance for ADAP clients who have

private insurance including those from the Federally Facilitated Marketplace (FFM), Medicare, or employer-sponsored.

• Co-pay assistance is provided through our prescription benefits manager (PBM) Ramsell after the client’s primary insurance has paid their share of the Rx.

• When an ADAP application is received for a client who is insured or eligible for other insurance including the FFM, ADAP asks for premium and formulary information. ADAP needs this information to determine whether the coverage is adequate. – Adequate means the insurance is affordable and meets/exceeds the essential health benefits

(EHBs) as demonstrated through all FFM health insurance.

• Clients desiring to opt-out of their employer-sponsored private insurance in lieu of enrollment into the FFM, can only do so: – When/if the employer-sponsored private insurance premium annual cost exceeds 9.56% of the

annual household income for the enrollee – When/if the employer-sponsored private insurance EHBs are deemed inadequate

• Medicare eligible clients DO NOT have the ability to opt-out

Health and Wellness for all Arizonansazdhs.gov

RamsellPrescription Benefit Manager (PBM)

• ADAP Assist clients may choose to use Avella Specialty Pharmacy each time they need a refill.

• Clients may also contact our PBM, Ramsell, to find other pharmacies that can be used in conjunction with their primary insurance.– Client is responsible for ensuring his or her pharmacy accepts both their

primary insurance and Ramsell ADAP Assist coverage • Ramsell will send new ADAP Assist clients their ID cards upon

enrollment. Replacement ID cards can only be issued by ADAP . Clients can contact ADAP at 602-364-3610 to request a replacement ID card.

• Ramsell can be reached at 888-311-7632 or at http://www.ramsellcorp.com/individuals/az.aspx

Health and Wellness for all Arizonansazdhs.gov

Medications Covered and/or Excluded

•ADAP Assist covers medication co-pays paid for by the primary insurance company with the following exceptions:

• Certain Over The Counter (OTC) drugs • Erectile Dysfunction (ED) • Fertility Agents• Contraceptives• Skin Coloring Agents • Retinoids (Retin-A, Differin, Accutane, Others)• Hydroquinone (Eldoquin, Others)• Prescriptions used for cosmetic purposes• Certain ancillary supplies

Health and Wellness for all Arizonansazdhs.gov

Prior Authorization

• ADAP formulary committee rules mandate the following medications require prior authorization from ADHS before copays will be covered:

• Egrifta (tesamorelin) • Serostim • Fuzeon (ENF, Enfuvirtide)* • Valcyte (Valganciclovir)*

• Medication specific PA forms available at http://www.azdhs.gov/phs/hiv/adap/assist.htm

* PA requirement up for review at April 2015 ADAP Medical Advisory Committee meeting

Health and Wellness for all Arizonansazdhs.gov

FFM Guidelines for Statewide Clients• Silver plans only• APTC must be determined and paid up front• In-network cost only; no out-of-network costs covered• Premium Assistance up to $350 per month

Deductible/Medical Copay Assistance up to $3000 per year– Must obtain medication through participating pharmacy in

Ramsell Network– Unable to pay for ER or inpatient services– Date of Service must be within current grant year (April 1-March

31)– Must be HIV-related

Health and Wellness for all Arizonansazdhs.gov

FFM Guidelines for Statewide Clients (Cont.)

• Clients who are not ADAP eligible are responsible for the payment of their own premiums.

• Any premiums exceeding $350.00 per month will result in a reduction of medical deductible/copay assistance – Example: Client premium $375 per month. Part B allows

$350 per month. Client difference is $25. $25 x 12 months = $300. Part B allows up to $3000 per year for medical copay/deductibles. $3000 - $300 client responsibility = $2700 balance for client to use on copayments and deductibles.

Health and Wellness for all Arizonansazdhs.gov

RWPB Contractor Assistance for Clients

• Contractors may assist Medicare, private and employer based insured clients with their medical copayments and deductibles up to $3,000 per year.– Must be paid using Health Insurance Premium and Cost Sharing

Assistance (HIPCSA) funding– Must ensure date of service within the current grant year. (April

1 through March 31) • Contractors may assist Medicare clients with Medicare

Supplemental insurance premiums.• Contractors may ONLY use HIPCSA funds to pay medication

copays for clients enrolled in AHCCCS with nominal copays or clients who are not ADAP eligible.

Health and Wellness for all Arizonansazdhs.gov

Southern Arizona AIDS Foundation (SAAF) Medical Benefits Manager (MBM)

The role of the Ryan White Part B Medical Benefits Manager (MBM), Southern Arizona AIDS Foundation, (SAAF), is:• To facilitate the payment of FFM premiums for ADAP eligible clients

statewide, after they: – Ensure the APTC has been applied in advance prior to paying FFM premiums

for “silver level” health plans – Ensure client is ADAP eligible prior to paying FFM premium

• To facilitate the payments of medical copayments and deductibles for RWPB FFM clients only, after they:– Ensure date of service on invoice is within the current grant year– Ensure the service is allowable under Ryan White

Health and Wellness for all Arizonansazdhs.gov

HRSA PCN #14-01 –APTC Overpayment • In response to HRSA PCN #14-01 • ADAP developed and implemented an affidavit

for all FFM clients that explained the procedure for identification and submission of APTC overpayment – Mandatory submission of Federal Income

Tax, including Form 8962, for all FFM enrollees beginning April 15, 2015 as proof of income (POI)

– Clients that did not file must submit an approved IRS extension request

– Clients exempt from filing must submit an approved IRS exemption notice

– ADAP/FFM enrollee placed on PCD until April 15, 2015 pending ADAP receipt of the affidavit or IRS extension request

– Potential for loss of ADAP coverage – Affidavit is part of all FFM enrollees initial

or birthday renewal yearly

Division of Public Health Services Office of the Assistant Director

150 N. 18th Avenue, Suite 110 DOUGLAS A. DUCEY, GOVERNOR

Phoenix, Arizona 85007 WILL HUMBLE, DIRECTOR

(602) 364-3610 (602) 364-3263 FAX www.azdhs.gov

AFFIDAVIT OF UNDERSTANDING FOR INDIVIDUALS ENROLLED IN A FEDERALLY FACILITATED MARKETPLACE (FFM) HEALTH PLAN

BEFORE INITIALING AND SIGNING, READ THIS DOCUMENT CAREFULLY AND BE SURE YOU UNDERSTAND.

If you have any questions or concerns, please call ADAP at 602-364-3610 or 800-334-1540 or your case manager. As an Arizona ADAP client receiving premium assistance with my enrollment in a Federally Facilitated Marketplace (FFM) health plan, I understand I am required to give to the Arizona ADAP any excess refund received after I file my Federal Income Tax with the Internal Revenue Service (IRS) for the previous income tax reporting year. The amount that I owe the Arizona ADAP will be found on line 26 of Form 8962 which is filed with my Federal Income Tax to the Internal Revenue Service (IRS). I understand the amount subject to return is due to the under-reporting of my annual income to the marketplace. In addition, I understand the amount due to Arizona ADAP may be less than the entire Federal Income Tax IRS return I receive or may be in addition to other amount(s) that I owe to the IRS. I also understand that if I do not submit the applicable portion of the Federal Income Tax IRS return issued in a timely manner, I may lose my Arizona ADAP coverage. Arizona ADAP coverage may also be discontinued until the over-payment amount indicated on line 26 of Form 8962 has been received by the Arizona ADAP. Please remit the applicable over-payment portion shown on line 26 of Form 8962 via check or money order “payable to ADHS” to:

ADAP Operations Manager 1740 W. Adams #010 Phoenix, Az. 85007

Initial: _________________

I have completely read this affidavit of understanding. By signing, I agree to the facts and conditions contained herein.

Applicant signature: __________________________________

Case Manager or ADAP witness signature: _________________________________

Date signed: __________________________________

References:

Federal Marketplace and the Internal Revenue Service (IRS) information can be found at http://www.irs.gov/Affordable-Care-Act/Affordable-Care-Act-Tax-Provisions

Health and Wellness for all Arizonansazdhs.gov

AHCCCS Nominal Copay Assistance • The Ryan White Part B Program now assists all Ryan White eligible/active clients with their nominal AHCCCS

medication copays effective May 1, 2014. • Thanks to an agreement with Avella Specialty Pharmacy, all eligible/active clients who choose to fill their prescriptions

with Avella will no longer have the nominal AHCCCS medication copayment.• If your clients are interested; 1) please make sure they are showing eligible/active with Ryan White; 2) have the client

contact an Avella Specialty Pharmacy at one of the locations listed below; 3) and let the pharmacy know s/he wants to participate in this program:

Phoenix (Central Ave.) 1101 N. Central Ave. Ste. 102 Phoenix, AZ 85004 Ph: (602) 257-1133 Fax: (602) 257-1134

Tucson National Distribution Facility4512 E. Camp Lowell Dr. Toll-free phone: (877) 546-5779Tucson, AZ 85712 Toll-free fax: (877) 546-5780Ph: (520) 918-0044Fax: (520) 918-0043

** The Ryan White Part B Program has sent a letter to all clients in the statewide CAREWare system that we show have transitioned to AHCCCS informing them of this available program.

Health and Wellness for all Arizonansazdhs.gov

Questions??