The State of ADAPs

1. The State of ADAPs Britten Pund National Alliance of State & Territorial AIDS Directors August 20, 2012

2. Presentation Agenda • Emerging trends in ADAP • FY2011 Year in Review • Looking Ahead to FY2012 • ADAPs and Health Reform • Expanded Access to Care • Update on the ADAP Crisis • ADAP waiting lists • ADAP cost-containment • Questions and Answers

3. National Alliance of State & Territorial AIDS Directors (NASTAD) • Represents the nation’s chief health agency HIV/AIDS and viral hepatitis staff in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands • Provides technical assistance and other support to health department HIV/AIDS and viral hepatitis programs • Provides national leadership on HIV/AIDS and viral hepatitis policy and programs • Educates about and advocates for necessary federal funding

4. FY2011 Year in Review

5. The National ADAP Budget

6. ADAP Crisis • From FY2008 to FY2011, federal ADAP funding (including Part B ADAP Earmark, Part B ADAP Supplemental and ADAP Emergency Funding) increased 10%. • From FY2008 to FY2011, state contributions to ADAP increased 5%. • From FY2008 to FY2011, estimated drug rebates increased 83%.

7. ADAP Client Enrollment and Utilization • On average, 2,710 new clients were enrolled in ADAP each month in FY2010.

8. ADAP Client Demographics • Seventy-seven percent (78%) of ADAP clients are male. • Blacks and Hispanics comprise 59% (32% and 27% respectively) of ADAP clients served. • Half (50%) of ADAP clients are between the ages of 45 and 64. • Two-thirds (68%) of ADAP clients had income levels at or below 200% of the Federal Poverty Level (FPL).

9. ADAP Client Insurance Status • Twenty-one percent (21%) of ADAP clients had private insurance. • Six percent (6%) of ADAP clients were dual beneficiaries of both Medicaid and Medicare.

10. ADAP Insurance Coordination • In June 2011, 41,085 ADAP clients were served through insurance coordination. • Spending on insurance purchasing/continuation represented an estimated $551 per capita in June 2011, about 63% of the average monthly cost per client, based on drug expenditures, in that month ($869).

11. ADAP Waiting Lists and Other Unmet Need • Fourteen ADAPs reported an ADAP waiting list. • Since that time, some ADAPs have been able to reduce the overall number of individuals on their waiting list.  • As states remove individuals from their waiting lists, however, they continue to add new individuals to their program.  • Demand for ADAP has not dwindled. • ADAP waiting lists will likely plateau and grow again in the coming months. 

12. ADAP Waiting Lists and Other Unmet Need (continued) • ADAP waiting lists reached their highest point on September 1, 2011 at 9,298 individuals. • Twenty-three ADAPs have instituted or anticipate instituting other cost containment measures. • ADAPs continue to focus on establishing program efficiencies to create long-term program sustainabilityincluding: • Implementing effective cost-containment measures • Coordinating with other payers to ensure Ryan White Program payer of last resort requirements

13. FY2011 ADAP Emergency Funding • In September 2011, ADAPs received $40 million in emergency federal funding through the Ryan White Program to address ADAP waiting lists and other unmet ADAP needs. • Allocations were made to 30 states. • As a result of receipt of this funding, Alabama, Florida, Georgia, Idaho, Louisiana, Montana, North Carolina, Ohio, South Carolina, Utah, and Virginia were able to reduce the overall number of individuals on their waiting lists.

14. ADAP Crisis Task Force Negotiations • In December 2011, the ACTF announced that it reached enhanced agreements with six of the eight major antiretroviral manufacturers. • To date, these negotiations have resulted in an additional $142 million in savings to ADAPs from January 2012 through December 2013. • The cumulative savings of the Task Force agreements from 2003 to 2011 is estimated at more than $1.3 billion.

15. Outlook for the Future • Impact of additional federal funding and enhanced pharmaceutical company agreements. • Continuation of ADAP waiting lists and cost-containment • Need for additional state and federal funding for the program remains. • Collaboration from all stakeholders.

16. Looking Ahead to FY2012 and FY2013

17. FY2012 Funding Outlook • FY2012 began on April 1, 2012. • The Ryan White Program received an overall increase of $15 million, which is for ADAPs, for a program total of $900 million. • All other parts of the Ryan White Program were flat funded.

18. FY2012 ADAP Emergency Relief Funding • In July 2012, Secretary Sebelius, announced the release of $69 million in FY2012 emergency funding for ADAPs, including $35 million in new funding that President Obama announced on World AIDS Day (2011) and $40 million in continued emergency funding from FY2011.  • All applications were funded at the requested amount. • 22 states applied for continuation funding. • 15 states applied for the new funding from World’s AIDS Day.

19. FY2012 ADAP Emergency Relief Funding (continued) • The emergency funding has resulted in the reduction and elimination of some ADAP waiting lists and other cost-containment measures currently in place.  • ADAP enrollment is not static and other ADAPs continue to experience increased strain on their programs. • ADAPs will continue to require additional funding to keep new waiting lists from being implemented. 

20. FY2013 Funding Opportunities • The House Appropriations Subcommittee on Labor, Health and Human Services, and Education passed a FY2013 Labor-HHS-Education Appropriations mark that is $6.8 billion less than FY2012 funding levels.  • ADAP received an increase of $67 million dollars for a total of $1 billion, which matches President Obama’s request. 

21. The House Subcommittee allocated $2.3 billion for the Ryan White Program, which is a cut of $47 million from FY2012 funding levels.  • Due to the increase in ADAP and this overall cut to the total Ryan White Program, actual cuts to the Ryan White Program will amount to approximately $114 million.  • The Senate version of the bill provides a $30 million increase for ADAP. 

22. ADAPs and Health Reform

23. Health Reform Implementation • Portions of health reform that impact ADAPs include: • Medicaid eligibility expansion in 2014 and the expansion of the CMS Section 1115 Waiver; • Increase in the number of individuals covered by insurance plans, including health exchanges in 2014, and the current Pre-existing Condition Insurance Plans (PCIPs); • ADAPs’ Medicare Part D expenditures counting toward True Out Of Pocket (TrOOP) expenditures; • Narrowing and closing of the Medicare Part D “doughnut hole;” • An increase in the Medicaid rebate amount for purchased drugs; and • 340B pricing transparency.

24. Medicaid Eligibility Expansion • Section 1115 waivers allow states the option to cover eligible pre-disabled adults living with HIV. • States have significant flexibility in the design of the waivers under the guidance and application template issued by CMS in June 2011. • In 2014, PPACA will expand Medicaid to all non-Medicare eligible individuals under age 65 with incomes up to 133 percent FPL regardless of disability status.

25. Increased Insurance Coverage for People Living with HIV/AIDS • In 2014, the implementation of health exchanges will expand insurance coverage options for individuals with incomes between 133 and 400% FPL and for small group employers. • Health exchanges will reduce age, gender, pre-existing and high-cost health condition discrimination. • Tax credits, subsidies and out-of-pocket spending caps will be available to persons with income between 133 – 400 percent of FPL.

26. ADAP and Medicare Part D • Under PPACA, ADAP expenditures made on behalf of Medicare Part D participants now count towards true out of pocket expenses (TrOOP). • There is also a 50 percent discount on brand name drugs while in the donut hole and starting in 2013. • The ability to use ADAP expenditures as TrOOP will allow ADAP clients to pass through the donut hole and thus reach 100% catastrophic coverage (rather than continued reliance on ADAP).

27. Essential Health Benefits • The minimum benefit plan must statutorily include coverage of: • Ambulatory patient services • Emergency services • Hospitalization • Laboratory services • Maternity and newborn care • Mental health and substance use disorder services • Pediatric services • Prescription drugs • Preventative and wellness services • Rehabilitative and habilitative services and devices

28. Essential Health Benefits (continued) • Ensuring that a full range of prescriptions are available under the EHB package, instead of the currently proposed one medication per drug class, is important for ADAPs as PPACA is implemented. • The IOM recommendations stress affordability balanced with coverage and benefits and supports state-by-state decisions about essential benefits. • HHS is continuing its process of developing the EHB package – a proposed rule defining EHB is expected in Spring 2012.

29. Expanded Access to Care

30. Current Initiatives • Individual company PAPs • Welvista ADAP Waiting List Initiative • For clients on ADAP waiting lists only • Welvista must be licensed in each state in order to fulfill medications. • In conjunction with HHS, working to reach consensus on a common PAP application form that would collect all information necessary for all PAP forms. • Finalizing with hopes to utilize beginning September 1. • Hosted on NASTAD website; updates to occur by NASTAD.

31. Current Initiatives • In collaboration with the Clinton Health Access Initiative, and HarborPath, working on a common portal that would collect all necessary information for PAPs as well as provide prescription fulfillment. • Accept either company PAP forms or common form • Provide distribution of medications to client of all drugs via mail order • Currently in pilot phase in Texas, Virginia and Alabama • This effort will reduce burden for providers, case managers and PLWH.

32. ADAP Waiting Lists

33. NASTAD Process for Updates • Weekly updates • Monday-Wednesday – connect with ADAPs anticipating cost-containment and waiting lists to check on current program status • Thursday – e-mail requesting an updated number of individuals currently on each states ADAP waiting list, as of that date • Friday – compile information received and release ADAP waiting list update

34. NASTAD Reporting Process • ADAP waiting list update contains individuals who have: • Completed the application process for their state ADAP • Been deemed eligible for the ADAP in their state • Been placed on the states ADAP waiting list or unmet need list • Information captured each week at the same point in time (all states provide an updated number based on a date provided by NASTAD)

35. What the ADAP WatchDoes Not Capture • Individuals who have not presented to ADAP • Individuals who have presented but were not eligible • Individuals who may have been disenrolled • Individuals who have “fallen out” of ADAP (e.g., no longer taking drugs, moved, obtained other coverage) • Individuals who may be in one or more of the above categories and accessing a PAP for medications

36. ADAP Waiting List Update

37. ADAP Waiting Lists (694 individuals in 7 states), as of August 16, 2012

38. Waiting List Organization • Of the seven states with ADAP waiting lists, four ADAPs utilize a first-come, first-served model for prioritizing clients. • Of the seven states with ADAP waiting lists, three ADAPsutilize a medical criteria model for prioritizing clients.

39. Waiting List Demographics

40. Access to Medications • Case management services are being provided to ADAP waiting list clients through: • ADAP (1 ADAP) • Part B (7 ADAPs) • Contracted agencies (4 ADAPs) • Other agencies, including other Parts of Ryan White (2 ADAPs)

41. ADAP Cost-containment Measures

42. Factors Leading to Implementation of Cost-containment • As of August 2, 2012, ADAPs reported the following factors contributing to consideration or implementation of cost containment measures: • Higher demand for ADAP services as a result of increased unemployment (19 ADAPs) • Level federal funding awards (18 ADAPs) • Increased demand for ADAP services due to comprehensive HIV testing efforts (15 ADAPs) • Escalating drug costs (15 ADAPs) • Increased insurance/Medicare Part D wrap around costs (11 ADAPs)

43. ADAPs with Other Cost-containment Measures: Financial Eligibility,as of August 2, 2012

44. ADAPs with Cost-containment, as of August 2, 2012 Alabama: reduced formulary, capped enrollment Alaska: reduced formulary Arizona: reduced formulary Arkansas: reduced formulary Florida: reduced formulary, transitioned 5,403 clients to Welvista from February 15 to March 31, 2011 Georgia: reduced formulary, implemented medical criteria, participating in the Alternative Method Demonstration Project Illinois: reduced formulary, instituted monthly expenditure cap ($2,000 per client per month) Kentucky: reduced formulary Louisiana: discontinued reimbursement of laboratory assays Montana: reduced formulary

45. ADAPs with Cost-containment, as of August 2, 2012 (continued) Nebraska: reduced formulary North Carolina: reduced formulary North Dakota: capped enrollment, instituted annual expenditure cap Puerto Rico: reduced formulary South Dakota: annual expenditure cap ($10,500 per client per year) Tennessee: reduced formulary Utah: reduced formulary Virginia: reduced formulary, restricted eligibility criteria Washington: instituted client cost sharing, reduced formulary, only paying insurance premiums for clients currently on antiretrovirals Wyoming: capped enrollment, reduced formulary, instituted client cost sharing

46. ADAP Considering New/Additional Cost-containment Measures Maine: reduce formulary Wyoming: institute waiting list

47. Questions and Answers

48. Resources • For an electronic copy of the 2012 National ADAP Monitoring Project Annual Report, please visit www.NASTAD.org. • For more information about the National ADAP Monitoring Project or the ADAP Crisis, please contact Britten Pund at bpund@NASTAD.org.

49. Contact Information Britten Pund Senior Manager, Health Care Access NASTAD Phone: (202) 434.8044  bpund@NASTAD.org www.NASTAD.org