ADAP & Coordination with Health Insurance in Massachusetts National ADAP Meeting Washington, DC August 23, 2012

1. ADAP & Coordination with Health Insurance in MassachusettsNational ADAP MeetingWashington, DCAugust 23, 2012 Annette Rockwell HDAP & Federal Grants Coordinator MDPH Office OF HIV/AIDS

2. HIV Drug Assistance Program (HDAP) • Consists of three program components: • Full-pay (reimbursement of pharmacies for drug costs) • Co-pay (covers portion of drug costs not covered by insurance). • CHII (Comprehensive Health Insurance Initiative) pays health insurance premiums, including private, COBRA, employment-based, MassHealth, and Commonwealth Care/Choice

3. Program Enrollment(as of May 31, 2012) • Total HDAP Enrollment: 6136 • Co-pay Enrollees: 5854 • CHII Enrollees: 1544 • Full Pay Enrollees: 282

4. Background • CHII was originally created in 1999 under the HRSA insurance continuation policy as a pilot program designed to assist HIV+ consumers in obtaining/maintaining health insurance coverage to cover drug treatment • The CHII program was voluntary until 2005, when, as a cost-savings measure, HDAP required all program enrollees to obtain health insurance coverage

5. CHII • CHII cannot make direct payments to clients • CHII does not cover: • Co-pays for office visits and outpatient services • Full cost of prescription drugs not covered by client’s insurance company • Inpatient services, ambulatory care or surgical procedures • Emergency room visits • Any deductibles, whether for medical visits or medications

6. Operations • To enroll in HDAP, applicants must submit a copy of a completed and submitted Medicaid application and private non-group insurance enrollment form • Exceptions are those who already have private insurance*, Medicaid, or the incarcerated

7. Operations Cont. Each HDAP client enrolled in CHII must: • Contact his/her health insurance company directly – HDAP staff are unable to contact the insurance company on behalf of a client due to insurance/HIPAA regulations • Recertify for HDAP/CHII every 6 months • Re-apply to Medicaid every 12 months • Forward recent health insurance bills to HDAP staff • Inform HDAP/CHII staff of any changes in his/her insurance premium (i.e. increase or decrease in premium amount)

8. Staff/Administrative • 1 FT CHII Coordinator • 1 PT CHII Coordinator/Data Manager • 1 FT Client Services/Pharmacy Relations Manager (with expertise in private and public insurance programs) • 5 FT HDAP Enrollment Specialists • Office support staff (including fiscal staff) These staff are cross-trained in HDAP and CHII-related functions

9. Successes • Cost savings associated with covering premiums as opposed to full cost of drugs • Clients’ access to comprehensive health care • Ability to navigate healthcare reform environment • Expertise gained in private and public insurance programs, where staff serve as resource to case managers/other providers

10. Enrollment & Expenditures by Year

11. Challenges • Increased demand on program staff & case managers to track client insurance status, premium bills, and provider networks • Dependence upon clients for information regarding changes to premiums/policies. Need to have very strict policies around premium refunds • Requests for client level Rx data from HRSA, etc. • Potential loss of revenue due to overdependence on partial pay rebates

12. Current Issues • Roll-out of requirement for social security numbers • Increased documentation requirements of residential addresses • Mandatory enrollment in 90-day mail order prescription access • Restricted open enrollment periods

13. Current Issues continued • Adjustment of private insurance market, including: • Decrease in available -0- deductible plans • Increase in costs of monthly premiums • Increase in costs of medical co-pays often utilized by HIV+ clients, i.e. hospital admissions; diagnostic tests (x-rays, CT scans); lab tests (CD4s, viral loads, resistance assays)

14. HDAP Contact Information State contact: • Annette Rockwell, DPH • Annette.rockwell@state.ma.us • 617-624-5762 Community Research Initiative of New England (CRI): • Website: www.crine.org • Telephone: 1-800-228-2714