Quick review - What is ADAP?

2. Quick review - What is ADAP? • ADAP stands for AIDS Drug Assistance Program. • ADAP is a federal Ryan White funding source awarded by the Health Resources and Services Administration (HRSA). • ADAP funds can be used to provide medication and insurance services to eligible individuals with a positive HIV diagnosis. • The State STD/HIV Program (SHP) gets ADAP funding from HRSA. • SHP uses ADAP funding to support medication and insurance services through our programs called L-DAP and HIP. 

3. NOW • L-DAP - LOUISIANA DRUG ASSISTANCE PROGRAM • covers drug costs for uninsured individuals only. Often referred to as Traditional ADAP. • HIP -HEALTH INSURANCE PROGRAM • covers insurance plan premiums as well as medical (non-drug) and drug copays, coinsurances, & deductibles (known as cost shares) for insured individuals. • LA HAP processes L-DAP enrollment through SHP. • HIP processes HIP enrollment through HAART.

4. NOW LA HAP Manage LDAP & HIP Contracts Process LDAP Enrollment • Louisiana Health Insurance Program (HIP) Services • & Enrollment • Insured plan premium • Drug cost share assistance • Medical cost share assistance • Participating HIP Pharmacies • Louisiana Drug Assistance Program • (LDAP) • Drug costs for uninsured clients. • Previously through 10 LSU Medical Center Outpatient Pharmacies. • Currently central distribution through OPH Pharmacy.

5. Coming soon… To allow for better coordination of our programs you'll see a few more changes with LDAP and HIP. • L-DAP - LOUISIANA DRUG ASSISTANCE PROGRAM • Will continue to cover drug costs for uninsured individuals and will soon cover drug copays, coinsurances, & deductibles (known as cost shares) for insured individuals. • HIP -HEALTH INSURANCE PROGRAM • Will continue to cover insurance plan premiums as well as medical (non-drug) cost shares for insured individuals. • LA HAP will soon process both L-DAP and HIP enrollment through a single application.

6. Coming soon… LA HAP Manage L-DAP & HIP Contracts Process L-DAP & HIP Enrollment • Louisiana Health Insurance Program (HIP) Services • Insured plan premium • Medical cost share assistance Coordinated through contract agency (TBA). • Louisiana Drug Assistance Program (L-DAP) • Drug costs for uninsured clients • Drug cost shares for insured clients Managed through contract PBM (TBA).

7. Okay, but how do I apply for these programs NOW? • If you are uninsured and need assistance paying for your HIV medications, apply to LDAP using the new LA HAP application that was released in December 2013. • LA HAP application is available on lahap.org • If you have any type of health insurance and need assistance with your premiums* and cost shares, apply to HIP using the HIP application • HIP application is available on haartinc.org under “services”  “HIP” *If you need assistance paying for premiums, please double check that the insurance plan you sign up with will accept premium payments from HIP.

8. Common mistakes when completing a LA HAP Application, Page 1 • BOTH Race and Ethnicity must be marked. For the purposes of this application, Hispanic is not considered a race. • The pregnancy section MUST be filled out. Even if male, the “not applicable” box can be checked.

9. Common mistakes when completing a LA HAP Application, Page 2 • Carefully consider the definition of “household” for the purposes of this application. People in the same household MUST be related by blood, state legal marriage and/or state legal adoption. • Live-in boyfriends/girlfriends and/or same sex partners* are NOT considered part of the same household and should not be included in this section or included as contributing to household income. • Common law marriage is not recognized in Louisiana. • Louisiana does not recognize people as being “separated” in a marriage until they are legally divorced. However, LA HAP recognizes it is likely that if someone has been separated from his/her spouse for greater than six months, it may difficult for that person to obtain income documentation from his/her estranged spouse. Therefore, income eligibility can be determined on the separated individual’s income alone. Contact LA HAP at 504-568-7474 for more information. *For the purposes of this application, only state legal marriages are considered. Therefore, even if a couple has a federally recognized marriage or was married in another state, they are not considered married unless the state of Louisiana recognizes their marriage.

10. Common mistakes when completing a LA HAP Application, page 2 • The client needs to provide proof of income for anyone listed in the “household” section that is 18 years of age or older and receives any source of income. • If the client’s household member(s) does not have any source of income, then the client needs to note that somewhere on the application. They can make a note in the household section, cover letter, in the comments section on page 3, etc.

11. Common mistakes when completing a LA HAP Application, Page 3 • All questions in this section need to be answered including the 4 subset questions. • If the client does not have Medicare, answer “no” to all the Medicare Part D and LIS questions. • If the client has SSDI, an SSDI start date is required.

12. Common mistakes when completing a LA HAP Application, Page 4 • If you are a case manager/social worker/advocate helping a client complete this application, please remember to sign your name above “person obtaining consent” and date it. • Also print your name, agency, and phone number in the appropriate boxes so that LA HAP can help your agency track which referrals you have submitted.

13. Common mistakes when completing a LA HAP Application, Page 5 If the client checks that they have been diagnosed with CDC-defined AIDS, then they need to put their HIV diagnosis date in addition to their AIDS diagnosis date, even if they are on the same date.

14. Common mistakes when completing a LA HAP Application, Page 5 • Lab values must be included and must have been drawn within 6 months of the day the application is successfully submitted to LA HAP. • The ARV regimen at time of labs needs to be filled out. • To be approved for LA HAP, the client must be on or prescribed ARV and/or OI medications on the LDAP formulary. If the client is not currently taking medications, include the ARV and/or OI meds they will be prescribed. • List all other medications that the client is taking.

15. Common mistakes – LA HAP Documentation • Must provide proof of residency that is dated within 6 months of the day the application is successfully submitted to LA HAP. • If the address on the proof of residency does not match the address on the LA HAP application, make a note of why that is the case and which address is correct. • Acceptable forms of proof of residency include: • A copy of a valid, in-date (non-expired) LA driver’s license or LA identification card • A copy of a current check stub listing applicant’s name and current address • A copy of a current lease or mortgage in applicant’s name • A copy of any current utility bill in the applicant’s name • A copy of a legal affidavit stating applicant’s current address • A copy of a legal document listing applicant’s name and current address (i.e. Federal/State program award • Letter (SSI, SSDI, Food Stamps, etc.), medical bill, a bank statement, etc).

16. Common mistakes – LA HAP Documentation • Must provide proof of income for the individual applying for LA HAP as well as all household member’s income. • Acceptable forms of proof of income include: • A copy of a current tax year document (i.e. Federal/State Tax Return, W2, 1099, etc.) • A copy of the most recent pay stub indicating the time period covered by the check (i.e. weekly, bi-weekly, monthly) • A statement from the unemployment office verifying no record of employment • A copy of current award letter for SSI, SSDI, SNAP, VA, Workers Compensation, unemployment, pension or other benefit • A copy of current monthly benefit check from SSI, SSDI, VA, Workers Compensation, unemployment, pension, or other benefit • A bank statement showing a gross monthly direct deposit of current SSI, SSDI, SNAP, VA, Workers Compensation, pension, unemployment, or other benefit • A legal document showing the current amount of child support or alimony received in a routine basis • A current legal affidavit declaring the amount of monthly cash income or a client’s lack of income • A current Certification of No Income

17. Tips for filling out a LA HAP Application • Answer all of the questions on the application and send all required documents. • If you are sending a follow up, include a coversheet stating that it is a follow up. Unclear paperwork is filtered and set aside to be researched. • Use black ink. Colored ink does not fax well and results in unreadable information that delays review. • Write the client name on the top of each page of the application. • Include a coversheet with the total number of pages you are sending. • REVIEW THE APPLICATION WITH YOUR CLIENT BEFORE FAXING • How do I know if LA HAP got everything?Turn on your fax machine’s transmittal notice and only fax one application at a time. This will give you a print out of how many pages were sent and if the transmission was successful.

18. Common mistakes when completing a HIP Application • The boxes next to the highlighted items are often not checked. • The agency information is often not filled out

19. Common mistakes when completing a HIP Application The information concerning pregnancy is often left blank or partially blank. Make sure the client answers every question in this section.

20. Common mistakes when completing a HIP Application • Make sure your client enters the entire household income for each section. For example, if your client works and his/her spouse receives unemployment, then the client’s salary/wages should be included in addition to the spouse’s unemployment amount. • Proof MUST be provided for all sources of income. In the above example, proof of the client’s salary/wages in addition to proof of the spouse’s unemployment amount must be sent in with the HIP application.

21. Common mistakes – HIP’s forms • This form is to be used if a client has a group health insurance policy, such as an insurance policy through an employer. • The client needs to take this form to his/her employer’s HR department to have them complete it.

22. Common mistakes – HIP’s forms • The client needs to have his/her physician fill out and sign this form. • This form is often referred to by HIP staff as an APS (attending physician’s statement).

23. Common mistakes - HIP’s12 month recertification vs. 6 month verification Clients must complete a 12 month recertification for HIP annually on their month of birth. This requires them to fill out an entire HIP application and check the box on the HIP application. Clients must also complete a 6 month verification on the month that falls 6 months after their birth month. This is a one page document that can be found by clicking the “6 month verification” link at haartinc.org

24. Income Eligibility for LA HAP & HIP • The new 2014 FPL guidelines have been released and are what LA HAP and HIP are currently using to determine income eligibility for their services.

25. We need your feedback! • Each one of us attempted to fill out LA HAP and HIP applications and provided feedback to the LA HAP staff on what could be improved. • Would you prefer to incorporate feedback and changes to these applications now? Meaning LA HAP staff would edit both applications and provide you with a new LA HAP application and a new HIP application. OR • Wait until the program transitions to a combined HIP/LDAP application and then incorporate all of the feedback and changes then? (hopefully within the next 6 months)

26. Third Party Payment Issue • In Louisiana, ADAP funds (which are used to provide medication and insurance services to individuals with an HIV positive diagnosis) contract through HIP to assist clients with paying for their health insurance premiums and cost shares (copay, coinsurance, deductible). • Recently, some insurance companies in Louisiana have decided NOT to accept premium payments from HIP, however, HIP can still assist with cost shares. • As of 2/12/14, • BCBS of Louisiana (which includes HMO of Louisiana) and Louisiana Health Cooperative (LAHC) have provided written confirmation that they will not accept HIP premium payments.  • SHP has contacted the compliance officers at Vantage and our request for information has been forwarded to their legal department for follow up.   • Humana has verbally stated they expect to continue accepting HIP payments. A final decision and written confirmation should be provided by the end of the week. • So far no off Marketplace insurer except BCBS of LA have made statements regarding a change of policy in acceptance of HIP payments. • We will continue to update our information as changes are frequently made concerning third party payment policies.

27. Client Options If a health insurance plan that does not accept premium payments from HIP is the best option for health care and the client is able, they can choose to pay their premiums themselves and receive copayment and deductible assistance from HIP for cost shares that do not require point-of-service (POS) payment. Pay premiumthemselves …but the insurance plan has already cashed the premium check from HIP, then the client needs to contact the insurance company and terminate their insurance coverage with that plan. Please contact HIP at 225-927-1269 to find out whether a client’s HIP check has been cashed by the insurance company Client can switch to a Marketplace plan or a plan off of the Marketplacewith an insurer that will accept 3rd party premium payments. If a client is currently enrolled in a health insurance plan that will no longer accept premium payments from HIP… • Switch plans …and the insurance company has not cashed HIP’s premium check yet, then the client does not have to do anything and the insurance coverage will terminate automatically. Be uninsured Client can choose to become / remain uninsured with the understanding of the consequencesof being uninsured, suchas: -Penaltyfor not obtaininghealth insurance* -Being reliant on LDAP and the public health medical care system *The penalty in 2014 is calculated in 1 of 2 ways. You’ll pay whichever of these amounts is higher: 1% of your yearly household income. The maximum penalty is the national average yearly premium for a bronze plan. $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285. The fee increases every year. In 2015, it’s 2% of income or $325 per person. In 2016, and later years it’s 2.5% of income or $695 per person. After that, it is adjusted for inflation. If you would have qualified for expanded Medicaid, you’re exempt from the law’s requirements to buy coverage because Louisiana declined expansion. Therefore, you won’t pay a penalty this year for not buying it. More information on penalty exemptions are available at www.healthcare.gov/exemptions

28. What can you and your clients do to advocate for increased healthcare options? • Learn and educate other about the benefits of Medicaid Expansion for Louisiana. • VOTE and help you clients register to vote - www.geauxvote.com • Contact your representatives - www.house.gov/representatives/find/ • Contact LAAN and CHANGE • Talk to the plans that will accept HIP premium payments about expanding their prescription drug formularies to include medications that benefit people living with HIV/AIDS. (NASTAD Sample Letter) • Learn the process for requesting off-formulary drugs through clients’ plans. • Educate medical providers on how and why they should sign up with the plans that will support our community by accepting HIP premium payments. • Identify and reach out to organizations both locally and nationally, that are already advocating around these topics, such as LAAN, CHANGE, and NASTAD . • NASTAD – National Alliance of State and Territorial AIDS Directors • Created a sample letter that anyone can use to send to insurance carriers • LAAN – Louisiana AIDS Advocacy Network • LAAN Chair – Joshua Holmes (jholmes@aidslaw.org) • CHANGE – Coalition of HIV/AIDS Nonprofits & Governmental Entities • Contact information: changenolanow@gmail.com

29. Sample Letter Created by NASTAD A PDF version of this letter is available at hivhealthreform.org Direct link: http://www.hivhealthreform.org/2013/12/09/hiv-advocates-continue-to-push-feds-for-effective-implementation-of-the-aca/

30. How to make an off-formulary request • Each insurance plan has a process for how to make an off-formulary request. Below are the processes for Louisiana Marketplace plans. • Blue Cross Blue Shield/HMO of Louisiana • Call Express Scripts at 1-866-781-7533to make an off-formulary request • Louisiana Health Cooperative: • Contact LAHC. For more details use this link: http://www.mylahc.org/Files/Repository/LAHC2014Formulary.pdf. • If approved, the drug will be covered at a “pre-determined cost-sharing level” and you will not be able to ask LAHC for a lower cost-sharing level. • Providers must complete a Coverage Determination Request Form and fax it to the Pharmacy Department available when providers log on to mylahc.org. • AAA Vantage Health Plan: • File an “exception request” by calling AAA Vantage’s Member Service department at (318) 361-0900 or (888) 823-1910. • The insured and the physician must request the formulary exception. • Humana: • Off-formulary requests can be made by phone, mail, or fax. • Phone: The patient, provider, or appointed representative should call Humana Clinical Pharmacy Review (HCPR) at 1-800-555-CLIN (2546), TTY: 711, Monday through Friday, 8 a.m. to 6 p.m. in your local time zone. • Mail/Fax form “Prior Authorization Request Form: Administrative Product – Nonformulary” available electronically - http://apps.humana.com/marketing/documents.asp?file=1312909 • Medicare: HCPR, Attn: Medicare Coverage Determination, P.O. Box 33008, Louisville, KY 40232 • Commercial: HCPR, Attn: Prior Authorizations, P.O. Box 33008, Louisville, KY 40232 • Fax: 1-877-486-2621

31. Common HIV Medications on Louisiana Marketplace plans This information is available on lahap.org

32. Louisiana Dental Plan Options • This is not a comprehensive comparison of all dental plans in Louisiana, but it is a good starting point. • HIP can assist with premium payments, but currently CANNOT assist with cost shares (copay, coinsurance, deductible). • Currently, the client is responsible for paying their own cost shares for their dental insurance.

33. Dental Insurance Vocabulary • Annual Maximum – the maximum amount that a dental plan will pay for services in a plan year. • Diagnostic and Preventive Care – routine dental care, such as cleanings and X-rays. • Basic Dental Work – minor restorative services and surgeries, such as fillings and extractions. • Major Dental Work – complex dental services and surgeries, such as crowns, bridgework, root canals, and denture repair/adjustments. • Waiting Period – a time period in which the dental plan will not pay for services, leaving the client responsible for 100% of any costs during this time period. This is a one-time wait period occurring when someone first signs up with a plan.

34. Louisiana Dental Plan Comparison

35. Contact Information • My Contact Information: • Julia Frisk, Public Health Associate 504-568-8387 julia.frisk@la.gov • HIP’s direct line: 225-927-1269 • Regions 1, 2, 3 contact Vena Lewis at ext. 147 (vlewis@haartinc.org) • Regions 4, 5, 6, 8 contact Kathy Mathews at ext. 127 (kmathews@haartinc.org) • Regions 7, 9 contact Kne-KoleGibson at ext. 126 (kgibson@haartinc.org) • LAHAP Staff • Jennifer Carlos Gomez, ADAP Coordinator • 504-568-5448 • Heather Weaver, TAB Coordinator • 504-568-5489 • Tiffany Medlock, Client Services Specialist • 504-680-9403 • Rosaline Morgan, Client Services Specialist • 504-568-8746 • Markham Bradburn, Client Services Specialist • 504-568-3623

36. Resources • This presentation is available on lahap.org  “Links”  “Technical Assistance Resources” or the direct link at http://lahap.org/information_links/default.html • Lahap.org • Haartinc.org under “services” • Healthcare.gov • HIV411.org • Cms.gov • Hivhealthreform.org • Enrollment Assistance: Enroll Louisiana Inc. (www.enrolllouisianainc.com) 4664 Jamestown Ave, Suite 125 Baton Rouge, LA 70808 Office: 225-228-1515 Fax: 225-612-6395 Email: info@enrolllouisianainc.com