Transcript Modified Adjust Gross Income (MAGI)

2015 ADAP Overview
Lisa Fuentes
Ryan White Part B Program Manager
Jimmy Borders,
ADAP Operations Manager
azdhs.gov
Health and Wellness for all Arizonans
Ryan White Part B/ADAP Team
Lisa Fuentes
HIV/AIDS Care Services Manager
Lora Andrikopoulos
RW Fiscal Monitor
Jimmy Borders
ADAP Operations Manager
John Lick
RW Quality Manager
Vacant
Reengagement in Care
Specialist
David Balkcom
RW Data Manager
Lynelle DorseyBrooks
RW Data Manager
Megan Swanson
HIV Surveillance
Epidemiologist
Greg Romero
Laura Kroger
ADAP Eligibility
Retention Coordinator
Coordinator
Louisa Vela
ADAP Eligibility
Coordinator
Claudia Cardiel
ADAP Eligibility
Coordinator
LisaMarie Bates
ADAP Admin Assistant
Jessica Alvidrez
ADAP Eligibility
Coordinator
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ADHS RWPB & ADAP
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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.
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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.
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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.
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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-applicationenglish.pdf
– Spanish version at
http://www.azdhs.gov/phs/hiv/documents/adap/adap-applicationes.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.
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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 lowincome individuals who have limited or no coverage
from private insurance or Medicaid.
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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.
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ADAP Assist
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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
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Ramsell
Prescription 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
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Medications Covered and/or Excluded
•ADAP Assist covers medication co-pays paid for
by the primary insurance company with the
following exceptions:
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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
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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
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FFM Guidelines for Statewide Clients
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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
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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.
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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.
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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
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HRSA PCN #14-01 –APTC Overpayment
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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
Phoenix, Arizona 85007
DOUGLAS A. DUCEY, GOVERNOR
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
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AHCCCS Nominal Copay Assistance
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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
4512 E. Camp Lowell Dr.
Tucson, AZ 85712
Ph: (520) 918-0044
Fax: (520) 918-0043
National Distribution Facility
Toll-free phone: (877) 546-5779
Toll-free fax: (877) 546-5780
** 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.
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Questions??
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