Texas HIV Medication Program and Ryan White Programs

May 27, 2015Rachel Sanor, LMSW, MBAManager, Texas HIV Medication ProgramTexas Department of State Health ServicesRachel.Sanor@dshs.state.tx.us(512) 533-3002

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Today’s Presentation

• Ryan White• Current Insurance Assistance Programs through Ryan White Part B

• Current Texas HIV Medication Program (THMP) Programs• ADAP• SPAP• TIAP

• ACA and Ryan White

• Future Horizons2

RYAN WHITE 3

Ryan White Program - The Parts

• Part A provides emergency the Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) most severely affected by the HIV/AIDS Epidemic (In Texas, Dallas and Houston are designated as EMAs and Austin, San Antonio, and Fort Worth are TGAs)

• Part B Provides grants to the 50 states, the District of Columbia, and Territories

• Part C Provides comprehensive primary health care in an outpatient setting for those living with HIV/AIDS

• Part D Provides family centered care for Women, Infant, Children, and Youth with HIV/AIDS

• Part F Provides funding for special projects, dental care, and education

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http://hab.hrsa.gov/abouthab/aboutprogram.html

Ryan White Part B Program• HIV/STD Prevention and Care Branch of the Department of

State Health Services administers the Ryan White Part B program

• DSHS selected seven Administrative Agencies (AAs) act as an administrative arm for DSHS by administering the Ryan White Part B program locally

• These AAs in turn collaborate with DSHS to select local healthcare providers through local competitive processes to directly provide Part B services to eligible clients.

• AAs also assist DSHS with providing technical assistance and monitoring of providers in accordance with DSHS standards.

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Part B Insurance Assistance • “Health Insurance Continuation (HIC) and Cost Sharing

Assistance” has been an allowable service category since the inception of the Ryan White program in 1991

• Local agencies currently provide health insurance continuation assistance for eligible persons up to 500% of the federal poverty line as funding allows.

• This assistance includes premium assistance, medication copayment assistance, and medical visit copayment assistance.

• “The Local AIDS Pharmaceutical Assistance” service category allows funding for medication copayment assistance.

• Local agencies can provide assistance for any appropriate policy, including employer sponsored and Marketplace plans.

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THMP PROGRAMS 7

Texas ADAP• Available for HIV Positive Texas residents at or below 200% FPL• Funded by Federal Ryan White and State General Revenue• Provides ADAP formulary medications to eligible individuals• 47 drugs• All FDA approved ARVs on formulary• Limited scope-includes 10 of the 14 PHS recommend drugs for

the treatment & prevention of OIs – no drugs to treat side effects or toxicities

• Medical criteria for the majority of drugs• Limits on the number of antiretroviral medications a client can

receive (4 per month)8

Texas HIV SPAP and TIAP Pilot

SPAP • Developed to assist eligible clients

with Medicare following the creation of the prescription drug benefit, Medicare Part D in 2006

• Implemented January 1, 2008• Provides assistance with Medicare

Part D out of pocket costs• The client must be enrolled in a

Medicare Part D plan or a Medicare Advantage Plan w/drug coverage to participate in the program

• Same eligibility requirements as ADAP

TIAP Pilot• Developed to assist clients who lost

insurance coverage to transition to COBRA and to help clients with unaffordable medication copayments with copayment assistance

• Implemented July 1, 2013• Provides assistance with COBRA

premiums, medication copayments, and medication deductibles

• Client must be eligible for COBRA or have a current insurance plan for program participation.

• Same eligibility requirements as ADAP and SPAP

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ACA AND RYAN WHITE 10

Current Environment• Eligibility Considerations• Ryan White funding is to be used only as a payer of last resort• Ryan White providers must show they have vigorously pursued

coverage for clients• However, health insurance must be a financially advantageous

option to be considered for eligible clients.• Cost of insurance varies based on client income for ACA plans• Clients with complicated medical needs should be considered for

insurance enrollment• Client enrollment in insurance is based on the clients’ ability to

pay or the programs ability to provide payment for assistance• THMP is vigorously screening for insurance status of current

ADAP recipients and applicants to insure only those eligible clients are receiving services.

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Future Horizons• TIAP Program Expansion• The Texas Ryan White Program is working on a pilot project that

would provide community funding for insurance expansion through premium assistance for eligible low-income Texans and medication copayment assistance through the THMP.

• This is being considered as part of a larger policy issue concerning the state of Texas and Marketplace Plans.

• Standardization of eligibility between Ryan White Part B and THMP, including using a Modified Adjusted Gross Income (MAGI) determination, has been implemented to more efficiently manage clients in an increasingly complicated environment.

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Questions?

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Thank You!

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