ADAP Funded Health Insurance Continuation in Massachusetts

							ADAP & Coordination with Health
  Insurance in Massachusetts

       National ADAP Meeting
          Washington, DC
          August 23, 2012


               Annette Rockwell
        HDAP & Federal Grants Coordinator
           MDPH Office OF HIV/AIDS
     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
             Program Enrollment
              (as of May 31, 2012)

   Total HDAP Enrollment:   6136

   Co-pay Enrollees:        5854

   CHII Enrollees:          1544

   Full Pay Enrollees:      282
               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
                             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
                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
                 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)
          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
                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
Enrollment & Expenditures by Year
State Fiscal Year   Enrolled   Total Expenditures

FY02                2301       $   9,716,375
FY03                2716       $ 10,703,342
FY04                4399       $ 15,887,838
FY05                4738       $ 17,708,142
FY06                4668       $ 13,543,197
FY07                5141       $ 14,585,106
FY08                5601       $ 15,591,533
FY09                5882       $ 16,099,405
FY10                6543       $ 16,886,192
FY11                7009       $ 18,634,462
                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
              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
        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)
      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