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New Mexico Department of Health AIDS Drug Assistance Program (ADAP) PROGRAM GUIDELINES ______________________________________________________________________ April 2011 NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 1 of 32 TABLE OF CONTENTS INTRODUCTION 3 MISSION 3 PROGRAM OVERVIEW AND DESCRIPTIONS 3-4 PROGRAM BENEFITS 4 ELIGIBILTY REQUIREMENTS 5 APPLICATION FOR SERVICES 5 RESIDENCY REQUIREMENTS 6 ELIGIBILTY DETERMINATION 7 COORDINATION WITH CASE MANAGEMENT SERVICES 8 INCOME QUALIFICATION 9-13 INCOME QUALIFICATION (DETERMINE FAMILY SIZE) 13-14 CLIENT INFORMATION UPDATES 15 REQUIRED ANNUAL ENROLLMENT AND SEMI-ANNUAL RECERTIFICATION 15 LAPSE OF ENROLLMENT OR INSURANCE COVERAGE 16 INTERRUPTION OR DISCONTINUATION OF SERVICES 16-18 INCARCERATION 18 MEDICAL CARE STANDARDS 19 FORMULARY 19 OUT OF STATE PHYSICIANS AND PRESCRIPTIONS 19 MEDICATION BRIDGE PROGRAM (BRIDGE) 20-21 INSURANCE ASSISTANCE PROGRAM (IAP) 22-25 NMMIP: IAP ENROLLMENTS & PREMIUM PAYMENTS 26 NM STATE PHARMACY SERVICES 27-28 RECORDS DOCUMENTATION 29 GRIEVANCE PROCEDURES 30 SECURITY AND CONFIDENTIALITY 31 ATTACHMENTS (LIST) 32 NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 2 of 32 INTRODUCTION Mission The mission of the New Mexico AIDS Drug Assistance Program (NM ADAP) is to provide stable and accessible treatment to extend life and improve health for qualified individuals with HIV disease; to promote access to HIV treatment and care; and to provide high quality service in pursuit of those goals. Program Overview The NM ADAP is a federal and state funded program that exists to ensure that persons living with HIV/AIDS in New Mexico who are otherwise underserved have access to HIV care, treatment, and medications. The Program currently provides assistance with medical insurance premiums and co-payments, provision of HIV related medications, and transitional medication access for clients applying for insurance coverage. The NM ADAP has a medical advisory body of infectious disease and other HIV specialty physicians and program staff that meet at least annually to review the NM ADAP formulary and make recommendations for improvements in the medical aspects of the program. Program Descriptions 1. Insurance Assistance Program (IAP): This component of the NM ADAP program provides assistance to persons living with HIV/ AIDS to cover the cost of health insurance premiums and prescription co-payments. Health plans eligible for IAP include commercial health insurance plans and the New Mexico Medical Insurance Pool (NMMIP). Plan coverage must include HIV and HIV related medications. The program will pay the health insurance premiums up to $600 per month for enrolled clients. This program is for health insurance ONLY; it does not pay costs associated with dental, vision or discount plans. Some employers may allow the NM DOH to pay premiums directly to them so that deductions are not taken out of client paychecks; it is up to the client to make these arrangements. The program also covers prescription co-payments for medications listed on the NM ADAP formulary. Payment is made to the retail pharmacy after the primary insurance has been billed. IAP does not distinguish between prescription co-payments and prescription deductibles. 2. Medication Bridge Program (Bridge): This component of the NM ADAP program provides support for HIV related medications for clients who are currently uninsured and who are in the process of applying for insurance coverage. This program provides a 30-day supply of HIV related medications. Only medications listed on the NM ADAP formulary are provided through this program. The applicant’s case manager must apply for this coverage. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 3 of 32 Program Descriptions (con’t) Pre-coverage medication access is provided to any fully enrolled client or client in the process of enrolling in the NM DOH program whose insurance coverage for prescription drugs is delayed. Most often this time period will be for 30 days or less, as most prescription coverage starts the 1st of the month following the insurance application acceptance/approval for coverage. Bridge coverage will provide required HIV related medications during this delay. The client and their case manager must provide verification of acceptance by a health plan or verification that an application for coverage has been submitted and is awaiting approval prior to authorizing this medication access. This documentation must be submitted to the NM DOH. 3. New Mexico Department of Health Mail Order Pharmacy: This portion of the program provides for the dispensing and delivery of medications on the NM ADAP formulary. Uninsured clients enrolled in Bridge and IAP clients enrolled in the New Mexico Medical Insurance Pool (NMMIP) will utilize the NM DOH Mail Order Pharmacy for medications on the NM ADAP formulary. The NM DOH Pharmacy is the only pharmacy that may be used to fill formulary prescriptions for NMMIP clients enrolled in the IAP Program and for those on the Bridge Program. Program Benefits 1. Access to a 30-day supply of HIV related medications for uninsured clients 2. Payment of insurance premiums of up to $600 per month (payments will be made directly to insurance company); clients are responsible for payment of any amount over the $600 cap and payment should be made directly to the insurance company 3. Medication co-payment coverage for medications on the NM ADAP formulary (payments will be made directly to pharmacies). NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 4 of 32 Eligibility Requirements In order to be eligible for Bridge and Insurance Assistance Programs, applicants must: Provide documentation of New Mexico residency (P.O. Box is NOT an acceptable address); Have a verified HIV positive diagnosis; For participation in the Insurance Assistance Program have a documented gross monthly income that is 300% of the Federal Poverty Level (FPL) or below; or for participation in the Medication Bridge Program have a documented gross monthly income that is 400% of FPL or below. Documentation must be submitted to support income declaration; Not be eligible for medication coverage through a 3rd party payer (Medication Bridge Program); Be currently enrolled in HIV case management with a NM Department of Health (NM DOH) contracted HIV Service Provider; Must provide lab results (CD4 and viral load dated within 6 months of enrollment); Homeless clients require a notarized statement of homeless status from case manager; Zero income clients require a client signed statement of zero income as well as a letter of support from the individual providing support to the client; Applicants do not have to document U.S. citizenship or immigration status in order to be eligible for services. However, eligible clients must live in the state of New Mexico and need to provide proof of New Mexico residency. Application for Services NM DOH ACCESS Applications are available from the NM DOH contracted service providers. Applications must be completed in their entirety before submission to NM DOH. The NM DOH only accepts and processes applications that are filled out completely and accurately. Applications must include documentation of residency, income verification, insurance documentation and current lab results. Applications received without the above mentioned documentation will be considered incomplete. Incomplete applications will be logged as incomplete and correspondence will be submitted to the service provider or case manager stating the necessary documents needed. The three day (working day) processing time from receipt of application will not apply to incomplete applications. Acceptance into the Program is on a first come first served basis. The applicant is responsible for providing all proof of residency and financial eligibility documentation. The physician is responsible for providing all proof of medical information. Time Frames During the NM DOH ACCESS application process, if needed, the case manager can request 30 days of emergency Bridge medications to cover the client until enrollment in insurance is approved/completed. Once insurance is approved, the case manager submits an IAP application. IAP applications will be reviewed upon receipt and approvals will be finalized once full NMDOH program enrollment has been approved. Approved IAP applications will usually be activated immediately. Once a decision is made, patients and case managers will receive written notification within 10-15 working days of final determination of IAP application status. Any changes to the IAP application once submitted will result in additional processing time. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 5 of 32 Residency Requirements In order to be eligible for New Mexico’s Medication Bridge/Insurance Assistance Programs, applicants must be residents of the state of New Mexico at the time of the application. Persons who reside elsewhere are not eligible. 1. A physical living address in New Mexico is required. A mailing address is also required if it is different from the physical living address. 2. Documentation verifying living address is required with NMDOH Program enrollment. Examples of documents that are acceptable for documenting residency include, but are not limited to: A current New Mexico driver’s license or identification card A current lease for a New Mexico street address in the individual’s name A current major utility bill in the client’s name for a New Mexico street address Cell phone bills will not be accepted Utility bills mailed to a PO box will not be accepted If the client cannot provide the above documentation, case managers should consult with NMDOH program staff, who may advise as to what will be accepted by the program. 3. If the program has any reason to believe the applicant may not reside in New Mexico, it may request additional proof of residency. 4. Persons who have established residency in New Mexico and who spend more than three (3) consecutive months, within the calendar year, outside of New Mexico will not be eligible for the program, even if they maintain a primary residency in New Mexico. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 6 of 32 Eligibility Determination Applicants are responsible for providing proof of eligibility. Payment for services will not be made until all eligibility requirements have been confirmed and clients have received notification of program enrollment. Applicants must provide: 1. If uninsured and requesting Medication Bridge Assistance: applicant and case manager MUST provide proof that other services to assist with obtaining medications have been applied for and/or utilized (i.e., Patient Assistance Programs) or proof that an application for coverage has been submitted and is awaiting approval (i.e., NMMIP or COBRA). ADAP funded assistance is payer of LAST resort. 2. Homeless applicants: MUST provide a notarized explanation of homelessness; a case manager verifying applicant’s homeless status will be accepted as proof of residency; if living in a shelter or enrolled in a homeless program, a letter from the program or shelter is required 3. A list of the applicant’s current medications, if currently taking medications 4. Proof of HIV+ status a. Verification of HIV status must be obtained before an applicant will be enrolled for services. A medical provider’s signature and current CD4 and viral load results on the appropriate section of the NM DOH ACCESS Application verifying that the applicant is HIV positive is required. Client reported HIV status is not acceptable to meet this requirement. 5. Proof of income - MUST submit one of the following: a. current year Social Security award letter (bank statements showing direct deposit are NOT acceptable as proof of current gross award) b. zero income explanation signed by client AND letter of support from individual providing the support to the client c. three (3) most recent consecutive employment pay stubs d. six (6) months of most recent CRS forms for self-employed applicants i. For self-employed applicants a federal income tax return is ONLY acceptable as proof of gross yearly income from January 1st to May 31st of the new year (i.e., a 2009 federal income tax return submitted on May 31st, 2010); and MUST include Schedule C business documentation. ii. After May 31st of each year CRS forms covering the most recent six month period needs to be submitted iii. Hand-written “logs” and spreadsheets are NOT a valid form of income documentation 6. A copy of insurance card or NMMIP enrollment letter a. A copy of prescription card, if separate from medical insurance coverage 7. A copy of the insurance summary of benefits MUST be provided and MUST include prescription benefit summary (Exception: NMMIP summary of benefits) 8. If COBRA eligible, a copy of COBRA documentation 9. Documentation showing monthly premium amount and name and address of premium payee NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 7 of 32 Coordination with HIV Case Management Services HIV case managers will encourage eligible clients to enroll in IAP and will assist the client in remaining enrolled in IAP. The HIV case manager will assist the client in applying for other benefits that provide drug coverage, such as NMMIP and also assist the client in successfully adhering to their medication regimens. NM DOH HIV program staff works in a close partnership with providers and case managers to support the client’s successful utilization of available benefits. All NM ADAP enrolled clients are required to be currently enrolled in HIV case management with a NM Department of Health (NM DOH) contracted HIV Service provider. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 8 of 32 Income Qualifications In order to receive services (insurance assistance and/or medications) through the NM ADAP, documentation of income is required to verify financial status for the client and household dependents. GROSS MONTHLY INCOME is used to determine client eligibility. Gross income is income BEFORE any taxes or other withholdings are deducted. Gross annual incomes for the Insurance Assistance Program may not exceed 300% of the Federal Poverty Level (FPL). Gross annual incomes for Medications Bridge Program may not exceed 400% of the Federal Poverty Level (FPL). NM DOH HIV Services Program’s Definition of Household Income: The sum of money received in a year by all members of the household (as defined by the Program). Income Sources: Work income/wages/salaries (overtime pay, tips, bonuses and commissions are all counted) Long Term Disability/all disability payments Self-employment income Pension/Retirement income Unemployment insurance income Child support payments Alimony Social Security Income (SSI) Social Security Disability Insurance (SSDI) (income amount counted is before the Medicare Part B premium is deducted) Income from interest paid by savings/checking accounts Survivor benefits Annuities Stocks, bonds, certificates and all other investments, if they pay dividends Inheritance Student loans and/or Scholarships, educational financial aid are not considered income Food stamps are not considered income NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 9 of 32 Income Qualification (con’t) Documentation of Income: Employment income Regular, non-seasonal employment: three most current consecutive paystubs Seasonal Employment: For clients employed seasonally by the same employer, submit a current paystub that shows “year to date earnings” and written explanation of income Multiple positions/employers throughout year: a copy of the most recent Federal Income Tax return is required and written explanation of income If the employed client does not fall into any of these categories, consult with the Program to discuss the individual’s specific case. Program staff will advise providers as to what will be accepted by the program. Calculating income using three consecutive paychecks Step 1: Calculate Average Paycheck Paycheck 1 $500.00 Paycheck 2 $348.58 Paycheck 3 $425.02 Average Paycheck $424.53 Twice a Bi-weekly Weekly Month Step 2: Determine number of pay periods in a 26 24 52 year Step 3: Multiply number of pay periods by $11,037.87 $10,188.80 $22,075.73 average paycheck to calculate annual income Step 4: Divide by 12 months to calculate $919.82 $849.07 $1839.64 monthly income NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 10 of 32 Income Qualification (con’t) Self-Employment CRS filings covering the most recent six month period. NM DOH will allow a 50% deduction from gross monthly receipts to cover the cost of maintaining a business. At the discretion of the Provider Liaison, Federal Tax Returns may be accepted as a last resort to document income. o Federal Tax Returns from the previous calendar year (i.e., 2009) will only be accepted through May 31st of the following calendar year (i.e., May 31, 2010). After May 31st of each year CRS forms need to be submitted. o The entire tax return must be submitted including the Schedule C. NM DOH will use line 1 from the Schedule C to determine gross receipts (aka, income). This figure will be multiplied by 50% to allow for business expenses. The remaining amount will be used to determine monthly income. Hand-written “logs” and spreadsheets are NOT a valid form of income documentation Calculating monthly self-employment income: For the 6 current CRS forms, total the gross receipts. Multiply this number by 50% and then divide that number by 6. For Federal tax forms, use the Schedule C line 1. Multiply this number by 50% and then divide by 12 to determine monthly income. If the self-employed individual does not fall into either of these categories, consult with your Provider liaison to determine what documentation of income is required. Spousal/Dependent Income If the spouse has no income, a zero income statement is required for the spouse. If the client’s spouse has income, documentation of spousal income is also required. Any client reported as married is required to provide documentation for verification of spouse’s income or no income. Unless the client is legally separated or divorced from spouse, documentation of spousal income must be included with application forms and the spousal income must be included as income. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 11 of 32 Income Qualification (con’t) Unearned Income (income not from employment) Current General Assistance Award Letter/TANF o Preferred: A recent printout of payments made within the past 3 months from the time NM DOH receives the ACCESS application or re-enrollment o Alternative: The most recent determination letter Current Pension/Retirement statement o Preferred: A statement dated within the past 3 months from the time NM DOH receives the ACCESS application or re-enrollment o Alternative: The most recent annual statement Current Social Security Award Letter (SSDI/SSI)/ Benefits Statement o Preferred: Award letter for the current year o Alternative: Letter from SSA dated within the past 3 months from the time NM DOH receives the ACCESS application or re-enrollment Current Trust Fund/Stock/Properties o Preferred: A statement dated within the past 3 months from the time NM DOH receives the ACCESS application or re-enrollment o Alternative: The most recent annual statement Current bank statement showing account balances if and only if the client lives off savings o Only Option: Statements from all accounts (checking and savings) dated within the past 30 days from the time NM DOH receives the ACCESS application or re-enrollment Clients cannot have more than $9,999 in liquid assets (i.e., checking, savings, and other cash accounts) to be eligible for the program. The Case Manager is responsible for verifying if the client has liquid assets and the balances of any. No Income (valid for six months) A signed statement from client of verifying no income and a signed statement from the person providing financial support to client. These statements may be made on a single letter. Exception: The only exception to be considered regarding a “Letter of Support” is in those instances when a client has not disclosed his/her HIV status to family/person providing support; in those cases, it is the case manager’s responsibility to verify the situation and provide notarized statement of income signed by client and case manager Income Calculations for Miscellaneous Situations: Social Security Disability Insurance Clients who also receive Medicare: Gross income includes the amount which is deducted from Social Security checks for Medicare Part B. If the client has received a one-time, annual bonus: Add to calculated YTD gross income and divide by 12 to calculate monthly gross income NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 12 of 32 Income Qualification (con’t) Other Miscellaneous Scenarios: Retirement/Private Disability – provide statement showing current monthly payments Unemployment benefits – provide statement showing current weekly payments Alimony and Child Support – provide statements/certified letters/court documents showing current monthly payments received All clients must complete a DOH ACCESS Recertification before the end of the 6-month enrollment period. If the Recertification is not completed before the 6-month enrollment period ends, the client’s enrollment will be considered lapsed/closed by NM DOH. Clients who are enrolled in the Insurance Assistance Program only need to complete the IAP 6- month Recertification form. A DOH ACCESS Recertification form does not have to be completed for these clients. The IAP Recertification Form serves as the DOH ACCESS recertification for clients. Determine Household Size (additional income documentation): NM DOH HIV Services Program’s Definition of Household: A family of two or more is defined as a group of persons related by birth, marriage, adoption or a legally defined dependent who live together. If reporting a household of more than one, case managers are to submit a written statement verifying the additional members and their relationship to the client. If reporting a household of more than one, income documentation is required for the other household members as follows: Spousal/Dependent Income Any client reported as married is required to provide the previously mentioned documentation for verification of spouse’s income or non-income. Unless client is legally separated or divorced from spouse, income of spouse must be included regardless of living situation. If the spouse has no income, a zero income statement is required from the spouse with a letter of support signed by client or by person providing support. If the client receives dependent income, verification of that income is also required. Examples of how to count household members: Family Members NOT counted: The client has a life partner, significant other, legally registered Domestic Partner or roommate (and no children in common). This is defined as a household of one. The adult client is reporting as zero income with a letter of support (from family or friends), this is a household size of one. The client lives with a child and a life partner who is not the other biological parent of their child. This is defined as a household of two. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 13 of 32 Income Qualification (con’t) Family Members counted: The client has a child and is married to the other biological parent. This is defined as a household of three. The client has only his or her children living with him/her. This is defined as a household composed of the number of children plus the client. A legally married husband and wife who live together are defined as a household of two. Any dependent household member who meets the definition for Dependent Status. Dependent household members are defined as those persons for whom the head of household has a legal responsibility to support. These relationships are defined as legal adoptions and guardianships. o Adopted family members must conform to the program requirements listed below for dependent children. o Guardianship status must be supported by court documents defining the guardian relationship/responsibility. Dependent child status shall not extend beyond age 18, except when the dependent child is enrolled as a student. In the case of student status, the age at which the dependent child status shall end is age 24. The client must attach documents to show that the child is enrolled in an educational institution and must be submitted every 6- months. All income, from full or part time employment, produced by all dependents must be declared as part of the household income. All dependents claimed must appear on the client’s Federal and State Income Tax Return for the most recent year. The program reserves the right to review this documentation to verify household number. Clients may not claim dependent status for individuals who reside outside the United States, unless those persons are listed on his/her most recent Federal Tax Returns filed; and there is a judicial ruling in the United States that defines a legal relationship and dependent status. All persons over the age of 18 (who are not covered by student status, and whom the head of household is claiming dependent status) must be named specifically in a legally defined Guardianship Relationship approved by a U.S. Judicial proceeding. NO exceptions will be made to this requirement. Notarized copies of documents must be made available upon request to the program. Adults (i.e., elderly parents, disabled adult child, etc.) are approved dependents if they meet the criteria above. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 14 of 32 Client Information Updates The client’s case manager will notify NM DOH HIV program of any changes to client information or insurance status immediately. Changes include (but are not limited to): Mailing address and other contact information pertinent to delivery of medications Insurance coverage (i.e., enrollment in private coverage) Insurance premium increases or changes in monthly premiums Transferring to another Provider Dis-enrolling from NMDOH program If there is a change in client demographic information: If an IAP enrolled client has changes in demographic information (i.e., mailing address, contact phone, etc.), case manager is to complete and submit an ACCESS Update form to NM DOH. If a client changes insurance plans: If an IAP enrolled client changes insurance plans and the new plan is IAP eligible, a new IAP application and insurance documentation needs to be submitted to NM DOH for review in order for the client to continue enrollment in IAP. If there is a premium increase or change of payee address: If an IAP enrolled client’s insurance plan updates information, such as premium increase or change of payee address, an IAP application does not need to be submitted to NM DOH. A copy of a statement or letter reflecting the change should be sent to NM DOH. Transfer of IAP clients: It is the responsibility of the client’s current case manager, when processing a client’s request to transfer to another provider, and completing the transfer form, to attach a copy of the client’s current ACCESS enrollment AND a copy of the current IAP application and all insurance documentation. Once the transfer form is received at the new provider, it is the new case manager’s responsibility to notify their IAP Coordinator of the client’s IAP enrollment status. Clients are permitted to transfer providers only 3 times per year. Required Annual Enrollment and Semi-Annual Re-Certification for IAP The Ryan White legislation and the NM DOH HIV Services Program require that clients enroll with the IAP annually and recertify semi-annually. Therefore, timely receipt of enrollments is required. All HIV case managers should have a reminder system in place to begin the re- enrollment process/ paperwork 30-45 days prior to the end of each client’s enrollment period. This will ensure that justifications, labs, income documentation, paperwork, signatures, etc. are complete and submitted in time, resulting in no lapse in coverage. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 15 of 32 Lapse of Enrollment or Insurance Coverage Under circumstances where a client’s IAP enrollment has lapsed and insurance is lost or back premiums are due, the case manager is to contact the IAP/ADAP Coordinator and provide the following information Client’s current enrollment status (active/lapsed/closed) Status of client’s ACCESS application (in process/submitted to NM DOH/returned by NM DOH for corrections/additional documentation) Information about back premiums due (number of months, total due) Case manager is to contact NMMIP to verify information HIV medications currently prescribed to client Case Manager’s recommendation for ensuring access to medications (i.e. Bridge or paying back premiums) Availability of other funding sources to assist the client in gaining access to medications (this should include any cost-sharing that the provider is able to do with other funding sources) The Program will determine the most cost-effective option for the individual client. This may include (1) placing the client on Bridge for formulary medications until the insurance can be re- instated or (2) the payment of back premiums due. While our highest priority is to ensure clients have access to medications, we emphasize that the timely enrollment and re-enrollment in the program needs to remain a high priority in provider organizations. To support this, the ADAP staff will continue to monitor the timeliness of enrollments and re-enrollments in the program under the Clinical Quality Management (CQM) Program. Performance that falls below 80% will be reported to providers so that the individual organizations can identify any issues with policies or practices that result in delayed or late enrollments and re-enrollments. Interruption or Discontinuation of Services Discontinuation or interruption of services from the NM ADAP may occur for a number of reasons. The following activities will result in discontinuation of enrollment in the Medication Bridge Program and the Insurance Assistance Program: The client no longer lives in New Mexico The client has died The patient’s income rises to more than the currently accepted level for program enrollment The client has deliberately reported false information on an enrollment or 6-month re- certification The following activities may result in interruption of services and/ or potential discontinuation of enrollment through the Medication Bridge and the Insurance Assistance program: It is discovered that the patient failed to report substantial income or insurance benefits that made him/her ineligible at time of enrollment or 6-month recertification The client fails to provide necessary proof of eligibility NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 16 of 32 The client fails to provide a current address within 60 days of mail being returned to the program as undeliverable The client fails to complete and submit the IAP application and / or IAP Recertification form with all required documentation before the end of their enrollment period Persons who are found to have intentionally provided false, fraudulent or misleading information may be asked to repay the NM ADAP program for the costs of services provided. If for any reason a client becomes ineligible for the Insurance Assistance Program or makes a decision not to re-enroll, payment of premiums must be made by the client directly to the insurance company in order to continue insurance coverage. Active NMMIP policy holders whose coverage is cancelled due to non-payment of premiums are barred from re-applying for NMMIP for one full year. This means that clients who are cancelled and attempt to re-apply to NMMIP will experience 12 months without insurance for HIV medical services. All clients who are in the twelve (12) month exclusion period at NMMIP because they have had their coverage cancelled will be referred to their case managers and medical providers for assistance in accessing treatment through other programs, such as the pharmaceutical companies’ drug assistance programs. Exceptions: Services will not be discontinued or interrupted in the following situations: Discontinuation or interruption in service constitutes an immediate risk to the pregnant client’s unborn child A deadline was missed because of physician-documented health issues (i.e., client is hospitalized or is too ill to respond to complete re-enrollment forms). The patient’s case manager may be asked to assist in verifying physician-documented health issues and the circumstances surrounding the event. A deadline was missed because of a documented catastrophe or “act of God” (i.e., client’s house burns down or client is delayed while traveling because of inclement weather). Proof of this catastrophe must be provided. The client had or has a medical or mental health care provider-documented mental health episode or impairment (i.e., client experienced a psychotic break and was incapable of completing the requested task, or client’s partner/immediate family member died 30 days prior to re-enrollment and was incapable of responding). The patient’s case manager may be asked to assist in verifying provider-documented health issues and the circumstances surrounding the event. The client performed as required, however someone from the client’s support team failed to meet the deadline (i.e., client’s HIV case manager received requested papers from client but failed to mail them to NM DOH HIV program by deadline). This exception must include a written explanation signed by the case manager’s supervisor. Clients, HIV case managers, and healthcare providers must submit the required documentation of one of the above circumstances. These documents go to the NM DOH HIV Program staff for review by the HIV Services Program Manager for special consideration. In the instance of a support system failure by an HIV case manager or healthcare provider, a note will be made in the NM DOH ADAP Quality Management log for historical tracking. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 17 of 32 Events resulting in potential discontinuation or interruption of services will be reviewed by the NM DOH HIV Services Program staff and by the HIV Services Program Manager. In the event that further review is required to resolve a situation, the HIV Services Program Manager will review the issue with the Medical Director and, if necessary, the Infectious Disease Bureau Chief, to resolve the issue. The client and client’s case manager will be notified by the Program of the final resolution. Incarceration Individuals who are incarcerated in the New Mexico Department of Corrections State Facility or the County jail system are residing in institutions and therefore are NOT eligible for medication and insurance assistance through the NM DOH HIV program or ADAP. However, HIV clients incarcerated in county jails are eligible to maintain their current enrollment in the program for HIV case management; and if enrolled in IAP and NMMIP, can maintain their current enrollment in those programs as long as NM DOH HIV program enrollment guidelines are followed. Any HIV client currently enrolled with NM DOH HIV program who becomes incarcerated in a New Mexico Department of Corrections State Facility (long-term incarceration) will be dis- enrolled from the NM DOH HIV program immediately, including the Insurance Assistance and Medication Bridge Programs. It is permissible for a Ryan White Case Manager or NM DOH representative to do “transitional case management” with an inmate pending release within 30 days. Inmates not enrolled in NM DOH HIV program, upon release, are given referrals to the provider locations in their areas for enrollment in case management and other services. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 18 of 32 Medical Care Standards If antiretroviral drugs are to be prescribed, current U.S. Department of Health and Human Services/National Institutes of Health (DHHS/NIH) Guidelines should be followed. It is expected that generally accepted treatment protocols will be followed. This is applicable to both public and private physicians. Any unusual practices or “off label” treatments need to be discussed with the NM ADAP Medical Director. The NM ADAP recommends that a patient receive laboratory evaluations while undergoing treatment. These evaluations should be in accordance with the DHHS/NIH Guidelines. Baseline viral load and CD4 lab values should be obtained prior to the start of antiretroviral therapy (ART) and then at least twice a year thereafter. Treatment guidelines are not intended to replace the judgment of a physician. The decision to prescribe certain treatments lies with the physician and the patient. However, it is expected that the current recommended protocols would be used for determining treatments. It is also expected that drug protocols will be in keeping with currently accepted practices and any guidelines set forth by the NM ADAP. Certain contraindicated drug combinations may not be dispensed without the approval of the NM ADAP Medical Director. If there are any questions, contact the NM ADAP Medical Director. If a patient chooses not to take HIV antiretroviral medications, this should be documented in his/her chart. There is no requirement for medical review when Opportunistic Infection-related medications are ordered in the absence of HIV antiretroviral medications. If a physician prescribes a sub-standard or off label therapy, NM ADAP may require periodic lab results in order for a patient to get drugs through NM ADAP. If this is a new patient, previous laboratory results, or a copy of published documentation of therapy (e.g. peer reviewed journal article, abstract, or study that is ongoing) may be required. NM ADAP Formulary The formulary for the NM ADAP consists of currently FDA approved antiretroviral medications as well as other drugs deemed necessary for the treatment and quality of life of the HIV patient (see attachments for the current list). This list includes antivirals, antifungals, drugs used in the treatment and prevention of opportunistic infections, and antidepressants. Funding As a federally funded program, NM ADAP must closely monitor our expenditures to ensure budget compliance. Should funding become limited, NM ADAP may have to institute access restrictions. These restrictions could range from limiting the formulary, reduced financial eligibility criteria, and imposed cost sharing, to creating wait lists or capping enrollment of new patients. Out of State Physicians and Prescriptions Prescribing and treating physicians are to be licensed to practice in the state of New Mexico. Prescriptions from out of state physicians will not be accepted for co-payment reimbursements or for New Mexico State Mail Order Pharmacy Services. Any out of state prescriptions will be referred back to the patient and their provider. Medications from the state pharmacy will not be delivered to an address outside of New Mexico. Medical services delivered by out of state medical providers are not eligible for reimbursement of services and co-payments via NM ADAP funds. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 19 of 32 Medication Bridge Program Eligibility Requirements: HIV+ Resident of New Mexico No liquid assets over $9,999 Gross income under 400% FPL Does not have insurance coverage Is not enrolled in any other program to obtain HIV medications (i.e., private, COBRA, Medicaid, Medicare Part D, etc.) current medical insurance does not provide adequate prescription coverage (clients enrolled in the Medication Bridge Program who have medical insurance without adequate prescription coverage CANNOT enroll in IAP) Clients fully enrolled with NM DOH HIV Program: Eligible for 30 days of medications listed on the NM ADAP formulary while awaiting enrollment approval in NMMIP, COBRA coverage or private insurance coverage o An NMMIP application is to be completed and submitted to NMMIP immediately and coincides with the ACCESS enrollment process to ensure the NMMIP enrollment approval does not exceed the 30 days of emergency medications Case managers can request medication assistance by faxing a memo with an explanation for the request to NM DOH at (505) 827-0561; NM DOH staff will notify case manager of approval or denial Uninsured HIV+ individuals enrolling with one of the provider locations: Eligible for 30 days of emergency medications listed on the NM ADAP formulary while their NM DOH ACCESS enrollment and NMMIP application are being processed Case managers are required to verify that the individual does not have any other form of coverage to access medications before contacting NM DOH to request emergency medications Case managers can request emergency medication coverage by faxing the pending ACCESS application and income documentation to NM DOH at (505) 827-0561. NM DOH staff will notify case manager of approval or denial Medicare Part D clients: NOT eligible for the Medication Bridge Program; case managers are advised to enroll Medicare clients, who are also not eligible for Medicare “extra-help”, in the NMMIP Carve-Out plan and the Insurance Assistance Program before they reach the gap (or “donut hole”) in their Part D medication coverage. Exception: Medicare clients over the age of 65 are not eligible for NMMIP Carve-Out coverage. Once those individuals reach the gap (or “donut hole”) in their Part D medication coverage, their case managers are to notify NM DOH and request enrollment in the Medication Bridge Program until they are no longer in the medication gap or have enrolled in another Part D plan for prescription coverage. Medicaid clients: NOT eligible for the Medication Bridge Program NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 20 of 32 Medication Bridge Program (con’t) Recently Discharged Hospital Patients: Applications received for clients who have recently been discharged from the hospital and who are taking antiretroviral medications or medications for treatment of an opportunistic infection will be expedited into NM ADAP. This will be done so a patient will not have their drug regimen interrupted, even if he/she is unable to provide immediate documentation of income. This information must be noted on the NM ADAP request. Please note that the patient must currently be taking HIV related medications. He/she is permitted to enroll in the NM ADAP based on self- declared income and is given ten (10) workdays to provide documentation of income and eligibility as specified in this guideline. Medications are to be provided based on this self- declared income for the first month of eligibility. If the patient was not discharged on any HIV related medications, then regular application requirements and admission into the NM ADAP time frames apply. It is the responsibility of the person completing the enrollment form to check with the patient to determine if he/she was discharged from the hospital on any type of HIV related medications. Miscellaneous Scenarios: Emergency medications requested by individual departments within NM DOH o If another NM DOH department is assisting dual-diagnosed individuals, they notify NM DOH HIV Program and individual is given referrals to apply for HIV services Pending enrollment in Medicare/Medicaid Extension of 30-day request: Approval of an extension for an additional 30-day medication supply is made by the ADAP Medical Director. Case Managers will submit extension requests with explanation to NMDOH staff, who, after all information is received, will then remit to ADAP Medical Director for review. Extensions will be considered under the following circumstances: Application for insurance coverage is still pending approval Client is ineligible for other coverage/programs that offer medication assistance Extended 6-month enrollment: Extended 6-month enrollment in the Medication Bridge Program requires an annual ACCESS application and a 6-month ADAP Recertification. The 6-month ADAP Recertification form is to be completed, and include current lab results, current income documentation and proof of residency. Case managers will submit documentation to NM DOH. After NM DOH approval, the case manager will receive a copy of the approved form with NM DOH authorizing signature and enrollment dates. Clients eligible for extended Bridge enrollment are limited but include: The client’s current medical insurance coverage does not cover prescription medications o Case manager will provide documentation verifying medical coverage without adequate prescription coverage o If a client has medical insurance without adequate prescription coverage for HIV medications, they cannot enroll in the Insurance Assistance Program Once they reach the annual coverage gap, Medicare Part D clients, over the age of 65, who are ineligible for NMMIP Carve-out coverage can enroll in Bridge until they obtain other prescription coverage or they are no longer in the coverage gap NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 21 of 32 Insurance Assistance Program (IAP) The Insurance Assistance Program (IAP) funding covers health insurance premiums and prescription co-payments for eligible clients. Current NM DOH ACCESS enrollment is required for enrollment in IAP. Eligibility Requirements: HIV+ Resident of New Mexico No liquid assets over $9,999 Gross income ≤ 300% FPL Insurance with prescription coverage that mirrors the NM DOH State ADAP formulary Enrollment process: IAP enrollment requires an annual IAP application and a 6-month IAP Recertification o IAP applications and 6-month IAP Recertifications are to be submitted with client original signatures; photo-copies and faxed copies will NOT be approved; incomplete forms/missing documents or if the client’s signature is missing, the applications will be returned to the case manager unapproved With each annual NM DOH ACCESS application the case manager submits an annual IAP application to re-enroll the client in IAP on the same date Six (6) months from the ACCESS enrollment start date, the case manager submits a 6- month IAP Recertification form which includes the required insurance documentation, current lab results, current income documentation and proof of residency o Case managers submit IAP Applications and Recertifications to NM DOH IAP forms are to be completed in their entirety; forms submitted incomplete or missing documentation are returned to the case manager unapproved IAP Applications and Recertifications are date stamped with date received in NM DOH office; documentation received is also logged by NM DOH by date received, approval or denial dates, provider, case manager and client name and if applicable, date returned to provider and reason for return o After NM DOH approval, the case manager receives a copy of the approved form with NM DOH authorizing signature and enrollment dates o NM DOH mails an enrollment letter to the client with their IAP enrollment dates, an explanation of the program and a copy of the NM DOH State ADAP formulary (if a client requests no mail, the client’s copy of the letter will be sent to the case manager to hand deliver to client at the time of their next face to face meeting); a copy of the letter is kept at NM DOH in the client file a copy of the letter is also sent to the case manager for the Provider client file o NM DOH enters and updates client IAP data in CareWare database NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 22 of 32 Insurance Assistance Program (IAP) (con’t) Client risks dis-enrollment from IAP and may become ineligible for services if: (see prior sections on Required Annual Enrollment and Semi-Annual Re-Certification for IAP; Lapse of Enrollment or Insurance Coverage; and Interruption or Discontinuation of Services for additional details) 1. IAP enrollment end date expires 2. Incomplete IAP Applications and Recertifications are returned to case manager after IAP end date 3. NM DOH ACCESS date expires 4. Client dis-enrolls from NM DOH HIV program 5. Client gross income changes and exceeds 300% FPL 6. Insurance coverage is canceled 7. Persons who are found to have intentionally provided false, fraudulent or misleading information will be barred from the program for a period of one year and could be asked to repay the program for the costs of services provided 8. If for any reason a client becomes ineligible for the Insurance Assistance Program or makes a decision not to re-enroll, payment of premiums must be made by the client directly to the insurance company in order to continue insurance coverage. 9. If a client fails to notify their case manager of any changes to their plans or premiums which result in non-payment of full premiums and loss of coverage that client will be responsible for paying premiums owed directly to the insurance company to have their policy reinstated 10. If offered insurance coverage through an employer or a spouse’s employer, clients are required to enroll in those plans. Should a client refuse enrollment in those plans available, that client will not be eligible to receive DOH assistance for medications or insurance. Required documentation: Current/active NM DOH ACCESS enrollment is required to maintain active enrollment in the Insurance Assistance Program o proof of an HIV or Acquired Immune Deficiency Syndrome (AIDS) diagnosis from a licensed physician or other qualified health care provider (Part C of ACCESS) o proof of New Mexico residency (submitted with annual ACCESS enrollment) o proof of gross income ≤300% of Federal Poverty Limit (submitted with annual ACCESS enrollment and 6-month IAP Recertification); Documentation of existing healthcare coverage (copies of medical and prescription insurance cards), covered services (summary of benefits detailing all benefits and costs) and proof of an HIV medication benefit in which the formulary mirrors that of the NM DOH State ADAP formulary (copy of prescription plan formulary) Annual IAP Application and 6-month IAP Recertification form Case Management requirements: Case managers assist clients in pre-determination of program eligibility, the annual IAP Application and 6-month Recertification process Case managers verify active insurance coverage, premium coverage, payee and monthly premium amount due before submitting IAP applications Case managers communicate directly with clients, pharmacies and/or insurance companies regarding status of payments on the behalf of clients NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 23 of 32 Insurance Assistance Program (IAP) (con’t) Request for Authorization to Pay & Invoicing: Each provider location designates an individual as the point of contact for the Insurance Assistance Program (IAP); “IAP Coordinator” IAP Coordinator at each location assures payment of premiums and co-payments will not be made until the provider has received approval for payment from NM DOH The provider will ensure Request for Authorization to Pay is delivered to NM DOH no later than the 15th of each month in which services are to be delivered Reimbursement provisions: o IAP will only authorize payment of two (2) months of premiums (i.e., if payment period is for April premiums then IAP can authorize March and April premiums to be paid). Any previously owed premiums are the client’s responsibility; UNLESS the client provided all required documentation in a timely manner and the application was not submitted by the case manager and deadlines were missed; in cases where the case manager is found to be at fault, the financial responsibility for past due premiums falls on the provider o Reimbursements for premiums are not to be in excess of $600 for any one client for any one-month period of coverage o Requests for payment of premiums or co-payments for any client not enrolled in the Insurance Assistance Program are NOT allowed o Request for payment may NOT include any medications not currently on the NM DOH State ADAP formulary o Request for payment may NOT include medication co-payments with receipts dated more than 60 days from date of current monthly invoice (i.e., if current IAP billing is due on April 15th, prescriptions receipts cannot be dated before February 15th) o Request for payment may NOT include any medication co-payments for clients enrolled in New Mexico Medical Insurance Pool; case managers are to inform NMMIP clients, if they choose to utilize a retail pharmacy and not the NM DOH state pharmacy, the client will be responsible for all medication co-payments o Medication co-payments will only be made to the pharmacy where the prescription is filled or directly to the client’s credit card company All Requests for Authorization to Pay MUST include the following supporting documentation: o A payment spreadsheet, one for each type of payment requested on behalf of approved clients: private insurance company premiums or HIV medication co- payments. Each spreadsheet will contain the following information: Name of client (last name first name) Membership (certificate) number or social security number Amount of premium or amount of co-pay reimbursement Amount requested to be paid Payee (include company name and full address) Prescription copayment requests will include documentation of proof of co-payment for HIV approved medications (such proof will include an RX number, date filled, name of drug and receipt of payment showing name of pharmacy and payee) NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 24 of 32 Insurance Assistance Program (IAP) (con’t) o If sending payment to a client’s credit card company; a copy of the client’s credit card statement showing medication purchase and co-pay amount is also required By the 20th of each month in which services are to be delivered, NM DOH staff will send the IAP Coordinator an Authorization to Pay memo detailing any changes or denials to the original request o The provider accepts as final any denial of payment by NM DOH for patients not covered by the Eligibility Criteria and for which NM DOH did not provide prior written authorization After receipt of Authorization to Pay from NM DOH, the provider submits an invoice to NM DOH in the total amount approved by NM DOH NM DOH staff submit invoices for processing to reimburse provider for payment of premiums and co-pays Provider issues checks for payment of health insurance premiums and/or medication co- payments to the payee noted on approved documentation o Provider reimburses insurance companies and pharmacies directly; no direct payments may be made to clients. o Direct payment to clients is prohibited Provider assumes responsibility for ensuring that payments are received by insurance companies no later than the 30th of each month in order to be processed before the 1st of the month deadline to ensure no loss or interruption of coverage Provider maintains records of premium and medication co-payments to insurance companies and/or clients for a period of five (5) years Provider accepts the reimbursement rates listed as payment in full for those services and does not bill the client for any remainder of any charges NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 25 of 32 New Mexico Medical Insurance Pool IAP Enrollments & Payments The NM DOH submits payment of premiums directly to BC/BS NMMIP for IAP enrolled clients. NM DOH works closely with NMMIP to ensure the shared client enrollment data is accurate and current. Monthly IAP enrollment lists are provided to the NMMIP contact person who then verifies that each client’s premium amounts are accurate. The NMMIP contact then submits, via secure electronic mail, an invoice to NM DOH. NM DOH staff then submits the invoice for payment. Reconciliation of NMMIP invoice is begun on the 5th of each month. NM DOH staff monitor client IAP enrollments; update premium records based on client birth date each month; submit a list of current client and premiums to be paid to NMMIP contact each month; verify with NMMIP contact that NMMIP has received changes in client enrollments submitted by case managers such as dis-enrollment from program or change of insurance coverage; work with NMMIP contact to reconcile each monthly invoice; and track client utilization and expenditures. NM DOH staff also enters client data in the QS1 pharmacy database including NMMIP data and any detailed notes of client status (dis-enrollments, case manager contact information, etc.) and communicate with the NMMIP contact, state pharmacy and case managers regarding any DOH/IAP/NMMIP enrollment issues. It is the responsibility of the case managers to submit NMMIP applications to NMMIP at the time of DOH enrollment. Case managers are to ensure that clients whose monthly insurance premiums exceed the IAP $600 cap understand that the program cannot exceed the cap and that the client knows the amount due each month, due dates, and remittance address for premium payments. Case managers are responsible to submit IAP applications in a timely manner to NM DOH to enroll the client for premium payment. Case managers are responsible for notifying NMMIP and NMDOH immediately of all dis- enrollments or terminations from the NMMIP and IAP. Any pending dis-enrollments for clients enrolled in IAP/NMMIP, being sent to NM DOH via mail need to be faxed to NM DOH IAP staff so information can be updated immediately. Case managers are responsible to communicate to NM DOH any new NMMIP enrollment or any changes in enrollment status immediately to ensure payment of premiums. Any new NMMIP approval letters, being sent to NM DOH via mail need to be faxed to NM DOH IAP staff so information can be updated immediately and premiums are paid. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 26 of 32 NM DOH State Pharmacy Services Services: NM State Pharmacy is a centralized mail order pharmacy NM State Pharmacy provides medications listed on the NM State ADAP formulary ONLY Clients eligible to utilize state pharmacy services are those enrolled in the Medication Bridge Program and NMMIP ONLY The state pharmacy will supply a client with thirty (30) days of medications ONLY (“vacation” or extended supply requests will be denied) The state pharmacy will NOT mail medications to an address outside of the state of New Mexico Accessing services: Case manager contacts NM DOH HIV Program to enroll client in Medication Bridge Program or submits IAP application providing NMMIP approval documentation NM DOH HIV Program notifies case manager of enrollment approval (or denial) o NM DOH HIV Program staff enters client information into pharmacy database NM State Pharmacy utilizes QS/1 Data Systems prescription database system Physicians fax or call prescriptions into the pharmacy o Medications on the NM ADAP formulary requiring pre-approval must be requested using the ADAP Medication Pre-Approval Request form (Attachment B – for physician/clinic use only) Pharmacy staff fill prescription and prepare for shipment o medications are shipped UPS o shipments cannot be sent to a PO Box; client must provide a residential street address for receipt of medications; in some cases, medications can be shipped directly to physician or HIV clinic In general, clients receive medications within 24 to 48 hours of shipment o In order for refill requests to be mailed out the same day; clients are to call the pharmacy before 3 p.m. o shipments are picked up by UPS between 3 and 4 p.m. each week day o there is no weekend delivery o refrigerated medications will NOT be shipped on a Friday; orders for refrigerated medications will be processed the following Monday The client must call the pharmacy each month to order refills o Refills must be requested seven (7) days prior to running out of medications. It is the client’s responsibility to notify their physician to send the new prescription to pharmacy, when required. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 27 of 32 NM State Pharmacy Services (con’t) Clients who dis-enroll from NM DOH HIV Program, the Insurance Assistance Program or the Medication Bridge Program are no longer eligible to access state pharmacy services. Case managers are to notify NM DOH HIV Program staff immediately if clients obtain other insurance coverage and are no longer eligible for IAP or pharmacy services. It is expected that medical providers and case managers will NOT contact the pharmacy to order new prescriptions without case manager verifying client enrollment in pharmacy services with NM DOH HIV Program staff. Case managers will not advise clients to contact pharmacy to order medications without case manager first verifying client enrollment in pharmacy services with NM DOH HIV Program staff. It is expected that medical providers and case managers will NOT contact the pharmacy to order new prescriptions for any clients who have prescription coverage other than Bridge or NMMIP. It is expected that case managers will NOT contact the pharmacy to try to order prescriptions for any clients known to have NM DOH or IAP enrollments that have enrollment dates that have expired or for clients who are not enrolled in NM DOH and IAP. If the pharmacy staff attempts to fill a prescription, but NMMIP is reporting inactive, they will advise the client to contact their case manager. The case manager will determine if the issue is with NMMIP (i.e., error in premium payment records) or an enrollment issue. If it is a payment issue, the provider IAP Coordinator will provide NM DOH the information needed to process a correction; if it is an enrollment issue, the case manager will need to work with client to provide required enrollment documentation to re-enroll the client in the program. If the pharmacy staff attempts to fill a prescription, but the database is reporting inactive, they will advise the client to contact their case manager. The case manager will determine if the issue is with enrollment status (i.e., client did not complete annual or 6-month enrollment before end date). The case manager will work with client to complete the necessary paperwork and submit to NM DOH to re-enroll the client in services. Under circumstances where a client’s MIP enrollment has lapsed and insurance is lost or back premiums are due, the case manager is to contact the IAP Coordinator. See Interruption or Discontinuation of Services section for details of information and action steps required to address this situation with the program. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 28 of 32 Records Documentation The following information will be kept in each client file: Documentation of HIV positive status Client income level based on FPL and all documents used to verify financial status Statement of no income and all documents used to verify (if applicable) A CD4+ and viral load count which is updated on the yearly ACCESS form (Part C) and the 6-month IAP Recertification form The name of the client’s HIV case manager (an HIV case manager is required for all clients enrolled in the NM DOH HIV program) The name, address and phone number of the client’s primary health care provider (ACCESS form Part C) Completed and signed IAP Application Completed and signed IAP/ADAP Recertification form every six months A copy of client’s insurance card (and prescription benefit card, if separate) Summary of Benefits from client’s insurance company (detailing both medical and prescription benefits and costs) Proof of monthly insurance premium amounts (if applicable) A copy of the IAP enrollment letter NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 29 of 32 Grievance Procedures Types of Grievances Consumers may express their dissatisfaction with the NM ADAP in writing Providers/agencies may express dissatisfaction with the NM ADAP Grievance Process If a consumer, provider or agency wishes to address a concern with a NM ADAP policy, the following procedure is recommended: The consumer, provider or agency is encouraged to address the concern immediately with the NM DOH HIV staff. In the event that the staff cannot resolve the issue, or the client remains concerned after response from NM DOH HIV staff, a written grievance should be forwarded to the HIV Services Program Manager for response If necessary, the NM HIV Services Program Manager will review the concern(s) with the Medical Director, the Infectious Disease Bureau Chief, and/ or the management team, to determine the appropriate response and communicate that response to the NM DOH HIV staff and client within fifteen (15) working days. Filing a Grievance Persons wishing to file a grievance may do so by submitting a written correspondence to the following address: Attention: HIV Services Program Manager HIV Services Program Infectious Disease Bureau, NM Dept of Health 1190 St Francis Dr, S-1200 Santa Fe, NM 87505 NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 30 of 32 Security and Confidentiality Security The physical location of NM ADAP program offices will be maintained in a secure manner. Staff will keep doors secure and all staff will be oriented to appropriate security when answering phones, etc. Client files must be maintained in a secure manner. Security must be ensured if client ADAP data is being cross matched with other databases (i.e. Medicaid registry) Confidentiality All agency confidentiality requirements for patient record information must be followed. All staff must be oriented to appropriate confidentiality precautions when answering phones, talking to clients or other staff, etc. All staff must use discretion and should not discuss sensitive office issues, records or patient cases with anyone other than those involved in NM HIV Services Program. Any known or suspected breaches of confidentiality will be immediately documented and brought to the attention of the employee’s immediate supervisor and/or the Local Privacy Officer (LPO). The LPO will initiate and direct an appropriate course of action HIV patient information may only be released to outside persons or agency representatives when the patient signs a properly completed authorization form. Computers must be password protected. Faxes containing patient identifying information may be received at both NM State Pharmacy and the ADAP Program, since secure fax machines are available. Internal and external documents must not contain the words HIV and/or AIDS except when necessary. Information with patient names and/or any other identifying information that is no longer needed must be shredded. All statistical data released by the NM ADAP must be carefully scrutinized to be sure that no individuals can be identified. The NM Medical Director will designate staff authorized to release statistical and other general information; persons without such authorization must refer queries to an authorized individual. NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 31 of 32 Attachments ATTACHEMENT A: NM State ADAP Medication formulary ATTACHEMENT B: ADAP Medication Pre-Approval Request (for physician/clinic use only) ATTACHEMENT C: 2011 Federal Poverty Guidelines ATTACHEMENT D: IAP Application form ATTACHEMENT E: IAP Recertification form ATTACHEMENT F: ADAP Recertification form ATTACHEMENT G: IAP Client Enrollment Letter ATTACHEMENT H: IAP Client Enrollment Letter Program Explanation (insert – 2 pages) ATTACHEMENT I: Summary of Patient Assistance Programs NMDOH/PHD/HIV Services– AIDS Drug Assistance Program Guidelines Revised April 15, 2011 Page 32 of 32
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