Self Employeed Application by ufm89218

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									COMMONWEALTH OF PENNSYLVANIA
 DEPARTMENT OF PUBLIC WELFARE
           SPECIAL
       PHARMACEUTICAL
          BENEFITS
          PROGRAM



        S
       P B
        P
       What is the SPBP?
A state and federally funded drug assistance
   program for low and moderate income
    individuals and families that pays for
 specific drug therapies for the treatment of
persons living with HIV/AIDS or a DSM IV
        diagnosis for schizophrenia.
      SPECIAL PHARMACEUTICAL
        BENEFITS PROGRAM
               SPBP

         SPBP/ADAP ADAP/SPBP
• REMEMBER IN MOST OTHER STATES
  THIS PROGRAM IS CALLED
  AIDS DRUG ASSISTANCE PROGRAM
                  ADAP
• IN PENNSYLVANIA IT IS CALLED THE
   SPECIAL PHARMACEUTICAL BENEFITS
  PROGRAM
                 SPBP
     COVERS DRUGS FOR HIV/AIDS AND
             SCHIZOPHRENIA
    Recent Developments
•    Annual Re-Certification

•    Current vs New Process

•    Medicare Part D Pennsylvania
      Participating Plans
    WHAT ARE THE CRITERIA FOR
    RE-CERTIFICATION TO SPBP?

          RESIDENCE                   INCOME
       APPLICANTS MUST BE A          THE CURRENT
         RESIDENT OF THE              CEILING IS
         COMMONWEALTH                 $30k WITH A
       NOT INSTITUTIONALIZED       FAMILY ALLOWANCE



•                              •
             SOCIAL                  MEDICAL
            SECURITY                  NEED
            NUMBER                    APPLICANTS
                                       DIAGNOSIS
             CLIENT INFO
                                      CONFIRMED
          ALREADY ON FILE
                                       IN PAST
           NOT NECESSARY
       SUPPORTING
     DOCUMENTATION

• EACH APPLICATION MUST INCLUDE
  SUPPORTING DOCUMENTATION.

• CLIENTS ARE RESPONSIBLE FOR
  PROVIDING CLEAR and LEGIBLE
  PHOTOCOPIES OF SUPPORTING
  DOCUMENTS FOR THE CRITERIA
RESIDENCE
    APPLICANTS MUST PROVIDE DOCUMENTATION
    SHOWING PROOF OF RESIDENCY IN
    PENNSYLVANIA
    EXAMPLES OF SUPPORTING DOCUMENTATION:
           UTILITY BILLS
           CABLE TV BILLS
           DRIVER’S LICENSE
           BANK STATEMENT
           SOCIAL SECURITY OR UNEMPLOYMENT
             AWARD LETTERS
           WRITTEN VERIFICATION FROM FAMILY MEMBERS,
             PARTNERS, HOMELESS SHELTERS, ETC.

    THE ADDRESS ON SUPPORTING DOCUMENTATION
    MUST MATCH THE ADDRESS ON THE APPLICATION
INCOME
  APPLICANTS MUST PROVIDE DOCUMENTATION
  SHOWING PROOF OF INCOME. INCOME CRITERIA IS
  BASED ON GROSS AMOUNT. CURRENTLY, THE
  CEILING IS $30,000 FOR INDIVIDUALS AND AN
  ALLOWANCE OF $2,480 FOR APPLICABLE FAMILY
  MEMBERS. FAMILY is defined on the application.


  EXAMPLES OF SUPPORTING DOCUMENTATION
         CURRENT PAY STUBS
         A LETTER FROM EMPLOYER(S)
         SOCIAL SECURITY OR UMEMPLOYMENT
           AWARD LETTER
         LEDGER SHEETS FROM AN ACCOUNTANT
         IN SOME CASES, INCOME TAX RECORDS

  SELF EMPLOYEED INDIVIDUALS MUST PROVIDE FINANCIAL
  INFORMATION THAT INCLUDES INCOME RECORDS 90 DAYS
  PRIOR TO THE DATE OF APPLICATION TO THE SPBP
WHAT IF THERE IS $0 INCOME ?
 The application will be determined pending and
   the applicant will be sent a letter to provide
SPBP staff with a letter detailing how daily needs
                 are being met.

For example, if a client’s friends, family, partner or
    homeless shelter is providing support, that
 information should be indicated in a letter sent
               with the application.
STATUS
   APPROVED: CLIENT IS SENT A LETTER
             WITH AN ELEGIBILITY CARD
             ATTACHED

   PENDING:   CLIENT IS SENT A LETTER
              WITH INSTRUCTIONS TO
              SUBMIT MISSING
              DOCUMENTATION

   DENIED:    CLIENT IS SENT A LETTER
              EXPLAINING WHY THE
              APPLICATION IS DENIED AND
              INSTRUCTED TO REAPPLY
              IF CIRCUMSTANCES CHANGE

   NOTE:      CASE MANAGERS, SOCIAL
              WORKERS, ET AL. DO NOT
              RECEIVE COPIES OF THIS
              INFORMATION (PLEASE ASK
              YOUR CLIENT)
SPBP MH Covered Drugs

         ABILIFY
        CLOZARIL
         GEODON
        RISPERDAL
        SEROQUEL
        ZYPREXA
Client Name and
SPBP ID Number
      Medicare PART D Plans
Participating Plans are those that
                                                    12 Plans
   have made special agreements with       1.       AmeriHealth Advantage
   the state of PA to accept payment           2.    First Health Premier
   of premiums for clients that are              3.   Humana Standard
   enrolled in PA servicing programs,
                                                4.    Humana Enhanced
   i.e. SPBP and PACE clients
                                             5.     Highmark BlueRX Plus
                                        6.      Memberhealth Comm Care RX
Partnering Plans are also referred                          Basic
   to as PA Participating Plans           7.      Ovations United Health RX
                                                            Basic
    Why 12 Specific Plans???            8.      Ovations AARP Medicare RX
                                                            Saver
      • Cost Effectiveness
                                        9.      Ovations AARP Medicare RX
 • Monitoring is More Manageable
                                           10. Elder Health Bravo RX II
  • Controlled # of Plans Ensures               11. Geisinger Gold RX
   Seamless Coordination of Benefits
                                               12. UPMC for Life PDP
             for Clients
  Premium Payments
• SPBP Notification from Clients
  – Clients need to notify SPBP of what
    Part D plan they have chosen
  – SPBP contacts claim processor and
    claim processor contacts plan
  – Premium payments paid by SPBP
    CONTACT US !
SPBP:                 TOLL FREE IN STATE     1.800.922.9384

SPBP ADDRESS:                  P.O. BOX 8021
                               HARRISBURG, PA. 17105-8021
www.dpw.state.pa.us/omap:
• Click on HIV/AIDS Information click Special Pharmaceutical Benefits
Program (SPBP) HIV Drugs or Clozaril Program
• Click SPBP Program Application with bolded area Atypical
Antipsychotic Medication and printout

SPBP Email:           spbp@state.pa.us

John Folby, Admin    Daneen Williams/Santos Osario, Coordinators
              Brenda Mitchell, SPBP Assistant

Any Office of Medical Assistance Pgm inquiries pamedicaid@state.pa.us
Medicare Questions:    1-800-633-4227      www.medicare.gov

								
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