1. Texas HIV Medication Program
THMP 101 with a Focus on Special Populations Eligibility
Presented by:
Marivel Cantu-Ressler, BSW

2. Presentation Outline
Overview of the Texas HIV Medication Program (THMP) including ADAP, SPAP and TIAP
THMP Application Process and Enrollment
Identification and discussion of challenging areas on the THMP application.

3. HIV Medication Resources
Private Insurance
Patient Assistance Programs
Medicare
Medicaid
Local Assistance Programs
THMP as the payer of last resort

4. Texas HIV Medication Program
Program established in 1987
Provides life-sustaining medications used for the treatment of HIV disease and its related complications to eligible low income Texans
Key Philosophies –Access to care and Retention in care
Administered by the HIV/STD Prevention and Care Branch within the Texas Department of State Health Services (DSHS)
Mandated under Chapter 85 of the Health and Safety Code
Authorized by the Federal Ryan White CARE Act, 42 USC, Section 300
Consists of two programs and a pilot program
AIDS Drug Assistance Program (ADAP)
State Pharmacy Assistance Program (SPAP)
Texas Insurance Assistance Program (TIAP)

5. Current Enrollment 19,597 unique clients served in State FY15
17,364 ADAP
2,182 SPAP and 300 TIAP Pilot
Programs are open to new enrollment/No waiting list
Clients served has increased significantly from 5,106 in 1996 to the 19,597 in 2015

6. THMP Eligibility Proof of Texas residency HIV Diagnosis
Uninsured or underinsured for prescription drugs
Low income – *Adjusted gross income less than 200% of the Federal Poverty Level (adjusted annually)
$23,540/year for a single person
$ 8,320/year for each + family member
* A spend-down calculation is applied to applicants’ gross income to determine an adjusted gross income for eligibility screening

7. THMP Application Processing
Applications are completed by clients, often with the assistance of a case manager, and reviewed by eligibility staff. A Medical Certification Form (MCF) must be filled out by the doctor
The applicant and/or their designated authorized person will be contacted if further information is needed, including information for SPAP or TIAP Pilot enrollment.
Once the application is processed, the applicant will be notified of the decision by mail.
If denied by the THMP, the denial letter can be used to access other assistance programs

8. Expedited Processing for Special Populations
In some instances applications can be expedited. The program will allow faxing for applications that meet the following requirements:
Pregnant Women
Children Under 18 Years of Age
Post-Incarcerated/Recently Released
CD4 Count Under 100
Insured or Recently Insured
Medicare
Recertification Applications
Urgent Situations (Identified by Staff)
Note: In order for an expedited application to be approved it must be complete and the applicant must meet all eligibility guidelines.
Expedited Processing for Special Populations

9. Texas HIV Medication Program
AIDS Drug
Assistance Program
(ADAP) Clients not eligible
for Medicare
Texas HIV
State Pharmacy
Assistance Program
(SPAP)
Clients eligible
for Medicare
17th HIV/STD Conference
May 2010

10. Texas ADAP Funded by Federal Ryan White and State General Revenue
Provides ADAP formulary medications to eligible individuals
50 drugs on Formulary
All ARV’s on the formulary are FDA approved
Limits on the number of antiretroviral medications a client can receive (4 per month)

11. Accessing Medications
Medications are distributed through a network of over 500 pharmacies located throughout the state
Mail order option is available
Pharmacies may charge a dispensing fee per prescription
A pharmacy cannot refuse service if a client is unable to pay
A list of participating ADAP pharmacies can be found at: s/pdf/pharlist.pdf

12. Accessing Medications
Each client approved to receive medication from the program will receive a letter containing:
A unique 6-digit client code number
The name and address of his/her assigned pharmacy
List of approved medications
Instructions for receiving medications from the program

13. ADAP Participating Pharmacies
Medications are dispensed in full bottle amounts
Pharmacies may charge a $5.00 dispensing fee per prescription
Clients concurrently approved for Medicaid must first utilize their Medicaid prescription benefits in order to receive THMP medications
Dispensing fees are not charged to a client concurrently approved for Medicaid

14. Texas HIV SPAP and TIAP Pilot
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
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.

15. Texas HIV SPAP/TIAP Benefit
The SPAP and TIAP will cover the out-of- pocket costs for an enrollee for medications covered on the enrollees’ Part D plan formulary or health insurance plan formulary – Excludes meds not covered by Medicare
Out-of-pocket costs include:
Deductibles, Co-payments
Medications during the coverage gap/donut hole
Co-payments/coinsurance after reaching catastrophic coverage
Enrollees are not responsible for the plan premiums under COBRA, but are under SPAP and participation in plans with unaffordable prescription copayments (usually employer-sponsored health plans)
Participants use a network pharmacy – a network of over 2,000 pharmacies in TX
Texas HIV SPAP/TIAP Benefit

16. Recertification
Purpose: To ensure that program enrollees continue to meet eligibility criteria
Required by our federal Ryan White funder, the Health Resources and Services Administration (HRSA)
Recertification is required every six months for ADAP and SPAP

17. Application Processing MAI Clients Post-incarceration
TDCJ clients contact THMP upon release and apps are generally processed within a few days.
Note: In order for an app to be approved it must be complete and the applicant must meet all eligibility guidelines.
Once approved, THMP contacts assigned pharmacy to request transfer of TDCJ prescriptions.
Faxed medication orders are processed, pharmacy receives order shipment in 3- 4 business days
Clients are recertified 6 months after THMP approval

18. Application Processing Post-incarceration
Fill out the THMP application
Application can be downloaded from the web: or contact the THMP to have a packet sent
Have the Medical Certification Form (MCF) filled out by doctor
Mail or fax the application and supporting documentation to the THMP
Be sure to indicate recently released on application ( fully complete question #12 on application)
Once the application is processed, the applicant will be notified of the decision by mail.

19. THMP Application Processing Challenges
Incomplete application, missing pages or has blanks
Application NOT signed
Missing or inadequate verification of income
Unclear, incomplete, inconsistent representation of household situation, family members, and/or marital status
Inadequate proof of Texas residency
Insurance/prescription status issues
Missing Supporter Statement
Missing or incomplete Medical Certification Form (MCF)

20. What Can Be Done?
The client is encouraged to explain in writing as much as possible to clarify any part of the application pertaining to them, especially:
Household information
Marital status (if separated, give detailed information about how long, where spouse is, etc.)
Employment situation, especially if not employed (written explanation of when/where last employed)
Support documentation, if zero income a completed THMP Supporter Statement is preferable or any other written support document or statement

21. What Can Be Done?
Note that additional documentation from Social Workers, Case Managers, LVN’s, RN’s will continue to be needed to clarify any unusual or complicated situations a client may be in
Applications must be completed fully, no blank spaces or marks across pages or areas, questions must be answered completely
If the client is uncertain about what the THMP requires in a given situation, they can call and request clarification from our eligibility staff

22. Questions? Comments?

23. Train Texas https://tx.train.org
State employees and non-state employees can create an account
address is used as the Login Name
Once on site
Course Title: Texas HIV Medication update
Couse ID Number:

24. Phone: 1-800-255-1090 Eligibility Fax: 512-533-3178 Website: www. dshs
Phone: Eligibility Fax: Website:
THMP Contact Information
Staff
Area of Expertise
Contact Number
Becky
Spanish, Insurance
Christine
Insurance, Post- Incarcerated
Eric
Recertification Lead
Heather
Data Manager
Imelda
Spanish, Eligibility
Juliet
SPAP Coordinator
Krystal
Eligibility
Marivel
Spanish, Post-Incarcerated
Mary
Pharmacy Coordinator
Rachel
Program Manager