ADAP 102:

1
ADAP 102

• National ADAP TA Meeting
• Beth Crutsinger-Perry, Ann Lefert, Lynne
  Greabell, Angela Seegars, Britten Ginsburg
• July 9, 2008

2
NASTAD Everything You Need To Know, but . . .

• NASTAD mission and vision
• The mission of NASTAD is to strengthen state and
  territory-based leadership, expertise and
  advocacy and bring them to bear on reducing the
  incidence of HIV infection and on providing care
  and support to all who live with HIV/AIDS.
• The vision of NASTAD is a world free of HIV/AIDS.
• Programs
• Care and Treatment
• Prevention
• Viral Hepatitis
• Government Relations
• Racial and Ethnic Health Disparities
• Operations
• Global

3
NASTAD (continued)

• Care and Treatment Team Mission
• NASTADs Care and Treatment program partners with
  state health departments to improve HIV care
  services through information dissemination,
  peer-based education and technical assistance,
  public policy and advocacy, and resource
  development.
• Care and Treatment Staff
• Beth Crutsinger-Perry
• Angela Seegars
• Britten Ginsburg

4
Major Projects

• Major Projects
• ADAP TA Cooperative Agreement
• TA Briefs
• Medicare Part D (survey and TA)
• Emergency Preparedness Guide
• On site TA/Peer Mentoring
• Drug Pricing TA

• National ADAP Monitoring Report
• ADAP/HIV Care Watch
• NASTAD News
• Reauthorization Implementation/Planning
• Part B TA
• MAI Brief
• ADAP TA Meeting
• ADAP Crisis Task Force
• ADAP Advisory Committee

5
National ADAP Monitoring Project Annual Survey
and Report Purpose

• The project documents new developments and
  challenges facing ADAPs, assesses key trends over
  time, and provides the latest available data on
  the status of ADAPs.
• Questions in the survey address topics including
  monthly and annual snapshots of ADAP budgets
  prescription utilization and expenditures
  formulary composition current and programmatic
  cost-containment measures program eligibility
  criteria and program demographics.
• The data collected from the survey will be
  compiled into the National ADAP Monitoring
  Project Annual Report which will be released in
  spring 2009 and will report state specific
  information on all of the topics addressed in the
  survey.

6
National ADAP Monitoring Project Annual Survey
and Report Report

• The National ADAP Monitoring Project Annual
  Report is used by states and the community to
  advocate for ADAP programs and funding.
• States can use the completed report to seek out
  similar programs across the county or to inform
  their program questions.
• Community members, including legislators, use the
  completed report to understand the use of ADAP
  funding.
• NASTAD staff use the report to respond to
  inquiries related to ADAP and to inform the work
  that NASTAD does on behalf of ADAP.

7
National ADAP Monitoring Project Annual Survey
and Report Data Collection

• Survey released August 20, 2008
• Survey returned September 17, 2008
• Report released Spring 2009
• Data from the survey is used in the report and in
  NASTADs daily work representing ADAPs.
• All of the questions in they survey should be
  responded to.

8
ADAP Watch Surveys

• Bi-monthly survey on current cost-containment and
  waiting list status in states.
• Collects information on the addition of new
  medications (if applicable) to ADAP formularies.
• Identifies program expansion efforts in ADAPs.
• At the start of the fiscal year, ascertains if
  Part B funds were shifted to ADAP to maintain
  program.
• Data is collected and released within two weeks,
  resulting in an up-to-date reflection of ADAP
  across the country.

9
Member Services NASTAD Website

• NASTAD Website Features.
• Program Info,
• including ADAP
• Advocacy Info
• Publications
• State-based
• Resources
• State-by-state
• Directory
• NASTAD Positions
• TA Info

10
NASTAD Website

• For health department staff, NASTAD website
• Provides access to health department-only content
  (e.g. NASTAD News)
• Allows you to upload resource materials
• Ability to request NASTAD TA and apply to become
  a peer TA provider
• Allows you to subscribe/unsubscribe to NASTAD
  various NASTAD listservs

11
NASTAD Website

• Access this information by logging in
• Login email address
• Password first name (all lower case)
• Questions, Problems, Log-in Issues? Contact.
• Lynne Greabell lgreabell_at_NASTAD.org
• Ashley Garner agarner_at_NASTAD.org
• [phone]

12
ADAP New Coordinator Welcome Page

• Accessible via NASTADs main page.
• Contains information pertinent to ADAPs.
• Links to all NASTAD documents related to ADAP.

13
ADAP Glossary
The ADAP Glossary and Frequently Asked Questions
(FAQ) were created to serve as an overview for
new/ incoming ADAP coordinators.
14
ADAP FAQ
The ADAP FAQ contains a series of frequently
asked questions and provides feedback that is
succinct and easily understood.
15
ADAP Peer Technical Assistance

• Process to request TA TA is requested through
  self-identification by ADAP, responses to
  surveys, and referrals
• Types of TA TA is delivered through information
  exchange and skills building from self
  identification
• Forms of TA Telephonic/conference calls, emails,
  ADAP and Part B listservs, TA publications,
  shared peer based materials, written reports on
  site visits/ face to face and web based
• Who does the TA TA is conducted by Health
  Department peers expert NASTAD staff and NASTAD
  consultants

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ADAP Peer Technical Assistance (continued)

• Timeframe of TA TA is provided either on a
  one-time, short-term, or long term basis,
  depending on specific need
• Results of TA TA is aimed at increasing
• Individual/organizational capacity of ADAP/ DOH
  staff
• Developing leadership
• Establish peer relationships

17
Medicare Prescription Drug Coverage

• Prescription drug benefit (Part D) began January
  1, 2006
• Drugs provided through private prescription drug
  plans or Medicare Advantage
• Majority of HIV-positive Medicare beneficiaries
  are dual-eligibles
• 1st years filled with implementation challenges
  for all Part D beneficiaries

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Medicare Part D Benefit Design
2006 2007 2008
Deductible Beneficiary is responsible for the deductible payment 250 265 265
Initial Coverage Limit Beneficiary pays 25 percent of total drug costs after the deductible up to this point 2,250 2,400 2,510
Out-of-pocket threshold Beneficiary is responsible for 100 percent of drug costs after reaching the initial coverage limit until they reach the out-of-pocket thresholdthis is known as the doughnut hole 3,600 3,850 4,050
Total Drug Spending Threshold (Catastrophic Limit) After reaching the catastrophic limit in total drugs costs, the beneficiary pays 5 percent coinsurance or a co-pay of 2 for generic drugs and 5 for brand name drugs 5,100 5,451 5,726
Source Centers for Medicare and Medicaid
Services http//www.cms.hhs.gov/MedicareAdvtgSpec
RateStats/07_PartDBenefitParameters.aspTopOfPage
19
Medicare Part D Standard Benefit, 2008
Plan Pays 75
SOURCES Kaiser Family Foundation, Fact Sheet
The Medicare Prescription Drug Benefit, October
2007.
20
Medicare Part D Low Income Subsidies
Low-Income Subsidy Level Monthly Premium Annual Deductible Co-payments
Full-benefit dual eligibles lt100 percent of poverty 0 0 1.05/3.10 /brand-name no co-pays after total drug spending reaches 5,451.25
Full-benefit dual eligibles 0 0 2.25/5.60 /brand-name no co-pays after total drug spending reaches 5,451.25
Institutionalized full-benefit dual eligibles 0 0 No co-pays
Individuals with income lt135 percent of poverty and resources lt7,500/individual 12,000/couple 0 0 2.25/5.60 /brand-name no co-pays after total drug spending reaches 5,451.25
Individuals with income 135 percent -150 percent of poverty Sliding scale based on income 50 15 percent of total costs up to 5,451.25 2.25/5.60 /brand-name thereafter
Note Resources include 1,500/individual and 3,000/couple for funeral and burial expenses. Note Resources include 1,500/individual and 3,000/couple for funeral and burial expenses. Note Resources include 1,500/individual and 3,000/couple for funeral and burial expenses. Note Resources include 1,500/individual and 3,000/couple for funeral and burial expenses.
Source Kaiser Family Foundation summary of Medicare prescription drug benefit low-income subsidies in 2008. Source Kaiser Family Foundation summary of Medicare prescription drug benefit low-income subsidies in 2008. Source Kaiser Family Foundation summary of Medicare prescription drug benefit low-income subsidies in 2008. Source Kaiser Family Foundation summary of Medicare prescription drug benefit low-income subsidies in 2008.
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Medicare Part D Key Points

• With the standard benefit, beneficiaries can only
  change plans once per year during open
  enrollment periods
• All beneficiaries who qualify for Low-Income
  Subsidy (LIS) can change plan once a month with
  effective date the 1st of the next month.
• All plans must cover all antiretrovirals (ARVs)
  in all formulations
• If find that plan does not cover an ARV, need to
  report to CMS Medicare Part D trouble contact
• Prior authorization not allowed on ARVs
• Plans have complete control over tier placement
  of drugs
• If it is felt that a drug is not placed on right
  tier, can go through exceptions and appeals
  process to try to lower its cost

22
Relationship to Ryan White Programs

• Medicare Part D adds another piece to the quilt
  that individuals use to get comprehensive HIV
  care
• As payer of last resort Medicare Part D
  coverage is to be used before services are
  provided through CARE Act
• ADAPs are particularly affected by Part D
• Many ADAPs provide wrap-around services to
  Medicare eligible clients
• In some areas, Part A drug purchasing programs
  and Part C clinics may also play a role in
  providing wrap-around services to Medicare
  beneficiaries
• ADAPs are allowed to provide wrap-around services
  by paying premiums, deductibles, co-insurance and
  co-payments

23
Policies Affecting ADAPs

• ADAP spending (federal or state funds) will not
  count toward true-out-of-pockets costs (TrOOP)
• Clients should be required to enroll in Medicare
  prescription drug plan (PDP) before accessing
  ADAP services (HRSA requirement)
• HRSA is requiring a cost-benefit analysis to
  justify ADAPs wrap-around coverage policy
• although havent heard if they are checking on
  this
• ADAPs have been unable to access LIS information
  in data exchanges with CMS
• ADAPs must coordinate with TrOOP facilitator to
  track payments

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Implementation Challenges for Clients

• Choosing right plan can be overwhelming and
  difficult
• Most regions have over 40 available plans
• Tremendous range in monthly premiums
• Many clients who are dual-eligible are not used
  to paying co-payments and other associated costs
• Past has shown that plans are often not complying
  with CMS regulations
• Some using prior authorization on ARVs
• Disenrollment challenges

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Implementation Challenges for ADAPs

• Policy differs from state to state, due to
  varying structure of ADAPs and different
  distribution systems
• Available resources financial and personnel to
  deal with implementation and ongoing counseling
• Many ADAPs not set up to pay premiums or
  co-payments
• Pharmacy issues for best coordination of
  benefits, ADAPs and clients must ensure that ADAP
  pharmacy and PDP pharmacies are able to
  coordinate
• ADAPs may choose to work with limited number of
  PDPs for this purpose
• Seeing increased co-payments and other costs

26
Implementation Challenges for ADAPs

• Consider different groups of beneficiaries when
  developing policies (low-income subsidy groups)
  policies may differ between populations
• ADAP policy will continue to change as benefit is
  implemented and issues/solutions are identified
  and resources gain or drain is determined
• Need ongoing one-on-one benefits counseling for
  clients brochure or training not sufficient
• Need to be sure clients choose best plan for them
• Requires coordination with ADAP

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Impact on ADAPS

• In 2007, NASTAD surveyed all jurisdictions
  regarding Medicare Part D and its impact on ADAPs
• 38 jurisdictions completed the survey
• 17 of ADAP clients are eligible for Medicare
  Part D (18,346)
• 69 of ADAP clients also eligible for Part D
  qualified for low-income subsidy
• NASTAD estimates that Part D saved between 73
  and 89 million in calendar year 2006

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Medicare-Eligible ADAPs Clients
NOTE Chart 1 includes responses from 25 states.
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Contact Information

• Care and Treatment Program Staff
• Beth Crutsinger-Perry, Associate Director, Care
  and Treatment Program - b crutsinger-perry_at_nastad.
  org
• Ann Lefert, Associate Director, Government
  Relations - alefert_at_nastad.org
• Angela Seegars, Manager, Care and Treatment
  Program - aseegars_at_nastad.org
• Britten Ginsburg, Senior Associate, Care and
  Treatment Program - bginsburg_at_nastad.org
• National Alliance of State and Territorial AIDS
  Directors
• 444 N. Capitol Street, NW
• Suite 339
• Washington, DC  20001
• Phone [phone] 
• Fax [phone]