Texas HIV State Pharmacy Assistance Program

1
Texas HIV State Pharmacy Assistance Program

• Katherine Wells, MPH
• AA Conference Call
• December 7, 2007

2
Presentation Objectives

• Define a State Pharmacy Assistance Program (SPAP)
• Discuss reasons for developing an SPAP
• Review SPAP benefit eligibility criteria
• Discuss what clients/agencies can do now

3
What is an SPAP?

• State funded program that helps the elderly and
  disabled access prescription medications
• 25 states have some type of SPAP
• Most provide medications or financial assistance
  with out-of-pocket costs
• Are certified by the Centers for Medicare and
  Medicaid Services (CMS)

4
Why do we need an SPAP?

• To help THMP clients with Medicare utilize the
  Medicare Part D drug benefit.

5
Medicare Modernization Act 2003

• Created Medicare Part D
• Allows SPAP to wrap around the Medicare Part D
  prescription drug benefit to fill in gaps in
  coverage
• SPAP assistance counts as True Out of Pocket
  Costs (TrOOP) to be counted toward a
  beneficiaries' out of pocket threshold
• Restricts ADAPs contributions from counting as
  TrOOP

6
THMP Medicare Part D

• In December 2005 3,300 (25) of THMP clients
  were Medicare Beneficiaries
• 2,200 clients were eligible for the LIS/Extra
  Help and were transitioned to Medicare Part D
• All clients with Medicare not deemed eligible
  for the LIS/Extra Help were required to apply for
  the assistance and submit SSA determination
  letter
• 850 Medicare eligible clients remain on THMP

7
THMP Medicare Part D

• Payments made by the THMP will not count toward a
  clients TrOOP
• THMP did not have the infrastructure to interface
  with Medicare, Medicare Part D Plans and
  pharmacies to pay Part D costs on behalf of
  clients

8
THMP Medicare Part D

• Solution develop a State Pharmacy Assistance
  Program
• Will serve clients who are currently being served
  by THMP with Medicare
• Will use existing state general revenue
• Instead of THMP paying 100 of the HIV medication
  costs, the SPAP will coordinate with Medicare
  Part D Plans and will pay a portion of the costs

9
Texas HIV SPAP - Status

• Anticipated launch January 1, 2008
• Signed a contract with Public Health Service
  Bureau to interface with Medicare on behalf of
  THMP
• Currently developing a Pharmacy Network
• Have begun to notify clients about the program

10
Texas HIV Medication Program
Texas HIV State Pharmacy Assistance Program
(SPAP) Clients eligible for Medicare
AIDS Drug Assistance Program (ADAP)Clients not
eligible for Medicare
11
SPAP Enrollee Distribution
Estimated Texas HIV SPAP enrollment, based on
clients with Medicare currently enrolled in the
THMP
12
Texas HIV SPAP Benefit

• The SPAP will cover the out-of-pocket costs for
  an enrollee for medications covered on the
  enrollees Part D plan formulary
• Out-of-pocket costs include
• Deductible
• Co-payments
• Medications during the coverage gap
• Co-payments/coinsurance after reaching
  catastrophic coverage

13
Texas HIV SPAP Benefit

• SPAP recipients can enroll in any Medicare Part D
  plan offered in Texas
• SPAP recipients will be responsible for monthly
  Prescription Drug Plan Premiums
• The SPAP cannot assist with medications not on
  the individuals Part D formulary
• The beneficiary must maintain enrollment in a
  Part D plan in order to access services from the
  THMP

14
Texas HIV SPAP Benefit

• Annual allowable amount per SPAP enrollee for
  2008 9,986

High End Risk Example
15
Medicare Part D Plan Enrollment

• Medicare open enrollment is from Nov 15 to Dec 31
• A one time Special Enrollment Period (SEP) will
  be available after Dec 31 for newly enrolled SPAP
  clients

16
Medicare Part D Plan Enrollment

• Before enrolling in a plan, the SPAP member needs
  to verify the plan covers their prescribed
  medications.
• You can enroll by
• Calling the plan directly
• Calling 1-800-MEDICARE
• Online at www.Medicare.gov
• You can apply for the Low-Income Subsidy/Extra
  Help through Social Security by
• Calling 1-800-772-1213
• Online at www.ssa.gov

17
Texas HIV SPAP Eligibility

• Meet all THMP eligibility requirements
• Texas resident
• HIV-positive
• Low Income adjusted gross income less than 200
  of the Federal Poverty Level
• (20,420 for a single person for 2007)
• Uninsured or underinsured for prescription drugs
• Eligible for Medicare
• Enrolled in a Part D Prescription Drug Plan
• Denied the full Low Income Subsidy/Extra Help

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How to apply for the SPAP

• SPAP eligibility is determined by THMP staff
• Complete the Texas HIV SPAP Enrollment form
• Submit a copy of the LIS partial approval or
  denial letter from SSA
• If not currently enrolled in the THMP a complete
  THMP application must also be submitted
• Applications can be printed from the THMP
  website www.dshs.state.tx.us/hivstd/meds

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Accessing Medications

• All SPAP recipients will receive a welcome
  packet, which will include an ID Card and
  participating pharmacy information
• Recipient will take their ID cards and
  prescriptions to a participating pharmacy
• Pharmacist will process prescriptions through the
  Part D Plan
• If medications are approved, remaining
  out-of-pocket costs will be billed to SPAP

20
What clients need to do now

• Enroll in a Medicare Part D Plan
• Apply for the LIS/Extra Help
• Notify the THMP-SPAP if they become eligible for
  Medicare
• Seek assistance from community agencies if help
  with monthly premiums is needed

21
Helpful Websites

• Texas HIV Medication Program Website
• www.dshs.state.tx.us/hivstd/meds
• Low Income Subsidy Application
• www.ssa.gov or 1-800-772-1213
• Medicare, including Part D Plan finder and
  enrollment information
• www.medicare.gov

22
SPAP Questions

• Texas HIV Medication Program
• 1-800-255-1090
• Katherine Wells - ext 3008
• Tara Geotas - ext 3004
• Becky Ruiz - ext 3006 (Spanish speaking)
• Public Health Service Bureau
• Help Desk - 1-888-311-7632