Attachment 1 - Guidelines for the CDPHE ADAP Insurance Contractor OVERVIEW OF HIAP ASSISTANCE

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1 Attachment 1 - Guidelines for the CDPHE ADAP Insurance Contractor Colorado ADAP contracts out administration and enrollment assistance services for the Health Insurance Assistance Program. This contractor and its subcontractors are intricately involved with the administration of the HIAP plan under the CDPHE AIDS Drug Assistance Program (ADAP). The intent is to ensure that rules are consistent applied, whenever possible, across all the ADAP subprograms: HIV Medication Assistance (HMAP), HIV Insurance Assistance (HIAP), Bridging the Gap Colorado (BTGC), and Supplemental Wrap Around Program (SWAP). To be eligible for any ADAP assistance subprogram, an applicant must be certified as meeting the core eligibility requirements of the Colorado AIDS Drug Assistance Program. CDPHE is the sole authority for making final determination in regard to core ADAP eligibility. OVERVIEW OF HIAP ASSISTANCE HIAP assistance includes payment of insurance premiums, deductibles, co-payments, and co-insurance for eligible individuals with HIV disease who currently have medical insurance or for those who have recently lost their insurance and are eligible to be reinstated (such as Consolidated Omnibus Budget Reconciliation Act or COBRA insurance policies). The eligibility level maximum for annual household income (based on percentage of Federal Poverty Level- or FPL) will be determined by the CDPHE Chief Medical Officer with input provided by the Colorado HIV/AIDS Care Advisory Committee. The current guidelines are set at 400% of FPL. Any change in these guidelines established by the Medical Director will be modified through the use of a unilateral funding letter provided to CDPHE s contracted agency, and communicated to the enrollment agency. Persons on Medicare or Medicaid are not eligible for this program. The annual maximum expenditure in aggregate per eligible Level 1 participant for these insurance premiums, deductibles, co-payments, and coinsurance shall not exceed the annual cost of providing this participant medication through the HIV Medication Assistance Program. The CDPHE Chief Medical Officer will determine this annual maximum expenditure with input provided by the Colorado HIV/AIDS Care Advisory Committee. In general, the current annual cap for insurance premiums, deductibles, co-payments, and co-insurance is $10,000 per client. However, the HRSA/ HAP ADAP manual (version ) states that it is important for the ADAP to remember that the assurance of cost neutrality is required for the aggregate cost of the health insurance program, not for each participating individual. Therefore the Contractor should contact the Health Access Unit Lead Worker at CDPHE with specific cost analysis information and receive official permission prior to exceeding this value. The current monthly premium is capped at $ per month, per individual, or an aggregate annual maximum of $10,000. However, since Colorado ADAP is eligible to file for rebates from pharmaceutical drug manufacturers for all claims for which they make a partial payment, the Contractor is strongly encouraged to dedicate at least some of the $10,000 maximum assistance toward the payment of medication deductibles, co-insurance, and co-payments. HIAP enrollees whose premiums exceed the maximum monthly premium payment amount must coordinate payment of any additional amount with their employer or insurance provider. As in the paragraph above, the Contractor should contact the Health Access Unit Lead Worker at CDPHE with specific cost analysis information and receive official permission prior to exceeding this value. If the HIAP enrollee does not pay the premium excess amount above the monthly cap on time, he/she will not be permitted to hold the enrolling agency, the program s contractor, or CDPHE liable for any discontinuation of insurance. The Contractor will ensure that the regional AIDS Service Organization (ASO) will maintain appropriate Release of Information (ROI) documentation for participants to successfully monitor eligibility and fulfill other program requirements. 5

2 CDPHE will grant limited access to the ADAP Data System for staff and subcontractors of the ADAP Insurance Contractor in order to fulfill duties described in their contract. Access to such data is summarized in Table 1, below. Table 1 Access to ADAP Data System records ADAP subprogram (Ramsell Group Number) HIV Medication Assistance (38002) HIV Insurance Assistance (38003) Bridging the Gap Colorado (38001) Supplemental Wrap Around Program (38007) Report Level Access (various) Documents & Notes Description of data access View only access to client records associated with the local Regional Service Providers. Full access to view, create, edit, and delete records and fields within records. Access to view client records and to create and edit premium payment information. View only access to client records associated with the local Regional Service Providers. Eligibility and Enrollment reports specific to the clients who are associated with the local ASO on their ADAP application/ recertification form View access of all eligibility related documents, as well as invoices, and insurance plan information for enrollees PART ONE ENROLLMENT SERVICES FOR INITIAL AND RECERTIFYING CLIENTS A. Enrollment Services For Clients Seeking Assistance Applying for ADAP for the First Time Clients who have never applied for ADAP in the past have a choice of sites from which to seek assistance. Some clients will come directly to the ADAP Office at CDPHE and some clients will seek the help of their community pharmacist. Some clients will choose to seek help from the CDPHE ADAP Insurance Administrator in Denver (or at the various Regional AIDS Service Organization offices throughout Colorado). For this third group of client, the Contractor is expected to provide the following services. 1) Assist the clients to complete the ADAP First Time Enrollment Form, the most updated version of which is posted at This includes gathering all required documentation. 2) Within 3 days following the receipt of a complete ADAP First Time Enrollment Form, deliver the form and documentation to the ADAP Office at CDPHE. Delivery must be in a secure manner approved by CDPHE, which current includes physical delivery and secure fax, but may include secure in the future. 3) Assess the health insurance coverage options available to the client and identify the option that appears to best meet the pharmacy, medical, and behavioral health needs of the client in the most cost effective manner to ADAP. Additional guidance on assessing plan options may be found later in this Attachment in the section Assessing Health Coverage Options. Such options may include: a. Employer-based health insurance, through their own employer or through another person who could place the client on an employer-based plan (e.g., a spouse s plan); b. A plan available through Connect for Health Colorado; c. A plan available directly from a commercial health insurance company; d. Colorado Medicaid; e. Medicare; f. The HMAP subprogram within ADAP for clients who lack any potential third-party payer. 4) Begin the process of enrolling clients in the coverage that appears to best meet their pharmacy, medical, and behavioral health needs. 6

3 a. If the best coverage option is assessed to be 3a, 3b, or 3c as described above, begin the process of online or paper enrollment. Do NOT commit, or instruct the client to commit, to any form of coverage or to any related financial obligation while the client s eligibility status is pending unless specifically instructed to do so in writing by the CDPHE ADAP Office. b. If the best coverage option is assessed to be 3d, 3e, or 3f as described above, refer the client back to the Colorado ADAP Office for further enrollment steps. 5) Once the client is deemed by the CDPHE ADAP Office to be eligible for ADAP, complete the enrollment process, which includes: a. Providing instruction to the client regarding HIAP and their responsibilities as a recipient of HIAP assistance, as described below in the Client Education and Notification part of this Attachment; b. Utilizing the ADAP Data System to set the plan dates (see Part I, Section F, below) and allocate the available HIAP assistance among premium payments, pharmaceutical copayments, and medical copayments; c. Finalizing the enrollment in the selected health plan as needed, including making arrangements with the client s employer to cover premiums, making initial premium payments to plans, and informing clients of their pharmacy options. B. Enrollment Services For First Time Clients Referred to the Contractor for Further Assistance Some clients who have never applied for ADAP in the past will chose to work directly with the CDPHE ADAP Office to obtain their initial ADAP certification. For these clients, the CDPHE ADAP Office will: 1) Determine the applicant s overall eligibility for ADAP; 2) Assess the health coverage option that appears to best meet the client needs for pharmacy, medical, and behavioral health services; 3) Give clients temporary eligibility for HMAP, pending coverage from another third party payer; 4) Give clients temporary eligibility for HIAP in order to access medications in an expedited manner until they can meet with a Insurance Subsidy Manager to coordinate benefits; 5) Refer the client to the Contractor for further HIAP assistance; 6) Send an with further enrollment instructions to the Contractor s Insurance Subsidy Manager and to the lead Insurance Subsidy Coordinator in the region where the client resides. Once the client is referred, the Contractor will provide the following services: 1) Verify the creditability of the coverage; 2) If the coverage is deemed creditable, utilize the ADAP Data System to set the plan dates (see Part I, Section F, below) and allocate the available HIAP assistance among premium payments, pharmaceutical copayments, and medical copayments. 3) Provide instruction to the client regarding HIAP and their responsibilities as a recipient of HIAP assistance, as described below in the Client Education and Notification part of this Attachment; 4) Finalize the enrollment in the selected health coverage as needed, including making arrangements with the client s employer to cover premiums, making initial premium payments to plans, and informing clients of their pharmacy options. In some instances, the Contractor may have questions or concerns about the health coverage option that was chosen by the client and/or the CDPHE ADAP Office. In these instances, the Contractor will: 1) Convey the question or concern in writing to the CDPHE ADAP Office, specifically addressing why an alternative option might better meet the client s needs for pharmacy, medical, or behavioral health services; 2) If the coverage was assessed by the Contractor not to be creditable, supply documentation to the CDPHE ADAP Office; 3) If instructed to do so by the CDPHE ADAP Office, assist the client in submitting an appeal; 4) As instructed by the CDPHE ADAP Office, continue the client s enrollment process in the original or alternative plan. 7

4 C. Enrollment Services for Recertifying Clients All ADAP enrollees must recertify their eligibility for services every six months. The recertification process is managed and conducted by the CDPHE ADAP Office and the client s recertification status is recorded in the ADAP Data System. In regard to recertification, the Contractor will provide the following services: 1) Utilize the ADAP Data System to identify HIAP enrollees who have failed to submit their semiannual ADAP Recertification Form and are due to lose their HIAP assistance as a result; 2) Make at least three attempts during a one month period to contact and re-engage the ADAP enrollee in recertification; 3) If the ADAP enrollee cannot be located or does not respond after three attempts, utilize the ADAP Data System to terminate premium payments and other forms of HIAP assistance for the enrollee; 4) Inform the CDPHE ADAP Office of the termination of HIAP assistance by ing the Health Access Unit Lead at the CDPHE ADAP Office. This will include the affected enrollee s ADAP Identification Number, a brief description of the attempts at re-engagement, and the rationale for the termination. In some instances, recertification will identify factors that affect an enrollee s ongoing HIAP assistance. For example, an enrollee might become employed by a company that offers health insurance and therefore no longer require coverage through Connect for Health Colorado. In these instances, the CDPHE ADAP Office will: 1) the Contractor s Insurance Subsidy Manager and the lead Insurance Subsidy Coordinator in the region where the client resides describing the situation with instructions on how to proceed; 2) Refer the client to the Contractor for further HIAP assistance; 3) Grant the enrollee temporary HIAP or other assistance, to assure continued access to health care when practical; If so instructed by the CDPHE ADAP Office, the Contractor will: 1) Utilize the ADAP Data System to set the plan dates (see Part I, Section F, below) and allocate the available HIAP assistance among premium payments, pharmaceutical copayments, and medical copayments. 2) Meet as soon as possible with the affected client for follow up actions; 3) Carry out any other required activities described in the sent from the CDPHE ADAP Office. Some ADAP enrollees will be actively de-certified by the CDPHE ADAP Office outside of the recertification period. This is usually because the CDPHE ADAP Office has determined that the client no longer meets ADAP eligibility requirements (e.g., is earning income in excess of the ADAP limit, has moved out of state, etc.). In these instances, the CDPHE ADAP Staff will terminate HIAP assistance in the ADAP Data System and will the Contractor s Insurance Subsidy Manager and the lead Insurance Subsidy Coordinator in the region where the client resides describing the situation and follow up actions, if needed. D. Assessing Health Coverage Options To assess the health coverage options available to a client, the Contractor should utilize the following criteria: 1) The creditability of the health coverage. Only creditable plans are eligible for HIAP assistance. More detailed guidance on assessing creditability is included below in this Attachment. 2) The cost effectiveness to ADAP. In general, if there are plans with roughly equivalent coverage, the lower cost plan is the one on which ADAP will be providing HIAP assistance. 3) Matching of coverage to client expressed needs. Formularies, provider networks, and specific benefits vary from one health plan to another. Two plans may be equivalent in terms of creditability and cost effectiveness, but one plan may have specific types of coverage or network participation that the other plan lacks, and therefore be better suited to meet a client s situation and needs. In terms of creditability, before HIAP funding can be used to support premiums or out-of-pocket costs, the Contractor must assess the health plan for creditability, which includes comprehensiveness, actuarial value, and affordability. 1) Comprehensiveness. The plan must cover the essential health benefits as defined under the Affordable Care Act, as provided by Colorado s benchmark plan. The essential health benefits are: ambulatory patient services; 8

5 emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness and chronic disease management; and pediatric service, including oral and vision care. 2) Actuarial Value. The Contractor should utilize the IRS/HHS Minimum Value Calculation Spreadsheet to determine if a plan meets the minimum actuarial value of 70%. Plans below the 70% level will be considered inadequate and will only be eligible for HIAP assistance through an appeal process (see below). Plans at or above the 70% level will be considered in excess of ADAP limits and will also require an appeal process to be considered for HIAP assistance. A copy of the IRS/HHS Minimum Value Calculation Spreadsheet will be supplied to the Contractor upon request. 3) Affordability. For plans to be considered to be affordable by Colorado ADAP, the annual amount charged for premiums must be less than or equal to 9% of the Modified Adjusted Gross Income for the ADAP enrollee. This is true of employer-based plans, plans offered on the exchange, and any other form of private (commercial) health insurance. In terms of cost effectiveness, Medicaid is usually the lowest cost option available. Clients residing in households at or below 133 percent of the federal poverty level (using the Modified Adjusted Gross Income calculation) will generally be eligible for Colorado Medicaid, and will be required to enroll in that option, with wrap around assistance provided by the SWAP subprogram. Some clients earning more than 133 percent of the federal poverty level may have a choice of coverage between an employer based plan and a plan available on Connect for Health Colorado. Again, unless there are extenuating circumstances, HIAP assistance is only available for the plan that is least costly to ADAP. As part of quality assurance processes, the CDPHE ADAP Office will sample the creditability and cost effectiveness assessments performed by the Contractor. The CDPHE ADAP Office is the final decision maker regarding creditability and cost effectiveness and may reverse a previous decision made by the Contractor. Clients may appeal decisions directly to the CDPHE ADAP, as described in the Appeals section of this Attachment. E. Assisting Clients To Appeal Enrollment Decisions The Contractor may assist clients in filing an appeal with the CDPHE ADAP Office regarding HIAP enrollment, such as: 1) An ADAP enrollee wishes to remain on an employer-based plan that exceeds the 9% limit when there are lower cost plans available through Connect for Health Colorado. 2) An ADAP enrollee prefers a plan offered through Connect for Health Colorado when the enrollee has access to an employer-based plan that is below the 9% limit. 3) An ADAP enrollee prefers a higher-cost plan offered through Connect for Health Colorado when a more affordable plan is available on the exchange. 4) An ADAP enrollee prefers not to enroll in Medicaid, although they appear to be eligible for Medicaid coverage. Regarding commercial or private insurance, an ADAP enrollee may request HIAP assistance for an alternative plan as opposed to a standard plan (based on comprehensiveness, actuarial value, and affordability), but one of the following six situations must be documented -- 1) There is a service that a patient needs, but it is only available on the alternative plan; 2) The alternative plan will cover a needed service that is consistent with the CDPHE Standards of Care, which the standard plan will not cover; 3) The standard plan would result in a long wait period for a needed service (generally defined as sixty days wait, but could be shorter in life-threatening situations); 4) The alternative plan would allow access to a local provider, where the nearest equivalent standard plan provider is outside a 70 mile radius of the client's residence; 5) The client has initiated, but not completed, time-limited treatment for a complex medical condition and switching to the standard plan would require a potentially detrimental change in providers in order to complete the treatment. 9

6 6) It is more cost effective to Colorado ADAP for the client to be on the alternative plan. 7) The client has a credible concern that enrollment in the standard plan might result in an employer or other party learning her or his HIV status or other sensitive information. Depending on which of the criteria that the client documents, the decision to allow an ADAP enrollee to be on an alternative plan might be time-limited. For example, if the ADAP enrollee has initiated, but not completed, time-limited treatment for a complex medical condition, that enrollee might be given permission to remain on an alternative plan only until the treatment is completed, and then be moved to the standard plan during the next open enrollment period. For criteria one through six, ADAP enrollees would need to provide documentation, as determined by the Colorado ADAP Office at CDPHE. Acceptable documentation would include written correspondence from an insurance company, plan sponsor, Connect for Health Colorado, or the ADAP enrollee s current medical provider. For criterion seven, the client will be interviewed by the Colorado ADAP Office. Regarding Medicaid, Colorado ADAP will provide HIAP support for private insurance rather than Medicaid only if private insurance provides something that Medicaid cannot. One of the following six situations must be documented -- 1) There is a service that a patient needs, but it is not available through Medicaid (such as Hepatitis C treatments for people co-infected with HIV and HCV); 2) The private plan will cover a needed service that is consistent with the CDPHE Standards of Care, which Medicaid will not cover; 3) Switching to Medicaid would result in a long wait period for a needed service (generally defined as sixty days wait, but could be shorter in life-threatening situations); 4) The private plan would allow access to a local provider, where the nearest equivalent Medicaid provider is outside a 70 mile radius of the client's residence; 5) The client has initiated, but not completed, time-limited treatment for a complex medical condition and switching to Medicaid would require a potentially detrimental change in providers in order to complete the treatment. 6) It is more cost effective to Colorado ADAP for the client to remain on HIAP and receive private health insurance. ADAP Enrollees would need to document that one or more of the six criteria are true, as determined by the Colorado ADAP Office at CDPHE. Acceptable documentation would include written correspondence from the Colorado Department of Health Care Policy and Financing, county social services, a Medicaid provider, or the ADAP enrollee s current medical provider. CICP is not considered private health insurance and is not treated as such by Colorado ADAP. An ADAP enrollee receiving CICP cannot request HIAP assistance to remain on CICP when they are determined to be eligible for Medicaid. Whenever possible, Colorado ADAP avoids making decisions that result in disruption of an enrollee s existing relationship with a care provider. However, avoiding Medicaid in favor of private insurance is very costly to Colorado ADAP when equivalent services are readily available through Medicaid (i.e., ADAP would be forced to bear the costs of unsubsidized premiums and higher out of pocket costs). Therefore, client preference alone cannot be used as a rationale for remaining on HIAP when the client is eligible for Medicaid. The target accuracy rate for entry of the above-listed data is 90 percent. CDPHE staff will periodically select a sample of records entered by the contractor and identify missing or obviously inaccurate data. If a client refuses to provide the requested data, it will not be counted as an error or omission by the contractor so long as the client refusal is documented in a note in the Ramsell Data System. If the accuracy rate of the contractor consistently falls below 90 percent, CDPHE may withhold payment of administrative costs until the situation is corrected. If evidence suggests that an applicant has used a false name, social security number, birth date or has supplied other false or misleading application information, the ADAP Insurance Contractor is required to promptly notify CDPHE ADAP 10

7 staff so that a fraud investigation can be opened. Applicants that are found to have provided false information with the intent of defrauding ADAP will be immediately and permanently barred from all ADAP assistance. Additional legal actions, including pursuit of a refund of fraudulently acquired benefits, may also be pursued, on advice of legal counsel. The ADAP Insurance Contractor and all subcontractors should verify that information is consistent throughout the application. For example, the name supplied by the applicant should be consistent on all documentation supplied by the applicant (Drivers License, Tax Return, Lease, etc.) Each time the Contractor or a subcontractor changes the eligibility status of an enrollee, the change must be explained with a note in the Ramsell Data System. Other notes are strongly encouraged, such as contacts made with the client, pending information from the client, and further information concerning residency, household size, and household income. F. Setting Plan Start and End Dates For most clients, plan start and end dates should be set in the ADAP Data System as follows: 1) If the client is insured through an employer-based plan, the initial plan start date should be the earliest possible date that their coverage could begin. If the enrollee s plan year is known, the plan start and end dates should reflect those dates. If not known, the plan start and end dates should be entered as a Ryan White Part B grant year (April 1 through March 31). 2) If the client is insured through Connect for Health Colorado, the plan start date should be the earliest possible date that their coverage could begin (which could be January 1 of the next coverage year, if it is outside the open enrollment period). The plan end date should be December 31 of the current calendar year. 3) In the event that insurance coverage does not take effect immediately, the plan start and end dates should be placed into the data system as a Future Plan, with effective dates set accordingly. In some circumstances, an applicant may be enrolled in HIAP for less than six months or may be given a mid-year disenrollment date prior to the next recertification. This would usually occur due to information supplied by the applicant about the start or duration of his or her health insurance coverage. For example, those individuals whose salary increases due to a change in employment in a way that would render them ineligible for an insurance program may be carried on HIAP (through a COBRA policy, etc.) for up to 180 days to cover any pre-existing condition waiver gap in coverage that would preclude the individual from receiving medications. Temporary HIAP enrollment should be thoroughly documented through a note in the Ramsell System and CDPHE ADAP Staff should be promptly notified by (with Ramsell client ID number). PART TWO CLIENT EDUCATION AND NOTIFICATION Clients receiving HIAP services from the Contractor should receive education on and notification of the following at enrollment, recertification, and ongoing throughout the eligibility period, as needed. A. Keeping the CDPHE ADAP Office Informed of changes. 11

8 The Contractor will emphasize the important of client s communicating with the CDPHE ADAP Office whenever there are any of the following types of changes in the information they reported on their First Time Enrollment or most recent Recertification Form: 1) Name changes 2) Changes in mailing or residential address 3) Changes in other contact information 4) Changes in employment or income (projected to be more than 10% annually) 5) Changes in eligibility for or coverage by health insurance, including Medicaid and Medicare 6) Incarceration The Contractors will actively inquire about these changes and will convey change information to the CDPHE ADAP Office as soon as possible. For changes that directly affect HIAP, clients should be asked to supply documentation, such as new Explanations of Benefits, letters explaining premium changes, or letters showing changes in payee addresses to the Contractor. Such documentation should be promptly uploaded into the ADAP Data System. B. Special Responsibilities for Clients Covered through Connect for Health Colorado The Contractor should inform clients of the following if they are insured through Connect for Health Colorado: 1) They MUST take the premium subsidy option. 2) Beginning January 1, 2015 any applicant for ADAP who fails to receive an Advance Premium Tax Credit due to failure to file a tax return will be ineligible for premium assistance under HIAP. The ADAP applicant may continue to be eligible for prescription copayment and prescription coinsurance assistance under HIAP. 3) Clients must report any change in their annual income that is greater than or equal to 10% to Connect for Health Colorado (via phone or on their website), or to request assistance in doing so from their HIAP Eligibility and Enrollment Coordinator. 4) If a HIAP enrollee receives a demand for repayment from the IRS, and the enrollee failed to report an increase in income as required by HIAP, then the enrollee could be personally responsible for the IRS repayment with no assistance from ADAP. If a HIAP enrollee experiences a reduction in income, which results in ADAP paying a higher premium than necessary, the enrollee could receive a reduced ADAP subsidy in a subsequent year (e.g., assistance only with copayments, not premiums). C. The HIAP Formulary and Pharmacy Network The Contractor should acquaint clients with the prescription drug formulary for the Health Insurance Assistance Program, which is posted online at Coinsurance, deductibles, and co-pays for any medication on this formulary may be paid through the Ramsell PBM system so long as there has been a primary payment made by the HIAP enrollee s insurance plan. In the event that the copayment is actually lower than the required amount to be collected in order for an insurance plan to pay on the claim, contact the CDPHE contract monitor to discuss possible reimbursement options. Clients should also be informed that not all pharmacies are part of the HIAP network. The network of pharmacies that can be accessed using the Colorado HIAP prescription drug co-pay card includes the four major HMAP pharmacies (Denver Health, University of Colorado, Walgreens at Rose, and Children s Hospital), as well as the Apothecary in Boulder, all King Soopers/ City Market and Walgreen Pharmacies in Colorado, and several independent pharmacies who have joined the network. The most up to date pharmacy list is available at If an insurance provider requires that a HIAP enrollee utilize a particular mail order facility that is unwilling to join the Ramsell/HIAP network in order to fill prescriptions, the Contractor will work with the non-participating pharmacy 12

9 provider to attempt to manage a pre-payment or direct billing. The HIAP fiscal administrator should then collect information about such claims that enable CDPHE to submit a partial pay rebate request as appropriate. If no work-around proves possible, the enrollee may be moved to the HMAP instead. E. Filling Prescriptions With HIAP Assistance The Contractor should explain to the client that they may receive a temporary HIAP identification card for immediate use. A permanent HIAP identification card will be created by Ramsell Public Health Rx and sent to the client. Permanent cards will typically be received within 7-10 days, and will look similar to the following: Colorado Medication Assistance Program Identification Card Name: Joe Public Current Expiration Date: Identification Number: (HIAP generated #) Group Number: RxBin: PCN: COADAP Clients should be instructed to present this card as well as their individual insurance plan card (for example Humana) to fill their prescriptions at their chosen PDP pharmacy. A card is not required to receive medications if the pharmacy has the appropriate information stored on file. However, the card may be used by an enrollee to confirm that they have met eligibility requirements for other Ryan White Part B funded providers, such as case management agencies. F. Maximum Days Supply of Medications Clients should be informed about the days supply of medication that can obtain with HIAP assistance. Depending on the rules and requirements of the enrollee s individual insurance plan, HIAP will pay up to a 90-day supply of a covered prescription. However, in the event of lost or stolen medications, the enrollee will only be eligible for a 30-day supply replacement under the HMAP. G. Lost or Stolen Medications The Contractor should inform clients how to handle lost or stolen medications. Clients should be assisted to: 1) Submit a request for replacement through their Eligibility/Enrollment worker, or directly through the CDPHE ADAP Office detailing the situation in which the prescription drug was lost or stolen, including a police report if appropriate. 2) If approved by CDPHE, the enrollee will be temporarily placed on the HMAP for one time replacement of the medication through an HMAP network pharmacy. Notes regarding any prescription utilization (in dollar value), prescription maximum, and prescription maximum /plan end dates should be made in order to accommodate return to HIAP after the one time claims have been processed. 3) The HMAP pharmacy will indicate to CDPHE when they have successfully adjudicated the claims so that the CDPHE ADAP staff may return them to the HIAP and return the record to the maintenance access of their eligibility enrollment worker. H. Travel Outside of Colorado The Contractor should inform clients that they may request one of the following accommodations due to temporary travel outside Colorado. 13

10 1) An enrollee may request that medications be sent to a temporary address. The maximum per-incident duration of each request is 30 days and there may be no more than three such requests per calendar year. 2) An enrollee may request up to a 60-day supply of prescribed medications up to twice per year. 3) If a HIAP enrollee is enrolled as a student at an out-of-state educational institution, but retains residency in Colorado, the enrollee may request shipment to the state where he/she attends classes during the period of his/her enrollment. Proof of enrollment at that educational institution may be requested, and the enrollee must also list a valid Colorado residential address on her/his ADAP application or recertification form. I. When A Medication Prescribed By A Physician Is Not Available On The Client s Insurance Plan, But Is Available On The HMAP Formulary The Contractor should inform clients on how to obtain medications that are not on their insurance plan, but are available through HMAP. Clients may direct the following requests to the Colorado ADAP Office: 1) If a patient's insurance does not include the antiretroviral or opportunistic infection medications on the HMAP formulary, the patient may access these medications free of charge at one of the designated HMAP pharmacies. the event that an enrollee s insurance plan does not cover a multi-drug medication (such as Complera) for which all of the component medications are available on their formulary, the enrollee must utilize the alternative provided under the insurance plan. HIAP will not pay the full cost of uncovered drugs in this circumstance. 2) If the enrollee s insurance plan does not include other items on the HMAP formulary, but does allow access to an alternative item in the same drug class, the patient will be instructed to access the alternative item using their insurance plan. In the event that the treating physician provides a written opinion that none of the alternative items that are available on an individual insurance plan are a viable option for their patient (i.e., would cause destabilization, significant side effects, etc.), Colorado ADAP will consider this a situation where there is no alternative item in the same drug class. 3) If an insurance plan does not include other items on the HMAP formulary, nor does the plan include an alternative item in the same drug class, the patient may request access to these items free of charge at one of the designated HMAP pharmacies if there is no way to access the medication through a patient assistance program. PART TWO ADMINISTRATIVE AND CLIENT SERVICE ROLES AND DUTIES OUTSIDE THE ENROLLMENT PERIODS A. Arranging for payments to providers, to support access to needed health services The Contractor will provide assistance to clients to ensure that payments for copayments and coinsurance are made to their health care providers, consistent with HIAP rules and procedures. Clients should be informed about the lead-time that is required to arrange for such payments, particularly if the health care provider has not previously participated in HIAP. A payment request must be generated using the ADAP Data System for each type of payment requested on behalf of approved clients. Each request will contain the following information: 1) Name of client (last name first name) 2) Ramsell ID number 3) Date of service 4) Amount of co-pay or reimbursement 5) Amount requested to be paid 6) Payee (include company name and full address) 7) Prescription copayment requests must include documentation of proof of co-payment for HIAP formulary medications (such proof will include the drug NDC number, RX number, date filled, name of dosage of drug and receipt of payment showing name of pharmacy and payee) 14

11 Federal ADAP funding regulations prohibit the reimbursement of payments of any kind directly to the client receiving those services. In general, therefore, all payment of premiums, co-insurance, deductibles, or co-pays must be made directly to the provider, the insurance company, or a third party administrator. However, State of Colorado funding has been designated to accommodate premium reimbursement directly to enrollees for whom there was no way in which to coordinate directly with the employer or insurance company (because they refused to cooperate, or there is a risk of divulging enrollee HIV status if there appears to be a legitimate fear of discrimination as a result). Reimbursements for premiums must be approved by CDPHE and the HIAP Project Administrator. Verification of the payment (premium, etc.) must be provided to the HIAP fiscal administrator or its subcontracted agencies each and every time prior to reimbursement. Medication co-payments, deductibles, and co-insurance payments made to plans that refuse to accommodate electronic adjudication of claims through the Ramsell database will only be made to the mail order pharmacy where the prescription is filled or if pre-payment is required, reimbursement may be made to the client, or to the Eligibility Enrollment site s credit card should they make the payment on the client s behalf. B. Making timely, accurate HIAP disbursements to health insurance companies, health care providers, employers, and other parties Disbursement requests related to HIAP should be delivered or faxed directly to the ADAP Insurance Contractor by sites conducting HIAP enrollment activities. All monthly HIAP health insurance premium checks should be issued and mailed between the 15 th and the 25 th of the month prior to their due date (Example: checks due May 1 would be issued between April 15 and April 25). All quarterly HIAP health insurance premium checks will follow the same rules as above; but will be issued once a quarter rather than monthly, being paid in the month prior to their due date. For clients newly enrolled in HIAP, the first health insurance premium payment shall be made by the ADAP Insurance Contractor issuing a check within three (3) days of receipt of information and will thereafter follow the normal routine for premium payments. Exceptions should be made whenever possible for urgently needed payments, including those necessary to avoid loss of insurance coverage. The ADAP Insurance Contractor should receive, review and generate a check for all medical visit co-pays, pharmacy copays or deductibles with a normal five (5) business day turnaround time from the date received. Such review will include verification that client has not yet reached the maximum allowed under this program, as described in the Assistance Limits section of these guidelines. Exceptions should be made whenever possible for urgently needed payments, including those necessary to be paid prior to a service being delivered to the enrollee. In general, if a payment is requested by an enrollee that has been continuously enrolled in the program for a service within that time when they were enrolled, a payment may be made for a past due service. The Eligibility Enrollment Worker should consult with the HIAP Fiscal Administrator to determine whether payment is appropriate, particularly if payment is required to continue to seek services at the facility. However, if a payment has already been sent to collections, and the medical provider itself would not be the entity that received payment for the service (a collection agency would be the beneficiary), such payments are not allowed. To the extent possible, payments for services billed to enrollees should be paid within the grant contract year in which they occurred. The Heath Access Unit Lead should approve invoices received significantly outside of this parameter. C. Maintaining records and supplying needed reports 15

12 The ADAP Insurance Contractor must maintain adequate financial and client records to enable CDPHE to assess the quality of services and to follow up on specific client issues or problems. In regard to disbursements made in conjunction with their ADAP Insurance contract, the Contractor must maintain check stubs for all payments made on a client s behalf should there be a question of a check being issued. The Contractor should also be prepared to respond promptly to requests from CDPHE or insurance counseling sites for retrieval of copies of cancelled checks should it be necessary as proof of payment having been made for either a client s monthly health insurance premium, medical co-pay or deductible. The ADAP Insurance Contractor must generate and deliver reports that are essential to the operation and monitoring of funded services, to include the following: 1) A Monthly Premiums and Expenses Report detailing all payments (premiums, co-pays and deductibles) made on behalf of clients. This report will be due on the tenth day following the close of each month. 2) A Monthly Enrollment Report showing clients enrolled by each site and associated premiums, to be used by the enrollment sites to verify that all expected clients are listed with accurate premium information. This report will be due on the tenth day following the close of each month. 3) Reports requested by CDPHE to allow it to meet federal reporting requirements. These will be due by the 15 th day following the close of each calendar quarter. 4) Reports requested by CDPHE to allow it to meet state reporting requirements. These reports will be due within 20 calendar days following a written request from CDPHE. D. Minimizing Negative Consequences from Unintentional errors and omissions The Contractor will act with due care to prevent negative consequences to clients due to unintentional errors and omissions on the part of Contractor staff and subcontractors, such as the failure to pay an insurance premium in a timely manner, resulting in permanent loss of health insurance coverage. The Contractor must report all errors and omissions that result in negative client effects within 2 business days following their detection by Contractor staff. At its discretion, CDPHE may conduct an investigation of such incidents and may require the Contractor to implement additional controls to prevent recurrence. Serious, unresolved issues that result in repeated negative consequences to clients may result in additional actions allowed under the Contract, including but not limited to withholding of administrative cost reimbursement, contract modifications, or contract cancellation. E. Storing Documents in the Colorado ADAP / Ramsell Database Naming Conventions- ALL PLANS Scanned documents should be opened with Adobe Acrobat and immediately converted into PDF format. Once the ADAP ID Number of the client is known, the PDF version of the application should be saved in a secure portion of the CDPHE (or Regional AIDS Service Provider s computer system) pending upload into the Ramsell data system. It is up to the Contractor to determine if, or how long, they wish to store paper or electronic versions of documents uploaded into the Ramsell system locally in a secured fashion. Documents should be uploaded to the system at the point of data entry whenever possible so that other eligibility staff may review them as needed. However, they should be uploaded within 3 days of data entry barring unforeseen technical barriers (scanner is down, etc.). During times of unusually high activity (such as open enrollment periods), the Contractor should make every effort to upload documents within 10 days. The name of the saved document should be the eleven digits of the ADAP (Ramsell) client ID, plus a two-digit month code, plus a two-digit year code, plus a document type identifier, followed by the PDF file extension. The month and year codes should be the month and year in which the document was processed, in the format mmyy. F. Informing the CDPHE ADAP Office of Client Factors Impacting Eligibility 16

13 In the course of performing the services outlined in this agreement, the Contractor may become aware of client factors that affect the client s continued eligibility for ADAP or the type of ADAP assistance that should be offered to the client. These factors should be reported to the CDPHE ADAP Office within 5 business days of their becoming known to the Contractor. Such client factors include: 1) Death of the client; 2) Change in the place of residence of the client, particularly outside Colorado; 3) Change in access to health insurance coverage (due to changes in employer, marriage, divorce, etc.); 4) Change in income level; 5) Change in household composition; 6) Potential error, omission, misrepresentation, deception, or fraud; 7) Other factors that could impact ADAP eligibility or health coverage. The document type identifiers are: a ADAP First Time Enrollment or ADAP 6 month Recertification form (regardless of whether it is HMAP, BTGC, HIAP or SWAP) ao A document to be attached to the ADAP Eligibility Form, such as proof of income not included in original application/ recertification. ao1 Another document to be attached to the ADAP Eligibility Form. Subsequent addenda will be numbered sequentially (ao2, ao3, ao4, etc.) bta Bridging the Gap application bto A document to be attached to the Bridging the Gap application, such as the Medicare Part D Card. bt1 Another document to be attached to the Bridging the Gap application. Subsequent addenda will be numbered sequentially (bt2, bt3, bt4, etc.) bti Bridging the Gap invoice, such as a Part D or Medicare Advantage plan monthly invoice or past-due notice. hia Agency Specific enrollment forms such as ROI, Policy and Procedure Documents, Grievance Procedures hpi Insurance Premium invoice or related document hci Insurance Co-pay invoice (medical or prescription paid through CAP system). hio Insurance other, such as historical applications and other documents from file (not current). G. Making Adequate Notes in the ADAP Data System It is essential that all eligibility enrollment staff with access to enter or change data in the Ramsell system enter specific notes as to any activity related to the eligibility of a client. Notes should also be entered regarding client contacts, discussions with pharmacy providers, and other information that might prove necessary or useful to any other enrollment staff, ADAP administration, or the Pharmacy Benefit Management staff. Notes regarding any questions or concerns that arise out of audit of client records or prescription claims will be placed into the Ramsell notes field and an will be generated to the Eligibility Enrollment staff using the appropriate Ramsell issued client ID number. H. Coordinating with HIV Case Management Services Medical or Non-Medical Case Managers will encourage eligible clients to enroll in the appropriate subprogram within the Colorado AIDS Drug Assistance Program, and will assist the client in remaining enrolled. Medical Case Managers will 17

14 also assist the client in successfully adhering to their medication regimens. All those involved in ADAP should work in a close partnership with providers and case managers to support the client s successful utilization of available benefits. All Colorado ADAP enrolled clients are strongly encouraged to be enrolled in HIV case management with a HIV Service provider. I. Early Intervention Linkage to Care Efforts On rare occasions, an individual is diagnosed with HIV or AIDS through an emergency hospitalization. Case Managers and Social Workers may request to facilitate ADAP enrollment for a patient prior to discharge from the hospitalization to assure continued access. The use of CDPHE linkage to care staff to facilitate this process, as well as to address any other emergency financial need is strongly encouraged to assure that the patient is not lost to care. J. Contacting applicants, case managers, employers, and others If applicants, case managers, employers, and others must be contacted in order to verify or obtain information essential for HIAP eligibility or delivery of assistance, the following protocol must be followed. 1) If the application was submitted directly by the applicant, and missing information is obtainable from the applicant him/herself, three attempts at least 6 hours apart must be made prior to contacting other individuals, such as the case manager or emergency contact. 2) Case managers should be contacted before emergency contacts, when available. 3) Calls to employers and emergency contacts should be done with the utmost concern for client confidentiality. Applicant HIV serostatus should never be disclosed to an employer or emergency contact. 4) Only the minimal information required to correct errors and omissions or otherwise aid the eligibility determination should be requested. 5) The Care and Treatment Program Manager or Health Access Unit Lead Worker at CDPHE can grant exceptions to these protocols in extraordinary circumstances, when the health or safety of the applicant or other person is at immediate risk. K. Transfer of Colorado ADAP enrollees between Eligibility / Enrollment and Case Management Sites: If a HIAP enrollee moves to a different region within the state, it is the responsibility of the client s current HIAP Eligibility Enrollment Worker, when processing a client s request to transfer to another region, to notify both the ADAP at CDPHE and the Eligibility Enrollment worker in the appropriate region. CDPHE Staff will associate the client with the appropriate person in their new region within the Ramsell data base. If the client is currently within their 6 month recertification period, the new worker will take over the responsibility for assuring that they remain in good standing from the point of that transfer. If a HIAP enrollee loses access to insurance (due to a COBRA policy ending, failure to make a premium payment on time, the client became eligible for Medicaid or Medicare), the Eligibility Enrollment Worker at that agency will notify the ADAP staff at CDPHE explaining the circumstances in which the insurance was lost, and facilitate the transfer of the client to the appropriate subprogram under ADAP. L. Working with Incarcerated Clients Individuals who are incarcerated in the Colorado 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 Colorado ADAP. However, HIV clients incarcerated in county jails are eligible to maintain their current enrollment in HIV case management; and if enrolled in HIAP, can maintain their current enrollment in that program short term so long as 18