South Carolina AIDS Insurance Assistance Program

1
South Carolina AIDS Insurance Assistance Program

• Program Overview
• August 2006

2
South Carolina AIDS Insurance Assistance Program

• SC has high risk insurance pool, but insurance
  pool unavailable for ADAP to purchase insurance
  for PLWHA
• Co-pay and deductible program implemented in 1997
  
• Insurance continuation program implemented in
  2001

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Criteria for SC Insurance Assistance Program
(using ADAP funds)

• 1) Cost effective in aggregate
• 2) Insurance formulary must be equivalent to that
  of CP (ADAP)

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South Carolina AIDS Insurance Assistance Program

• Insurance Assistance Program
• Insurance Co-pay/Deductible
• Insurance Continuation
• Assists patients in keeping health insurance
  does not find insurance for patients

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South Carolina AIDS Insurance Assistance Program

• Eligibility Criteria
• South Carolina resident
• Documented HIV infection or AIDS diagnosis
• Low income

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SC ADAP Insurance Assistance Program

• Assists patients with health insurance for
  prescriptions to pay out-of-pocket costs and/or
  premiums through reimbursement process.
• Reimburses for patients eligible prescription
  co-pays and deductibles. Income eligibility the
  same as Central Pharmacy.
• Helps patients at risk of losing medical
  insurance by reimbursing their portion of health
  care insurance premiums. Only patients at or
  below 300 of the federal poverty level and with
  liquid assets below 10,000 qualify.

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Insurance Co-pay Program

• Reimburses co-pays and deductibles for eligible
  medications (those on ADAP formulary only) on
  patients behalf in two ways
• Pharmacies
• Consortia
• SC DHEC does not pay directly, but reimburses
  pharmacies or local consortia through MOAs with
  pharmacies contracts with consortia

8
Insurance Billing Process

• Invoices or receipts on eligible medications
  (those listed on our formulary) are submitted to
  Insurance program for payment by consortia
  serving patient, or pharmacy where the
  prescription is filled.
• Reimbursement requests are processed by program
  staff and submitted to DHEC Finance for payment.
• Reimbursements to pharmacies for patients
  antiretroviral co-pays are eligible to receive
  340B rebates from the drug manufacturers.

9
Staffing of Insurance Assistance Program

• Staff of two persons
• Applications Enrollment
• Recertifications
• Billing

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Submission of Rebates

• Need to carefully review Pharmaceutical
  Agreements for exclusions
• Tracking format simple Excel spreadsheet for
  essential data elements
• Submitted quarterly for those medications for
  which ADAP has paid co-pays (not merely premiums)
• Time from request to payment can be lengthy some
  requests will be challenged

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CY 2005 ADAP Patients Served
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SC Insurance Assistance Program Enrollment July
2006

• Continuation Program - 88 clients

• Co-pay Deductible Program - 553 clients

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Challenges to Insurance Assistance Program

• Marketing Strategy
• Finding clients before they lose insurance
• Making sure providers ask the right questions
• Payor of last resort!
• Premium payments deducted from payroll (some
  employers work with us)

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Benefits of Insurance Assistance Program

• Primary goal to assist individuals (PLWHA) at
  risk of losing health insurance
• Secondary benefit income generating

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Cost Savings

• Rebate income generation in 2005 approximately
  200,000 per quarter

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Medicaid Interface

• Both Central Pharmacy (CP) and the Insurance
  Assistance Program have active interface with
  Medicaid
• Challenges occur when Medicaid revises patient
  status
• CP back bills Medicaid
• Insurance program denies payment and has pharmacy
  back bill

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Medicare Part D

• Dual eligible and full Low Income Subsidy drug
  benefit patients are not eligible for ADAP
  services
• ADAP is not paying premiums, co-pays or
  deductibles at this time this will be
  reevaluated on a regular basis

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SC ADAP Contact Information

• ADAP policies or procedures
• JoAnn Lafontaine, 803-898-0752
• lafontjp_at_dhec.sc.gov
• Prescriptions, Refills, or Adherence
• Central Pharmacy, 803-896-6250
• Insurance Program applications enrollment
• Patti Sullivan, 803-898-0214
• Insurance Billing
• Matthew Williams, 803-896-4268