General Instructions for Completing the ADAP State Profile
Please use the attached profile to verify and update the information for your State. All responses should reflect aggregate or average figures based on the Title II program year, which begins April 1 and ends March 31. (For example, the program year for 2003 is April 1, 2003 through March 31, 2004.)
When completing the form, please provide legible responses (hand-written responses are acceptable). If information from previous years is correct, then no changes are needed; however, if a correction or update is necessary, simply strike through the incorrect information and legibly enter the correct data. If you have further questions about how to answer specific questions, please call the ADAP Branch Chief, Division of Service Systems (DSS) at (301) 443-2834.
I. Contact Information Box
Please provide the name of the person responsible for the administration of the State's/Territory's AIDS Drug Assistance Program (ADAP). This person should serve as the contact for all inquiries from DSS regarding the ADAP. Also include the name of the ADAP administrative agency, its complete mailing address, telephone number, fax number, and an E-mail address, if available. Additionally, please indicate in the respective boxes, whether your State's/Territory's ADAP has submitted a notification of intent to use ADAP funds to purchase insurance, or will request to use, or have been approved to use ADAP funds under the Flexibility Policy.
II. ADAP Funding Summary
Project the amount to be allocated from the sources noted. If you expect no resources to be allocated from a particular source, indicate a zero. The amount of the total Title II grant-award is listed for reference purposes only.
- If the State ADAP received a Supplemental Treatment Drug Grant, enter the amount of the required match for this grant award.
III. Formulary Summary
Indicate the total number of drugs, the number of protease inhibitors and the number of other antiretrovirals you expect to be on your formulary.
Please note: Saquinavir is available in two forms (Invirase and Fortovase). Both forms are counted as one (1) protease inhibitor (PI). (As of early 2003, there were six PIs available.)
In the box entitled "Advisory Body," indicate whether or not your ADAP utilizes a formal advisory body for making decisions on drugs to include on the ADAP formulary and/or decisions about limitation on access to certain formulary drugs. If an informal process or mechanism is utilized, write-in "No." In the Notes section, describe the advisory body membership and the frequency of meeting.
IV. Financial Eligibility Summary
- Indicate the expected financial eligibility criteria as a percent of the Federal Poverty Level (FPL) and verify or correct your ADAP's financial eligibility criteria for previous years.
- Project the percentage of enrolled ADAP clients who have incomes below 200% FPL and verify or correct this information for previous years. If necessary, provide an estimate for previous years' data.
- Indicate the expected Medicaid financial eligibility criteria as a percent of the FPL, and enter the existing Medicaid financial eligibility criteria.
- For the "Co-Payment" boxes, if your program has a fixed amount as a co-pay (e.g., $2 per prescription), indicate that amount for each fiscal year appropriate or enter "no" if not applicable. If your ADAP uses a sliding fee scale, answer "yes" or "no" for each year applicable and describe the sliding fee scale in the Notes section.
- Please provide specific dollar amounts for the "Asset Limit" and "Annual Income Cap" boxes if these apply to your program during each fiscal year. If your program does not have these characteristics, write "No" for each year applicable.
- In the "Frequency of Re-certification" box, please specify the time period (e.g., annually, semi-annually, or quarterly) to depict how often clients are re-certified as eligible to receive ADAP services.
V. Medical Eligibility Summary
If the only clinical criterion for accessing ADAP and/or protease inhibitors (PIs) is a positive HIV diagnosis, write "yes" in the first box. If there are other specific criteria for accessing ADAP or PIs, complete the remainder of the table projecting information for other years as indicated. Please write in the specific criteria where applicable. Use the Notes section to provide an explanation, if necessary.
VI. Client Utilization Summary
- Project the number of clients who will be enrolled in your ADAP (active clients carried forward from 2002 plus new enrollees). Clients refer to the total number of individuals who are enrolled in your program whether or not they utilized ADAP services during the program fiscal year.
- For the box entitled "Number Using ADAP Each Month," project the monthly number of clients who will receive at least one drug through your ADAP.
- For the box entitled "Percentage of Clients on Protease Inhibitors," provide an estimate for the average percentage of clients accessing at least one PI during the designated year, and complete/verify figures for previous years.
- Indicate any caps on limits on the number of antiretroviral medications a client may receive monthly.
- Information on program caps or waiting lists should reflect your projections for the upcoming program fiscal year recognizing that some may be a continuation of previous years. For any answer that is not "No" enter a specific value (i.e., for per patient expenditures, a dollar ceiling; for ADAP program limits, the absolute number of people served/to be served; for PI access limits, the absolute number served/to be served; for wait lists, the projected number on a wait list for services).
VII. Cost-Saving Strategies Summary
- If you anticipate participating in the 340B Drug Discount Program during the year, indicate direct purchase or rebate in the Office of Pharmacy Affairs (OPA) box, utilizing the "OPA Codes."
- If your ADAP anticipates receiving manufacturers' rebates during the year, please use the "Mfr Rebate Codes" to complete the box entitled "Manufacturers' Rebate."
- For the "Manufacturers' Discount" box and the "Pharmacy Discount" box, please indicate with a "Yes/No" if your ADAP utilizes or anticipates utilizing either of these cost-savings strategies. The term "Manufacturers' Discount" applies to situations where the ADAP has directly negotiated a discounted purchase price with a manufacturer. The term "Pharmacy Discount" applies to situations in which the ADAP has negotiated a discount off of the Average Wholesale Price (AWP) with pharmacy providers (e.g., AWP minus 10 per cent, or purchase price equals the Medicaid rate).
- For the box entitled "Manufacturers' Patient Assistance Program(s)" please indicate with a "Yes/No" if your ADAP utilizes and/or coordinates with these programs to provide ADAP clients with some of their prescribed medications.
- In the Notes section, please describe any additional cost-saving strategies used by the ADAP.
VIII. Medicaid Coordination Summary
- Please provide a "Yes/No" response for the boxes in this table, denoting particular screening and coordination strategies between your ADAP and the State Medicaid program. The following definitions may prove helpful:
- Online Interface—the ADAP or some entity acting on its behalf has computer access for verifying an individual's Medicaid eligibility and/or enrollment status.
- Dual Application—an application for Medicaid is completed at the same time as an application to ADAP.
- Proof of Application—an individual cannot be enrolled in ADAP without proof that they have previously applied to Medicaid.
- Proof of Denial—an individual cannot be enrolled in the ADAP without proof that Medicaid has denied them coverage.
- Case Manager Reviews—the case manager reviews, enrolls, and/or monitors a client's Medicaid eligibility status.
- Common Administration—the ADAP and Medicaid program are administered by the same entity.
- Coordinated Benefits—in States and Territories where individuals may receive medications from Medicaid and ADAP concurrently (e.g., Medicaid is limited to "x" number of prescriptions, per month and other prescriptions must be provided through ADAP), the programs coordinate their services to assure that ADAP covers the less costly medication(s).
- Retroactive Billing—the ADAP has a process in place for recouping payments made on behalf of clients whose Medicaid eligibility had not been definitively determined at the time payment was made but is subsequently approved retroactively to the date of application for Medicaid coverage.