National RWHAP Part B ADAP Budgets
Section 2
All 50 states, the District of Columbia, territories and affiliated jurisdictions receive formula-based Part B ADAP earmark funding and, if applicable, Part B ADAP supplemental funding and ADAP Emergency Relief funding. In FY2021, RWHAP Part B programs (n=59) were Congressionally appropriated nearly $1.27 billion, with $900 million (71%) awarded by HRSA to ADAP specifically (i.e., via Part B ADAP Earmark [n=59], Part B ADAP Supplemental [n=6], and ADAP Emergency Relief Funding [n=18]). By comparison, RWHAP Part B programs and ADAPs were awarded $1.283 billion and $900 million in FY2020, representing a –1% and 0% change for each, respectively.
RWHAP Part A and B programs may choose to allocate a portion or all of their federal funding to ADAP. For FY2021, four ADAPs reported receiving RHWAP Part A contributions, representing between <1% and 2% of their total ADAP budgets. Twenty-four ADAPs reported receiving RWHAP B base funding contributions, which ranged from <1% to 23% of their total budgets. Seventeen ADAPs reported receiving RWHAP Part B supplemental funding contributions, ranging from <1% to 19% of their total budgets.
ADAPs generally require additional funding streams to both sustain and expand their infrastructure and service delivery, particularly to meet the goals of federal EHE efforts and the challenges associated with the ongoing COVID-19 pandemic. In fact, rebates make up the largest proportion of the overall ADAP budget for FY2021 (38%), compared with federal ADAP earmark funding constituting 37% of the overall ADAP budget. Rebates – payments received by many ADAPs from pharmaceutical manufacturers after paying for medications for clients – account for both the repayment to ADAP from a manufacturer for a drug expenditure and any additional savings generated, which may be used to offset ADAP expenditures and/or allocated to Part B for allowable services and activities.
For a five-year comparison, the total amount of rebates received and allocated to ADAP budgets in FY2021 ($799 million) represents a 5.6% increase versus those received and allocated to ADAP budgets in FY2017 ($756 million1). Twenty-eight survey respondents were able to report estimated allocations of ADAP-generated rebates to their Part B programs, totaling $148.7 million in FY2021.
Separately from rebates, ADAPs may also generate program income, which includes payments received from third-party payers for the usual and customary cost of medications filled for insured ADAP clients, even if the medications were purchased at 340B (or sub-340B) pricing. In FY2021, $81 million was the amount of program income contributing to the budgets of ten ADAPs, representing 3.9% of the total ADAP budget. Five ADAPs reporting allocating program income to their Part B programs, totaling $48.7 million.
Additional sources that may be available to ADAPs include other federal funding (e.g., Ending the HIV Epidemic funds allocated to the Part B program, carry-over from prior Part B Base or ADAP Earmark awards), state general revenue funding, and private donations.
Total ADAP Budget, By Source, FY1996–FY2021
Rebates are tracked separately from front-end discounts and account for both repayment to ADAP from a manufacturer for a drug expenditure and any additional savings generated.
Note: 47 programs reported FY2021 data. Alabama, American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Maryland, Mississippi, Northern Mariana Islands, Republic of Palau, US Virgin Islands, Virginia, and West Virginia did not provide data.
ADAP Rebates and Program Income Allocations, FY2021
Note: 41/47 (87%) programs providing data reported applying rebates to their FY2021 ADAP budgets; 29/47 (62%) programs reported allocating a portion of rebates received to the state/territory Part B program. 10/47 (21%) programs reported applying program income to their FY2021 ADAP budgets; 6/47 (13%) programs reported allocating a portion of income received to the state/territory Part B program. Of all rebates and program income reported by responding ADAPs, 61% and 62%, respectively, remain with the ADAPs to support treatment and insurance access priorities; 39% and 38%, respectively, are allocated to the part B programs in support of core medical and support services, clinical quality management, and administrative expenses (including planning and evaluation) as part of a comprehensive system of care for low-income PLWHA.