ADAPs must continually navigate a dynamic healthcare environment to not only ensure continuity of medication access for clients, but also to meet the evolving and comprehensive needs of low-income PLWHA. The need to expand and adapt ADAP service delivery is not without opportunities, including those associated with the Affordable Care Act and a slow-but-steadily growing number of states moving to expand their Medicaid programs. But there are also challenges, particularly when it comes to coordinating with other highly complex components of the U.S. healthcare system straining under the weight of high costs and the myriad challenges associated with COVID-19.
ADAP-Funded Insurance Programs
The ACA has enabled tens of thousands of PLWHA, including ADAP clients, to transition to expanded Medicaid and private insurance available through the federal and state Marketplaces. The ACA’s public and private insurance expansions have had a profound impact on ADAPs and the clients they serve despite fluctuations in federal and state policy affecting Medicaid and private insurance. ADAP continue to support more clients than ever to afford insurance coverage.
ADAPs have been able to repurpose expenditures associated with paying the full cost for medications by migrating clients towards Medicaid (particularly in those states that have expanded Medicaid) and enrolling them in less costly and more comprehensive insurance coverage. This has created opportunities for shifting funds toward the expansion of ADAP services – including maximizing program eligibility criteria and broadening formulary coverage for full-pay medication program clients – as well as vital RWHAP Part B core medical/support services and other priorities.
In CY2021, all 47 ADAPs responding to the survey reported using funds for insurance purchasing/continuation, including premium, deductible, and copayment/coinsurance payments for multiple insurance types, representing $635.6 million in estimated expenditures (30% of the total ADAP budget for the year) for 126,266 clients, with an average cost per client of $5,033.
The percentage of ADAP clients served by an ADAP-funded insurance program has grown 20% between 2013 (i.e., the last year before full ACA implementation) and 2021, but has leveled off over the past three years (54% of ADAP clients in CY2021 were served by ADAP-funded insurance programs either with or without full-pay program assistance, compared with 55% in CY2020, 53%, CY2019 and 54% in CY 2018).
In CY2021, 33% were enrolled in private insurance (e.g., individual market plans purchased on or off Marketplaces and employer-sponsored coverage). Among clients served who were enrolled in private insurance, 47% were enrolled in a qualified health plan (QHP) on the ACA Marketplace.
Programmatic Challenges and Opportunities
Many ADAPs grappled with a number of program-level challenges in CY2021, including pharmacy network issues, health department staff turnover (51% of respondents reported this as somewhat or very challenging), ensuring maintenance of client eligibility, timely rebate payments from manufacturers (64% of respondents reported this as somewhat or very challenging), and coordination with other 340B covered entities regarding 340B and program income right-of-way determinations to avoid duplicate discounting.
General ADAP Program Challenges, CY2021
To help meet the challenges and complexities associated with prescription drug and insurance service delivery in a dynamic healthcare environment, contractual services provided by pharmacy benefit managers (PBMs), medical benefit managers (MBMs), and insurance benefit administrators have become increasingly important to ADAPs nationally. Of 47 programs providing data, 38 (80%) and 32 (68%) utilize PBM services for their full-pay medication programs and ADAP-funded insurance programs, respectively.
A number of ADAPs have implemented medical benefit coverage policies – including HRSA HAB-permitted coverage of antiretroviral drug administration and office visit costs for full-pay medication program clients and cost-sharing requirements for insured clients – and are strengthening their administrative capacity to meet this need and/or contracting with MBMs to provide claim processing and payment support.
COVID-19 and the Public Health Emergency
The COVID-19 pandemic continues to place significant burdens not only on PLWHA and their providers, but also public health systems responsible for maintaining vital HIV safety net programs across the U.S. ADAP challenges during the first year (2020) of COVID-19 were reported in the 2021–2022 Monitoring Project Report, with additional analysis reported at the International AIDS Conference last year in Montreal.
Yet despite these challenges, several ADAPs implemented innovative strategies in CY2020 and CY2021 to ensure streamlined enrollment for PLWHA in need of ADAP services and continuity of services for existing clients. These include recertification requirements waived or modified (prior to the release of Policy Clarification Notice 21-02), self-attestation, e-consent, verbal consent, increased medication supplies (e.g., 90-day refills), and early refills. Many of these innovative practices were ongoing in 2022, with several programs either very likely or somewhat likely to continue these practices.
A potential challenge for many ADAPs is the end of the Medicaid continuous coverage requirement authorized by the Families First Coronavirus Response Act signed into law on March 18, 2020, which effectively prohibited states from terminating most Medicaid enrollees’ coverage until after the public health emergency (PHE) ends.6 Continuous coverage has allowed millions of people, including PLWHA, to stay covered without any interruption during the pandemic. With the “unwinding” of the continuous coverage requirement – the process by which states will resume annual Medicaid recertification reviews – a sizeable number of low-income PLWHA may lose their Medicaid coverage and, consequently, require immediate enrollment (or re-enrollment) in ADAP.
To what extent ADAPs will be impacted by the unwinding and resulting churn of Medicaid clients is unclear. As of July 1, 2022, only five ADAPs reported being able to estimate the number of PLWHA who will likely transition to Medicaid to ADAP following the end of the PHE. The federal government has pledged to give states at least 60 days’ notice before the end of the PHE, after which time states will have an unwinding period of 12 months to initiate recertifications for all beneficiaries.
6As part of an end-of-the-year spending bill, signed into law on December 29, 2022, Congress set an end to the continuous enrollment provision on March 31, 2023, and phase down the enhanced federal Medicaid matching funds through December 2023. The Biden administration announced its plans to let the COVID-19 PHE expire in May 2023.