Capitalizing on Opportunities to Expand and Support Insurance Coverage for ADAP Clients
Since its implementation, the Affordable Care Act (ACA) has allowed RWHAP Part B programs and ADAPs to shift expenditures associated with paying the full cost for clients’ medications to critical program improvements and service delivery expansions (e.g., raising the income limit for client eligibility, increasing funding for new and/or existing services). Federal/state policies, including those that impact the ACA and overall access to insurance, could impede RWHAP Part B programs’ and ADAPs’ effectiveness and contributions to the goals of the EHE.
The ACA has enabled tens of thousands of PLWHA, including RWHAP Part B/ADAP clients, to transition to expanded Medicaid and private insurance available through the ACA Marketplace. The ACA’s public and private insurance expansions have had a profound impact on RWHAP Part B programs and ADAPs and the clients they serve despite fluctuations in federal and state policy affecting Medicaid and private insurance. RWHAP Part B programs and ADAP continue to support more clients than ever to afford private insurance coverage. In CY 2019, across the 49 jurisdictions providing data on this topic, 129,185 ADAP clients were served through ADAP-funded insurance programs (14% premium assistance only; 43% cost-sharing assistance only; 39% premium and cost-sharing assistance).
The percentage of ADAP clients served by an ADAP-funded insurance program has grown 19% between 2013 (i.e., the last year before full ACA implementation) and 2020, but has leveled off over the past three years (55% of ADAP clients in CY 2020 were served by ADAP-funded insurance programs either with or without full-pay program assistance, compared with 53% in CY 2019 and 54% in CY 2018). As of December 31, 2019, 31% 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, 44% were enrolled in a qualified health plan (QHP) on the ACA Marketplace.
The majority of clients served by an ADAP-funded insurance program in calendar year 2019 (53%) received premium assistance. Premiums represented 58% of all ADAP insurance expenditures in CY 2019 – a 1% increase from CY 2018.
Twenty-six ADAPs reported covering Medicaid co-payments in CY 2019. In that year, 48% of ADAP clients served with incomes below 139% FPL resided in one of 15 states without Medicaid expansion. In CY 2020, however, the majority (52%) of ADAP clients served with incomes below 139% FPL resided in one of 12 states without Medicaid expansion. Compared with higher rates of viral suppression among ADAP clients served in Medicaid expansion states in CY 2018 (83% vs. 73% in states without Medicaid expansion), viral suppression rates among ADAP clients served in states without Medicaid expansion in CY 2019 were higher than those in Medicaid-expansion states (80% vs. 85%). In CY 2020, preliminary data demonstrates that viral suppression rates were the same in both cohorts: 86%.
ADAP Clients Served by Insurance Continuation, by Insurance Payment Type, Calendar Year 2019
Dynamic Program Expenditures in a Dynamic HIV Care Environment
One of the more significant observed differences between CY 2019 and CY 2020 involved ADAP program expenditures, totaling $2.22 and $2.43 billion across 47 and 45 jurisdictions providing expenditure data, respectively. Limiting the comparison to jurisdictions providing expenditure data for both years, CY 2020 ADAP program expenditures were approximately 10% higher than those reported in CY 2019. CY 2020 ADAP program expenditures are approximately 18% higher than those reported across 54 jurisdictions in CY 2018, and 39% higher than those reported across 53 jurisdictions in CY 2016.
A number of ADAP programs reported decreased total expenditures in CY 2020 compared with CY 2019. Jurisdictions that saw significant (>5%) increases in total ADAP program expenditures between CY 2019 and CY 2020 included California (12%), Connecticut (19%), Florida (18%), Kansas (11%), Louisiana (20%), Maryland (14%), New Jersey (13%), New York (12%), North Carolina (12%), and Puerto Rico (48%).
CY 2020 prescription drug expenditures associated with full-pay medication program coverage increased 9% in California, compared with CY 2019 program expenditure reporting. Prescription drug expenditures increased by 22% in Connecticut and Florida, 5% in Georgia, 14% in Maryland, 12% in North Carolina, and 49% in Puerto Rico.
Six jurisdictions saw significant expenditure increases associated with insurance premium assistance in CY 2020 compared to CY 2019: California (35%), Florida (35%), Georgia (45%), Louisiana (25%), New Jersey (30%), and North Carolina (27%). Four states saw significant increases in cost-sharing assistance (deductibles, copayments, or coinsurance) in CY 2020 versus CY 2019: California (13%), Maryland (47%), New York (14%), and North Carolina (20%).
For CY 2019, five ADAP programs reported implementing cost-containment measures. Five jurisdictions either continued cost-containment measures implemented in CY 2019 or implemented new cost-containment measures in CY 2020. In CY 2021, eight jurisdictions, including four jurisdictions that hadn’t implemented cost-containment measures in the two years prior, either continued or implemented cost-containment measures. Most programs reported limiting the number of Marketplace or off-Marketplace plans available for premium payment support under their ADAP-funded insurance programs. Two programs reported restricting their formularies, including one ADAP’s decision not to add a new ARV product to its formulary. One reported reassigning or reducing staff who were previously funded with ADAP rebate dollars.
Whether overall or program-level expenditure changes, or the implementation of cost-containment measures, are associated with EHE activities or the impact of COVID-19 on program utilization cannot be determined from the data provided.
COVID-19: An Unprecedented Challenge to Part B Programs and ADAPs
The COVID-19 pandemic has placed 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. The pandemic stretched health departments to the brink of their capacity. The majority of RWHAP Part B and ADAP programs surveyed nationally by NASTAD in 2020 reported staff assigned away from their routine activities to respond to COVID-19. Many programs acted quickly to develop innovative service delivery approaches in response to emerging needs of PLWHA.
Many ADAPs had established protocols in place to ensure access to medications during times of disrupted access (see NASTAD’s ADAP Emergency Preparedness Resource Guide). Many ADAPs worked with their pharmacy benefit managers (PBMs) and pharmacy networks to review and deploy existing policies, innovative medication access strategies, and program allowances aimed at easing access barriers against the backdrop of quarantine requirements, social distancing recommendations, and pharmaceutical supply chain disruptions.
Among the many considerations for RWHAP Part B programs and ADAPs as they worked – and continue to work – to ensure the continued health and safety of their clients living with HIV:
- Early refill and dispensing limit overrides. ADAPs have discretion to allow for early refill overrides and to extend fills to 60 or 90 days.
- Streamlined recertification and annual renewal policies. RWHAP Part B programs and ADAPs have discretion to eliminate or streamline the recertification process, including utilizing self-attestation that there have been no changes in financial eligibility, residence, and third-party coverage (see HRSA HAB PCN 21-02). Clients may "sign" the self-attestation virtually or at their next provider visit. In some cases, RWHAP Part B programs and ADAPs set up electronic signature or phone-based options via case management agencies.
- Network exceptions. Some ADAPs worked with their PBMs and pharmacy networks to approve limited pharmacy network exceptions for individuals experiencing difficulty accessing their regular pharmacy.
- COVID-19 Testing. RWHAP Part B funds can be used to cover COVID-19 testing for eligible clients via the Outpatient/Ambulatory Health Services category (or primary insurance cost sharing associated with COVID-19 testing via the Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals category).
A number of responding jurisdictions noted the COVID-19-related challenges they faced. According to one Southern state:
“The Part B program office and its subrecipients faced and addressed a variety of challenges due to the COVID-19 pandemic. Most notable challenges were likely experienced by many programs. These challenges included. 1. consideration of, attention to and fast adaptation for new pandemic emergency circumstances 2. impact of trauma on workforce and patients 3. healthcare workforce efforts redirected to focus on COVID-19 screenings and treatment 4. additional administrative burden and 5. active hurricane season.”
Many jurisdictions noted the specific ways in which they overcame challenges to meet the needs of clients served by the Part B program and ADAP. According to one Northeastern state respondent:
“Throughout the COVID-19 pandemic, [our program] has worked with its Part B-funded subrecipients to respond to questions and concerns; to implement social-distancing measures; to identify resources for personal protective equipment (PPE); to identify resources and guidance for immediate telehealth needs; to provide guidance for re-deployment of frontline staff; and to in all ways possible, sustain critical services for PLWHA, including ADAP, case management services, housing services, and other supportive services, while adhering to public health guidance.”
To what extent COVID-19 has impacted RWHAP Part B and ADAP client enrollment, retention, program utilization, or care outcomes cannot be fully determined from the CY 2019 and CY 2020 data included in this report.
Among the most common COVID-19-related challenges reported ADAP programs in CY 2020 included ensuring maintenance of client eligibility (79% reported this as “very challenging” or “somewhat challenging”), issues with document sharing (61%), remote/telework of health department staff (68%), clients churning on and off ADAP (63%), and churning within ADAP programs (61%). As noted by the same Northeastern state referenced above, with respect to challenges faced by their ADAP program:
“The COVID-19 global pandemic required a series of temporary policy and operational measures to support barrier-free client access to medication and/or premium assistance. These temporary policies present additional ongoing challenges including, but not limited to, the requirement to conduct a retroactive review of [ADAP] applications submitted during the state-of-emergency to ensure fidelity to HRSA PCN 13-02, as well as challenges associated with limited access to health care and/or medical case management providers given stay-at-home advisories and temporary closures of medical facilities.”