adap enrollment worker regional update binder · texas hiv medication program guide for enrollment...

ADAP Enrollment Worker Regional Update

July 10-11, 2019

Hosted by Texas Department of State Health Services

Texas HIV Medication Services

Texas HIV Medication Program Contact Information

Mailing Address Texas Department of State Health Services

ATTN: MSJA - MC 1873 PO Box 149347

Austin, TX 78714-9347

Phone Number 1-800-255-1090

Fax Number512-533-3178

THMP Website dshs.texas.gov/hivstd/meds/

http://www.dshs.texas.gov/hivstd/meds/

https://www.dshs.texas.gov/hivstd/meds/

Table of Contents Page

Tab 1: Essential Elements and Program Guide

Essential Elements of the ADAP Enrollment Worker ................................ 1-1 Texas HIV Medication Program (THMP) Guide for Enrollment Workers ...... 1-3

Tab 2: THMP Case Analyses ............................................................ 2-1

Tab 3: DSHS HIV/STD Program Policies and Procedures

Procedure 020.050: Public Complaints Related to the Delivery of Section Programs .......................................................................................... 3-1 Policy 220.001: Eligibility to Receive HIV Services ............................... 3-10 Policy 220.100: Purchasing Emergency Medications for Clients Awaiting an Eligibility Decision from the Texas HIV Medication Program ................... 3-27 Policy 590.001: DSHS Funds as Payment of Last Resort ....................... 3-30 Policy 591.000: HIV/STD Prevention and Care Branch Limitations on Ryan White and State Services Funds for Incarcerated Persons in Community Facilities Policy ................................................................................ 3-40 Policy 700.001: Texas HIV Medication Program Requests to Change State HIV Medication Formulary ................................................................. 3-43 Policy 700.002: Rights of the Texas HIV Medication Program to Limit the Number of Clients Assigned to a Pharmacy ......................................... 3-49 Policy 700.003: HIV/STD Medication Pharmacy Eligibility Criteria ........... 3-51 Policy 700.004: HIV Medications Ordering Process for Pharmacies ......... 3-56 Policy 700.005: Medicare Part D ........................................................ 3-60 Policy 700.006: Multi-Month and Special Circumstance Medication Supply and Coverage .................................................................................. 3-62

Appendix

Application for Medication Assistance – English ...................................... A-1 THMP Application Status Chart ............................................................ A-9 Six Month Self-Attestation of Eligibility Changes .................................. A-10 THMP Required Documentation ......................................................... A-11 THMP Client Eligibility – CY 2019 Income Guidelines ............................ A-13 THMP Recertification Fax Cover Sheet ................................................ A-14 ADAP ARIES Upload Notice Form ....................................................... A-15 How to Ensure Applications Are Complete and Current ......................... A-16 TEXAS THMP SPAP Letter .................................................................. A-20

Texas THMP SPAP – 2019 ................................................................. A-22 2019 Plans for THMP SPAP Medicare Part D Premium Assistance ............ A-25 THMP Insurance Assistance Program (TIAP) ........................................ A-26 THMP Eligibility for Special Populations - Post Incarcerated Individuals ... A-30 Lambda Legal Fact Sheet: Your Right to HIV Treatment in Prison & Jail .. A-32 THMP Guidelines for Expedited Applications ........................................ A-34 Medication Ordering ......................................................................... A-36 THMP Guidance - Out of State Texas Residents ................................... A-38 THMP Temporary Out of State or Extra Medication Request Form .......... A-43 THMP Medication Formulary and Maximum Quantities .......................... A-44 Eligibility and Enrollment for Hepatitis C-AIDS Drug Assistance Program A-50 THMP HCV Direct-Acting Antiviral Medical Certification Form ................. A-52 THMP Medical Certification Form ........................................................ A-54

Tips from THMP Things to watch out for Info often missed

Essential elements of the proposed ADAP Enrollment Worker (AEW) Position

Education:

• To be defined locally, but must have at minimum a high school degree or equivalency;

Experience:

• To be further defined locally, but must have documented experience (paid, internship and/or as

a volunteer) working with Persons Living with HIV/AIDS or other chronic health conditions;

• To be further defined locally, but experience in performing intake/eligibility, referral/linkage

and/or basic assessments of client needs preferred;

Skills:

• Must demonstrate proficiency in the use of PC‐based word processing and data entry to ensure

ADAP applications and re‐certifications are completed accurately in a timely manner;

• Must demonstrate the ability to quickly establish rapport with clients in a respectful manner

consistent with the health literacy, preferred language, and culture of prospective and current

ADAP enrollees;

• Must demonstrate general knowledge of, or the ability to learn, health care insurance literacy

(third party insurance and Affordable Care Act (ACA) Marketplace plans);

• Bilingual (English/Spanish) preferred;

o AEWs working in care systems with a high prevalence of non‐English speaking clients

must be fluent in the preferred language of the high prevalence non‐English speaking

clients;

Training:

• Must complete all THMP ADAP training modules within 30 days of hire;

• Must complete all training required of Agency new hires, including any training required by

TDSHS HIV Care Services Branch Standards of Care, within established timeframes;

• Must complete all annual or periodic training or re‐certifications within established timeframes;

• AEWs who will also provide general Ryan White Program Intake/Eligibility services to

prospective Agency clients must complete all applicable required training within established

timeframes;

Duties:

• Meet with all potential new ADAP enrollees; explain ADAP program benefits and requirements;

and assist clients with the submission of complete, accurate APAP applications;

o Track the status of all pending applications and promptly follow‐up with applicants

regarding missing documentation or other needed information to ensure completed

applications are submitted as quickly as feasible;

o Maintain communication with designated THMP staff to quickly resolve any missing or

questioned application information or documentation to ensure any issues affecting

pending applications are resolved as quickly as possible;

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o Completed applications must undergo secondary review by a peer ADAP Enrollment

Worker or Supervisor before submission. This peer or supervisor must meet all

requirements of the ADAP Enrollment worker, including required training.

• Submit completed applications via the most efficient method available (e.g. the Public Health

Information Network or PHIN), including ARIES, once the document upload capability is rolled

out;

• Ensure annual re‐certifications are submitted by the last day of the clients birth month and

semi‐annual Attestations are completed six months later to ensure there is no the lapse in

ADAP eligibility and loss of benefits;

o Proactively contact current ADAP enrollees 60‐90 days prior to the enrollee’s re‐

certification or attestation deadline to ensure all necessary documentation is gathered

to complete the re‐certification/attestation on or before the deadline;

• Must document per TDSHS and Agency requirements all activities performed on behalf of ADAP

enrollees including re‐certifications and attestations

Performance Measures:

• AEW will ensure:

o ≥ 95% of new enrollee ADAP applications are accepted by the THMP upon initial

submission;

o ≥95% of new enrollee applications are submitted within ten (10) business days of initial

contact with the client;

o 100% of applications rejected or held by the THMP because of missing or inaccurate

documentation are followed‐up with the applicant within two (2) business days of

notice from the THMP;

o ≥95% of ADAP eligibility Re‐certifications and Attestations are completed on or before

the lapse of ADAP program benefits

o All efforts made on behalf of the applicant are documented in the appropriate file (e.g.

medical record) within one (1) business day of occurrence;

• Agency will provide aggregated data regarding AEW performance measures to the TDSHS Care

Services Group as directed;

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Texas HIV Medication Program Guide for Enrollment Workers – Revised May 2018

Page 1: Is Your Application Complete?

Use this flow chart to help you and the client understand if the application is complete.

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Page 2: Personal Information, Alternate Contacts, Jail Release

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Q.1. Personal InformationMake sure the client’s demographic information is complete.

Q.2 Previous NamesThis information helps THMP identify a client who may already be on theprogram. THMP has to ensure that it is assisting the same person.

Use documentation that shows the client’s current name to decrease the chances of THMP pending an application. Such documentation could be

a Texas I.D. or D.L. with the client’s current name, or documentation showing a legal name change.

THMP will pend an application if a name change is suspected but not clarified on the application.

Q.3. Social Security numbers (SSN), and Tax I.D. numbers (TIN):The client should have checked one of the boxes or written “N/A” if theclient doesn’t have a SSN or TIN.

THMP cannot assume a client does not have SSN/TIN numbers simply because the boxes are left blank. The application will be considered incomplete and denied if this information is not provided.

SSNs or TINs (or the last 4 digits), are often listed on paystubs. THMP might require that SSN.

If a SSN was previously provided to THMP but not provided in the current application, then THMP will need to address this.

AEW Performance Measure: Is the application complete? Did the AEW include supporting documentation to help justify approval?

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Q.8. Residential AddressThe client should provide a residential address (except for clients whoare homeless-more on this later).

Proof of Residency

Document used to prove Texas residency must include the residential address the client listed on the application.

A list of acceptable documents that prove Texas residency is found in the Appendix. Please visit dshs.texas.gov/hivstd/meds/document.shtm for the most updated list of acceptable documents.

Q.9. Mailing AddressClients will need to provide a different mailing address if they don’twant THMP to send mail to their residence. However, a residentialaddress should always be provided to help prove Texas residency.

THMP must have a way to contact clients or send important information that might affect the clients’ eligibility and access to medication.

Examples of alternative mailing addresses: • Address of a trusted friend/family member• Address from homeless or rehabilitation shelter• The social service agency/clinic if the social service

agency/clinic accepts mail for clients.• P.O. Box

THMP will not, under any circumstances, accept a P.O. Box or a business address (that leases out mail boxes to customers)

AEW Performance Measure: Is the application complete? Did the AEW include supporting documentation to help justify approval?

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as a residential address. Having a P.O. Box does not prove Texas residency.

THMP will not, under any circumstances, accept an Out of State address as residential or mailing address. The client will have to prove Texas residency and an Out of State address should alert you to ask about the client’s residential location.

Homeless Population, Residential Address/ Proof of Texas Residency, and Communication THMP understands that clients who are experiencing homelessness might have difficulty in providing proof of Texas residency while others might not. In this case, THMP will accept the following as proof of Texas residency:

Proof of Residency

A letter from a homeless, transitional, or rehabilitation center statingthe client is currently residing there. Must have a date and be writtenon the shelter’s agency letterhead.

A letter from the AEW or case manager stating the client is currentlyhomeless and living on the streets, couch surfing, or how the client isconsidered homeless. Must be completed and signed by the AEW,dated, and on the agency’s letterhead.

Some clients who are experiencing homelessness might be able toprovide a valid Texas I.D., D.L., or other documents found in the listof acceptable documentation. You will have to make it clear on theapplication and the letter that the residential address on thesedocuments does not match because the client is now consideredhomeless.

AEW Performance Measure: Is the application complete? Did the AEW include supporting documentation to

help justify approval?

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Communication:

THMP currently mails letters to clients regarding recertification due dates or other information needed. Therefore, THMP strongly encourages AEWs and case managers to help homeless clients identify a mailing address THMP can use to contact them. Otherwise, AEWs and case managers should warn their clients about the possibility of “dropping” from THMP or medications being placed “on hold” if a due date is missed or if mail is returned.

Examples of alternative mailing addresses: • Address of a trusted friend/family member• Address from homeless or rehabilitation shelter• The social service agency/clinic if the social service

agency/clinic accepts mail for clients.• P.O. Box

If the client cannot identify a mailing address due to homelessness, AEWs and case managers should make it clear on the application that the client is homeless and doesn’t have a way to receive mail. While THMP staff does it’s best to not place medications on hold, it cannot guarantee that medications will not be placed on hold.

If a client misses a recertification due date, medications must be placed on hold in order to verify eligibility for continued assistance. Any client who misses their eligibility due date will be dropped from THMP and will have to reapply regardless of the circumstance.

AEWs or case managers should always call THMP directly if there is a change of address.

AEW Performance Measure: Is the application complete? Did the AEW include supporting documentation to

help justify approval?

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Q.10. Phone Numbers, Voicemail Options, Voicemail Messages

A client should provide THMP with a reliable phone number. Pay special attention to the voicemail options. THMP will respect clients’ requests to refrain from leaving voicemail messages.

There will be times when THMP will need to contact clients with important information that may affect their access to medication.

THMP will refrain from leaving a voicemail message, however, AEWs and case managers will ensure clients understand that if THMP is restricted from leaving voicemail messages (or mailing information), clients will need to communicate with THMP often.

Voicemail from THMP THMP will only leave a detailed voicemail message if the client indicates it’s okay to do so and if THMP knows that phone number truly belongs to the client. However, THMP will not leave a voicemail message if they suspect the phone number no longer belongs to the client.

THMP Program Specialists are instructed to leave generic voicemail messages without stating they are calling from the Texas HIV Medication Program or THMP. Program Specialists will say they are calling from “the state” or from “the Department of State Health Services” or from “DSHS”. THMP encourages AEWs and case managers to let their clients know THMP Program Specialists might leave a vague voicemail message.

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Placing medications “on hold” usually alerts the client to call THMP. However, THMP prefers that the client stays in contact with the program and updates THMP with new contact information as needed. This will decrease the chances of an interruption in the clients’ regimen.

Medications will be placed “on hold” for any of the following reasons:

1. THMP correspondence sent to client was returned to THMP due toan “incorrect address” or “return to sender” label. This could meanthe client is no longer a Texas resident.

Making it clear on the application that a client is homeless can help THMP refrain from putting medications on hold for this reason, however it is not guaranteed. The client’s medications will still be placed on hold if due dates are missed.

2. Pending information for recertification has not been provided by thedue date.

3. HMS reports the client may have an active insurance policy. Themedications will be dropped until the client can provide insuranceinformation or proof of prior coverage.

4. Notification from the pharmacy or agency informing THMP that theclient has moved out of state, their marital status has changed, orinsurance information has changed.

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Authorization for Release of Information

Q.11. AEW or Agency Worker Contact InformationAll A E W s , A g e n c y W o r k e r s o r c a s e m a n a g e r s will need to include their information in box #11. They should provide a direct phone number or an extension since they will be the point of contact if more information is needed. THMP Program Specialists might need to convey very specific information regarding the client’s eligibility and they will need direct numbers or extensions to convey these important messages.

If an AEW is not using ARIES, it is VERY IMPORTANT to include a fax number because that is how some AEWs will receive a THMP denial or pending letter after an application has been processed.

Clients are often confused about the relationship between the service provider and THMP or they haven’t been made aware of what THMP is. This confusion or lack of information often

leads clients to exhibit mistrust and withhold information when a THMP Program Specialist calls clients directly. Therefore, in order to reduce anxiety for the client, THMP Program Specialists will contact the AEWs for pending information. The AEWs should encourage their clients to call them directly before they call THMP.

AEW Performance Measure: Is the application complete?

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Q.11b. Alternate Contact (optional for theclient)

A client might identify a family member or friend who is aware of his/her HIV status and can provide information or relay messages to the client. The client can authorize THMP to speak with this trusted source by providing the name and contact information in section 11b.

This is optional. However, this is helpful when a client does not have a good mailing address or voicemail messaging available. This is also helpful when a client is unable to call THMP directly due to illness, incarceration, hospitalization, or other circumstances.

Secondary Reviews AEWs are required to have another person review the application before it is submitted to THMP via mail, fax, or ARIES. This decreases the chances of submitting an incomplete application that will be denied. This is part of the AEWs performance review.

Primary Reviewer: the worker who first completed the application with the client.

Secondary Reviewer: somebody in the agency who has attended an AEW training. This could be an AEW (if the AEW isn’t the person who first completed the application), a supervisor, or a program manager.

This is often missed on applications. Copies of applications with previously filled signatures will not be considered as “reviewed” and the AEW will receive a “No” for this

performance measure.

AEW Performance Measure: Was a Secondary Review done by the agency?

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Q.12. and Q.13. Marital Status

The application will be considered incomplete and denied if this section is left blank.

THMP follows the definition of Legal and Common Law Marriage as defined by the State of Texas.

The spouse’s income information (as well as the Household information) is needed to determine if the client meets the income guidelines for eligibility. THMP will need the spouse’s name, date of birth, Social Security number, and proof of income in order to determine eligibility.

Ensure your client stays consistent throughout the application. If the client states they are common law married or refers to their partner as a “spouse” at any time, even if they are not legally married, then THMP will consider this partnership a marriage until the client provides a written explanation regarding a separation or dissolving of partnership. Often times, a client will interchange the words “boyfriend”, “girlfriend”, and “spouse” throughout the same application.

If your client is not legally married and is unsure of how to report their status due to a long-term relationship or their living situation, ensure

your client understands that the spouse’s information will be required if they report to THMP as “married”.


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The following tips will help you determine if and when the spouse’s information is needed:

1. Married/Common Law:THMP will request the spouse’s name, date of birth, SocialSecurity number, and income information. If the spouse (or client)has never worked or hasn’t worked in years, that information shouldbe included on the application by writing “never worked” in theemployment section for the spouse.

THMP cannot assume a spouse or client is not employed by leaving employment questions unanswered. THMP must know when and where the client AND spouse last worked

if one or both are not currently employed.

2. Divorced:The client will need to provide a copy of the divorce decree if theyhave been divorced for less than 6 months or if THMP finds conflictinginformation.

THMP only requests to see the first page (which lists the namesof the individuals) and the last page (which shows the signaturesof the divorced individuals and the signature or official stamp of thejudge or court).

THMP will NOT request the name, date of birth, SSN, or incomeinformation of the ex-spouse if a copy of the decree is attached to theapplication.

THMP will not accept child support documentation as proof of divorce.

3. Separation:If the client is separated, they will need to provide a brief statement inthe box next to question 12 explaining:

a) the duration of the separation.b) if they continue to receive financial support from the spouse

during the separation.c) if the separation is temporary.

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If the estranged spouse still provides financial support, THMP will need the estranged spouse’s name, date of birth, Social Security Number, income information.

If the client is recently separated, it is possible THMP will ask for the spouse’s name, date of birth, Social Security Number, income information regardless of the situation. Even if the estranged spouse doesn’t provide financial support. These will be reviewed on a case by case basis.

If the couple has filed for divorce, it will be helpful to submit any documentation that shows the start of that process.

4. Separated and Lost Contact/Unable toDivorce/Deportation/Domestic Abuse:

Separated and Lost Contact with Spouse If a client states that they have been separated and have lost contact with the spouse, THMP will not ask for the estranged spouse’s information as long as the situation is explained in the space provided (next to question #12) and as long as THMP doesn’t find conflicting information.

Unable to Divorce Due to Financial Constraints If the couple has not been able to finalize a divorce due to financial constraints, then THMP will not ask for the estranged spouse’s information as long as the couple is not living in the same household and as long as the situation is explained in the space provided (next to question #12). THMP might request proof they are not living in the same household (i.e. an apartment leasing contract, a written note from the client, etc.).

Domestic Abuse If the client states they are afraid to ask the estranged spouse for income information due to domestic abuse, THMP will not require the spouse’s income information. However, the AEW or case manager will have to provide a written explanation. The client will have to provide his/her own proof of income or support.

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5. If the Spouse Lives in a Different State:If the client is married but their spouse lives in a different state, THMPwill still request the spouse’s name, date of birth, SSN, and incomeinformation.

If the client and spouse are separated and the estranged spouse lives in a different state, THMP will request the estranged spouse’s income information if the client’s sole financial support comes from the estranged spouse.

6. If the Spouse Lives in a Different Country:THMP will only require a supporter statement if the spouse lives in adifferent country.

7. If the Client Applied for THMP Before:Because a client may have applied for THMP in the past, it is possibleTHMP has the client listed as “married” and has the former spouse’sinformation.

If the client was once married and now identifies as single, the client will need to provide proof of divorce or an explanation of separation. In this case, THMP cannot assume the client is divorced or separated even if they identify as “single” on the current THMP application.

This is also true for a client who reports a new common law spouse. THMP needs documentation showing the client is divorced from the person they told THMP they were once married to.

8. Paystubs, Tax Forms, or Data Broker Indicate Client isMarried:Pay stubs, tax forms, or Data Broker might indicate the client files as“married”. It’s possible the client has not updated this information withtheir employer or with the IRS, however, THMP cannot assume that.

The client will need to provide proof of divorce or an explanation of marital status if the client says they is no longer married but income information states otherwise.

THMP will not, under any circumstances, assume the client is single, divorced, or separated if this section is left incomplete and if a written explanation is not provided.

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THMP understands that not all cases are alike and marital statuses can vary in different ways. THMP will review these applications on a case by case basis and request certain information according to the marital situation.

Written explanations help THMP staff understand the marital situation and reach a determination quickly. They also decrease the chances of pending or denying an application.

AEW Performance Measure: Is the application complete? Did the AEW include supporting documentation to help

justify approval?

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Q.14. Guardian Information for Clients Under 18 Years Old:

If the client lives with their parent(s)…

If the client lives with a guardian…

The parents’ income information will be used to determine eligibility.

THMP will not ask for the guardian’s income information.

Parents’ will need to provide their SSNs and DOBs.

Guardians will not need to provide their SSNs or DOBs.

The client’s income information will not be calculated if the client is under 18, employed, and lives with their parents.

The client’s income information will not be calculated if the client is under 18, employed, and lives with their guardians.

Relationship to the child must be made clear by indicating if the client lives with their parent(s) or a guardian.

If the client is under 18 and lives independently, the client’s income information will be used to determine eligibility if the client is employed.


justify approval?

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Q.15. Household Information

This section should only include a spouse, biological, adopted, or step-children under the age of 18. The client is considered an adult at the age of 18.

If the client lives alone, the client should have written “1” for question 15 and “self” in the list of members.

THMP uses the Federal Poverty Income Guideline at 200% to determine eligibility (more on this in the Income section). The number of household members and the household income is what helps to determine if the client qualifies for the program.

Therefore, it is extremely important this section is complete. The application will be considered incomplete and denied if this

section is left unanswered.

THMP will not, under any circumstances, assume the client lives alone if this section is not complete even if the client identifies

as single in his/her marital status.

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THMP defines a “family” as:

A single person living alone, with roommates, or living withothers who do not meet the definition of “family”.

A client and spouse (legal or common-law). A client as the single parent of biological, adopted, or step-

children under the age of 18 living in the home. Must becustodial parent.

A client, spouse, and biological, adopted, or step-childrenunder the age of 18.

Dates of Birth must be provided. Adult children over the age of 18 will not be counted as part of the household even if they live in the home, if they are fully supported by parents, or if parents pay for their education.

THMP cannot assume children l i s t e d a s residing in the home are under the age of 18. Dates of birth MUST be provided. If dates of birth are not provided, then all children will be assumed

to be over 18.

Examples of household members and household size on next page.


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Examples of Household Members and Family Size Household Members

(for clients over 18 years old) Household

Size

Client 1

Client and a roommate 1

Client and parent/grandparent/aunt/uncle/family member 1

Client and girlfriend/boyfriend/partner 1

Client who is single and couch surfing 1

Client and spouse 2

Client and common law spouse 2

Client, spouse, and 3 adult children 2

Client, 2 biological children under the age of 18 3

Client, spouse, 3 biological children under the age of 18 5

Client, spouse, 2 biological children (mother’s), 2 biological children (spouse’s and living in the same house), all under

the age of 18

6

Client, client’s son and son’s wife 1

Client and adult daughter who supports client 1

Adult client and client’s care taker, even if the care taker is

a parent

1

Make a Case: If the client is single and unemployed but lives with/supported by a friend, roommate, or family member, then it will be helpful to include the supporter in the list of household members. The supporter will not be required to submit income information unless the supporter is a spouse.

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Q. 18. Jail Applications

THMP’s Post-Incarceration Coordinator has been assigned to process all applications for clients who have been released from jail for less than 6 months. These applications are expedited.

Because you might not be used to working with clients who are recently released from jail, this question often goes unanswered. If the client was released less than 6 months ago, this information should be shared

and the application can be expedited (if deemed necessary by our Post-Incarceration Coordinator).

Applications for clients who were released over 6 months ago will follow the regular THMP eligibility process.

Make a Case

If you know your client was incarcerated, it can be helpful to share that information with THMP even if the release date was over 6 months. Knowing a client’s release date can help THMP understand the client’s situation.

For example, it is possible the client is not working or has not worked for a few months after the client’s release date. If the client was incarcerated for many years, then the client may not have income information to provide or earnings reported on databases like the Data Broker. Knowing this information can help a THMP Program Specialist decide if they need to request a Tax Return Form or additional information.

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Q. 19. Income, Employment, Benefits

Proof of Income The client and spouse (legal or common law marriage) must submit proof of income even if the spouse is not

applying for THMP.

Document used to prove income must include complete pay periods and must show 1 months’ worth of income.

A list of acceptable documents that prove income is found in the Appendix. Please visit dshs.texas.gov/hivstd/meds/document.shtm for the most updated list of acceptable documents.

If the client and/or spouse are not employed, they must indicate how they are supported.

The information in the screen shot above is a quick reference to help you understand which information and proof of income THMP will need to determine income eligibility. (More on income documentation in the following pages.

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THMP cannot assume the client is employed or unemployed and/or supported without providing proof of income or support.

THMP will not, under any circumstances, approve an application without income information or a supporter statement.

Income Calculation Sheet (MAGI)

THMP will complete a MAGI form for each client in-house.

THMP will complete the MAGI form using Data Broker information first. If Data Broker information is not available, THMP will complete the MAGI form using income information submitted with the application.

THMP’s requirements for proof of income WILL NOT change. A MAGI form will not be accepted in lieu of income documentation. If income information is not submitted, the application will be denied as incomplete.

Submit an application for the client even though they might be over scale. THMP will make the final determination.

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Income and Data Broker If there is a conflicting information between what the client reports on the application and what Data Broker (DB) reports in terms of income, the earnings on the DB report will be taken as the official income.

The following are acceptable proof of income (Refer to Required Documentation for a shorter version of this information at dshs.texas.gov/hivstd/meds/document.shtm).

Current Pay Stubs from Employment: THMP can determine income eligibility by calculating the gross earnings reported on pay stubs. THMP requires 1 months’ worth of pay stubs in order to see a better picture of the monthly household income.

Often times, clients will submit a copy of their first pay stub from a new job. Depending on the client’s hire date and pay schedule, the first pay stub may not reflect a complete work period. Consequently, a pay stub reporting an incomplete work period will not reflect the clients’ normal monthly income. The client may submit the first pay stub received, however, it is possible an extra pay stub will be requested in order to calculate the clients’ usual monthly earnings.

Disabled/Veteran/Retired: A copy of applicant’s and spouse’s benefit award letter or any other official document showing the amount received on a monthly basis. These awards might come from RSDI, SSI, SSDI, VA, DARS, or other agencies.

*Definitions: RSDI is Retired, Survivors, and Disability Insurance (for retiredadults, widows, orphan children) SSI is Supplemental Security Income SSDI is Social Security Disability Insurance VA is Veteran’s Affairs DARS is Department of Assistive and Rehabilitative Services 401k and IRA (Individual Retirement Account)-after a client loses their job, the client can receive this money and it’s usually a one- time payment. It could be enough to support themselves with for a few months or couple of years.

Alimony and Child Support: A copy of applicant’s benefit award letter or any other official document showing the amount received on a regular basis from Alimony and Child Support.

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If the child support is an informal agreement between parents (not filed in court), a written statement from the AEW or one of the parents should be included with the application.

Unemployment Benefits/Income: A copy of applicant’s benefit award letter or any other official documentation showing the amount received on a regular basis.

Copy of IRS Tax Return Form: If self-employed, a copy of the Tax Return Form for the most recent year can be submitted. If the client doesn’t have a copy of the tax return form, it can be obtained directly from the IRS by calling 1-800-908-9946, by submitting the form 4506-T to the IRS by mail, online at www.irs.gov, and possibly in person at the client’s local IRS Tax Office.

The tax return forms must: Include all attachments. Must be signed by the client, or an accountant, a tax preparer, or

e-signed.

Income Verification Form: To be completed by employer and if paid in cash or written check ONLY.

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Information to look for on an income verification form: • Cash wages and pay schedule.• Employer’s Signature. The form will become null and void if

signed by the client.• If the employer indicates the client is paid with a pay

stub, this form will become null and void and the clientwill be required to submit copies of pay stubs.

• If the employer indicates the client is or will be insured, theclient will need to provide insurance information.

This form can now be used as both proof of income and proof of Texas residency if the client’s information is listed. However, it cannot be used as proof of Texas residency alone.

Self-Employment Logs: Self-Employment logs now accepted for all clients who are self-employed. THMP will no longer request proof of non-filing for self-employment.

THMP Self-Employment Logs: THMP created this log and it can be found on their website at dshs.texas.gov/hivstd/meds/document.shtm.

This log contains all the information THMP needs to reach a determination.

Non-THMP Self-Employment Logs Any client who is self-employed can now submit a non-THMP Self-Employment Log that reflects earned income from the last 30 days along with a letter completed and signed by the AEW explaining type of work, approximate monthly income, and form of payment.

The written statement must be on letter head, completed by the AEW, and it must accompany the Non-THMP Self-Employment Log or it will be considered incomplete.

Written Explanation completed and signed by the AEW or case manager: If the client does not have a self-employment log and cannot access the THMP Self-Employment Log online, the AEW can write an explanation (on the agency’s letter head) explaining the type of work the client does, the form of payment received, and the frequency of pay (which may vary depending on the type of work).

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THMP Self-Employment Log

dshs.texas.gov/hivstd/meds/document.shtm.

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Options for documentation of Self-Employment

Option Type of Work Form of Payment

Frequency of Pay

Option 1 THMP Self-Employment Log found at dshs.texas.gov/hivstd/meds/document.shtm

Option 2 Non-THMP Self-Employment Log + Written statement from the AEW or case manager

Option 3 A written explanation from the AEW

Written Explanation from Client (LAST RESORT AND UNDER CERTAIN CIRCUMSTANCES.)

CONTACT THMP BEFORE YOU ASK YOUR CLIENT TO SUBMIT THIS.

A client can submit a written statement if they are a day laborer, work for different people at a time, or earn income through non-traditional activities. A verbal or written explanation from the AEW can serve as supportive documentation for the client’s living and/or work situation.


justify approval?

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If the client reports they are supporting themselves by other means than regular employment, the following will be required:

THMP will not, under any circumstances, accept a Supporter Statement completed and signed by the client.

*Agencies often send their version of a supporter statement. Some of theagency forms are more acceptable than others in terms of theinformation requested/applied on the form. The closer the form appearsto the THMP supporter statement, the greater the likelihood THMP canaccept it but situations vary.

THMP will not accept another agency’s supporter statement as proof of residency.


justify approval?

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Supporter Statement To be completed and signed by the supporter.


justify approval?

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Income Guidelines and Spend Down Below is the income guideline THMP uses to determine eligibility. This changes every year.

Texas HIV Medication Program Client Eligibility – CY 2019 Income Guidelines

If family unit size is: The adjusted family income may not exceed:

1 $24,980 2 $33,820 3 $42,660 4 $51,500 5 $60,340 6 $69,180 7 $78,020 8 $86,860

For each additional family member in household, add $8,840

Please note that all dollar amounts are listed at 200% of the current Federal Poverty Income Guidelines; no further doubling of the amounts are required.

Source: Federal Register, Effective January 11, 2019

Effective with TX DSHS as of January 17, 2019

Spend Down Our goal is to try to approve all eligible clients for THMP. If the client is over scale, it is possible that they will still qualify for THMP if a Spend Down is conducted. A Spend Down is when the medication cost is deducted from the client’s gross income. If the Spend Down shows a client’s gross income remains above the FPL, then the Spend Down will serve as documentation to prove that a client does not qualify for THMP.

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Q. 20. Employment

The client and spouse will need to report employment or unemployment even if the spouse is not applying for THMP.

THMP will need to know the clients’ and spouses’ employment status. If a client is not employed, they will need to tell THMP when/where they were last employed. This will help THMP determine if a Tax Return form is needed. It can also help THMP reconcile questions that may arise due to recent employment and earnings found on the Data Broker database.

Employed: Clients and their spouse must provide income information from all current jobs. Many times clients’ job statuses change by the time THMP processes an application. They may need to provide proof of termination. The information on the next page will help you decide when to ask a client to provide proof of termination. This information also applies to the spouse.

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Self-Employed: If the client and/or the spouse are self-employed, they will have to provide a self-employment log.

Never Worked: If the client and/or spouse have never worked in the U.S., then they should indicate this by writing “never worked” in the Employment section of the application.

By leaving this information blank, THMP cannot assume that the client and/or spouse have never worked or aren’t currently employed.

The clients’ and spouses’ current employment status must be made clear. If this information is left blank, the application can be considered incomplete and denied.

When/Where last employed: It is helpful for THMP to know when/where the client and spouse were last employed especially if one or both are not currently employed.

Proof of Termination

THMP might find recent employment information on the Data Broker database that can indicate the client is working multiple jobs, thus, earning more income. Because THMP needs to justify that a client qualifies for the program based on income, the client will need to provide proof of termination if they recently lost a job. The client will need to provide proof of termination for the following reasons:

If recent earnings, make the client over scale: The client will need to provide proof of termination if they no longer have the job that is making them over scale.

If the client has recently lost employment: The client will have to provide proof of termination if the date of separation i s n o t r e p o r t e d on Da t a B r o ke r and t h e i n c omei s mak i ng t h em ove r s c a l e .


justify approval?

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If the client has a different job: The client will have to provide the new income information. They will also have to provide proof of termination from the former employer ONLY if the client appears to be over scale with potentially having both jobs.

For example: A client was employed with Alorica in January 2019 and was averaging $15,000 annually. The client states that job ended and he’s been employed with Prestigious since February 2019 and is averaging $20,000 annually. Combining those two incomes ($35,000) would make the client over scale as a household of 1. Therefore, the client will have to provide proof of termination from Alorica.

If the client reported 1 job but Data Broker reports the client has multiple jobs: The client will have to provide proof of income and/or termination for all jobs if income from all jobs will make the client over scale.

It will be helpful to ask the client for his Tax Return Form if the client has multiple temporary jobs.

If the client has earnings reported on Data Broker for a job that they continuously deny to have. The client will need to provide proof of income or termination especially if the income will make the client over scale.

If the client reports that their Social Security Number (SSN) has been compromised and another person is earning income under the client’s SSN and name. The client will have to provide proof that they have taken legal action to fix this situation (documentation from the Social Security Administration or police reports, etc.).

Steps to obtain proof of termination:

1. The THMP Program Specialist will check if Data Broker or TheWork Number provided a date of separation.

2. THMP will check if the client filed for Unemployment Benefits (onData Broker) at or around the time the client reports to have losthis/her job. The client should have submitted an UnemploymentBenefits award letter.

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3. If the information in steps 1 and 2 are not available, then the THMPProgram Specialist will call the employer’s phone number to verifyemployment. However, the phone number isn’t always provided on TheWork Number.

THMP Program Specialists never tell the employer they are calling from the Texas HIV Medication Program. If asked, the THMP Program Specialists say they are calling from the Department of State Health Services.

If the THMP Program Specialist is not able to obtain proof of termination, then the client will be asked to provide it. The client’s AEW or case manager can assist the client by calling or faxing the employer directly.

It is often difficult for the client to obtain proof of termination, however, the attempt needs to be made by the client if all else fails.

If the client, the AEW, and the THMP Program Specialist have all been unsuccessful in obtaining proof of termination, then the AEW can write a letter on behalf of the client describing their attempts and THMP will accept this documentation as proof of termination. However, THMP might not accept this as proof of termination if the income from that job indicates the client might be over scale.

Other Benefits

TIERS: Search for SNAP benefits (food stamps), Medicaid (SSI), Temporary Assistance for Needy Families, etc.

Housing or Rental Assistance: The client will need to provide proof of housing assistance currently received.


justify approval?

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Q. 22, 23, 24 Health Insurance or Medication Assistance

Health Insurance Clients who have health insurance or COBRA must also complete page 6 of application.

The client must answer question 22. If the client is not insured, they should check the first box and move on to question 23. This is one of the most common reasons for

which applications go on incomplete status. The application will be considered incomplete and denied if this question is unanswered.

THMP cannot assume the client is not insured if this information is not provided.

The client must provide proof of prior coverage if his/her insurance terminated less than 90 days ago.

If the client has insurance, a copy of the insurance card (front and back) and Rx card (front and back) are required.

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The TIAP team will determine if the client qualifies for TIAP assistance. The client must still meet all other requirements for THMP eligibility.

If the person has COBRA, THMP needs the election paperwork and/or need to know when the last payment was made and for how much. This amount is usually on the COBRA election paperwork. However, if another agency has been assisting, then THMP will need to know who has been assisting with payments and when the last payment was made.

If a person is dropped for insurance, medications cannot be dispensed to the person after they are found ineligible.

Medicare Clients who have Medicare must also complete page 6 of the THMP application.

If a client has Medicare, it is important that they complete the SPAP enrollment form and apply for the Low Income subsidy. AEWs should help the client apply for the help online in order to get a quick response. Visit this website for more information: cms.gov.

For both programs: Clients need to have their copayments for antiretroviral medications paid by THMP on a monthly basis or every 90 days in order to avoid being dropped from THMP due to six months of inactivity. It is a program requirement that prescriptions be refilled. If dropped, clients will have to fully reapply and their COBRA payments might end.

If the client is electing COBRA, the client must submit their election paperwork to their COBRA administrator by the election due date and provide a copy of the paperwork to THMP.

A client needs to contact THMP if they have found new employment.


justify approval?

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A client who receives Medicare or has insurance coverage should complete this page AND ALSO sign page 5 of the application.

The client should sign this form AND page 5 of the application.


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Signature Page (Page 5)

It is important for the AEW to ensure the client understands that they are about to sign a legal document and, therefore, all information must be true to the best of the clients’ ability.

Applications will be considered outdated after 60 days from the date of signature. An application signed 60 days ago OR not signed at all will be considered incomplete and denied.

THMP will not accept old applications. Check the last revised date at the bottom left corner of the application. The latest application is posted on THMP’s website.

An application will be denied if the client’s signature AND/OR date are missing.

After October 1, 2017, the application will be denied if any information is missing.

AEW Performance Measure: Is the application complete? Was the application submitted 10 days from the client’s

signature?

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AEWs should discuss the attestation with the client and ensure the client understands it all before the client signs the application. THMP encourages AEWs to read the attestation to the client before they sign.

“I understand that my information will be shared with my HIV service providers and Agency Workers. I will contact THMP if I want an exception to be made.”

Please ensure the client understands that information will be shared with the client’s current HIV service providers and AEWs. Often times, clients will change service providers or seek assistance from other agencies without informing THMP.

If a doctor, agency, or pharmacy that is assisting a client in real time contacts THMP, THMP will release certain information to them.

The client must contact THMP if they do not want THMP to share this information with service providers or AEWs.

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Every client must complete pages 1-5 of the application.

Pages 6-8 should only be completed and signed if applicable to the client’s living situation.

• Page 6………..Copayment Assistance (COBRA, private health insurance, employer sponsored insurance and Medicare)

• Page 7………..Form A: Supporter Statement (If the client is supported by another person.)

• Page 8………..Form B: Income Verification Form (If the client is paid in cash or written check.)

Medical Certification Form (MCF) (Page 9 and 10)

The MCF is now 2 pages. PLEASE ENSURE YOU FAX BOTH SIDES OF THE MCF.

• New and dropped clients should submit a new MedicalCertification Form (MCF) when they apply/reapply.

• Clients who are recertifying should only submit an MCF ifthe clients’ medications are changing.

• If recertifying, the MCF should be faxed separate from therecertification application so medication changes can bemade immediately. This will ensure the client can orderthe medications currently prescribed.

• Medications/regimens may change for clients in the courseof time. If the client is “active” with THMP but has beenprescribed a different HIV regimen, then the doctor willneed to complete, sign, and submit a new MCF to THMPbefore the client orders the new regimen. If the client is“active” on THMP, then the client will not have to reapplyjust because his/her regimen has changed.

• MCFs can only be completed and signed by a certifieddoctor, a physician’s assistant, or a nurse practitioner.

• The MCF is THMP’s complete formulary and the onlymedications available at the time. New HIV medicationswill need to be approved before they are added to theTHMP’s formulary.

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Communication with AEWs and Clients THMP Program Specialists will follow these steps when they need to request missing or extra information.

1. Fax an incomplete or pending letter to the AEW.2. Send communication on ARIES with application status.3. Upload a denial letter on ARIES.4. Mail an incomplete, pending, or denial letter to the client.

Program Specialists will call AEWs if more information or clarification is needed to make a determination, however, that is not THMP’s primary form of communication for application statuses.

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Self-Attestation (6-month follow-up)

A client will have to submit a Self-Attestation form six months after the client is approved or reapproved (six months after their birth month).

A self-attestation form will provide an update to THMP if the client’s residency, income, or insurance information has changed. This follow up will help THMP determine if the client is still qualified to receive THMP assistance.

The client will need to submit proof of residency, proof of income, and new insurance information with the self-attestation form if the client reports that any or all of these have changed.

How will the Client Obtain a Self-Attestation Form?

THMP will mail a self-attestation form 60 days before it’s due. The due date is on the last day of the client’s half birthday month.

For example, if a client’s birth month is in March, their half birthday month is in September (6 months after March). THMP will mail the self-attestation form to the client on August 1st

and it will be due in the THMP office by the last day of the half birthday month (September 30th).

Mailing the form to the client 60 days before it’s due will give the client ample time to complete this requirement. A hold will be put on the client’s medication if THMP does not receive the self-attestation form by the due date.

Because clients can apply to the program any time during the year, the due date for the first self-attestation form might be shorter or longer than 6 months.

THMP will mail the self-attestation form to the address on file. If the client has moved, they might not receive the self- attestation form and runs the risk of interruption in their regimen.

How to Submit a Self-Attestation Form to THMP:

The form must be signed by the client and/or the AEW. The client or AEW can fax or mail the self-attestation form directly to THMP.

The client can call THMP directly and do a self-attestation over the phone if the client doesn’t have changes to report.

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A self-attestation with changes cannot be done over the phone because the client will have to submit new required documentation to reflect the changes. That information will be due by the last day of their half-birthday month.

Self-attestations will NOT be done over the phone if the client is sitting with an AEW or case manager. The AEW or case manager should send the self-attestation with or without changes by fax or mail, along with required documentation to reflect changes.

The AEW can call the client and complete a self- attestation over the phone and then fax or mail the self-attestation form to THMP.

If the client reports any changes, required documentation will need to be submitted with the self-attestation form by the due date.

AEW Performance Measure: Was the recertification/self-attestation done before the

due date? Is the application complete? Did the AEW include supporting documentation to help

justify approval? Was the self-attestation or recertification submitted

within 10 days of the client’s signature?

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Recertification Process (Done annually by the last day of their birthday month)

Active clients will have to reapply to THMP in order to determine if the client is still eligible for THMP assistance.

How will the Client Obtain a Recertification Application?

THMP will mail the recertification application to the address on file. If the client has moved, they might not receive the application and runs the risk of interruption in their regimen.

THMP will mail a recertification application 60 days before it’s due. The due date is on the last day of the client’s birth month.

For example, if a client’s birth month is in April, THMP will mail the recertification application form to the client on March 1st and it will be due in the THMP office by the last day of the birth month (April 30th).

Mailing the form to the client 60 days before it’s due will give the client ample time to complete this requirement. A hold will be put on the client’s medication if THMP does not receive the recertification application by the due date.

An AEW can also give an application to the client if the client is within his recertification period.

Because clients can apply to the program any time during the year, the due date for the first recertification application might be shorter or longer than 6 months.

How to Submit a Recertification Application to THMP: The client can fax or mail the recertification application directly to THMP.

The AEW can fax, mail, or send the recertification application via ARIES to THMP.

The client’s medications are put on hold if the client misses his/her deadline.

THMP can mail a 2nd recertification application to the client or the AEW can give the client an application as long as they are within their eligibility period.

MCFs for recertification applications should be faxed separately if the client has a change in regimen.

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AEW Performance Measure: Was the recertification/self-attestation done before the

due date? Is the application complete? Did the AEW include supporting documentation to help

justify approval? Was the self-attestation or recertification submitted

within 10 days of the client’s signature?

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Application Status Approved The application is complete and the client has met all

requirements for THMP assistance. The client is considered an “active” client.

Pending THMP has verified information that conflicts with what isreported on the application, therefore, a determinationcannot be reached.

THMP staff will fax a Pending Letter to the AEW and mailto the client to request the missing information.

The application will be held for 30 days to give theclient time to submit all necessary documents.

The application is denied after 30 days if pendinginformation is not submitted.

Third party information was found that contradicts what’sbeen reported on the client’s application (for example,information was found that indicates the client is marriedbut they applied as single) and THMP is waiting foradditional information that will resolve this conflict.

The client has an urgent need to enroll in the program(expedited) and can get missing information to the programquickly.

On Hold The client is currently approved for the program but his/her medications have been placed on hold due to one of the following reasons:

THMP correspondence sent to client wasreturned to THMP due to an “incorrect address”or “return to sender” label. This could mean theclient is no longer a Texas resident.

Pending information for recertification has notbeen provided by the due date.

HMS reports the client may have an activeinsurance policy.

The medications will be dropped until the client canprovide insurance information or proof of prior coverage.

THMP cannot assist a client who is currently hospitalized.The AEW or the client will have to inform THMP of theclient’s discharge from the hospital before a medicationorder can be approved.

Notification from the pharmacy or agency informing THMP that the client has moved out of state, their marital status has changed, or insurance information has changed.

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Application Status cont.

Purged The application has been on “pending” status forover 30 days.

The application or self-attestation was sent “Out ofCycle” (too early for recertification).

The application is a duplicate. The client has moved out of state after they

submitted a THMP application. The client is deceased. These applications go through a second review

before they are purged.Dropped The client has been dropped from the program

because they have not ordered from THMP for 6consecutive months.

THMP determined THMP is not the payer of lastresort due to changes in insurance or Medicarecoverage.

The client will have to reapply for the program.

Rejected/Denied: A complete application was submitted but the clienthas not met all requirements for THMP assistance.

The client is currently hospitalized, living in anursing home facility, or is currently in jail.

THMP staff will fax a rejection letter to the AEWwho will assist the client to apply for PatientAssistance Programs (PAP). A rejection letter will bemailed to the client.

THMP Staff will mail a rejection letter and PAPinformation directly to a client who has applied toTHMP without the assistance of an AEW.

Recertification The client is due for recertification. The client willbe kept on an “active” status until the applicationdue date (last day of birth month).

The client will be dis-enrolled from the program ifTHMP does not receive an application by the duedate as it will be impossible for THMP to make adetermination for continued eligibility.

If a client is denied for recertification, medicationscannot be dispensed to the client after they arefound ineligible.

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Useful Information to Look for on Pay Stubs

Look for deductions for health insurance, medical insurance, or drug discount programs. It’s okay for the client to have a visual or dental insurance plan. Health or medical insurances need to be investigated. Forward these applications to the TIAP team.

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Tax Return Forms

THMP will accept Tax Return Forms from the most recent tax year.

Reasons THMP Might Request a Tax Return Form: • The client and/or spouse is/are self-employed.• If the client just moved to Texas, has never worked in this state,

and is not currently employed.• If the client hasn’t been employed in over a year and the Data

Broker does not report recent earnings for the client. (Anexception will be made for those recently released from jail orhomeless persons.)

• The client works multiple, overlapping jobs (ex: home health careproviders and temporary jobs, etc).

• Jobs that are considered contract labor in which the employer submitsa 1099-MISC to the IRS and clients have to pay their own taxes.

Information THMP Looks for on Tax Return Forms • Schedule C for those who are self-employed. A Schedule C

must accompany the THMP application.• Social Security Number (SSN) or Tax Identification Number (TIN)• Marital status• Dependents• Total Income• Investments• Interests• Annuities• 401k information• One-time paid benefit information• Insurance deductions

Note: An exception to request a Tax Return Form may apply to Special Population applicants, such as: undocumented persons, those recently released from incarceration, and homeless persons.

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Case Analysis Texas HIV Medication Program

July 2019 2-1

Lupe DOB: 9/8/1980

Diagnosed 5 years ago

Proof of Texas ResidencyNone at the time of completing the application.

IncomeNo proof of income at the time of completing the application.

EmploymentClient and spouse both employed.

HouseholdClient, spouse, 10-year-old son

Marital StatusLegally married

Situation New patient at your agency. Client is 4 weeks pregnant. Has employer-based insurance Didn’t bring supporting documentation to her appoint-

ment.

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Lupe

Case Analysis Worksheet

Each case represents a client who has come to see you in your agency to request assistance with HIV medications.

1.Recognize potential issues. List terms or phrases thatseem to be important for understanding your client’s situa-tion and what needs to be submitted to THMP.

2.Use the Required Documentation list to complete thechart below. (Remember, some documents can be used for more than 1requirement. For example, a pay stub with the matching address can be used for both proof of residency and income.)

What do we know? What do we need to know?

Can you complete an application with the in-formation the client has provided during this ini-

tial visit?

List two items from the Re-quired Documentation list that you think would be useful for this client to prove Texas residency.

List two items from the Re-quired Documentation list that you think would be useful for this client to

prove income or support.

List 1-2 items from the Re-quired Documentation list

that you think would be re-quired for insurance pur-

poses (if applicable).

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Lupe 3. How many people are in the household? List them.

4. Can you foresee any reasons for which this client’s application wouldbe denied or pended?

5. Would a written explanation be useful for this client? If so, whatwould it say?

6. How can you best help this client submit a complete application?

7. Look back at your answers. How did you ensure you’re meeting yourAEW performance measures with this particular case?

2-4

Alyssa DOB: 10/10/2003

Diagnosed New ly Diagnosed.

Proof of Texas ResidencyNone.

Income$0 Parents brought proof of income at the time of completing the application.

EmploymentClient: none Father: construction work; paid in cash by supervisor Mother: not employed

HouseholdClient, mother, father, and 2 siblings under the age of 18.

Marital StatusNever Married

SituationChild of immigrants and client just moved to the U.S. Mother is an established patient at your agency.

2-5

Alyssa




2.Use the Required Documentation list to complete thechart below. (Remember, some documents can be usedfor more than 1 requirement. For example, a pay stubwith the matching address can be used for both proof ofresidency and income.)



tial visit?







2-6

Alyssa 3. How many people are in the household? List them.


5. Would a written explanation be useful for this client? If so, what wouldit say?



2-7

Jack

DOB: 2/5/1951

Diagnosed: 25 years ago


IncomeAward letter for Social Security at $600/monthly.

EmploymentDoes yard work for extra cash when needed.

HouseholdClient and his father.

Marital StatusNever Married

SituationJust has Medicare. Established patient at your agency. Experiences transportation issues.

2-8

Jack







tial visit?







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Jack 3. How many people are in the household? List them.





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Joan

DOB: 3/3/1965



Income$0

EmploymentNone.

HouseholdClient.

Marital StatusDivorced 8 years ago.

SituationEstablished patient at your agency. Active on THMP. Concerned because her medications are on hold and she doesn’t know why.

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Joan







tial visit?







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Joan 3. How many people are in the household? List them.





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Marquette

DOB: 3/15/1977

Diagnosed: New ly Diagnosed.


Income$0

EmploymentNot employed.

HouseholdClient, his brother, his brother’s spouse and brother’s children.

Marital StatusMarried. Spouse lives in another country.

SituationCD4 Count 70 Moved to the U.S. 6 months ago. New patient at your agency. His brother helps him and accompanied him to his appointment.

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Marquette







tial visit?







2-15

Marquette 3. How many people are in the household? List them.





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Joe DOB: 4/8/1983



Income$0

EmploymentNot employed.

HouseholdClient.

Marital StatusMarried but hasn’t seen his spouse in 7 years.

SituationReleased from jail 3 months ago. Homeless. New patient at your agency. Concerned because he has run out of medications after be-ing released from jail.

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Joe







tial visit?







2-18

Joe 3. How many people are in the household? List them.





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Michael

DOB: 2/13/1987


Proof of Texas ResidencyA written statement signed by his mother.

IncomeNone at the time of completing the application.

EmploymentStarted a new job 1 month ago

HouseholdClient and his mother.

Marital StatusDivorced for about 1 year.

SituationLost employer-paid insurance just over 1 month ago but now has a new job. New patient at your agency.

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Michael







tial visit?







2-21

Michael 3. How many people are in the household? List them.





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Public Complaints Related to the Delivery of Section Programs1

Procedure Number 020.050 Effective Date September, 1996 Revision Date July 1, 2015 Subject Matter Expert Section Chief of Staff Approval Authority TB/HIV/STD Section Director Signed by Felipe Rocha, M.S.S.W.

1.0 Purpose

The purpose of this policy/procedure is to provide the TB/HIV/STD Section (Section) with a method of resolving client complaints about the delivery of services. It is the policy of the Section to effectively and promptly address all client complaints.

This policy is not intended to address allegations filed against the Section or its Branches regarding staff actions or to be used to request a change or modification of a decision, policy or procedure. This policy should also not be used for purposes of filing a privacy complaint. If a complaint involves a violation of privacy, these complaints will be handled by the agency privacy officer and/or the U.S. Health and Human Services Office of Civil Rights2. (See section 5.4 of this Policy for further information.)

2.0 Authority

Title II of the Ryan White Care Act Amendments of 2000.

3.0 Definitions/Acronyms

Complaint – an allegation of wrongdoing, discrimination or an expression of dissatisfaction with services which may involve an immediate and serious threat to a client, misuse of resources by providers, or denial of services to clients by an entity.

Contractor/Provider – a person, agency or facility approved by DSHS that

1 https://dshs.texas.gov/hivstd/policy/procedures/020-050.shtm 2 https://www.hhs.gov/ocr/index.html

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has entered into a contract with DSHS to deliver state or federal TB, HIV or STD programs to clients.

Immediate and/or serious threat – a situation posing a high possibility for serious injury to a client if the client is not protected from harm or the threat is not removed.

Investigation – the process of gathering information sufficient to allow a decision to be made regarding the validity of the complaint, and/or determining referrals that should be made to ensure the complaint is handled by the appropriate entity.

Services – program activities offered by a provider on behalf of the DSHS TB/HIV/STD Section and its Branches.

TB/HIV/STD Section – a Section in the DSHS Disease Control and Prevention Services Division which includes: the HIV/STD Prevention and Care Branch, the TB/HIV/STD Epidemiology and Surveillance Branch, the TB and Refugee Health Services Branch, and the Pharmacy Branch.

4.0 Persons Affected

• All TB/HIV/STD Section employees• Section Branch Managers• Section Chief of Staff• DSHS Contractors• DSHS Regional staff

5.0 Procedures

5.1 Contractor Responsibility

Current contractors and applicants seeking contractual status with DSHS are required to have a procedure in place to resolve civil rights client complaints consistent with federal and state regulations in order to receive DSHS funds.

5.2 Processing a Complaint

Any individual wishing to file a complaint can do so in writing, in person, by email, fax or telephone. Complaints should include all details regarding the problem and a desired resolution or outcome. While not required, clients submitting complaints via telephone are encouraged to follow-up in writing in order to minimize the miscommunication of client concerns.

If a complaint is received via email and it contains personal health information, Section staff should follow TB/HIV/STD Section Security

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Procedure 2016.01, TB/HIV/STD Section Confidential Information Security Procedures3. Email, whether encrypted or non-encrypted may not be used to transmit confidential information. Transmitting attachments containing confidential information via email is also prohibited.

5.2.1 Complaints Received Through the HIV Care Services Group

Complaints received through the HIV Care Services Group will initially be assessed by the Group’s Manager or the Group’s Team Lead. The assessment will determine whether the complaint can be more quickly and appropriately resolved through the local Administrative Agency (AA) processes or if it should be handled using the Complaint Triage Committee (see Section 5.2.2). If the AA is the more appropriate and timely organization to conduct the investigation, the Group Manager or Team Lead will request that the AA conduct the investigation.

The Group Manager or Team Lead will track the progress of the investigation through the AA’s final findings. If the AA’s final findings are unsatisfactory, the Group Manager or Team Lead will refer the complaint to the Complaint Triage Committee.

Any complaint received by the Group that involves an immediate and/or serious threat shall immediately be referred to the Complaint Triage Committee.

The Group manager or Team Lead will be responsible for collecting appropriate information about these complaints, tracking their successful resolution and keeping all confidential files related to these investigations.

5.2.2 Complaint Triage Committee

All complaints are assigned through the Complaint Triage Committee (the Committee) except for HIV Care Services Group complaints specified in Section 5.2.1. The Committee is responsible for:

• Determining if a situation poses an immediate or serious threat;• Reviewing complaints and determining the issue(s) to be addressed;• Assigning investigation/resolution responsibility to appropriate DSHS

staff, local agency or region;• Receiving reports on outstanding complaints and monitoring timely

resolution; and• Approving complaint resolutions and authorizing staff to close

complaint files.

3 https://dshs.texas.gov/hivstd/policy/procedures/2016-01.shtm

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The Complaint Triage Committee shall consist of the following staff positions:

• HIV/STD Prevention and Care Branch Manager• TB/HIV/STD Epidemiology and Surveillance Branch Manager• TB and Refugee Health Services Branch Manager• The Pharmacy Branch Manager

5.2.3 DSHS Staff Procedures

Any regional or Section staff receiving a complaint must record all the details on the Complaint Intake Form, 020-050A4. The staff receiving the complaint shall immediately take the complaint to a Triage Committee Member (TCM) who will:

1. Determine whether a complaint involves an immediate and/or seriousthreat to a client. If the complaint is received by a Regional office,regional staff will make the determination. Investigations of complaintsposing an immediate and/or serious threat are given the highestpriority and all allegations of abuse, neglect or other immediate healththreats require immediate action;

2. Notify other Triage Committee members;3. Assign the complaint to the appropriate Section/Branch employee or

Regional employee;4. Assign a due date;5. Take the original intake form to the Section Chief of Staff who will:

• Assign a tracking number• Send an acknowledgement letter to the complainant (unless the

complaint is received from an anonymous source). The letteracknowledges receipt of the complaint, indicates who to contact ifthere are any questions regarding the ongoing investigation,includes the complaint tracking number for reference, and anapproximate date when a resolution can be expected (if available).

• Ensure the assignee has a copy of the complaint and all supportingdocumentation; and

• Place copies of all documents into a pending file for tracking.

NOTE: Regional staff should immediately fax intake forms to a Triage Committee Member, ensuring that any confidential information in the complaint follow the appropriate security procedures below which are from TB/HIV/STD Section Procedure 2016.015. Regional staff should follow-up

4 https://dshs.texas.gov/hivstd/policy/procedures/020050a.pdf 5 https://dshs.texas.gov/hivstd/policy/procedures/2016-01.shtm

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with a phone call to ensure the complaint is acted upon in a timely manner.

From TB/HIV/STD Section Procedure 2016.01, "TB/HIV/STD Section Confidential Information Security Procedures," Section 5.2, Faxing:

1. Confidential information sent using a facsimile must be faxed under acover sheet. The cover sheet must not contain the words HIV, AIDS,or STD anywhere on it.

2. The information to be faxed must be• de-identified (client's name and all other identifying information

removed) OR• the identifying information must be sent in a separate fax

transmission only after the sender has confirmed receipt of the firstfax with the receiver; OR

• All TB/HIV/STD related information has been removed or convertedto a code

• Anyone sending a fax must confirm that the information faxed wasreceived by the intended recipient

3. Fax machines used to send or receive confidential information must belocated in a secure area.

4. Programs are encouraged to use separate fax machines instead ofmultifunctional machines which include faxing capabilities.

Email, whether encrypted or non-encrypted, may not be used to transmit confidential information. Transmitting attachments containing confidential information via email is also prohibited.

5.3 Complaints Involving Violations of Privacy or Discrimination

If a complaint involves a violation of privacy, the assignee must inform the Section Security Officer and proceed as instructed.

If a complaint alleges discrimination, the assignee should inform the Health and Human Services Commission (HHSC) Office of Civil Rights6 and proceed as instructed.

5.4 Investigating the Complaint

• Section/Branch or Regional employees investigate all complaints(except for complaints received by the HIV Care Services Group asoutlined in Section 5.2.1 of this Policy).

• If a complaint lacks sufficient information to conduct an investigation,additional information should be requested from the complainant.

• Requests for additional information for complaints deemed to be an

6 https://hhs.texas.gov/about-hhs/your-rights/civil-rights-office

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immediate and/or serious threat to the client should be requested by telephone or in person.

• A complaint may be closed if the complainant does not respond to thisrequest within ten business days and sufficient information is notavailable from another source to enable a determination.

• When the complaint involves personnel outside the jurisdiction of theBranches, the assignee may investigate and/or refer the complaint tothe appropriate authority.

• Resolution of complaints should be made at the lowest possibleorganizational level.

• Unless there is a serious and/or immediate threat to the client,complainants who have not pursued local resolution prior to contactingthe Section will be referred back to the most appropriate level of thelocal organization. Investigation of the complaint will be conductedunder the local complaint process of the contractor.

• The assignee should investigate as appropriate and/or maintaincontact with the Region, the service provider, the HIPAA officer, orother offices/agencies actively involved in investigating and resolvingthe complaint.

• A complaint remains open until notified by the contractor that theinvestigation has been completed and an appropriate resolution hasbeen implemented.

5.5 Determine findings/resolution

After the investigation is complete, the assignee takes the results of their investigation to the Complaint Triage Committee for review and approval of final disposition. One or more of the following actions should be recommended and documented on the Complaint Intake Form:

1. The assignee determines the allegation was non-verifiable or invalidand dismisses the complaint.

2. The assignee determines the allegation was substantiated andcorrective action is warranted. Corrective action may take one or moreof the following forms:• A written warning issued to the facility or individual(s) involved.• A written plan of corrective action to be submitted to the Section by

the facility or individual(s) involved. The corrective action plan willindicate a time frame in which the corrective actions will becompleted.

• Any of the sanctions described in TB/HIV/STD Section Policy540.001, "Sanctions Imposed Upon a Contractor for Non-Compliance with Contracts Involving State/Federal Funds."

3. The investigation of allegations related to licensed social services or

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health care professionals may result in the referral of the information to the appropriate licensing and/or regulatory authority for further action.

4. The assignee in consultation with the Complaint Triage Committeedetermines if the complaint should be addressed by a DSHScontractor, subcontractor or other entity. The Committee will makeappropriate referrals and, when necessary, monitor the results of thereferral.

5. Complaints that potentially involve unlawful activity must be reportedto the Texas Health and Human Services Commission Office of theInspector General.

6. The final report of an investigation involving discrimination will be sentto the HHSC Office of Civil Rights for review prior to release of thereport.

5.6 Notify Appropriate Individual(s) of Findings/Resolution

When appropriate action has been determined, the resolution is approved by the Committee and documented in writing. Written notification of findings and recommended action are sent to appropriate individuals as determined by the Committee. Any letters regarding the findings and resolution may be signed by the assignee. Copies of documentation are provided to appropriate Regional staff.

5.7 Closing the Complaint

The assignee writes a summary to document complex and/or detailed investigation information and signs the intake form to indicate the complaint has been closed. All supporting documents are filed with the complaint and are forwarded to the Committee. The Committee signs and forwards to the Section Chief of Staff for closing of complaint and filing. The Chief of Staff will also be responsible for preparing appropriate record retention schedules and disposition of complaint files once the required retention period is reached.

5.8 Resolution Time Frames

The following resolution time frames should be followed:

Type of Complaint Recommended time frame Immediate and/or serious threat to a client

Initial investigation within 24 hours; resolution as soon as possible.

Other complaints Initial investigation within ten days; resolution within 60 days.

Incomplete information Complainant must comply within 10 days;

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resulting in requests for additional, verifiable information

resolution within 30 days after receipt of additional information or as soon as possible if the complaint poses immediate or serious threat to a client.

If the investigation cannot be completed within the appropriate time frame, the assignee should notify the complainant in writing. A copy should be sent to the Section Chief of Staff.

Complaints handled by Regional offices must be resolved within the same time period as those handled by the Section.

5.9 Confidentiality and Anonymous Complaints

The identity of the complainant may not be considered exempt from the Public Information Act (Texas Government Code, §5527. Section staff should ensure the complainant understands names and other identifying information will not be voluntarily released, but if the Office of General Counsel advises release of certain information upon receipt of an Open Records request, the Unit will be required by law to release the information.

Complaints filed by an individual who does not wish to reveal his/her name or who does not want his/her name used during an investigation will be investigated to the fullest extent possible, based on the information submitted.

To ensure a breach of confidentiality does not occur, transmission of confidential information via fax, email or other methods should be de-identified with the client’s name removed (See TB/HIV/STD Section Procedures 2016.01, TB/HIV/STD Section Confidential Information Security Procedures8). Email, whether encrypted or non-encrypted may not be used to transmit confidential information. Transmitting attachments containing confidential information via email is also prohibited.

5.10 Multiple Complaints from Same Person

Multiple complaints received from the same individual about the same organization or situations are tracked using the same number for each incident. Each incident should be addressed in an appropriate manner and the action taken should be documented and routed through the Section Chief of Staff to ensure the completeness of records.

7 https://statutes.capitol.texas.gov/Docs/GV/htm/GV.552.htm 8 https://dshs.texas.gov/hivstd/policy/procedures/2016-01.shtm

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6.0 Revision History

Date Action Section 9/1/2017 Changed "TB/HIV/STD Unit" to "TB/HIV/STD

Section" to reflect new program designation -

7/1/2015 Revisions made to update Unit and Branch names and new procedures for processing complaints.

All

10/7/2014 Converted format (Word to HTML) - 7/17/2006 Substantial revisions, considered a new policy.

Combines previous policy 020.050 and procedure BUR-BCO-211.001.

All

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Eligibility to Receive HIV Services9

Policy Number 220.001 Effective Date July 7, 2006 Revision Date March 18, 2019 Subject Matter Expert Manager, HIV Care Services Group Approval Authority Manager, HIV/STD Prevention and Care Branch Signed by Shelley Lucas, M.P.H.

This policy is under revision. Contact [email protected] to view the proposed policy and changes from the current policy. DSHS will accept public comment until July 3, 2019.

1.0 Purpose

The purpose is to outline the eligibility criteria for individuals to receive services funded though Ryan White HIV/AIDS Program (RWHAP) Part B, State Services, and the State of Texas’ AIDS Drug Assistance Program (ADAP).

2.0 Authority

Texas Health and Safety Code: Chapter 85, §§85.003, 85.013, 85.014 - 85.031; Ryan White HIV/AIDS Treatment Extension Act 2009; Health Resources & Services Administration (HRSA) Policy Clarification Notice (PCN) #16-02.

Replaces Policy #10-02. Policy Clarification Notice (PCN) #13-02.

3.0 Policy

Eligibility for an individual to receive assistance under RWHAP Part B, including the Texas HIV Medication Program (THMP) and/or State Services will be established to ensure appropriate client access to needed services while adhering to payor of last resort (PoLR) requirements.

9 https://dshs.texas.gov/hivstd/policy/policies/220-001.shtm

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4.0 Definitions

Administrative Agency (AA) – Entity responsible for ensuring a comprehensive continuum of care exists in their funded area(s). This is accomplished through the management, distribution, and oversight of federal and state funds, and under contractual agreement with the Texas Department of State Health Services (DSHS).

AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV Medication Program (THMP), administered by DSHS HIV/STD Prevention and Care Branch.

AIDS Regional Information and Evaluation System (ARIES) – Web-based, client-level software that RWHAP Part B /State Services-funded HIV providers use to report all RWHAP and State Services-funded services provided to RWHAP Part B-eligible clients.

Annual 12-Month Eligibility Recertification – The process of screening and determining eligibility for a period of months. Clients must be screened for program eligibility every six months (no later than the last day of the clients’ birth month for the annual 12-month recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation). Assessment includes: documentation of Texas residency, income, and proof of insurance/(payor). This documentation is submitted by the last day of the applicant’s birth month.

Applicant – An individual requesting RWHAP Part B, State Services and/or THMP-funded services and undergoing the eligibility process.

Client – An applicant who has been determined to be eligible for services, has successfully completed the eligibility process, and is receiving services.

Federal Poverty Level (FPL) – A measure of income level determined by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2) that is updated periodically in the Federal Register and primarily used to determine eligibility for certain programs and benefits. FPL is the set minimum amount of gross income that an individual or a family needs for food, clothing, transportation, shelter, and other necessities. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines.

Half Birth Month – Half Birth Month is the month that is six months after the client’s birth month (e.g. birth month is January, half birth month is July, and so on). For purposes of this policy, the end of the Half Birth Month shall be considered the last day of the month it falls in, regardless of a client’s

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birth date.

Human Immunodeficiency Virus (HIV) – an infection that destroys some types of white blood cells and is transmitted through blood or bodily secretions such as semen and as further defined by the Centers for Disease Control and Prevention (CDC) and in accordance with the Health and Safety Code, §81.101.

HIV supplemental (confirmatory) test – a test that confirms the diagnosis of HIV after a preliminary positive test has been completed.

HIV Service Delivery Area (HSDA) – Geographic service area set by the Department of State Health Services for the purposes of allocating federal and state funds for HIV medical and psychosocial support services.

HIV Services – Any social or medical assistance defined in the HIV Services Taxonomy10 paid for with RWHAP Part B and State Services funded through DSHS.

Initial Eligibility Determination Period – The 30-day period during which client undergoes initial eligibility assessment.

Medicaid – A joint federal and state health insurance program for some people with limited income and resources.

Medicare – A federal health insurance program for people who are 65 years old and older, certain younger people with disabilities, or for those who meet other special criteria.

Modified Adjusted Gross Income (MAGI) – A figure used to calculate income eligibility for lower costs in Marketplace Health Plans as well as eligibility for Medicaid, Children’s Health Insurance Plan (CHIP), and RWHAP Part B/State Services-funded HIV medical and support services. Generally, modified adjusted gross income is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income an individual may have. MAGI must be calculated using the DSHS provided Income Calculation Form, which can be found on the MAGI documents page11.

New Eligibility Determination – The process of assessing an applicant’s eligibility upon entrance into RWHAP Part B, State Services, and/or THMP-funded services. Assessment includes: documentation of HIV status, Texas residency, income, and insurance (payor).

10 https://dshs.texas.gov/hivstd/taxonomy/default.shtm 11 https://dshs.texas.gov/hivstd/magi/

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Nucleic Acid Amplification Test (NAAT) – A laboratory test that amplifies the HIV RNA and detects viral genes instead of viral antibodies or antigens.

Payor of last resort (PoLR) – RWHAP or State Services funds cannot be used as a payment source for any service that can be paid for or charged to any other billable source. Providers are expected to make reasonable efforts to secure other funding instead of RWHAP Part B or State Services funding, whenever possible.

Provider – A local organization, individual clinician, or group of clinicians who provide services to people living with HIV (PLWH).

Six-Month Self-Attestation – process of a client confirming no change in previous eligibility declaration and documentation. This process occurs by the last day of the half birth month, six months after the client’s birth month.

Spend-down – THMP considers the cost of medications provided to applicants and spends down client income based on this cost. This generates an adjusted FPL that is used for program eligibility determination. THMP medication pricing is confidential, and will not be shared with agency workers or applicants.

State Pharmacy Assistance Program (SPAP) – This program, operated by THMP, aids with premiums and out-of-pocket costs associated with qualifying Medicare Part D prescription drug plans for low-income Texans.

Subrecipient – A non-federal entity that receives a subaward from a pass-through entity or recipient (AA) to provide services to clients and implement policy.

Texas Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas.

Texas HIV Medication Program (THMP) – Provides medications for the treatment of HIV and its related complications for low-income Texans. The THMP is the official ADAP for the State of Texas. It also operates the SPAP and Texas Insurance Assistance Program (TIAP).

Texas Insurance Assistance Program (TIAP) – This program, which is operated by THMP, aids with premiums and out of pocket medication costs for low-income Texans with qualified insurance plans.

Texas Resident – An individual who resides within the geographic boundaries of the state.

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Veteran – A former member of the Armed Forces of the United States of America. Veterans are eligible to receive RWHAP Part B and State Services-funded services. Please see DSHS Policy 590.001 DSHS Funds as Payment of Last Resort12 for more detailed guidance.

Viral Load – A laboratory test that measures the amount of HIV viral copies in a milliliter of blood.


• DSHS HIV Care Services and THMP staff• Administrative Agencies (AAs)• Subrecipients/Providers• Applicants/Clients for HIV services funded by RWHAP Part B and State

Services

6.0 Responsibilities

6.1 DSHS Division for Laboratory and Infectious Disease Services (LIDS)

Ensures that systems are in place to provide care and services to Texans who are eligible to receive these services through RWHAP Part B and State Services funding, and ensures that these funds are used as payment of last resort. Staff will assure that AAs appropriately monitor eligibility documentation for these payment sources as well as conduct appropriate assessments to determine eligibility for other third-party payers using MAGI.

6.2 Administrative Agency (AA)

Develop policy for determination of eligibility; use MAGI to determine income; determine how providers will be trained to determine eligibility; and monitor provider billing of third party payers to determine compliance with PoLR requirements.

6.3 Subrecipient and Provider

Develop policies and procedures to determine eligibility for services while ensuring RWHAP Part B and State Services funds are used as payment of last resort; develop policies and procedures to ensure that individuals seeking covered services are screened for eligibility using MAGI to identify other payer sources such as the Marketplace, Medicaid, and CHIP. Screening should occur as indicated in this policy. If individuals are determined potentially eligible for other benefits, refer them to the specific programs


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and assist them in completing the eligibility determination process. When providing emergency assistance to priority populations in crisis (e.g., an individual who is recently released from the criminal justice system who requires assistance in acquiring HIV medications), contractors must refer clients into appropriate program services and assist in obtaining any required eligibility documentation. Providers should also ensure the proper documentation of any and all eligibility screening and intake activities in the clients’ respective charts—paper and/or electronic (e.g., ARIES).

6.4 Applicant, Client, and Family

Provides the required documentation to determine eligibility for services funded under RWHAP Part B, State Services, and THMP.

7.0 Requirements

7.1 Initial Eligibility and Annual 12-Month Recertification of HIV Status, Texas Residency, and Income

Upon initiation of services, as well as every 12 months, providers must determine whether an applicant meets the following RWHAP Part B/State Services eligibility criteria:

• have a diagnosis of HIV infection;• provide documentation of Texas residency; and• provide complete and accurate income documentation.

Recertification of HIV status after initial eligibility determination is not required.

Clients must be screened for program eligibility every six months (no later than the last day of the clients’ birth month for the annual 12-month recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation).

7.1.2 Initial Eligibility Determination Period

A 30-day determination period for all Ryan White Part B and State funded services can be accessed by clients who are:

• Newly diagnosed within the previous six months;• New to the State of Texas/local HSDA and in need of medical services;• Engaging in care for the first time after being diagnosed for longer

than six months;• Returning to medical care after an absence of six months or longer

and/or;

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• In need of early intervention services.

As applicants are being linked to services, providers should work to complete the eligibility process and collect required documents. An eligibility determination must be complete within 30 days of program application initiation.

Providers must have an established alternative source of funding should a client be found to be ineligible for Ryan White Part B, or State funded services. This must be documented in agency policy, and tracked in client file if applicable. Policy must delineate process for any necessary administrative adjustments if a cost is found to be unallowable.

*Please note that this initial determination period does not apply to clientsapplying to any THMP program. All required documentation must besubmitted with THMP application.

7.1.3 Documentation of HIV-Infection Status

To be eligible for services paid for by RWHAP Part B/State Services/THMP, an individual must have a diagnosis of HIV infection. Affected individuals (people who are not living with HIV) may be eligible for RWHAP services in limited situations; services for affected individuals must always benefit PLWH. For further clarification on providing services to affected individuals, please see HRSA Policy Clarification Notice (PCN) #16-02, Eligible Individuals and Allowable Uses of Funds13.

There are many different ways to document HIV infection. Some examples of acceptable forms of documentation are provided below; however, this should not be viewed as a complete list.

Laboratory Documentation

Proof of HIV infection may be found in laboratory test results that bear the client’s name. Some examples include:

• Positive result from HIV screening test (HIV 1/2 Combo Ab/Ag enzymeimmunoassay [EIA]);

• Positive result from an HIV 1 RNA qualitative virologic test such as aHIV 1 Nucleic Acid Amplification Test (NAAT); or

• Detectable quantity from an HIV 1 RNA quantitative virologic test (e.g.viral load test)

NOTE: HIV testing technology changes rapidly and standards of HIV

13 https://hab.hrsa.gov/sites/default/files/hab/program-grants-management/ServiceCategoryPCN_16-02Final.pdf

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confirmation continue to evolve. Providers must stay informed of advances in testing technology as newer tests may also provide proof of HIV infection.

Other Forms of Documentation

Some examples are:

• A signed statement from an entity with prescriptive authority attestingto the HIV-positive status of the person; or

• A complete THMP Medical Certification Form signed by a physician(required by THMP); or

• A hospital discharge summary documenting HIV infection of theindividual

NOTE: Exposed infants of HIV-positive mothers can be served with documentation of the mother’s HIV-positive status up to the age of 18 months. Children older than 18 months must meet the same criteria for proof of HIV as listed above to continue services.

Facilitating linkage with an HIV Preliminary Positive result

A preliminary positive is a positive result from an HIV screening test. Although a preliminary positive is not considered proof of HIV status (because it is not a supplemental test in the current HIV testing algorithm), individuals with such a result are very likely to have HIV infection and would benefit from quick linkage to ongoing medical care. Having only a preliminary positive result from one HIV test should not be a barrier in linkage to medical care.

A preliminary HIV-positive result should not be used to apply for the THMP.

The ability to use a preliminary positive test result to facilitate linkage to care does not negate the responsibility of the HIV testing site to conduct supplemental testing. The receiving medical provider must be informed of the individual’s unconfirmed preliminary positive HIV test result. Once the supplemental results are received from the lab, HIV testing staff must provide these results to the individual and, if a Release of Information is signed, to the HIV care provider. Clinics receiving such individuals may choose to arrange an abbreviated first appointment, during which the individual could receive counseling on HIV infection, orientation to medical care, conduct eligibility screening, and/or begin laboratory work. Note: HIV medical providers may elect to conduct the HIV supplemental test if a memorandum of understanding (MOU) is signed with the HIV testing

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agency.

Providers should contact their AA with questions about acceptable documentation of HIV infection.

7.1.4 Documentation of Texas Residency

To be eligible for services paid for by RWHAP Part B/State Services/THMP, an applicant must reside within the geographic boundaries of Texas and express intent to remain within the state and not claim residency in any other state or country.

Individuals do not lose their Texas residency status because of a temporary absence from the state. For example, a migrant or seasonal worker may leave the state during certain periods of the year, but maintains a home in Texas, and returns to that home after this temporary absence. This individual will not lose their Texas residency status.

Students

• Students from another state who are living in Texas to attend schoolmay claim Texas residency based on their student status while theyare residing in Texas.

• ADAP Only: Students living out-of-state (living in a state other thanTexas), but who claim Texas residency based on their student statusmust provide a denial from that state’s ADAP and documentation ofschool enrollment in order to be approved for the Texas ADAP.

Acceptable proof of residency documents must include the applicant’s full legal name and residential address, and be unexpired or from the last 30 days.

Documentation of proof of Texas residency can be determined using one of the following:

• valid (unexpired) Texas Driver’s License;• Texas State identification card (including identification from criminal

justice systems);• recent Social Security, Medicaid/Medicare or Food Stamp/TANF benefit

award letters;• IRS Tax Return Transcript, Verification of Non-Filing, W2, or 1099;• current employment records (pay stub);• post office records;• official state mail;• current voter registration;• rent or utility receipts for one month prior to the month of application

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in the client’s name; • a mortgage or official rental lease agreement in the client’s name;• valid (unexpired) motor vehicle registration;• proof of current college enrollment or financial aid;• property tax receipt;• a letter of identification and verification of residency from a verifiable

homeless shelter or community center serving homeless individuals; or• a statement/attestation (does not require notarization) with client’s

signature declaring that client has no resources for housing or shelter.For THMP, a letter from an agency worker attesting that the individualhas no resources for housing or shelter will be accepted.

If none of the items listed above are available, Texas residency may be verified through:

• Credit card, phone, or cable bill with address clearly indicated ondocument; or

• Formal business correspondence; or• Bank brokerage statement with address clearly indicated on

document; or• statement from landlord/neighbor/another reliable source; or• submission of the DSHS-THMP Supporter Statement. This is only

accepted when no other proof of residency is available and must beaccompanied by a signed statement on agency letterhead from theagency enrollment worker detailing steps that were taken to obtainproof of residency and why they were not successful; or

• observance of personal effects and living arrangement (e.g., visit toresidence). For THMP, a signed statement on agency letterheaddetailing this observance and why other forms of proof of residencywere not available will be accepted.

There is no further proof of residency requirements (e.g. requirement for a photo ID, documentation of immigration status) other than those listed above. AAs, subrecipients and/or providers may not impose more stringent proof of residency requirements regarding eligibility for RWHAP and State HIV funded services than those listed in section 7.1.4 of this policy.

All eligibility staff shall be made aware of this policy no less frequently than annually.

Providers should contact their Administrative Agency, or THMP with questions about acceptable documentation of Texas residency.

7.1.5 Documentation of Income

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To be eligible for services paid for by RWHAP Part B/State Services/THMP, an applicant must submit proof of income and FPL. Subrecipients and providers must use the DSHS-provided Income Calculation Worksheet14 to calculate an applicant’s income. These worksheets can be found online on the MAGI documents page15.

Income Calculation Worksheet

The Income Calculation Worksheet is divided into ‘Section A’ and ‘Section B’. This form calculates an individual’s federal poverty level based on their modified adjusted gross income (MAGI).

Section A is used to calculate:

• income for clients who do not have access to a ‘Tax Return Transcript’or other standardized tax return forms (form 1040, 1040 EZ, etc.);

• income for clients whose income has changed since filing taxes for themost recent year; and

• clients who are 'Married Filing Jointly'.

Documents that may be used to complete Section A are outlined below:

• pay stubs (30 continuous days of payment within the last 60 days);• supporter statement;• employer statement;• agency letter;• Social Security Income (SSI) Award Letter;• Social Security Disability Income (SSDI) Award Letter; or• other income documentation.

Note: If the client is unable to provide any other form of income documentation, bank statements are acceptable forms of income documentation for both the RWHAP Part B and THMP/ADAP program.

Section B is used to calculate income for clients who have access to the following:

• Standardized tax return forms (form 1040, 1040 EZ, Tax ReturnTranscript, etc.).

The Income Calculation Worksheet is self-calculating and produces the FPL percentage based on both household and individual income. A copy of the worksheet and supporting documentation must be kept in the primary client

14 https://dshs.texas.gov/hivstd/meds/files/IncomeCalculationForm.xls 15 https://dshs.texas.gov/hivstd/magi/

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record. These documents should also be submitted with THMP applications.

THMP income calculation includes income information received through third-party verification and is subject to a spend-down, therefore THMP eligibility cannot be assumed by enrollment workers before a submitted application is processed.

7.1.6 Local Criteria for Eligibility Determination

AAs may impose additional criteria to determine eligibility, such as those based on income and county of residence. Additional criteria can be imposed if justified though a needs assessment or planning process that includes public input and comment. Additional eligibility criteria may vary depending on service category. However, further eligibility determination must be applied to all individuals equally and must not pose an undue hardship on individuals.

All RWHAP Part B and State -funded services must have an income limit not to exceed 500% of FPL.

The current THMP financial eligibility criteria may be found at https://www.dshs.texas.gov/hivstd/meds/.

7.2 Screening Clients for Third Party Payers

AAs must ensure that their sub-recipients/providers are coordinating

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benefits and the use of third party reimbursement by:

• monitoring how subrecipients/providers determine client eligibility toensure that RWHAP Part B and State Services funds are the payors oflast resort; and

• monitoring the documentation that shows clients have been screenedfor and enrolled in eligible programs prior to the use of RWHAP Part Band State Services funds; and

• requiring and monitoring how subrecipients/providers use a third-partypayer verification system.

Providers must screen individuals for their ability to pay as well as their eligibility for other potential sources of payment for these services. Programs/benefits that must be used first include:

• private/employer insurance;• Medicare (including Part D prescription benefit);• county indigent health programs;• patient assistance programs (PAPs);• Medicaid;• Children’s Health Insurance Programs (CHIP); or• other comprehensive healthcare plans.

Documentation of eligibility status must be filed in the client’s primary record.

THMP independently screens for third-party payers, which may result in denial from the program.

7.3 Six-month Self-Attestation (Half Birth Month)

To assess eligibility at the 6-month mark, providers may accept client self-attestations of change/no change in income, residency, and insurance status (self-attestations are not acceptable forms of documentation at the annual/12-month recertification). Self-attestations may be signed by the client or the provider, with verbal affirmation from the client. This process occurs by the last day of the month, six months after the client’s birth month.

Related communications from RWHAP Part B providers must be transmitted in a confidential manner. If a client has had a change in income, residency/address, or insurance status, they must submit appropriate supporting documentation.

Self-attestations must be documented in the client’s primary record and updated in ARIES, even if there is no change (the date stamp in ARIES

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should reflect the most recent recertification date). Supporting documentation must be kept in the client’s primary record.

For clients enrolled in the THMP, a copy of the self-attestation must be sent to THMP before the end of the half birth month. THMP will accept self-attestation forms signed by the client, or signed by the provider who spoke directly to the client. THMP will also accept self-attestations with no changes over the phone with the client.

Recertification of HIV status after the initial eligibility determination is not required.

While eligibility for services must be determined every six months for active clients, providers should assess changes in eligibility at the time of service. The providers’ policies and procedures must address how clients will be contacted regarding their 6-month recertification, and how changes in eligibility will be assessed at the time of service. Consult the table below for guidance on the recertification process and required documentation.

Required Documentation Table

Eligibility Criteria

Initial Eligibility Determination

Annual 12-Month Recertification (by last day of Birth Month)

6-Month SelfAttestation (by lastday of Half Birth-Month)

HIV status Documentation is ONLY required for initial eligibility determination.

N/A N/A

Income Supporting documentation is required to complete the Income Calculation

Supporting documentation is required to complete the Income Calculation

Self-attestation of no change is acceptable. Attestation must be

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Worksheet.

Acceptable documentation for Section A (not exhaustive list):

• pay stubs (30continuous days ofpayment within thelast 60 days);

• supporter statement;• employer statement;• Social Security

Income (SSI) AwardLetter

• Social SecurityDisability Income(SSDI) Award Letter

• agency letter; or• other income

documentation.

Acceptable documentation for the Section B includes:

• Tax Return Transcript• Tax Filing Documents

Worksheet.

Acceptable documentation for Section A (not exhaustive list):

• pay stubs (30continuous days ofpayment within thelast 60 days);

• supporter statement;• employer statement;• Social Security

Income (SSI) AwardLetter

• Social SecurityDisability Income(SSDI) Award Letter

• agency letter; or• other income

documentation.

Acceptable documentation for the Section B includes:

• Tax Return Transcript• Tax Filing Documents

documented in the client’s primary record and date stamped in ARIES.

If there has been a change in income, complete the Income Calculation Worksheet and provide backup documentation.

Providers should assess changes in eligibility every time the client comes in to receive a service.

Residency Documentation is required Documentation is required If address has not changed, self-attestation of no change is acceptable. Attestation must be documented in the client’s primary record and date stamped in ARIES. For THMP clients, a copy should be sent to THMP.

If address has changed updated documentation of residency must be placed in the client file and sent to THMP, if applicable.


Insurance/Third Party Payer

Provider must verify if applicant is enrolled in other health coverage and document status in client file. For THMP clients, a copy of this documentation should be sent to THMP.

Provider must verify if applicant is enrolled in other health coverage and document status in client file. For THMP clients, a copy of this documentation should be sent to THMP.

If client’s insurance/third party payer status has not changed, self-attestation of no change is acceptable. Attestation must be documented in the client’s primary record and date stamped

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Enrollment must be pursued if client is income eligible for Medicaid, CHIP, Health Insurance Marketplace plans, or various other health plans.

Enrollment must be pursued if client is income eligible for Medicaid, CHIP, Health Insurance Marketplace plans, or various other health plans.

in ARIES. For THMP clients, a copy should be sent to THMP.

Documentation of client’s insurance eligibility status must be filed in the client’s primary record(s). For THMP clients, a copy should be sent to THMP.


7.4 Client’s Responsibility for Reporting Changes

A client must immediately report any changes that might affect their eligibility to the provider(s) and THMP if applicable. If a client has experienced a change in circumstances related to eligibility, they must submit appropriate documentation of the change to the provider(s) within 30 days of the reported change and ensure the provider(s) receives the documentation. A client must also report any changes at the 6-month mark. If a client fails to provide appropriate documentation of the change, their services may be delayed until the provider(s) can confirm eligibility.


Date Action Section 3/18/2019 Changed infant exposure age from 12 months to

18 months to align with clinical panel recommendation and practice in the field.

7.1.3

7/31/2018 Significant revisions throughout the policy. All 10/30/2017 Policy revised to align with THMP/ADAP eligibility

certification schedule. All

9/27/2016 Policy revised to add definitions; clarify documentation requirements for HIV Infection Status and Texas Residency; clarify Re-certification requirements; add requirement for MAGI for financial eligibility determination; and reflect advances in testing technology.

All

9/25/2014 Converted format (Word to HTML) -

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1/15/2013 Policy revised to reflect HRSA issued Policy Clarification Notices relating to Implementation of the Affordable Care Act

-

9/27/2012 Policy revised to clarify eligibility as it applies to HRSA’s “recertification” language and to give guidance for additional eligibility

-

11/20/2011 Policy language revised to clarify documentation requirements

-

6/25/2008 Policy revised to allow for testing technology advances

All

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Purchasing Emergency Medications for Clients Awaiting an Eligibility Decision from the Texas HIV Medication Program16

Policy Number 220.100 Effective Date May 22, 1996 Revision Date November 18, 2002 Approval Authority TB/HIV/STD Section Director

1.0 Purpose

To provide guidance on the appropriate use of grant funds to purchase emergency medications for clients awaiting an eligibility decision from the Texas HIV Medication Program. This policy is directed to contracting agencies providing HIV-related public health services whose activities allow for medication purchases (i.e., Ryan White Title II, state services, and Early Intervention programs). Implementation of this policy will assure that grant funds reimburse for medication only if no other parties will pay and is not intended to supplant the use of the Texas HIV Medication Program.

2.0 Authority

Health and Safety Code §85 Subchapter C, HIV Medication Program; Insurance Code, Article 51-6D Cancellation Prohibited for HIV and AIDS

3.0 Where to Go for Assistance

Clients needing medications to manage an HIV-related condition and seeking assistance to purchase prescribed medication must seek assistance from their private insurance company if appropriate. Case managers should assist clients who do not have private insurance coverage to apply for health care benefits with Medicaid and with their local or county indigent health care program if they may be eligible.

The Texas HIV Medication Program is another resource; however, the program does not aid clients whose insurance covers medications. Clients enrolled in Medicaid or local or county indigent health care programs may simultaneously qualify for assistance from the Texas HIV Medication


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Program.

4.0 Private Insurance

Clients whose private insurance covers the prescribed medications must use the insurance company's coverage to purchase HIV medications. Case managers should direct clients who are having trouble paying insurance premiums to the insurance assistance program in their HIV service delivery area for eligibility determination. The cost to the state of helping pay premiums is much less than the cost of the client's care should that person lose insurance coverage.

By law (Insurance Code, Article 3.51-6D) an insurance company cannot drop clients because they are HIV positive or have AIDS. If a client refuses to submit claims to the insurance company for medication reimbursement, contractors may not use grant funds to purchase medications that are on the Texas HIV Medication Program formulary for that client.

5.0 Indigent Non-Insured

Clients who lack insurance or whose insurance does not cover the prescribed medications and who need help paying for medications should immediately apply to the following programs with the case manager's assistance:

• Medicaid,• the local or county indigent health care program, and• the Texas HIV Medication Program.

Local indigent programs may help eligible clients purchase medications that are over the Medicaid monthly allotment or that the Texas HIV Medication Program does not cover. The Texas HIV Medication Program will only provide medications that are on the formulary for eligible clients.

Clients may need to have prescriptions filled before they receive eligibility certification for the Texas HIV Medication Program. In these cases, contractors may purchase medications for clients who are awaiting an eligibility decision only if the client's physician determines that taking the medications is an emergency and if no more than a 30-day supply is purchased.

Contractors cannot buy more than a 30-day supply of medications that are on the Texas HIV Medication Program formulary for each client. If the Texas HIV Medication Program denies the client coverage, the client's case manager should work with the client and the client's attending physician to find alternate funding sources. Alternate sources may include manufacturers' compassionate use programs, religious groups, or other

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community programs.

Address any questions about implementing this policy to the Texas HIV Medication Program at (800) 255-1090 or the HIV/STD Prevention and Care Branch at (512) 533-3000.

6.0 Compliance

The HIV/STD Prevention and Care Branch, Texas HIV Medication Program, and Field Operations Branch staff will work together to verify that contractors follow this policy. During site visits, these staff members will look for documentation of applications, referrals, phone calls, etc. Contractors that violate this policy will face administrative sanctions.


Date Action Section 9/1/2017 Changed "TB/HIV/STD Unit" to "TB/HIV/STD

Section" to reflect new program designation -

9/25/2014 Converted format (Word to HTML) - 12/30/2002 Removal of Medication Reimbursement Initiative.

Program no longer in existence. All

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DSHS Funds as Payment of Last Resort17

Policy Number 590.001 Effective Date September 1994 Revision Date September 30, 2016 Subject Matter Expert HIV Services Consultants Approval Authority HIV/STD Prevention and Care Branch Manager Signed by Shelley Lucas, M.P.H.

1.0 Purpose

This policy establishes funding from the Texas Department of State Health Services (DSHS) for HIV-related medical and support services as payment of last resort (PoLR). It directs DSHS-funded Administrative Agencies (AA) and contracting service providers to establish and enact policies and procedures to assure that DSHS funds are used as PoLR.

2.0 Background

DSHS receives federal grants funds through the Ryan White HIV/AIDS Program (RWHAP) and state general revenue funds to provide HIV-related medical and support services to low-income residents of Texas; the state funding for this program is referred to as State Services funds (SS). Federal and state laws and policies require that RWHAP/SS funds be used as PoLR. These funds may not be used for any item or service for which payment has been made or can reasonably be expected to be made by any other payer. Other payers include at minimum public or private health insurance coverage including Medicaid, Medicare, CHIP, Marketplace and employer-based health insurance. Local AA may provide information about other resources that should be considered as payers.

3.0 Authority

Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87, October 30, 2009); Texas Health and Safety Code §12.052, §85.003, §85.013, §85.014 - §85.03, and §85.032; HRSA HIV/AIDS Bureau (HAB)


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Policy Clarification Notices # 07- 07, 13-02, and 13-04.

4.0 Definitions

Administrative Agency (AA) – Entity responsible for ensuring a comprehensive continuum of care exists in their funded areas. This is accomplished through the management, distribution, and oversight of HIV care and treatment services funded by federal and state funds and under contractual agreement with DSHS.

CHIP – The Children’s Health Insurance Program (CHIP) is designed for low-income families who exceed the income limits for Medicaid.

Cost Sharing – An amount of money clients are expected to contribute to the cost of their medical care. Cost sharing includes co-payment or co-insurance payments and deductible costs for health insurance or client fees charged by providers. Cost sharing requirements may be established through provider policy or be specified by the client's health insurance plan. Fees associated with cost-sharing requirements are subject to the limits on client contributions in this policy.

Federal Poverty Level (FPL) – A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits.

HIV Services - Definitions of eligible services are found at HIV Medical and Support Service Categories.

Medicaid – A state and federal insurance cooperative program that provides medical coverage to eligible low-income persons.

Medicare – A federal insurance program providing coverage primarily to people who are aged 65 and over and to those who are permanently disabled.

Modified Adjusted Gross Income (MAGI) – A calculation required by DSHS used to determine eligibility for Medicaid, CHIP, and for reduced-cost insurance on the Health Insurance Marketplace. Generally, MAGI is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income. Program eligibility considerations for DSHS-funded services should be based on household income (see Sliding Fee Discount Schedule below for determining a schedule of fees for services and the corresponding sliding fee discount schedule). Household is defined as the applicant, the applicant’s legal or common law spouse, and minor dependent children (under the age of 18, may be biological, adopted, or step children) living 51% of the time or more in the applicant’s home. MAGI forms and requirements can be found

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on the MAGI documents page.

Provider – A local organization, individual clinician, or group of clinicians contracted to provide HIV services supported with DSHS funds. The contractor is the responsible entity even if there is a subcontractor involved who actually provides the services.

Sliding Scale Discount Schedule – Sliding scale fees are based on the cost of services received and the HIV-positive client’s individual income only. Client charges are subject to the limits on client contribution specified in this policy.

Texas HIV Medication Program (THMP) – The THMP provides HIV treatment drugs directly to eligible uninsured or underinsured clients through the AIDS Drug Assistance Program (ADAP); assistance with payments associated with Medicare Part D prescription drug plan through the State Pharmaceutical Assistance Program (SPAP); and assistance with medication copayments, coinsurance, deductibles, and premiums for employer-sponsored commercial health insurance through the piloted Texas Insurance Assistance Program (TIAP).

5.0 Persons Affected by Policy

• DSHS HIV care services and THMP staff• Administrative Agencies• Service Providers• Clients


6.1 DSHS HIV Care Services Staff

Ensures that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients. Staff reviews policies developed by AA regarding PoLR and assures that AA monitors provider implementation of these policies.

6.2 THMP Staff

Ensures that THMP funding is used as PoLR for eligible services and eligible clients. Verifies client income, insurance status, and residency status before enrolling in the appropriate THMP program and then recertifies eligibility every six months.

6.3 Administrative Agency

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Develops and assures compliance with local policies required by DSHS policies, and monitors provider billing of third party payers to determine compliance with PoLR requirements.

6.4 Providers

Develop and implement policies and procedures to ensure that DSHS funds are used as PoLR.

6.5 Client

A person who receives RWHAP Part B or State-funded services for HIV care, treatment or medications.

7.0 Screening for Other Payment Sources

DSHS Policy 220.001, Eligibility to Receive HIV Services18 requires AAs and providers to implement policies and procedures to certify client eligibility for DSHS-funded HIV services every six (6) months. Providers should be guided by the requirements of this policy and local policies to document client eligibility for services and requirements for referral of clients who may be eligible for public or private insurance or another medical benefit program.

As specified in policy 220.001, local areas may specify eligibility criteria in addition to those outlined in policy 220.001. Local eligibility determination and referral vary in terms of the processes used to determine eligibility, the titles of personnel who conduct eligibility screening, and the service categories under which eligibility determination and benefits coordination is completed. Regardless of these differences, AAs must assure that policies and procedures tailored to the local eligibility criteria and determination and recertification processes incorporate DSHS and local standards for comprehensive eligibility review; timely referral; vigorous follow up; and documentation for these tasks.

Vigorous efforts to enroll the client in any health plan or program for which the client appears to be eligible must be documented in client file utilizing DSHS Attestation of Client Eligibility for Marketplace Plans and process, or approved local forms and processes.

7.1 Affordability and Health Insurance Assistance

If clients are concerned about the affordability of job-related or Marketplace insurance, they should be counseled about the availability of health insurance assistance (HIA) services if such assistance is appropriate under


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local policies and guidelines (see DSHS Policy 260.00219). Clients who require assistance with Medicare Part D drug plans and eligible employer-based health insurance may be eligible for assistance through the piloted TIAP.

7.2 Special Considerations for Insurance Plans with Non-Continuous Enrollment

While enrollment periods for Medicaid and CHIP are continuous, other programs have limited enrollment periods. If clients appear eligible but are outside an enrollment period, they must receive counseling about opportunities for future enrollment and be referred to organizations or individuals that can further assist them. These efforts must be clearly documented in client file.

7.3 Special Considerations for Clients Eligible for Veterans Affairs Benefits

Clients eligible for benefits through the Department of Veterans Affairs (VA) should receive education on the services available through the VA and be referred to VA health centers if they so choose. However, DSHS-funded services must be made available to VA-eligible clients who choose not to receive care through the VA systems. Such clients are dually eligible for RWHAP and VA services and therefore exempted from the PoLR requirement. As with all efforts of vigorous pursuit, a client’s refusal for referral to VA services must be clearly documented in client file.

8.0 Verification of Coverage

AA must maintain policies that require providers to verify third party payment coverage for eligible services at every visit.

9.0 Client Refusal to Enroll

Per HRSA HIV/AIDS Bureau (HAB) Policy Clarification Notice # 13-04, Eligible clients who refuse to enroll in programs or insurance plans must receive continued counseling on their eligibility at each recertification opportunity and may not be refused treatment services because of the refusal. Vigorous efforts of benefit counseling and enrollment must be documented in the client file.

10.0 Service Provider Enrollment in Health Insurance Plans

Health insurance plans cover some, but not all RWHAP/SS-eligible services.


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Eligible services typically covered by health plans include outpatient health services, outpatient mental health services, inpatient and outpatient substance abuse treatment, home health services, pharmaceuticals/drugs, home and community health services, home health services, and hospice services. Providers of these services who receive DSHS funds must make reasonable efforts to enroll as participating or approved providers in the health plans carried by their clients. No waivers are available. If an organization subcontracts the medical services listed above, the requirements below apply to their subcontractors.

10.1 Enrollment in Texas Medicaid

A contracting provider who delivers Medicaid- eligible services must be enrolled as a Medicaid provider. AAs must maintain policies requiring contracting providers to furnish Texas Medicaid ID numbers as demonstration of enrollment, or other documentation that establishes that the provider has initiated the application process. If the provider's application is denied, AAs may use DSHS funds to contract with that provider only if no other Medicaid-enrolled providers are available. Contracting providers who have been denied enrollment must continue to make good faith efforts to enroll, and must make evidence of these efforts available to the AA or DSHS upon request.

10.2 Enrollment in Other Health Insurance Plans

AAs must maintain and enforce policies that direct contracting providers (including subcontractors) that deliver medical services typically covered by other public or private health plans to make good faith efforts to enroll as in-network providers on the plans carried by their clients. Providers may prioritize their efforts to enroll in the plans carried by the greatest number of clients. Providers must provide documentation of their efforts to enroll annually to AAs or DSHS. Providers must show due diligence in their efforts to enroll, including requesting inclusion on the list of Essential Community Providers (ECP) compiled by the Center for Consumer Information & Insurance Oversight, informing health plans of their ECP status as 'write ins' if they are not included on the CCIIO list, and making health plans in their area aware of the unique services they provide.

10.3 Referral to In-Network or Enrolled Providers

Providers who are not in-network or approved providers on a client's health insurance plan must refer clients to appropriate providers that are in-network on a client's plan. If no such provider is available, the provider may deliver the service but must show proof of attempted billing to the client's health plan.

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AAs must make providers aware of any limitations on health insurance assistance to clients with out-of-network cost sharing obligations.

10.4 Use of DSHS funds for Charges Denied by Health Plans

DSHS funds may not be used to reimburse providers for denied claims that result from failure to follow plan requirements such as prior authorization or referral approval. DSHS funds may not be used to reimburse providers for rejected claims if the rejection is a result of provider error, including incomplete or late submission of claims. AAs must maintain and enforce policies to this effect.

11.0 Client Charges for Billable Services

DSHS-funded AAs must maintain policies requiring funded providers who deliver services typically billable to public and private health plans to maintain policies and procedures on client charges. For purposes of this policy, providers of Outpatient/Ambulatory Medical Care; Local Pharmacy Assistance Programs/AIDS Pharmacy Assistance Programs; Mental Health Services; Medical Nutrition Services; Home and Community-Based Health Services; Home Health; Hospice; Early Intervention Services (if such services are primarily associated with HIV testing and referral); and inpatient and outpatient Substance Abuse Treatment are considered to provide billable services.

To adhere to RWHAP legislation, all providers that deliver these services with DSHS funds must develop a sliding fee discount program that includes the following: (1) a schedule of fees for services; (2) a corresponding sliding fee discount schedule; (3) a system/policy to waive or reduce fees to assure receipt of care; (4) policies that prohibit refusal of services to clients who are unable to pay fees or refuse payment of fees; and (5) a limit on annual aggregate charges (cap on charges) based on the HIV-positive client's individual income. "Aggregate Charges" applies to annual charges imposed for all services regardless of terminology (i.e. enrollment fees, premiums, deductibles, cost-sharing, co-payments, coinsurance, etc.) and applies to all service providers from whom individuals receive services.

11.1 Fee Schedules/Charge Master

Providers must develop a fee schedule that is consistent with locally prevailing rates and is designed to cover reasonable costs. The fee schedule must be used as the basis for seeking payment from patients as well as third party payers.

The schedule may include a documented decision to impose only nominal

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charges. Such a charge may not be specific to RWHAP/SS clients, and must be similar to charges for non-RWHAP/SS clients. A nominal charge must be a fixed fee that does not reflect the true value of the service(s) provided and is considered nominal from the perspective of the patient. The nominal charge must be less than the fee paid by a patient in the first “sliding fee discount pay class” beginning above 100% of FPL.

11.2 Sliding Fee Discount Schedule (SFDS)

Affected providers must also develop a SFDS based on the client's ability to pay. Eligibility for the SFDS is based on a percentage of FPL using only the HIV-positive client’s annual individual income calculated from Mock MAGI or MAGI worksheets. The SFDS must be revised annually, at a minimum, to reflect updates to the federal poverty guidelines. The provider must establish policies and operating procedures to assure that the SDFS is applied uniformly to eligible patients.

11.2.1 Determining Eligibility for Sliding Fee Discounts

Providers of billable services must have supporting processes/operating procedures in place for assessing MAGI for all clients, or must have a documented procedure for using the MAGI calculated during certification/re-certification for DSHS-funded services. If a client has had no changes in income, household composition, residence, immigration status, or insurance coverage since the previous full MAGI-based eligibility screening a self-attestation of ‘no changes’ may be used to satisfy eligibility determination requirements. If a client attests there have been no changes, the MAGI calculation from the previous eligibility screening should be used. Eligibility determination should be conducted in an efficient, respectful, and culturally appropriate manner to ensure that administrative operating procedures for such determinations do not themselves present a barrier to care. Patient privacy and confidentiality must be protected throughout the process. Once assessed, a patient who meets the income guidelines would receive a sliding fee discount based on the SFDS. As required by RWHAP, clients with an individual annual income at or below 100% FPL must receive a full discount, meaning no charges may be assessed. Nominal fees may not be applied to this group. Regardless of client income, services cannot be refused based on the client's ability to pay, and this must be reflected in SFDS polices and operating procedures.

11.2.2 Clients with Third Party Coverage Who Are Also Eligible for SFDS

Clients with health insurance coverage have incomes that would make them eligible for the SFDS established by the provider. Such clients must use their

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insurance, but may be eligible to have the co-payment or co-insurance required by their insurance plan reduced based on the SFDS, subject to potential legal and contractual limitations20. If this is allowed, the charge to these clients is the maximum amount an eligible patient in that pay class is required to pay for a certain service regardless of insurance status. If the client receives HIA services, the reduced charge may be paid through these funds if the service is HIV-related and otherwise qualifies for payment by HIA. Providers may not seek reimbursement from RWHAP/SS for the difference between the insurance charge and the reduced charge collected from the payment. However, the terms of contracts that providers hold with health insurance plans may not allow discounting of client co-pays and co-insurance and discounting client cost sharing obligations may also be inappropriate for Medicare clients. Providers may wish to consult with their third party payers or legal counsel and/or private legal counsel regarding the permissibility of discounting patients’ out-of-pocket costs. How a provider will approach the issues of cost sharing requirements and SFDS must be documented in policies on SFDS.

11.3 Posting of Fee Schedule

The SFDS must be publicly posted and must contain language that assures clients that services are available regardless of ability to pay.

11.4 Collecting and Waiving Client Fees

Service providers must make reasonable attempts to collect fees. The provider must establish policies on waiving client fees. The policy must include criteria for waiving charges, and should specify the staff with the authority to approve fee waivers. This policy must be consistently applied.

11.5 Caps on Client Charges

RWHAP legislation requires that clients be charged no more than a maximum amount (cap) in a calendar year. The cap is based on the HIV-positive client's individual MAGI as follows:

• 5% for patients with incomes between 100% and 200% of FPL• 7% for patients with incomes between 200% and 300% of FPL• 10% for patients with incomes greater than 300% of FPL

Provider policies must specify that once a client's annual aggregate charges reach the cap, no additional client charges may be made.

20 Such limitations may be specified by applicable federal and state law for Medicare and Medicaid and/or terms and conditions of private payor contracts.

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11.5.1 Tracking Client Charges and Out of Pocket Expenditures

Providers must track client charges to assure that they do not exceed the aggregate caps specified in section 11.5. Providers are not responsible for tracking charges from other providers, but if clients produce reasonable documentation for these charges they should be included in the tracked total. Examples of client out of pocket charges include client fees for services, drug co-payments or co-insurance payments, premiums, and enrollment fees.

12.0 Program Income

Income resulting from payments for HIV services by clients or from insurance companies is considered program income. Service providers must retain program income derived from DSHS-funded services and must follow DSHS rules on reporting and use of such income. Providers must also follow any additional requirements of DSHS-funded AAs specified in contract or policy.

13.0 Additional Resources

DSHS response to comments during the public comment period for Policy 590.001 DSHS Funds as Payment of Last Resort:

https://dshs.texas.gov/hivstd/policy/policies/590001comments.shtm


Date Action Section 9/30/2016 Client charges must be calculated using individual

income. Revised client charges and SFDS language 11.2

3/15/2016 Due to extensive revision, treated as new policy. All 9/22/2014 Converted format (Word to HTML) - 6/20/2007 Due to extensive revision, treated as new policy. All

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HIV/STD Prevention and Care Branch Limitations on Ryan White and State Services Funds for Incarcerated Persons in Community Facilities Policy21

Policy Number 591.000 Effective Date December 1, 2013 Revision Date Subject Matter Experts HIV Care Services Group Manager

HIV Medication Group Manager Approval Authority HIV/STD Prevention and Care Branch Manager Signed by Shelley Lucas, MPH

1.0 Purpose

To ensure HIV program funds, including Ryan White (RW) and State Services (SS) program funds, are the payor of last resort for HIV medications and outpatient care for incarcerated persons.

2.0 Authority

Ryan White Treatment and Modernization Act (2006); Health Resources and Services Administration (HRSA) Policy 07-04; Texas Code of Criminal Procedure Article 104.002 (a); Texas Attorney General (AG) Opinion Letter 98-072 (1998); AG Opinion DM-380 (1996); AG Opinion JM-643 (1987).

3.0 Definitions

Community Medical Provider - A local community-based organization, community health clinic, or hospital clinic that provides HIV-related medical care to RW-eligible clients.

Incarcerated Person - Refers to an individual involuntarily confined in association with an allegation or finding of behavior that is subject to criminal prosecution.

Community Facility - A person under custody outside of the prison or jail system; generally includes pre-release facilities, half-way houses, home


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detention and substance abuse treatment centers.

Local Jail - Any city, county or other municipality jail system.

4.0 Background

In the area of treatment for HIV infection, both federal and state program funds must be used as a payor of last resort. Federal law and policy prohibit use of federal RW Program funds for payment of treatment and care services where another entity is reasonably or legally required to provide or pay for such treatment. The policy similarly treats SS funds as the payor of last resort.

Texas law states a county is liable for all expenses incurred in the safekeeping of prisoners confined in the local jail. This includes all medical expenses. In certain circumstances, counties can seek reimbursement, but this does not alleviate the underlying legal responsibility for the county to provide care. The Texas Department of Criminal Justice (TDCJ) is also responsible for all medical expenses for inmates within the state prison system.

5.0 Policy

RW and SS funds may not be used to pay for medical care or medications for any person incarcerated in a state or federal prison, or a local jail.

5.1 Fiscal Responsibility for Medical Care

Sometimes a local jail transports inmates to a community provider to receive outpatient medical care. The local service provider can provide care; however, the local jail must remain responsible for the cost. RW and SS fund cannot be used to pay for this service.

5.2 Limited Transitional Medical Services for Persons Residing in Community Facilities Not Part of the Correctional System

RW and SS funds cannot be expended to pay for medical care or medications if medical care or services are available within the community facility for any type of medical condition or disease.

RW and SS funds can be used to provide outpatient medical care or HIV medications for eligible persons if no medical care or medical services are provided and are not reasonably expected to be available within the facility.

Examples include half-way housing and drug treatment centers. In these situations, transitional medical services cannot exceed 180 days.

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5.3 Allowable Transitional Social Services

RW and SS funds can be used to provide transitional social services to establish or re-establish linkages in the community. Case management that links a soon-to-be released inmate with primary care is an example of appropriate transitional social service. Transitional social services should also not exceed 180 days.

6.0 Programs Not Affected

This policy does not affect projects or programs using funds from the Centers for Disease Control and Prevention (CDC) for delivery of testing or provision of immunizations or STD medications in local jails.


Date Action Section 12/1/2013 This policy is newly

released. All

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Texas HIV Medication Program Requests to Change State HIV Medication Formulary22

Policy Number 700.001 Effective Date January 8, 1996 Revision Date April 1, 2015 Approval Authority HIV/STD Prevention and Care Branch Manager

1.0 Purpose

To set out the specific steps for processing requests for additions or deletions to the Texas HIV Medication Program's (THMP) HIV medication formulary.

2.0 Authority

The Texas Administrative Code, Title 25 §98.103(a), Medication Coverage, (a) states, "The medications provided under the Texas HIV MedicationProgram, and the specific eligibility criteria for them shall be determined bythe commissioner of health, considering the recommendations of the HIVMedication Advisory Committee." US Department of Health and HumanServices, Health Resources and Services Administration Program Policy 97-04, states AIDS Drug Assistance Program (ADAP) funds awarded under TitlesI or II of the Comprehensive AIDS Resources Emergency (CARE) Act mayonly be used to purchase FDA-approved medications and the devices neededto administer them.

Questions regarding this policy should be directed to the HIV/STD Prevention and Care Branch Manager (Branch Manager) or the THMP Manager.

3.0 How to Request

All persons or organizations (requestors) wishing to request a change to the HIV medication formulary must do so in writing. The change may be in the form of an addition or deletion to the formulary. All medications must be FDA approved prior to requesting the medication be added to the formulary. Written requests should be submitted to the THMP Manager, Attn: MSJA, MC


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1873, Texas Department of State Health Services, Post Office Box 149347, Austin, Texas 78714. All persons making written requests for formulary additions will receive a letter acknowledging the receipt of the request from the THMP Manager.

4.0 Processing Public Requests

All publicly-generated written formulary change requests received by the THMP Manager will be presented at the next scheduled meeting of the Texas HIV Medication Advisory Committee (the Committee). At that time, the Committee will review the formulary change request(s) and determine if the request(s) will be included on the agenda for the following meeting. The requestor who submitted the formulary change request may be contacted by the THMP staff, at the Committee’s request, to obtain additional information.

4.1 Special Exceptions for HIV-Related Medications

At the discretion of the THMP Manager, in concurrence with the TB/HIV/STD Section Director (Section Director), any publicly generated written request for new FDA-approved medications to treat HIV infection to be added to the formulary may be automatically included on the agenda for consideration at the next scheduled meeting of the Committee.

4.2 Information Packets

The THMP staff will send each of the Committee members a packet containing a copy of the original written request and any additional information on all FDA approved medications listed on the agenda to be discussed at the next Committee meeting. Failure of the requestor to provide the appropriate information to the Committee will result in the medication being removed from the meeting agenda.

4.3 Presentations

The Committee reserves the right to table their decision regarding adding a medication and to ask the requestor to present additional information about the medication to the Committee at the next meeting. If additional information is necessary and the requestor is unable to attend, the Committee may select a Committee member to present the information or may elect to have a colleague familiar with the requested medication make the presentation.

4.4 Advisory Committee Recommendations

The Committee should reach a conclusion on all public requests to add or delete a medication from the formulary. The Committee's disposition shall

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take the form of a recommendation. Only the Commissioner of Health (the Commissioner), with input from the Section Director, has the authority to grant a change to the formulary, defined as either the addition of a new medication or the deletion of an existing medication. The Committee, after reviewing and discussing the information pertaining to the medication, will make its recommendation(s) to the Program. The Committee may:

• recommend the addition of a medication,• recommend the deletion of a medication, or• choose to not recommend the addition or deletion of a medication.

Should the Committee choose to not recommend the addition or deletion of a medication, the Committee may:

• make a final disposition of the request, or• table the request and direct the Program Administrator to gather

additional information on the medication and resubmit the request atthe following meeting of the Committee.

The Committee's final recommendation to add or delete a medication will be routed by the THMP Manager to the Commissioner for action.

4.5 Processing Committee Recommendations

After the Committee forwards a recommendation to the THMP Manager, the Manager must complete HIV/STD Form No.700.001A23. The THMP Manager will route the recommendation in memorandum form along with form 700.001A to the Commissioner of Health for approval. The memorandum must be directed from the THMP Manager; through the Branch Manager; through the Section Director; through the Infectious Disease Prevention Section Director, through the Division of Disease Control and Prevention Assistant Commissioner; through the Chief Financial Officer, to the Commissioner.

The Commissioner will sign form 700.001A conferring approval or rejecting the request and return the form.

5.0 Processing Section Requests

Only the Branch Manager, or the THMP Manager in concurrence with the Section Director, may request a change to the HIV medication formulary without first seeking the recommendation of the Committee. Section requests of this type shall be based upon budget necessity. Completion of form 700.001A shall serve as the official request and shall indicate that the

23 dshs.texas.gov/hivstd/policy/policies/700001A.doc

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Committee was not consulted. The THMP Manager will route the request in memorandum form along with form& 700.001A to the Commissioner for approval. The memorandum must be directed from the THMP Manager; through Branch Manager and the Section Director; through the Assistant Commissioner for Disease Control and Prevention; through the Chief Financial Officer; to the Commissioner.

The Commissioner will sign form 700.001A conferring approval or rejecting the request and return the form.

5.1 Variations of Existing Formulary Medications

New formulations, strengths, or packaging variations for medications currently available on the Program formulary shall be addressed by the Program on a case-by-case basis. At the discretion of the THMP Manager, in concurrence with the Branch Manager and the Section Director, the Program may:

• automatically add the new version of the medication to the Programformulary should the Program determine such inclusion to have eithera neutral or beneficial impact to the Program budget, without requiringthe Commissioner’s approval, or

• place the variant medication on the agenda of the next scheduledCommittee meeting for discussion should the Program have concernsof any sort regarding the formulation, packaging, or increased cost ofthe new version of said medication.

If the new version of the formulary medication is presented before the Committee for discussion, the Committee may:

• recommend the addition of the new version of a formulary medication,or

• choose to not recommend the addition of the new medication to theProgram formulary.

Should the Committee choose to not recommend the addition of a new version of the formulary medication, the Committee may:

• make a final disposition of the request, or• table the request and direct the THMP Manager to gather any

additional information deemed necessary by the Committee regardingthe new variation of the formulary medication, and resubmit therequest at the following meeting of the Committee.

The Committee’s final recommendation to add a new version of a medication already on the Program formulary will be automatically added to the

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formulary by the THMP Manager in concurrence with the Branch Manager and Section Director.

6.0 Notification of Disposition

The Branch Manager will notify the THMP Manager of the final disposition. The THMP Manager shall also notify the public requestor of the final disposition if the original request was publicly generated. The Program shall immediately notify the Committee of the final disposition if the request was Program generated.

The Program will notify clients, providers, and HIV/STD contractors of the addition or deletion of a medication through any combination of the following methods:

• by mail,• by fax,• by publication as a notice in the Texas Register,• through the media, and• electronically (via email or the internet if possible).

7.0 Production and/or Distribution Problems with Existing Formulary Medications

Should the Program experience problems with obtaining a particular formulary medication due to manufacturing or distribution interruptions from the medication’s manufacturer, the Program will call such problems to the attention of the Committee if the situation occurs for an extended length of time or in repeated intervals over a given period. Shortages in medication stock can pose serious barriers to client therapy and adherence; should the Program be unable to consistently guarantee the availability of a given medication for eligible Program clients; the Committee reserves the right to make recommendations to delete a medication from the Program formulary or modify the requirements for obtaining that medication from the Program.

8.0 Additional Resources

File File Type File Size Form 700.001A - Request to Change State HIV Medication Formulary24

PDF 99 kB


Date Action Section

24 http://www.dshs.state.tx.us/hivstd/policy/policies/700-001A.pdf

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9/1/2017 Changed "TB/HIV/STD Unit" to "TB/HIV/STD Section" to reflect new program designation

-

4/1/2015 Update with current job titles and processes. All 10/7/2014 Converted format (Word to HTML) -

Created standalone version of form 700.001A 8.0 11/13/2002 Converted format (WordPerfect to Word) -

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Rights of the Texas HIV Medication Program to Limit the Number of Clients Assigned to a Pharmacy25

Policy Number 700.002 Effective Date October 29, 1996 Revision Date April 1, 2015 Approval Authority HIV/STD Prevention and Care Branch Manager

1.0 Purpose

The Texas HIV Medication Program (THMP) reserves the right to limit the number of clients assigned to a particular pharmacy, at any given time, when the demand for a particular location exceeds a client level that the Program is able to accurately monitor for the maximum benefit of the Program's clients.

2.0 Authority

Imposing limits on the number of clients served by a pharmacy is necessary to ensure that Program guidelines and regulations are monitored and upheld. The THMP Manager and the HIV/STD Prevention and Care Branch Manager have the authority to impose these limits. Visit the DSHS website for a complete list of Pharmacy Guidelines26.

3.0 Imposing Limits on the Number of Clients Assigned to a Pharmacy

The Program will send a letter to pharmacies if and when it is necessary to establish a client limit. Limitations imposed on a pharmacy will be based on the length of the Program's relationship with the pharmacy; proximity of the pharmacy to clients, providers, and other participating pharmacies; the pharmacy's method for ordering medications from the Program; and the population served by the pharmacy. Using this criteria, the Program will stop adding clients to a pharmacy when the Program determines it in the best interest of the Program and clients.

25 https://dshs.texas.gov/hivstd/policy/policies/700-002.shtm 26 www.dshs.texas.gov/hivstd/policy/policies.shtm

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4.0 Providing Self-Imposed Client Limit

A pharmacy with a self-imposed client limit should contact the Program to inform the Program of the established limit. The Program will strive to place a roster hold on the pharmacy once the established limit has been met. It is the pharmacy's responsibility to notify the Program when the pharmacy is again able to accept new clients.

5.0 Pharmacy's Serving in Excess of an Established Client Limit

The Program may reassign the current clients being served by a pharmacy in order to avoid exceeding the imposed or established client limit. Clients currently assigned to a pharmacy when an excess client limit is identified will remain with the pharmacy until either (1) the client requests a transfer to another participating pharmacy, or (2) the client is dropped from the Program.


Date Action Section 4/1/2015 Update job titles and some changes in procedure All 10/7/2014 Converted format (Word to HTML) - 11/13/2003 Converted format (WordPerfect to Word) -

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HIV/STD Medication Pharmacy Eligibility Criteria27

Policy Number 700.003 Effective Date June 27, 1997 Revision Date January 31, 2018 Approval Authority HIV/STD Prevention and Care Branch Manager

1.0 Purpose

To provide eligibility criteria for pharmacies requesting to participate in the Texas HIV Medication Program (THMP).

2.0 Authority

25 TAC §98.113 Participating Pharmacy; HIV/STD Policy No. 700.004; 25 TAC §98.111 Confidentiality.

The TB/HIV/STD Section, under its authority, requires that participating pharmacies be Medicaid providers.

3.0 Background

The Texas HIV Medication Program (THMP) established in 1987 operates under the direction of the HIV/STD Prevention and Care Branch in the TB/HIV/STD Section. The THMP provides antiretrovirals and other medications to treat and prevent opportunistic infections that can occur in patients infected with HIV. In order to carry out its function of providing medications to patients who would otherwise have no means to pay for drug therapy, it is necessary for the THMP to identify and enter into agreements with local pharmacies.

4.0 Eligibility Criteria

Each pharmacy must have a current license with the State Board of Pharmacy to distribute outpatient drugs. All but Class C and D pharmacies are required to be Medicaid participating pharmacies.


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5.0 How to Request to Become a Participating Pharmacy

5.1 Request to Become a Participating Pharmacy

Pharmacies requesting to participate on the THMP may either go to the THMP webpage28 or call 1-800-255-1090 during regular business hours. Requesting pharmacies will need to fill out the Memorandum of Agreement (MOA) found on the THMP webpage and return to the Program for processing and approval through the mail.

5.2 Approval Process

Only pharmacies meeting the eligibility criteria will be reviewed. The THMP will review each request on a case-by-case basis. The review process takes approximately two to three months.

When the THMP receives the pharmacy’s filled out MOA, the information given by the pharmacy will be verified with the State Board of Pharmacy. Upon a favorable report from the State Board of Pharmacy, the THMP will make a determination as to whether the addition of the pharmacy to the Program will benefit the THMP and/or client(s). The THMP will consider the community’s need, pharmacies that serve the general public and will exclude pharmacies that solely serve residential facilities such as nursing homes, hospitals, and/or state and federal residential facilities. Approval to participate in the THMP is authorized by the THMP Manager or his/her designee.

When the THMP Manager approves the MOA, the MOA is forwarded to obtain the appropriate authorized signatures. The MOA is not executed until the signature of the Assistant Commissioner of the Disease Control and Prevention Services Division is obtained. Participation in the THMP will become effective on the date of the last signature on the MOA. When all authorized signatures are obtained on the MOA, the THMP will send an approval letter with a copy of the signed MOA to the pharmacy.

Pharmacies may not request any medications until participation in the THMP becomes effective. Participating pharmacies must follow HIV/STD Policy No. 700.004 when ordering medication from the THMP.

5.3 Distribution Points for Chain Pharmacies

Pharmacies that are part of a chain may request a central distribution point as a participating pharmacy location, from which the chain will bear responsibility for distributing the medication. The ordering process is similar

28 www.dshs.texas.gov/hivstd/meds/document.shtm

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to that described in Policy 700.004, HIV Medications Ordering Process for Pharmacies, except that the central distribution point then takes responsibility for shipping the medications to their local pharmacies and any additional shipping or replacement costs incurred when shipping the medications.

Those pharmacies wishing to order using a central distribution point, are also required to ensure the medications are delivered to clients within ten (10) days from the client’s request date. In addition, the pharmacies are also responsible for keeping all program required records and ensure that all other pharmacy requirements are also met.

5.4 Rebates

Pharmacies participating and receiving medications through this program are NOT eligible to file for drug manufacturer rebates for those medications.

5.5 Unfavorable Reports from the State Board of Pharmacy

Pharmacies that apply and receive an unfavorable report from the State Board of Pharmacy will be denied participation in the Program without further review. For pharmacies with a central distribution point, this review will apply to the distributing pharmacy.

5.6 Justification of Denial

The THMP Manager will provide written justification to the HIV/STD Prevention and Care Branch Manager (Branch Manager) of the decision to deny a pharmacy’s request to participate in the Program. The Branch Manager will review the justification and make the final decision to approve or deny the request. Following the Branch Manager’s review, the THMP will provide written notification to the pharmacy when denied participation in the THMP. Appeals or questions regarding a denial will be forwarded to the Branch Manager for review. The decision of the Branch Manager is final.

6.0 Program Requirements

• All participating pharmacies must sign a MOA with the TexasDepartment of State Health Services (DSHS). Renewal MOA’s mustalso be signed in accordance with agreed upon MOA effective dates.

• Only clients authorized by the THMP are eligible to receive medicationsdistributed through the THMP.

• Medications must be ordered directly from the THMP and will beshipped from the DSHS pharmacy warehouse.

• Client confidentiality must be protected in accordance with all

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applicable state and federal laws (25 TAC §98.111 Confidentiality). • Participating pharmacies are to maintain all client records and

supporting documents, including statistical records, in accordance withstate law and for a period of three years after termination ofparticipating status from the THMP.

• Access to any pertinent books, documents, papers, and records of aparticipating pharmacy must be afforded to DSHS, the US Departmentof Health and Human Services (DHHS), the Comptroller General of theUnited States, or any of their duly authorized representatives for thepurpose of performing an audit, examination, excerpts, andtranscriptions of transactions.

• The THMP, including participating pharmacies, will not discriminateagainst (applicant or eligible) clients on the grounds of race, creed,color, handicap, age, ability to pay, sex, or national origin (45 CFRParts 80, 81, 84, and 90).

• The THMP reserves the right to limit the number of clients assigned toa particular pharmacy at any given time. Pharmacies may also contactthe THMP at any time to inform the THMP that the Pharmacy hasreached a capacity level for clients so that a hold may be instituted onthat Pharmacy’s roster.

• Pharmacies will no longer collect dispensing fees from clients(see Texas HIV Medication Program Participating PharmacyGuidelines29). Pharmacies will invoice the THMP directly each monthfor dispensed THMP medications, not to exceed $5.00 per medication.This includes Medicaid eligible and non-eligible clients.

• The THMP program is considered the payor of last resort. Programrecipients must utilize all third party payor sources before accessingmedications from the THMP. The Pharmacy must immediately notifythe THMP if they become aware of a program recipient having thirdparty payor sources that covers prescriptions.

• The THMP is only authorized to serve recipients residing in the state ofTexas. The Pharmacy must immediately notify the THMP if theybecome aware of a program recipient residing outside the state ofTexas. Pharmacies may not forward program medications out of stateor to another location unless it’s a distribution point pharmacy (seesection 5.3 of this policy)

• Additional guidelines can be found at the Texas HIV MedicationProgram Participating Pharmacy Guidelines webpage30.

7.0 Renewal of MOA

Repeated and persistent complaints by clients about a pharmacy service

29 http://www.dshs.state.tx.us/hivstd/meds/pharmacy.shtm 30 https://www.dshs.texas.gov/hivstd/meds/document.shtm

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and/or discriminatory practices will be considered during the renewal phase of the MOA process. If a program recipient calls the THMP with a complaint about a pharmacy including a pharmacy’s discriminatory practices, the THMP will refer the client to the State Board of Pharmacy for appropriate disposition.

8.0 Termination

Participation in the THMP may be terminated if the pharmacy’s standing with the State Board of Pharmacy changes to an unfavorable standing.

Participation in the THMP may be terminated if funds allocated should become reduced, depleted, or unavailable during any agreement period, and DSHS is unable to obtain additional funds for such purposes. The THMP will immediately provide written notification to the pharmacy of such fact, and such agreement will be terminated upon receipt of that notification.

Participation in the THMP may be terminated in the event that federal or state law or other requirements should be amended or judicially interpreted so as to render continued fulfillment of this agreement, on the part of either party, unreasonable or impossible.

Failure to follow program requirements or adhere to the MOA will result in non-renewal or early termination of the MOA.


Date Action Section 1/31/2018 Changed section 6.0 (ninth bullet) to reflect that

clients will no longer be charged a dispensing fee. Pharmacies will bill THMP for dispensing fees.

6.0

9/1/2017 Changed "TB/HIV/STD Unit" to "TB/HIV/STD Section" to reflect new program designation

-

1/9/2017 Addition of new sections 5.3 and 5.4 to address shipment of medications to a central source when dealing with chain pharmacies. Other minor revisions to remaining sections to reflect addition of sections 5.3 and 5.4.

5.3 and 5.4

4/1/2015 Revisions reflect new titles and procedures. All 10/7/2014 Converted format (Word to HTML) -

Created standalone version of form 700.001A 10.0 11/13/2002 Converted format (WordPerfect to Word) -

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HIV Medications Ordering Process for Pharmacies31

Policy Number 700.004 Effective Date March 25, 1996 Revision Date January 31, 2018 Approval Authority HIV/STD Prevention and Care Branch Manager

1.0 Purpose

The purpose of this policy is to establish the process through which participating pharmacies will order and dispense HIV medications through the Texas HIV Medication Program (THMP).

2.0 Authority

Texas Administrative Code (TAC), 25 TAC §98.113, Participating Pharmacy; 25 TAC §98.114, Prescription Fees.

3.0 Background

The Texas Department of State Health Services (DSHS) receives funding to help offset the cost of medications approved by the Food and Drug Administration (FDA) for the treatment of HIV infection. Access to the THMP is available to eligible indigent persons with HIV infection (clients). The Program provides medications, listed in the current Texas HIV Medication Program Guidelines, through participating pharmacies.

4.0 Ordering Medications

To place an order, fax the THMP at (512) 533-3171. The fax line is open 24 hours a day, seven days a week. The pharmacy is expected to provide the following information when placing an order with the THMP:

• pharmacy ID number (assigned by the Program),• name of the pharmacy representative placing the order,• client code number of the client for whom the medication is being

ordered. All orders for HIV medication must include the client’s


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assigned THMP code number (i.e., 09302), and name, strength, and number of days’ supply of the medication(s) being ordered.

All records must be maintained according to the Memorandum of Agreement signed between the participating pharmacy and the DSHS.

5.0 Ordering Medications for Chain Pharmacies

Pharmacies that are part of a chain may request a central distribution point as a participating pharmacy location, from which the chain will bear responsibility for distributing the medications.

The ordering process is similar to that described in Section 4.0 of this Policy, except that the central distribution point then takes responsibility for shipping the medications to their local pharmacies and any additional shipping or replacement costs incurred when shipping the medications.

Those pharmacies wishing to order using a distribution point, are also required to ensure the medications are delivered to clients within ten (10) days from the client’s request date. In addition, the pharmacies are also responsible for keeping all program required records and ensure that all other pharmacy requirements are also met.

6.0 Verifying Client Eligibility

Clients are not required to show proof of THMP eligibility to the pharmacy. The pharmacy is responsible for reviewing the client approval letter for verifying the client's eligibility with the THMP prior to placing an order. Pharmacies requesting copies of a client’s approval letter for its files should call the THMP at 1-800-255-1090. The THMP will mail the requested copy to the pharmacy within five working days.

Eligible Medicaid recipients who are also clients must first utilize their Medicaid pharmacy benefits each month in order to be eligible to receive medications from the THMP during that month. The THMP is responsible for verifying Medicaid eligibility. The pharmacy is responsible for ensuring that the Medicaid benefits are used before requesting medications from the THMP.

7.0 Medication Shipments

Medications are shipped from the DSHS pharmacy warehouse to the pharmacy. Medication shipments will include a packing slip listing the order information provided by the pharmacy. The pharmacy is responsible for reporting discrepancies in medication shipments to the Program as soon as possible.

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8.0 Dispensing Medications

Prior to dispensing medications, participating pharmacies should ensure that the client is approved, currently active on the THMP, and certified as eligible to receive specific THMP medications. The THMP will not be responsible for medications that are dispensed to a client who is not approved to receive them from the THMP.

All medications should be dispensed unopened, without re-packaging, in full-bottle increments, not to exceed the quantities stated in the current Texas HIV Medication Program Participating Pharmacy Guidelines.

The THMP operates as a provider program, not a reimbursement program. Participating pharmacies should not dispense medications to clients from the pharmacy's own inventory. The THMP assumes no responsibility for replenishing pharmacy inventories. Participating pharmacies whose policy is to dispense medications from their own stock and request replacement medications, are subject to the rules outlined in this policy and are not guaranteed to receive reimbursement for medications dispensed from their own stock.

8.1 Dispensing

Pharmacies will no longer collect a $5.00 dispensing fee from clients for each prescription filled (see Texas HIV Medication Program Participating Pharmacy Guidelines32). Pharmacies will invoice the THMP directly each month for dispensed THMP medications, not to exceed $5.00 per medication. This includes Medicaid eligible and non-eligible clients.

8.2 Medication Replacements

DSHS will not replace any medication that is lost, stolen, or damaged unless adequate documentation of the circumstances is provided.

8.3 Rebates

Pharmacies participating and receiving medications through this program are NOT eligible to file for drug manufacturer rebates for those medications.

9.0 Time Frames

Pharmacies should allow three to five working days to receive medication shipments from the pharmacy warehouse. Upon receipt of the prescription, the pharmacist should inform the client of this. Replacement requests for

32 http://www.dshs.state.tx.us/hivstd/meds/pharmacy.shtm

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medications dispensed prior to ordering from the THMP must be received by the THMP within 30 days of dispense date and are not guaranteed to be filled.


Date Action Section 1/31/2018 Changed section 8.1 to reflect that clients will no

longer be charged a dispensing fee. Pharmacies will bill THMP for dispensing fees.

8.1

1/9/20117 New sections 5.0 and 8.3 added to reflect ordering by chain pharmacies. Other minor revisions to remaining sections to reflect addition of sections 5.0 and 8.3.

5.3 and 8.0

4/1/2015 Update references, phone numbers and procedures.

All

10/7/2014 Converted format (Word to HTML) - 11/13/2002 Converted format (WordPerfect to Word) -

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Medicare Part D33

Policy Number 700.005 Effective Date June 14, 2006 Revision Date April 1, 2015 Subject Matter Expert Texas HIV Medication Program Manager Approval Authority HIV/STD Prevention and Care Branch Manager Signed by Shelley Lucas, M.P.H.

1.0 Purpose

The purpose of this policy is to ensure HIV-infected Medicare eligible clients have continued access to medications.

2.0 Authority

Ryan White Care Act, 2000; Centers for Medicare and Medicaid Services

3.0 Background

On January 1, 2006, the Centers for Medicare and Medicaid Services introduced prescription drug coverage for all people with Medicare. This benefit is called Medicare Part D and is being marketed to the public as Medicare Prescription Drug Benefit. Insurance companies and other private companies are working with Medicare to offer a variety of plans. This benefit is provided through Prescription Drug Plans (PDP), Medicare Advantage Plans (MA), and some employers and unions for their retirees. Medicare Part D offers comprehensive drug coverage for prescription drugs including HIV medications.

4.0 Definitions

Medicare - A federally-funded health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with end-stage renal disease.

Low-Income Subsidy (Extra Help) - A federal program administered by the


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Social Security Administration that assists with the out-of-pocket costs associated with Medicare Part D.

Medicare Savings Programs - A federal program that assists with out-of-pocket costs associated with Medicare Part B. This includes the following benefits: Medicaid and Qualified Medicare Beneficiary (MQMB), Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualified Individuals (QI). Individuals who receive these benefits are automatically approved for the Low-Income Subsidy.

Wrap Around Resources - Services from Ryan White financial assistance and state-funded agencies that can be provided to Medicare beneficiaries to help pay for out-of-pocket costs associated with Medicare Part D including premiums, deductibles, co-pays and/or coinsurance.

5.0 Policy

Medicare beneficiaries who qualify for the full low-income subsidy must be enrolled in a Medicare Part D Prescription Drug Plan (PDP) and access medications through their PDP prior to receiving medication assistance from Ryan White and/or state-funded providers.


This policy affects HIV-infected Medicare beneficiaries seeking medication assistance from Ryan White and/or state-funded providers.


Date Action Section 4/1/2015 Update references and delete changed procedures. All 10/7/2014 Converted format (Word to HTML) -

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Multi-Month and Special Circumstance Medication Supply and Coverage34

Policy Number 700.006 Effective Date May 1, 2019 Revision Date This is a new policy. Subject Matter Expert Manager, Texas HIV Medication Program Group Approval Authority HIV/STD Prevention and Care Branch Manager Signed by Shelley Lucas, M.P.H.

1.0 Purpose

This policy provides guidance on multi-month and special circumstance medication supply coverage for medications provided by the Texas HIV Medication Program (THMP).

2.0 Authority

Texas Administrative Code (TAC), 25 TAC §98.103, Medication Coverage.

3.0 Background

The Texas Department of State Health Services (DSHS) receives federal and state funding to purchase and distribute life-saving HIV medications to eligible clients (e.g. low-income, uninsured, or underinsured). The THMP is responsible for managing and overseeing all related operations throughout the state.

Federal funds for the THMP are provided to DSHS by the Health Resources and Services Administration (HRSA), which allows the dispensing of a 90-day medication supply on a regular, ongoing basis. Having the option of a 90-day supply can be beneficial to clients and pharmacies. THMP can alsoprovide a 30-day supply of medication that can be filled at a pharmacyoutside of Texas for clients who have been temporarily displaced or travelout-of-state due to unforeseen circumstances and meet criteria describedin table 7.2 below.


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Both the 90-day medication supply and the 30-day out-of-state emergency refills will help support adherence to medication treatment for some THMP clients. Treatment adherence is critical to maintain the health of persons living with HIV and to reduce HIV transmission by reducing clients’ viral load (amount of virus within the blood).

4.0 Definitions

AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV Medication Program (THMP), administered by DSHS HIV/STD Prevention and Care Branch.

Client – An applicant who has been determined to be eligible for services, has successfully completed the eligibility process, and is receiving services, including medications through the THMP.

Medical Care Team – One or more professionals working to provide services and care to people living with HIV (PLWH). This team can include, but is not limited to, clinicians, case managers, and pharmacists.

Medical Provider – A local organization, individual clinician, or group of clinicians who provide treatment and medical care to people living with HIV (PLWH).

Multi-Month Medication Supply – A medication that is prescribed and/or dispensed in a quantity exceeding one month, or 30 days.

Recertification – In order to continue receiving services through THMP, clients must submit documentation every 12 months to verify their eligibility to remain enrolled in the program.

Self-Attestation – Process of a client updating THMP about any changes or confirming no change in previous eligibility declaration and documentation. Clients must complete a self-attestation every six (6) months.

State Pharmacy Assistance Program (SPAP) – Assists THMP enrollees who have Medicare and an active Medicare Part D prescription card with their premiums and copayments for prescription medications.

Texas Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas. DSHS oversees the Texas HIV Medication Program.

Texas HIV Medication Program (THMP) – Provides medications for the

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treatment of HIV and its related complications for low-income Texans. The THMP is the official AIDS Drug Assistance Program for the State of Texas. It also operates the State Pharmacy Assistance Program (SPAP) and Texas Insurance Assistance Program (TIAP).

Texas Insurance Assistance Program (TIAP) – Assists THMP enrollees who are covered by an eligible private or employer-sponsored health insurance with paying for prescription medication copayments. TIAP can also pay COBRA premiums for qualifying plans.

Texas Resident – An individual who resides within the geographic boundaries of the state of Texas.

Viral Load – A laboratory test that measures the amount of HIV viral copies in a milliliter of blood.


• Providers/Physicians• Pharmacists working at THMP participating pharmacies• THMP clients• THMP staff

6.0 Policy

It is the policy of the Department of State Health Services (DSHS) to approve dispensing up to a 90-day supply of certain medications on a regular, ongoing basis upon prescription by a treating physician. THMP clients who need to travel outside of Texas for an extended period due to certain emergency or circumstantial situations may also be eligible to receive early prescription fills or scripts to cover up to a 90-day period.

THMP clients who are covered under TIAP or SPAP and have health insurance are not automatically eligible for a 90-day medication supply on a regular, ongoing basis. These clients must contact their insurer or Medicare Part D representative and follow the policy or requirements their insurance provider or Medicare Part D Plan has established for 90-day prescription fills. If extended fills are approved by their insurance or Medicare Part D plan, THMP will work with the client to cover expenses for the prescription.

Clients who have a regular prescription for a 30-day supply and meet criteria for one of the special travel or out-of-state situations may collect a 90-day fill (picking up 90-days’ worth of medication at one time) if theprescription is filled and picked up at a pharmacy in Texas prior to theclient’s departure. Clients who need to pick up medication outside of Texas

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may be eligible to receive a 90-day supply of medication; however, prescriptions filled at an out-of-state pharmacy can only be filled as a 30-day supply at one time (totaling up to three 30-day fills). All THMP clients needing medication accommodations due to travel or out-of-state situations must complete the appropriate documentation and receive approval from the program.

Prescribing providers, pharmacists, and clients should familiarize themselves with the coverage guidelines, responsibilities, and limitations that could impact fulfillment of multi-month prescription requests.

7.0 Medication Coverage Guidelines

7.1 90-Day Medication Supply

THMP has approved certain medications provided by the program to be dispensed to patients in quantities up to a 90-day supply on a regular, ongoing basis. The option for a 90-day supply is not a requirement and it is up to the prescribing physician to determine whether a medication should be refilled for 30 or 90 days.

A list of medications approved to be dispensed as a 90-day supply is posted in the Pharmacy and Medical Provider Guidelines35 and available on the program’s website.

7.2 Medication Supply for Special Travel or Out-of-State Situations

THMP clients who have not been prescribed 90-day refills on a regular basis or who have a prescription for a medication that is not approved to be dispensed as a 90-day supply according to the list of medications36 may be approved to receive up to a 90-day supply of medication in special out-of-state situations listed in the table below. Clients are only eligible to receive medications in quantities greater than a 30-day supply at one time if the prescription is picked up in the state of Texas.

If a client experiences any of the situations listed in the table below and needs a medication refill while out-of-state, the client may be eligible to receive a 30-day supply from a pharmacy located outside of Texas for up to three consecutive months (90 days total). Due to proof of residency requirements, any prescription filled outside of Texas will always be for 30 days at a time, even if the client’s regular prescription is written for a 90-day supply.

35 www.dshs.texas.gov/hivstd/meds/files/formulary.pdf 36 https://www.dshs.texas.gov/hivstd/meds/files/formulary.pdf

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Each of these special out-of-state situations apply to Texas residents who are temporarily in another state; they do not apply for out-of-state residents visiting Texas. DSHS Program Policy 220.001, Eligibility to Receive HIV Services37 states that an individual does not lose their Texas residency status due to a temporary absence from the state. For example, a migrant or seasonal worker may leave the state during certain periods of the year but maintain a home in Texas and return to that home after the temporary absence. THMP participants can maintain program eligibility if they maintain a Texas residential address during these absences.

Table 7.2: Medication Supply Details for Special Out-of-State Situations

Table 2

Situation Medication Assistance

Required Documentation

Notes

Temporary travel out of Texas.

May request up to a 90-day supply ofprescribed medicationsat their assigned THMPpharmacy twice peryear.

Must submit the THMP Temporary Out of State or Extra Medication Request Form.

Documentation and/or proof of travel may be required.

If a prescription filled in a quantity greater than a 30-day supply is lost, the replacement and all remaining fills will be for 30-days only.

A client is enrolled as a student at an out-of-state educational institution and retains residency in Texas, but client is denied by the ADAP in state where the institution is located.

May request to pick up medications in the state where the student attends classes during the period of education enrollment.

Must submit current proof of out of state educational enrollment and an ADAP denial letter from the attending state’s ADAP.

A 30-day order will be allowed at a local pharmacy on an ongoing basis in the state where the recipient attends school, with verification of school enrollment required with every self-attestation and recertification.

Migrant/ Seasonal Workers

Temporary Job Assignments

The client may request up to a 90-day supply for coverage while working out-of-state.

Any fill supplying more than 30 days at one time must be picked up from client’s assigned THMP pharmacy in Texas.

Client must submit the Temporary Out of State or Extra Medication Request Form.

Multi-month supply for this situation may be approved up to twice a year, nonconsecutively.


Temporary leave May request up to a Client must submit a Client will be allowed to pick


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Notes

for an extended period to care for family or attend to other personal matters out of state.

90-day supply to bepicked up at one timefrom their assignedTHMP pharmacy priorto leaving Texas.

If client is unable to pick up prescription(s) in Texas, client may request to pick up medications at an out-of-state pharmacy for a total of up to 90 days (three 30-day fills).

statement explaining their extended leave of more than 60 days in addition to the Temporary Out of State or Extra Medication Request form.

up medication at a local pharmacy in the state where visiting, but fills will only be for 30 days at a time.

Multi-month supply and/or out-of-state fills for this situation may be approved up to twice a year, nonconsecutively.


Natural Disaster Displacement Out of State.

The client may request to pick up medications at an out-of-state pharmacy for a total period of up to 60 days.

Client must submit a statement of intent to return to Texas or apply to ADAP in the state where client decides to remain.

Client will be allowed to pick up medication at a local pharmacy in the state where the client is staying, but fills will only be for 30 days at a time.

TIAP/SPAP clients with insurance who meet any of the situations listed above in this table.

The client may request to pick-up medications at an out-of-state pharmacy.

Clients must contact their insurer or Medicare Part D Plan to determine eligibility and requirements regarding the maximum quantity of medication that can be supplied at one time (if picking up medication in Texas prior to extended travel) as well as the maximum duration that a client is able to pick up a prescription outside of Texas.

Clients who need to fill a prescription while out-of-state must submit the Temporary Out of State or Extra Medication Request Form to THMP.

Clients also need to check with their insurer or Medicare Part D Plan and follow any of their requirements for these out-of-state situations.

Clients leaving Texas for an extended period (up to 90 consecutive days) must check with their insurer or Medicare Part D plan to determine whether their plan provides 90-day prescription fills and if so, which medications are eligible for extended fills. If 90-day fills are permitted,client should follow therequirements set by theinsurer or Medicare Part Dplan.

Clients residing in hurricane-prone areas

A client may request an early 30-day fill of medication between the months of June and November, which are recognized as Hurricane Season. This fill can be collected anytime during the stated period and allows for two fills to be picked up

The client must reside in a county designated as a coastal area by the National Oceanic and Atmospheric Administration (NOAA)38 or in a county with a disaster declaration during

Early fill will only be provided for medications that the client currently receives as a 30-day fill. Clients with prescriptions for 90-day fills are not eligibleto get an early fill during hurricane season.

This situation allows clients

38 https://www.census.gov/programs-surveys/geography.html

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Notes

on the same day. Hurricane Harvey39.

Client must submit the Extra Medication Request form in order to collect early fill.

in hurricane-prone areas to get one early refill during hurricane season—it does not change the total number of prescription fills available.

This medication assistance situation only applies to ADAP participants; TIAP/SPAP clients with insurance are not eligible to receive this early fill.


8.1 Medical Provider

Reviews list of medications40 approved for a 90-day supply by ADAP and only write prescriptions for those included on this list; exceptions exist for client’s approved to receive extra medication due to situations stated in section 7.2 of this policy, Medication Supply for Special Situations.

Providers should reserve prescribing a 90-day medication supply for people on stable medication regimens; medications that are new or have changed in dose for a patient are not eligible to be dispensed as 90-day supply.

Submits updated Medical Certification Form (MCF) to THMP whenever a change in client’s regular, ongoing therapy occurs, including a change in medication supply quantity. Supply quantity must be documented on MCF for each medication prescribed.

Providers do not need to write a new script or submit an updated MCF if their client has a regular prescription for a 30-day supply but needs additional medication on a temporary basis due to one of the situations listed in Table 7.2.

8.2 Pharmacist

Stays up-to-date on medications41 that are eligible for a 90-day supply through the THMP. Only dispenses multi-month prescriptions for medications on the approved list or when a Temporary Out of State or Extra Medication Request Form approved by THMP is submitted for an

39 https://gov.texas.gov/news/post/diaster-proc 40 https://www.dshs.texas.gov/hivstd/meds/files/formulary.pdf 41 https://www.dshs.texas.gov/hivstd/meds/files/formulary.pdf

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active prescription.

8.3 Client

A Client who needs an early refill (extra medication) or a multi-month supply of medication due to any situations described in section 7.2 of this policy, Medication Supply for Special Travel or Out-of-State Situations, must complete the Temporary Out of State42 or Extra Medication Request Form43 and obtain approval by the THMP. Clients with 90-day prescriptions may need to submit the Extra Medication Request Form if they are traveling or temporarily out of the state and the timing of their prescription refills does not coincide with the amount of medication needed to cover the duration of their travel.

The client must ensure that their prescriptions are active for the entirety of time requested by an extended fill. It is the client’s responsibility to recertify their eligibility to maintain access to medications. If the client remains out of state longer than 90 days, he or she may be required to fully reapply, including current proof of Texas Residency.

A client should talk to their provider if they are interested in getting a 90-day supply of their prescribed medications on an ongoing basis. However, if a client is submitting a request for early or additional medication fills because of a temporary travel situation, they do not need to get authorization or a new script from their provider, but they must submit the required documentation noted in Table 7.2.

8.4 THMP

Keeps the list of medications approved for a 90-day supply and the MCF up to date. Notifies providers and pharmacists to check the guidelines when changes to the list have been made.

9.0 Limitations

Medications approved to be dispensed as a 90-day supply and fulfilling requests for a multi-month medication supply are at the discretion of the THMP and subject to availability and funding constraints. Only those medications included on the THMP Medication Formulary and Maximum Quantities44 in the Pharmacy Guidelines are eligible to be dispensed in quantities exceeding 30 days, unless otherwise approved by the THMP,

42 https://dshs.texas.gov/hivstd/meds/files/MedicationGuidelinesOutofStateTexasResidents.pdf 43 https://dshs.texas.gov/hivstd/meds/files/ExtraMedRequest.pdf 44 https://dshs.texas.gov/hivstd/meds/files/formulary.pdf

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such as situations listed in section 7.2 of this policy.

10.0 Medication Replacements

A lost fill over 30 days will only be replaced as a 30-day supply. If a 90-day fill is lost, the client will only be eligible for 30-day medication refills from that date forward. Returning to a 90-day supply will be reassessed by THMP on a case-by-case basis in collaboration with the client’s medical care team.


Date Action Section 5/1/2019 This is a new policy. All

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APPLICATION FOR MEDICATION ASSISTANCE Texas Department of State Health Services

ATTN: MSJA - MC 1873 PO Box 149347, Austin, TX 78714-9347

1-800-255-1090• Mail the completed application and copies of supporting documentation to the address listed above.• Make copies of your completed application and do not send any original documents, they will not be returned.• For help with your application, call your local community organization. For additional information on AIDS service

organizations, case management services and community resources in your local area, please call 2-1-1.

• If you have any questions, comments or concerns regarding the Texas HIV Medication Program (THMP) and thisapplication for assistance, please call the program directly at 1-800-255-1090.

• For additional information, including Frequently Asked Questions and downloadable copies of program documents, pleasevisit the THMP web site at www.dshs.texas.gov/hivstd/meds/.

• If approved for the program, you will need to update your eligibility at least every six months.

Important Information for Former Military Services Members: Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves, or National Guard may be eligible for additional benefits and services. For more information, please visit the Texas Veterans Portal at veterans.portal.texas.gov.

Is your application complete?

PRIVACY NOTIFICATION With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See www.dshs.texas.gov for more information on privacy notification. (Reference: Texas Government Code, Sections 522.021, 522.023, 559.003 and 559.004)

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http://www.dshs.texas.gov/hivstd/meds/

https://veterans.portal.texas.gov/

http://www.dshs.texas.gov/

mm/dd/yyyy

For agency Primary Reviewer Date use only: Secondary Reviewer Date

PERSONAL INFORMATION 1. Last Name First Name Middle Name Suffix (Jr., Sr., III)

2. Previous names (including maiden name, aliases, and name changes)

3. Do you have a SSN?No Yes

Social Security Number: Tax ID (only if you do not have a SSN):

4. Date of Birth: 5. Preferred Language: English Spanish Other:

6a. Current Gender Male Female Unknown Transgender: Male to Female Transgender: Female to Male

6b. Sex at Birth Male Female Unknown

7b. Race (check all that apply) White Black/African American Asian (if Asian, please select subgroup)

Asian Indian Korean Chinese Vietnamese Filipino Japanese Other Asian

Native Hawaiian or other Pacific Islander (please select subgroup)

Native Hawaiian Guamian or Charmorro Samoan Other Pacific Islander

Other/Unknown American Indian/Alaska Native

6c. If applicable, are you currently pregnant? Yes No Due Date:

7a. Ethnicity (check the one that best describes you) Hispanic (if Hispanic, please select subgroup)

Mexican, Mexican American, Chicano/a Puerto Rican Cuban Another Hispanic, Latino/a or Spanish origin

Non-Hispanic

8. Residential Street Address – (No P.O. Boxes or Rural Routes) Apartment Number

City State Zip Code

If you wish to have mail sent somewhere other than your residential address please provide an alternate mailing address: 9. Mailing Address - (P.O. Boxes and Rural Routes accepted here) Apartment Number

City State Zip Code

10. Home Phone Number (area code + number)

May we leave a voice mail? Yes No

Work/Alternate Phone (area code + number)

May we leave a voice mail? Yes No If you are unavailable, are there any special instructions as to how we should leave a message for you?

AUTHORIZATION OF RELEASE 11. Agency Worker (if applicable): Agency Worker Phone & Fax #:

Direct Line: Fax: Agency:

11b. Alternate contact: The following individual(s) may speak on my behalf regarding my application and program status. These individuals may be family members or friends.

Name of Person Relation to You Phone Number

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MARITAL STATUS 12. What is your current Marital Status:

SingleWidowedDivorced, Date:Separated, Date: (explanation required)Married/Common Law (provide spouse information below and complete page 4 forboth yourself and your spouse)

If you are separated, please explain your current legal situation.

13. Spouse Name: Spouse SSN:

Spouse Date of Birth: Is spouse also on program? Yes No

IF UNDER 18 : GUARDIAN INFORMATION 14. If you are under the age of 18 list parent or guardian information. Your parent or parents who live with youmust complete the Income Section on the next page.A. Name of Parent or Guardian B. Name of Other Parent or Guardian (if applicable)

Social Security Number Date of Birth Social Security Number Date of Birth

HOUSEHOLD INFORMATION 15. Including yourself, how many people live in your home?Complete the following table for your family. This only includes your legal or common-law spouse and children under 18 (including biological, adopted and step-children who live with you).

Name Age and Date of Birth (Birth Date Required for under 18) Relationship

16. Do you receive HOPWA/Section 8 housing assistance/subsidized housing? Yes No(If yes, include agency verification)

17. Is there anything else you would like to tell us about your living situation that could help clarify yourapplication? For example, if you live with someone who supports you please explain your situation.

Please note: If there are special circumstances surrounding your household situation that would need to be explained or verified by a social worker, Agency Worker, or public health nurse, please have them provide a detailed support statement on your behalf and attach it to your application when applying for assistance. 18. Have you recently been released or are you currently incarcerated in a jail or prison? Yes No Facility Name Correctional ID # Release Date

Approximate Length of Incarceration

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INCOME, EMPLOYMENT and BENEFITS 19. How do you support yourself? Please check ALL that apply below, for you and your spouse:

Documentation is required for both you and your spouse, if married I am employed • Include 2 current, consecutive pay stubs. If paid weekly, submit 4

consecutive pay stubs, for you AND your spouse.

I work but I’m paid in cash • Have your employer complete the Income Verification Form. You

may be required to submit a Tax Return Form signed by you, or a taxpreparer, or proof of e-file, and/or bank statements.

I have more than one job • Include 2 current, consecutive pay stubs for each job. If paid

weekly, submit 4 consecutive pay stubs for each job. You may berequired to submit a Tax Return Form signed by you, or a taxpreparer, or proof of e-file.

I am self-employed • Include a complete copy of your most recent Federal Income Tax

Return Form. Your personal tax return form must be signed byyou, or a tax-preparer, or must include proof of e-file.

I’m under 18 • Parent must fill out this page.

I receive disability benefits, unemployment benefits, retirement/pension, VA benefits, or other awarded benefits • A copy of your benefit award letter or other official documentation

showing the amount received on a regular basis.

I’m a student • Submit proof of enrollment and financial aid from your school’s

financial aid office.

I don’t work. A relative, friend, or agency provides financial or housing support. • The person who supports you must complete the Supporter

Statement (Page 7).• Provide proof of agency assistance you receive (if applicable).

I am homeless • Provide proof of agency/shelter assistance you receive (if applicable).

Other (please explain here)

20. Employment: We may verify your income with other sources such as the Texas Workforce Commission. Spouseinformation is required (common law or legally married). Parents of applicants under 18 must be complete this.

Applicant or Parent A (if minor) Spouse or Parent B (if minor)

Employment Status

Full time Part time Self Employed Unemployed Temp/seasonal

Full time Part time Self Employed Unemployed Temp/seasonal

Job 1: Employer (current or last)

Job Title (current or last)

End date (if unemployed)

Job 2: Employer (current or last)

Job Title (current or last)

End date (if unemployed)

21. Income and Benefits: Report MONTHLY gross income (the amount received before taxes/deductions). Submit proofof income!Wages, salary, commissions, tips, unemployment benefits $ $

Social Security Income (SSI or SSDI) $ $

Retirement / Pension $ $

Other Income (includes financial aid, alimony, investment income) $ $

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HEALTH INSURANCE or MEDICATION ASSISTANCE 22. If you currently have health care coverage or health insurance, why are you applying for this program? (Please check ALL that apply. Submit documentation from the insurance plan verifying your situation.)

I do not have health care coverage or health insurance (proceed to question 23). I need help paying my medication deductibles, medication copayments, or coinsurance expenses. Private insurance (complete Copayment Assistance: Insurance on page 6) Medicare (complete Copayment Assistance: Medicare on page 6) My insurance does not cover prescription drugs or it doesn’t cover one or more HIV meds I need. Coverage will end soon (specify ending date): Expenses have or are about to exceed the plan’s annual prescription cap.

Amount of annual prescription cap: $ Other limitations on coverage or payment (specify):

23. How are you currently getting medications for HIV (antiretroviral therapy)? (check ALL that apply) I am not currently taking medications for HIV (antiretroviral therapy). I am currently receiving medications through the Texas HIV Medication Program (THMP). Private Health Insurance, Employer (If a card is issued, submit a copy the front and back of the card.)

Private Health Insurance, Individual (If a card is issued, submit a copy the front and back of the card.) Patient Assistance Program (PAP) Medicaid (including Star and Star +) Medicare (Part A, Part B, Part C or Part D) ACA, “ObamaCare” or Marketplace Plans Indigent Care (City/County plans such as MAP, Gold Card, Carelink or local agency assistance) Veteran’s Affairs (VA) Other:

24. Have you previously had any health insurance: Yes No If yes, please list name and date coverage ended. If your insurance terminated in the last 90 days, submit proof of termination. Insurance Name: End Date:

Insurance Name: End Date: ADDITIONAL INFORMATION

25. Is there anything you would like to clarify on this application? Please use this space to provide any additional information that may help THMP process your application. Attach additional pages if needed.

THMP ASSISTANCE AGREEMENT IMPORTANT – READ, SIGN AND DATE THE FOLLOWING CERTIFICATION AND AUTHORIZATION: 1) I understand that this application is a legal document. My signature (1) attests that all the information given is true and correct, (2) authorizes the release

of my medical information to the Texas HIV Medication Program (THMP) and (3) attests that I reside in the State of Texas. 2) I understand that it is my responsibility to notify the THMP immediately if my/our income increases; if I/we move from Texas; if my/our residential or mailing

address changes; or if my/our marital, household or insurance status changes. 3) I understand that the THMP may request verification of the information I have provided in order to process my application, and also at any time thereafter.

I also understand that the processing of my application may be delayed until such requested verification is received. 4) I understand that the THMP may verify information provided on this application with data resources made available to the program for the purpose of

eligibility determination. 5) I understand that deliberately omitting or giving false information could cause me to be removed from the THMP and/or criminally prosecuted. 6) I understand that the THMP reserves the right to limit enrollment based upon availability of funds. 7) I understand that the THMP is required to recertify my eligibility status at least every six months in order to continue receiving services. 8) I understand that I must order HIV medications from this program on a monthly basis and that I will be dropped from the program if I don’t order

medications for six consecutive months. 9) I understand that my information will be shared with my HIV service providers and Agency Workers. I will contact THMP if I want an exception

to be made. Signature of Applicant (please print and sign)

Date (required)

Signature of Parent (if applicant is under 18 years of age) (please print and sign)

Date (required)

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COPAYMENT ASSISTANCE – Complete if you have: Medicare part D (State Pharmaceutical Assistance Program - SPAP) Or Private Insurance (Texas Insurance Assistance Program - TIAP)

Applicants with MEDICARE or PRIVATE INSURANCE should fill out this form in addition to the main THMP form. The SPAP provides help with co-pays, coinsurance and gap coverage associated with a Medicare Part D prescription drug plan. The TIAP provides help with co-pays, coinsurance and premiums associated with COBRA plans and private insurance. First and Last Name Social Security Number Date of Birth

DO YOU HAVE MEDICARE? FILL OUT THIS SECTION FOR SPAP Your Medicare Number Effective Date of Medicare Part A (listed on your

Red White & Blue Medicare Card)

Are you enrolled in a Medicare Prescription Drug Plan (Part D)? No Yes (if yes, please provide plan information below)

Rx Plan Name: Effective Date:

Have you applied for the Low Income Subsidy or Extra Help through the Social Security Administration? No Yes (please indicate application status below)

Low Income Subsidy/Extra Help Application Status Approved, 100% Assistance Approved, partial assistance (attach copy of approval letter)

Denied Assistance (attach a copy of pre-decisional or denial letter)

Awaiting determination, application date:

DO YOU HAVE INSURANCE? FILL OUT THIS SECTION FOR TIAP Are you enrolled in a private insurance plan? No Yes (if yes, please provide plan information below)

Plan Name: Effective Date: Member ID:

Do you have an Affordable Care Act (ACA) Marketplace Plan? Yes No PROVIDE COPY OF FRONT & BACK OF INSURANCE CARD Is this an Individual, Non-ACA, Off Marketplace Plan? Yes No Is this plan offered through an employer? Yes No

If you have COBRA or may be eligible for COBRA, please submit copies of your COBRA paperwork (TIAP may assist with COBRA Premiums and Copayments): Have you already submitted your COBRA paperwork?

No Yes date submitted: COBRA Administrator’s Phone Number:

COBRA Election/Enrollment Due Date: COBRA Initial Payment Due Date: COBRA Account #:

COPAYMENT ASSISTANCE AGREEMENT IMPORTANT – READ, SIGN AND DATE THE FOLLOWING COPAYMENT ASSISTANCE AGREEMENT: 1) I understand that it is my responsibility to (a) enroll in a Medicare Prescription Drug Plan and apply for the Low Income Subsidy if I have Medicare, (b)

maintain my enrollment in an insurance plan or a Medicare Prescription Drug Plan, and (c) pay the monthly prescription drug plan premium directly tothe prescription drug plan.

2) If I have private insurance, it is my responsibility to inform the program of any changes in my private insurance benefits or COBRA.3) I understand that it is my responsibility to notify the THMP immediately if my/our income increases; if I/we move from Texas; if my/our residential or

mailing address changes; my/our marital, or household status changes; or my Medicare benefits are terminated, I lose my insurance coverage or myeligibility for Medicaid or Medicare changes.

4) I understand that the THMP reserves the right to limit enrollment based upon availability of funds.5) I understand that the THMP is required to recertify my eligibility status at least every six months in order to continue receiving services.6) I understand that information may be shared with THMP staff and my insurance plan. I hereby give consent to the THMP to obtain or release my

demographic, medical and /or insurance coverage information with other entities as necessary.7) I agree to participate in a periodic follow up by the THMP Insurance Assistance Program staff to determine the effectiveness of the program.8) I understand that I must order HIV medications from this program on a monthly basis and that I will be dropped from the program if I don’t order

medications for six consecutive months.9) I understand that this is a legal document. My signature (a) attests that all the information given is true and correct, (b) authorizes the release of my

medical information to the THMP, and (c) attests that I reside in the State of Texas.

Signature of Applicant (please print and sign) Date (required)

Signature of Parent (if applicant is under 18) (please print and sign) Date (required)

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FORM A: SUPPORTER STATEMENT If an applicant has no income or is unable to provide any documentation showing how they manage, this form can be used as documentation. This form must be completed, signed, and dated by the person providing support within the last 60 days; it should not be filled out by the person applying for the program.

I, , certify that I currently support (printed name of supporter)

, who resides at the following (printed name of person you support)

address: . (person you support’s street address, city, state, & zip code)

I have supported him/her since . My relationship to the applicant (Date)

is . (examples: parent, spouse, roommate, friend, sister, etc.)

The type of support I provide is (check all that apply):

Room Food/Clothing Rent/Mortgage Utility Bills

Cash Assistance in the amount of $ per month

Other:

Additional explanation (if necessary):

I can be reached at the following phone number(s) to verify this information:

By signing this form, I affirm that the above information is an accurate statement of assistance being provided to the applicant. I understand that if I deliberately omit or give false information the applicant may be removed from the program and/or criminally prosecuted.

Signature of Supporter (please print and sign) Date (required)

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FORM B: INCOME VERIFICATION This form should be used only when no supporting income documentation is available. If paystubs are available to the employee copies must be submitted. This should be signed and dated within the last 60 days by the employer only. I. Employee InformationEmployee Name:

Employee Address:

II. Employer Contact InformationBusiness Name:

Business Address:

Business Phone Number:

Contact Name: Contact Phone Number:

III. Employee IncomeType of work performed by the employee:

First Day of Employment: Last Day of Employment (if applicable):

Average number of hours worked per week:

Method of payment (check one): Cash Personal check Payroll check Other (please specify)

Frequency of payment (check one): Weekly Biweekly Semi-monthly Monthly Daily Other (please specify)

Gross earnings $ per pay period

Estimated amount of weekly tips or commissions: $ per week

IV. Employee Health CoverageIs employer-sponsored health coverage offered? Yes No

If yes, is/was this employee enrolled in health coverage? Yes No

V. Additional InformationWill there be any changes to this person’s employment in the next few months?

VI. CertificationI verify that the above information is true and correct to the best of my knowledge.

Signature of Employer (please print and sign) Date (required)

A-8

THM

P A

pp

licat

ion

Sta

tuse

s

Ap

pro

ved

Pen

din

g

On

Hol

d

Pu

rged

D

rop

ped

R

ejec

ted

/Den

ied

Rec

erti

fica

tion

App

licat

ion

is

com

plet

e.

Clie

nt h

as m

et

all

requ

irem

ents

fo

r TH

MP

assi

stan

ce.

Clie

nt is

co

nsid

ered

an

“act

ive”

clie

nt.

App

licat

ion

is

inco

mpl

ete.

A

dete

rmin

atio

n ca

nnot

be

reac

hed.

Inco

mpl

ete

appl

icat

ion

held

for

30

days

.

App

licat

ion

purg

ed a

fter

30

day

s.

Pen

din

g w

ill

sto

p a

s o

f S

ept

1, 2

01

7.

Med

icat

ions

ar

e “o

n ho

ld”

beca

use:

1)TH

MP

rece

ived

retu

rned

mai

l.Clie

nt n

eeds

to u

pdat

ein

form

atio

n w

ithTH

MP.

2)Pe

ndin

gin

form

atio

nfo

rre

cert

ifica

tion

was

not

prov

ided

by

the

due

date

.

3)Th

e cl

ient

has

an a

ctiv

ein

sura

nce

polic

y.

4)Cha

nge

inre

side

ncy,

mar

ital

sta

tus,

heal

thin

sura

nce.

Inco

mpl

ete

appl

icat

ion

has

been

on

“pen

ding

” st

atus

for

over

30

days

.

Clie

nt m

oved

ou

t of

sta

te

afte

r he

/she

su

bmitte

d a

THM

P ap

plic

atio

n.

The

clie

nt is

de

ceas

ed.

Thes

e ap

plic

atio

ns

will

be

shre

dded

af

ter

seco

nd

revi

ew.

Clie

nt h

as n

ot

orde

red

from

TH

MP

for

6 co

nsec

utiv

e m

onth

s.

Clie

nt’s

med

ical

in

sura

nce

is

suffic

ient

and

TH

MP

is n

o lo

nger

the

pa

yor

of la

st r

esor

t.

The

clie

nt w

ill h

ave

to r

eapp

ly fo

r th

e pr

ogra

m.

Clie

nt h

as n

ot m

et

all r

equi

rem

ents

fo

r TH

MP

assi

stan

ce.

Clie

nt is

cur

rent

ly

hosp

ital

ized

, liv

ing

in a

nur

sing

hom

e fa

cilit

y, o

r is

cu

rren

tly

in ja

il.

A r

ejec

tion

lett

er

will

be

faxe

d to

th

e En

rollm

ent

Spe

cial

ist.

A r

ejec

tion

lett

er

will

be

mai

led

dire

ctly

to

a cl

ient

w

ho h

as a

pplie

d to

TH

MP

with

out

the

assi

stan

ce o

f an

Enro

llmen

t Spe

cial

ist.

Clie

nt is

due

for

re

cert

ifica

tion

and

has

to

reap

ply.

Clie

nt w

ill b

e ke

pt o

n an

“a

ctiv

e” s

tatu

s un

til t

he

rece

rtifi

catio

n ap

plic

atio

n du

e da

te.

Clie

nt w

ill b

e di

s-en

rolle

d fr

om the

pr

ogra

m if

TH

MP

does

n’t

rece

ive

an

appl

icat

ion

by

the

due

date

.

Onl

y a

one-

tim

e 30

day

ex

tens

ion

will

be

giv

en.

Med

icat

ions

ca

n’t be

di

spen

sed

if th

e cl

ient

is fo

und

to b

e in

elig

ible

.

A-9

Six Month Self-Attestation of Eligibility Changes

THMP eligibility requires an update to your eligibility every six (6) months. Please answer all questions below and provide any required documents for changes in your income, insurance status or residency. THMP will require this information by the date listed on the enclosed letter (Your Self Attestation will be due 6 months after your birth month).

Name: Phone Number:

Social Security Number: Date of Birth:

Address► (please provide your current address)

Residential address:

Mailing address:

If you have moved, please include a copy of your driver’s license with your new residential address, utility bill, rental agreement, or other documentation of your new address

Income (Includes income of legal or common law spouse if married)

I/We have no incomeMy/Our income has not changedMy/Our income has changed

If your income has changed since your last recertification, please include appropriate documentation of a tax return form, two consecutive paystubs, Social Security award letter, or other documentation to prove your income.

Insurance Status

MedicaidMedicareMedicare Part D

ACA health planPrivate InsuranceNo Form of Insurance

If you have insurance coverage of any kind, please include front and back copies of your insurance cards. You will also need to complete and submit the Co Pay Assistance enrollment form (pg. 6 of the application)

Client or Staff Signature: Date:

I attest that my signature on this form indicates the information provided is accurate and complete to the best of my knowledge.

***In person attestations must be signed by the client. Phone attestations must include the name, signature, and agency name of the staff member completing the form. ***

Staff Name: Agency/Program: Phone #: Fax #:

___________________________ ____________________________ _______________ _______________

A-10

THMP REQUIRED DOCUMENTATION:DOCUMENTS THMP WILL ACCEPT

Please see next page for what THMP will take.

This list does not contain all information needed. Please refer to the application for more detailed information or call THMP.

All parts of the application must be filled out. We need the most up-to-date information. Please sign and date page 5 before you turn in the application.

If you need an application, go to this link: dshs.texas.gov/hivstd/meds/document.shtm

(1) THMP needs proof of where you live. This proof must have your full nameand be current and valid. If you have questions, please call your local agency or THMP.

(2) THMP needs proof of your income. We need to know how much money you earnand how often you get paid. If you are married, we also need this for your spouse. Thisincludes if you are common-law married. We also need to know how many childrenunder the age of 18 live with you. This includes children you are the legal parent of andyour stepchildren. We use this information to calculate your family income.

If you do not earn income, we can accept other documents: If you are a student

We can take a letter that shows you are enrolled in school and your current financial aid award letter. This needs to be from your school, not from FAFSA.

If you pay your bills with savings

We can take a copy of your most recent bank account statement. This should show both deposits and withdrawals.

If you pay your bills with child support

We need your child support letter from the OAG. If your child support is an informal or verbal agreement between you and the child’s parent, we can take a letter from yourself and the other parent. Your child support document needs to say how much you receive and how often.

If you are homeless

Provide a letter from the shelter or agency case manager/ eligibility worker explaining your situation and where you get mail (also accepted as Proof of Texas Residency for those who are homeless).

If somebody else supports you

We can take a copy of the THMP Supporter Statement (on page 7). This needs to be filled out and signed by the person who supports you.

(3) If you are new to the program, ask your doctor to fill out a “MedicalCertification Form’ (MCF). This will tell us what medicines you need.

THMP may request additional information, including a copy of your most recent IRS Tax Return Transcript or IRS Proof of non-filing, if needed.

A-11

http://www.dshs.state.tx.us/hivstd/meds/document

What THMP Can Take: Proof of Residency

Choose one. Must be where you live.

Proof of Income Choose one. Must show a month’s worth of income.

Proof of Insurance

Motor vehicle records examples: • Vehicle registration• Driver’s license• Auto insurance

State Documents examples: • Driver’s License• ID card from the state of Texas• Current Medicaid/SNAP/TANF

benefit award letters,unemployment letters, or legalnotices

• Federal Documents,examples:

• Social Security benefit awardletters, Medicare, voterregistration cards, USPSconfirmation records showingyou changed your address, IRSTax Return Transcript, or IRSVerification of Non-Filing

Documents from bills you are currently paying, examples: • Mortgage or rental agreement

with signature page• Property tax documents• Electric gas, land-line phone,

cable bill, credit cardstatements, bank statement,hospital or medical bills

Official business correspondence, examples:

• Current employment records(such as a pay stubs), W2or 1099, letter of hire, letterof termination, financial aidstatement, letter ofenrollment, statements ofincome or deductions forbusiness

Must show current business you are engaged in. CREDIT CARD INVITATIONS OR JUNK MAIL WILL NOT BE ACCEPTED.

Current Pay Stubs from Employment: • Paystubs in order for 30

days of currentemployment

Award letter: • Disability• Veteran’s benefits• Retirement benefits• Alimony benefits• Unemployment benefits

Wage Verification Form (pg. 8 of application): • Paid in cash or proof of a

new job (for new job,include paystubs received,even if you’ve only receivedone up to date)

Copy of Tax Return: • If self-employed, a copy of

most recent tax year TaxReturn forms

• Your personal tax returnmust be signed by you, ora tax-preparer, or mustinclude IRS Proof of E-filing

If you do not have a copy of your personal tax return, you may ask for a copy of your IRS Tax Return Transcript from the IRS Ask for your Tax Return 30 days before your THMP application is due

Self-Employment Log: • A self-employment log that

reflects earned incomefrom the last 30 daysalong with a letterexplaining the type of workyou do, how often you getpaid, and the form ofpayment you receive(example: cash, writtencheck, barter).

If you have health insurance: • Examples: employer

sponsored policy,ACA/MarketplacePlans, private policy(your own, or as adependent on yourspouse’s or parents’policy), Medicare

• Include proof ofcoverage, completedCopaymentAssistance Form (pg.6 of the THMPapplication)

• And, a copy of yourinsurance card (frontand back)

If your insurance policy ended less than 90 days ago, please submit proof of termination (Certificate of Creditable Coverage or Certificate of Prior Coverage) is required

If you are interested in applying for COBRA assistance, provide the following: • Proof the health

insurance policytermination, pg. 6 ofthe THMP application

• Copies of COBRApaperwork, and copyof insurance card(front and back)

• For eligible policies,THMP will pay yourCOBRA premium,prescriptiondeductibles, and copays.

A-12

Texas HIV Medication Program Client Eligibility – CY 2019 Income Guidelines

If family unit size is: The adjusted family income may not exceed:

1 $24,980

2 $33,820

3 $42,660

4 $51,500

5 $60,340

6 $69,180

7 $78,020

8 $86,860

For each additional family member in household, add $8,840

Please note that all dollar amounts are listed at 200% of the current Federal Poverty Income Guidelines; no further doubling of the amounts are required.

Source: Federal Register, Effective January 11, 2019

Effective with TX DSHS as of January 17, 2019

A-13

THMP RECERTIFICATION FAX COVER SHEET

TO: FROM: Enrollment Worker/Agency

Fax number: Agency eligibility expires:

Phone number: Date:

Re: CC:

ARIES ID: Total pages:

Client name: DOB:

THMP RECERTIFICATION CHECK LIST

TYPE OF RENEWAL DOCUMENTS BEING FAXED: (select one)

SIX MONTH SELF ATTESTATIONS (Must attach THMP Six Month Self Attestation and include proof of income or support and Texas Residency)

ANNUAL RECERTIFICATION (Must attach THMP application without the medical certification form)

Please indicate which documents are being faxed to THMP: Yes or No

Signed Self-Attestation of No Changes: Yes or No

MAGI/Mock MAGI (choose one): Yes or No

Income Documents: Yes or No

Texas Residency Documents: Yes or No

Health Insurance: Yes or No IF YES, answer the following:

List name of insurer: Policy # Expiration date: Insurance Termination/Cancellation Notice: Yes or No

Case manager: Phone: Ext:

Supervisor: Phone: Ext:

Date:

NOTES: The information contained in the accompanying transmission is or may be protected by confidentiality statues and is confidential. This transmission is intended only for use by the addressee or entity above named. If you are not the intended recipient, or the employee or agent responsible for the delivery of this message to its intended recipient, you are hereby notified that any use, dissemination, distribution or copying of this communication is strictly prohibited. No applicable privilege is waived or relinquished by the party sending the accompanying transmission. If you have received this transmission in error, please notify us immediately at 1-800-255-1090. Under certain facts, improper dissemination may be a criminal offense.

A-14

ADAP ARIES Upload Notice FORM (Updated 10/2018) Please submit this document as the cover sheet to the ADAP application being submitted. Ensure the application is complete,

has been reviewed, and that this form, the application, and support documents are uploaded into ARIES. Send email notification with ARIES ID to appropriate consolidated email address: ADD REGIONAL EMAIL BOX HERE. Make

sure the subject line reads: ADAP Application, with ARIES ID. If expedited, user will want to type “Expedited”.

New Enrollment Annual Recertification Six Month Self Attestation Expedited

A. THMP Application (revised 10/2017)I. Completed and signed within 60 daysII. Submitted within 1 day of completion via ARIES

B. Diagnosis of HIV: Medical Certification Form revised 6/2017 (if applicable)

C. Documentation of Texas Residency

D. Documentation of Income (Included Spouse and Dependent if applicable)

E. Copy of Insurance Card (if applicable)

Date of Upload: MM/DD/YYYY Client ARIES ID: Number of pages uploaded: Submitting Agency: Agency Address: City/State/Zip: Name of AEW: Phone # (ext.) Name of AEW Supervisor: Phone # (ext.)

I, ___________________________________________certify that the ADAP application for ____(ARIES Client ID)__ has been completed, reviewed for accuracy, and uploaded under the Eligibility tab in ARIES. The ADAP ARIES Upload Notice Form will be sent to THMP in accordance to the notification process.

AEW Signature Date The facsimile transmission (and/or document accompanying it) may contain confidential information belonging to the sender which is protected by patient confidentiality. The information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this transmission in error, please notify me immediately to arrange for the return of the document.

A-15

How

to E

nsur

e Ap

plic

atio

ns a

reCo

mpl

ete

and

Curr

ent

Star

t with

the

docu

men

ts

Help

the

clie

nt a

sses

s ex

actly

wha

t doc

umen

ts

to b

ring

to th

e TH

MP

appl

icat

ion

appo

intm

ent.

If th

e cl

ient

nee

ds to

ha

ve p

ages

from

the

appl

icat

ion

com

plet

ed

(Inco

me

Verif

icat

ion

Form

, Sup

port

er

Stat

emen

t, M

CF),

give

th

em to

the

clie

nt to

ha

ve co

mpl

eted

.

If th

e cl

ient

nee

ds h

elp

loca

ting

docu

men

ts o

r ju

st n

eeds

ext

ra h

elp,

sc

hedu

le a

ppoi

ntm

ent t

o as

sist w

ith th

is.

Onl

y co

mpl

ete

the

THM

P ap

plic

atio

n w

ith th

e cl

ient

afte

r all

docu

men

ts

are

colle

cted

. Th

is en

sure

s you

will

be

subm

ittin

g cu

rren

t and

co

mpl

ete

appl

icat

ions

.

A-16

Wha

t is

the

diff

eren

ce b

etw

een

an in

com

plet

e ap

plic

atio

n an

d an

app

licat

ion

with

ver

ifica

tion

issu

es?

Fact

or

Inco

mp

lete

ap

plic

atio

n

Ver

ific

atio

n I

ssu

es

Inco

me:

Th

e ap

plic

atio

n do

es n

ot p

rovi

de p

roof

of

inco

me

for

all s

ourc

es li

sted

in t

he

appl

icat

ion,

or

proo

f of in

com

e is

mor

e th

an 6

0 da

ys o

ld.

The

appl

icat

ion

prov

ides

pro

of o

f in

com

e th

at is

not

acc

epte

d by

TH

MP

The

appl

icat

ion

does

not

pro

vide

end

da

te a

nd n

ame

of la

st e

mpl

oyer

if

unem

ploy

ed.

The

appl

icat

ion

stat

es t

he c

lient

is

mar

ried

, bu

t do

es n

ot in

clud

e sp

ouse

’s

inco

me

or e

xpla

natio

n of

spo

use’

s fin

anci

al s

ituat

ion

The

appl

icat

ion

stat

es t

he c

lient

has

ch

ildre

n liv

ing

in t

he h

ome,

but

doe

s no

t lis

t na

mes

and

dat

es o

f bi

rth.

Clie

nt d

oes

not

prov

ide

proo

f of

inco

me

for

all w

ages

rep

orte

d to

Tex

as W

orkf

orce

Com

mis

sion

The

clie

nt p

rovi

des

pays

tubs

tha

t do

not

m

atch

any

thin

g re

port

ed b

y Te

xas

Wor

kfor

ce C

omm

issi

on w

ages

.

Texa

s W

orkf

orce

Com

mis

sion

doe

s no

t cl

early

show

tha

t fo

rmer

job

ende

d, a

nd

that

job

or t

hat

job

plus

the

new

job

wou

ld

mak

e th

e cl

ient

ove

r sc

ale

Clie

nt d

oes

not

repo

rt s

pous

e (a

nd w

e do

n’t

have

pro

of o

f sp

ouse

’s in

com

e)

Clie

nt is

sta

ting

a m

arita

l sta

tus

that

is

differ

ent

from

wha

t TH

MP

has

on f

ile o

r fin

ds t

hrou

gh v

erifi

catio

n, a

nd d

oes

not

expl

ain

why

The

clie

nt li

sts

child

ren

in t

he a

pplic

atio

n th

at it

app

ears

do

not

live

in t

he h

ome.

A-17

Fact

or

Inco

mp

lete

ap

plic

atio

n

Ver

ific

atio

n I

ssu

es

Ap

plic

atio

n

Inte

grit

y Is

sues

:

Page

s ar

e m

issi

ng

The

appl

icat

ion

is u

nsig

ned

or t

he

sign

atur

e is

mor

e th

an 6

0 da

ys o

ld.

Inco

me

Ver

ifica

tion

form

or

Sup

port

er

Sta

tem

ent,

if r

equi

red,

are

not

sig

ned

by

the

empl

oyer

or

supp

orte

r or

the

si

gnat

ure

is m

ore

than

60

days

old

.

The

appl

icat

ion

is fo

r a

new

enr

ollm

ent,

an

d th

ere

is n

ot a

Med

ical

Cer

tific

atio

n Fo

rm.

Ther

e ar

e un

expl

aine

d bl

anks

on

the

appl

icat

ion.

The

appl

icat

ion

prov

ides

con

trad

icto

ry

info

rmat

ion

thro

ugho

ut.

N/A

Insu

ran

ce:

The

appl

icat

ion

indi

cate

s th

e cl

ient

is

insu

red

or h

ave

Med

icar

e Pa

rt D

, bu

t do

es n

ot c

ompl

ete

the

SPAP

/TIA

P fo

rm.

The

clie

nt d

oes

not

repo

rt h

ealth

in

sura

nce,

but

it is

fou

nd d

urin

g ve

rific

atio

n.

A-18

Fact

or

Inco

mp

lete

ap

plic

atio

n

Ver

ific

atio

n I

ssu

es

Res

iden

cy

The

appl

icat

ion

does

not

incl

ude

valid

pr

oof o

f res

iden

cy

The

proo

f of

res

iden

cy p

rovi

ded

is n

ot

acce

pted

by

the

THM

P

The

appl

icat

ion

prov

ides

an

out

of s

tate

or

out

of co

untr

y m

ailin

g ad

dres

s,

resi

dent

ial a

ddre

ss, or

em

ploy

er

addr

ess,

and

the

re is

no

expl

anat

ion

give

n.

It a

ppea

rs t

he c

lient

may

live

in a

diff

eren

t st

ate

or c

ount

ry.

A-19

TX THMP/SPAP Program:

TEXAS THMP SPAP:

The THMP State Pharmacy Assistance Program was developed in 2008 to assist

enrollees who have Medicare access prescription drugs through a Medicare Part D

prescription drug plan, as a part of Healthcare Reform. The SPAP helps to pay for THMP approved medications as well as medications to help with side effects and

other conditions as related to the THMP approved medications. As long as the part

D plan covers the medications, the SPAP will assist with the client’s deductible,

copayments and any out of pocket costs associated with the client’s prescription

coverage.

The THMP SPAP currently assists with Medicare part D premium payments under

$25.00/month, the client needs to contact the program for the assistance.

1. All ADAP clients who are eligible for Medicare A and/or B are eligible for part Dassistance. Once a client has identified they have Medicare they must apply for theExtra Help through the Social Security Administration and enroll into a part D plan. TheTHMP SPAP can special enroll clients into a part D plan throughout the year.

a. The Extra Help with Prescription Drug costs is administered through the Social SecurityAdministration. An applicant can either mail the application to the SSA office or applyonline. We highly encourage all Medicare D applicants to apply online because adecision is made more quickly via an online application 7-10 days and the paperapplications 60 days. To apply online:

www.ssa.govClick on Benefits

Click on Help with paying Medicare prescription drug costs

Apply

All clients must apply even though they might be denied because THMP SPAP

requires a decision on file.

b. The existing ADAP client must complete the SPAP copay enrollment form and return itto the program by either mail or fax. The person may fill out section 1 and sign and datethe page if they do not have a part D plan. An enrollee may be placed onto the SPAPprogram prior to receiving a decision for the Extra Help from the Social SecurityAdministration. If an enrollee does not have an active Part D Plan, the person will beplaced onto ADAP until a LIS determination has been made and the client has enrolledinto a part D plan.

A-20

http://www.ssa.gov/

c. Once a decision has been made by the Social Security Administration, the followingsteps occur.

i. If the decision is 100%, level 1 extra help, then the person is dropped from theADAP program because THMP SPAP is not able to assist when a person hasthe full extra help.

ii. If a partial decision is made or if the person is denied the extra help, then theperson needs to enroll into a part D plan, fill out the SPAP enrollment form andwill be enrolled into the SPAP program for copayment assistance.

2. New enrollees, who are new to the ADAP/SPAP program, or who have been previouslydropped need to fill out the full THMP/ADAP/SPAP application, apply for the extra helpand submit their application with supporting documentation.

Helpful Website Links:

Social Security Administration Extra Help online application.

ssa.gov/medicare/

2019 Medicare and You handbook:

medicare.gov/sites/default/files/2018-09/10050-medicare-and-you.pdf

Medicare Part D drug finder:

medicare.gov/find-a-plan/questions/home.aspx

Understanding Extra Help pdf

ssa.gov/pubs/EN-05-10508.pdf

Your Texas Benefits Link for QMB/SLMB application through Texas

Medicaid yourtexasbenefits.com

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https://www.ssa.gov/medicare/

https://www.medicare.gov/sites/default/files/2018-09/10050-medicare-and-you.pdf

https://www.medicare.gov/sites/default/files/2018-09/10050-medicare-and-you.pdf

https://www.medicare.gov/find-a-plan/questions/home.aspx

https://www.ssa.gov/pubs/EN-05-10508.pdf

https://www.yourtexasbenefits.com/

Texas THMP SPAP - 2019 The THMP State Pharmacy Assistance Program assists THMP enrollees with their premiums (plans under $25.00 in 2019) and copayments for prescription medications who have Medicare and an active Medicare part D prescription card.

How will I get my medications? To get your medications you will need to go to a participating THMP SPAP pharmacy. The pharmacist will need your SPAP ID card or approval letter, Medicare Part D Prescription drug card and valid prescriptions. Using your ID cards, the pharmacist will submit a claim to your Part D Plan. Once your Part D Plan has paid its portion of your medication, the pharmacist will submit the remaining balance to the Texas THMP SPAP. As long as your medication is approved by your Medicare Part D plan and is a Medicare approved drug, the SPAP will pay the remaining out-of-pocket costs for your prescription.

How do I change my Medicare Part D Prescription Drug Plan? You are able to switch plans during open enrollment from October 15th through December 7th for 2019. Before you change plans, make sure all of the medications you take are covered by the plan. You may find out what the plans cover by looking at the Medicare website (www.Medicare.gov), by calling 1-800-MEDICARE or by calling the plan directly. If you need help please call 1-800-MEDICARE, talk with your pharmacist, doctor or case manager, or call the Texas THMP SPAP at 1-800-255-1090 option 4.

How much does a Medicare Part D Plan cost? In 2019, the average plan premium is around $34.00 per month and the least

expensive premium is $10.00 per month. THMP SPAP will pay for your stand-alone Part D plans that are under $25.00/month in 2018, the drug deductible, co-pays and costs during the coverage gap. Once enrolled in a plan you will need to have the plan send to you the billing invoice and not have the plan take the premium out of your Social Security check. You will provide the THMP SPAP your first invoice and an invoice every six months when you complete the self-attestation and annual recertification. You must order your antiretroviral medications through the SPAP copay program to receive the monthly premium assistance. If you do not order through the SPAP copay program, after six months of inactivity your account will be deactivated and you will need to fully reapply to the program. You must contact the THMP SPAP if there are changes in your monthly premium payments.

You may also contact the THMP at 1-800-

25 5-1 0 9 0 and s pe ak wi th t h e SPAPcoordinator for additional resourceinformation.

What medications will the Texas THMP SPAP cover? The THMP SPAP will pay for your copayments as long as the medication is covered by your Part D plan and the medication is not a Medicare excluded drug. Some plans include Medicare-excluded drugs on the plan formulary as a supplement; although those medications are listed on that plan’s formulary, the SPAP will not pay for those medications. If a medication is not covered

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http://www.medicare.gov/

by the Part D plan you choose, the SPAP will not be able to help you with obtaining that medication. All of the plans are required to cover all of the FDA-approved anti-retroviral medications used in the treatment of your disease; however, it is still important to check with your plan to make sure that all of your antiretroviral medications are covered. Some antiretroviral medications need prior approval; therefore, you will have to follow your plan’s rules and work with your doctor’s office to get these approvals.

How much will my medications cost? You won’t have to pay any costs at the pharmacy as long as you use a THMP SPAP in-network pharmacy, your medications are on your Medicare Part D plan formulary and the medication is approved by Medicare. If you are charged for a medication by the pharmacy and you think the copay should be covered by the SPAP, call the SPAP at 1-800-255-1090 or ask the Pharmacist to callRamsell Corporation at 1-888-311-7632.Keep in mind, if your Part D Plan does notcover a certain medication, the SPAP won’tbe able to help you with that medication.You are also responsible for paying any extrafees charged by your plan if you buy any ofthe excluded medications.

How will Health Care Reform and the donut hole closing affect me in 2019? According to the new healthcare law, in 2019, if you enter the prescription drug donut hole, your brand named prescriptions will be processed at a 70% discount by the pharmaceutical companies and the government subsidy paid by your plan will be 5%. You will not be affected by this change, the SPAP will continue to pay your out-of-pocket costs during the coverage gap, as long as your medication is on your Medicare Part D plan formulary and the medication is not a Medicare excluded drug.

What pharmacies can I use?

You must use a pharmacy that works with your plan and the THMP SPAP. A list of THMP SPAP pharmacies can be found at http://www.ramsellcorp.com/individuals/tx.aspx To find a pharmacy near you, call Ramsell Corporation at 1-888-311-7632 or the THMP at 1-800-255-1090 or go to the website listed above. Contact your plan if you have questions about the plan’s pharmacy network.

What is the Low Income Subsidy & how do I apply? Like the THMP SPAP, the Low Income Subsidy (LIS, also known as Extra Help) is a Federal program that helps with Medicare Part D Costs. All applicants in the THMP SPAP must to apply for this assistance. If you qualify for the full LIS (Level 1 or 100%), you’ll be able to get benefits directly from Medicare and will not be eligible for help from the SPAP. If you are denied the LIS or are approved for the partial LIS, you’ll be eligible for the SPAP as long as you continue to meet the other SPAP eligibility requirements. Please reapply for the LIS program if your gross income drops below $16,168 for a household of one.

To apply for the LIS, call the Social Security Administration (SSA) at 1-800-772-1213, or visit their website at www.ssa.gov to apply online. To have an application mailed to you, please call the Texas THMP SPAP at 1-800-255-1090.

How often do I need to reapply for the SPAP? The Texas THMP SPAP will mail you a renewal application when it is time for you to reapply for the assistance. You must tell the Texas THMP SPAP if your household income increases, your marital status changes, or your Medicare benefits end. It is also important to let the Texas THMP SPAP know if your address or phone number changes. Medications will be placed on hold for any returned mail to the THMP SPAP, so please

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http://www.ramsellcorp.com/individuals/tx.aspx

http://www.ramsellcorp.com/individuals/tx.aspx

http://www.ssa.gov/

keep your address up to date. To report any of these changes, call the SPAP at 1-800-255-1090 option 4.

THMP SPAP Eligibility Requirements – All of the requirements listed below must be met:

• Eligible for the Texas HIV MedicationProgram

o Please check website for currentincome guidelines.http://www.dshs.texas.gov/hivstd/meds/faq.shtm

o a Texas resident, ando meets all other THMP eligibility

requirements• Eligible for Parts A and/or B Medicare• Enrolled in a Medicare Part D

Prescription Drug Plan• Denied the full Low Income Subsidy or

approved for the partial subsidy forprescription drug assistance by the

Social Security Administration. A complete copy of the letter is required.

Questions or Concerns Please call the THMP at 1-800-255-1090 option 4 and ask to speak with Juliet Garcia 8 a.m. and 5 p.m., Monday through Friday.

Este es un mensaje IMPORTANTE para clientes Del Programa de THMP y que tienen Medicare sobre el nuevo programa de cobertura de Medicare Para Medicinas Recetadas llamada Medicare RX (Medicare Parte D). Si necesita información en Español, favor de llamar al 1-800-255-1090 (ext. 3006) y pedir hablar con Becky Ruiz.

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THMP INSURANCE ASSISTANCE PROGRAM (TIAP)

The THMP Insurance Assistance Program (TIAP) assists THMP eligible applicants with their prescription out of pocket costs, such as prescription deductibles and copayments and can pay insurance premiums for applicants with private insurance or COBRA eligibility.

To receive assistance, the individual must be eligible for THMP and have one of the following:

1) EMPLOYER SPONSORED INSURANCE

Most employer sponsored insurance plans take the premiums directly out of employee’s paychecks. Also, an individual may have coverage and be considered a dependent; such as: spouse, domestic partner or child of the insured (primary policy holder). NOTE: In some situations, the employer may allow a 3rd party payer to pay the premium directly to the employer. Please talk to a TIAP representative regarding this situation, by calling 1-800-255-1090.

2) COBRA (Consolidated Omnibus Budget Reconciliation Act)

An individual and/or their beneficiaries may be eligible to keep the employer’s insurance for 18-36 months when they have a qualifying event, such as loss of their job or reduction in hours and their employer has 20 or more employees. The individual must accept COBRA within 60 days of leaving the job. If an individual is found disabled by the Social Security Administration, the individual may qualify for an 11-month extension of their COBRA benefit. To get specific information about COBRA, the individual should contact their previous employer’s Human Resources or Personnel Department or the Texas Department of Insurance Consumer Help Line at 1-800-252-3439.

3) STATE CONTINUATION

An individual is eligible for state continuation coverage for up to 6 months if they can show that they have been continuously covered under fully insured group coverage for at least three (3) consecutive months prior to the termination of employment, and if the loss of coverage is not due to the individual’s termination of employment for cause. If an individual is uncertain about access to state continuation coverage, they should contact their employer or human resources office to verify.

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TIAP AND THE AFFORDABLE CARE ACT (ACA)/MARKETPLACE PLANS

TIAP CAN NOT ASSIST with premiums or prescription deductible andcopays for individuals enrolled in an ACA/Marketplace Plan. Theapplicant may need to contact a community agency that has fundingfor such assistance.

If the client is currently Active on THMP and the program learns thatthe client is now enrolled in an ACA plan, the client will be droppedfrom the THMP immediately.

TIAP ELIGIBILITY

To become eligible for TIAP assistance, the applicant must meet THMPrequirements and submit a complete application, which includes page6, the COPAYMENT ASSISTANCE ENROLLMENT FORM, along with acopy (front/back) of the insurance card.

Once the application is received, TIAP staff must determine applicant’sTHMP eligibility and then verify how the prescription benefit works.TIAP staff must call the primary plan and/or pharmacy benefitmanager (ex: Express Scripts, Prime Therapeutics, CVS Caremark,OptumRx, etc.) and request detailed information (on the phone)including type of insurance, prescription deductible, co pays andmaximum out of pocket cost and verify that the prescribedAntiretroviral (ARV) medications are covered by the plan. ARVmedications are sometimes considered specialty medications and mayrequire that medications be filled by a specialty pharmacy.

Once the applicant is approved, they are enrolled onto TIAP andassigned an ID, Group, BIN and PCN through Ramsell, the TIAP’sPharmacy Benefit Manager located in California. This information isprovided to the client via an approval letter from TIAP staff and a cardprovided from Ramsell. The Card or information in the letter must beprovided to the pharmacy (within the TIAP pharmacy network that isalso part of their plan’s network) so that the program can pay theclient’s prescription deductible and the copays for all medications ontheir current insurance drug formulary.

It is important that once approved for TIAP assistance, the programcover the client’s co pays for ARV’s and other medications. The clientmust remain medication compliant and MUST NOT use co pay cardsoffered by the Drug Manufacturers or other co pay assistancefrom other sources. If the client does not use TIAP for co payassistance, it may lead to termination from the program.

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COBRA PREMIUM ASSISTANCE AND TIAP

If the applicant experiences a qualifying event such as termination ofemployment or reduction of hours, COBRA may be offered by theemployer. If client is interested in continuing insurance coverage, theTIAP program may be able to assist the client with medical premiumpayments for up to 18 months. The client will receive a COBRAelection packet that includes:

COBRA election due date effective and end dates of COBRA period premium amount who payment is payable to where payment is mailed

The client should elect the medical benefit with prescription coverageand return the signed packet to their designated COBRA administrator.TIAP staff will not submit COBRA elections. Due to HIPPA guidelines,the applicant should make sure that the Staff with TIAP haveauthorization to communicate with their COBRA Administrator. Thismay require the client provide an Authorization, either in writing orverbally to their COBRA Administrator.

If the applicant is eligible for TIAP and verification of the prescriptionbenefit criteria are met, the clients medical COBRA premiums will bepaid directly to the COBRA administrator for continuation of insurance.TIAP will only assist in paying the COBRA Medical Premium and theirout of pocket costs at the pharmacy, such as prescription deductibleand copays for any medication covered by their plan. TIAP does notcover copays for doctor’s appointments or labs.

TIAP APPROVAL FOR COBRA AND/OR MEDICATION CO PAYS

If the applicant is eligible for TIAP and verification of the prescriptionbenefit criteria are met, the clients medical COBRA premiums will bepaid directly to the COBRA administrator for continuation of insurance.TIAP will only assist in paying the COBRA Medical Premium and out ofpocket costs at the pharmacy, TIAP does not pay copays for doctor’sappointments or labs.

The client’s medications will be covered at a participating pharmacy.The client must use a pharmacy that works with their plan and TIAP.A list of THMP TIAP pharmacies can be found at:http://www.ramsellcorp.com/individuals/tx.aspx The client maycontact their plan with questions about the plan’s pharmacy network.

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TIAP AND RECERTIFICATION/SELF-ATTESTATION

The Texas TIAP will mail a renewal application annually, which is dueon client’s birth month. Also, six-month Self-Attestations will berequired and mailed. The client must inform TIAP if household incomeincreases, marital status changes, or private insurance, COBRA ends.It is also important to let TIAP know of changes in client’s address andphone number.

Medications will be placed on HOLD for any returned mail to the THMPTIAP, so please keep address up to date. To report any of thesechanges, the client must call the TIAP at 1-800-255-1090 and speakwith an Insurance Specialist.

The client must remain compliant and be ordering medicationsregularly; TIAP staff will review client order history thru the Ramsellportal. Clients must continue to take ARV medications while on theTIAP program or they may be dropped for inactivity and be required tofully reapply.

IMPORTANT

All incoming applications, New and Recertification/Self-Attestations will be screened for active insurance. If a client is foundto have active health insurance and this was not indicated on theirapplication, the application will be PENDED, while requesting insuranceinformation and the Copay Assistance Enrolment form. If the client isalready an active ADAP client, their medications will be placed onHOLD. The client must use their insurance to order medications whileit is determined if the client is eligible for TIAP.

THMP relies on clients and eligibility workers to provide healthinsurance information for all clients as it becomes available to them.

If a client loses their insurance within 90 days of submitting a THMPapplication (New or Recertification) the client must provide verificationthat their insurance policy has terminated or is no longer active and/orprovide a copy of their insurance card (front and back).

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THMP Eligibility for Special Populations: Post-Incarcerated Individuals

HIV/STD Prevention and Care Branch policy 591.00 effective December 1, 2013, states THMP must be a payer of last resort for HIV medications. Ryan White and State Services funds may not be used to pay for medical care or medications for any person incarcerated in a state or federal prison, or a local jail.

Individuals can request medication assistance once they have released from incarceration. THMP provides expedited application processing for recently released individuals. Applications are expedited for those being released from federal prisons (FBOP), state jails (such as TDCJ), city jails and county jails. Applications are also expedited if an individual is releasing from a detention facility such as Immigration and Customs Enforcement (ICE) and others.

Individuals may be released from incarceration with a very limited supply of medications or sometimes no medications at all depending on the type of correctional/detention facility they release from. Typically, if an individual is in care and taking medications while incarcerated at a federal or state facility, they are provided a limited supply of medications at release (30-day supply from state facilities and the Federal Bureau of Prisons). Individuals released from city/county jails and detention centers may not be provided medications while in custody or prescriptions for medications at release.

The goals of expedited processing for this population are to provide continuity of care for those individuals already on medications and to facilitate prompt access to medication assistance for individuals returning to care upon release or for those newly diagnosed while incarcerated and accessing medications for the first time.

Most post-incarcerated individuals lack health care coverage or health insurance when released. They also may have limited income and benefits or no income at all. Due to these circumstances, the majority of post-incarcerated individuals are eligible for THMP assistance.

Completing an Application for a Post-Incarcerated Individual

Applications for post-incarcerated individuals may be sent to THMP via fax, mail or ARIES upload. Via fax to: 512-533-3178 Attention: Marivel Cantu-Ressler

Please be sure to complete the most current version of the THMP application with the client. All THMP documents including the newest application are located on the web page for the program.

If a client has released from incarceration provide the following details: indicate when they were released from the facility, including the month, day and year of release and specify the length of incarceration in days, weeks, months or years. This information helps to determine when an application for a released individual is expedited.

Provide information about the facility they released from such as official facility name and location. This is particularly useful if an individual is releasing from an out of state facility or a federal prison.

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Include the individuals’ correctional ID number (the majority of released individuals know or have access to this information, especially if they were provided an identification card while incarcerated).

The THMP verifies that an individual has released from incarceration. THMP must be a payer of last resort for HIV medications and cannot provide medications to incarcerated individuals.

To avoid delays in processing, submit a fully completed application including a Medical Certification Form, proof of Texas residency and proof of income and/or benefits for household. Include:

Proof of income and/or benefits (if applicable) for released individual and spouseor common law spouse if applicant is married.

Provide proof of Texas residency (See THMP Required Documentation form foracceptable documents). THMP may accept other documents for proof of residencyfor post incarcerated individuals. An applicant may provide recent release/paroledocuments and proof of residency statements on letterhead from transitionalprograms/shelters/treatment centers etc. Agency worker/case managers maycontact Marivel Cantu-Ressler if there are extenuating circumstances.

If a client is residing at a transitional program, shelter, halfway house, treatmentcenter etc., provide a statement on letterhead from the facility. Statement mustbe specific to applicant and include identifying information (individuals nameand/or date of birth or social security number).

THMP must have a way to contact clients or send them important information thatmay affect access to medications. Clients with a residential address must provideit, they always have the option to provide a different mailing address.

Processing of Applications for TDCJ Post-Incarcerated Individuals

An application may be completed by TCOOMI while an individual is incarcerated in TDCJ. These applications are sent to THMP prior to the individuals release from incarceration. The applicant is instructed to contact THMP once they release. TDCJ applicants are released with a thirty-day supply of medications and they have access to prescriptions for HIV medications (limited to three refills, thirty-day supply each). If an individual is approved to THMP and utilizes all three refills, they must obtain new prescriptions from their doctor to continue accessing medications from THMP.

Updated May 2019

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Your Right to HIV Treatment in Prison and Jail

Prisoners living with HIV may have trouble getting the health care they need and deserve. If untreated or mistreated, HIV can result in serious illness or even death. To prevent these things from happening, people living with HIV in prison should be aware of—and insist upon—their legal right to medical care.

YOU HAVE A RIGHT TO MEDICAL CARE IN PRISON The U.S. Supreme Court has ruled that prison officials must provide medical treatment to prisoners. Under the Eighth Amendment of the U.S. Constitution, prisoners have the right to see a healthcare professional and be treated for serious medical problems.1 Prisoners have this right to medical care regardless of whether they are in a federal, state, or local prison or jail.

Proving a Violation of the Right to Medical Care

To prove that the right to medical care while in prison has been denied in violation of the Constitution, a prisoner must show that prison officials treated him or her with “deliberate indifference to serious medical needs.”2 Deliberate indifference is when a prison official “knows of and disregards an excessive risk to inmate health or safety.”3 To prove deliberate indifference, a prisoner must show that: 1) s/he has a serious medical need; 2) the prison official knows about the need; and 3) the official has ignored that need.

It is not difficult to prove part one because even people living with HIV who have no visible symptoms have “serious medical needs.” A person living with HIV must have regular blood tests to find out whether it is time to start taking HIV medications. If the person is already taking HIV medications, blood tests are needed to find out whether the medications are still working. And after medications have been prescribed, a prison official’s failure to give a person those medications (on schedule) may result in drug resistance, a drop in immune function, and life-threatening infections.

A person with HIV always has “serious medical needs.” Therefore, it is very important that prison officials are made aware of and are taking care of those needs.

Work Within the System First

If a prisoner finds it necessary to go to court over a prison official’s failure to provide medical care, the prisoner first needs to comply with the Prison Litigation Reform Act (PLRA).4 The PLRA applies to almost any lawsuit challenging the conditions of a person’s imprisonment (including the quality of medical care) and requires prisoners to use and “exhaust” any grievance process provided by the prison system before filing a claim in court. This means that the prisoner must follow all the steps the prison system

makes available for dealing with the problem (including use of all available appeals within the prison system) before a court will seriously consider a lawsuit filed by that prisoner.

Though the steps a prisoner must take will vary from state to state, and even from prison to prison, the required steps usually include: 1) telling the person who is failing to provide adequate care about the serious medical need that is not being met; 2) filing a formal written complaint (or “grievance”); 3) asking the decision-makers to reconsider any unfavorable decision (also called appealing the decision); and 4) pursuing all such appeals to the highest level possible within the prison system.

The specific procedures established by the prison—which may be different or more complicated than those listed above—must be followed. If a lawsuit is filed before the prisoner makes every attempt to solve the problem within the prison itself, a court is likely to dismiss the case without ever considering the merits of the prisoner’s claims.5

GETTING TREATMENT WHILE IN PRISON OR JAIL Listed below are some steps prisoners—and others helping them, such as partners, friends and family members—can take to make it more likely they will receive adequate HIV treatment while incarcerated. These same steps should also be helpful if you can’t get the care you need and later decide to file a claim in court.

Let prison medical staff know about your serious medical needs. If you are receiving medical care for your HIV before entering the jail or prison, getting written documents about your medical needs can be helpful in obtaining HIV care while in prison.

• Ask your doctor to do a complete physical and bloodwork-up before you to go to prison. That way, currentinformation about your condition will be available. Also, ifyour health gets worse while in prison, you will have someevidence to show a court that your health has gone downhill.

• Ask your doctor to write a letter explaining your HIVstatus. In this letter, the doctor (or other medical careprovider) should explain: the doctor’s treatment plan for you;the names, dosages, and schedule for the prescriptionmedications you have been taking; and the importance of

NATIONAL HEADQUARTERS | 120 WALL STREET, SUITE 1500 | NEW YORK, NY 10005 | T 212-809-8585 | F 212-809-0055 www.lambdalegal.org

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f

continuous care in preventing drug resistance and a decline in your long-term health. It is best if you can get this letter before you enter the prison, but it is useful to get even if you are already incarcerated. (You can get a sample letter from Lambda Legal to give to your health care provider showing the types of information that should be included.)

As long as they are providing “adequate” care, prison health officials are not required to follow your doctor’s particular treatment plan. Still, it will be helpful to have your doctor (or other healthcare professional) inform prison officials about your serious medical needs in a written letter. Make several copies of the letter. Give the original to a prison official and give a copy to one or more people you trust, in case you need another copy later.

• Also, if possible, talk to your criminal defense attorneyabout your medical needs. Your attorney may havesuggestions on how best to ensure access to proper medicationand be able to advocate on your behalf before you enter theprison or jail.

File a formal complaint ("grievance") with prison officials. If you believe you are being denied adequate medical care, first follow the procedures set up by the prison for dealing with this kind of problem.

1. Find out how to file a formal complaint at your prison.Learn what procedures prisoners must follow to file a grievanceand take the steps required by those procedures.

2. Follow-up on the complaints you file. If a grievance isdenied, dismissed, or rejected (or no action is taken on it) andthe problem has not been fixed, file an appeal.

3. Keep going until the problem is fixed. If an appeal is denied,dismissed or rejected, you should attempt to appeal thatdecision to the next level—and do so until you have reachedthe highest level and “exhausted” all remedies available withinthe prison system.

Even if filing a written complaint, following up and appealing does not solve the problem right away, taking these steps will put you in a better position to seek a solution in court.

Keep detailed records about your care and any complaints you file.

• Keep a diary about your medical condition and thetreatment you receive. Prisoners usually are allowed to writethings down about their medical treatment, the medical staffthey have seen, the effects of any delay in treatment, and thenumber of days they have gone without treatment. Alwaysinclude dates, a list of any witnesses to the events you describe,and any other information that would help show that a prisonofficial was aware of your serious medical needs.

• Keep proof of how you tried to get the problem fixed.Try to make and keep copies of all complaints you file and allresponses you receive. If you cannot keep copies, write downthe dates you filed these grievances and, in as much detail aspossible, the reason(s) for filing a grievance on each date. Alsomake notes about any responses, determinations and appeals.

These types of documents, notes and logs are important because they may help an attorney or other advocate obtain necessary treatment for you. They might also be useful for pursuing a claim in court.

CONFIDENTIALITY AND PRIVACY In prison, it may be hard to get HIV care and keep your HIV status private at the same time. Outside of prison, medical care providers generally have to keep medical information about patients confidential; however, privacy rights for medical information may be more limited while in prison.

In demanding adequate medical care in prison, you may find it necessary to reveal your HIV status to more people—and more often—than you normally would. If it is important to you to keep your HIV status private, you should avoid discussing it except when seeking, demanding or receiving medical care. In addition, you should mark as “confidential” all documents that mention your HIV status.

Sometimes, prisoners find they are unable to hold on to medical papers (as suggested above) because of a concern that guards or other inmates will see them. If you face this problem, use your best judgment in determining whether to hold on to such documents. If someone on the outside will be helping you try to get the care you need, also let them know about any confidentiality concerns you have.

Updated: July 2010

For more information Visit Lambda Legal’s website (www.lambdalegal.org), call our Help Desk at (866) 542-8336, or write us at 120 Wall St., Ste. 1500, New York, NY 10005.

1 Estelle v. Gamble, 429 U.S. 97, 102 (1976). 2 Farmer v. Brennan, 511 U.S. 825, 836 (1994). 3 Id. at 837-38. 4 U.S. Pub. L. 104-134, § 801 et seq. (amending various statutes, including 42 U.S.C. 1997(e)). 5 The federal right to medical treatment while incarcerated described above is the main source of claims based on inadequate medical care. Other legal claims may be available under other laws (for example, disability discrimination laws, state medical malpractice laws, etc.), and the procedures that must be followed before a prisoner can pursue other types of claims may be very different from the procedures required by the PLRA. This document does not attempt to address the requirements for these other types of claims.

www.lambdalegal.org

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Expedited Applications

***The THMP is not an Emergency medication program and all Expedited

Applications submitted must be COMPLETE with required supporting

documentation ***

Program rules specify that special consideration should always be taken for:

• Pediatric cases/children under the age of 24

• Pregnant females

When deemed necessary by management, the program also allows for expedited

processing of applications. The standard cases for expedited processing of an

application are based on current turnaround times and previously established

hierarchies of necessity such as the following:

• CD4 of 100 or below

Laboratory documentation of the CD4 count should be submitted with the

application, and the count should be within the past 90 days (do not submit

a Medical Certification Form (MCF) reporting a CD4 count that was taken

months ago when a more current CD4 count has since been taken; do notprovide the same CD4 that was used for the applicant on their last expedited

application).

In order to ensure continued access to care and avoid lapses in therapy for the

applicant the following situations may be evaluated individually at intake to determine

if immediate processing is necessary:

• Loss of a patient’s health insurance coverage

includes situations where applicant has a limited window to enroll in COBRA

continuation and TIAP staff needs to determine the applicant’s options

regarding COBRA versus standard ADAP enrollment. Documentation showing

that their policy has terminated within 90 days is required, and if electing

COBRA, will also need COBRA election paperwork and copy of insurance card

(front and back).

• Applicants with Medicare Part D

includes applicants losing Part D plan coverage and who will need ADAP

assistance, or who are losing their full Low Income Status (LIS/Extra Help) and

need to be enrolled in the SPAP program. This change in status also needs to

be specified on the application, and any documentation the applicant has

received confirming the change should be included with the application.

A-34

• Applicants losing Medicaid

includes applicants who are losing Texas Medicaid coverage or whose Medicaid

just ended within the past 30 days.

• Applicants who have moved to Texas or returned to Texas and who

lost their coverage for medications from the state where they were

previously residing

includes assistance from out-of-state resources, such as that state’s ADAP,

Medicaid or other form of assistance covering RX meds within that state. If an

applicant presents themselves as a new resident to Texas and reports that

they had medication assistance prior to their move, the case

manager/advocate/eligibility worker should establish what type of prior

coverage this was and what type of documentation can be included with the

ADAP application indicating that the coverage has indeed ended (or is about to

end).

Our expectation is that information clearly documents this situation on the

application submitted, including proof that assistance has terminated. This

information is not available to the Texas ADAP by any shared ADAP database.

A-35

Medication Ordering

Mary Richards, Pharmacy Coordinator

A list of Participating Pharmacies and a map of locations are available at:

dshs.texas.gov/hivstd/meds/pharmacy.shtm

When a client’s application is complete and they are approved, they are

given their own unique ID number, and are assigned a pharmacy from the

participating pharmacy list. Their doctor will write their prescription and

send it to the pharmacy, and send THMP the Medical Certification Form

which tells THMP which medications to approve.

The pharmacy can be changed over the phone by the client. It can also

be changed by the AEW only if the client has verbally agreed to a

pharmacy change. The change takes effect immediately. (If the client has

medications already ordered at their previous pharmacy, they should pick

them up, or tell the pharmacy to arrange to return them to THMP.)

Every pharmacy with more than ten clients receives a monthly listing of

their assigned clients. If your agency has a pharmacy associated with it,

you can check that listing to see if a client is currently assigned to them.

When the client is ready to refill their prescription, they call the pharmacy

and tell them to order from THMP. The pharmacy faxes in the medication

order to THMP, and THMP staff enter the order. Then the DHS Pharmacy

Warehouse ships the medication to the dispensing pharmacy, which then

dispenses the actual bottles to the client. For most parts of the state, the

medications reach the pharmacy within 1-2 business days, depending on

what time of day the order was placed.

Pharmacies had the option of charging a dispensing fee of $5 per

medication for non-Medicaid clients. Pharmacies on the current

Memorandum of Agreement with THMP should not charge clients a

dispensing fee. The pharmacy will invoice dispensing fees to THMP.

Participating pharmacies that have not signed the current Memorandum of

Agreement should contact THMP to discuss payment for dispensing fees.

The client can order their medicine up to ten days before their days’

supply runs out. If a client needs an extra or early refill of medication,

THMP needs a written justification faxed to 512-533-3171, including the

following information:

A-36

http://www.dshs.texas.gov/hivstd/meds/pharmacy.shtm

o Client name and date of birth

o Social security number or THMP client number

o What they are requesting (early OR 2-month supply at the

normal time)

o A brief description of why

o If traveling, what dates they are leaving and returning

Please refer to the Extra Medication Request Form for additional information regarding 90-day prescriptions.

If there are any problems with the client’s order, THMP will include the

reason on the fax we send back to the pharmacy. For example:

o The client is on hold because mail was returned

o The client needs to recertify and has not responded

o The client has insurance and is on hold

o The medication was ordered too recently

o The medication is not on the client’s list

o The client has Medicaid and needs to use their available slots before

ordering from THMP

o The client is not assigned to the ordering pharmacy

o The client is not currently on the program

o Has not applied

o Has applied but not yet been approved

o Is missing information from the application

o Was denied for the program

o The client was dropped from the program

o After 6 months without orders

o Because they moved out of state

o Because another source was paying for medications

A-37

THMP Guidance—Medication Supply for Texas Residents Temporarily Out of State or on Special Travel

THMP clients who have not been prescribed 90-day refills on a regular basis or who have a prescription for a medication that is not approved to be

dispensed as a 90-day supply according to the list of medications (PDF : 216 kB) may be approved to receive up to a 90-day supply of medication in

special out-of-state situations listed in the table below. Clients are only eligible to receive medications in quantities greater than a 30-day supply at

one time if the prescription is picked up in the state of Texas.

If a client experiences any of the situations listed in the table below and

needs a medication refill while out-of-state, the client may be eligible to receive a 30-day supply from a pharmacy located outside of Texas for up to

three consecutive months (90 days total). Due to proof of residency requirements, any prescription filled outside of Texas will always be for 30

days at a time, even if the client’s regular prescription is written for a 90-day supply.

Each of these special out-of-state situations apply to Texas residents who are temporarily in another state; they do not apply for out-of-state

residents visiting Texas. DSHS Program policy 220.001, Eligibility to Receive HIV Services states that an individual does not lose their Texas

residency status due to a temporary absence from the state. For example, a migrant or seasonal worker may leave the state during certain periods of

the year but maintain a home in Texas and return to that home after the

temporary absence. THMP participants can maintain program eligibility if they maintain a Texas residential address during these absences.



Notes

Temporary travel out of Texas.

May request up to a 90-day supply of

prescribed medications at

their assigned THMP pharmacy

twice per year.

Must submit the THMP

Temporary Out of State or Extra

Medication Request Form.

Documentation

and/or proof of travel may be

required.

If a prescription filled in a quantity

greater than a 30-day supply is lost,

the replacement and all remaining

fills will be for 30-days only.

A-38

https://dshs.texas.gov/hivstd/meds/files/PharmacyGuidelinesMedTable.pdf

https://dshs.texas.gov/hivstd/policy/policies/220-001.shtm

https://dshs.texas.gov/hivstd/policy/policies/220-001.shtm

Situation Medication

Assistance

Required

Documentation

Notes

A client is

enrolled as a student at an

out-of-state educational

institution and retains

residency in Texas, but

client is

denied by the ADAP in state

where the institution is

located.

May request to

pick up medications in the

state where the student attends

classes during the period of

education enrollment.

Must submit

current proof of out of state

educational enrollment and

an ADAP denial letter from the

attending state’s ADAP.

A 30-day order will

be allowed at a local pharmacy on

an ongoing basis in the state where the

recipient attends school, with

verification of school enrollment

required with every

self- attestation and recertification.

Migrant/ Seasonal

Workers

Temporary Job

Assignments

The client may request up to a

90-day supply forcoverage while

working out-of-state.

Any fill supplying

more than 30 days at one time

must be picked up from client’s

assigned THMP pharmacy in

Texas.

Client must submit the


Medication Request Form.

Multi-month supply for this

situation may be approved up to

twice a year, nonconsecutively.

If a prescription

filled in a quantity greater than a 30-

day supply is lost, the replacement

and all remaining fills will be for 30-

days only.

A-39


Assistance

Required

Documentation

Notes

Temporary

leave for an extended

period to care for family or

attend to other

personal matters out

of state.

May request up to

a 90-day supply to be picked up at

one time from their assigned

THMP pharmacy prior to leaving

Texas.

If client is unable to pick up

prescription(s) in Texas, client may

request to pick up medications at an

out-of-state

pharmacy for a total of up to 90

days (three 30-day fills).

Client must

submit a statement

explaining their extended leave of

more than 60 days in addition

to the Temporary Out of State or

Extra Medication

Request form.

Client will be

allowed to pick up medication at a

local pharmacy in the state where

visiting, but fills will only be for 30

days at a time.

Multi-month supply and/or out-of-state

fills for this situation may be

approved up to twice a year,

nonconsecutively.


Natural

Disaster Displacement

Out of State.

The client may

request to pick up medications at an

out-of- state

pharmacy for a total period of up

to 60 days.

Client must

submit a statement of

intent to return to

Texas or apply to ADAP in the state

where client decides to

remain.

Client will be

allowed to pick up medication at a

local pharmacy in

the state where the client is staying,

but fills will only be for 30 days at a

time.

A-40


Assistance

Required

Documentation

Notes

TIAP /SPAP

clients with insurance

who meet any of the

situations listed above

in this table.

The client may

request to pick-up medications at an

out-of-state pharmacy.

Clients must

contact their insurer or Medicare

Part D Plan to determine eligibility

and requirements regarding the

maximum quantity of medication that

can be supplied at

one time (if picking up medication in

Texas prior to extended travel) as

well as the maximum duration

that a client is able to pick up a

prescription outside of Texas.

Clients who need

to fill a prescription while

out-of-state must submit the


Medication Request Form to

THMP.

Clients also need

to check with their insurer or

Medicare Part D Plan and follow

any of their requirements for

these out-of-state situations.

Clients leaving

Texas for an extended period

(up to 90 consecutive days)

must check with their insurer or

Medicare Part D plan to determine

whether their plan

provides 90-day prescription fills

and if so, which medications are

eligible for extended fills. If

90-day fills arepermitted, client

should follow therequirements set

by the insurer orMedicare Part D

plan.

A-41


Assistance

Required

Documentation

Notes

Clients

residing in hurricane-

prone areas

A client may

request an early 30-day fill of

medicationbetween the

months of Juneand November,

which arerecognized as

Hurricane Season.

This fill can becollected anytime

during the statedperiod and allows

for two fills to bepicked up on the

same day.

The client must

reside in a county designated as a

coastal area by the National

Oceanic and Atmospheric

Administration (NOAA) or in a

county with a

disaster declaration during

Hurricane Harvey.

Client must

submit the Extra Medication

Request form in order to collect

early fill.

Early fill will only

be provided for medications that

the client currently receives as a 30-

day fill. Clients with prescriptions

for 90-day fills are not eligible to get

an early fill during

hurricane season.

This situation

allows clients in hurricane-prone

areas to get one

early refill during hurricane season—

it does not change

the total number of prescription fills

available.

This medication

assistance situation only

applies to ADAP participants;

TIAP/SPAP clients with insurance are

not eligible to receive this early

fill.

A-42

https://www.census.gov/geo/landview/lv6help/coastal_cty.pdf





https://gov.texas.gov/news/post/diaster-proc




THMP Temporary Out of State or Extra Medication Request Form

Fax to 512-533-3171

If you need an early or extended supply of medications, please fill out this

form and fax to the number above. THMP can provide limited exceptions to

the normal ordering schedule. You must be in Texas to pick up your 90

day supply.

Name: _____ D.O.B. _______ THMP ID #: ________

Give the date of your departure and the date of your return. List the reason

for your temporary departure (temporary job assignment, seasonal work,

caring for sick family, migrant work, etc.) or why you need an early refill

(medications were lost or damaged, etc.)

Date of Departure: Date of Return: ______

(Choose One)

3 Month Supply (at normal time) Early Refill (one month)

Reason:

If you are a student attending an out of state university you must submit

proof of enrollment and proof of ADAP denial from the state where you will

attend school. This may allow monthly medication access through THMP at

an out of state pharmacy based on your eligibility.

Based on your birth month recertification, your eligibility may be terminated

upon your return to Texas. It is your responsibility to recertify your eligibility

to maintain access to medications while you are temporarily out of Texas. In

the event that you remain out of state longer than 90 days you may be

required to fully reapply including current proof of Texas Residency.

Client Signature: Date:

Notification Contact Phone Number: _________________

To be completed by THMP Staff: _______________ Date: _________

ADAP Early Refill (one month) Approved ______ Denied ________

ADAP 3 month supply (at normal time) Approved ______ Denied ________

Ramsell Out of State Monthly order Approved ______ Denied ________

A-43

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mg/

Edur

ant 2

5mg/

Vire

ad T

AF

25m

g 30

/btl

30 ta

blet

s 90

tabl

ets

Prez

cobi

x (d

arun

avir

/ cob

icis

tat)

1 PI

80

0 m

g/15

0 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

Pre

zcob

ix c

ount

s a

s 2

med

icat

ion

s to

war

ds a

4 a

ntire

trov

iral

drug

com

bina

tion

limit.

Prez

ista

(dar

unav

ir)

1 PI

60

0 m

g ta

blet

s 60

/btl

60 ta

blet

s 18

0 ta

blet

s Pr

ezis

ta (d

arun

avir)

1

PI

800

mg

tabl

ets

30/b

tl 30

tabl

ets

90 ta

blet

s R

escr

ipto

r (de

lavi

rdin

e)

1 N

NR

TI

200

mg

tabl

ets

180/

btl

180

tabl

ets

N/A

R

eyat

az (a

taza

navi

r)

1 PI

15

0 m

g ca

psul

es

60/b

tl 60

cap

sule

s 18

0 ca

psul

es

Rey

ataz

(ata

zana

vir)

1

PI

200

mg

caps

ules

60

/btl

60 c

apsu

les

180

caps

ules

R

eyat

az (a

taza

navi

r)

1 PI

30

0 m

g ca

psul

es

30/b

tl 30

cap

sule

s 90

cap

sule

s R

eyat

az O

ral P

owde

r (at

azan

avir)

1

PI

50 m

g pa

cket

s 30

/box

5

boxe

s N

/A

Selz

entry

(mar

aviro

c)

1 EI

15

0 m

g ta

blet

s 60

/btl

60 ta

blet

s 18

0 ta

blet

s

Selz

entry

(mar

aviro

c)

1 EI

30

0 m

g ta

blet

s 60

/btl

60 ta

blet

s;

120

w/ S

ustiv

a or

In

tele

nce

180

tabl

ets

stav

udin

e (D

4T, g

ener

ic o

f Zer

it)

1 R

TI

15 m

g ca

psul

es

60/b

tl 60

tabl

ets

180

tabl

ets

stav

udin

e (D

4T, g

ener

ic o

f Zer

it)

1 R

TI

20 m

g ca

psul

es

60/b

tl 60

tabl

ets

180

tabl

ets

stav

udin

e (D

4T, g

ener

ic o

f Zer

it)

1 R

TI

30 m

g ca

psul

es

60/b

tl 60

tabl

ets

180

tabl

ets

stav

udin

e (D

4T, g

ener

ic o

f Zer

it)

1 R

TI

40 m

g ca

psul

es

60/b

tl 60

tabl

ets

180

tabl

ets

stav

udin

e or

al p

owde

r (D

4T, g

ener

ic

of Z

erit)

1

RTI

1

mg/

ml p

owde

r for

ora

l sol

utio

n 20

0 m

l/btl

(6.7

oz

) 12

bot

tles

N/A

Strib

ild (E

lvite

grav

ir 15

0 / C

obic

ista

t 15

0 /E

mtri

va 2

00 /

Vire

ad 3

00)

1 ST

R

Elvi

tegr

avir

150

mg

/ Cob

icis

tat

150

mg

/ Em

triva

200

mg

/ Vire

ad 3

00 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

Str

ibild

cou

nts

as 4

med

icat

ions

tow

ards

a 4

ant

iretr

ovira

l dru

g co

mbi

natio

n lim

it.

Sust

iva

(efa

vire

nz)

1 N

NR

TI

50 m

g ca

psul

es

30/b

tl 90

cap

sule

s 27

0 ca

psul

es

Sust

iva

(efa

vire

nz)

1 N

NR

TI

200

mg

caps

ules

90

/btl

90 c

apsu

les

270

caps

ules

Su

stiv

a (e

favi

renz

) 1

NN

RTI

60

0 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

Sym

tuza

(dar

unav

ir / c

obic

ista

t /

emtri

cita

bine

/ te

nofo

vir)

1

STR

da

runa

vir 8

00m

g/co

bici

stat

15

0mg/

emtri

cita

bine

200

mg/

teno

fovi

r 10

mg

tabl

ets

30/b

tl 30

tabl

ets

N/A

S

ymtu

za c

ount

s as

4 m

edic

atio

ns to

war

ds a

4 a

ntire

trov

iral

drug

com

bina

tion

limit.

Tivi

cay

(dol

uteg

ravi

r sod

ium

) 1

EI

50 m

g ta

blet

s 30

/btl

60 ta

blet

s 18

0 ta

blet

s Tr

ium

eq (a

baca

vir

600m

g/do

lute

grav

ir 50

mg/

lam

ivud

ine

300m

g)

1 ST

R

600/

50/3

00 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

Triu

meq

cou

nts

as 3

med

icat

ions

tow

ards

a 4

ant

iretr

ovira

l dru

g co

mbi

natio

n lim

it.

Triz

ivir

(AZT

300

/3TC

150

/Zia

g 30

0)

1 R

TI

AZT

300/

3TC

150

/Zia

gen

300

tabs

60

/btl

60 ta

blet

s 18

0 ta

blet

s T

riziv

ir co

unts

as

3 m

edic

atio

ns t

owar

ds a

4 a

ntire

trov

iral d

rug

com

bina

tion

limit.

Truv

ada

(Vire

ad 3

00/E

mtri

va 2

00)

1 N

RTI

/R

TI

Vire

ad 3

00 m

g / E

mtri

va 2

00 m

g 30

/btl

30 c

apsu

les

90 c

apsu

les

Tru

vada

cou

nts

as 2

med

icat

ions

tow

ards

a 4

ant

iretr

ovira

l dru

g co

mbi

natio

n lim

it.

Vide

x EC

(did

anos

ine,

DD

I) 1

RTI

12

5 m

g en

teric

coa

ted

caps

ules

30

/btl

30 E

C c

aps

90 E

C c

aps

dida

nosi

ne E

C (D

DI,

gene

ric o

f Vi

dex)

1

RTI

20

0 m

g en

teric

coa

ted

caps

ules

30

/btl

30 E

C c

aps

90 E

C c

aps

dida

nosi

ne E

C (D

DI,

gene

ric o

f Vi

dex)

1

RTI

25

0 m

g en

teric

coa

ted

caps

ules

30

/btl

30 E

C c

aps

90 E

C c

aps

dida

nosi

ne E

C (D

DI,

gene

ric o

f Vi

dex)

1

RTI

40

0 m

g en

teric

coa

ted

caps

ules

30

/btl

30 E

C c

aps

90 E

C c

aps

Vide

x Pe

di P

wdr

(did

anos

ine,

DD

I) 1

RTI

20

mg/

ml,

(2 g

m) p

edi p

wdr

sol

n 10

0 m

l/btl

4 bo

ttles

N

/A

Vide

x Pe

di P

wdr

(did

anos

ine,

DD

I) 1

RTI

20

mg/

ml,

(4 g

m) p

edi p

wdr

sol

n 20

0 m

l/btl

4 bo

ttles

N

/A

Vira

cept

(nel

finav

ir m

esyl

ate)

1

PI

250

mg

tabl

ets

300/

btl

300

tabl

ets

900

tabl

ets

Vira

cept

(nel

finav

ir m

esyl

ate)

1

PI

625

mg

tabl

ets

120/

btl

120

tabl

ets

360

tabl

ets

Vira

cept

Ora

l Pw

dr (n

elfin

avir

mes

ylat

e)

1 PI

50

mg/

gm o

ral p

owde

r 14

4 gm

/btl

12 b

ottle

s N

/A

Vira

mun

e XR

(nev

irapi

ne)

1 N

NR

TI

400

mg

tabl

ets

30/b

tl 30

tabl

ets

90 ta

blet

s Vi

ram

une

(nev

irapi

ne) 1

4-da

y in

duct

ion

1 N

NR

TI

200

mg

tabl

ets

(indu

ctio

n do

se)

14/b

liste

r pac

k 14

tabl

ets

N/A

Vira

mun

e (n

evira

pine

) 1

NN

RTI

20

0 m

g ta

blet

s (re

gula

r dos

e)

60/b

tl 60

tabl

ets

180

tabl

ets

Vira

mun

e O

S (n

evira

pine

) 1

NN

RTI

50

mg/

5 m

l sus

pens

ion

240

ml/b

tl (8

oz)

4

bottl

es

N/A

Vi

read

(ten

ofov

ir)

1 N

RTI

30

0 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

Vite

kta

(elv

itegr

avir)

1

II 85

mg

tabl

ets

30/b

tl 30

tabl

ets

90 ta

blet

s Vi

tekt

a (e

lvite

grav

ir)

1 II

150

mg

tabl

ets

30/b

tl 30

tabl

ets

90 ta

blet

s Ab

acav

ir (g

ener

ic o

f Zia

gen)

1

RTI

30

0 m

g ta

blet

s 60

/btl

60 ta

blet

s 18

0 ta

blet

s Zi

agen

OS

(aba

cavi

r sul

fate

) 1

RTI

20

mg/

ml s

uspe

nsio

n 24

0 m

l/btl

(8 o

z)

4 bo

ttles

N

/A

zido

vudi

ne (A

ZT, g

ener

ic o

f Ret

rovi

r)

1 R

TI

100

mg

caps

ules

10

0/bt

l *

400

caps

N

/A

zido

vudi

ne (A

ZT, g

ener

ic o

f Ret

rovi

r)

1 R

TI

300

mg

tabl

ets

60/b

tl 60

tabl

ets

240

tabl

ets

zido

vudi

ne O

S (A

ZT, g

en o

f Ret

rovi

r O

S)

1 R

TI

10 m

g/m

l sus

pens

ion

240

ml/

btl (

8 oz

) 8

bottl

es

N/A

***

NO

TE

***

Cur

rent

ly, a

clie

nt m

ay r

ecei

ve a

tota

l of 4

ant

iretr

ovir

als

(RT

I’s, N

RT

I’s, P

I’s, E

I’s o

r N

NR

TI’s

) ab

ove

per

mo

nth,

with

Com

bivi

r, T

ruva

da a

nd E

mtr

iva

each

cou

ntin

g as

2 m

edic

atio

ns, a

nd T

riziv

ir an

d A

trip

la c

ount

ing

as 3

med

icat

ions

. U

nder

sp

ecifi

c ci

rcum

stan

ces,

a 5

-dru

g an

tiret

rovi

ral c

ombo

may

be

allo

wed

in w

hich

Nor

vir

is u

sed

as a

boo

stin

g ag

ent,

and

may

req

uire

TH

MP

con

sulta

tion

prio

r to

app

rova

l.

Antir

etro

vira

l Med

icat

ion

Cla

ss C

odin

g (a

bove

)

EI

Entry

Inhi

bito

r II

Inte

gras

e In

hibi

tor

RTI

R

ever

se T

rans

crip

tase

Inhi

bito

r

PI

Prot

ease

Inhi

bito

r N

NR

TI

Non

-Nuc

leos

ide

Rev

erse

Tra

nscr

ipta

se In

hibi

tor

NR

TI

Nuc

leot

ide

Rev

erse

Tra

nscr

ipta

se In

hibi

tor

STR

Si

ngle

Tab

let A

ntire

trovi

ral R

egim

en

Opp

ortu

nist

ic In

fect

ion

Med

icat

ion

Cla

ss C

odin

g (b

elow

) PC

P Pn

eum

ocys

tis C

arin

ii Pn

eum

onia

O

I O

ppor

tuni

stic

Infe

ctio

n

OPP

OR

TUN

ISTI

C IN

FEC

TIO

N M

EDIC

ATIO

NS

Dru

g N

ame

Prio

rity

Cla

ss

Stre

ngth

/For

m

Per U

nit

MAX

Qty

/30-

day

scrip

t M

AX Q

ty/9

0-da

y sc

ript

Not

es

acyc

lovi

r 2

OI

200

mg

caps

ules

10

0/bt

l *

200

caps

ules

N

/A

NO

TE

: acy

clov

ir m

ay n

ot b

e av

aila

ble

in a

ll st

reng

ths

due

to

man

ufac

ture

r sh

orta

ges.

T

HM

P p

rovi

des

eith

er a

cycl

ovir

or

Val

trex

(va

lacy

clov

ir) e

ach

mon

th.

acyc

lovi

r 2

OI

400

mg

tabl

ets

100/

btl *

20

0 ta

blet

s N

/A

acyc

lovi

r (cu

rrent

ly u

nava

ilabl

e)

2 O

I 80

0 m

g ta

bs (c

urre

ntly

una

vaila

ble)

10

0/bt

l *

200

tabl

ets

N/A

azith

rom

ycin

2

OI

250

mg

tabl

ets

30/b

tl 60

tabl

ets

N/A

T

HM

P p

rovi

des

eith

er a

zith

rom

ycin

or

clar

ithro

myc

in.

*M

ust b

e di

spen

sed

in fu

ll bo

ttle

amou

nts.

Ple

ase

prov

ide

# da

yssu

pply

the

bottl

e w

ill la

st w

ith e

ach

orde

r.az

ithro

myc

in

2 O

I 60

0 m

g ta

blet

s 30

/btl

* 30

tabl

ets

N/A

clar

ithro

myc

in

2 O

I 50

0 m

g ta

blet

s 60

/btl

60 ta

blet

s 18

0 ta

blet

s T

HM

P p

rovi

des

eith

er a

zith

rom

ycin

or

clar

ithro

myc

in.

Clin

dam

ycin

3

OI

150m

g ca

psul

es

100/

btl

100

caps

ules

N

/A

Clin

dam

ycin

3

OI

300

mg

caps

ules

10

0/bt

l 10

0 ca

psul

es

300

caps

ules

C

lotri

maz

ole

Troc

he

3 O

I 10

mg

loze

nges

70

/btl

70 lo

zeng

es

N/A

da

pson

e 1

PCP

25 m

g ta

blet

s 30

/btl

90 ta

blet

s N

/A

TH

MP

pro

vide

s ei

ther

dap

sone

, N

ebup

ent o

r S

MZ

-TM

P.

daps

one

1 PC

P 10

0 m

g ta

blet

s 30

/btl

60 ta

blet

s N

/A

dara

prim

3

OI

25 m

g ta

blet

s 10

0btl

*

100

tabl

ets

N/A

*

Mus

t be

disp

ense

d in

full

bottl

e am

ount

s. P

leas

e pr

ovid

e #

days

supp

ly th

e bo

ttle

will

last

with

eac

h or

der.

Egrif

ta (t

esam

orel

in a

ceta

te P

/F)

3 O

I 1

mg

vial

s 60

vl/b

ox

1 bo

x N

/A

etha

mbu

tol

2 O

I 40

0 m

g ta

blet

s 10

0/bt

l *

100

tabl

ets

N/A

*

Mus

t be

disp

ense

d in

full

bottl

e am

ount

s. P

leas

e pr

ovid

e #

days

supp

ly th

e bo

ttle

will

last

with

eac

h or

der.

Epcl

usa

3 O

I 40

0 m

g/10

0 m

g ta

blet

s 28

/btl

28 ta

blet

s N

/A

Fam

cicl

ovir

3 O

I 25

0 m

g ta

blet

s 30

/btl

60 ta

blet

s 18

0 ta

blet

s Fa

mci

clov

ir 3

OI

500

mg

tabl

ets

30/b

tl 60

tabl

ets

180

tabl

ets

fluco

nazo

le

2 O

I 50

mg

tabl

ets

30/b

tl 12

0 ta

blet

s N

/A

fluco

nazo

le

2 O

I 10

0 m

g ta

blet

s 30

/btl

120

tabl

ets

480

tabl

ets

fluco

nazo

le

2 O

I 20

0 m

g ta

blet

s 30

/btl

120

tabl

ets

480

tabl

ets

Gyn

azol

e-1

(but

ocon

azol

e) 2

%

3 O

I 5

gm c

ream

1

tube

1

tube

N

/A

Ison

iazi

d 3

OI

50m

g/m

l Syr

up

1 bt

l 1

btl

N/A

Is

onia

zid

3 O

I 10

0 m

g ta

blet

s 10

0/bt

l 10

0 ta

blet

s N

/A

Ison

iazi

d 3

OI

300

mg

tabl

ets

30/b

tl 30

tabl

ets

N/A

leuc

ovor

in

3 O

I 10

mg

tabl

ets

24/b

tl *

48

tabl

ets

N/A

*

Mus

t be

disp

ense

d in

full

bottl

e am

ount

s. P

leas

e pr

ovid

e #

days

leuc

ovor

in

3 O

I 25

mg

tabl

ets

25/b

tl *

50

tabl

ets

N/A

su

pply

the

bottl

e w

ill la

st w

ith e

ach

orde

r.

meg

este

rol a

ceta

te O

S

3 O

I 40

mg/

ml s

uspe

nsio

n 24

0 m

l/btl

(8 o

z) *

3 bo

ttles

N

/A

*M

ust b

e di

spen

sed

in fu

ll bo

ttle

amou

nts.

Ple

ase

prov

ide

# da

yssu

pply

the

bottl

e w

ill la

st w

ith e

ach

orde

r.

Mep

ron

OS

(ato

vaqu

one)

3

OI

750

mg/

5ml s

uspe

nsio

n 21

0 m

l/btl

(7 o

z)

2 bo

ttles

N

/A

Mon

ista

t-1 (t

ioco

nazo

le) 6

.5%

3

OI

4.6

gm c

ream

1

tube

1

tube

N

/A

Myc

obut

in (r

ifabu

tin)

2 O

I 15

0 m

g ca

psul

es

100/

btl *

10

0 ca

psul

es

N/A

*

Mus

t be

disp

ense

d in

full

bottl

e am

ount

s. P

leas

e pr

ovid

e #

days

supp

ly th

e bo

ttle

will

last

with

eac

h or

der.

Myt

esi (

crof

elem

er)

3 O

I 12

5 m

g ta

blet

s 60

/btl

60 ta

blet

s 18

0 ta

blet

s N

ebup

ent (

pent

amid

ine)

1

PCP

300

mg

vial

for i

nhal

atio

n 1

vial

1

vial

N

/A

TH

MP

pro

vide

s ei

ther

dap

sone

, N

ebup

ent o

r S

MZ

-TM

P.

Ora

vig

Bucc

al (m

icon

azol

e bu

ccal

) 3

OI

50 m

g ta

blet

s 14

/btl

28 ta

blet

s N

/A

Pred

niso

ne

3 O

I 10

mg

tabl

ets

100/

btl

100

tabl

ets

N/A

Pr

imaq

uine

Pho

spha

te

3 O

I 26

.3 m

g ta

blet

s 10

0/bt

l 10

0 ta

blet

s N

/A

Rifa

mpi

n 3

OI

150

mg

caps

ules

30

/btl

60 c

apsu

les

N/A

R

ifam

pin

3 O

I 30

0 m

g ca

psul

es

60/b

tl 60

cap

sule

s N

/A

SMZ-

TMP

DS

1 PC

P 80

0/16

0 m

g ta

blet

s 10

0/bt

l *

200

tabl

ets

N/A

T

HM

P p

rovi

des

eith

er d

apso

ne, N

ebup

ent o

r S

MZ

-TM

P.

*M

ust b

e di

spen

sed

in fu

ll bo

ttle

amou

nts.

Ple

ase

prov

ide

# da

yssu

pply

the

bottl

e w

ill la

st w

ith e

ach

orde

r.SM

Z-TM

P O

S 1

PCP

200m

g/40

mg/

5ml s

uspe

nsio

n 47

3 m

l/btl

(1 p

t) *

2 bo

ttles

N

/A

Spor

anox

(itra

cona

zole

) 2

OI

100

mg

caps

ules

30

/btl

120

caps

ules

48

0 ca

psul

es

Spo

rano

x is

ava

ilab

le in

gen

eric

form

, but

is c

urre

ntly

che

aper

to

disp

ense

bra

nd n

ame.

*

Mus

t be

disp

ense

d in

full

bottl

e am

ount

s. P

leas

e pr

ovid

e #

days

supp

ly th

e bo

ttle

will

last

with

eac

h or

der.

Spor

anox

OS

(itra

cona

zole

) 2

OI

10 m

g/m

l sus

pens

ion

150

ml/b

tl (5

oz)

* 4

bottl

es

N/A

Sulfa

diaz

ine

3 O

I 50

0 m

g ta

blet

s 10

0/bt

l 10

0 ta

blet

s 30

0 ta

blet

s Te

rcon

azol

e-3

0.8%

3

OI

20 g

m c

ream

1

tube

1

tube

N

/A

Terc

onaz

ole-

7 0.

4%

3 O

I 45

gm

cre

am

1 tu

be

1 tu

be

N/A

Valc

yte

(val

ganc

iclo

vir)

2

OI

450

mg

tabl

ets

60/b

tl 60

tabl

ets

120

1st m

onth

in

duct

ion

dose

180

tabl

ets

(exc

lude

s fir

st

mon

th in

duct

ion

dose

) Va

ltrex

(val

acyc

lovi

r)

2 O

I 50

0 m

g ca

psul

es

30/b

tl 60

cap

sule

s 18

0 ca

psul

es

TH

MP

pro

vide

s ei

ther

acy

clov

ir o

r V

altr

ex (

vala

cycl

ovir)

eac

h m

onth

. Va

ltrex

(val

acyc

lovi

r)

2 O

I 1

gm c

apsu

les

30/b

tl 60

cap

sule

s 18

0 ca

psul

es

Vfen

d O

/Sol

(vor

icon

azol

e)

3 O

I 40

mg/

ml s

olut

ion

75 m

l/bot

tle

1 bo

ttle

N/A

Vo

ricon

azol

e O

S

3 O

I 40

mg/

ml s

olut

ion

75 m

l/bot

tle

1 bo

ttle

N/A

Vo

ricon

azol

e 3

OI

50 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

Voric

onaz

ole

3 O

I 20

0 m

g ta

blet

s 30

/btl

30 ta

blet

s 90

tabl

ets

OPP

OR

TUN

ISTI

C IN

FEC

TIO

N M

EDIC

ATIO

NS

(with

ava

ilabi

lity

issu

es)

*** N

OTE

***

Due

to is

sues

con

cern

ing

prod

uct a

vaila

bilit

y, p

leas

e co

ntac

t the

THM

P di

rect

ly s

houl

d a

patie

nt w

ish

to o

btai

n th

e fo

llow

ing

med

s: IV

gan

cicl

ovir,

inte

rfer

on-a

lpha

, am

phot

eric

in-B

, IVI

G, o

r N

ysta

tin s

uspe

nsio

n. I

f ava

ilabl

e, s

tren

gths

& m

ax q

uant

ities

for t

hose

med

s ar

e lis

ted

belo

w.

Dru

g N

ame

Prio

rity

Cla

ss

Stre

ngth

/For

m

Per U

nit

MAX

Qty

/30-

day

scrip

t M

AX Q

ty/9

0-da

y sc

ript

Not

es

Amph

oter

icin

-B

3 O

I 50

mg

vial

1

x 50

mg

vial

50

via

ls

N/A

Cyt

oven

e I.V

. (ga

ncic

lovi

r)

3 O

I 50

0 m

g vi

al

10 m

l/vl,

25 v

l/cs

50 v

ials

N

/A

Inte

rfero

n-al

pha

3 O

I 18

mu

vial

3

ml/v

ial

50 v

ials

N

/A

IVIG

(for

ped

iatri

c us

age)

3

OI

2.5

gm v

ial

2.5

gm v

ial

4 vi

als

N/A

IV

IG (f

or p

edia

tric

usag

e)

3 O

I 5

gm v

ial

5 gm

via

l 4

vial

s N

/A

Nys

tatin

Sus

3

OI

16oz

/473

ml,

100K

uni

ts/m

l 16

oz/

bottl

e 1

bottl

e N

/A

HC

V D

IREC

T-AC

TIN

G A

NTI

VIR

AL M

EDIC

ATIO

NS

*** N

OTE

*** T

hese

med

icat

ions

requ

ire a

sep

arat

e M

edic

al C

ertif

icat

ion

Form

.

Dru

g N

ame

Prio

rity

Cla

ss

Stre

ngth

/For

m

Per U

nit

MAX

Qty

/30-

day

scrip

t M

AX Q

ty/9

0-da

y sc

ript

Not

es

Dak

linza

(dac

lats

avir)

3

OI

30 m

g ta

blet

s 28

/btl

28 ta

blet

s N

/A

Dak

linza

(dac

lats

avir)

3

OI

60 m

g ta

blet

s 28

/btl

28 ta

blet

s N

/A

Dak

linza

(dac

lats

avir)

3

OI

90 m

g ta

blet

s 28

/btl

28 ta

blet

s N

/A

Epcl

usa

(sof

osbu

vir/v

elpa

tasv

ir)

3 O

I 40

0 m

g/10

0 m

g ta

blet

s 28

/btl

28 ta

blet

s N

/A

Har

voni

(led

ipas

vir/s

ofos

buvi

r)

3 O

I 90

mg/

400

mg

tabl

ets

28/b

tl 28

tabl

ets

N/A

M

avyr

et (g

leca

prev

ir/pi

bren

tasv

ir)

3 O

I 10

0 m

g/40

mg

tabl

ets

84/b

tl 84

tabl

ets

N/A

R

ibav

arin

3

OI

200%

cap

sule

s 84

/btl

252

caps

ules

(3 b

tl)

N/A

So

vald

i (so

fosb

uvir)

3

OI

400

mg

tabl

ets

28/b

tl 28

tabl

ets

N/A

Te

chni

vie

(om

bita

svir/

parit

apre

vir/r

itona

vir)

3

OI

12.5

mg/

75 m

g ta

blet

s 58

/btl

58 ta

blet

s N

/A

Viek

ira X

R P

AK

(om

bita

svir/

parit

apre

vir/r

itona

vir a

nd

dasa

buvi

r) 3

OI

200/

8.5/

33 m

g ta

blet

s 84

/btl

84 ta

blet

s N

/A

Vose

vi

(sof

osbu

vir/v

elpa

tasv

ir/vo

xila

prev

ir)

3 O

I 40

0 m

g/10

0 m

g/10

0 m

g ta

blet

s 28

/btl

28 ta

blet

s N

/A

Zepa

tier (

elba

svir/

graz

opre

vir)

3

OI

1% ta

blet

s 28

/btl

28 ta

blet

s N

/A

(Rev

ised

Oct

ober

201

8)

Eligibility and Enrollment for Hepatitis C-AIDS Drug Assistance Program

Eligibility

Eligibility will be restricted to those who meet the following qualifications:

• Age 18 or older

• Co-infected with chronic HCV genotype 1, 2, 3, 4 or 5 and HIV, with a certification from

their medical provider indicating the client is a good candidate for HCV treatment

• Negative pregnancy test, if applicable

• Prescriber must be experienced in HCV care or treating in collaboration with a specialist

in HCV care, agree to monitor patient during the treatment, and maintain an appropriate

treatment plan

• Income-eligible for participation in the ADAP (income at or less than 200 percent of

federal poverty level)

• Actively filling HIV medication prescriptions

• Review for other funding sources including Medicare, Medicaid, VA, Private Insurance,

and Pharmaceutical company Patient Assistance Programs (PAP)

• The client’s medical provider is willing to share follow-up data and documentation on the

enrolled patient at 12-week intervals

*Note: Genotype 5 Sovaldi, Ribavirin requires Peg Interferon not offered HCV DAA ADAP formulary

Eligibility will be denied or the client will be dis-enrolled for the following reasons:

• Patient has previously failed to complete therapy with DAA for HCV due to patient non-

adherence to therapy due to substance abuse and required enrollment in treatment

program has failed.

• Patient is non-adherent to therapy for more than 7 days

• Insufficient resources to procure DAA

• Exceptions will be considered for circumstances beyond the prescriber or patient’s

control

Enrollment Process

Community education about the ADAP for HIV and HCV (ADAP-HCV) co-infected individuals

will begin with the Administrative Agencies. The Administrative Agencies are regional agencies

that administer HIV funds to local organizations offering care and supportive services. Through

a series of webinars and emails, the Administrative Agencies and their funded community

agencies will learn how to identify those clients who are appropriate for the pilot program. All

ADAP-HCV pilot documents will be available online to facilitate program application. The

THMP application, used for initial eligibility and recertification, will be revised to ask clients

about their HCV status and if they wish to be considered for the ADAP-HCV program. This will

allow for those clients currently on the ADAP program to receive HCV treatment. Clients

considered for the program will receive a special Medical Certification Form (MCF) specific to

HCV DAAs that they will need to fill out with their medical doctor (see attachment 1).

A-50

The THMP Eligibility Specialist will work with community agencies and the client to enroll

each eligible client into the ADAP-HCV. The medical provider will be followed up with at 12

and 24 weeks to determine treatment effectiveness.

Effective November 1, 2017

A-51

TEXAS HIV MEDICATION PROGRAM (THMP) HCV DIRECT-ACTING ANTIVIRAL MEDICAL CERTIFICATION FORM

(TO BE COMPLETED BY PHYSICIAN) Texas HIV Medication Code (if known) The information on this form is necessary to determine the patient’s eligibility for program-supplied, HIV-related therapy as prescribed by you. All information on this form will be kept strictly confidential by the Department of State Health Services. Personal identifying information is never released.

PATIENT INFORMATION

Full Name:

Mailing Address: Apt. #

City, State, Zip: Phone # ( )

Date of Birth: / / Social Security Number: Month Day Year

***This form is intended as a supplement to the standard THMP Medical Certification Form and should be submitted only if HCV DAAs are being requested for your patient. ***

PRESCRIBED HCV DAAs (Note that this program only covers the HCV DAAs listed below):

DAKLINZA (daclatasvir) 30 mg/day -OR- 60 mg/day -OR- 90 mg/day 12 weeks -OR- 24 weeks

EPCLUSA (sofosbuvir/velpatasvir) 12 weeks

HARVONI (ledipasvir/sofosbuvir) 12 weeks

MAVYRET (glecaprevir/pibrentasvir) 8 weeks 12 weeks 16 weeks

Ribavirin (specify daily dosage) 800 mg/day 1000 mg/day 1200 mg/day 1400 mg/day

SOVALDI (sofosbuvir) * 12 weeks 16 weeks 24 weeks

TECHNIVIE (ombitasvir/paritaprevir/ritonavir) 12 weeks

VIEKIRA XR (ombitasvir-paritaprevir-ritonavir and dasabuvir) 12 weeks 24 weeks

VOSEVI (sofosbuvir/velpatas/voxilaprevir) 12 weeks

ZEPATIER (elbasvir-grazoprevir) 12 weeks 16 weeks (concluded on next page)

A-52

By signing this form, I certify that the following is true:

1. I am experienced in HCV care or am treating HCV in collaboration with a specialist in HCV care.2. I attest that this patient has not previously failed to complete therapy with DAA for HCV due to patient non-

adherence to therapy.3. I attest that this patient does not have any contraindications to the prescribed DAA and/or is not taking a

medication that is contraindicated with the prescribed DAA.4. I attest that this patient is competent and willing to be treated and adhere to treatment guidelines, including

receiving required laboratory tests.5. If ribavirin is prescribed, I attest that this patient is not pregnant (if female) or (if male) does not have a female

partner who is pregnant. I attest that my patient is aware that Ribavirin may cause birth defects and/or death of theexposed fetus and that extreme care must be taken to avoid pregnancy in female patients and in female partnersof male patients. My patient has been instructed to use at least two forms of effective contraception duringtreatment and for six months after treatment has been stopped. For female patients, I will perform pregnancytesting monthly during ribavirin tablet therapy and for six months after therapy has stopped.

6. I agree to monitor the recommended clinical and laboratory parameters before, during and after treatment, and asclinically indicated.

7. I agree to maintain an appropriate treatment plan for this patient.8. I understand that I must notify the THMP program if the patient is non-adherent to therapy for more than seven

days, and that eligibility will be suspended if this happens.9. This patient is not currently receiving HCV DAAs through a Pharmacy Assistance Program (PAP).

In order to assess the effectiveness of this medication, we must receive follow-up data and documentation on enrolled patients. Please provide contact information for your office so we may follow up on treatment progress at 8 weeks periodically. Please note that an inability to respond to program inquiries may result in the discontinuation of HCV DAAs through this program.

Person in your office to contact: ___________________________________________________________

Best day/time to call:

Eligibility will be denied or the client will be dis-enrolled for the following reasons: • Patient has previously failed to complete therapy with DAA for HCV due to patient nonadherence to

therapy.• Patient is non-adherent to therapy for more than seven days• Insufficient resources to procure DAA (limited funds are available for HCV DAA treatment pilot)• Exceptions will be considered for circumstances beyond the prescriber or patient’s control.

By signing this form, I attest that this patient is a medically suitable candidate for HCV DAA treatment:

PHYSICIAN SIGNATURE: TX MD/DO LICENSE #:

PRINTED NAME OF PHYSICIAN:

OFFICE ADDRESS:

TELEPHONE: DATE / /

Texas HIV Medication Program, ATTN: MSJA – MC 1873, PO Box 149347, Austin, TX 78714-9347

(4/2018)

A-53

TEXAS HIV MEDICATION PROGRAM MEDICAL CERTIFICATION FORM

(TO BE COMPLETED BY PHYSICIAN) Texas HIV Medication Code (if known): ____________________

The information requested is necessary to determine the patient’s eligibility for program-supplied, HIV-related therapy as prescribed by you. All information requested will be kept strictly confidential by the Texas Department of State Health Services; personal identifying info is never released.

*** Both pages are required. *** PATIENT INFORMATION

Full Name: ___________________________________________________________________________________________

Mailing Address: _________________________________ Apt. #: ______________________________________________

City, State, Zip: ____________________________ Phone with area code: ________________________________________

Date of Birth (MM/DD/YY): __________________ Social Security Number: _______________________________________

Requested Pharmacy: ________________________________________________________________________________

I hereby certify that this patient has been diagnosed with HIV infection, and I am reporting the following viral load and CD4 count:

Plasma RNA Viral Load:

copies/ml

Test Date:

/ / Current CD4 Count: Test Date:

/ /

In the sections below, mark the appropriate box to specify supply quantity for each medication prescribed. Black-filled boxes indicate the medication is not eligible for a 90-day supply. Some medication strengths or formulations are excluded from 90-day availability based on minimal demand. Please refer to the THMP Medication Formulary and Maximum Quantities Table for more details.

I certify that this patient is being prescribed the following medications (eligibility criteria for each drug is detailed in the THMP Program Guidelines):

Quantity Prescribed (days)

Quantity Prescribed

(days)

Quantity Prescribed

(days) 90 30 90 30 90 30 Dapsone OR pentamidine OR SMZ/TMP (choose one) Acyclovir OR famciclovir OR Valacyclovir (choose one) Gynazole (butoconazole) OR Monistat (tioconazole) OR terconazole topical creams Azithromycin OR Clarithromycin (choose one) atovaquone (Mepron) clindamycin Ethambutol clotrimazole troche lozenges Fluconazole isoniazid Itraconazole nystatin oral suspension leucovorin calcium tablets (provide RX dosage details) Oravig (miconazole buccal tablets) megesterol acetate oral suspension prednisone pyrimethamine (Daraprim) primaquine phosphate Rifabutin rifampin valganciclovir (Valcyte) sulfadiazine Egrifta (tesamorelin acetate P/F) voriconazole Mytesi (crofelemer)

*** Continue to next page. Both pages are required. ***

A-54

https://www.dshs.texas.gov/hivstd/meds/files/formulary.pdf

*** Continued from previous page. Both pages are required. *** PRESCRIBED ANTIRETROVIRALS: MONTHLY CLIENT LIMIT OF FOUR ANTIRETROVIRALS (ARVs)

Quantity Prescribed (days)

Quantity Prescribed

(days) 90 30 90 30 abacavir (Ziagen)* invirase (Saquinavir) atazanavir (Reyataz) Isentress (raltegravir) Atripla (Sustiva/Truvada)* Isentress HD (raltegravir) Biktarvy (bictegravir/emtricitabine/tenofovir) Juluca (dolutegravir/rilpivirine)* cobicistat (Tybost) lamivudine (3TC) Combivir (AZT/3TC)* lopinavir/ritonavir (Kaletra)

Complera (Edurant/Truvada)* maraviroc (Selzentry) – CCR5 monotropism proof via assay must be attached.

darunavir (Prezista) nelfinavir (Viracept) delavirdine (Rescriptor) nevirapine (Viramune XR) Descovy (Emtriva/Viread TAF)* Odefsey (Edurant/Emtriva/Viread TAF)* didanosine (DDI EC) Prezcobix (Prezista/Tybost)* dolutegravir (Tivicay) rilpivirine (Edurant)

efavirenz (Sustiva)

ritonavir (Norvir) 90-day supply may not exceed 360 tablets

elvitegravir (Vitekta) stavudine (D4T) emtrictabine (Emtriva) Stribild (Vitekta/Tybost/Emtriva/Viread TDF)* enfuvirtide (Fuzeon) Symtuza (darunavir/cobicistat/emtricitabine/tenofovir)* Epzicom (abacavir/3TC)* tenofovir (Viread TDF)

etravirine (Intelence) –For treatment experienced w/viral resistance/toxicity to ARV agents tipranavir (Aptivus)

Evotaz (Reyataz/Tybost)* Triumeq (Tivicay/abacavir/3TC)*

fosamprenavir (Lexiva)-if unboosted dosage, written justification from physician required Trizivir (AZT/abacavir/3TC)*

Genvoya (Vitekta/Tybost/Emtriva/Viread TAF)* Truvada (Emtriva/Viread TDF)* indinavir (Crixivan) zidovudine (AZT) *Note: Combivir, Descovy, Evotaz, Epzicom, Prezcobix, Truvada & Juluca each count as 2 ARVs; Atripla, Complera, Odefsey, Trizivir,Triumeq & Biktarvy each count as 3 ARVs; Stribild, Symtuza, and Genvoya each count as 4 ARVs. HLA-B*5701 test result of negative isrequired for treatment-naïve patients starting medications that contain abacavir (Ziagen, Epzicom, Trizivir or Triumeq).

PHYSICIAN SIGNATURE: ______________________________________ TX MD/DO LICENSE #:____________________

PRINTED NAME OF PHYSICIAN: ________________________________________________________________________

OFFICE ADDRESS: ___________________________________________________________________________________

TELEPHONE:_______ ____________ FAX:__________________DATE (MM/DD/YY): ______________________________

***NOTICE*** Changes in therapy after initial approval and/or recertification may be faxed to (512) 533-3178.

If this form is completed as part of an initial program application or recertification, it should be submitted together with all requested documentation by fax (512-533-3178) or mailed to:

Texas HIV Medication Program ATTN: MSJA - MC1873 PO Box 149347 Austin, TX 78714-9347

A-55