1.0 Purpose

This policy establishes eligibility requirements and allowable expenditures for the Texas HIV Medication Program Texas Insurance Assistance Programs (THMP-TIAPs), which include the Texas Insurance Assistance Program (TIAP) and TIAP-PLUS. The Texas Department of State Health Services (DSHS) Texas HIV Medication Program (THMP) funds the TIAPs.

This policy also provides guidance and requirements for enrollment in TIAPs for THMP applicants and participants with health insurance. It does not address eligibility requirements for public insurance programs or job-based coverage.

Factors that determine the best health insurance plan for a client and the final cost of the plan to a client are specific to each client and beyond the scope of this policy. Refer clients to subrecipient agencies to help them choose and enroll in other programs or purchase health insurance.
 

2.0 Authority

Texas Health and Safety Code, Chapter 85, Section 85.003; Ryan White Treatment Extension Act 2009; Health Resources and Services Administration (HRSA) Policy Clarification Notices (PCNs):

• HRSA PCN 13-01
• HRSA PCN 13-02
• HRSA PCN 13-03
• HRSA PCN 13-04
• HRSA PCN 16-02
• HRSA PCN 18-01
   

3.0 Background

The Ryan White HIV/AIDS Program (RWHAP) provides access to HIV-related outpatient and support services to low-income people. HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort, establishes the RWHAP Part B and state services funds available through DSHS as the payor of last resort. Similarly, the Public Health Service Act requires grantees to use funds awarded through all RWHAP Parts as payment of last resort (HRSA PCN 13-02).

THMP, as an AIDS Drug Assistance Program (ADAP), provides medications approved by the U.S. Food and Drug Administration (FDA) to low-income people living with HIV who have limited or no coverage from private insurance, Medicaid, or Medicare. THMP may purchase health insurance or pay medication copayments.

As an alternative to direct payment for medications, ADAPs can pay for health insurance premiums and medication cost-sharing (deductibles, co-payments, co-insurance costs, or a combination thereof for medications) for ADAP-enrolled clients with another payor. The intention is to preserve or purchase client health insurance as an alternative payment mechanism for medications.

For DSHS ADAP, the State Pharmaceutical Assistance Program (SPAP) assists with Medicare Part D (see HIV/STD Policy 700.005 – Medicare Part D). The TIAPs make health insurance assistance payments outside of Medicare.

The passage of the Patient Protection and Affordable Care Act (ACA) prohibits the exclusion of pre-existing conditions and eliminates limits on maximum insurance payments for a beneficiary's health care services. These changes make insurance more accessible and useful for people with chronic conditions like HIV. Eliminating exclusions for pre-existing conditions gives people living with HIV the choice and ability to change plans or pick up new insurance after gaps in coverage.

In response to the ACA, HRSA PCN 18-01 strengthens requirements that RWHAP grantees and their contractors vigorously pursue enrollment in health insurance for eligible clients. The cost of providing health insurance assistance must be cost-effective or lower than the cost of providing these health services through grant-supported direct delivery.
 

4.0 Definitions

Administrative Agency (AA) – A DSHS contractor that disburses DSHS funds via subcontractors (community agencies) to provide comprehensive services to people living with HIV within the service planning area.

Advance Premium Tax Credit (APTC) – An advance, refundable tax credit that eligible individuals and families can take to help them purchase health insurance through the Health Insurance Marketplace. 

Co-Insurance – A cost-sharing requirement that requires the insured to pay a percentage of costs for covered services or prescriptions (e.g., 10% of the prescription price).

Co-Payment – A cost-sharing requirement requiring the insured to pay a specified dollar amount for each service unit (e.g., $10 for each prescription dispensed).

Community Agency or AA Subcontractor – A local organization contracted by an AA to provide services for people living with HIV.

Deductible – A cost-sharing requirement that requires the insured to pay a certain amount for health care services or prescriptions before insurance covers these costs.

Job-Based or Employer-Based Insurance Coverage – A health insurance plan in which employees or family members are part of one group policy provided by their employers.

Open and Special Enrollment Periods – Specified times of the year when clients are eligible to purchase insurance on the Health Insurance Marketplace.

Out-of-Pocket (OOP) Costs – Expenses for health care not reimbursed by insurance, including deductibles, co-insurance, and co-payments for covered services, plus costs for services not covered.

Pharmacy Benefits Manager (PBM) – PBMs provide various services as third-party administrators that manage prescription drug benefits for various healthcare payers. For THMP, DSHS contracts a PBM to provide cost-sharing assistance to eligible participants of THMP programs. This includes coordinating the payments of deductibles, co-payments, and coinsurance; coordinating the payment of health insurance premiums; providing claims-level data; maintaining a network of pharmacies for third-party coordination of benefits; providing staff with electronic access to claims adjudication and participant enrollment; enacting internal controls to ensure that only approved, on-formulary medications are paid for and ensures that network pharmacies do not use 340B stock or file for pharmaceutical rebates for medications purchased under this program.

Premium – The amount paid by an insured person to an insurance company to keep their insurance policy.

Qualifying Event – A change in status that allows a person to change or purchase insurance outside of open enrollment periods (involuntary loss of insurance, becoming or gaining a dependent, marriage or divorce, etc.).

Supplemental Insurance – An insurance policy that covers expenses not covered by other insurance and requires a premium.

Texas HIV Medication Program Texas Insurance Assistance Programs (THMP-TIAPs) – Provide premium payments, medication deductible payment assistance, and medication copayment assistance for eligible insurance plan purchases. This includes TIAP and TIAP-PLUS.

Texas Insurance Assistance Program (TIAP) – Provides medication copayment and deductible assistance with eligible private or employer sponsored health insurance policies.

TIAP-PLUS – Provides premium payments, medication deductible payment assistance, and medication copayment assistance for eligible Marketplace or Off-Marketplace health insurance plan purchasing.

THMP-TIAPs Benchmark – The sum of the average ADAP expenditure and the average medical expenditure on covered clinical services, which is the total per client expenditure on directly delivered clinical services used for THMP-TIAPs and calculated annually (see HIV/STD Policy 270.001 – Calculation of Estimated Expenditures on Covered Clinical Services for the benchmark calculation description). THMP also considers rebate income generated from TIAPs when calculating cost-effectiveness. THMP allows participants currently in the program who do not meet the benchmark to continue the program if they have continuous enrollment.
 

5.0 People and Organizations Affected

• HIV Care and Medications Unit staff, specifically THMP staff
• DSHS-funded AAs and ADAP Liaisons
• Community Agencies and ADAP Enrollment Workers (AEWs)
• THMP applicants and participants
  
   

6.0 Responsibilities

6.1 THMP and TIAPs

THMP must enroll and maintain eligible THMP applicants and participants in THMP-TIAPs. THMP provides training and technical assistance to community agencies, especially AEWs, to ensure understanding of and enrollment in appropriate plans. THMP makes health insurance premium payments before each health insurance plan’s due date.
 

6.2 Community Agencies and AEWs

Community agencies ensure that AEWs or other agency staff screen every client for potential third-party payors or other assistance programs. This must take place before applying to THMP, during open enrollment, and after a qualifying event. Requirements for assessment of potential third-party payors and other assistance programs are in HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort.

After THMP deems program applicants eligible, AEWs may refer clients to assisters, certified organizations, and individuals trained and certified by the Marketplace to help with enrollment.

THMP publishes a pre-approved health insurance plan list each year. If a client requires medications, medical providers, or other assistance only available in a health insurance plan not on the THMP pre-approved list, they should send plan information to THMP. THMP staff will determine eligibility for the health insurance plan before plan enrollment.

AEWs must communicate with clients and other relevant community agencies to remind them to keep THMP informed of changes in insurance or other changes that might impact eligibility.

Patient Assistance Programs (PAPs) and Cost-Sharing Assistance Programs (CAPs) are not subject to the payor of last resort policy except for Local AIDS Pharmaceutical Assistance Programs (LPAPs).
 

6.3 Administrative Agencies and ADAP Liaisons

ADAP Liaisons ensure community agencies comply with this policy to ensure THMP is the payment of last resort.
 

6.4 THMP Applicants and Participants

People who apply for or want to continue participating in THMP, including the TIAPs, must provide complete applications, including renewal applications. They must meet the requirements of HIV/STD Policy 220.001 – Eligibility to Receive HIV Services. Clients enroll in qualifying health insurance and communicate changes in insurance or eligibility status to THMP, their AEW, or other agency staff who assist with the THMP application process. Applicants and participants have the right to refuse insurance and apply to THMP independently or with the assistance of a community agency.
 

7.0 Scope of THMP-TIAPs

TIAP covers health insurance deductibles, co-payments, and co-insurance payments related to medication expenses. TIAP-PLUS covers these payments plus health insurance premiums for eligible health insurance plans. THMP pays these expenses through a PBM. THMP participants must use a participating pharmacy.

THMP-TIAPs do not cover fines or tax obligations for clients. These programs do not cover OOP costs unrelated to medication cost-sharing, including outpatient health care deductibles or co-payments, inpatient hospitalization, or emergency department care. THMP ensures THMP-TIAPs cover only medication cost-sharing. THMP does not pay applicants or participants directly. THMP uses a PBM to pay premiums to insurance companies and OOP payments to pharmacies.

Per federal law, anyone who took an Advance Premium Tax Credit (APTC) on a marketplace health insurance plan must file a federal income tax return with form 8962 (Premium Tax Credit) to reconcile their federal taxes. TIAP-PLUS clients who took an APTC must follow this law. If the client underestimated their APTC amount, the IRS may send the client an overpayment refund. If the client overestimated their APTC amount, the IRS may send the client a bill, which THMP can pay. The client must send either the overpayment refund or the underpayment bill to THMP’s identified PBM. 
 

8.0 Expenditure on THMP and Covered Clinical Services as Benchmark for Cost Comparison

To evaluate the cost-effectiveness of health insurance, DSHS benchmarks state expenditures on clinical services typically covered by health insurance plans. THMP also considers rebate income in determining cost-effectiveness for THMP-TIAPs. A description of how DSHS estimates expenditures on covered clinical services is in HIV/STD Policy 270.001 – Calculation of Estimated Expenditures on Covered Clinical Services.
 

9.0 Client Eligibility for THMP-TIAPs

To be eligible for THMP-TIAPs, a person must meet THMP eligibility criteria in HIV/STD Policy 220.001 – Eligibility to Receive HIV Services, and have or get qualifying health insurance. Qualifying health insurance includes insurance that includes appropriate primary care services and at least one drug in each class of core antiretroviral therapeutics from the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Qualifying health insurance also includes a participating pharmacy convenient to the applicant.
  

10.0 Health Insurance Plan Eligibility for THMP-TIAPs

THMP-TIAPs cover plans on individual and group markets, including plans available through the Health Insurance Marketplace and job-related health insurance. THMP-TIAPs do not cover plans offering only catastrophic coverage, plans without a pharmacy benefit, or supplemental insurance that assists only with hospitalization.
 

11.0 Client Eligibility for THMP-TIAPs

Access to health insurance may be available to or currently carried by clients eligible for coverage due to their employment or membership in a group, such as a church, union, or professional organization. The person with the membership or employment that qualifies them for health insurance is the covered member or policyholder. The policyholder may be able to add dependents and a spouse or partner to their coverage. Access to health insurance is also available to uninsured persons through the Health Insurance Marketplace.

THMP-TIAPs only covers expenses associated with the eligible client. For example, if the client is a dependent of the policyholder, then TIAP-PLUS will only cover the premium costs of adding said dependent to the plan and the OOP medication expenses for the client. There is an exception to this practice. TIAP-PLUS will assist an eligible client with the entire cost of a group policy that includes coverage for people not eligible for THMP when the inability to cover these expenses would result in the eligible client losing health insurance.
 

12.0 Exception Process for Plans that Exceed Benchmark Costs

THMP-TIAPs only approve requests for health insurance assistance exceeding benchmark costs when circumstances exist that make financial support of health insurance necessary to preserve the health of the client. For example, a client may have significant co-morbidities that are costly to treat and, if left untreated, will limit the success of HIV treatment.
 

13.0 Cost Control Policies for THMP-TIAPs

13.1 Response to Lack of Funds

• If funding is limited, THMP may:
  
  Implement annual expenditure limits
• Lower financial eligibility criteria to a level not lower than 125 percent of the federal poverty level
• Stop enrolling new applicants and start a waiting list of eligible applicants
   

13.2 Restrictions on Off Formulary Payments

THMP-TIAPs do not cover health insurance when prescriptions for drugs have higher co-pays or co-insurance because they are outside the plan's formulary. These health insurance plans are not eligible for participation in THMP-TIAPs.

However, THMP-TIAPs will cover medications the participant’s health insurance plan covers after an appeals process or prior authorization.
 

13.3 Prohibition on the Use of Drug Manufacturer Co-Pay Assistance Cards and Other Programs to Reduce OOP Payments

Clients enrolled in THMP-TIAPs may not use drug manufacturer co-pay assistance cards for medications they receive through their health insurance while on THMP. Failure to adhere to this guidance and continued usage of drug manufacturer co-payment assistance will result in the removal of the client from THMP.
 

14.0 Guidance on Co-Pay Card Usage

Clients need to make sure their chosen pharmacy is in-network with both the primary insurance and in the THMP participating pharmacy network. When at the pharmacy, clients need to present both the THMP Co-Pay card and the primary insurance card. Failure to follow this guidance after two reminders from THMP will result in the removal of the client from the program.
 

15.0 Clients Disenrollment

Clients can request to disenroll from TIAP-PLUS any time. If a client is deceased, left Texas, no longer for eligible for services, or no longer requires THMP services, they will be disenrolled.
 

16.0 Revision History