 |  Appendix 3 | APPENDIX 4 : STATE ADAP PROGRAM ELIGIBILITY |  Appendix 5 |
| Appendix 3 | APPENDIX 4 : STATE ADAP PROGRAM ELIGIBILITY | Appendix 5 |
| State | Financial Eligibility | Medical Eligibility |
|---|---|---|
| Alabama | Income at or below 250% of Federal Poverty Level. No third party insurance that pays for more than 50% of the cost of covered medications. | HIV+, CD4 <500 (CD4 count requirement is waived for pregnant women and neonates). |
| Alaska | Income at or below 200% of Federal Poverty Guidelines for Alaska. | HIV+ and licensed practitionerís prescription. |
| Arizona | Income at or below 200% of Federal Poverty Level. | HIV+ |
| Arkansas | Based on annual income, less medical expenses. Income at or below 100% of Federal Poverty Level. Can usually cover any uninsured person until insurance begins. | HIV+ and a doctorís prescription. |
| California | Income at or below 400% of Federal Poverty Level. If above, must make a sliding scale co-payment based on annual state income tax liability & family size up to annual earnings of $50,000, applicant's health insurance does not provide drugs as a benefit or the co-payment plan is causing financial hardship or you cannot be enrolled in HMO, health insurance programs or public programs. | HIV + or AIDS diagnosis, over 18yrs of age, prescription for a covered drug from a CA licensed physician. |
| Colorado | Annual income at or below 185% of Federal Poverty Level. | HIV + and doctorís prescription. |
| Connecticut | Total annual net income less than 300% of Federal Poverty Level. No asset limitations. | Certification from doctor of HIV+ status and prescription. |
| Delaware | 230% of Federal Poverty Level, no co-pay. Sliding scale/co-payments: 231%-300% FPL = 7% co-payment, 300% + = 10% co-payment. Co-payments are for cost of service and total allowable annual charges cannot exceed either 7% or 10% of gross income, depending on the co-pay. | HIV+ |
| District of Columbia | Income at or below 300% of Federal Poverty Level. | HIV+ |
| Florida | Income at or below 200% of Federal Poverty Level. Enrollees with incomes 100%-200% of FPL are assessed for co-payments according to a sliding fee scale. | CD4 <500: this requirement can be waived. Documentation required: HIV status, CD4 count, financial statement & enrollment form. |
| Georgia | 125% of Federal Poverty Level. | HIV diagnosis and CD4<500. |
| Hawaii | 400% of Federal Poverty Level set for Hawaii. Assets <$10,000 excluding home & car. | HIV+ |
| Idaho | 400% of Federal Poverty Level. | HIV+, CD4 <500. |
| Illinois | Income at or below 200% of Federal Poverty Level; insurance provides less than 80% of cost of prescription medication. | HIV+ |
| Indiana | Indiana residency requirement and income at or below 300% of Federal Poverty Level. | HIV+, CD4 <500. When protease inhibitors are added, there may be additional CD4 count and viral load requirements. |
| Iowa | Income at or below 200% of the Federal Poverty Level. | HIV+, recent CD4 count. |
| Kansas | 300% of Federal Poverty Level - will assist with spend down. | Doctorís certification of HIV status. |
| Kentucky | Income at or below 300% of Federal Poverty Level, adjusted for family size. Cash assets of less than $10,000. Access to protease inhibitors requires income at or below 200% of FPL, adjusted for family size. (currently no asset limit for access to protease inhibitors; should be added within 1-3 months). | HIV+, CD4 <550 or history of cytologically-confirmed PCP with an exception made for pregnant women needing AZT for preventing perinatal transmission. |
| Louisiana | Income at or below 200% of Federal Poverty Level. Assets less than $4,000 (not including home or car). Not qualified for Medicaid or private insurance. | HIV+. Recent viral load test result. Able to discontinue contraindicated medications. |
| Maine | Income at or below 200% of Federal Poverty Level. | HIV+, CD4 <400 or viral load >20,000. |
| Maryland | Annual gross income at or below $29,400, adjusted for household size. Sliding scale/ co-payments for incomes over $26,000. | HIV+, prescription for a covered drug. |
| Massachusetts | <$27,000 net annual income, limit raised by $2,200 for each dependent. Massachusetts residency required. | HIV+ |
| Michigan | Income at or below 185% of Federal Poverty Level. Must have applied for Medicaid within the past 60 days and have pending or denial status. Not eligible for Veterans Administration benefits. Michigan resident. | HIV diagnosis and <500 CD4. No CD4 count requirement for pregnant women. |
| Minnesota | Income at or below 300% of Federal Poverty Level. Liquid assets less than $25,000 (not including home and car). Minnesota residency. Uninsured or responsible for >/= 20% of prescription cost or >/= $15.00 per prescription. Canít be in State Medical Assistance or GA Medical Care Programs. | HIV+ and doctorís prescription. |
| Mississippi | Total household income below 200% of Federal Poverty Level. | HIV+, CD4 <500 or viral load >30,000. |
| Missouri | Income at or below 185% of Federal Poverty Level. Missouri residency. | HIV+ |
| Montana | Applicant must provide evidence that the cost of the covered medications will create a severe financial burden on his/her household. | HIV+, prescription for a covered medication. |
| Nebraska | Income at or below 200% of Federal Poverty Level. | HIV+ |
| Nevada | Income at or below 200% of Federal Poverty Level. Less than $4,000 in assets (car & residence not counted). | HIV+, CD4 count <500 (exception for pregnant women and neonates). |
| New Hampshire | Income at or below 300% of Federal Poverty Level (income limit may be adjusted based on medical expenses incurred). | HIV+ |
| New Jersey | Annual income at or below $30,000 for one person. Limit increased by $10,000 for each member of household up to $70,000 per year. Must be NJ resident. | HIV+, doctorís certification that applicant needs medication. |
| New Mexico | Income at or below 300% of Federal Poverty Level, adjusted for family size. Liquid assets of less than $10,000. | HIV+ |
| New York | Income: <$44,000 for a household of one, <$59,200 for two, <$74,400 for three +; liquid assets <$25,000. New York state residency. | ADAP & ADAP Plus: HIV+. Home Care: AIDS or HIV illness and chronic medical dependency due to physical or cognitive impairment from HIV infection. |
| North Carolina | Net annual income at or below 125% of Federal Poverty Level, effective April 1, 1997 (was 110% of FPL). | HIV+ |
| North Dakota | Income at or below 150% of Federal Poverty Level; above that there is a sliding scale: 150%-200% of FPL = 90% coverage, 200%+ of FPL = 80% coverage. | HIV+ |
| Ohio | Income at or below 281% of the Federal Poverty Level, currently <$1,410 per month after taxes (additional allowance for dependents). Ohio residency. | HIV+ |
| Oklahoma | Income at or below 150% of Federal Poverty Level (out-of-pocket drug costs can be taken into account to ìspend downî to this income limit). Oklahoma residency requirement | HIV+, doctorís prescription for a covered drug. |
| Oregon | Full coverage up to 235% of the Federal Poverty Level. Donation requested between 235-274% of FPL. Sliding scale for incomes between 274%-415% of FPL. Liquid assets under $20,000. | HIV+ |
| Pennsylvania | Gross annual income of less than $30,000 with an allowance of $2,480 for each additional family member. PA residency (not institutionalized). Social Security card. | Prescriptions for covered drugs. |
| Puerto Rico | Certified as medically indigent by the Medicaid program or limited/no coverage by a drug prescription plan, as documented by the state, health insurance plan, Consortia or Community-Based Organization. Guidelines for income are provided, starting at $400 per month for one person or $800 per month for one person depending which table you look at. | HIV+, CD4 <500 or viral load >10,000. |
| Rhode Island | Income at or below 400% of Federal Poverty Level. | HIV+ |
| South Carolina | Applicants at or below 300% of Federal Poverty Level qualify for free medications. A sliding fee scale is used to determine how much an applicant must pay if he or she is above this threshold. | HIV+, CD4 <500 (CD4 requirement waived for pregnant women/neonates and may be waived for other reasons on a case-by-case basis). |
| South Dakota | Income at or below 300% of Federal Poverty Level. | HIV+ and doctorís prescription. |
| Tennessee | Income at or below 300% of Federal Poverty Level. Liquid asset limit of $8,000. | HIV+ |
| Texas | 200% of Federal Poverty Level (if married, spouseís income is counted), Not eligible for Medicaid, or used up the months Medicaid pharmacy benefit. Co-payment of $5.00 per prescription may be required for non-Medicaid eligible clients. Current income guidelines: For 1 person - <$15,480 2 - <$20,720 3. $25,960 4. $31,200 , 5. $36,440 | HIV+. Meet the eligibility criteria for at least one of the drugs on the formulary. |
| Utah | 100% of Federal Poverty Level =full coverage. Sliding scale: 101%-150% of FPL = 1.5% co-pay required, 151%-200% = 3% co-pay, 201%-250% = 5%, 251%-300% = 10%, 301%-350% = 15%, 351%-400% = 20%, 401%-450% = 30%, 451%-500% = 40%, Over 501% = 50%. | HIV+ |
| Vermont | Income at or below 200% of Federal Poverty Level. Sliding scale/co-payments for incomes over 200% of FPL. In the process of being revised to make more generous. | HIV+ |
| Virginia | Income at or below 200% of Federal Poverty Level (residents of northern Virginia may have incomes up to $17,428). | HIV+, recent CD4 count and viral load. |
| Washington | Income at or below 370% of Federal Poverty Level. Assets of less than $10,000 (not including home and car)., | HIV+ |
| West Virginia | Income at or below 300% of Federal Poverty Level. | HIV+ |
| Wisconsin | 200% of Federal Poverty Level, Wisconsin State residency. Must have applied for coverage under, and have been denied eligibility for, medical assistance within 12 months prior to application. | HIV+. Physicianís indication of need for prescription. |
| Wyoming | Income at or below 300% of Federal Poverty Level. | HIV+ |
Appendix 3 |
Appendix 5 |
| Last modified: 7/19/97 The Network |
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