AIDS TREATMENT NEWS Issue #305, October 16, 1998
John S. James

Unfortunately, few California ADAP recipients have been warned in advance that their eligibility is about to expire. Usually they first learn about this when their pharmacist tells them that their prescription was not approved--and often no one they are working with knows what is going on, or what needs to be done to assure continued drug supply.

If your prescription is rejected on the grounds that you are no longer eligible for California ADAP--even if you have an ADAP card which gives a later expiration date--you should:

1. Make sure that your pharmacist has submitted an emergency authorization form (the PMDC prior authorization form) so that your drug supply is not interrupted. Under a new system which was started in October 1998, the pharmacist will receive instructions with the rejection notice. You must sign the form, acknowledging that you have been informed that you must re-apply to ADAP within 30 days. Without your signature, ADAP will not pay the pharmacist for the prescription.

2. Within 30 days you need to apply again to ADAP so that your eligibility will be re-established for another year; this cannot be done at the pharmacy, but must be through an ADAP enrollment center in your area. Your doctor may need to provide some medical information, so start early, as there could be delays due to the need for coordination among four different offices--pharmacist, doctor, enrollment center, and PMDC (Professional Management Development Corporation, located in San Leandro, which is the California ADAP contractor).

3. For answers to questions about these procedures, you, your pharmacist, or others can call PMDC toll-free, 888-311-7632 (888-311-PMDC), Monday through Friday 9 a.m. to 7 p.m., Saturday 9 a.m. to 5 p.m., or Sunday 11 a.m. to 4 p.m. Callers can use the voicemail to reach an eligibility worker during these hours.

If necessary, PMDC can refer you to an ADAP enrollment center in your area.

You can also call the same number 24 hours a day to verify your own eligibility electronically, using your ADAP identification number (which is usually the same as your Social Security number). Use the voicemail to select the electronic verification system.

According to the PMDC PHARMACY PROVIDER MANUAL, a pharmacy which gets a "not eligible" message should call PMDC before turning the patient away. But there is no way to know how often this is done.

The rest of this article has background on why the problem has surfaced now, and on the process of applying or re- applying for ADAP.

Background: California ADAP

The Federal ADAP program is run separately by each state, which makes its own rules (subject to Federal regulations). To be eligible to receive prescription drugs under this program, you must have HIV, be a resident of the state, and have income within limits which are set by that state. The drugs which can be covered by ADAP vary tremendously by state. This article applies only to California.

Why Now?

California's current blizzard of prescription rejections started on September 1, and became much worse on October 1. There are likely to be many additional rejection notices in November (although a new procedure may handle them more smoothly). By next year this problem will largely correct itself automatically. Why did it happen now?

About a year ago California fundamentally changed the administration of its ADAP program. Before, each county (or other ADAP jurisdiction--for example, the city of Berkeley has its own program, separate from Alameda County in which it is located) was responsible for administering its program. California's ADAP data was kept in about 60 different file formats scattered throughout the state, which usually made it impossible to provide usage statistics quickly enough to project the need accurately when funding decisions were made. And patients had to use the same pharmacy every time.

For these and other reasons, California centralized its ADAP program last year. Now a central office (PMDC) maintains the eligibility records for everyone in the program, and tells pharmacists when they can fill prescriptions and be paid for them. Enrollment of patients is still handled at the local ADAP jurisdictions (not by PMDC), but PMDC provides one-day training and certification to the local eligibility workers, so that the process will be uniform throughout the state. ADAP prescriptions can now be filled throughout the state at any California pharmacy which participates in the ADAP program (more than two thirds of them do).

Last year all the ADAP jurisdictions were given several months to get their databases to PMDC; the deadline was November 1. Much of the data was in poor condition. If the eligibility expiration date was not available, PMDC was given permission to set this date to one year after the county's records were centralized--which gave the patient the benefit of the doubt (federal rules require that eligibility be re- established every year.)

Now, one year later, those expiration dates are arriving. For example, Berkeley got its records to PMDC early, by September of last year, so eligibility for those clients expired this year on September 1. (Berkeley's ADAP program made a commendable, but rare, effort to notify its clients in advance.) San Francisco had many ADAP clients lose eligibility on October 1, and did not notify them. In many areas, patients will get the rejections from their pharmacies in November. PMDC has estimated that about 1500 to 1800 patients will have prescriptions initially rejected this fall; that is about 15% of the 12,000 to 13,000 who are currently using the system.

Persons who signed up for ADAP within the last year, after the centralization of the program, are less affected. They have an ADAP card from the new, centralized system, and this card includes their expiration date, so at least they can mark their calendars and know when it is necessary to re- apply. Before, some counties did not have cards, and some of the cards that did exist were inaccurate. And clients did not receive the new cards when their records were centralized, but only when they re-enrolled in ADAP after that time.

Why are California ADAP clients (patients) not notified ahead of time when their eligibility is about to expire, and told what they need to do to remain in the program? There are several reasons. Many have asked not to receive calls or mail from the program, to guard their confidentiality. And PMDC itself is not set up to notify clients, even those willing to be contacted. It does notify the counties and other ADAP jurisdictions, but even San Francisco did not pass this warning on to its clients.

Perhaps the best solution would be for PMDC to fax a notice to be provided to the client with their prescription, one month before the eligibility period ends.

California ADAP Hints

1. Keep all your ADAP documentation together where you can find it.

2. If you are already in California ADAP, make sure you know your eligibility expiration date. If you do not know it, you can find it from PMDC. Call when they are open (see "Alert," at the beginning of this article), and be prepared to give them your ADAP member identification number.

A good time to re-enroll is just after you have filled your last monthly prescription in your current eligibility period. Start early, because re-enrollment may require coordination with your doctor's office.

3. If your prescriptions are rejected because you are no longer eligible, you need to (1) sign the pharmacist's paperwork to get emergency approval for those prescriptions (usually a 30 day supply), and (2) re-enroll in ADAP if you are still a California resident and still meet the income requirements. (See "Alert," at the beginning of this article.)

4. You need to enroll or re-enroll at a center which handles ADAP enrollment; if you do not know where one is in your area, call a local AIDS service organization, or call PMDC. Then call the enrollment center to find out when a trained eligibility worker will be available, and to find out exactly what documentation you must bring. You must prove residency and income, and may need to provide some medical information as well. (See "Applying or Re-Applying to California ADAP," below.)

Sparsely populated counties will usually have only one enrollment center. San Francisco, on the other hand, has over 20 (the public health centers, San Francisco General, many AIDS service organizations, etc.)--even though San Francisco is a single ADAP jurisdiction.

Once the eligibility worker faxes your enrollment application, PMDC can usually process it within a day or two.

5. It helps to call in your prescription ahead of time. Unfortunately there is only a three-day window when you can pick up the medication before it runs out (assuming a 30-day prescription; the rule in California ADAP is that the pharmacist will not be authorized payment for a refill or new prescription for the same medicine, until the date when the old one is within 10% of running out). But you can call in your prescription before that three-day window, to give the pharmacist more time to resolve any problems that may occur. (Note that ADAP is probably the most complicated reimbursement system that your pharmacist will handle, because it can only be a payer of last resort; therefore ADAP must interact will all other applicable health plans.)

6. You may want to deal with your pharmacy during hours that PMDC is open, so that you or the pharmacist can work out any problem then, instead of waiting until the next day when there may be somebody else on duty who is not familiar with the problem.

(Every transaction between the pharmacy and PMDC has a claim number. In case of a rejection, the pharmacy can phone and give the claim number to the PMDC staff, which can usually identify the problem immediately.)

7. You often get better service for ADAP prescriptions from independent pharmacies, or from a particular stores in a chain which has much AIDS experience. Chain stores, which often rotate pharmacists all over the state, account for a disproportionate share of the complaints from patients.

8. You can receive ADAP prescriptions by mail (usually from Stadtlanders Pharmacy, which is set up to handle ADAP's complex billing coordination). In many areas this may be necessary to preserve confidentiality.

9. If you are too ill to come to the pharmacy, a person with the appropriate power of attorney can sign the emergency authorization form for you--or someone else can bring you the form to sign, then return it to the pharmacy to pick up the prescription. A few pharmacies could come to you to get your signature and deliver the medication.

10. Clients who do not use any ADAP drug for over 90 days will be automatically suspended, but can be re-instated if they show that they are still eligible and are using the drugs in a medically accepted way.

Applying or Re-Applying to California ADAP

Each enrollment center will use the same 15-page ENROLLMENT PROCEDURES AND GUIDELINES FOR DETERMINING ADAP ELIGIBILITY manual, and will have an eligibility worker trained in its use. Some points to note:

* Currently (October 1998) all California ADAP recipients must have a Federal Annual Adjusted Gross Income under $50,000. Those between $32,200 and $50,000 might have a co- payment, depending on family size. The preferred documentation for establishing income is either the Federal or California income tax return; however, other documentation can be used, including current pay stubs, SSI/SSA check stubs, private disability insurance statement, letter of financial support from family or guardian, benefit determination worksheet from your social worker, or signed and notarized income affidavit from the applicant. A copy of this documentation must be kept with your file at the eligibility center.

If you do have an ADAP copayment, the amount will depend on your *taxable* income. Often the payment will be lower if you use your California tax return, instead of your Federal tax return.

Note that ADAP is income-based, while Medicaid (Medi-Cal) is asset-based.

* Applicants must provide identification and establish residency. "Suitable forms of identification may include a driver's license, immigration card, state identification, school identification, or United States passport" (quotes are from the ENROLLMENT PROCEDURES... manual, April 1998). Also, applicants must reside in California; if residence cannot be established with the identification, "applicants must present a rental or lease agreement, phone bill, utility bill or another similar document that will demonstrate that the applicant maintains a residence in California." A P.O. box cannot be used for the residency requirement--but may be used as a mailing address. Persons without this documentation (such as homeless, living with and supported by family or partner, etc.) "may prove residency by providing a letter (on agency letterhead) from their AIDS case manager, AIDS service provider, or social service provider, providing the location and time period services have been/continue to be provided to the client."

* Medical information. Applicants must provide a letter of diagnosis signed by a practicing and licensed California physician, with an original signature (the original diagnosis letter should not be necessary if you re-apply at the same ADAP enrollment center at which you previously applied, since your documentation should be on file there). To improve the data collected by the program, applicants are asked to provide the date of original diagnosis, date and value of most recent CD4 count, and name, address, and phone number of prescribing physician.

The eligibility worker must also know if the applicant has asymptomatic HIV, symptomatic HIV, or an AIDS diagnosis.

* Insurance. Since ADAP is the payer of last resort, all other payment options must be used first. This means that if a person is receiving 100% Medi-Cal benefits (including in a Medi-Cal managed care program), *without* a Medi-Cal share- of-cost, they are not eligible for ADAP (since they have no out-of-pocket prescription expenses). ADAP can pay co-payment of private insurance, but only in cases of financial hardship. And it can pay when the private insurance prescription drug benefit has been maxed out.

* Clients who are not getting Medi-Cal, but may be eligible for it, must apply for Medi-Cal, and provide proof of application within 30 days of their ADAP application, or their ADAP eligibility will be suspended until this is done.

California's Medicaid (Medi-Cal) eligibility allows ownership of one vehicle, one home which is used as one's primary residence, and up to $2,000 in additional assets (bank accounts, IRAs, a second vehicle, etc.) It also requires a medical disability. Any income is allowed; however, anything over $620 per month is Medi-Cal "share-of-cost"--meaning that this income must be used for the medical expenses, before Medi-Cal will pay. In cases of financial hardship, California ADAP's payments can help pay Medi-Cal share of cost (see ELIGIBILITY GUIDELINES, AIDS DRUG ASSISTANCE PROGRAM, updated November 21, 1997). In California financial hardship is not difficult to show, especially in cities where rent alone can be more than the $620 a month income which Medicaid rules expect people with large medical expenses to live on.

* Persons getting *Medicare* often can get ADAP in addition, since Medicare usually does not cover outpatient prescriptions.

* Rules for persons with private insurance are complex. ADAP can pay co-payments if the client can demonstrate that there would be a financial hardship. ADAP will pay after the prescription benefit has been exhausted, and will pay for drugs covered by ADAP but not by the private insurance. However, "applicants who must access their prescription benefits from a preferred provider not participating in the PMDC Pharmacy Network are not eligible for ADAP."

Also, applicants with private medical insurance must complete and sign an Assignment of Benefits and Release of Information form--so that their insurance company can be billed first, before ADAP pays. They cannot keep their private insurance from knowing their HIV status and also receive ADAP.

* Children. ADAP clients must usually be 18 years of age or older. Children under 18 may be considered on a case-by-case basis, if no other program will cover them (usually Medi-Cal or California's HIV Children Program would be used).

* The eligibility worker will fax the application to PMDC, but must also mail the original signed Assignment of Benefits and Release of Information.

Jail inmates can use ADAP, but only if they are accused only of county or local offenses. They cannot use ADAP if they are charged with or convicted of any state or federal offense-- even if they are housed in a county or city jail. Supposedly these prisoners have other HIV treatment programs available.

[There are efforts to change this rule. Previously, prisoners in California could get drugs through ADAP if they were being held on city or county charges or convictions (regardless of additional state or federal charges or convictions; California refuses to use ADAP to pay for state or federal prisoners, even if they are housed in a local jail). But inconsistency resulted, since San Francisco deemed city/county time as served first, while Los Angeles considered the local time to be served last. The immediate goal is to devise a more rational rule that can be applied consistently.]

* Grievance process. Applicants who have been denied eligibility or service may file a formal grievance with the California Office of AIDS through their local ADAP Coordinator of their county or other health jurisdiction. (However, we believe that most problems can be handled much faster, usually within a day, by calling PMDC--and appealing to its management, if one is not satisfied with the decision of the eligibility specialist or pharmacy technician at PMDC who first handles the problem.)

If you are treated unprofessionally by pharmacy staff, PMDC can usually get the problem corrected, since the pharmacies and chains must contract with them to sell medications through the ADAP program. PMDC has had good results even with the chains.

Ultimately appeals are limited, since California does not consider ADAP an "entitlement" program.

Contacting PMDC

If you are denied eligibility or services which you believe you should receive, the problem can often be resolved quickly by PMDC, the management contractor for the California ADAP. PMDC can be called toll-free at 888-311-7632 (888-311-PMDC), fax 800-848-4241). PMDC is open 9 a.m. to 7 p.m. Monday through Friday, 9 a.m. to 5 p.m. Saturday, and 11 a.m. to 4 p.m. Sunday.

(Before calling, you might want to check for additional information at a Web site, http://www.pmdc.org [not available yet as this article goes to press]. The Web site will be more current than this article, and may have answers which will help you understand and state the problem better.)

At PMDC, most enrollment problems can be handled by an Enrollment and Eligibility Specialist (select on the main menu of the voicemail). There is also a Pharmacy Technician choice (usually fused by the pharmacist or pharmacy worker).

If you are not satisfied with the answer of the eligibility specialist, you can appeal to the Enrollment Eligibility Coordinator (and CFO) of PMDC, Eric Flowers. Choose the Executive Directory submenu on the PMDC voicemail. Pharmacy issues can be appealed to Sylester Flowers, a pharmacist and president and CEO of PMDC.

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