Arizona ADAP Adequacy & Affordability Review Process

March 16, 2022 | Jimmy Borders | HIV

Ryan White Part B (RWPB) and AIDS Drug Assistance Programs (ADAP) must ensure that funding is not used to make payments for any item or service that has been paid, or can reasonably be expected to be paid, by another payer or program (e.g., Medicaid, Medicare, private insurance). While the RWPB is the “payer of last resort,” it is also able to provide wraparound for health care and supportive services not covered by public health coverage or private health insurance plans, and also to pay for such coverage, if cost effective in the aggregate. RWPB programs and ADAPs use their eligibility determination and recertification processes to verify and/or document that client(s) are receiving RWHAP Part B/ADAP services as their payer of last resort. RWPB programs and ADAPs should develop additional mechanisms beyond eligibility determination and recertification to ensure that they are not providing services duplicative of other programs or payers for which client(s) might be eligible.

To meet the HRSA payer of last resort expectation and ensure the client’s choice of health plan is both adequate and affordable, it is imperative that all non-Medicare private insurance health plans be reviewed by ADAP eligibility staff prior to enrollment. Helping the client enroll into the best health plan option is a win/win for all parties involved.

As a way to help explain what ADAP staff will be looking for during our review, below are the criteria used to access both adequacy and affordability:

Adequacy

Adequacy is determined using the following cross checks:

• Known HIV-related Medical Providers’ (i.e. Infectious Disease, etc.) are included/in network for the health plan under review.
• Known laboratories (Sonora Quest, LabCorp, etc.) are included/in network for the health plan under review.
• All HIV-related medications (i.e. ARV’s, HCV, etc.) are included/covered with no/minimal prior authorization restrictions for the health plan under review.

Please note: The ADAP eligibility staff may need to contact the health plan directly and/or review the health plan website, benefit summary or other pertinent documents for clarification prior to final determination.

• Example: During the adequacy review, it is discovered no known HIV-related Medical Providers’ in the local area are included/in network for the health plan under review. Because of this systemic failure, this health plan would be deemed inadequate and the client can be considered for other possible insurance options including the Federally Facilitated Marketplace (FFM).

Affordability

The ADAP healthcare plan choice affordability guidelines were adopted based on the criteria set forth under the original release of the Affordable Care Act Legislation. Under these terms, our program determines affordability using the following cross checks:

• The annualized monthly premium for the ADAP enrollee must be less than 9.56% of the ADAP enrollee’s household income.
  • Example: Household Size = two (2)
    • Monthly health insurance premium = $100.00
    • Annualized health insurance premiums = $1200.00
    • ADAP enrollee’s household annual income = $45,000
    • 56% of the household annual income = $4302.00
    • Annualized health insurance premiums of $1200.00 is less than 9.56% of the household annual income of $4302.00 thus enrollment into the health insurance plan is deemed affordable.

ADHS is aware of the possibility for clients to fall into the family glitch. Unfortunately, because our income and insurance eligibility are determined on household income and size, we are unable to make coverage exceptions based on this anomaly. The programmatic expectation applied for the clients that find themselves in the family glitch, is for the spouse with the option to add someone to their health insurance to do so, while the insurance-less spouse offsets the added cost their spouse faces with the deduction-less income they bring to the household. We realize this solution may not apply to all client circumstances but please keep in mind alternative payer of last resort options are limited due to circumstances far beyond our control.

As always, if anyone has any questions about this article or any ADAP-related matter, please do not hesitate to reach out directly at careandservices@azdhs.gov.