Current through Register Vol. 48, No. 12, March 22, 2024
Drugs provided under this Part are paid for on behalf of
low-income individuals with acquired immunodeficiency syndrome (AIDS) or human
immunodeficiency virus (HIV).
a)
Eligibility requirements. To qualify for services under this Part, a person
shall have been enrolled in the AIDS Drug Assistance Program (ADAP) as of June
4, 1996, or:
1) Apply to the Department for
acceptance for ADAP and comply with all recertification requirements, which
occur every six months from the point of enrollment; and
2) Be diagnosed as having AIDS or HIV and be
currently receiving HIV care, including having received a viral load test
result and CD4 count within the six months prior to the date of the application
or recertification.
b)
Financial and insurance requirements
1)
Applicants with no active prescription insurance coverage at the time of
enrollment shall qualify financially with anticipated gross monthly income, as
determined by the Department, at or below 300% FPL of the most recent Federal
Poverty Guidelines published annually by the U.S. Department of Health and
Human Services for the size of the household. (See Appendix A.)
2) Applicants with active prescription
coverage at the time of enrollment shall qualify financially with anticipated
gross monthly income, as determined by the Department, at or below 500% FPL for
the size of the household.
A) The applicant's
health insurance provider must be willing to participate with the Department's
contracted dispensing pharmacy for dispensing and billing purposes and only for
drugs on the current ADAP formulary.
B) Only 30-day prescription fills will be
accepted. If an applicant is planning to travel outside of Illinois for two to
three months and needs a longer prescription fill, the applicant shall obtain
prior approval from ADAP for a medication exception. The applicant shall
provide a clear copy of the front and back of all prescription insurance
cards.
C) Applicants who were
enrolled in ADAP on July 1, 2011, in the 301-500% FPL income bracket shall be
grandfathered into ADAP on a go-forward basis, as long as the applicant's
recertifications are complete and submitted on time and do not exceed 500% FPL.
If an applicant within this cohort is closed from the program due to failure to
reapply on time, then the applicant will be assessed using the 300% FPL
eligibility limit.
D) Applicants in
the 301-500% FPL income bracket who have not been covered under creditable
coverage for a continuous six month period prior to the date of application,
but would have been eligible for a creditable coverage program recently offered
under a State or federal government entity, will be assessed on the same
standard as those with active prescription coverage.
3) Applicants shall not be eligible for the
Medical Assistance Program (Medicaid) on the date that drugs are obtained
(individuals with financial/medical assistance applications pending or
individuals in spenddown unmet status may participate).
4) If eligible for Medicare Part D, the
applicant shall enroll in Medicare Part D and provide information on the Part D
coverage plan.
5) If enrolled in a
Medicare Supplement plan (Medigap), the applicant shall provide information on
Medigap plan and coverage.
6) If
eligible for federal Extra Help, the applicant must enroll and provide
information on coverage.
c) Residency requirement. The applicant shall
be a legal resident of Illinois, as defined by Section 2-10 of the Illinois
Public Aid Code, except that:
1) The
provision of Section 2-10 of the Illinois Public Aid Code stating that
applicants for or recipients of public aid must meet the requirements for
duration of residence contained in applicable Sections of the Public Aid Code
shall not apply to this Part; and
2) The provision of Section 2-10 of the
Illinois Public Aid Code regarding recipients of aid under Article III, IV, or
VI shall apply to any recipient of services under ADAP.
d) Persons enrolled in ADAP shall recertify
their eligibility every six months to continue receiving drugs through ADAP.
1) The Department will establish
recertification procedures, as required by federal regulations and guidelines.
Recertification applications, and any necessary new verifications, shall be
received by the Department at least three business days prior to the expiration
date of the client's current enrollment to avoid any interruption in
service.
2) If the Department does
not receive a recertification application at least three business days prior to
the expiration date of the client's current enrollment, the client will be
removed from ADAP and will be required to meet the eligibility requirements of
subsections (a) through (c) of this Section in order to continue receiving
drugs through ADAP.
3) To avoid
interruption in care, the Department will make reasonable attempts to notify
recipients or their designees when an incomplete recertification application
has been received.
e)
The Department will suspend a client's enrollment in ADAP under the following
circumstances:
1) Failure to submit a
completed initial or recertification application at least three business days
prior to the expiration date of the client's current enrollment; or
2) Failure to use a minimum of one drug from
any category of the ADAP formulary within 90 days after enrollment in
ADAP.
f) The Department
will send written notice of suspension within 30 days after the suspension,
which may be appealed in accordance with subsection (l). The suspension will be
lifted when the circumstances that initiated suspension have been
rectified.
g) The Department will
permanently terminate a client's enrollment in ADAP if the client submits
fraudulent application information. The Department will send written notice of
termination within 30 days after the termination, which may be appealed in
accordance with the provision of subsection (l).
h) Subject to the availability of funds, the
Department may implement cost control measures at any time to ensure the
long-term sustainability of the program. Any cost control measures taken
pursuant to this Section will be made only after a 90-day notice period to all
applicants and providers.
i) All
drugs provided under ADAP have been approved by the federal Food and Drug
Administration. The Department will request the advice of the medical issues
subcommittee of the Ryan White ADAP Medical Issues Advisory Board when
necessary to assist with determining which drugs will be covered, based on
criteria that include the medical appropriateness of the drug for treatment of
HIV/AIDS and associated complications. The following categories of drugs may be
covered under ADAP:
1) Category I - Drugs for
Anti-Retroviral Therapy;
2)
Category II - Drugs for Pneumocystis jiroveci (carinii) pneumonia (PCP)
Prophylaxis and Treatment;
3)
Category III - Drugs for Prophylaxis and Treatment of Opportunistic Infections
and Anti-Microbials;
4) Category IV
- Drugs for Treatment of Neoplasms; and
5) Category V - Other Drugs Requiring Prior
Approval.
j) All
prescriptions shall be filled by the Department's pharmacy
contractors.
k) The Department may
require participants to pay a copayment for prescriptions received. If a
copayment is charged, it shall not exceed the sliding fee structure specified
in Part B of the Ryan White HIV/AIDS Treatment Extension Act of 2009 (see
Appendix B).
l) The Department will
make a disposition and issue a written decision on an application filed
pursuant to this Section within 30 business days after the date the Department
receives the application. The Department will make a disposition and issue a
written decision on a recertification application filed pursuant to this
Section within 30 business days after the date the Department receives the
completed application, accompanied by all supporting verification documents
that are provided by the applicant or on record with the Department. An
applicant may appeal the Department's denial of an initial application,
recertification application, or suspension or termination of benefits in
accordance with Practice and Procedure in Administrative Hearings.