Picking Up the Insurance Bill
ADAP Programs and the ADAP Plus Insurance Continuation Program
You know that old commercial where the guy is shaving, and he says "I liked the shave I got with this razor so much that I bought the company"? That’s how I feel about ADAP -- the AIDS Assistance Program.
Now, I'm not HIV-positive, and I don't presume that I "know what it's like" to be HIV-positive. But I have worked in the field of HIV/AIDS services for a long time, and I know many of the problems faced by people with the virus
For the last nine years I've been a member of New York's Statewide Advisory Committee for the ADAP programs. In that time I've been continually impressed with the dedication and commitment of the ADAP staff -- they are determined to get people the care they need. I was so impressed, in fact, that this spring I joined the staff to help spread the word about the programs -- especially about APIC, the new ADAP Plus Insurance Continuation program.
I think I know what you're saying: "Yeah, yeah, yeah. I know about the ADAP programs." As I've been talking to people about ADAP/APIC, I've found that while most people think they know about ADAP, they often know only a few of the services, or have old information. So I've written this article for Body Positive to help get the word out about ADAP in general and the APIC program in particular. I'm also asking for your help to get this word out, but we'll talk about that at the end. First, the good stuff:
What Is ADAP?
The AIDS Drug Assistance Program is a federally funded, state-administered program that pays for HIV/AIDS drugs and care. Every state has an ADAP program, and the size of the program is determined by the number of people with AIDS that the state can document. New York has the largest and most extensive ADAP program in the country. It is a partnership program that receives contributions from New York State, New York City, Long Island, and the Lower Hudson and Dutchess County regions. We cover the largest number of people of any ADAP program in the country, and we pay for:
- Over 450 different drugs used to treat HIV and HIV-related side effects (including all the combination medications).
- Vitamins and nutrition supplements.
- Primary care visits (going to the HIV clinic).
- Lab tests (e.g., viral load tests, CD4 cell counts, etc.), X-rays, etc.
- Dental care.
- Limited mental health care.
- Up to $30,000 of home healthcare.
- Insurance premiums, and in some cases deductibles and co-payments (see below).
ADAP does not pay for hospitalizations and emergency room visits.
How Do You Qualify for ADAP?
To be eligible for ADAP in New York State, you must document that you:
- Are HIV-positive.
- Live in New York State.
- Have an income below $44,000 (for a household of one), $59,200 (for a household of two), or $74,400 (for a household of three or more).
- Have less than $25,000 in liquid assets (savings, stocks, bonds, etc.).
In addition, a separate medical application must be submitted by your doctor.
Applications that are submitted with all the required documentation are processed within two weeks. When you are approved, you are issued an ADAP card and instructions on how to use it. You must present this card and prescription at an enrolled pharmacy to receive covered medications at no charge. You must show it to participating healthcare providers to received covered medical services at no charge, and it entitles you to receive home care services from enrolled agencies without charge.
Can Undocumented People Receive ADAP?
YES!!! And if they meet the ADAP criteria, they may also be eligible for insurance premium payments through the APIC program.
What Is APIC?
APIC is the ADAP Plus Insurance Continuation Program, and it is the latest service to be added to the list of ADAP programs. APIC was added in July of this year, and will pay health insurance premiums for HIV-positive people who meet ADAP's eligibility criteria. APIC may also pay for the employee portion of employer-sponsored health insurance, or COBRA continuation coverage for individuals who leave work and want to keep their health insurance. In some cases the ADAP program can pay deductibles and co-payments as well.
What if I don't have health insurance? I thought people who were HIV-positive couldn't buy coverage, or the insurance companies would charge us more.
Since 1992, it has been illegal for insurance companies to refuse to sell you health insurance because of your health status, sex, occupation, etc. And they can't raise the price for people who are HIV-positive. If they are selling a policy in your county and you have the money to buy it, they have to sell it to you at the same price, regardless of your HIV status.
So can I get the money together, buy a policy, and get the APIC program to pick up my second month's premium?
Yes. If you meet the ADAP eligibility criteria, can get the money together for the first month's premium, and your policy is cost-effective, APIC will pay the premiums starting with month two and continuing indefinitely.
How do they decide whether my policy is cost-effective? Why is New York doing this anyway?
When you apply for APIC, you have to attach a photocopy of your policy. To determine whether the insurance is cost-effective, the staff will look it over to make sure that it covers the types of services that ADAP covers. For ADAP to cover your premium, the policy must cover at least the drugs and primary care that you would otherwise get through ADAP. With the large numbers of ADAP enrollees on combination medications in New York State, it's cheaper in the long run for ADAP to pay for the insurance coverage this way than it is to pay directly for the drugs.
Are there policies that don't cover primary care and AIDS drugs?
Yes, there are. Medicare Supplemental policies (also called "Medigap" policies) have very limited coverage for prescriptive drugs. The richest policies pay only $3,000 a year for medications. Some individual policies have no prescription drug coverage. Some policies have no or little coverage for care that you get from a doctor who is not in the network. If the doctor isn't in the network, the policy sometimes won't provide any coverage for prescriptions written by that physician. These are all examples of policies with holes or gaps that would cause you to turn to the ADAP program, regardless of your coverage.
What about family coverage, or coverage through my spouse's or domestic partner's policy?
If the person who is infected is covered by a family policy, or under a spouse's or domestic partner's coverage, APIC can still pay for the coverage -- again, if the HIV-positive person meets the ADAP eligibility criteria, if the coverage is cost-effective, and if the necessary documentation is provided.
What about coverage of deductibles and/or co-payments?
This is decided on a case-by-case basis. There are three basic ways that ADAP can help with the costs of health insurance: It can (a) pay the premium; or (b) pay the deductibles and co-payments; or (c) pay the premium, deductibles, and co-payments. If the cost of your deductibles and co-payments is so high that it will keep you from using your health insurance to get healthcare, the program will consider enrolling you in ADAP or ADAP Plus. You would assign your insurance benefits to the program and use your ADAP card to get your drugs and healthcare. The program would then reimburse the provider for the services rendered and present the bills to the insurance company. These bills would be used to meet your deductible and co-payment amounts.
How do I find out what policies I can buy in my county?
The New York State Insurance Department has a website (www.ins.state.ny.us) that lists all the companies selling individual and family coverage by county. The website also lists the price of the coverage and has a lot of other information for consumers about buying insurance. If you don't have access to the Internet, at home or at your public library or elsewhere, you can call the State Department of Insurance at (800) 342-3736 and they can mail you the information in a week or two.
Additional Questions About ADAP
Can people on Medicaid get ADAP?
People on regular Medicaid are not eligible for ADAP. People who have Medicaid with a spend-down, however, can qualify for ADAP and use it to fulfill the spend-down. Those who have Medicaid but who have been sanctioned for drug and/or alcohol use can keep their ADAP card during their sanction period. When the sanction is up and they qualify for regular Medicaid again, their ADAP card will become invalid.
Can people with health insurance qualify for ADAP?
Yes, they can. Sometimes your health insurance may not pay for a drug your doctor prescribes. Check with ADAP at (800) 542-AIDS [542-2437] to see if a prescribed drug is one of the ones ADAP covers.
If you are eligible to have ADAP pay your deductible and co-payment, you may assign your insurance benefits to the program. ADAP will then pay the provider for the services rendered, and present the bills to the insurance company, which will reimburse ADAP what the insurance company would have paid for that service (if anything). If it is early in the year, and you haven't been hospitalized, it may take some time for the proof of payment ADAP submits to the insurance company to add up to enough to satisfy the deductible. Once this has happened, any further bills ADAP submits to the insurance company will be reimbursed to APIC.
What if my Medicaid application is being processed?
You can receive ADAP benefits during the interim. When your Medicaid card becomes valid, the ADAP card becomes invalid.
What if I'm getting out of prison?
Apply for an ADAP card as soon as you hear that you'll be going home. This can be an important bridge to make sure you get medical treatment while looking for a job and/or applying for SSI, SSD, and/or Medicaid. ADAP will process your application, then send a letter saying your ADAP application has been accepted. Your card won't be activated until you send the program a letter saying that you are within four to six weeks of getting out. In the letter you should also state where you want your ADAP card sent. If you get released suddenly, or at a faster schedule than you were anticipating, don't worry. As soon as you are out, call the ADAP program at (800) 542-AIDS and a staff member will help you figure out how to get your ADAP card.
Help Get the Word of the ADAP/APIC Programs To People In Your Community
We need to get this news to every PWA, every provider, every migrant farm, every prison, every village and town throughout the state, from Montauk to Dunkirk, from the Adirondacks to the shores of Lake Erie. Here's how you can help:
- Take a copy of this article to your support group, your doctor's waiting room, your church, synagogue, mosque, bridge group. Tell other people about it. Remember, every New Yorker knows someone who is HIV-positive.
- Mention this program online. If you are in online support groups or chat rooms, mention it. Memorize the ADAP phone number, (800) 542-AIDS, and get it out there.
- Take a copy of this article to your case manager, social worker, or private doctor's administrative staff. Point out that these services can get people with HIV broader services and better coverage. Some providers can get more money from billing private insurance than they can from billing the ADAP program.
- Make copies of this article and put them up on bulletin boards, or lay them out on literature tables at workshops, gatherings, and meetings. Make an announcement about these programs at every meeting you go to. Place a notice in your church bulletin and/or the newsletter for your HIV service organization.
- Invite an ADAP/APIC representative to your HIV service organization to train the case management, social work, or billing staff. Amy Abbey and I cover the Downstate region, and Sue Wade covers the Upstate region. Call us at (800) 542-AIDS and ask the hotline staff to refer you to the worker for your area.
Karin Timour is a Health Program Administrator II with the New York State AIDS Institute's HIV Uninsured Care Programs. She is a frequent contributor to Body Positive who is based in New York City.