Can THMP send program changes to all ADAP participating pharmacies and ensure they get the monthly updates?

Currently, you can sign up to get information through THMP’s listservs: THMP News, THMP Participating Pharmacies, and THMP Eligibility. THMP does share program news and updates as well as specific pharmacy related news as updates occur. In addition, THMP has been inviting the ADAP regional liaisons to attend weekly team huddles. ADAP regional liaisons, who are housed within the AAs, are expected to communicate program information to stakeholders such as ASOs, CBOs, FQHCs, participating pharmacies, and other relevant partners.

The ADAP Eligibility Workers (AEWs) and Medical Case Management (MCM) staff should have ongoing contact with the provider. They should be able to alert the medical provider of approvals and/or ADAP status. How can we make this happen?

DSHS continues to put THMP status updates in the AIDS Regional Information and Evaluation System (ARIES), which holds information securely for THMP, for access by authorized staff at Ryan White HIV/AIDS Program (RWHAP) funded clinics and agencies. We also mail denial letters to client homes. That process will not change. AEWs and MCM staff should work with providers to relay this information. We will continue to reiterate that expectation with our contractors.

Do all clients see an ADAP Enrollment Worker (AEW)?

No. Clients do not have to see an AEW to apply for and receive THMP services. Clients may apply to the program on their own in addition to seeing an AEW.

Will DSHS put in place a more streamlined way to apply and re-apply for THMP/ADAP benefits?

Yes. DSHS is in the process of replacing its eligibility system. HRAR, the new system, will allow clients to complete their application electronically with a streamlined process for initial submission, recertification, and self-attestation.
 

Will ADAP keep accepting new clients?

Yes, as funding is available, ADAP will continue to accept clients who apply and are eligible. THMP will notify stakeholders prior to implementing a waitlist.
 

How can we speed up the process for a shorter time for delivery of meds to clients? Why don’t we have better technology where clients can apply for ADAP and upload documents?

We are in the process of replacing our IT system. When complete, the HRAR Project will allow clients to complete their THMP application electronically with a streamlined process for initial submission, recertification and self-attestation.
 

Would DSHS reinstate denial (drop) letters for clients? Would this also include any documentation regarding adding the patient to a potential waitlist?

We still put denial letters in the AIDS Regional Information and Evaluation System (ARIES), which holds information securely for THMP, for access by authorized staff at Ryan White HIV/AIDS Program (RWHAP) funded clinics and agencies. We also mail denial letters to client homes. That process will not change. Clients can use such letters to get on a patient assistance program (PAP), which will cover the cost of medication. DSHS has not finalized whether a waitlist is necessary or what the waitlist process will look like, but in the event of a waitlist, denial letters would be included in ARIES and mailed to clients. However, THMP will engage with stakeholders prior to implementing a waitlist.

The client’s doctor or medical provider must be an authorized ARIES user to access client information.
 

Can medical providers look up to see if the person is on the THMP waitlist?

DSHS does not know yet whether a waitlist is necessary. We are working with an actuary to project the growth of the program. We are also looking at the funding required to support that growth and actively seeking out additional funding and exploring more program changes that would prevent the need for a waitlist.
 

Can THMP notify agencies that submit THMP applications on application outcomes?

Yes, we already do this in ARIES for access by authorized staff at RWHAP funded clinics and agencies. In addition, we mail denial, approval, and pending letters to client homes.
 

How far behind is THMP in processing initial applications/recertifications? Will DSHS provide biweekly or regular updates from THMP on the status of the program?

THMP has been inviting the ADAP liaisons to attend weekly team huddles to provide them with status updates on the program. As of June 2021, THMP is processing eight weeks out. Staff are currently working overtime to help address the delay in application processing. An application is considered backlogged if processed more than 14 days after receipt. Additionally, training has been provided on the new application to reduce the number of applications that the program receives that are incomplete. Incomplete applications slow program processing time by increasing the number of times staff must review each application. THMP is requesting additional temporary positions to get application reviews caught up.
 

Will the new system stop the use of fax machines and make it real time?

We are in the process of replacing our IT system. When complete, the HRAR Project will allow clients to complete their THMP application electronically with a streamlined process for initial submission, recertification and self-attestation.

THMP will continue to accept applications by mail and fax for clients who prefer these modes of communication.
 

Can the THMP application indicate a client is denied for THMP so they can try the marketplace and state this in the client's denial letter?

We can look into adding language to the denial letter to share with clients, including information about other options if they are not eligible for THMP.

We still put denial letters in the AIDS Regional Information and Evaluation System (ARIES), which holds information securely for THMP, for access by authorized staff at Ryan White HIV/AIDS Program (RWHAP) funded clinics and agencies. We also mail denial letters to client homes. That process will not change.

If clients are not eligible for THMP, DSHS encourages ADAP Enrollment workers to enroll eligible clients in available health plans or refer clients to expert enrollment entities to cover medical care and medication costs. Other available resources include patient assistance programs (PAPs). Also, RWHAP-funded providers can use Local Pharmaceutical Assistance Program (LPAP) funds to pay for medications on the local LPAP formulary.

What will DSHS do to ensure that THMP does not have another budget shortfall?

As we found out over the past year, the situation can change rapidly, and there is no guarantee things won’t change again at some point. However, DSHS has taken several steps to put the program on a more stable footing, and those improvements will endure into the future. DSHS:

• Made organizational changes, such as restructuring the program’s financial team.
• Reengaged with an independent actuary for financial projections. 
• Reestablished roles and responsibilities and adopted new tools for budgetary oversight and tracking. 
• Considered the need for a waiting list and asked the Texas Legislature for exceptional item (EI) funding to support the longer-term financial stability of the program. 
• Explored expanding insurance purchasing as an additional long-term strategy for financial stability. 
• Implemented controls to better manage pharmacy inventory, such as ensuring manual checks against the ITEAMS system, conducting regular monthly hand counts of medications, and ensuring adequate cross-training of staff. 
• In coordination with the Medication Advisory Committee, reviewed the drug formulary to make recommendations for changes.
• Make changes to the ADAP application process with the implementation of the HRAR portal.

Other than the EI funding request to the Texas Legislature, what other possible funding options will DSHS seek?

We are exploring other options as possible sources of revenue including:

• Federal Ending the HIV Epidemic funds.
• Additional federal COVID-19 relief funds.
• Continue to apply for federal ADAP supplemental funds.
• Continue to apply for federal ADAP emergency relief funds.

Does THMP receive 340B funding? If so, is it enough to help with the deficit?

THMP is a 340B entity. This allows the DSHS Pharmacy to buy medications for ADAP participants at 340B prices or below. THMP cannot get rebates for medications purchased at 340B prices, which means that the program’s ability to generate additional revenue is limited.
 

What cost will the state incur by having an actuary do monthly audits? Will the actuary or DSHS provide the estimated cost of continuing THMP versus expanding Medicaid in Texas? Will DSHS know if expanding Medicaid would be more cost effective?

We will pay less than $2,000 per month in federal Ryan White funds for actuary services. DSHS program and budget staff will determine the program’s financial health using projections provided by the actuary in conjunction with DSHS budget monitoring tools. This will not include an analysis of Medicaid expansion; decisions about Medicaid are under the purview of the legislature.
 

Does DSHS expect clinics to pick up the costs of medication?

If clients are not eligible for THMP, DSHS encourages ADAP Enrollment workers to enroll eligible clients in available health plans or refer clients to expert enrollment entities to cover medical care and medication costs. Other available resources include patient assistance programs (PAPs). Also, RWHAP-funded providers can use Local Pharmaceutical Assistance Program (LPAP) funds to pay for medications on the local LPAP formulary.
 

What are the opportunities to generate revenue and offset budget spending?

We will continue to explore all possible revenue sources and cost-saving measures, including:

• Federal Ending the HIV Epidemic funds.
• Federal COVID-19 relief funds.
• Federal ADAP supplemental funds.
• Federal ADAP emergency relief funds.

Do you anticipate the THMP/ADAP application backlog will increase?

It is hard to say if the application backlog will increase or not. Staff are currently working overtime to help address the delay in application processing. An application is considered backlogged if processed more than 14 days after receipt. Additionally, training has been provided on the new application to reduce the number of applications that the program receives that are incomplete. Incomplete applications slow program processing time by increasing the number of times staff must review each application. THMP is requesting additional temporary positions to get application reviews caught up.
 

Is it possible to use Ending the HIV Epidemic (EHE) funds to help support the medication program?

We cannot use the EHE funds to help support THMP. The current CDC guidance does not allow for purchasing medications for people living with HIV. 
 

How are HRSA and the pharmaceutical companies being brought into this budget shortfall conversation?

We are working with HRSA and agency leadership to find a better system. We have monthly meetings with our HRSA project officer focusing on how a standard deduction might look for the Texas ADAP. We are also pursuing technical assistance from National Alliance for State and Territorial AIDS Directors (NASTAD) as recommended by HRSA. The goal is to understand how other states approach setting their Federal Poverty Level (FPL) as well as other approaches taken to generate 340B revenue.

Additionally, THMP is part of the ADAP Crisis Task Force (ACTF), which negotiates reduced drug prices on behalf of AIDS Drug Assistance Programs (ADAPs) in all 50 states, the District of Columbia, and the U.S. territories. These meetings include the pharmaceutical companies. We also invite pharmaceutical companies to take part in meetings including the Medication Advisory Committee meetings where we discuss concerns.
 

Do we anticipate getting funds to cover this deficit from the American Rescue Plan Act? Was there anything in Biden's stimulus that can help the program?

The American Rescue Plan Act provides COBRA premium assistance and has been able to assist with THMP’s Texas Insurance Assistance Program (TIAP). The funding from the American Rescue Plan Act will help TIAP cover eligible individuals by providing premium assistance from April 1, 2021, through September 30, 2021, instead of using general revenue as the source of funding.
 

How is the money that is returned from Part A jurisdictions used to support the program?

DSHS uses the money given by Part A jurisdictions to buy HIV medications for clients statewide.

How will DSHS share funding information with the community?

THMP will be transparent for all aspects of our programs. We will provide updates on our website and in calls and meetings with stakeholders.

The communication plan is to share updates with everyone involved. This is a priority for us. DSHS will:

• Create a THMP Moving Forward Together website which will include the THMP Moving Forward Together Draft plan.
• DSHS will be seeking feedback from the community regarding the plan in the near future.
• THMP will continue inviting the ADAP regional liaisons to their weekly team huddle meetings so that ADAP regional liaisons can share this information with their providers and the community.
• THMP will send updates through their listservs. You can register for the THMP listservs by visiting the THMP website.
   

How will DSHS work with priority stakeholders to ensure that client services are not disrupted?

Our plan is to:

• Host ongoing calls and meetings for priority stakeholders: clients, AEWs, ADAP regional liaisons, services providers, and other community stakeholders.
• Speak to providers, ADAP enrollment workers, and ADAP regional liaisons about the potential influx of ineligible clients needing community medication resources and assistance with applying to PAPs, in the event of a waitlist.
• Engage THMP pharmacies at the local level through:
  • pharmacy listserv
  • website messages
  • fax blasts
• Ensure ADAP enrollment workers and liaisons get timely, accurate and complete information if we implement a waitlist.

How can the community stay abreast of these issues and changes? Advocates and leaders need to know so they can communicate with their clients.

The community can:

• Attend THMP partnership meetings and conference calls, which THMP will share through their listservs, on the DSHS website, and email notification to established community providers and stakeholders.
• Read the DSHS HIV/STD website for updates.
• Submit unanswered questions to hivstd@dshs.texas.gov.
• Once published, share the THMP Moving Forward Together Plan with your colleagues and community.
• Attend the DSHS THMP Medication Advisory Committee (MAC) meetings and participate in the Texas HIV Syndicate.

Does ADAP have regular meetings with contracted pharmacies?

THMP does not have routine meetings with participating pharmacies. We have memoranda of agreement with pharmacies across the state to deliver medications to clients enrolled in THMP programs. These pharmacies are called “participating pharmacies.”

THMP sends monthly data to larger pharmacies that are located with clinics, and they are sharing with the clinics. In addition, THMP has been inviting the ADAP regional liaisons to attend weekly team huddles. There are four ADAP regional liaisons funded by THMP. Their geographic/Administrative Agency (AA) responsibilities are as follows:

• The Dallas ADAP regional liaison housed with Dallas County and covers the Dallas County and Tarrant Co AAs.
• The Houston ADAP regional liaison is housed with The Resource Group (TRG) and covers the TRG and Houston Part A AAs.
• The San Antonio ADAP regional liaison is housed with University Health Systems (UHS) and covers the UHS and South Texas Developmental Council AAs.
• The Bryan-College Station regional liaison is housed with Brazos Valley Council of Governments (BVCOG) and covers the BVCOG and Lubbock StarCare AAs.

ADAP regional liaisons, who are housed within the AAs, are expected to communicate program information to stakeholders such as ASOs, CBOs, FQHCs, participating pharmacies, and other relevant partners.
 

What is the DSHS plan to communicate routine updates to the community?

Our plan is to:

• Host ongoing calls and meetings for priority stakeholders: clients, ADAP Enrollment workers, ADAP regional liaisons, services providers, and other community stakeholders.
• Through THMP’s quarterly regional calls, weekly huddles, and listservs, THMP communicates regularly with providers, ADAP enrollment workers, and ADAP regional liaisons. THMP will use these channels if there is a potential influx of ineligible clients needing community medication resources and assistance with applying to PAPs, in the event of a waitlist.
• Engage THMP pharmacies at the local level through:
  • pharmacy listserv
  • website messages
  • fax blasts
• Ensure ADAP enrollment workers and liaisons get timely, accurate and complete information if we implement a waitlist.
• Provide updates and information at quarterly MAC meetings.
• Keep all updates current on the DSHS website link.

The community can:

• Attend THMP partnership meetings and conference calls, which THMP will share through their listservs, on the DSHS website, and email notification to established community providers and stakeholders.
• Read the DSHS HIV/STD website for updates.
• Submit unanswered questions to hivstd@dshs.texas.gov.
• Once published, share the THMP Moving Forward Together Plan with your colleagues and community.
• Attend the DSHS THMP Medication Advisory Committee (MAC) meetings and participate in the Texas HIV Syndicate.

What would be the purpose of the next town hall? What is the purpose of the partnership meetings (previously known as a town hall meetings)?

The March 2021 Town Hall was the first step to begin the conversation on how to better communicate with the community. The June 30 Partnership Meeting (formerly known as a Town Hall meeting) will focus on providing updates. We will share information on the steps we took since the first Town Hall.
 

Will clients receive a letter from THMP educating them on the budgetary shortfall and upcoming changes?

Clients will receive notice at least 60 days prior to a program change that impacts client eligibility. Clients can also stay up to date with THMP on the Moving Forward Together website.
 

How is DSHS communicating with Texas ADAP clients who were told they were no longer eligible for the program that they can rejoin the program due to the delay in the elimination of the spend down provisions?

We sent a letter to all ADAP clients affected. The letter stated that their eligibility would be reassessed. We completed this in March 2021, with all eligible clients reinstated into the program.
 

What is the plan for THMP to notify clients being dropped from the ADAP program in June? Do they have a clear plan of action?

Current discussions are focusing on the potential need to remove the spenddown and then introduce a standard deduction once the TAC is updated. We are working on an analysis that will help us identify the amount to set for the standard deduction. We have reached out to the National Alliance of State and Territorial AIDS Directors (NASTAD) for technical assistance. NASTAD has been helping us better understand the way other states have chosen to implement financial adjustments similar to a spenddown. In the event we reinstate the removal of the spenddown, we will notify ADAP clients and other key community partners and stakeholders in advance and no sooner than August 31, 2021.

In addition, with the outcome of the 87th Texas Legislature’s Exceptional Item funds, we do not anticipate the need to start a waitlist for ADAP over the next two years.
 

When will meeting minutes for the Medication Advisory Committee (MAC) be updated and made available online?

DSHS is in the process of updating the MAC meeting minutes. You can read the most recent available minutes on the MAC webpage. We will post the 2021 meeting minutes soon. 

What good is the Medication Advisory Committee (MAC) if DSHS won't even let them know, much less ask for input?

The duty of the MAC is to advise and provide recommendations to THMP and the executive commissioner including, but not limited to, topics such as budget, formulary recommendations, and programmatic changes.

We communicate with the MAC not only through our quarterly meetings, but also through our three sub-committees:

• Formulary sub-committee
• Eligibility sub-committee
• Data and Governance sub committee

In addition, we are working to improve communication with the MAC through more timely sharing of information with the MAC. We have also been partnering with the MAC’s chair and co-chair throughout the Moving Forward Together process. Both the chair and co-chair of the MAC were involved with moderating the THMP Town Hall breakout sessions, as well as the THMP Listening Session, and the THMP Partnership meeting.
 

What will DSHS do differently to keep the community involved to prevent this from happening again?

The THMP Moving Forward Together Plan includes steps that we are taking to improve our partnership with the affected community, including:

• Engaging THMP participating pharmacists at the local level.
• Providing guidance to ADAP Enrollment workers to effectively assist clients and prospective clients.
• Engaging clients and medical providers.
• Working with DSHS leadership to update the Texas Administrative Code (TAC), Rule 98.115, Texas HIV Medication Program Fiscal Planning. The community will have an opportunity to provide informal and formal public comment.
• Hosting regularly scheduled partnership meetings and agenda-driven events.

DSHS recently stopped convening the majority of the Achieving Together work groups working to end the epidemic. This isn't conducive to open conversation with the community. Do you have a date when these will resume?

Several Texas HIV Syndicate and Achieving Together workgroups were temporarily paused during the TB/HIV/STD Section transition from LIDS to CHI. All workgroups have reconvened at this time.
 

Does THMP work with Achieving Together? Where does this program (THMP) change fit into the Texas END HIV plan?

The Achieving Together plan was developed by the Texas HIV Syndicate and other community stakeholders to guide efforts to address the HIV epidemic in Texas. The Texas HIV Syndicate continues to serve as the integrated HIV prevention and care community planning body for the DSHS HIV Program. The DSHS HIV Planning Program, which puts on the Texas HIV Syndicate is working with THMP on the Moving Forward Together plan. The DSHS HIV Planning Program is looking to find ways to integrate the Moving Forward Together initiatives into the Texas HIV Syndicate and to align the Moving Forward Together and Achieving Together plans.
 

How will DSHS get input on the plan from people living with HIV (PLWH)?

The THMP Moving Forward Together Plan includes steps that we are taking to improve our partnership with the affected community, including:

• Engaging THMP participating pharmacists at the local level.
• Providing guidance to ADAP Enrollment workers to effectively assist clients and prospective clients.
• Engaging clients and medical providers.
• Working with DSHS leadership to update the Texas Administrative Code (TAC), Rule 98.115, Texas HIV Medication Program Fiscal Planning. The community will have an opportunity to provide informal and formal public comment.
• Hosting regularly scheduled partnership meetings and agenda-driven events.

The community can:

• Attend THMP partnership meetings and conference calls, which THMP will share through their listservs, on the DSHS website, and email notification to established community providers and stakeholders.
• Read the DSHS HIV/STD website for updates.
• Submit unanswered questions to hivstd@dshs.texas.gov.
• Once published, share the THMP Moving Forward Together Plan with your colleagues and community.
• Attend the DSHS THMP Medication Advisory Committee (MAC) meetings and participate in the Texas HIV Syndicate.

Why are the requirements to join the MAC changing?

The requirements to join the MAC have not changed. The MAC does have several open positions (two consumer and two physician). We are in the process of filling them. A committee of DSHS staff members and a representative from the HHSC Ethics Office reviewed the applications and made a recommendation to the DSHS Commissioner. The Advisory Committee Coordination Office (ACCO) provided the review tool used by the review team. The commissioner will make the final decision. Once the final decision is made, we will update the THMP MAC website with the new members.

Should local agencies start implementing strategies now or when budget cuts take place?

We have enough funding to cover services through August 31, 2021. Available funding in FY2022 will determine the financial health of the program moving forward. State appropriations are still being decided by state lawmakers and we are working with an independent actuary to determine if or when additional cost containment measures may need to be implemented. We will notify stakeholders prior to implementation of any changes.

Some contracts have been reduced or eliminated in anticipation of budgetary constraints in FY2022 and those contractors have been notified of reductions.

We welcome suggestions at hivstd@dshs.texas.gov.
 

How will we know when cost containment measures are rescinded?

We will share changes to cost containment measures with impacted clients or applicants electronically via THMP listserv, post on the website, announce at the MAC meeting, and at any future partnership meetings.

Can you provide more details about the database miscalculation that contributed to the budget shortfall? How did it happen?

In August 2020, following annual medication inventory, staff were not able to match the number of medications on the product distribution report with the number of medications counted by hand. Staff discovered that about 25% of medications shipped in FY2020 were still being counted in inventory. This was due to the following factors:

• Erroneous data from a report tied to the ITEAMS inventory tracking system that showed medications still in inventory that had already been shipped to clients. Previously, these errors were changed manually as they were identified.
• Due to staff losses and reassignments during COVID-19, the manual process for changing medications to SHIPPED status stopped accidentally due to a lack of knowledge transfer.
• Monthly stock-on-hand counts during FY2020 as outlined in program procedures were not conducted regularly.
• The medication spend plan was not revised to account for temporary COVID-19 policy changes that increased THMP’s overall medication costs.

Is DSHS still using the database that miscalculated medication inventory? How will DSHS better monitor inventory so this does not happen again?

The ITEAMS system is still in use. ITEAMS will be replaced entirely with a new pharmacy inventory management system that includes on-board reporting functionality. The ITEAMS replacement project is scheduled for completion in 2022. Other controls are in place to ensure accurate medication tracking, including:

• Stabilizing the ITEAMS system to maintain its current functionality until its planned end-of-life in 2022.
• Addressing the reporting error in coordination with IT to ensure the report accurately captures medication status as SHIPPED when it goes out via our shipping contractor. In the meantime, IT staff have developed a revised report to capture all medications that are either SHIPPED or PACKED to track medications that will no longer be in inventory.
• Continuing to manually change medication statuses until the reporting error can be resolved. This was previously done by IT staff, and to create efficiencies in making timely changes, in November 2020, Pharmacy staff developed a process to be able to make the manual changes themselves.
• Performing monthly inventory hand-counts of medications to check against reported inventory levels and setting monthly inventory hand-count dates (and makeup dates in case they are needed) for 12 months at the start of each fiscal year.
• Reviewing ITEAMS data match inventory from different systems. This creates more checks and balances across systems.

The glitch caused a $35 million budget error. Was the glitch the primary driver of the program budget shortfall?

No. The glitch was one, but not the only, contributing factor that caused the budget error.

In August 2020, following annual medication inventory, staff were not able to match the number of medications on the product distribution report with the number of medications counted by hand. Staff discovered that about 25% of medications shipped in FY2020 were still being counted in inventory. This was due to the following factors:

• Erroneous data from a report tied to the ITEAMS inventory tracking system that showed medications still in inventory that had already been shipped to clients. Previously, these errors were changed manually as they were identified.
• Due to staff losses and reassignments during COVID-19, the manual process for changing medications to SHIPPED status stopped.
• Monthly stock-on-hand counts during FY2020 as outlined in program procedures were not conducted regularly.
• The medication spend plan was not revised to account for temporary COVID-19 policy changes that increased THMP’s overall medication costs.
• In the short-term, this error is being remediated with a revised query that treats both packed and shipped orders as completed orders and by manually changing the status to shipped in ITEAMS using handheld scanners.

A project to stabilize ITEAMS is now underway, and the application is expected to be replaced altogether with a new pharmacy inventory management system in 2022.

DSHS is also matching ITEAMS inventory data with data from different systems for more checks and balances across systems.

We are now conducting monthly manual stock on hand counts.
 

Is the $34.4 million JUST for ADAP, or is it Part B overall? Did this software system glitch only show up this year?

The $34.4M is specific to the number of medications that were shipped to clients but not counted by the pharmacy’s inventory report.

In August 2020, following annual medication inventory, staff were not able to match the number of medications on the product distribution report with the number of medications counted by hand. Staff discovered that about 25% of medications shipped in FY2020 were still being counted in inventory. This was due to the following factors:

• Erroneous data from a report tied to the ITEAMS inventory tracking system that showed medications still in inventory that had already been shipped to clients. Previously, these errors were changed manually as they were identified.
• Due to staff losses and reassignments during COVID-19, the manual process for changing medications to SHIPPED status stopped.
• Monthly stock-on-hand counts during FY2020 as outlined in program procedures were not conducted regularly.
• The medication spend plan was not revised to account for temporary COVID-19 policy changes that increased THMP’s overall medication costs.
• There are several ongoing activities to remediate this issue.

In the short-term, this error is being remediated with a revised query that treats both packed and shipped orders as completed orders and by manually changing the status to shipped in ITEAMS using handheld scanners. Additionally, we are now conducting monthly manual stock on hand counts. DSHS is also matching ITEAMS inventory data with data from different systems for more checks and balances across systems.

A project to stabilize ITEAMS is now underway, and the application is expected to be replaced altogether with a new pharmacy inventory management system in 2022.
 

Do we have a timeframe of when the pharmacy system will be upgraded?

We will replace ITEAMS entirely with a new pharmacy inventory management system that includes on-board reporting functionality. We scheduled the ITEAMS replacement project for completion in 2022.

When income is determined to be between 100 and 200 percent of FPL, who is considered the payer of last resort – ADAP or Ryan White? How should it be determined which a client should apply for? What are the program limitations that help determine this?

RWHAP funds ADAP. We consider them both the payor of last resort. Many jurisdictions encourage clients to attempt to enroll in ADAP before accessing other service categories through RWHAP, such as Local Pharmacy Assistance (LPAP) or Emergency Financial Assistance (EFA). This is so local areas can keep more money at the local level. Check with your local Administrative Agency for guidance and clarification.
 

What can people living with HIV do if they are denied ADAP?

If clients are not eligible for THMP, DSHS encourages ADAP Enrollment workers to enroll eligible clients in available health plans or refer clients to expert enrollment entities to cover medical care and medication costs. Other available resources include patient assistance programs (PAPs). Also, RWHAP-funded providers can use Local Pharmaceutical Assistance Program (LPAP) funds to pay for medications on the local LPAP formulary.

Has DSHS set a date to lower the FPL?

DSHS does not have a plan to lower the FPL currently. The program has enough funds to support an FPL of 200% for the rest of fiscal year (FY) 21 (through August 31, 2021).
 

Will DSHS create a mechanism to identify people impacted by cost containment and proactively reach out to them? Providers have been asking for information about specific people impacted and have not been able to get real numbers and data from THMP.

THMP sent information to local AAs. This information let them know how many people would be over income, per THMP’s income guidelines, with the elimination of the spend down. We could not share a list of specific individuals because we reassess each client’s eligibility at the next six-month self-attestation or recertification. We did ask agencies to look at people at or near the 200% FPL because these are individuals who would likely be ineligible for THMP. We also reassessed income and sent either an approval or second denial letter, as applicable, to those already impacted.

If the medication budget is the issue, why are medications available on THMP formulary that do not relate to treatment of HIV or Hepatitis C infection? Who is the contact for information regarding HCV meds and service access in Houston?

A recent cost saving measure THMP pursued is approval to suspend medications from THMP Formulary. Initially, THMP proposed suspension of 17 medications. After meeting with the Medication Advisory (MAC) formulary subcommittee, suspension of 12 out of the 17 medications proposed by THMP was recommended to the full MAC. At the April 30th, 2021 meeting, the MAC voted to recommend suspension of 12 medications as a cost saving measure for the treatment of:

• Chronic conditions,
• HIV medication side effects,
• Injection Opportunistic Therapy,
• and Hepatitis B
• Per Texas Health and Safety Code section 85.061, the commissioner is authorized to approve or suspend medications from the formulary. THMP recently received notification from the DSHS commissioner, to suspend all 17 medications to assist the program with additional cost savings.

It is important to note, the committee requested that these medications be suspended, not removed, to allow the program to reactivate them when the budget situation for THMP improves. In addition, the MAC also requested the program allow a total of 90 days from notification to allow participants to transition to another source for these medications before removal. During this time, new approvals for these medications will be suspended.

Please contact:
Houston Health Department
Bureau of HIV/STD and Viral Hepatitis Prevention
Hotline: 832-393-5010
hivstdvh@houstontx.gov

If the DSHS pharmacy is a Class A pharmacy, can they accept insurance for HIV medication? Could a patient disenroll from THMP because of new insurance coverage, but continue to get medication from the DSHS Pharmacy, billing insurance to generate revenue?

The DSHS Pharmacy does not accept insurance right now.
 

Is the insurance program you are referring to for THMP implemented through Ryan White Part B?

If clients are not eligible for THMP, DSHS encourages ADAP Enrollment workers to enroll eligible clients in available health plans or refer clients to expert enrollment entities to cover medical care and medication costs. Other available resources include patient assistance programs (PAPs). Also, RWHAP-funded providers can use Local Pharmaceutical Assistance Program (LPAP) funds to pay for medications on the local LPAP formulary.

Is THMP exploring injectable medication?

Yes. An injectable medication, Cabotegravir-Rilpivirine (Cabenuva), was on the agenda for the April 30, 2021, MAC meeting. The MAC did recommend we add it as a pilot.

However, we may need to delay the addition of Cabenuva to the THMP formulary until the logistics of how to ship the injectable to providers is solidified.

Several states are facing the same struggle with Cabenuva in terms of how to best ship and coordinate Ryan White coverage for the associated office visit fee.

We have not made any definitive decisions and will discuss more with the MAC and formulary subcommittee, once the action memo has been returned.

What is the DSHS plan to communicate with PAPs about the potential need of moving clients from THMP to a PAP?

If we have a waitlist and/or a significant increase in THMP denials, we will notify our partners, PAPs, AEWs and other enrollment workers. We will share the potential increase of Texas clients moving from THMP and applying for PAPs. We are also exploring how we can share communications more robustly.

We invited pharmaceutical companies to take part in meetings and Medication Advisory Committee Meetings where we discuss budget shortfall issues to inform potential increases in PAP requests.

We will send letters telling them of denial or placements on a waitlist so clients can apply for a PAP as early as possible. We commit to doing this in a timely manner.
 

Is anyone working with pharmaceutical companies to make the process to get medications smoother and easier by this summer given THMP funding issues?

We invite pharmaceutical companies to take part in Partnership Meetings and Medication Advisory Committee Meetings. This is where we discuss budget shortfall issues that may lead to potential increases in PAP requests.

Additionally, THMP is part of the ADAP Crisis Task Force (ACTF), which negotiates reduced drug prices on behalf of AIDS Drug Assistance Programs (ADAPs) in all 50 states, the District of Columbia, and the U.S. territories. These meetings include the pharmaceutical companies. We also invite pharmaceutical companies to take part in meetings and Medication Advisory Committee meetings where we discuss concerns.
 

How does the THMP budgetary shortfall and possible implementation of a waitlist really impact providers? You write prescriptions and then we find out it is not covered.

DSHS does not anticipate implementing a waitlist within the next two years. However, in the event of a waitlist, medical providers and AEWs could see an increase in requests for PAP assistance paperwork. RWHAP-funded providers might also see an uptick in the use Local Pharmaceutical Assistance Program (LPAP) funds to pay for medications on the local LPAP formulary.
 

Due to the delay in processing ADAP applications, clinics will often pay for patient medications until the THMP application is processed (either approved or denied). What is the solution for this situation?

We are in the process of replacing our IT system. When complete, the HRAR Project will allow clients to complete their THMP application electronically with a streamlined process for initial submission, recertification and self-attestation. This will help reduce the time it takes to review complete applications.

If clients are not eligible for THMP, DSHS encourages ADAP Enrollment workers to enroll eligible clients in available health plans or refer clients to expert enrollment entities to cover medical care and medication costs. Other available resources include patient assistance programs (PAPs). Also, RWHAP-funded providers can use Local Pharmaceutical Assistance Program (LPAP) funds to pay for medications on the local LPAP formulary.
 

Many PAPs will not enroll someone if they are eligible for THMP. Will there be documentation stating the THMP status of such people? What will that look like?

Yes, DSHS continues to put status updates and denial letters in the AIDS Regional Information and Evaluation System (ARIES), which holds information securely for THMP, for access by authorized staff at Ryan White HIV/AIDS Program (RWHAP) funded clinics and agencies. We also mail denial letters to client homes. That process will not change. Clients can use such letters to get on a patient assistance program (PAP), which will cover the cost of medication.

What guidance did HRSA provide to DSHS on the spend down?

HRSA determined we were not applying spend down evenly because the spend down was determined by the cost of each client’s drugs. This means that if a doctor prescribed a name brand drug to a client, this client was able to lower their eligibility income level more than a client whose doctor prescribed a less expensive, generic drug.

We are working with HRSA to find a better system, and possibly a standard deduction. This could adjust annual income of clients evenly and fairly.
 

The spend down elimination is on hold until at least June 30, 2021. What is the plan after that?

We will continue to work with HRSA and agency leadership to determine the best way forward. We will notify stakeholders well in advance of any changes taking effect.
 

Why would a spend down be necessary, if eligible in another program?

ADAP is a payor of last resort (PoLR) program. This means that no other programs are available to a client to assist with medication coverage if they are eligible for ADAP. A spend down helps clients that are applying by allowing clients to lower their eligibility income level by deducting the annual cost of their medications (based on what THMP pays) from their annual income.

Is there a way THMP can hire more staff to ensure applications are getting approved in time, so our clients don’t go without their medication if they don’t qualify for a PAP?

THMP is requesting additional temporary positions to get application reviews caught up.
 

With the departure of the previous Director of the HIV/STD Prevention and Care Unit, what does that mean for the TMHP?

Due to the vacancy of the Director of the HIV/STD Prevention and Care Unit, all programs within this unit are now reporting to TB/HIV/STD Section Director, Felipe Rocha, until we fill the position. We shared the job posting with the field and encourage interested applicants to apply.
 

Can you please explain or confirm the rumor that HIV staff are being combined with another department? How will that affect the THMP?

The DSHS TB/HIV/STD Section (THSS) began working within the DSHS Community Health Improvement (CHI) Division under the leadership of Dr. Manda Hall in January 2021. Our THMP operations were not affected. CHI provided temporary oversight due to the deployment of Laboratory and Infectious Disease Services (LIDS) Associate Commissioner Imelda Garcia to COVID-19 response. CHI helped THSS ensure that THMP continues to provide uninterrupted services until oversight was transferred back to LIDS on June 1, 2021.
 

If the waitlist is implemented, how is it expected that these patients obtain the needed medications? Will DSHS assign someone to manage the waitlist?

With the outcome of the 87th Texas Legislature’s Exceptional Item award, we do not plan to implement a waitlist for ADAP during this biennium. We are continuing to work with an actuarial firm to project the future growth of the program to anticipate future budgetary needs.
 

What role can the Strike Force play in the hiring process of the new Director of HIV/STD Prevention and Care?

The position is being reviewed and will be reposted. The Strike Force can share this job posting with members of the community that maybe eligible and encourage them to apply.

Would dis-enrolled clients have priority over new applicants on the waitlist?

We are looking at the best way to put a waitlist in place. We would determine this based on statute, rules, and budgetary limitations.
 

How will DSHS process new applicants on a waitlist?

All individuals would still complete the application process, but DSHS has not finalized what the waitlist process will be for new applicants. We will notify stakeholders well in advance of any changes taking effect.
 

What is the start date of the waitlist?

DSHS has not set a specific date for a waitlist. We are working with an actuary to project the growth of the program. We are also looking at the funding required to support that growth and actively seeking out additional funding and exploring more program changes that would prevent the need for a waitlist.
 

How do 340B rebates impact THMP and local providers?

THMP is a 340B entity. This allows the DSHS Pharmacy to buy medications for ADAP participants at significantly reduced prices. However, THMP cannot get rebates for medications purchased at 340B prices, which means that the program’s ability to generate additional revenue is limited.

Providers generating 340B and other program income from their association with the Ryan White HIV/AIDS Program Part B (RWHAP-B) grant are required to use the program income for RWHAP-B eligible services, such as providing HIV medication to eligible clients.