1.0 Purpose

This policy establishes eligibility requirements and allowable expenditures for the Texas HIV Medication Program Texas Insurance Assistance Programs (THMP-TIAPs), which include the State Pharmacy Assistance Program (SPAP), Texas Insurance Assistance Program (TIAP), and TIAP-PLUS. The Texas Department of State Health Services (DSHS) Texas HIV Medication Program (THMP) funds the TIAPs. This policy establishes the standards THMP uses to evaluate cost-effectiveness and compliance with payor of last resort requirements when program funds are used for insurance assistance.

This policy also provides guidance and requirements for enrollment in TIAPs for THMP applicants and participants with health insurance. It does not address eligibility requirements for private or public health insurance programs, including employer-sponsored coverage.

Factors that determine the best health insurance plan for a client and the final cost of the plan to a client are specific to each client and beyond the scope of this policy. 
 

2.0 Authority

Texas Health and Safety Code §85.003, Department as Lead Agency and Primary Resource; Texas Administrative Code (TAC) Title 25, §19.08, Limitations and Cost Containment; Centers for Medicare & Medicaid Services; Ryan White Comprehensive AIDS Resources Emergency (CARE) Act; Ryan White Treatment Extension Act 2009; Health Resources and Services Administration (HRSA) Policy Clarification Notices (PCNs):

• HRSA PCN 13-01, Clarifications Regarding Medicaid-Eligible Clients and Coverage of Services by the Ryan White HIV/AIDS Program
• HRSA PCN 13-04, Clarifications Regarding Clients Eligible for Private Health Insurance Coverage of Services by Ryan White HIV/AIDS Program
• HRSA PCN 16-02, RWHAP Services Eligible Individuals and Allowable Uses of Funds
• HRSA PCN 18-01, Clarifications Regarding the Use of Ryan White HIV/AIDS Program Funds for Health Care Coverage Premium and Cost Sharing Assistance
• HRSA PCN 21-02, Determining Client Eligibility & Payor of Last Resort in the Ryan White HIV/AIDS Program
   

3.0 Background

The Ryan White HIV/AIDS Program (RWHAP) provides access to HIV-related outpatient and support services to low-income people. HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort, establishes the RWHAP Part B and state services funds available through DSHS as the payor of last resort. Similarly, the Public Health Service Act requires grantees to use funds awarded through all RWHAP Parts as payment of last resort (HRSA PCN 13-02).

According to the Ryan White Treatment Extension Act 2009, Section 2616. 300ff–26 PROVISION OF TREATMENTS. (f) USE OF HEALTH INSURANCE AND PLANS—(1)(a), a State may expend a grant under section 2611 to provide the therapeutics described in such subsection by paying on behalf of individuals with HIV/AIDS the costs of purchasing or maintaining health insurance or plans whose coverage includes a full range of such therapeutics and appropriate primary care services. HRSA HAB’s guidance in PCN 18-01 clarifies that the health care coverage purchased must include “at least one U.S. Food and Drug Administration (FDA) approved medicine in each drug class of core antiretroviral medicines” outlined in the HHS treatment guidelines (i.e., the minimum formulary requirement for ADAP). THMP, as an AIDS Drug Assistance Program (ADAP), provides medications approved by the U.S. Food and Drug Administration (FDA) to low-income people living with HIV who have limited or no coverage from private insurance, Medicaid, or Medicare. THMP may purchase health insurance or pay medication copayments as an alternative method to provide core antiretroviral (ARV) therapeutics to program enrollees.

For DSHS ADAP, the SPAP assists with Medicare Part D. On January 1, 2006, the Centers for Medicare and Medicaid Services introduced prescription drug coverage for people with Medicare. The Centers for Medicare and Medicaid Services call this benefit Medicare Part D and market it to the public as a Medicare Prescription Drug Benefit. Insurance companies and other private companies work with Medicare to offer a variety of plans. The Centers for Medicare and Medicaid Services provide this benefit through Prescription Drug Plans (PDPs), Medicare Advantage Plans (MAs), and some employers and unions for their retirees. Medicare Part D offers comprehensive drug coverage for prescription drugs, including HIV medications.

HRSA PCN 18-01 strengthens requirements that RWHAP grantees and their contractors vigorously pursue enrollment in health care coverage for which an eligible person may qualify. Consistent with payor of last resort requirements, THMP-TIAP assistance may be used only when other coverage is unavailable, insufficient, or does not fully cover allowable medication-related costs. The cost of providing health insurance assistance must be cost-effective in the aggregate when compared with the cost of providing covered medications directly through THMP and, where applicable, other HIV outpatient or ambulatory services supported through the program.
 

4.0 Definitions

AIDS Drug Assistance Program (ADAP) – A federally funded program that provides medications and other HIV-related services to low-income, uninsured, and underinsured people with HIV or AIDS. ADAP services are available in all 50 states and U.S. territories. The THMP serves as the state's official ADAP.

Administrative Agency (AA) – An organization contracted with the Department of State Health Services (DSHS) to administer Ryan White Part B and State Services funds within a defined geographic service area. The AA ensures a comprehensive continuum of HIV care by overseeing fiscal management, program monitoring, and data quality. It also manages user access and enforces role-based access standards within the TCT application for its service network. For a list of HIV Administrative Agencies, including contact information and coverage areas, visit HIV Administrative Agencies.

Advance Premium Tax Credit (APTC) – An advanced, refundable tax credit that eligible individuals and families can take to help them purchase health insurance through the Health Insurance Marketplace.

Antiretroviral (ARV) – A drug used to prevent a retrovirus, such as HIV, from replicating. The term primarily refers to ARV HIV drug.

Co-Insurance – A cost-sharing requirement that requires the insured to pay a percentage of costs for covered services or prescriptions (e.g., 10 percent of the prescription price).

Community Agency or AA Subcontractor – A local organization contracted by an AA to provide services for people living with HIV.

Consolidated Omnibus Budget Reconciliation Act (COBRA) – A federal law that allows qualified workers to keep their group health insurance after qualifying life events. 

Copayment – A cost-sharing requirement that requires the insured to pay a specified dollar amount for each unit of service (e.g., $10 for each prescription dispensed).

Deductible – A cost-sharing requirement that requires the insured to pay a certain amount for health care services or prescriptions before the health insurance plan covers these costs.

Disenrollment – The process of removing an individual from the program due to failure to comply with participation requirements or other payor of last resort rules.

Drug Manufacturer Copay Assistance Cards – Copay cards from the drug manufacturers that reduce out-of-pocket expenses for brand-name medications for patients with health insurance. 

Job-Based or Employer-Based Insurance Coverage – A health insurance plan in which employees or family members are in one group policy provided by their employers.

Low-Income Subsidy (Extra Help) – A federal program administered by the Social Security Administration that assists with the out-of-pocket costs associated with Medicare Part D.

Medicare – Is a federal health insurance program for people who are 65 years old or older. Clients can sign up for Medicare three months before they turn 65. People may be eligible for Medicare earlier if they have disabilities or meet other special criteria.

Medicare Savings Programs – A federal program that assists with out-of-pocket costs associated with Medicare Part B. This includes the following benefits: Medicaid and the Qualified Medicare Beneficiary (MQMB), Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualified Individuals (QI). The Social Security Administration automatically approves individuals who receive these benefits for the Low-Income Subsidy.

Open and Special Enrollment Periods – Specified times of the year when clients are eligible to change plans or purchase insurance. For clients with Medicare, visit Medicare Open Enrollment Period for more information. For clients with ACA Marketplace Insurance, visit Health Insurance Marketplace. Clients with private or employer-sponsored insurance should contact their employer for their specific enrollment time period.

Out-of-Pocket (OOP) Costs – Expenses for health care not reimbursed by insurance, including deductibles, co-insurance, and copayments for covered services, plus costs for services not covered.

Pharmacy Benefits Manager (PBM) – PBMs provide various services as third-party administrators that manage prescription drug benefits for various healthcare payers. For THMP, DSHS contracts a PBM to provide cost-sharing assistance to eligible participants of THMP TIAPs. This includes coordinating the payments of medication deductibles, copayments, and coinsurance; coordinating the payment of health insurance premiums; providing claims-level data; maintaining a network of pharmacies for third-party coordination of benefits; providing staff with electronic access to claims adjudication and participant enrollment; enacting internal controls to ensure that only approved, on-formulary medications are paid for and ensures that network pharmacies do not use 340B stock or file for pharmaceutical rebates for medications purchased under this program.

Premium – The amount paid by an insured person to an insurance company to keep their insurance policy.

Qualifying Event – A change in status that allows a person to change or purchase insurance outside of open enrollment periods (e.g., involuntary loss of insurance, becoming or gaining a dependent, marriage, or divorce).

State Pharmacy Assistance Program (SPAP) – The Texas SPAP helps HIV-positive individuals with their OOP costs associated with Medicare Part D prescription drug plans, including co-payments, deductibles, coinsurance, and premiums during the coverage gap (the “donut hole”).

Supplemental Insurance – An insurance policy that covers expenses other insurance companies may not cover. For example, a Medigap Policy helps pay for the “gaps” in coverage related to Medicare Part A and Part B. The individual may be responsible for the cost of services not covered by Medicare. Supplemental Insurance requires a premium payment.

Texas HIV Medication Program Texas Insurance Assistance Programs (THMP-TIAPs) – Through SPAP, TIAP, and TIAP-PLUS, THMP provides insurance assistance to eligible participants to help cover insurance premiums, medication deductibles, and medication copayments.

Texas Insurance Assistance Program (TIAP) – Provides medication copayment, medication deductible, and premium assistance with eligible private or employer-sponsored health insurance policies, as well as COBRA.

TIAP-PLUS – Provides premium payments, medication deductible payment assistance, and medication copayment assistance for eligible Marketplace or Off-Marketplace health insurance plan purchasing.

THMP Pre-Approved Plans – Health insurance plans that THMP reviews and identifies each year as eligible for THMP-TIAPs enrollment.

THMP PBM Copay Card – A copay card issued by THMP’s PBM that pays for the participant’s OOP costs for medications.

Wrap Around Resources – Services from the Ryan White program and state-funded agencies available to Medicare beneficiaries to help pay for OOP costs associated with Medicare Part D, including premiums, deductibles, copays, and coinsurance.
 

5.0 People and Organizations Affected

• HIV Care and Medications Unit staff, specifically THMP staff
• DSHS-funded AAs and ADAP Liaisons
• Community Agencies and ADAP Enrollment Workers (AEWs)
• THMP applicants and participants
  
   

6.0 Responsibilities

6.1 THMP and TIAPs

THMP must enroll and maintain eligible THMP applicants and participants in THMP-TIAPs. THMP provides training and technical assistance to community agencies, especially AEWs, to ensure understanding of and enrollment in appropriate plans. THMP makes premium payments for health insurance before each health insurance plan’s due date. THMP makes copayments at the time of service.
 

6.2 Community Agencies and AEWs

Community agencies ensure that AEWs or other agency staff screen every client for potential third-party payors or other assistance programs. This must take place before applying to THMP, during open enrollment, and after a qualifying event. These screenings support THMP’s payor of last resort obligation by requiring reasonable efforts to identify and pursue available public, private, employer-sponsored, Medicare, Medicaid, Marketplace, COBRA, and other assistance resources before THMP funds are used. Requirements for assessment of potential third-party payors and other assistance programs are in HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort.

AEWs must communicate with clients about THMP eligibility determinations and ensure clients can receive additional support if needed. They must also communicate with clients and other relevant community agencies to remind them to keep THMP informed of changes in insurance or other factors that might impact eligibility. AEWs and community agencies will help clients navigate insurance systems through education and guidance as needed.

Patient Assistance Programs (PAPs) and Cost-Sharing Assistance Programs (CAPs) are not subject to the payor of last resort policy except for Local AIDS Pharmaceutical Assistance Programs (LPAPs).
 

6.3 Administrative Agencies and ADAP Liaisons

THMP Liaisons ensure community agencies comply with this policy to ensure THMP is the payment of last resort.
 

6.4 THMP Applicants and Participants

People who apply for or want to continue participating in THMP, including the TIAPs, must provide complete applications, including renewal applications. Participants must select both “phone” and “mail” in contact preferences for THMP to provide the required support. They must attest that they are prescribed at least one ARV medication on the ADAP formulary (see Section 13.3 for utilization). They must meet the requirements of HIV/STD Policy 220.001 – Eligibility to Receive HIV Services. Clients enroll in qualifying health insurance and communicate changes in insurance or eligibility status to THMP, their AEW, or other agency staff who assist with the THMP application process. Applicants and participants have the right to refuse insurance and apply to THMP independently or with the assistance of a community agency for direct medication assistance. Medicare beneficiaries must enroll in a Medicare Part D Prescription Drug Plan as required by HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort. Participants must also report access to new or changed third-party coverage and cooperate with reasonable efforts to use available coverage first so that THMP funds remain the payor of last resort.
 

7.0 Scope of THMP-TIAPs

THMP-TIAPs do not cover fines or tax obligations for participants. These programs do not cover OOP costs unrelated to medication cost-sharing, including outpatient health care deductibles or copayments, inpatient hospitalization, or emergency department care. THMP ensures THMP-TIAPs cover only medication cost-sharing. THMP does not pay applicants or participants directly. THMP uses a PBM to pay premiums to insurance companies and OOP payments to pharmacies.

Per federal law, anyone who took an Advance Premium Tax Credit (APTC) on a marketplace health insurance plan must file a federal income tax return with form 8962 (Premium Tax Credit) to reconcile their federal taxes. TIAP-PLUS participants who took an APTC must follow this law. If the participant underestimated their APTC amount, the IRS may send the participant an overpayment refund. If the participant overestimated their APTC amount, the IRS may send the client a bill, which THMP can pay. The participant must send either the overpayment refund or the underpayment bill to THMP’s identified PBM.

THMP pays expenses through a PBM. THMP participants must use an in-network pharmacy that also participates in THMP PBM’s network of pharmacies for insured participants. For medications requiring special administration, the pharmacy must be in-network, even if delivered and administered at a secondary site.
 

7.1 TIAP

TIAP covers health insurance premiums, medication deductibles, medication copayments, and medication co-insurance payments for eligible health insurance plans.
 

7.2 TIAP-PLUS

TIAP-PLUS covers health insurance premiums, medication deductibles, and medication copayments for eligible health insurance plans.
 

7.3 SPAP

SPAP covers health insurance deductibles, copayments, and co-insurance payments related to medication expenses and Part D premium payments for eligible Medicare recipients.

Medicare beneficiaries who do not qualify for the full low-income subsidy must enroll in a Medicare Part D Prescription Drug Plan (PDP) and access medications through their PDP before receiving medication assistance from the THMP.
 

8.0 THMP Review of Health Insurance Plans

THMP reviews health insurance plans before approving them for THMP-TIAPs enrollment. THMP’s review determines whether a plan meets program requirements for minimum formulary coverage, medication access, participating pharmacy access, provider access, and program cost-effectiveness. 

THMP may consider total program cost, anticipated or actual rebates, medication cost-sharing, premium cost, participant access needs, and other program savings when determining whether a plan is appropriate for THMP-TIAPs. THMP’s review is conducted at the program level and is used to support THMP’s obligation to operate as payor of last resort and to use program funds prudently.

The THMP plan review process is different from the benchmark calculation described in HIV/STD Policy 270.001 – Calculation of Estimated Expenditures on Covered Clinical Services. Policy 270.001 describes a benchmark used for covered clinical services and local health insurance assistance planning. Community agencies, AEWs, and AAs do not calculate or apply that benchmark to approve THMP-TIAPs plans.

THMP publishes a pre-approved plan list each year. Community agencies and AEWs must use the THMP pre-approved plan list and THMP guidance when assisting participants with THMP-TIAPs enrollment. THMP makes the final determination about whether a plan is approved for THMP-TIAPs.
  

9.0 Eligibility for THMP-TIAPs

To be eligible for THMP-TIAPs, a person must meet THMP eligibility criteria in HIV/STD Policy 220.001 – Eligibility to Receive HIV Services, and have or obtain qualifying health insurance. 

Individuals must have a valid prescription for at least one core ARV medication listed in the Guidelines from a licensed physician.
  

10.0 Health Insurance Plan Selection for THMP-TIAPs

THMP-TIAPs may assist with eligible health insurance plans available through Medicare, the Health Insurance Marketplace, off-Marketplace individual plans, employer-sponsored coverage, COBRA continuation coverage, or other group coverage when the plan meets THMP requirements.

To be approved for THMP-TIAPs, a health insurance plan must:

• include appropriate medication coverage, including at least one drug in each class of core antiretroviral therapeutics;
• provide access to pharmacies that participate in the participant’s health plan and THMP’s PBM network;
• support access to appropriate HIV-related care and medication services;
• allow THMP or its PBM to coordinate premium or medication cost-sharing payments, as applicable; and
• meet THMP’s program cost-effectiveness review.

THMP publishes a pre-approved list of health insurance plans each year for the THMP TIAP-PLUS. THMP may also review and implement an insurance premium cap annually for insurance plan. 

THMP-TIAPs cover plans on individual and group markets, including plans available through Medicare, the Health Insurance Marketplace, and job-related health insurance. THMP-TIAPs do not cover plans offering only catastrophic coverage, plans without a pharmacy benefit, or supplemental insurance that assists only with hospitalization.
 

10.1 COBRA Continuation Coverage

TIAP will assist participants with COBRA if the participant is outside of the Marketplace open enrollment election period, and the participant is paying the COBRA premiums. THMP can assist the participant with their COBRA benefit until the benefit ends or the Marketplace Open Enrollment starts, whichever comes first. THMP cannot assist a participant within the first or the last 60 days of the participant’s COBRA election period, because the participant would be eligible for an ACA Marketplace plan at that time through special enrollment. 
 

11.0 Access to Health Insurance accepted by THMP-TIAPs

Access to health insurance may be available to or currently carried by participants eligible for coverage due to their employment or membership in a group, such as a church, union, or professional organization. The person with the membership or employment that qualifies them for health insurance is the covered member or policyholder. The policyholder may be able to add dependents and a spouse or partner to their coverage. Access to health insurance is also available to uninsured people through the Health Insurance Marketplace.

THMP-TIAPs only cover expenses associated with the eligible participant. For example, if the participant is a dependent of the policyholder, then TIAP-PLUS only covers the premium costs of adding said dependent to the plan and the OOP medication expenses for the participant. There is an exception to this practice. TIAP-PLUS assists an eligible participant with the entire cost of a group policy that includes coverage for people not eligible for THMP when the inability to cover these expenses would result in the eligible participant losing health insurance.
 

12.0 Review of Plans not on the THMP Pre-Approved Plan List

THMP may review a health insurance plan that is not on the THMP pre-approved plan list when a participant has documented medication, provider, pharmacy, or other health-related needs that may not be met by a pre-approved plan.

If a client needs a plan that is not on the THMP pre-approved list, the community agency or AEW should send plan information to THMP. THMP determines whether the plan meets THMP-TIAPs requirements. If THMP does not approve the plan, the client must choose another insurance plan or receive assistance through another source.

THMP-TIAPs only approve requests for health insurance assistance exceeding THMP’s program cost-effectiveness requirements when documented circumstances make financial support of health insurance necessary to preserve the health of the participant and when the request remains consistent with federal and state payor of last resort requirements. For example, a participant may have significant co-morbidities that are costly to treat and, if left untreated, will limit the success of HIV treatment. In such cases, THMP may approve an exception when the record demonstrates that the coverage is medically necessary, no reasonable lower-cost alternative will adequately meet the participant’s needs, and the exception is justified as a prudent use of program funds.
 

12.1 Plan Referral to TIAP-PLUS After Open Enrollment

If the client’s insurance plan is not cost-effective (e.g., high copays, limited formulary coverage, hit OOP Max, or high total cost), THMP may assess to provide full-pay medication assistance through ADAP until the client can secure a more affordable plan or until they meet other eligibility criteria.  
 

13.0 Cost Control Policies for THMP-TIAPs

13.1 Response to Lack of Funds

Based on cost containment requirements of 25 TAC §98.108, if funding is limited, THMP may:

• Implement annual expenditure limits
• Lower financial eligibility criteria to a level not lower than 125 percent of the federal poverty level
• Stop enrolling new applicants and start a waiting list of eligible applicants

THMP will share this information with stakeholders at least 60 days before implementation.
 

13.2 Restrictions on Off Formulary Payments

THMP-TIAPs do not cover health insurance when prescriptions for drugs have higher copays or co-insurance because they are outside the plan's formulary. These health insurance plans are not eligible for participation in THMP-TIAPs.

However, THMP-TIAPs may cover medications that the participant’s health insurance plan covers after an appeals process or prior authorization.
 

13.3 Requirements for Prescriptions and Utilization of Health Insurance

If a participant whose premiums THMP pays fails to fill medications for more than 90 days, THMP may disenroll the participant from TIAPs.

THMP staff review the participant’s usage to ensure participants are using the program. If there is no usage after 30 days, THMP staff call and provide guidance to the participant on the correct usage of the program benefits. If there is still no usage after 60 days, THMP staff call and mail a reminder letter to each participant (for those who agree to receive mail) about the correct use of the program benefits. If THMP is unable to contact a participant by phone or mail, it will provide the participant's information to Agency Enrollment Workers (AEWs) for additional outreach efforts.
After 90 days with no participant utilization, THMP disenrolls the participant from insurance assistance. See Section 15.0 for general participant disenrollment provisions.

THMP will send a letter notifying participants of their disenrollment from TIAPs if they say yes to mail. THMP shares the lists of participants disenrolled each month with AEWs for outreach and to ensure continued medication access.

Upon disenrollment, THMP cancels future insurance premium payments. The insurance will end on the last day of the month unless the participant secures another payor for the insurance policy. If the participant remains eligible for THMP after their insurance ends, THMP will transition them to ADAP for direct medication assistance.

13.3.1 Exception: If the participant has met their maximum OOP during the plan year’s coverage, the participant remains enrolled but is no longer able to use the copay benefit for the rest of the coverage year. However, participants must still maintain their eligibility by submitting the twice-a-year renewal during their birth month and the half-birth month.
 

13.4 Prohibition on the Use of Drug Manufacturer Copay Assistance Cards and Other Programs to Reduce OOP Payments

Participants enrolled in THMP-TIAPs may not use drug manufacturer copay assistance cards for medications they receive through their health insurance while on THMP. Failure to adhere to this guidance and continued usage of drug manufacturer copayment assistance will result in the removal of the participant from THMP.
 

14.0 Guidance on PBM Co-Pay Card Usage

Participants need to make sure their chosen pharmacy is in-network with both the primary insurance and in the THMP PBM’s participating pharmacy network. When at the pharmacy, participants need to present both the THMP PBM copay card and the primary insurance card. Failure to follow this guidance after the reminders from THMP (see Section 13.3) will result in the removal of the participant from the relevant TIAPs. See the video How To Use Your THMP Ramsell Copay Card on how clients can use their insurance and Ramsell copay card effectively.
 

15.0 Participant Disenrollment

Participants can request to disenroll from THMP TIAPs at any time.

If a participant is deceased, moves out of Texas, or no longer requires THMP services, THMP disenrolls the participant. When THMP determines through the renewal process that a TIAPs participant is no longer eligible, THMP will cancel future insurance premium payments and disenroll the participant from TIAPs at the end of the month following the eligibility determination or at the end of the last month for which premiums were paid, whichever is later. The insurance ends on the last day of that month unless the participant secures another payor for the insurance policy. This timeframe gives the participant an opportunity to secure another payor for the insurance policy or transition to direct medication assistance. Section 13.3 addresses utilization-based disenrollment.
 

16.0 Revision History