700.007 Texas Insurance Assistance Program

Policy Number 700.007
Effective Date October 6, 2021
Revision Date  
Subject Matter Expert Texas HIV Medication Program Staff
Approval Authority HIV/STD Prevention and Care Branch Manager
Signed by Felipe Rocha, M.S.S.W.

1.0 Purpose

This policy establishes eligibility requirements and allowable expenditures for the Texas Insurance Assistance Program (TIAP). TIAP is funded by the Texas Department of State Health Services (DSHS) Texas HIV Medication Program (THMP).

This policy also provides guidance and requirements for enrollment in TIAP for THMP applicants and participants with health insurance. It does not address eligibility requirements for public insurance programs or job-based 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. Refer clients to expert agencies and organizations to help with choosing and enrolling in other programs or purchasing health insurance.

2.0 Authority

This policy is authorized by:

3.0 Background

The Ryan White HIV/AIDS Program (RWHAP) provides access to human immunodeficiency virus (HIV) related outpatient and support services to low-income people. DSHS 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 that grantees use funds awarded through all RWHAP Parts as payment of last resort (HRSA PCN 13-02).

THMP, as an AIDS Drug Assistance Program (ADAP), provides medications approved by the U.S. Food and Drug Administration (FDA) to low-income people 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 to direct payment for medications, ADAPs can pay for medication cost-sharing (deductibles, co-payments, and/or co-insurance costs) for ADAP-enrolled clients with another payer. The intention is to preserve or purchase client health insurance as an alternative payment mechanism for medications.

For DSHS ADAP, the State Pharmaceutical Assistance Program (SPAP) provides assistance with Medicare Part D (see DSHS Policy 700.005, Medicare Part D). The TIAP makes health insurance assistance payments outside of Medicare.

The passage of the Patient Protection and Affordable Care Act (ACA) prohibits the exclusion of pre-existing conditions and eliminates limits on maximum insurance payments for a beneficiary's health care services. These changes make insurance more accessible and useful for people with chronic conditions like HIV. The elimination of exclusions for pre-existing conditions gives people living with HIV the choice and ability to change plans or pick up new insurance after gaps in coverage.

In response to the ACA, HRSA PCN 18-01 strengthens requirements that RWHAP grantees and their contractors vigorously pursue enrollment in health insurance for eligible clients. The cost of providing health insurance assistance must be cost-effective, or lower than the cost of providing these health services through grant-supported direct delivery.

4.0 Definitions

Administrative Agency (AA) – A DSHS contractor that disburses DSHS funds via subcontractors (community agencies) to provide comprehensive services to people living with HIV within the service planning area.

Co-Payment – 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).

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

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

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.

TIAP Benchmark – The sum of the average ADAP expenditure and the average medical expenditure on covered clinical services, which is the total per client expenditure on directly delivered clinical services used for TIAP and calculated annually (see DSHS Policy 270.001, Calculation of Estimated Expenditures on Covered Clinical Services for benchmark calculation description). Any participant currently on the program who does not meet the benchmark is allowed to continue on the program as long as they have continuous enrollment.

Open and Special Enrollment Periods – Specified times of the year when clients are eligible to purchase insurance on the Health Insurance Marketplace.

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

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

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

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

Supplemental Insurance – An insurance policy that covers expenses not covered by other insurance and requires a premium.

5.0 People and Organizations Affected by this Policy

This policy affects:

  • DSHS HIV/Sexually Transmitted Disease (STD) Prevention and Care Branch 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 TIAP

THMP must enroll and maintain eligible THMP applicants and participants in TIAP. THMP must provide training and technical assistance to community agencies, especially AEWs, to ensure understanding of and enrollment in appropriate plans. THMP must make health insurance premium payments in a timely manner.

6.2 Community Agencies and AEWs

Community agencies must ensure that AEWs or other agency staff screen every client for potential third-party payers or other assistance programs. AEWs must refer clients to expert agencies or organizations for help with enrollment. This must take place before applying to THMP and during open enrollment or after a qualifying event. Requirements for assessment of potential third-party payers and other assistance programs are in DSHS Policy 590.001, DSHS Funds as Payment of Last Resort.

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).
If a client is eligible for enrollment in a health care plan, the client should send plan information to THMP. THMP staff must determine the client’s THMP and plan eligibility before plan enrollment.

AEWs must communicate with clients and other relevant community agencies to remind them to keep TIAP informed of changes in insurance or other changes that might impact eligibility. 

6.3 Administrative Agencies and ADAP Liaisons

ADAP Liaisons must 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 to participate in THMP must provide complete applications, including renewal applications. They must meet the requirements of DSHS Policy 220.001, Eligibility to Receive HIV Services. TIAP clients must be enrolled 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.

7.0 Scope of TIAP

TIAP covers health insurance premiums, deductibles, and co-insurance payments related to medication expenses. THMP pays these expenses through a Pharmacy Benefits Manager (PBM). TIAP participants must use a participating pharmacy.

TIAP will not cover fines or tax obligations for clients. TIAP will not cover OOP expenses unrelated to medication cost-sharing, including outpatient health care deductibles or co-payments, inpatient hospitalization, or emergency department care. THMP will ensure that TIAP covers only medication cost-sharing. THMP will not pay applicants or participants. THMP will use a PBM to pay premiums to insurance companies and OOP payments to pharmacies.

8.0 Expenditure on THMP and Covered Clinical Services as Benchmark for Cost Comparison

To evaluate the cost-effectiveness of health insurance, DSHS must benchmark state expenditures on clinical services typically covered by health insurance plans. A description of how DSHS estimates expenditures on covered clinical services is in DSHS Policy 270.001, Calculation of Estimated Expenditures on Covered Clinical Services.

9.0 Client Eligibility for TIAP

To be eligible for TIAP, a person must meet THMP eligibility criteria in DSHS Policy 220.001, Eligibility to Receive HIV Services, and get qualifying health insurance. Qualifying health insurance includes appropriate primary care services and at least one drug in each class of core antiretroviral therapeutics from the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Qualifying health insurance also includes a TIAP participating pharmacy convenient to the applicant.

9.1 Considerations for Benchmarking and Income Eligibility Criteria

Clients may receive TIAP only for health insurance plan costs lower than the TIAP benchmark. THMP-funded health insurance assistance is considered a component of THMP, not a separate program.  Therefore, eligibility criteria for TIAP are the same as for other programs operated by THMP.

10.0 TIAP Eligible Plans

TIAP covers job-related health insurance and plans on individual and group markets, excluding plans available through the Health Insurance Marketplace. TIAP does not cover plans that offer only catastrophic coverage, plans without a pharmacy benefit, or supplemental insurance that assists only with hospitalization.

11.0 Client Eligibility for TIAP

Access to health insurance may be available to or currently carried by clients 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.

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

11.1 COBRA Continuation Coverage

Clients may request help with the continuation of health coverage, or the Consolidated Omnibus Budget Reconciliation Act (COBRA) if they lose access to job-related insurance through job loss, reduction of work hours, or another qualifying event. COBRA is time-limited and usually more expensive than the job-related coverage formerly available to the client electing to use COBRA. If the client chooses to use COBRA, TIAP will provide coverage subject to the conditions of this policy.

12.0 TIAP Exception Process for Plans that Exceed Benchmark Costs

TIAP will approve requests for health insurance assistance that exceed benchmark costs only when circumstances exist that make financial support of health insurance necessary to preserve the health of the client. For example, a client may have significant co-morbidities that are costly to treat and if left untreated, will limit the success of HIV treatment.

13.0 Cost Control Policies for TIAP

13.1 Response to Lack of Funds

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 

13.2 Restrictions on Off Formulary Payments

TIAP will not cover health insurance when prescriptions for drugs have higher co-pays or co-insurance because they are outside the plan's formulary. These health insurance plans are not eligible for TIAP.

However, TIAP will cover medications that are covered after an appeals process or after prior authorization. 

13.3 Prohibition on the Use of Drug Manufacturer Co-Pay Cards and Other Programs to Reduce OOP Payments

TIAP clients may not use drug manufacturer co-pay cards for medications they receive through their health insurance while on TIAP. Failure to use TIAP co-payment assistance will result in removal from TIAP.

14.0 Revision History

Date Action Section
10/6/2021 This is a new policy. All