Services, Fees, Medicaid and Funding for ADAP
The ADAP Formulary of drugs includes anti-retroviral, anti-neoplastic, and opportunistic infection therapies, and prophylaxis for pneumocystic carinii pneumonia (PCP). New drugs are added to the formulary based upon available funding, and the changing clinical profile of the epidemic and the most recent clinical trials data.
ADAP Plus covers a full range of HIV Primary Care services, provided on an out-patient ambulatory basis, including an annual comprehensive medical evaluation, HIV disease monitoring, and the treatment of both HIV and non-HIV related illness.
Services covered through the HIV Home Care Program include: skilled nursing, personal care, homemaker and home health aid services; intravenous medications and supplies and durable medical equipment. A maximum lifetime benefit of $30,000 for home care services is allowed.
PrEP-AP covers a specific set of services, including but not limited to, HIV testing, counseling, STI/STD testing and primary care services, consistent with PrEP clincal guidelines.
No fees are charged to program participants. The Program pays enrolled pharmacies directly for all medications dispensed. The Program coordinates benefits at the pharmacy for people who have ADAP and another payment source for medications (i.e., Medicare Part D or a private insurance plan). ADAP, ADAP Plus, PrEP-AP and the HIV Home Care Program use established Medicaid rates coding for payment of covered services to enrolled providers.
Individuals enrolled in Medicaid are not eligible for the programs. Individuals awaiting Medicaid eligibility determination or having Medicaid Spenddown requirements are eligible. The program interfaces with Medicaid to prevent duplication of enrollment and billing. The programs seek to identify individuals who are potentially eligible for Medicaid and encourage them to apply to Medicaid. Medicaid is the preferred medical coverage for individuals who meet their eligibility requirements, because of Medicaid's broader range of covered services.
The programs are funded through a partnership between New York State, New York City, Lower Hudson, and Long Island using funds from Part A and Part B of the federal Ryan White Treatment Extension Act of 2009. The New York State Department of Health provides funds, from the New York Public Health Care Reform Act.