Summary
The uninsured care programs for HIV/AIDS or those who are at risk provide access to free health benefits for NYS residents who are uninsured or underinsured. The programs include: AIDS Drug Assistance Program (ADAP), ADAP Plus, HIV home care program, ADAP Plus Insurance Continuation Program (APIC) and the Pre-Exposure Prophylaxis Assistance Program (PrEP-AP).
AIDS Drug Assistance Program (ADAP)
ADAP pays for medication for the treatment of HIV/AIDS and opportunistic infections. ADAP can help people with no insurance, partial insurance, with a spenddown, and Medicare. ADAP pays secondary to any drug coverage that one has. ADAP is one of the Uninsured Care Programs in NYS.
The ADAP formulary includes anti-retroviral, anti-neoplastic, and opportunistic infection therapies, and a broad range of HIV-related medications. New drugs approved by the FDA are added to the formulary based upon available funding, and the changing clinical profile of the epidemic.
For a list of eligible medications go to the ADAP formulary at: https://www.health.ny.gov/diseases/aids/general/resources/adap/formulary or call the ADAP Plus Hotline at (800) 542-2437.
ADAP Plus (Primary Care)
ADAP Plus (Primary Care) provides free primary care services at selected clinics, hospital outpatient departments, office-based physicians and lab vendors. The services include medical exams, many laboratory tests, ambulatory care for medical evaluation, dermatology, neurology, family planning, nutritional assessment and counseling, ¬early intervention and ongoing treatment, genotypic and phenotypic resistance testing, hepatitis C testing, viral load testing, dental and oral surgery, eye care, OB/GYN, pediatric, oncology, mental health, multiple vitamins and minerals, and iron supplements. For a complete listing go to https://www.health.ny.gov/diseases/aids/general/resources/adap/doh4043.htm
The following services are not covered by ADAP Plus: Emergency Room services, inpatient services, radiology, rehabilitative therapy (vocational, physical, speech, etc.), HIV counseling and testing, substance abuse and alcoholism services, case management, psychiatric day treatment, therapeutic visits (visits with a nurse to discuss treatment adherence), glasses or contact lenses and durable medical equipment (unless the client is enrolled in the HIV Home Care Program, see below).
HIV Home Care Program
The HIV Home Care Program provides coverage for home care services to chronically dependent individuals as ordered by their physician, including skilled nursing care, home health aide services, personal care services, homemaker services, adult day treatment, nutritional counseling, IV infusion care, physical therapy – limited to 3 lifetime visits, and durable medical equipment when ordered by a physician for specific conditions. Services must be ordered through a home health care agency, which is enrolled in the program. There is a maximum lifetime benefit of $30,000 for home care services.
The HIV home care program will not provide transportation services, substance abuse and alcoholism services, case management, social work, mental health nursing visits, speech therapy, occupational therapy, respiratory therapy, in-patient services or orthotics/prosthetics.
ADAP Plus Insurance Continuation Program (APIC)
APIC will pay premiums for commercial health insurance for applicants who have existing coverage purchased directly from an insurance company or agent, coverage through their employer where the employee contribution for the coverage creates a financial hardship, or COBRA coverage when a person loses their job and cannot afford the premiums.
Policies considered for payment must be comprehensive and provide full prescription and primary care coverage without annual coverage caps. The insurance policy must be cost effective, and the insurance coverage must be comprehensive. If the policy is work-related, premiums must be greater than 4% of income and the employer share must be greater than 50% of the premium cost.
PrEP Assistance Program (PrEP-AP)
The New York State Department of Health, AIDS Institute created a Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) to pay for outpatient services to HIV-negative individuals at risk for HIV infection, as well as for the care and monitoring necessary to successfully use PrEP (an anti-HIV infection medication).
Providers are reimbursed for a specific set of services, including but not limited to HIV testing, counseling, STD testing and supportive primary care services consistent with clinical guidelines, see https://www.hivguidelines.org. Reimbursement is based on Medicaid primary care fee-for-service rates. No co-payment can be charged to participants. To find a PrEP provider visit https://www.greaterthan.org/get-prep. Hospitals and clinics enrolled in the NYS Medicaid program are eligible to enroll in PrEP-AP.
PrEP is an HIV prevention medication in which people who do not have HIV take a daily pill (Truvada) to reduce their risk of becoming infected. The PrEP medication is provided to uninsured HIV negative individuals through the manufacturer’s patient assistance program (PAP). Health care providers are responsible for assisting patients with the PAP application to receive the medication.
Visit Gilead Sciences, the makers of Truvada – the HIV prevention medication, at the Gilead Advancing Access program to find free or low-cost medication: https://www.gileadadvancingaccess.com/financial-support/uninsured.
For individuals with insurance who need help with copay and deductible costs, Gilead’s Advancing Access Co-Pay Coupon provides up to $4,800 per year, with no monthly limit, to cover out-of-pocket expenses for PrEP, including copays, coinsurance, and deductibles.
The program does not restrict benefits based on income; however, it is not available for those on Medicaid, Medicare Part D or any other government prescription drug program. For more information call (800) 226-2056.
For more information about how health care providers can participate in PrEP-AP, call 1-800-542-2437. For general information about PrEP, call the AIDS Institute’s Clinical Education Initiative at 1-866-637-2342.
Accessing the Uninsured Care Programs For HIV/AIDS
FORM OF BENEFIT
Upon determination of eligibility, an Uninsured Care Programs Identification Card or a PrEP-AP Identification card is issued including instructions on how to use it.
Participants must present this card and their prescription at an enrolled pharmacy to receive covered medications. They must also present the card to participating health care providers to receive covered medical services. Participants will receive home care services from an enrolled agency.
Please note that the PrEP-AP Identification card cannot be used to obtain the HIV prevention medication at pharmacies. PrEP-AP participants obtain the medication through the manufacturer’s patient assistance program (PAP).
APIC
Most APIC beneficiaries have their health insurance premiums paid each month directly from UCP to their insurance company. Those whose employee contributions are deducted directly from their pay checks will receive a monthly check from UCP. To receive reimbursement for employment-based coverage, individuals must provide documentation of payroll deductions or other payment for their health insurance.
FEES
There are no fees for covered services.
PROVIDERS
The ADAP Plus Hotline at 800-542-2437 or 1-844-682-4058, can assist recipients in determining which hospitals, clinics, doctors, home care agencies, and pharmacies are participating providers in their area.
Clinics or physicians interested in becoming enrolled providers should call Provider Enrollment at the UCP office: 518-459-1641.
Pharmacies
ADAP has enrolled over 3,100 local pharmacies statewide. Any pharmacy enrolled in the New York State Department of Health Elderly Pharmaceutical Insurance Coverage Program (EPIC) is eligible to join the ADAP pharmacy network.
Health Care Providers
ADAP Plus providers include hospitals, clinics and drug treatment programs. All facilities provide a full range of HIV primary care services. Eligible physicians must be enrolled in the Medicaid HIV Enhanced Fees for Physicians (EFP) Program.
A listing of dental providers is available at:
https://www.health.ny.gov/diseases/aids/general/resources/dental_resource_directory/
PrEP-AP
Find a clinic that understands PrEP and is able to manage ongoing treatment.
Greater Than AIDS
The PrEP locator: https://www.greaterthan.org/campaigns/lets-talk-about-prep/Health Centers including Planned Parenthood: https://www.plannedparenthood.org/get-care
Sexual Health Clinics:
https://www1.nyc.gov/site/doh/services/sexual-health-clinics.page
Home Care
The HIV Home Care Program has provider agreements with over 50 home health agencies, long term home health care programs, hospices and licensed home care service agencies. Home care agencies are screened through the New York State Department of Health Bureau of Long-Term Care.
How the Uninsured Care Programs For HIV/AIDS Coordinates with Other Benefits
AIDS HEALTH INSURANCE PROGRAM (AHIP)
Individuals cannot get both AHIP and APIC. Those who meet the eligibility criteria for both must apply for AHIP, they do not have a choice as to which benefit to choose. See below, AIDS Health Insurance Program for more information.
MEDICAID
Individuals eligible for Medicaid are not eligible for the uninsured care programs for HIV/AIDS. However, these programs can serve as a transition to Medicaid by providing interim assistance to persons eligible for, but not yet enrolled in Medicaid, or if the individual is eligible for Medicaid with a spenddown, these programs assist the individual in meeting the Medicaid spenddown requirements. Medicaid will cover the cost of PrEP.
MEDICAID SPENDDOWN
Participants in the ADAP and ADAP Plus programs who are on the Medicaid spenddown program can submit receipts for medical services paid for by these programs to meet the participant’s spenddown amount.
Once the Medicaid spenddown is met, ADAP coverage is suspended since the individual now has active Medicaid.
For more information on the Medicaid spenddown program and payment by the uninsured care programs , refer to
When a Medicaid spenddown participant has Medicare Part D, see below, Medicare Part D
Note: When an ADAP recipient’s Medicaid is active, it will be the secondary payer and will cover drugs and services not covered by Medicare Part D. At the beginning of each month if Medicaid is not active, the participant can use ADAP towards meeting the spenddown. One may obtain a receipt from the pharmacist to bring to Medicaid to activate Medicaid coverage.
MEDICARE
The Uninsured Care Programs may not bill for Medicare covered services. However, if services requested are custodial or otherwise not covered by Medicare, the uninsured care programs may cover them.
AHIP
Individuals can have AHIP together with Medicare Parts A and B, as long as doing so is deemed to be cost-effective. APIC does not pay the cost of the Medicare B premium.
APIC
APIC does not pay the cost of the Medicare B premium.
MEDICARE PART D
ADAP
Participants who are eligible for Medicare Part D must enroll in a Medicare Part D plan as it is not automatic. ADAP will coordinate benefits with Medicare Part D.
ADAP is generally a secondary payer to Medicare Part D plans. If a drug is covered by both ADAP and Part D, ADAP will help pay the co-payments and deductibles not covered by the Part D plan.
ADAP will not cover any co-payments or deductibles if a drug is not on ADAP’s list of covered drugs.
If the drug is covered by ADAP, but the Part D plan does not cover it, ADAP will cover the cost of the drug; however since all Medicare Part D plans are required to cover all antiretroviral medications and are required to cover at least two drugs in every drug class, this will be the allowed. It is expected that the Medicare.gov Planfinder will be updated for the 2023 Annual Election Period to factor in ADAP coverage so that a beneficiary with both programs can understand their cost sharing.
Exception: While ADAP is typically secondary payer to Medicare Part D, if the participant has Medicaid with a spenddown which has not yet been activated (typically because the spenddown is so high), ADAP becomes the primary insurer and Medicare Part D is secondary. To learn more about this, go to NY Health Access at http://www.wnylc.com/health/entry/197.
PrEP-AP
Medicare will cover the cost of PrEP. Since Medicare Part D covers PrEP, if a beneficiary qualifies, they must enroll in Medicare Part D.
MEDICARE ADVANTAGE
APIC and AHIP can pay Medicare Advantage premiums directly to the insurer.
ADAP can be used with Medicare Advantage plans to pay for medication copayments.
ADAP Plus can be used with Medicare Advantage plans to pay for HIV primary care and lab tests if the provider is an ADAP Plus provider.
COBRA
APIC and AHIP can help to pay for COBRA premiums.
THIRD PARTY HEALTH INSURANCE
Individuals with third-party insurance who cannot meet the plans deductibles or co-payments, or whose policies have waiting periods, may enroll in the uninsured care programs and these programs will coordinate participant benefits with those of their insurance company.
Recipients should present all their health care plan cards when accessing services so the provider should first bill the primary carrier first and ADAP and ADAP Plus for any out-of-pocket expenses.
WORKER’S COMPENSATION
Worker’s compensation benefits include all necessary medical care arising from job-related injury or illness. Therefore, no ADAP or ADAP Plus payments will be made for services covered by Worker’s Compensation.