Section 692.5  Definitions

 

"AIDS Drug Assistance Program" or "ADAP" means a program that provides drugs to prolong the lives of low income persons with Acquired Immumodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) infection who are not eligible under Article V of the Illinois Public Aid Code for Medical Assistance.  (Section 2310-315(13) of the Civil Administrative Code of Illinois)

 

"CD4 count" means the measurement of the number of CD4 cells in a sample of blood, which tells how strong the immune system is and indicates the stage of HIV disease.

 

"Creditable coverage" means coverage of an individual as defined in 45 CFR 146.113(a)(1) (Public Welfare:  Rules relating to creditable coverage).

 

"Department" means the Illinois Department of Public Health.

 

"Extra Help Program" means a federal program that assists very low income (less than $1,000/month) Medicare Part D eligible individuals with their prescription drug coverage. The program pays Medicare Part D premiums and all copayments except $2 and $3 on generic and brand, respectively. The program was established by the  Patient Protection and Affordable Care Act (P.L. 111-148).

 

"Medicaid" means the State-managed program under the federal Social Security Act (42 USC 1396) that pays medical care expenses for low-income individuals, including those with HIV/AIDS.

 

"Medicare" means the federal program under the Social Security Act (42 USC 1395) that pays for certain health care expenses for people age 65 or older. Enrolled individuals must pay deductibles and co-payments. 

 

"Prescription insurance" means insurance paid for or provided by an employer, family member or the applicant that covers prescription medications.

 

"Viral load" means a measurement of human immunodeficiency virus (HIV) in a sample of blood or other body fluids. 

 

(Source:  Amended at 37 Ill. Reg. 11371, effective July 2, 2013)

 

Section 692.6  Incorporated and Referenced Materials

 

The following materials are incorporated or referenced in this Part:

 

a)         Illinois Statutes

 

1)         Civil Administrative Code of Illinois [20 ILCS 2310]

 

2)         Illinois Public Aid Code [305 ILCS 5]

 

b)         Federal Statutes

 

1)         Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87)

 

2)         Patient Protection and Affordable Care Act (P.L. 111-148)

 

3)         Social Security Act (42 USC 1395 and 1396)

 

c)         Illinois Administrative Rules

 

Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100)

 

d)         Federal Regulations

 

45 CFR 146.113(a)(1) (2012) (Public Welfare:  Rules relating to creditable coverage)

 

(Source:  Amended at 37 Ill. Reg. 11371, effective July 2, 2013)

 

Section 692.10  Drugs to Prolong the Lives of Non-Medicaid Persons with Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) Infection

 

Drugs provided under this Part are paid for on behalf of low-income individuals with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV).

 

a)         Eligibility requirements.  To qualify for services under this Part, a person shall have been enrolled in the AIDS Drug Assistance Program (ADAP) as of June 4, 1996, or:

 

1)         Apply to the Department for acceptance for ADAP and comply with all recertification requirements, which occur every six months from the point of enrollment; and

 

2)         Be diagnosed as having AIDS or HIV and be currently receiving HIV care, including having received a viral load test result and CD4 count within the six months prior to the date of the application or recertification.

 

b)         Financial and insurance requirements

 

1)         Applicants with no active prescription insurance coverage at the time of enrollment shall qualify financially with anticipated gross monthly income, as determined by the Department, at or below 300% FPL of the most recent Federal Poverty Guidelines published annually by the U.S. Department of Health and Human Services for the size of the household. (See Appendix A.)

 

2)         Applicants with active prescription coverage at the time of enrollment shall qualify financially with anticipated gross monthly income, as determined by the Department, at or below 500% FPL for the size of the household.

 

A)        The applicant's health insurance provider must be willing to participate with the Department's contracted dispensing pharmacy for dispensing and billing purposes and only for drugs on the current ADAP formulary. 

 

B)        Only 30-day prescription fills will be accepted.  If an applicant is planning to travel outside of Illinois for two to three months and needs a longer prescription fill, the applicant shall obtain prior approval from ADAP for a medication exception.  The applicant shall provide a clear copy of the front and back of all prescription insurance cards.

 

C)        Applicants who were enrolled in ADAP on July 1, 2011, in the 301-500% FPL income bracket shall be grandfathered into ADAP on a go-forward basis, as long as the applicant's recertifications are complete and submitted on time and do not exceed 500% FPL.  If an applicant within this cohort is closed from the program due to failure to reapply on time, then the applicant will be assessed using the 300% FPL eligibility limit.

 

D)        Applicants in the 301-500% FPL income bracket who have not been covered under creditable coverage for a continuous six month period prior to the date of application, but would have been eligible for a creditable coverage program recently offered under a State or federal government entity, will be assessed on the same standard as those with active prescription coverage.

 

3)         Applicants shall not be eligible for the Medical Assistance Program (Medicaid) on the date that drugs are obtained (individuals with financial/medical assistance applications pending or individuals in spenddown unmet status may participate).

 

4)         If eligible for Medicare Part D, the applicant shall enroll in Medicare Part D and provide information on the Part D coverage plan.

 

5)         If enrolled in a Medicare Supplement plan (Medigap), the applicant shall provide information on Medigap plan and coverage.

 

6)         If eligible for federal Extra Help, the applicant must enroll and provide information on coverage.

 

c)         Residency requirement.  The applicant shall be a legal resident of Illinois, as defined by Section 2-10 of the Illinois Public Aid Code, except that:

 

1)         The provision of Section 2-10 of the Illinois Public Aid Code stating that applicants for or recipients of public aid must meet the requirements for duration of residence contained in applicable Sections of the Public Aid Code shall not apply to this Part; and

 

2)         The provision of Section 2-10 of the Illinois Public Aid Code regarding recipients of aid under Article III, IV, or VI  shall apply to any recipient of services under ADAP.

 

d)         Persons enrolled in ADAP shall recertify their eligibility every six months to continue receiving drugs through ADAP.

 

1)         The Department will establish recertification procedures, as required by federal regulations and guidelines. Recertification applications, and any necessary new verifications, shall be received by the Department at least three business days prior to the expiration date of the client's current enrollment to avoid any interruption in service.

 

2)         If the Department does not receive a recertification application at least three business days prior to the expiration date of the client's current enrollment, the client will be removed from ADAP and will be required to meet the eligibility requirements of subsections (a) through (c) of this Section in order to continue receiving drugs through ADAP.

 

3)         To avoid interruption in care, the Department will make reasonable attempts to notify recipients or their designees when an incomplete recertification application has been received.

 

e)         The Department will suspend a client's enrollment in ADAP under the following circumstances:

 

1)         Failure to submit a completed initial or recertification  application at least three business days prior to the expiration date of the client's current enrollment; or

 

2)         Failure to use a minimum of one drug from any category of the ADAP formulary within 90 days after enrollment in ADAP.

 

f)         The Department will send written notice of suspension within 30 days after the suspension, which may be appealed in accordance with subsection (l). The suspension will be lifted when the circumstances that initiated suspension have been rectified.

 

g)         The Department will permanently terminate a client's enrollment in ADAP if the client submits fraudulent application information.  The Department will send written notice of termination within 30 days after the termination, which may be appealed in accordance with the provision of subsection (l).

 

h)         Subject to the availability of funds, the Department may implement cost control measures at any time to ensure the long-term sustainability of the program. Any cost control measures taken pursuant to this Section will be made only after a 90-day notice period to all applicants and providers.

 

i)          All drugs provided under ADAP have been approved by the federal Food and Drug Administration.  The Department will request the advice of the medical issues subcommittee of the Ryan White ADAP Medical Issues Advisory Board when necessary to assist with determining which drugs will be covered, based on criteria that include the medical appropriateness of the drug for treatment of HIV/AIDS and associated complications.  The following categories of drugs may be covered under ADAP:

 

            1)         Category I − Drugs for Anti-Retroviral Therapy;

 

2)         Category II − Drugs for Pneumocystis jiroveci (carinii) pneumonia (PCP)  Prophylaxis and Treatment;

 

3)         Category III − Drugs for Prophylaxis and Treatment of Opportunistic Infections and Anti-Microbials;

 

            4)         Category IV − Drugs for Treatment of Neoplasms; and

 

            5)         Category V − Other Drugs Requiring Prior Approval.

 

j)          All prescriptions shall be filled by the Department's pharmacy contractors.

 

k)         The Department may require participants to pay a copayment for prescriptions received.   If a copayment is charged, it shall not exceed the sliding fee structure specified in Part B of the Ryan White HIV/AIDS Treatment Extension Act of 2009 (see Appendix B).

 

l)          The Department will make a disposition and issue a written decision on an application filed pursuant to this Section within 30 business days after the date the Department receives the application.  The Department will make a disposition and issue a written decision on a recertification application filed pursuant to this Section within 30 business days after the date the Department receives the completed application, accompanied by all supporting verification documents that are provided by the applicant or on record with the Department. An applicant may appeal the Department's denial of an initial application, recertification application, or suspension or termination of benefits in accordance with Practice and Procedure in Administrative Hearings.

 

(Source:  Amended at 37 Ill. Reg. 11371, effective July 2, 2013)

 

Section 692.15  Application Requirements

 

Applications for participation in ADAP shall be submitted on forms provided by the Department.  Information requested on the application will include, but not be limited to:

 

a)         Patient information, including marital status, race/ethnicity, pregnancy information, and risk factors;

 

b)         Residency information, including mailing address and prescription address, if different from mailing address;

 

c)         Demographic (name, date of birth, relationship) and income information on household members who qualify as legal dependants to the ADAP applicant, and who may also contribute to the household income, which would  affect the federal poverty level for the applicant as defined by ADAP's federal partner, the United States Health Resources and Services Administration (HRSA);

 

d)         Applicant's income information, including, but not limited to:

 

1)         Gross monthly income, from sources such as wages, unemployment compensation, Social Security, Social Security Disability, veterans' pension, veterans' disability, private disability, workers' compensation, temporary assistance for needy families, general assistance, retirement income, child support, alimony or other spousal support, or any/or all other sources of income provided by the applicant;

 

2)         Documentation of income from paycheck stubs, benefit statement, award letter, court order, federal tax return, or other documentation provided by the applicant or available to the Department;

 

e)         Medical provider information, including, but not limited to, HIV physician, prescribing physician if HIV physician does not prescribe HIV medication, and ADAP liaison (individual to contact on applicant's behalf);

 

f)         Insurance/benefit information, including, but not limited to, prescription insurance, Medicare,  Medicare Part D, Medicare Supplement, Medicaid, Illinois Cares Rx, and veterans' benefits;

 

g)         Clinical information, including, but not limited to, current diagnosis, initial diagnosis, most recent CD4 count, and most recent viral load count; and

 

h)         Client verification and authorization to release confidential information.

 

(Source:  Added at 36 Ill. Reg. 3909, effective February 22, 2012)

 

Section 692.16  Non-Discrimination

 

The Department will ensure that no individual participating in any program or activity of ADAP will be discriminated against because of race, color, religious belief, political affiliation, sex, sexual orientation, national origin or handicap. Pursuant to the requirements of State and federal law, the Department will make reasonable accommodations for individuals with disabilities.

 

(Source:  Added at 36 Ill. Reg. 3909, effective February 22, 2012)

Section 692.APPENDIX A   2023 Poverty Income Guidelines

 

2023 Health and Human Services Poverty Guidelines
Persons in Family	100% Poverty Guideline	Maximum Gross Annual Income ADAP 300% Eligibility
1	$14,580	$43,740
2	19,720	59,160
3	24,860	74,580
4	30,000	90,000
5	35,140	105,420
6	40,280	120,840
7	45,420	136,260
8	50,560	151,680
For additional persons, add	5,140	15,420
See:  Federal Register:  88 FR 3424, January 19, 2023

 

(Source:  Amended at 47 Ill. Reg. 9428, effective June 21, 2023)

Section 692.APPENDIX B   Ryan White HIV/AIDS Treatment Extension Act of 2009 Sliding Fee Scale

 

Sliding Fee Scale
Individual/Family Annual Gross Income	Total Allowable Annual Charges
Equal to or below the official poverty line	No charges permitted
101 to 200 percent of the official poverty line	5 percent or less of gross income level
201 to 300 percent of the official poverty line	7 percent or less of gross income level
more than 300 percent of the official poverty line	10 percent or less of gross income level

 

(Source:  Amended at 36 Ill. Reg. 3909, effective February 22, 2012)