Florida ADAP Meeting Minutes October 1, 2010 Tampa, Florida

Transcription

1 Florida ADAP Meeting Minutes October 1, 2010 Tampa, Florida Tom Liberti welcomed the ADAP workgroup members and introductions were made. Members and bureau staff present included, Dr. Jeffrey Beal, David Brakebill, Anita Brown, Michael Dey, Mitchell Durant, Jennifer Benz-Findley, William Green, Tom Liberti, Joe May, Dr. Allison Nist, Michael Rajner, Joe Lennox-Smith, Muzette Thomas and Lorraine Wells. Guests in attendance were Ken Bargar, Lisa Cohen, Lanny Cross, Dr. Kenneth Goodman, Julia Hidalgo, Alma Howard, Ted Howard, Gene McCarty, Sean McIntosh, David Poole, Elizabeth Rugg, Michael Ruppal, Denise Robinson, Jim Roth, Mick Sullivan, Michelle Scavnicky, Coy Stout, Alex Tabraue and Debra Tucci Tom introduced and acknowledged the following invited guests: Dr. Kenneth Goodman, Medical Ethicist with University of Miami, Florida Bioethics Network, Lanny Cross, Consultant with NASTAD and Part A grantees in Florida including Aubrey Arnold, Sonja Swanson-Holbrook and Maribel Zayas from the Miami-Dade CHD. Tom Liberti, Bureau Chief, Florida Department of Health, Bureau of HIV/AIDS Tom Liberti provided an overview of the meeting. He explained the purpose of the meeting was to have an ADAP workgroup meeting, and include invited guests and consultants to assist the state of Florida with making key decisions in regards to the ADAP program. He explained that we are currently halfway through the Ryan White year and we still have a structural deficit in the ADAP program and we need to address key funding issues. He also provided an update on the landscape of the epidemic of HIV/AIDS in Florida. He explained that we are trying to accomplish the following during the meeting: 1) Bring everyone up to date on the Florida ADAP Crisis, formulary, Patient Assistance Programs (PAPs), funding, etc. 2) Be able to offer solutions to the challenges. 3) Discuss and debate options (i.e. eligibility and formulary) and get feedback that will aid the department in making some very important and difficult. Tom Liberti provided the following national perspective: There has been a national ADAP crisis for many years. Alabama and North Carolina have had a waiting list for many years. Prior to the recession, all state waiting lists had been cleared. Then shortly after that, everyone was hit hard, especially the southern states driven by flat funding, the recession, linkage to care and testing programs, etc. There are two ways to deal with the current ADAP issues: o Cost containment measures reduce the costs. o Increase resources in some way to alleviate the waiting lists. After the 2006 Ryan White Reauthorization, The Florida ADAP Program was cut by $4 million dollars. Dr. Jeff Beal, Medical Director, Bureau of HIV/AIDS provided the following comments: He explained how remarkable the ADAP staff has been during this crisis by providing guidance to direct us throughout the state. The Ryan White Programs (Part A, B, C, D and F) have come together to work with the community based organizations and have created innovative ways to address the issues. All together we have remained focused on ensuring that patients have access to medications. 1 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

2 He is grateful for the pharmaceutical companies and their assistance with the Patient Assistance Programs to provide medications to clients. Dr. Kenneth Goodman, Medical Ethicist with University of Miami, Florida Bioethics Network expressed his appreciation for being invited to the meeting. He explained he is a faculty member of the University of Miami, and has an ethics network and explained the importance of considering the ethical perspective when making decisions about the ADAP program. Tom Liberti asked Michael Rajner to provide a brief update. Michael Rajner explained that his advocacy work is not being covered by any specific entity and he is solely a volunteer. He noted that his recent visits to Washington were about funding and the bills put forth seeking $126 million to address the ADAP crisis. He asked Congressman Hastings to send a letter to the speaker and the rest of the leadership. During his floor speech, the congressman urged that $25 million dollars be allocated immediately to address the crisis. Michael Rajner also explained that Congresswoman Debbie Wasserman Schultz along with Congressman Alcee Hastings and Congresswoman Kathy Castor will be addressing increased funding. He recently received an on the Federal AIDS Policy Partnership list serve that Speaker Nancy Pelosi is going to support $75 million over the next year for ADAP crisis. Lanny Cross, ADAP Program Specialist, NASTAD Consultant Lanny Cross provided a power point presentation and explained that he was the ADAP Director for New York from and has vast experience dealing with a previous ADAP Crisis. He explained that cost containment measures can be addressed in three ways: 1. Who? Examining eligibility. 2. What? Formulary and what you pay. 3. Price. He introduced and provided the history of the ADAP Crisis Task Force and explained the Fair Pricing Coalition. He further discussed the value of the agreements of the ADAP Crisis Task Force and the negotiation goals and issues that have been addressed. Comments/Questions to Lanny Cross: Tom Liberti commented on what would have happened if the negotiations had not occurred with the Task Force. There has been a significant savings and if this had not occurred, there would have been more people on the waiting lists. He further stated that The AIDS Institute will be tracking issues and including them in the follow-up notes to the Bureau. A challenge with PAP medication delivery/pick up was explained. Many individuals, with transportation challenges, are tasked with picking up medications or receiving them from different sources; multiple pharmacies, mail, physicians offices, different quantities and different application processes for Patient Assistance Programs (PAPs). These issues have caused harm to the patients and their ability to take the proper dosage of medications at the right times. Welvista was discussed and how their program allows for a single application process for the patient to access multiple Patient Assistance Programs was explained. Tom Liberti stated that he will be meeting with the Jeffrey Lewis, President from Heinz Family Foundation to discuss Welvista and future plans for Florida. He also noted, although the issue of the PAP s should be addressed, there is a challenge that we still need to overcome. He explained that elected officials and policy makers hear that the 2 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

3 community has X amount of people on the waiting lists, that they are working with the drug companies, patients are getting their medications, so why should they do anything about funding if no one is going without medications? He stated that yes, we are thankful for the pharmaceutical companies and the patient assistance programs, and that they have provided somewhat of a safety net. However, it is obvious that the safety net has holes in it and is not a long term solution. Lorraine Wells, ADAP Program Director, Bureau of HIV/AIDS Joe May, Program Administrator, Patient Care Section, Bureau of HIV/AIDS Lorraine Wells and Joe May provided a power point presentation and overview of the Florida ADAP Program and its history. They addressed the mission, infrastructure, administration, demographics, and program goals. Lorraine and Joe expressed gratitude to the company representatives in the room who have helped us get through the crisis by providing information and support. Joe May provided the following background information: ADAP is available in all 67 counties, 72 access points around the state. The program is administered by 170 ADAP staff from around the state. Florida is a direct purchase state that buys in bulk and gets a 340B pricing discount upfront. Drugs go to the central pharmacy in Tallahassee. There are 13 county Health Departments that have pharmacies on site and do their own dispensing. The remaining CHDs are serviced by the central pharmacy. The mission of ADAP is to provide Life-Saving Medications, Disease Management Training and Information to Our Clients in a Cost-Effective Way. Explained the formulary slide that showed the program prior to August 1 st, 2010 when there was approximately 100 medications, 30 ARV s, 21 opportunistic infections, 49 other medications that addressed wasting, depression, etc. Provided a snapshot of who ADAP is serving and the income level. The program truly serves the underserved population. Gender and Race/Ethnicity; 71% Male, 28% Female and 1% Transgender; Ethnic or Racial breakdown: Blacks account for 36%, Whites 28%, Hispanic 26% Haitian 9%, and others 1% (Asian, Pacific Islander, Native American and multiple races) Age of ADAP Client: largest group is years old representing 51% of clients and years old is the next largest age group accessing ADAP services. There are a number of quality management strategies that are being implemented in the ADAP program. Currently examining the National HIV/AIDS Strategy for ways to improve client outcomes. Lorraine Wells provided the following information: ADAP has a Quality Management (QM) program that is comprehensive and the most important component is improving client health outcomes. This aligns nicely with the National HIV/AIDS Strategy although we have been doing it for quite some time. For ADAP certification and re-certifications, clients have to provide lab results that are not more than 6 months old. They are used for monitoring, reporting and QM. We examine medication pick-up data for client adherence; this is an indicator while looking at other components of QM. We work closely with the local health departments. 3 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

4 Core outcome measures are to examine CD4 and viral load ranges and monitor the number of clients on anti-retroviral therapy (ARV) which is effective for reducing hospitalization. As a result of QM, a large number of clients have achieved a suppressed viral load. Explained the role of the Medical Director and his relation to the Florida AIDS Education and Training Centers and how he does chart review, works with case managers, medical providers, which contributes to client health outcomes. Explained the Reward Adherence Medication Program (RAMP). It promoted treatment adherence and addressed transportation challenges. However, due to funding constraints RAMP had to be discontinued. Joe May and Lorraine Wells discussed the following Trends that are impacting the ADAP Program: Since 2006: Identified 20,000 HIV positive persons in Florida through public testing initiatives, a significant percentage impacting the ADAP program. AICP has had a waiting list since July of Although the local areas have done an extraordinary job paying premiums they are running out of funding. This is a trend that will continue to lead people to the ADAP program. As of October 1 st, the Health Council of South Florida was able to take 50 people and enroll them into the state AICP program. However, with over 400 people still on the wait list, there is more work to be done. Since 2008, the people coming into the program are showing higher CD4 counts, possibly due to the changes in the recommended treatment guidelines. Monitored trend of new enrollments with over 300 new persons per month. Currently 1.1 million people are unemployed in the state of Florida with an unemployment rate of 11.7% million Floridians are uninsured. Lorraine Wells and Tom Liberti provided an overview of ADAP Funding and Enrollment: Over the last three years ADAP has been funded through Ryan White consistently at $83 million Ryan White ADAP funding is $85 million. In 2006, we had $88 million and we have lost over $4 million since then in ADAP funding. General Revenue (GR) is funding that the Florida Legislature contributes. Currently there is $9.5 million contributed, which is not a lot for the 3 rd largest state in the Country. 2 years ago GR was $10.5 million and has since been cut by $1 million. During the last three legislative sessions, the Florida DOH has been cut by $210 million. Much of these cuts are based on the fiscal crisis and economic downturn. Explanation of current funding: $85 million Ryan White funds, $9.5 million in GR and some new Health Resources and Services Administration (HRSA) emergency ADAP money, which has stipulations and complicates issues by restricting DOH from solving the ADAP crisis in a way that would work for Florida. 4 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

5 Lorraine Wells reviewed a detailed timeline leading up the waiting list and continues to present day. Joe May described the following funding slide: Ryan White $85,188,435 General Revenue $9,500,000 Total $94,688,435 Ryan White (Pharmaceuticals) $74,221,505 General Revenue (Pharmaceuticals) $9,500,000 ADAP Pharmaceuticals Contract: Miami $3,241,945 Insurance Continuation (AICP) $2,683,311 Administration $5,041,674 Total $94,688,435 Lorraine Wells summarized the funding and explained that there is approximately $18-19 million gap to fulfill the needs of the ADAP program. She further explained that if we don t close the gap we will run out of funding in January. As of right now we have used 60% of funding when we would normally be at about 45% for this time of year. Joe May explained the high risk pools and how it is very expensive with out of pocket costs up to $15,000. Florida chose not to develop a state plan so the federal plan is currently operating in Florida. In 2014 the high risk pools go away when the insurance exchanges come in. Lorraine Wells explained that now ADAP dollars can count toward true out of pocket expenses (TrOOP) which translates to a huge savings for the ADAP program. She explained that certain health care reform changes become effective in 2014, a large number of clients will potentially be eligible for Medicaid. Tom Liberti summarized the issue of Medicaid eligibility explaining that there are over 20 ways to get into Florida Medicaid. The Medically Needy program has caused people to bounce in and out of Medicaid. The Bureau is confident that the people on Florida ADAP are not also on or qualified for Florida Medicaid. Staff will continue to monitor or review this issue carefully. He also referenced the disability issue at the national level where states are reducing eligibility for HIV patients through CD4 counts. Tom also summarized the issues regarding cost containment and eligibility for discussion. He explained that last year 18,000 is the number of people enrolled in ADAP, not the number being provided medications. From the timeline of April 1, 2010 to April 1, 2011 we will have approximately $18-19 million deficit even with the Federal money. Also, he explained that the $6.9 million from HRSA has special strings attached to it that opens up another range of issues. The HRSA stipulations restrict our ability to solve the unique problems in Florida. We are appealing their decision, and need to make some tough policy decisions which include the possibility of having to disenroll hundreds or perhaps thousands of individuals. Dr. Kenneth Goodman provided an overview of the statewide ethics network which links health professionals around the state to help resolve difficult ethical issues which include research and clinical settings. He identified that there are ethical and moral obligations to the issues being discussed around ADAP. He asked the group if they agreed with the following statement: The 5 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

6 civil society has a moral responsibility to make sure that people have adequate healthcare. He noted that we need adequate resources to achieve such moral responsibility. He suggested the following recommendations to the group: Take shared values and provide access to healthcare by working collaboratively. Identify resources to move drugs to people. Address the link between ethics and policy to make decisions about the waiting lists. Things change rapidly and are dynamic, be aware of that when setting processes. Identify ways to allocate resources to eliminate collateral damage. There is a duty by the legislature to provide the resources. The ethics network can be used as a resource to this group. Ana M. Viamonte Ros, M.D., M.P.H.; Florida s State Surgeon General Dr. Viamonte Ros thanked all of the individuals and members for their efforts. She explained that she was hoping to gain a sense of the discussion that will arm her with the information to go to the legislature to make her case for the ADAP program. She noted that at the state level, folks need to be educated and she explained that she has visited all 67 county health departments to see and identify the issues, challenges and barriers. She did find people that would not have agreed with Dr. Goodman s statement that everyone deserved a certain level of health care. Dr. Viamonte Ros agrees with concerns about the 1,700 people on the Florida ADAP waiting list. She explained that the challenges in pleading a case to legislators is different because they believe individuals are receiving care and not going without medications. Although the process may have challenges and flaws, the bottom line is that they are not going without medication. At the federal level, they are asking us to use the dollars in a certain way, but how do we argue with them? How do we respond? She is seeking the information, data and ammunition to go back to the legislators and Federal partners and argue about what we need to be doing. Tom Liberti explained that the patient assistance programs (PAPs) are being used to supplement the problem. Although people are getting medications from PAPs, there are many challenges to accessing the PAP s. It is difficult and problematic and is not a long term solution to the problem. He explained that we have the option of looking at the trust fund to provide gap support that we believe we can repay with the federal funding we receive next year. He provided a brief summary of the current fiscal crisis and began discussions on the eligibility and cost containment issues for ADAP. Tom explained that we are seeking a tiered-approach. For example, if we need this much, we could do this, if we get this, then we could do that. Tom raised the following questions for discussion about cost-containment measures: 1. How do you feel about lowering eligibility? 2. How do you feel about annual expenditure caps? Comments/discussion regarding the cost-containment measures Joe Lennox-Smith explained that not all insurance policies are equal; each has its own criteria. He explained that unless the person has experienced the stress of dealing with the severity of the waiting list, then it is not morally right to do this to someone. William Green commented that disenrollment is very difficult when we are talking about healthcare programs. What would the process be and the timeframe? If we decided to lower the Federal Poverty Level (FPL), etc. we will need to see the data. 6 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

7 Dr. Beal asked Lanny Cross that if we lower the FPL, would it be fair to say the pharmaceutical companies might not guarantee eligibility; currently the agreement is to provide eligibility up to ADAP poverty level. Lanny Cross explained that one company has 300 FPL, but they would not want to incentivize states to drop their FPL. Joe Lennox-Smith argued the point of a moral obligation to people that have been in care and that care being uninterrupted. Tom Liberti explained that everything we are referring to is about reducing program expenditures. None of the cost containment options are appealing. David Brakebill explained that in terms of eligibility, we have to keep in mind that any program is subject to availability of funds. Joe May noted that for an individual who is at 300% FPL it represents $2,700 dollars a month. Persons at or above this income level do have some financial options. Tom Liberti stated that we need to advocate for a policy that reduces the disenrollment number. Once we officially change the eligibility, we cannot put on the impacted clients the waiting list. So there are ramifications that need to be considered. Michael Dey noted that 300% to 400% are the numbers they are working with. We have multiple funding sources around the state at the table. Would there be a process to look at areas and different things per area? Do you have that flexibility? If the funders were approached and flexible to pick up the gap in need. Jennifer Benz-Findley raised concerns that clients have to go through different pharmaceutical companies to gain medications. Tom Liberti noted that they are looking at Welvista as a possible solution in Florida. Sonja Swanson-Holbrook raised concern that once final decisions are made on April 1 st what would that look like for Part A? Tom Liberti replied that if we have total flexibility to use the HRSA money it should reduce the impact on Part A funding. Sonja Swanson-Holbrook explained similar to Welvista, Med Net is another resource people are using. Elizabeth Rugg has developed the program. Michael Rajner raised the issue that eligibility creates numerous other challenges. He suggested a sliding fee scale. Currently you get either everything for free or you have to pay $10,000-$15,000 for other related costs. William Green explained share of cost. This is based on income. Joe May asked if the group would consider making it mandatory. Michael Rajner commented that we need a dollar amount and not just say 300% FPL. Dr. Allison Nist raised concern about managing a program based on the reliability of access of medications. It is going to be very difficult. The restriction from HRSA would cause us to disenroll 2,000 to 3,000, but with flexibility, that number could be as low as 343 persons. Tom Liberti expressed again that we will have to make some difficult decisions regarding disenrollment, eligibility. He proposed the following cost-containment measure to the group: Lab Reductions: o Reduce the number of CD4 and Viral Load Tests. o Currently ADAP clients are permitted up to four (4) HIV viral load laboratory tests and four (4) CD4/CD8 laboratory tests a year through the DOH, Bureau of Statewide Laboratories. 7 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

8 Comments/Discussion on Lab Reductions Dr. Beal reported that the current HRSA recommendation is a minimum expectation of 2 tests annually. Julia Hidalgo stated that patients, Part A, or the care providers would pay for the tests if the state does not cover the costs. Michael Rajner stated that we should look at what the National HIV/AIDS Strategy states regarding laboratory testing. Michael Dey asked for clarification; if patients are in care that means they are being seen once in a year. Tom Liberti noted that they currently cover the cost of testing with Ryan White funding, currently at $845,000. Muzette Thomas noted that a doctor recently explained that he does not test his patients more than once a year. Michael Rajner agreed that he is okay with changing to twice a year, with exceptions, if needed. Dr. Beal provided some history of the waitlist. We used faculty from the Florida AIDS Education Training Center (FLAETC) and using Department of Health and Human Services (DHHS) guidelines, the guidance was devised based on stages of HIV disease. However, since then, HRSA has put out guidance which suggests a tier-system in recognition of stages of diseases for States to consider in developing waiting lists. Today, of the 236 exception requests, Dr. Beal and the Medical team approved 71. He explained some challenges with the current exception process. Dr. Beal reviewed proposed cost containment measures regarding exceptions: Eliminate exception requests (pregnant women and adolescent children will continue to be exempted). Emergency requests would be an option if the physician feels that the person adamantly needs to be in ADAP and cannot wait for a PAP enrollment. Such requests would be made by a phone call to the Medical Team by the patient s clinician. Comments/Questions regarding the Exception Process: William Green asked for clarification on the process for an exception denial. Dr. Beal explained the exception process. He stated that medical exceptions are signed and dated by the physician, and then go to the Case Managers and/or ADAP staff to determine eligibility. The documentation, medical exception request and prescriptions requested are then sent to Tallahassee. The ADAP staff in Tallahassee verifies accuracy of the eligibility determination and forwards the exception then to Medical. The prescribing clinicians often do not know that there is a delay in the exception reaching medical due to the process and required documentation. Sometimes it is the patient who does not keep their appointment or bring the required documents to ADAP or Case Managers in a timely fashion. When Medical gets the paperwork, it is often incompletely filled out by the providers and it has taken days to weeks to get answers to questions needed to complete our process from Case Managers and Medical Office Staff. If Medical receives appropriate documentation, we have been compliant with approving or denying the exceptions within 2-5 business days of receipt. The determination of approval for ADAP or Waiting-listing is communicated to the ADAP Tallahassee staff who then notifies the local ADAP staff. The local ADAP staff has the responsibility of informing the providers and case managers of the Medical Exception determination. If providers are stating that they are not getting the information, it is often a disconnect at the local level. 8 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

9 Jennifer Benz-Findley raised the issue of the sliding fee scales and why we are not considering implementing them. Lorraine Wells explained that the complexities of the sliding fee scale are challenging. Implementing a sliding scale today will not come close to cover the gap we are dealing with. She noted that the sliding scale fee is on the agenda for coordination in William Green noted that if you are saying that there are 343 patients between % of FPL, maybe they are able to contribute based on their income. It might be worth considering sliding scales. Michael Rajner commented that sliding scale fee allows for access. Mitchell Durant commented that with the exceptions, one of the issues is the paperwork. He expressed his concern to not do away with exceptions, but to make it an emergency only process. Dr. Beal responded that changing it to emergency only will help with reducing the paperwork as well as assist the process with being more effective. Maribel Zayas commented that while planning for a budget with a deficit of $20 million you will need to plan for eligibility and collection of that fee for two years from now. Julia Hidalgo commented that when conducting chart reviews we have seen many zero income individuals that have expenditures for daily living. Therefore, when considering implementing sliding scale fees, you will need to look at social security and other pay sources. Michael Rajner raised the previous issue regarding the elimination in regards to pregnant women, and whether they should be screened through other programs prior to being considered for ADAP. He explained that we previously discussed that they should go through Medicaid and expressed that as a gay man living in the state of Florida, he feels there is an inequity and it should be thoroughly reviewed. Lorraine Wells reviewed the proposed cost containment measures regarding reinstituting asset caps. Comments/Questions related to Asset Caps: Jennifer Benz-Findley asked if the PAP programs are going to implement the asset cap as well. Julia Hidalgo stated that you might want to consider if any of the assets can be liquidated, (home ownership and cars) due to the market situation of the client, ability to take a loan, etc. William Green asked if there was a distinction between cash, liquid and other assets. Debbie Tucci commented that the asset caps discussion was challenging in her area based on determining the difference between cash, liquid and other assets. Michael Rajner addressed an issue with the assets in south Florida. He explained that owning various properties should not count against the individual. He feels the policy could discriminate against a person s profession (i.e. real estate broker). Lorraine Wells asked for feedback on eliminating the policy of provision of drugs in jails. The current policy allows clients who have an open script to access in order to prevent drug interruption. Michael Dey asked what type of cost containment could this have on the ADAP program. Lorraine Wells responded that it is not a large number but it does benefit those who find themselves in need. Joe Lennox-Smith commented that he doesn t see it as a large impact. 9 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

10 Jennifer Benz-Findley commented that she disagrees with the elimination of this, since there is no other option for people in her area once they are released. Lisa Cohen explained that there are not that many people in the programs and the goal is to link them into other programs. Dr. Beal explained that although it is a small amount of money, it still addresses moral and ethical issues to ensuring access to medications for those without other options; the jails should be responsible and provide the medical needs of their inmates. Michael Rajner explained that Armor Correctional provides the medications in Broward County. Lorraine Wells explained the difference between the correctional institution and jails; and that each county is different in terms of having access to the medications through the jails. Lorraine Wells asked for feedback on Enforcing Policy for Closures (No Grace Periods). They have recently implemented automatic closures (allowing 60 days to pick up medications). HRSA says we are being gracious by giving them 60 days. William Green raised concern regarding automatic closure and referenced people not picking up their medications. He feels the community does not have a clear understanding of what automatic closure really means. Lorraine Wells responded that if the client is not actively picking up their medications, then the computer will automatically close the file for lack of activity. She explained that originally you have 30 days to pick up the medications allowing a 5 day grace period. After 30 days, then the patient would have to see the doctor. This reinforces the policy for picking up medications within the 30 day timeline or 5 business days (from date of pickup). Jennifer Benz-Findley raised concern regarding the warnings of people being automatically closed out. Is there notification to inform clients before they are closed out? Lorraine Wells responded that the ADAP staff does get notice when the clients are due for pickup. It is their responsibility to share that information with the case manager. Mitchell Durant commented that he agrees with the policy, but he asked to keep the possibility of waivers in place, where we can re-open without putting them on a waiting list. Muzette Thomas asked if the case managers could be told that the people are going to be automatically closed out. Lorraine Wells explained that each area is coordinated differently at the local level. She expressed that they are informed once they are overdue for pick-up. She reiterated the process of automatic closure. Dr. Beal clarified that we are proposing the change to 30 days, plus the 5 grace period versus the 60 days. Lorraine Wells explained that the impact of the change will affect approximately 562 individuals and the numbers change daily. Michael Rajner expressed the need for flexibility. He suggests a re-entry policy for extenuating circumstances so the individual is not completely closed out, including the option for a 45 day period. Dr. Beal stated that ADAP has provided an increased opportunity for his clients to be adherent. Aubrey Arnold stated that this should be consistent with rule 64D which clearly states that eligibility is every 6 months, once you fall out of that time period, there is no grace period, etc. Tracking is critical, the case managers are aware of what is happening. In his 10 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,

11 area, it applies to Part B, ADAP, AICP, state Housing Opportunities for People with AIDS (HOPWA), and eligibility lasts for six month timeframe. Michael Rajner asked if the members could get a copy of the rule 64D, including the dollar amount of FPL, etc. He requested the materials be made available when these items are discussed. Dr. Beal suggested that when things are sent out, that it be distributed widely to the other providers, Ryan White, Part A, Part B, and private physicians. Muzette Thomas shared that in her area, the case managers were able to effectively communicate the information to the clients when the changes to ADAP were being made. Lorraine Wells addressed the final cost containment measure for overdue for enrollment. At the end of 6 months, if you don t come in for your renewal, complete paperwork, get ADAP recertification, then your case is closed out and the individual goes on the waiting list if they present for services. Joe Lennox-Smith asked if we are being proactive that the ADAP staff is letting people know if they are overdue. Lorraine Wells responded that the method of follow-up sometimes is different based on the case manager and the local area, etc. William Green stated that we need to look at standardized policies across the local areas to make all of these policies effective. Sonja Swanson-Holbrook explained that in her area they have a well coordinated program and they meet regularly with the ADAP case management agencies to address challenges, barriers, etc. Julia Hidalgo suggested the following additional cost containment measures: work with individuals to take responsibility at the local level, identify other resources, and identify individuals who have insurance and are on ADAP or who need to be moved off. She explained that there needs to be a rapid response for disenrollment. Joe Lennox-Smith explained that unless the client has their insurance policy in front of them; they do not know what they have. Tom Liberti explained that he just got a call from the director of HRSA, Mary Wakefield, and she wanted to ensure that she understands the severity of the problem here in Florida. He further explained that after taking into consideration the options we proposed, she stated that they are going to review everything and they will be meeting next week. Tom Liberti expressed final thoughts and thanked everyone for attending. He expressed gratitude for the rich discussion and clear understanding of the problem, recommendations provided, the review of the deficit, and assistance in making some decisions. Mitchell Durant asked if an executive summary or minutes from this meeting will be distributed to the group. Lorraine Wells agreed that they would distribute them at a later date. Dr. Viamonte Ros expressed thanks and asked if folks wanted to follow-up that they could contact her. No further business to discuss, meeting adjourned at 4:02PM. 11 F l o r i d a A D A P M e e t i n g M i n u t e s / O c t o b e r 1,