ADR Frequently Asked Questions
ADR Frequently Asked Questions
- Does the certification and recertification process count as an ADAP service that should be reported?
Answer: Certification and recertification is not an ADAP service, and therefore should not be reported in the ADR.
- If a client is initially ineligible for ADAP and is declined and then two months later loses his/her insurance and is eligible, which date should be used for the completed application?
Answer: Grantees should use the application date under which the client was approved.
- How do I report Medicare Advantage as a type of insurance?
Answer: Medicare Advantage is an alternative to private health insurance for Medicare beneficiaries. You can report Medicare Advantage under "Other public".
- Should ADAPs stop reporting after the donut hole (Medicare)?
Answer: After leaving the Donut Hole, a Medicare Part D beneficiary enters the Catastrophic Coverage. From this point on, the Medicare Part D beneficiary pays $2.60 per month for generics / $6.50 per month for name brand medications or 5% of the medication's retail cost, whichever cost is higher. If ADAP continues to pay these amounts for the client, please continue to report amounts under "Amount Paid for Medicare Part D".
- Can ADAP medications be dispensed for less than 30 days?
Answer: Yes, medications may be dispensed for less than 30 days. Grantees can enter the actual number of days for any period less than 30 days; however, for all other time periods, 30-day increments are used (30, 60, 90, etc).
- For states that run state high risk insurance pool and a PCIP, how should they report? Should the PCIP be entered as a high risk insurance pool?
Answer: Yes. Both PCIPs and high risk insurance pools will be coded under the high risk insurance pool question in the ADR (Item #12).
- Where are copays for medical visits reported?
Answer: Grantees should report copays for medical visits under "Receipt of Insurance Services" and "Amount Paid for Co-Pays and Deductibles" (items #20 and #23).
- I'm new to the ADAP/ADR process, but have been doing RSR reporting. Am I correct in my interpretation of the materials that there is no provider report due, just Grantee and client-level data?
Answer: It is correct that there is no provider report in the ADAP Data Report. It consists of the Grantee Report and the Client Level Data Report. However, you may need your PBM or contractor(s) to supply you with your client level data.
- Why is HAB using the UCI when the URN is already in CAREWare? Will the URN be used interchangeably with the UCI in CAREWare? URN has a U in string. The UCI doesn't so they aren't identical.
Answer: The URN is used as the UCI in RSR. Both the URN and UCI contain the same unique 12-character alphanumeric code that distinguishes one Ryan White client from all others (including the "U"). For the ADR, HAB simply uses the term UCI as all grantees do not necessarily use CAREWare. The UCI is used to generate the eUCI, a 41 string character to de-identify the client data.
- In the ADR Grantee Report, if we did not receive any new funding during the report period, am I permitted to enter zero in Item #5?
Answer: For question # 5 on the grantee report (funding receiving during reporting period), a response of zero is permitted.
- What if a client is pregnant more than 1 time in the reporting period? What should be reported? What if the pregnancy and outcome are reported in two different periods?
Answer: The pregnancy variable has been changed since this question was asked. Grantees now report if a client was pregnant at any time during the reporting period. Therefore, the issue outlined in the question is no longer applicable.
- What does the eUCI generator do? Does it create the UCI and then encrypt it?
Answer: The eUCI generator can both create the UCI and then convert the 12 character UCI into a 40 character string using the SHA-1 hashing algorithm. The SHA-1 is a trap door algorithm, meaning that the original UCI is unrecoverable from the eUCI and therefore meets the highest the highest privacy and security standards. When using an ADR-Ready System such as CAREWare and TRAX for the ADR, the eUCI is generated directly from the raw data elements when the XML file is created. More information can be found in the eUCI User Guide.
- If the client has high risk insurance, what insurance option should be chosen?
Answer: For individuals enrolled in a high risk insurance pool or PCIP, insurance should be reported based on who pays the premium for the insurance. If an individual pays the premium, select private. If the Federal or state government pays the premium, select "other public". If Ryan White funds pay for the premium, select "no insurance."
- How should I round the cost data?
Answer: Grantees should round all amounts to the nearest whole number.
- Do grantees have to report historical start dates in formulary?
Answer: No. Grantees only need to include the date that an ARV was added to the formulary if the date was within the reporting period. If the medication was added prior to the reporting period, grantees do not need to enter this date.
- May grantees report medications for insurance clients?
Answer: Medications not paid in full under ADAP should not be reported in the client level data report. In addition, if ADAP purchases the medications and then bills insurance, these medications should also not be reported in client-level data.
- May grantees submit CD4 and VL data for insurance clients?
Answer: CD4 and VL data are only required for ADAP clients who are receiving medications paid in-full by ADAP. CD4 and VL data for all other clients should not be reported in the ADR.
- Is it feasible for HRSA to develop a tool to automatically pull ADR and RSR CLD from HRSA Approved systems especially if a state has this data residing on one server and they pre-approve HRSA's ability to do it?
Answer: HAB has no plans to automatically pull ADR or RSR CLD from HRSA approved systems.
- May ADAPs provide services to a client before eligibility has been determined?; What if it is an emergency?
Answer: It is not allowable for an ADAP to provide services before a client has been determined to meet that ADAP’s eligibility criteria (i.e. “presumptive eligibility”). Expedited enrollment (i.e. “emergency enrollment”) is allowed if the process ensures that clients have been determined eligible prior to services being provided. Providing temporary assistance to ADAP-eligible clients while eligibility is determined for Medicaid or other insurance (i.e. “provisional status”) is allowed, with the clear understanding that Medicaid is back-billed if Medicaid is awarded retroactively. Data for these clients should be reported in the ADR client report. ADAP services that are retroactively paid for by Medicaid (i.e. backbilling) should be reported. ADAPs are not required to go back into their data system and delete services for which they backbilled Medicaid and received reimbursement.
- Is it permissible for ADAPs to purchase medications through their 340B program and bill insurance for their insurance clients?
Answer: It is allowable for a grantee to use ADAP funds to purchase medications at 340B pricing and to then bill the medication to insurance for ADAP-eligible clients with insurance, so long as they: 1) do not pass on the 340B pricing to the insurance company, and 2) treat the difference between the 340B price and the insurance payment as program income. ADAPs that purchase medications through 340B and then bill insurance are considered to be providing an insurance service to the client, not a medication service. An insurance service is paying for a co-pay, deductible, insurance premium or Medicare Part D service. If an ADAP is not paying for any of these insurance services, the client is not considered an ADAP client.
- All ADAP clients must be recertified every six months from the date of their initial certification or subsequent recertification. Is there a cushion period for client recertification? For example, if a client fails to recertify, say one week after the six-month anniversary of her certification, is the client automatically disenrolled? Does the six-month recertification requirement mean that ADAPs must certify their clients on a daily basis? Will the ADR be capable of capturing individual recertifications?
Answer: The grantee must ensure that eligibility happens every 6 months, but are given flexibility as to whether they recertify all clients at the same time or have a “rolling” recertification based on some other factor (e.g. original enrollment date, birthdate, etc.). If a client does not recertify by the date specified by the grantee, the client is ineligible for the program as of that date; there is no grace period or “cushion”. ADAPs are required to report the recertification date for every existing client. The ADR is able to capture individual dates of recertification.
- Our program uses federal as well as non-federal funding for our ADAP clients. For the clients served with non-federal funds (such as state) , can we use a different set of certification or reporting rules?
Answer: All funds that go into the ADAP program are considered ADAP funds and therefore must align with the ADAP guidelines (“same program/same rules”); and all data should therefore be reported in the ADR. If, however, a State chooses to establish a separate program funded by non-ADAP funds, the State could choose to have different rules for that program and data for that program would not be reported on the ADR. The State needs to be cognizant of the fact that 340B pricing would not be available to the separate, non-ADAP-funded program.
- If a client is enrolled in ADAP but then Medicaid challenged, should they be reported?
Answer: By the term, “Medicaid challenged” HAB assumes you mean the following scenario: a situation in which a client was deemed eligible for ADAP and provided an ADAP service, but later was deemed eligible for Medicaid. The client was granted retroactive eligibility for the same period and Medicaid was back-billed for the services provided by ADAP. Data for these clients should be reported in the ADR client report. ADAP services that are retroactively paid for by Medicaid (i.e. backbilling) should be reported. ADAPs are not required to go back into their data system and delete services for which they backbilled Medicaid and received reimbursement.
- Are ADAPs allowed to dispense more than a 30 day supply of medication?
Answer: Each State has the authority to determine its own policy on the maximum day supply of medication for its ADAP clients.
- Is an ADAP permitted to pay insurance premiums for in-patient care?
Answer: ADAPs are allowed to pay insurance premiums for plans that cover inpatient care. However, Ryan White funds may not be used to pay copays or deductibles for inpatient care.
- For reporting the medication cost, are we permitted to approximate the cost of ADAP medications purchased in bulk? Are there other ways to calculate the cost purchased in bulk?
Answer: ADAPs should not approximate cost for the purchase of medications. Each purchase includes quantity and price that would allow the ADAP to provide a specific cost for the medication. If the ADAP carries stock from one reporting period to the next, the ADAP should prorate the cost for the period for which they are reporting. The amount of medication cost reported in #29 must be the actual price calculated from the quantity purchased and the total price.
- Can CAREWare be used solely to create the XML? Do grantees have to use CAREWare to create the XML?
Answer: There are several options to create the ADR client-level XML:
RxRex- helps you move your data from an Excel spreadsheet into an Access database, and then into the proper XML format
CAREWare ADAP module-requires grantees to set up the module first and then import or enter the data into CAREWare.
You may also generate the XML yourself. Programmers will be able to generate the XML file by following the specifications in the ADAP Data Report (ADR) XML Schema Implementation Guide.
- I understand that I must report clinical data for clients receiving ADAP-funded medications. However, some clients may switch from receiving ADAP-funded medications to receiving insurance services within the same reporting period. Is there a minimum amount of time during which a client must receive ADAP-funded medications for the clinical data to be required??
Answer: Clinical data must be reported on all clients who received ADAP funded-medications at any time during the reporting period.
- If a new client application is completed near the end of the year but the 1st service is not received during the reporting year, how should grantees report this?
Answer: Grantees would report items #15 and #16 for this client and for item #18, report the option of “enrolled, services not requested”.
- Is unknown/blank acceptable for CD4 and/or viral load?
Answer: For clients receiving ADAP-funded medication, CD4 and viral load data are required to be reported. This data should come from clinical sources such as a lab, physician’s report or from your surveillance program, not from client self-report. HAB’s TA providers can work with grantees who are having difficulty gathering these data for the ADR.
- Do grantees report dispensing fees for medications only or also for copay or deductible medications?
Answer: Grantees should report dispensing fees for medications that were paid in full by ADAP. Grantees should not report dispensing fees for medication copays or deductibles or for medications that were initially purchased by the ADAP and then reimbursed by insurance.
- Is HAB considering an alternative method of completing the ADR Grantee Report other than filling in the online forms (i.e. an ADR Grantee Report XML upload)?
Answer: HAB is exploring this possibility.
- Is it possible for HAB to prepopulate the formulary list after the first submission?
Answer: HAB will be pre-populating the formulary list after the first submission. ADAPs must remember to add any new medications as well as uncheck the medications that are no longer available in the pertinent reporting period.
- Does the certification and recertification process count as an ADAP service that should be reported?