Mar. 29--Taxpayers are expected to pay thousands of dollars because the state failed to meet a deadline for picking a new insurance administrator for an HIV drug program. This comes as the state faces an estimated $8 billion shortfall in its next budget.
Missing the deadline means the state must pick up the total cost to keep medically and financially fragile residents on life-preserving drugs, rather than just the co-pays for the drugs.
At issue is a federally funded program to help people afford drugs to fight the AIDS virus. Ohio uses a third-party administrator to handle payments, but Ohio didn't get a new contractor in time to provide a seamless transition from the old administrator to the new.
As a result, processing claims and co-pays will be delayed at least four weeks -- and possibly until June 1. The previous administrator declined to extend its contract, and the new one needs time to gear up.
The 4,000 Ohioans already being subsidized won't be affected, officials said. But case managers at AIDS agencies say many clients are fearful.
"When you get information like this, it's big news," said Pamela Gibbs, president of the board of directors of the Ohio Aids Coalition.
"There are at least 30 different drugs out there. And this is a group of people who have to take their drugs every single day. If there's a break in the medication, you can become drug-resistant."
That would increase the risk that additional strains of a drug-resistant, infectious disease would spread. And if HIV patients stop taking the drugs, physicians might need to start over to find an effective combination to treat the virus.
For that reason, the state will pick up the bill for current clients caught in the transition -- though it will do so using federal tax dollars. The additional cost, based on 80 patients, is expected to be $19,000 because the state negotiates drug discounts, said Katherine E. Shumate, HIV-care services administrator for the Ohio Department of Health.
In Columbus alone, one group tallies as many as 125 of its clients as being affected.
"The first thing I will do is err on the side of making sure someone gets pills," Shumate said. "These medications are so crucial to life."
Drugs for one person can cost $6,000 for a three-month prescription. Co-pays also can be expensive, ranging from $10 to more than $1,000 for three months.
For this reason, Congress provides each state with an annual grant to help those with HIV and related conditions afford medications. Ohio gets $21 million a year, of which $13.8 million is earmarked for medications.
Ohio uses the money three ways:
--Financially eligible residents get free medication. Under a state-negotiated contract with CVS/Caremark, co-pays for specific HIV drugs are covered. The drugs are discreetly mailed to clients.
--Those employed but unable to afford their company plans get premiums paid through the state. This spares tax dollars by sharing drug costs with private insurance plans. Again, CVS/Caremark fills the prescription and the state plan picks up co-pays.
--Employees whose insurance plans don't work with CVS/Caremark can still fill their prescriptions using another pharmacy covered by their plan. They then submit their co-pay bill. The state reimburses the pharmacy.
The transition won't affect those who can still fill at CVS/Caremark. It has agreed to wait for reimbursement of co-pays. But those using myriad other pharmacies can't get co-pays reimbursed temporarily because the new third-party administrator isn't yet set up to process them. And if they can't afford co-pays, they might go without the drugs. Hence, Ohio decided to enroll those clients in the full-pay prescription plan under CVS.
Ohio timed the bidding of its new-third party administrator so the new company would begin on April 1, Thursday. The old contract ends on Wednesday.
The process, governed by the Ohio Department of Administrative Services, took longer than expected, Shumate said:
The Columbus AIDS Task Force has started informing clients of the changes, said President Peggy Anderson.
"Anytime there's a change, particularly when it comes to the financial coverage of resources that our clients rely on, they do get scared that maybe their medical care will be affected," she said.
The task force, which serves about 1,200 people a year, is reassuring clients. It figures that 100 to 125 of its clients will be affected.
But not all may need to sign up for the transition gap coverage: The task force is negotiating with small pharmacies to wait until June for co-pay reimbursement. And it's trying to find other social-service dollars -- for groceries, for example -- to free up money for medications.
"It's just frustrating," Anderson said. "I know the state is trying to fix this."
The worry for clients and caseworkers is how fast claims will get paid starting in June when the new administrator is geared up "and the floodgates open."
bcarmen@dispatch.com
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