NATIONAL RYAN WHITE HIV/AIDS PROGRAM PART B & ADAP MONITORING PROJECT ANNUAL REPORT

Transcription

1 2 8 A N N U A L R E P O R T NATIONAL RYAN WHITE HIV/AIDS PROGRAM PART B & ADAP MONITORING PROJECT ANNUAL REPORT

2 TABLE OF CONTENTS Charts for each major finding, tables, with data provided by state, and a complete ADAP glossary are included in the full report. State-level data from this report are available on the NASTAD website. 6 SECTION The Ryan White HIV/AIDS Program (RWHAP) Part B Program Funding and Structure CHART Part B Budget, by Source, FY26-FY27 8 CHART 2 ADAP Budget, by Source, FY996-FY27 TABLE RWHAP Part B Budget and ADAP Budget, FY27 2 TABLE 2 RWHAP Part B Budget, Including ADAP, by State and by Source, FY27 3 TABLE 3 RWHAP Part B and ADAP Budget, FY26 and FY27 6 TABLE 4 Major FY27 RWHAP Part B Budget Categories Compared with FY26 7 TABLE 5 ADAP Cost Recovery and Other Cost-Saving Mechanisms (Excluding Drug Rebates), Calendar Year SECTION 2 A Synergistic and Complementary System of Care CHART 3 Engagement in RWHAP Part B and ADAP, Calendar Year CHART 4 RWHAP Part B Clients Served, by Viral Load, Calendar Year CHART 5 ADAP Clients Served by Program, by Viral Load, Calendar Year CHART 6 RWHAP Part B Clients Served and Top Ten States, by Clients Served, Calendar Year CHART 7 ADAP Clients Served and Top Ten States, by Clients Served, Calendar Year CHART 8 ADAP Clients Served, by Program Type, Calendar Year CHART 9 ADAP Viral Load Suppression Rate, by Clients Served, Calendar Year TABLE 6 RWHAP Part B and ADAP Clients Enrolled and Served, Calendar Year 26 3 TABLE 7 RWHAP Part B and ADAP Clients by Viral Load, Enrolled During 2-Month Period, Calendar Year TABLE 8 RWHAP Part B Program Administration, TABLE 9 RWHAP Part B Core Medical Program Expenditures and Utilization, TABLE RWHAP Part B Support Services Program Expenditures and Utilization, TABLE Select RWHAP Part B Core Medical and Support Services Funded/Provided, TABLE 2 Other RWHAP Part B Program Expenditures, Including ADAP, TABLE 3 ADAP Program Expenditures, Calendar Year GLOSSARY A glossary of key ADAP terms can be found on the NASTAD website.

3 5 SECTION 3 Affecting Change in Structural Inequities CHART RWHAP Part B Clients Served, by Race, CHART ADAP Clients Served, by Race, Calendar Year CHART 2 ADAP Clients Served, by Ethnicity, Calendar Year CHART 3 ADAP Clients Served, by Income, Calendar Year CHART 4 ADAP Clients by Viral Load, by Risk Behavior or Exposure (Male-to-Male Sexual Contact), Race, Ethnicity, and Income, Enrolled During 2-Month Period, Calendar Year 26 6 CHART 5 ADAP Client Engagement in Hepatitis C (HCV) Treatment, Calendar Year CHART 6 RWHAP Part B Clients Served, by Demographic, Calendar Year CHART 7 ADAP Clients Served, by Demographic, Calendar Year CHART 8 CHART 9 RWHAP Part B/ADAP Provision of Services for Incarcerated Individuals, Calendar Year Top RWHAP Part B/ADAP Services Provided to Incarcerated Individuals, Calendar Year CHART 2 Top RWHAP Part B Services Provided to Recently Incarcerated, Calendar Year TABLE 4 RWHAP Part B and ADAP Clients Served, by Race, Calendar Year TABLE 5 RWHAP Part B and ADAP Clients Served, by Ethnicity, Calendar Year TABLE 6 RWHAP Part B and ADAP Clients Served, by Age, Calendar Year 26 7 TABLE 7 RWHAP Part B and ADAP Clients Served, by Gender, Calendar Year 26 7 TABLE 8 RWHAP Part B and ADAP Clients Served, by Income Level, Calendar Year TABLE 9 ADAP Clients Served by Other Payers, Calendar Year TABLE 2 TABLE 2 ADAP Clients Served, by Risk Behavior or Exposure and Hepatitis C Co-infection, Calendar Year ADAP Clients by Viral Load, by Risk Behavior or Exposure (Male-to-Male Sexual Contact), Race, Ethnicity, and Income, Calendar Year SECTION 4 What s at Stake in a Changing Health Care Landscape CHART 2 ADAP Clients Served, by State Medicaid Expansion, Calendar Year CHART 22 ADAP Clients Served, by ACA Marketplace Type, Calendar Year CHART 23 ADAP Clients Served by Insurance Continuation, by Insurance Payment Type, Calendar Year CHART 24 ADAP Clients Served by Medicaid Expansion State, by Viral Load, Calendar Year CHART 25 ADAP Clients Served and Estimated Expenditures in Insurance Purchasing and Continuation, 26 9 TABLE 22 ADAP Funds Used and Clients Served Through Insurance Purchasing and Continuation, 26 9 TABLE 23 ADAP Clients Served Through Insurance Purchasing and Continuation, TABLE 24 RWHAP Part B and ADAP Client Financial Eligibility Requirements, as of January, TABLE 25 ADAP Policies Related to Insurance Purchasing as of January, TABLE 26 ADAP Policies Related to Medicare Part D as of January, APPENDIX HIV/AIDS Antiretroviral and Opportunistic Infection Medications APPENDIX 2 Infographic 2 APPENDIX 3 Infographic METHODOLOGY ACKNOWLEDGEMENTS

4 SUMMARY For over twenty years, NASTAD s National Ryan White HIV/AIDS Program (RWHAP) Part B and AIDS Drug Assistance Program (ADAP) Monitoring Project (previously known as the National ADAP Monitoring Project) has documented key trends among ADAPs as well as challenges and successes experienced by these life-saving programs. In the National ADAP Monitoring Project s Annual Report published in 27, NASTAD first incorporated data and topics for the broader RWHAP Part B program into the Annual Report in an effort to contextualize the realities of ADAP program structure, budgets, and utilization within the broader RWHAP Part B system. In this 28 edition of the Annual Report, NASTAD has expanded the National ADAP Monitoring Project to the National RWHAP Part B and ADAP Monitoring Project. As such, the narrative and findings now span the totality of the RWHAP Part B program and reflect the reality that the achievements of ADAPs and other elements of the RWHAP Part B programs are inextricably linked. RYAN WHITE Ryan White was diagnosed with HIV following a blood transfusion in 984. He was 3 years old at the time. Following his diagnosis, Ryan was barred from his Indiana school and became a national hero because of his fight to return to school. Ryan fought discrimination and stigma and became the face of public education about HIV and AIDS. Ryan White died in April 99, months before the legislation bearing his name was passed. 4

5 The Part B program is the Part of the RWHAP infrastructure through which state and territorial health departments are funded to provide core medical and support services to eligible clients. The RWHAP Part B program includes the administration of ADAPs to ensure access to lifesaving treatment. As in other Parts of the RWHAP, Part B is administered by the Health Resources and Services Administration s HIV/AIDS Bureau (HRSA/HAB). All 5 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the six U.S. Pacific Territories/ Associated Jurisdictions are eligible for Part B program funding. Administration and service delivery of each jurisdiction s RWHAP Part B program is unique, reflecting the needs and challenges of the clients they serve as well as the political and structural landscape in which they exist. Access to treatments, inclusive of antiretrovirals (ARVs), A opportunistic infection (OI) medications, and medications to treat other comorbid conditions (e.g., hepatitis C (HCV), substance use, mental health) is critical but not sufficient in ensuring optimal health outcomes (e.g., viral suppression) among PLWH. The full complement of RWHAP Part B services support adherence to, and the overall effectiveness of, treatment. In implementing a seamless, nimble, and effective RHWAP Part B program, ADAPs and other core medical/support services must functionally align in terms of funding, administration, infrastructure, service delivery, and overall purpose. 5

6 E C T I O S N 6

7 OVERVIEW OF THE RWHAP PART B PROGRAM RWHAP Part B programs were created under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, passed by Congress and signed into law by President George H.W. Bush in 99. This landmark, bipartisan legislation was enacted to sustain a responsive care system as a payer of last resort (i.e., source of care for those under- or uninsured via private insurance, Medicaid, Medicare) for people living with HIV (PLWH). In providing RWHAP funds directly to states and territories, legislators created a structure in which a nationwide response to the needs of PLWH was available. As with other Parts of the law, RWHAP Part B programs deliver an array of services, both medical (core medical) and non-medical (support), to assist clients in achieving sustained virologic suppression and overall optimal health and well-being. Allowable RWHAP Part B program services collectively reflect the diverse and unique experiences of PLWH as well as a commitment to a patient-centered model for care delivery. 7

8 The Drug Reimbursement Program was first implemented in 987 via Congressional appropriation to provide the newly Food & Drug Administration (FDA)-approved treatment, zidovudine (AZT), to PLWH without private insurance or ineligible for Medicaid, Medicare, or other state programs. These state-based programs were absorbed into the then RWHAP Title II program in 99 and were subsequently changed to AIDS Drug Assistance Programs in 996. Over time, ADAPs have expanded their coverage (i.e., their drug formularies) in accordance with the Ryan White HIV/AIDS Program Section 266(c)(6) of the Public Health Service Act. They have also increased their capacity in supporting clients via ADAP-funded insurance continuation. CHART RWHAP Part B Budget, by Source, FY26-FY27 Other (includes Part B Supplemental) $3,. $2,5. $2,. $,5. $,. $5. $ 4 3 FY26 Rebates State Part B Base 4 3 FY27 te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. Percentages may not total due to rounding. THE NATIONAL RWHAP PART B PROGRAM BUDGET RWHAP was last reauthorized in 29 and the most recent authorization ended on September 3, 23. In the absence of Congressional action on authorization, the program continues to operate as Congress maintains annual appropriations to the program. Based on a formula and eligibility-based distribution mechanism, RWHAP Part B programs are eligible to receive the following categories of federal funding: Part B Base, Part B Supplemental (if applicable), Part B ADAP Earmark, Part B ADAP Supplemental (if applicable), and ADAP Emergency Relief Funding (if applicable). In FY27, RWHAP Part B programs (n=59) were Congressionally appropriated a total of $.4 billion, with $898.8 million appropriated to ADAP specifically (i.e., via Part B ADAP Earmark (n=59), Part B ADAP Supplemental (n=9), and ADAP Emergency Relief Funding (n=9)). RWHAP Part B programs have discretion to allocate a portion or all their Part B Base and/or Part B Supplemental to ADAP. For FY27, 26 RWHAP Part B programs reported having allocated 8

9 at least some portion of their RWHAP Part B Base and/or Part B Supplemental to ADAP. As the largest component to the RWHAP Part B program with the greatest number of clients served, ADAPs represented 7 of the overall Part B budget in FY27. The proportion of the RWHAP Part B budget used for ADAP ranged from in the Federated States of Micronesia to 99. in New York. Between 996, the earliest year in which NASTAD has collected this data, and 27, the total ADAP budget has grown 89 with an average growth of per year. Yet these awards alone do not meet the needs of RWHAP Part B programs or their clients. Instead, jurisdictions must often seek additional funding opportunities to sustain their infrastructure and service delivery. Additional sources that may be available to RWHAP Part B programs include other federal funding (e.g., carry-over from prior Part B Base or ADAP Earmark awards), state general revenue funding, private donations, and rebates received as part of medication purchasing. RWHAP Part A programs in eligible metropolitan areas may contribute directly-appropriated funds to their Part B counterparts. Such decisions are made locally and reflect an effort between RWHAP Parts A and B programs to mutually ensure each other s success in serving the needs of PLWH. Taken together, these additional funding sources make up of the FY27 RWHAP Part B program and of ADAP budgets. SOURCES OF FUNDING The breakdown of other sources of funding for RWHAP Part B programs: Part B Supplemental: 24 RWHAP Part B programs received funding Part B ADAP Supplemental Treatment Grants: 9 ADAPs received funding ADAP Emergency Relief Funding: 9 ADAPs received funding Part A Contribution Allocated to Part B: 2 RWHAP Part B programs received funding State Contribution: 3 RWHAP Part B programs received funding Drug Rebates: 46 RWHAP Part B programs received funding Other State/Federal Funds: 23 RWHAP Part B programs received funding 9

10 CHART 2 ADAP Budget, by Source, FY996-FY27 Other (includes Part B ADAP Supplemental) Rebates State ADAP Earmark $2,5. $2,. $, First antiretroviral (AZT, an NRTI) approved by the FDA; Federal government provides grants to states to help them purchase AZT, marking beginning of federally funded, state-administered AZT Assistance Programs. 99 ADAPs incorporated into Title II of the newly created Ryan White CARE Act. 995 First protease inhibitor approved by FDA, and the highly active antiretroviral therapy (HAART) era begins. 996 First reauthorization of CARE Act federal ADAP earmark created; first non-nucleoside reverse transcriptase inhibitor (NNRTI) approved by FDA. 2 Second reauthorization of CARE Act. Changes for ADAPs include: allowance of insurance purchasing and maintenance; flexibility to provide other limited services (e.g., adherence support and outreach); and creation of ADAP supplemental grants programt. 23 NASTAD s ADAP Crisis Task Force formed to negotiate with pharmaceutical companies on pricing of antiretroviral medications; first fusion inhibitor approved by FDA. 24 President s ADAP Initiative (PAI) announced, allocating $2 million in one-time funding outside of the ADAP system to reduce ADAP waiting lists in states. 26 Third reauthorization of the CARE Act, now called, Title XXVI of the PHS Act as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 26 or the Ryan White Program. Changes for ADAP include: new formula for determining state awards, which incorporates living HIV and AIDS cases; new minimum formulary requirement; and an increase in the ADAP Supplemental set-aside and changes in eligibility and matching requirements. 27 New minimum formulary requirement effective July ; first CCR5 antagonist and integrase inhibitor approved by FDA. 29 Fourth reauthorization of the Ryan White Program. The reauthorization was for four years and included several technical changes. 2 Patient Protection and Affordable Care Act (PPACA) signed into law. ADAP emergency funding announced by the Obama Administration, allocating $25 million in funding to address ADAP waiting lists and cost-containment measures. 2 ADAP emergency funding continued at $4 million. In December 2, President Obama announced an additional $35 million for ADAPs to address ADAP waiting lists and cost containment measures. Awards from this funding will be available to states based on a competitive application. $.,. $5. $ FY996 FY997 FY998 FY999 FY2 FY2 FY22 FY23 FY24 FY25

11 22 ADAP emergency funding awarded at $75 million, including the continuation of FY2 funding the allocation of an additional $35 million announced by President Obama in December The first open enrollment period for insurance through the insurance marketplace established under the Affordable Care Act ends on March 3, 24. The second open enrollment period begins on vember 5, The third open enrollment period for insurance through the insurance marketplace established under the Affordable Care Act ends on April 3, The fourth open enrollment period for insurance through the insurance marketplace established under the Affordable Care Act ends on April 3, Open enrollment for insurance through the insurance marketplace established under the Affordable Care Act begins on October. 25 The second open enrollment period for insurance through the insurance marketplace established under the Affordable Care Act ends on April 3, FY26 FY27 FY28 FY29 FY2 FY2 FY22 FY23 FY24 FY25 FY26 FY27 te: 53 ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond.

12 TABLE RWHAP Part B Budget and ADAP Budget, FY27 State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming Part B FY27 Budget $34,856,967 $,482,387 $23,877 $26,67,93 $5,73,949 $269,279,83 $3,597,639 $28,887,65 $9,862,533 $27,93,487 $5, $22,93,958 $8,372,52 $26,943 $6,5,484 $8,225,242 $6,684,32 $77,94,84 $22,685,54 $4,473,6 $39,78,597 $66,7,269 $5,87,849 $48,436 $88,56,476 $49,9,64 $45,578,33 $22,65,277 $24,25,98 $58,74,775 $3,49,977 $4,44,82 $47,45,749 $5,463,79 $9,74,28 $5,82,667 $376,387,22 $8,93,967 $2,463,76 $94,2 $37,352,2 $26,775,65 $3,477,972 $2,697,473 $56,988,34 $53,25 $5,869,7 $57,97,967 $3,79,72 $65,35,765 $58,22,298 $3,862,59 $,47,98 $2,329,563 $8,796,927 $36,7, $6,28,223 $28,427,955 $,485,5 ADAP FY27 Budget $24,456, $76,434 $43 $2,987,9 $2,758,46 $2,33,4 $2,695,458 $2,848,895 $7,37,46 $7,833,982 $5,33,74 $6,84,896 $6,943 $4,52,529 $6,2,37 $48,6,423 $27,59,439 $2,97,636 $2,93,673 $23,275,597 $42,638,89 $3,297,596 $83 $58,53,556 $8,78,82 $23,24,35 $2,832,733 $3,867,976 $53,296,752 $2,55,35 $8,88,283 $27,563,474 $2,963,79 $77,23,6 $2,397,84 $375,887,95 $63,533,427 $,4,439 $,625 $3,796,65 $24,4,823 $,749,476 $86,57,299 $5,25,55 $3,25 $,9,979 $33,4,49 $2,45,224 $6,35,765 $6,95,5 $9,277,88 $97,98 $,7,3 $57,364,253 $24,, $5,243,938 $2,68,59 $95,759 % of Part B Budget $2,654,2,43 $,984,838,26 7 te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. The total FY27 budget includes federal, state, and drug rebates. Cost recovery funds, with the exception of drug rebates, are not included in the total budget. 2

13 TABLE 2 RWHAP Part B Budget, Including ADAP, by State and by Source, FY27 State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming FY27 Budget Part B Base $34,856,967 $,482,387 $23,877 $26,67,93 $5,73,949 $269,279,83 $3,597,639 $28,887,65 $9,862,533 $27,93,487 $5, $22,93,958 $8,372,52 $26,943 $6,5,484 $8,225,242 $6,684,32 $77,94,84 $22,685,54 $4,473,6 $39,78,597 $66,7,269 $5,87,849 $48,436 $88,56,476 $49,9,64 $45,578,33 $22,65,277 $24,25,98 $58,74,775 $3,49,977 $4,44,82 $47,45,749 $5,463,79 $9,74,28 $5,82,667 $376,387,22 $8,93,967 $2,463,76 $94,2 $37,352,2 $26,775,65 $3,477,972 $2,697,473 $56,988,34 $53,25 $5,869,7 $57,97,967 $3,79,72 $65,35,765 $58,22,298 $3,862,59 $,47,98 $2,329,563 $8,796,927 $36,7, $6,28,223 $28,427,955 $,485,5 $7,89,622 $5, $23,734 $4,79,92 $3,324,876 $33,46,827 $3,42,8 $2,794,7 $2,55,7 $3,828,733 $5, $3,743,37 $3,448,57 $2, $,628,955 $573,728 $9,567,69 $3,69,959 $,44,425 $,4,957 $4,72,76 $6,42,8 $796,35 $47,623 $7,965,275 $4,989,4 $4,994,96 $2,4, $5,94,9 $3,58,58 $5, $,268,944 $2,47,677 $5, $,286,8 $,876,383 $35,252,36 $,497,54 $5, $5, $5,555,55 $3,63,642 $,728,496 $,822,83 $5,972,5 $5, $,496,654 $,28,283 $5, $5,25,284 $23,234,672 $,78,64 $5, $5, $7,8,93 $3,67,896 $,37,285 $3,6,22 $5, Part B Base Contribution Allocated to Part B $5,34,622 $5, $4,79,92 $33,46,827 $3,42,8 $2,794,7 $2,55,7 $3,743,37 $3,448,57 $,628,955 $43,728 $9,567,69 $3,69,959 $28,945 $,4,957 $5,562,45 $633,487 $7,965,275 $4,989,4 $4,994,96 $2,4, $4,326,5 $3,58,58 $5, $,286,8 $,876,383 $37,347 $,497,54 $33,267 $5,555,55 $2,77,792 $,728,496 $5,782,789 $,496,654 $,28,283 $5, $23,234,672 $,26,8 $5, $3,435 $4,568,497 $,37,76 $,37,285 $3,6,22 $4, Part B Base Contribution Allocated to ADAP $2,55, $3,324,876 $3,828,733 $6, $,23,48 $4,72,76 $839,73 $62,863 $,578,85 $5, $,268,944 $2,47,677 $34,944,689 $96,733 $859,85 $,822,83 $89,722 $5,25,284 $5,84 $486,565 $2,62,434 $2,247,9 $, % of Budget Part B Supplemental $4,, $52,453 $35,, $7, $,89,27 $26,365,55 $2,286,473 $,776,38 $9, $6,375, $8,7, $,87,78 $3,46, $,92,97 $,97,877 $35,, $7,3, $42,576 $8,24,3 $2,46,384 $2,8, $2,7,676 $946,25 $2,824,5 Part B Supplemental Allocated to Part B $2,, $52,453 $35,, $,89,27 $26,365,55 $2,286,473 $,776,38 $9, $5,3,766 $,59,8 $3,67,74 $,92,97 $,97,877 $8, $2,46,384 $2,8, $2,498,36 $946,25 $2,824,5 Part B Supplemental Allocated to ADAP $2,, $7, $,26,234 $8,7, $27,97 $248,26 $35,, $6,5, $8,24,3 $22,64 % of Budget $2,654,2,43 $35,58,3 $234,92,44 $79,734,232 $77,867,478 $4,96,82 $72,864,8 Part B supplemental awards were provided to 5 states that met federal eligibility criteria, applied for funding, and were able to meet the mandated matching requirement or receive a waiver. te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. The total FY27 budget includes federal, state, and drug rebates. A dash () indicates the Part B program did not report data. 3

14 TABLE 2 RWHAP Part B Budget, Including ADAP, by State and by Source, FY27 (Continued) Part B ADAP Earmark Part B ADAP Supplemental 2 % of Budget Part A Contribution Allocated to Part B Part A Contribution Allocated to ADAP % of Budget State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming $,8,565 $567,987 $43 $,586,446 $4,368,38 $2,954,339 $9,644,42 $8,848,895 $2,625,46 $2,95,249 $88,224,56 $35,272,7 $6,943 $2,8,994 $732,939 $29,66,5 $8,45,232 $,794,56 $2,49,529 $5,22,89 $6,799,88 $,7,339 $83 $25,998,2 $4,46,547 $3,4,35 $6,262,483 $7,764,926 $,64,5 $349,45 $,62,79 $6,54,95 $963,79 $3,23,6 $2,397,84 $7,486,859 $23,92,394 $23,76 $,625 $6,796,65 $4,638,54 $4,749,476 $27,85,5 $5,42,55 $3,25 $,9,979 $3,282,28 $45,224 $4,35,48 $66,57,26 $2,95,566 $47,98 $498,98 $8,4,45 $9,936,928 $,443,938 $4,636,529 $238,83 % of Budget $8,934,9 $237,273 $2,669,4 $2,72,7 $2,53,73 $27,97 $3,972,34 $2,384,6 $67,772 % of Budget ADAP Emergency Funding $9,, $5,26,556 $77,295 $895,285 $3,, $9,, $9,, $,322,937 $9,, 2 $7,635 $4,234,39. $88,868,44 3 $42,627,846 $47,25,73 $4,45,26 2 Part B ADAP supplemental awards were provided to 9 states that met federal eligibility criteria, applied for funding, and were able to meet the mandated matching requirement or receive a waiver. 4

15 $5, $86,928 $,96,55 $32,53,966 $6,63,878 $,73,623 $27,932 $37,372 $2,63,336 $,56,69 $97,25 $,754,254 $6,979 $75, $,548,2 $5,82,52 $5, $5, $687,8 $34,74 $96,393,763 $,99,796 $,, $,45,56 $,, $,94,676 $44,535 $8,8 $2,5, $24,74 $85, $,62,676 $75, $5,32,25 $6,979 $75, $2,, $4,34,33 $786, $,677,5 $7,, $29,463,378 $8, $2,658,673 $,36,2 $32,676 $4,547, $2,25, $5,5, $3,38,54 $5, $5,72,945 $3,, $8,567,3 $7,2, $4,, $8,5, $27,356 $8,3,46 $4,, $5,676,265 $,88,85 $4,84,34 $2,, $75, $6,8,74 $4,669,275 $875,948 $5,, $85,637 $6, $5, $9,472,677 $,642,86 $, $93,335,74 % of Budget Part B State Contribution ADAP State Contribution Part B Estimated Drug Rebates $7,75, $9,4,745 $4,, $85,33,627 $6,5, $3,, $4,5, $,, $52,89,684 $2,, $3,3, $2,, $6,465,9 $4,, $25,, $,992,654 $25,, $3,3, $,2, $5,57,574 $29,5, $22, $4,, $5,, $2,, $47,, $63,44,679 $3,, $,, $5,, $2,, $7,, $29,67,64 $2,73,84 $8,3,79 $2,, $25,, $3,695,787 $5, $66,62 $2,76,37 $,85,882 $3,8, $,25, $3, $723,825, $54,75 $93,447 $,65,5 $3,875,38 $4,, $82, $452,52 $,34,268 $43,44 $7,55,355 $27,847 $3, $3,874,62 $87,333 $3,5, $5,72,89 $8,72,779 $,744,49 $,8,646 $,966,44 $4,487,43 $8,74,943 $39,234 $68,5 $2,35,543 $476,76 $4,4 $256,499 $2,55, $4,86,84 $56,983 $7,344, $8,26 $27,847 $,245,992 $3,8, $,577,29 $9,94 $5,, $54,93 $39,5 $33,84 $4,46, $34,856,967 $,482,387 $23,877 $26,67,93 $5,73,949 $269,279,83 $3,597,639 $28,887,65 $9,862,533 $27,93,487 $5, $22,93,958 $8,372,52 $26,943 $6,5,484 $8,225,242 $6,684,32 $77,94,84 $22,685,54 $4,473,6 $39,78,597 $66,7,269 $5,87,849 $48,436 $88,56,476 $49,9,64 $45,578,33 $22,65,277 $24,25,98 $58,74,775 $3,49,977 $4,44,82 $47,45,749 $5,463,79 $9,74,28 $5,82,667 $376,387,22 $8,93,967 $2,463,76 $94,2 $37,352,2 $26,775,65 $3,477,972 $2,697,473 $56,988,34 $53,25 $5,869,7 $57,97,967 $3,79,72 $65,35,765 $58,22,298 $3,862,59 $,47,98 $2,329,563 $8,796,927 $36,7, $6,28,223 $28,427,955 $,485,5 $2,654,2,43 ADAP Estimated Drug Rebates ADAP Other State or Federal % of Budget % of Budget FY27 Budget Part B Other State or Federal 5 te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. The total FY27 budget includes federal, state, and drug rebates. A dash () indicates the Part B program did not report data.

16 TABLE 3 RWHAP Part B and ADAP Budget, FY26 and FY27 % Change ADAP FY27 Budget % Change State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming Part B FY26 Budget $32,438,47 $,422,2 $2,555 $38,77,66 $9,596,226 $348,282,72 $3,675,46 $,454,83 $5,792,729 $3,96,89 $5, $77,239,237 $87,5,62 $26,33 $5,365,842 $6,859,654 $62,527,863 $38,9,297 $2,536,933 $4,9,367 $8,88,98 $67,353,22 $3,82,36 $5,796 $75,633,359 $37,4,42 $4,535,277 $8,352,9 $22,79,25 $49,9,953 $2,69,934 $7,575,29 $22,275,84 $4,432,69 $56,472,887 $6,546,878 $389,764,66 $74,339,27 $,996,733 $48,923 $38,84,8 $2,722,523 $3,6,65 $5,48,49 $54,926,772 $53,86 $6,25,6 $5,8,352 $897,449 $66,355,878 $62,276, $,26,492 $,583,94 $2,97,598 $66,49,872 $28,467,749 $2,7,397 $28,,86 $,54,34 Part B FY27 Budget $34,856,967 $,482,387 $23,877 $26,67,93 $5,73,949 $269,279,83 $3,597,639 $28,887,65 $9,862,533 $27,93,487 $5, $22,93,958 $8,372,52 $26,943 $6,5,484 $8,225,242 $6,684,32 $77,94,84 $22,685,54 $4,473,6 $39,78,597 $66,7,269 $5,87,849 $48,436 $88,56,476 $49,9,64 $45,578,33 $22,65,277 $24,25,98 $58,74,775 $3,49,977 $4,44,82 $47,45,749 $5,463,79 $9,74,28 $5,82,667 $376,387,22 $8,93,967 $2,463,76 $94,2 $37,352,2 $26,775,65 $3,477,972 $2,697,473 $56,988,34 $53,25 $5,869,7 $57,97,967 $3,79,72 $65,35,765 $58,22,298 $3,862,59 $,47,98 $2,329,563 $8,796,927 $36,7, $6,28,223 $28,427,955 $,485, ADAP FY26 Budget $23,84,642 $837,98 $,593 $37,42,438 $9,97,997 $37,462,98 $26,92,487 $8,675,379 $3,26,73 $6,64,26 $47,86,477 $68,378,953 $6,33 $2,46,232 $5,577,223 $49,52,93 $32,827,57 $2,792,7 $3,85,583 $4,99,57 $57,42,378 $2,786,898 $796 $5,449,5 $23,427,297 $23,28,5 $,45,86 $7,38,585 $42,93,67 $,875,36 $6,249,637 $8,957,465 $2,432,69 $89,259,8 $2,3,266 $348,97,5 $6,899,332 $,54,765 $2,44,782 $7,29,7 $,693,98 $3,4,25 $48,45,68 $3,86 $,839,894 $35,655,443 $397,449 $34,25,44 $2,799,255 $9,283,798 $,477,37 $,372,598 $5,373,5 $6,389,37 $5,899,434 $5,47,449 $99,34 $24,456, $76,434 $43 $2,987,9 $2,758,46 $2,33,4 $2,695,458 $2,848,895 $7,37,46 $7,833,982 $5,33,74 $6,84,896 $6,943 $4,52,529 $6,2,37 $48,6,423 $27,59,439 $2,97,636 $2,93,673 $23,275,597 $42,638,89 $3,297,596 $83 $58,53,556 $8,78,82 $23,24,35 $2,832,733 $3,867,976 $53,296,752 $2,55,35 $8,88,283 $27,563,474 $2,963,79 $77,23,6 $2,397,84 $375,887,95 $63,533,427 $,4,439 $,625 $3,796,65 $24,4,823 $,749,476 $86,57,299 $5,25,55 $3,25 $,9,979 $33,4,49 $2,45,224 $6,35,765 $6,95,5 $9,277,88 $97,98 $,7,3 $57,364,253 $24,, $5,243,938 $2,68,59 $95, Comparison $2,6,2,76 $2,6,95,246 $2,654,2,43 $2,653,93,649 $2,7,258,66 $2,7,253,3 $,984,838,26 $,984,832, Comparison s are based on only those states that reported data for both time periods. 6 te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. The total FY27 budget includes federal, state, and drug rebates. Cost recovery funds, with the exception of drug rebates, are not included in the total budget.

17 TABLE 4 Major FY27 RWHAP Part B Budget Categories Compared with FY26 State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming 26 Part B Base Contribution Allocated to Part B $,3,435 $5, $567,62 $32,2,623 $3,368,9 $2,4,656 $3,52,76 $3,23,35 $,64,6 $552,79 $9,484,776 $,884,89 $,363,2 $,2,658 $5,2,842 $658,866 $7,884,962 $4,5, $4,858,272 $,974,7 $3,45,88 $6,37 $,25,992 $,973,852 $5, $,252,658 $,826,62 $34,554,72 $,39,795 $354,968 $6,875,236 $3,52,83 $,676,625 $,72,4 $5,648,3 $9,862,99 $5, $5,3,464 $22,296,256 $,65,243 $6,534 $5, $6,96,764 $,7,963 $3,443,23 $5, 27 Part B Base Contribution Allocated to Part B $5,34,622 $5, $4,79,92 $33,46,827 $3,42,8 $2,794,7 $2,55,7 $3,743,37 $3,448,57 $,628,955 $43,728 $9,567,69 $3,69,959 $28,945 $,4,957 $5,562,45 $633,487 $7,965,275 $4,989,4 $4,994,96 $2,4, $4,326,5 $3,58,58 $5, $,286,8 $,876,383 $37,347 $,497,54 $33,267 $5,555,55 $2,77,792 $,728,496 $5,782,789 $,496,654 $,28,283 $5, $23,234,672 $,26,8 $5, $3,435 $4,568,497 $,37,76 $,37,285 $3,6,22 $4, % Change Part B Base Contribution Allocated to ADAP $6,3,333 $3,242,73 $3,855,989 $,55,493 $,,5 $46,285 $5,822,278 $56,37 $4, $, $788,556 $45,32 $323,955 $46,84 $393,466 $3,525,55 $, Part B Base Contribution Allocated to ADAP $2,55, $3,324,876 $3,828,733 $6, $,23,48 $4,72,76 $839,73 $62,863 $,578,85 $5, $,268,944 $2,47,677 $34,944,689 $96,733 $859,85 $,822,83 $89,722 $5,25,284 $5,84 $486,565 $2,62,434 $2,247,9 $, % Change Part B Supplemental Directed to Part B $83,73 $8,7, $6,, $729,64 $6,93,74 $3,9,62 $74,25 $9,4 $44,79 $6,238,788 $8, $,9,37 $2,4, $327,45 $2,29,875 $2,7, 27 Part B Supplemental Directed to Part B $2,, $52,453 $35,, $,89,27 $26,365,55 $2,286,473 $,776,38 $9, $5,3,766 $,59,8 $3,67,74 $,92,97 $,97,877 $8, $2,46,384 $2,8, $2,498,36 $946,25 $2,824,5 % Change $27,4,488 $234,92,44 - $27,9,636 $79,734,232 8 $43,597,243 $4,96,82 4 te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. This table does not include the Other State or Federal category ($2,2,595), which is reported in the total budget in Tables and 2. A dash () indicates the Part B program did not report data. 7

18 TABLE 4 Major FY27 RWHAP Part B Budget Categories Compared with FY26 (Continued) 26 Part B Supplemental Directed to ADAP 27 Part B ADAP % Supplemental Change State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming $,, $2,, $,974,38 $27,97 $2,465,6 $23,76,22 $3,5, $4,349,57 $2,54,25 $392,86 27 Part B Supplemental Directed to ADAP $2,, $7, $,26,234 $8,7, $27,97 $248,26 $35,, $6,5, $8,24,3 $22,64 % Change Part B ADAP Earmark $8,74,238 $54,2 $,593 $,4,54 $4,27,65 $98,388,924 $9,438,47 $8,675,379 $2,57,73 $2,785,27 $85,246,28 $34,52,732 $6,33 $2,2,697 $696,33 $28,935,77 $7,927,474 $,76,438 $2,458,767 $4,99,57 $6,2,24 $,3,933 $796 $25,368,234 $4,256,662 $2,528,5 $5,976,7 $7,547,547 $9,77,553 $34,898 $,569,87 $6,25,85 $932,69 $29,697,958 $2,3,266 $6,36,829 $22,53,6 $96,733 $6,64,782 $4,423,7 $4,543,98 $27,28,45 $5,85,98 $3,86 $,839,894 $2,655,443 $397,449 $3,728,37 $62,53,382 $2,8,434 $393,466 $486,656 $7,493,329 $9,564,262 $,399,434 $4,487,43 $223,84 27 Part B ADAP Earmark $,8,565 $567,987 $43 $,586,446 $4,368,38 $2,954,339 $9,644,42 $8,848,895 $2,625,46 $2,95,249 $88,224,56 $35,272,7 $6,943 $2,8,994 $732,939 $29,66,5 $8,45,232 $,794,56 $2,49,529 $5,22,89 $6,799,88 $,7,339 $83 $25,998,2 $4,46,547 $3,4,35 $6,262,483 $7,764,926 $,64,5 $349,45 $,62,79 $6,54,95 $963,79 $3,23,6 $2,397,84 $7,486,859 $23,92,394 $23,76 $,625 $6,796,65 $4,638,54 $4,749,476 $27,85,5 $5,42,55 $3,25 $,9,979 $3,282,28 $45,224 $4,35,48 $66,57,26 $2,95,566 $47,98 $498,98 $8,4,45 $9,936,928 $,443,938 $4,636,529 $238,83 % Change Part B ADAP Supplemental $8,934,9 $82,3 $2,669,4 $2,73,766 $32,44 $,974,38 $27,97 $25, $3,972,34 $6,353,9 $67,772 $54,8 $4,576,2 $8,934,9 $237,273 $2,669,4 $2,72,7 $2,53,73 $27,97 $3,972,34 $2,384,6 $67, $6,975,745 $72,864,8 $78,82,745 $88,868,44 $4,24,836 $42,627,846 Part B ADAP Supplemental awards were provided to states that met federal eligibility criteria, applied for funding, and were able to meet the mandated matching requirement or receive a waiver. te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. This table does not include the Other State or Federal category ($2,2,595), which is reported in the total budget in Tables and 2. A dash () indicates the Part B program did not report data. 8

19 9 $8,32,63 $5,495,298 $3,, $2,78,5 $27,75 $9,66,735 $,56,69 $2,645,42 $,66, $2,55, $8,865,9 $7,2, $32,44,89 $225, $85,396,784 $5, $86,928 $,96,55 $32,53,966 $6,63,878 $,73,623 $27,932 $37,372 $2,63,336 $,56,69 $97,25 $,754,254 $6,979 $75, $,548,2 $5,82,52 $5, $5, $687,8 $34,74 $96,393, $297,897 $,99,645 $,84,449 $,936,694 $757,87 $395,66 $688,2 $4,56,223 $2,672,688 $9,54,85 $,592,847 $,322,937 $4, $,99,639 $75,, $9,, $5,26,556 $77,295 $895,285 $3,, $9,, $9,, $,322,937 $9,, $47,25,73 26 ADAP Emergency Funding 27 ADAP Emergency Funding $5, $3,3 $7,635 $2,, $43,97 $,22,548 $3,967,3 $5, $3,3 $7,635 $2,, $43,97 $,22,548 $3,967, $7,635 $4,234,39 $4,45,26 % Change 27 Part A Contribution Allocated to Part B 27 Part A Contribution Allocated to ADAP % Change % Change 26 Part A Contribution Allocated to Part B 26 Part A Contribution Allocated to ADAP Part B 26 State Contribution Part B 27 State Contribution % Change

20 TABLE 4 Major FY27 RWHAP Part B Budget Categories Compared with FY26 (Continued) ADAP 26 State Contribution ADAP 27 State Contribution ADAP 26 Estimated Drug Rebates State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming $2,49,796 $,, $2,64, $,5, $,244,688 $44,535 $64,8 $6,, $547,982 $,5 $25, $,5, $,63,678 $3,424,39 $8,995 $9, $2,, $4,34,33 $25, $786, $,267, $,674,66 $7,2, $2,855,6 $8, $28,456 $,36,22 $367,5 $,99,796 $,, $,45,56 $,, $,94,676 $44,535 $8,8 $2,5, $24,74 $85, $,62,676 $75, $5,32,25 $6,979 $75, $2,, $4,34,33 $786, $,677,5 $7,, $29,463,378 $8, $2,658,673 $,36,2 $32,676 % Change Part B 26 Estimated Drug Rebates $4,433,389 $5 $5, $49, $,3, $522,74 $6, $,468,47 $5,, $346,847 $7,298,896 $,25, $3,435,78 $,5, $,5, $55,, $, $8,, $6,365 $3,5, $2,, $6,65,83 $2,78,432 $5,, $2,898,75 $5, Part B 27 Estimated Drug Rebates $2,25, $5,5, $3,38,54 $5, $5,72,945 $3,, $8,567,3 $7,2, $4,, $8,5, $27,356 $8,3,46 $4,, $5,676,265 $,88,85 $4,84,34 $2,, $75, $6,8,74 $4,669,275 $875,948 $5,, $85,637 $6, $5, $9,472,677 $,642,86 $, % Change $6,46,275 $,96, $,2, $77,63,243 $3,5, $4,5, $3,3, $5,, $2,, $3,, $,6,68 $25,8,267 $7,5, $,5, $,96,69 $29,78,798 $275, $,49,95 $,297,26 $,5, $55,, $73,884,554 $3,872, $,2, $5,, $2,, $6,5, $8,, $3,, $23,, $4,6, $6, $24,76 $8,597,633 $3,3, $4,5, $5,232,86 $4, ADAP 27 Estimated Drug Rebates $7,75, $9,4,745 $4,, $85,33,627 $6,5, $3,, $4,5, $,, $52,89,684 $2,, $3,3, $2,, $6,465,9 $4,, $25,, $,992,654 $25,, $3,3, $,2, $5,57,574 $29,5, $22, $4,, $5,, $2,, $47,, $63,44,679 $3,, $,, $5,, $2,, $7,, $29,67,64 $2,73,84 $8,3,79 $2,, $25,, $3,695,787 $5, $66,62 $2,76,37 $,85,882 $3,8, $,25, $3, % Change $9,866,764 $4,547,969 - $62,633,86 $93,335,74 $8,94,262 $723,825,92 - te: 53 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. This table does not include the Other State or Federal category ($2,2,595), which is reported in the total budget in Tables and 2. A dash () indicates the Part B program did not report data. 2

21 TABLE 5 ADAP Cost Recovery and Other Cost-Saving Mechanisms (Excluding Drug Rebates), CY26 State/Territory Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York rth Carolina rth Dakota rthern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Republic of Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (U.S.) Virginia Washington West Virginia Wisconsin Wyoming Private Insurance Medicaid Other $,28,854 $7,9 $2,96 $34,8 $,433,76 $6,285 $248,89 $4,594,853 $,42,479 $2,, $3,42 $73,339 $35,256,84 $3,472 $778,46 $48,37 $, $,5 $8,62 $277,4 $464,55 $892,675 $33,7 $,598,67 $2,, $5,436 $4,32,74 $85,68 $82,595 $5, $5, $45,875 $743,4 $,5,772 $,28,854 $6, $,5 $9,53 $277,4 $72,26 $927,475 $2,77,7 $6,285 $282,62 $6,92,92 $,42,479 $23,, $3,42 $78,775 $35,256,84 $4,32,74 $,5,772 $3,472 $85,68 $96, $5, $48,37 # of ADAPs $75,863,697 6 $47,5,96 4 $,8,48 4 $24,778,94 23 te: 52 ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, Republic of Palau, and Rhode Island did not respond. A dash () indicates the ADAP did not report data. A zero () indicates the ADAP responded zero () to the question. 2

22 E C T I O S 2 N 22

23 HOW RWHAP PART B PROGRAMS FUNCTION RWHAP Part B programs are comprised of the following key components: core medical/support service delivery, including ADAP; quality management (i.e., a series of activities that focus on enhancing the quality of HIV care provided and increasing access to services); and program administration (i.e., administrative, planning and evaluation, salaries, overhead, client eligibility and enrollment, and data system management and reporting). Depending on the programmatic structure, staffing, and capacity, RWHAP Part B programs may elect to contract out one or more of these key components to an external organization. Twenty-three RWHAP Part B programs reported doing so in 26 with administrative and quality management cited as the activities most commonly externalized. The RWHAP Part B program provides services to eligible clients via core medical and support services, each of which might be delivered to clients directly by the state/territory health department or by a sub-recipient agency. In calendar year 26, 33 RWHAP Part B programs reported contracting with one or more sub-recipient agency by individual client service and 36 programs funded sub-recipient agencies to provide multiple discrete services simultaneously. The majority of RWHAP Part B programs reported having funded greater than 5 sub-recipient agencies to deliver core medical and/or support services in their jurisdiction. Two programs funded one sub-recipient agency, seven funded two to five sub-recipient agencies, 8 funded five to ten sub-recipient agencies, and six funded ten to fifteen sub-recipient agencies. Additionally, RWHAP Part B programs may select different agency settings to fund through their procurement 23

24 processes. The types of sub-recipient agencies funded to provide core medical and/ or support services in calendar year 26 vary considerably: standalone medical clinics operated within the health department (8 RWHAP Part B programs) or external to the health department (3 RWHAP Part B programs); clinics integrated within hospitals or similar (e.g., federally qualified health centers (FQHCs)) operated by the health department (nine RWHAP Part B programs) or operated by an external organization (3 RWHAP Part B programs); AIDS Service Organizations (ASOs) (42 RWHAP Part B programs); non-aso community-based organizations (CBOs) (36 RWHAP Part B programs); and other agencies (six RWHAP Part B programs). This reflects the diversity of the RWHAP Part B program services themselves and the varying capacity of sub-recipient organizations. Across all sub-recipient agencies, RWHAP Part B programs must adhere to all category definitions specified in HRSA/HAB policy clarification notice (PCN) 6-2 and use at least 7 of federal RWHAP awards (e.g., Part B Base, Part B Supplemental) to fund core medical services (unless a 75/25 waiver is approved by HRSA/HAB). PCN 6-2 identifies multiple ways in which RWHAP Part B programs may deliver each discrete service category and gives flexibility to states and territories in customizing their provision of care. CHART 3 Engagement in RWHAP Part B and ADAP, Calendar Year 26 Part B ADAP Client enrollment Client utilization Client retention Client optimal health outcome Client enrollment the number of clients enrolled by Part B program or ADAP in 26 Client utilization the number of clients served by Part B program or ADAP in 26 Client retention the number of clients who were successfully recertified twice in a 2-month period of time by Part B program or ADAP Part B client health outcome the number of clients served by Part B program or ADAP who reported a suppressed viral load in 26 te: 52 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, Oklahoma, and Republic of Palau did not respond. 53 ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, and Republic of Palau did not respond. 24

25 RWHAP PART B SERVICES IMPACT ON CLIENTS VIRAL LOAD SUPPRESSION One overarching goal of the RWHAP Part B program is to assist clients in achieving viral suppression. To do so, they provide access to treatment and medical care as well as services that ensure continuous adherence to both. This includes but is not limited to insurance coordination/continuation services under ADAP and RWHAP Part B Health Insurance Premium and Cost-Sharing Assistance for Low-Income Individuals. ADAP-funded insurance programs support their clients in accessing medications and services necessary to ensure adherence to these treatments. Yet the RWHAP Part B premium and cost-sharing assistance allows for additional flexibility than ADAP-funded insurance alone in paying medical costs (e.g., it is not subject to the cap on ADAP funding used for adherence, outreach, and monitoring services). In 26, 28 RWHAP Part B programs reported having provided services to clients under Health Insurance Premium and Cost-Sharing Assistance for Low-Income Individuals. RWHAP Part B programs should deliver the full complement of insurance-related services to eligible clients, including but not limited to ADAP, to maximize their access to services that impact their viral load suppression and other health outcomes. CHART 4 RWHAP Part B Clients Served, by Viral Load, Calendar Year 26 2 Viral Load 2 copies/ml Viral Load > 2 copies/ml Unknown 6 te: 52 Part B programs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, Oklahoma, and Republic of Palau did not respond. Data reflect clients enrolled in Part B programs over the past 2 months or the most recent 2 months for which data are available. Data reflect clients enrolled in Part B programs over the past 2 months or the most recent 2 months for which data are available. Percentages may not total due to rounding. ADAP-funded insurance is defined as when an ADAP client is enrolled in insurance (public or private insurance) and the ADAP pays for part or all the clients co-payments/cost-sharing assistance, deductibles, and/or premiums. ADAPs began purchasing insurance for clients in 22 when HRSA specifically clarified this option. In calendar year 26, 5 ADAPs reported using funds for insurance purchasing/continuation, representing $398.2 million in estimated expenditures (2 of the total ADAP budget for the year) for 2,63 clients (5), with an average cost per client of $3,3. By comparison, 44 ADAPs reported using 25

26 CHART 5 ADAP Clients Served by Program, by Viral Load, Calendar Year 26 Viral Load < 2 copies/ml Viral Load > 2 copies/ml Unknown 8 VL All Clients Full-Pay Prescription Only ADAP-Funded Insurance Only Full-Pay Prescription and ADAP-Funded Insurance te: 52 ADAPs reported data. American Samoa, Federated States of Micronesia, Guam, Marshall Islands, rthern Mariana Islands, Republic of Palau, and Rhode Island did not respond. Data reflect clients enrolled in ADAPs over the past 2 months or the most recent 2 months for which data are available. Percentages may not total due to rounding. funds for insurance purchasing/continuation in 23 (i.e., the last year before the Affordable Care Act (ACA) was fully implemented) for 3 of all clients served by ADAP. From 23 to 26, ADAPs have reported an average increase each year in the proportion of clients served by insurance purchasing/continuation programs with the largest increase between years 24 and 25 (). Among those clients served by ADAP-funded insurance, rates of viral suppression are significantly higher than among those served by the ADAP full-pay prescription program alone. The percentage of clients reported as virally suppressed among those served by ADAP-funded insurance only and those served by both the ADAP-funded insurance and the full-pay prescription programs is 8. By comparison, just 7 of clients served by the full-pay prescription program only were reported as virally suppressed. This is likely because access to insurance ensures ADAP clients may seek a multitude of services that directly affect retention in care and adherence to treatment, including HIV medical care, substance use treatment, and mental health treatment, among others. 26