The CARE Act gives States the authority to determine financial and medical eligibility criteria for participation in ADAPs. Individuals with HIV disease who do not have another source of payment must demonstrate financial need, which States typically define using a multiple of the Federal Poverty Level (FPL). For help in determining the size and content of ADAP formularies, most States (50) have established Advisory Groups to assist with decision making on these and other difficult issues. These groups include expert clinicians, public health officials and planners, medical ethicists, and representatives of consumers and service providers.

All States require documentation of HIV status for ADAP enrollment. At present, nine States also require individuals to demonstrate disease progression (e.g., a lab test showing a CD4 count of 500 or less). In addition, four ADAPs have specific criteria for accessing protease inhibitors and/or antiretrovirals.

The table below summarizes financial eligibility criteria. Fourteen States have established income eligibility at 200 percent or less of FPL. (See State-by-State description of criteria below).

Rapid growth in client enrollment, utilization, and expenditures has resulted in major challenges to States as they try to promote access to treatment while ensuring that ADAPs remain fiscally sound. State responses include: maximizing resources through different cost-savings strategies, establishing representative advisory bodies to help with difficult program decisions; including defining eligibility criteria, and seeking additional funds from State legislatures or other resources.

Financial Eligibility Criteria

ADAP Eligibility Criteria, FY 2004

Based on projections from States in their Ryan White CARE Act FY 2004 Title II grant applications ADAP Profile: (1) South Dakota does not include protease inhibitors on their formulary (2) Developing ADAP (3) Utah uses a sliding fee scale for incomes from 201-500% FPL (4) South Carolina uses a sliding fee scale for incomes from 301% to 550% FPL (5) Oregon uses a sliding scale that is tied to the annual income cap amount.