Form 2 ADAP Client Report

D: ADR Client-Level Data Elements (ADAP Data Report)

Field #	Variable Description	Variable definition	Allowed Values	Rationale
	Reporting period	The report period identifier.	2012P1= 04/01/2012-09/30/2012 2012P2= 10/01/2012 – 03/31/2012 Note that values will continue and be sequential i.e. 2013P1, 2013P2
	Encrypted UCI	The encrypted, unique client identifier generated by the HAB UCI generation utilities.	41-character string
	ADAP number	The unique provider organization identifier assigned through the ADR Web Application.	State ADAP number
Client Demographics: To describe the socio-demographic characteristics of all clients enrolled in the ADAP, whether or not they received services
	Ethnicity	Client’s ethnicity. OMB-approved categories are used.	Hispanic/Latino(a) Non-Hispanic Unknown	Description of clients served
	Race	Client’s race. Select all that apply. OMB-approved categories are used.	White Black or African American Asian Native Hawaiian/Pacific Islander American Indian or Alaska Native Unknown	Description of clients served
	Gender	Client’s current gender	Male Female Transgender Unknown	Description of clients served
	Transgender	Client’s current transgender status. To be completed only if the response is “Transgender” in Q6.	Male-to-Female Female-to-Male Unknown	Description of clients served

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Client Demographics: To describe the socio-demographic characteristics of all clients enrolled in the ADAP, whether or not they received services
	Pregnancy status	Value indicating whether the client was pregnant at any time during the reporting period. This should be completed for HIV+ women only.	No (skip to #10) Yes Not applicable (skip to #10) Unknown(skip to #10)	Description of clients served
	Pregnancy outcome	Value indicating whether this pregnancy resulted in a live birth. This should be completed for HIV+ women who reported being pregnant in item #8.	Yes No Don’t know	Description of clients served
	Client’s year of birth	The year in which the client was born	YYYY	Description of clients served
	HIV/AIDS status	Client’s HIV/AIDS status as of the end of the reporting period	HIV positive, not-AIDS HIV positive, AIDS status unknown CDC-defined AIDS Unknown	Description of clients served
	Poverty level	Client’s annual household income as a percent of the Federal Poverty Level (FPL) at the end of the reporting period.	Equal to or below the FPL 101-200% of the FPL 201-300% of the FPL 301% - 400% of the FPL 401% - 500% of the FPL Over 500% of the FPL Unknown/ unreported	Description of clients served
	High Risk Insurance	Was this client in a High Risk Insurance Pool at any time during the reporting period?	No Yes Don’t know	Description of clients served
	Client’s health insurance coverage during the reporting period	Indicate all sources of client’s health insurance during the reporting period. Report all that apply.	Medicare Part A/B Medicare Part D Medicaid Private Other public No insurance Other	Description of clients served

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Clinical Information: To describe the clinical characteristics of ADAP clients who received ADAP-funded medications. All clients receiving ADAP-funded medications should have at least one CD4 and one VL reported during the 12 month reporting period.
	Report the date of the most recent CD4 count for this client during this reporting period	Value indicating the date of the most recent CD4 count for this client during this report period	MM/DD/YYYY	To determine the impact of ADAP-funded medications
	Report the value of the most recent CD4 count for this client during this reporting period	Value indicating the value of the most recent CD4 count for this client during this report period	Value: ###	To determine the impact of ADAP-funded medications
	Report the date for the most recent Viral load count for this client during the reporting period	Value indicating the date of the most recent Viral load count for this client during this report period	MM/DD/YYYY	To determine the impact of ADAP-funded medications
	Report the value of the most recent Viral load count for this client during the reporting period	Value indicating the value of the most recent Viral load count for this client during this report period	Value: ###	To determine the impact of ADAP-funded medications

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Enrollment and Certification: To describe client enrollment patterns and certification processes
	Was the individual a new or existing client?	Newly enrolled clients in ADAP this reporting period refers to individuals who meet all of the following criteria: applied to ADAP for the first time ever; met the financial and medical eligibility criteria of the ADAP during the period for which you are reporting data Examples of clients who should NOT be included in this number are the following: Clients who have been recertified as eligible or clients who have been re-enrolled after a period of having been decertified/disenrolled. Clients who have moved out of the State and then returned, and Clients who move on and off ADAP because of fluctuations in eligibility for a Medicaid/ Medically Needy program, based on whether they met spend-down requirements. An existing ADAP client is a client who met the following criteria: enrolled in ADAP in a previous reporting period and; continues to be enrolled in the current reporting period, regardless of whether they used ADAP services in either reporting period. Note: An individual enrolled in ADAP (new or existing client) may or may not use services. Use of services is not required to be an enrolled client.	Newly enrolled client Existing Client (skip to question #23)	HAB ADAP Performance Measures

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Enrollment and Certification: To describe client enrollment patterns and certification processes
	What was the date of receipt of the completed client ADAP application?	The date that the completed application was received by the ADAP program.	MM/DD/YYYY	HAB ADAP Performance Measures
	What was the date of approval of this client’s ADAP application?	The date that the client was approved to begin to receive ADAP services. This is when the client was first enrolled in the ADAP program.	MM/DD/YYYY	HAB ADAP Performance Measures
	What was the date this client first received an ADAP-funded service?	The date that the client first received any ADAP-funded service. An ADAP-funded service includes medications and insurance assistance (co-pays, deductibles or premiums).	MM/DD/YYYY	HAB ADAP Performance Measures
	What was this client’s recertification date during this reporting period?	The date on which a client was determined to be eligible to continue to receive ADAP services. Note: All individuals enrolled in ADAP, regardless of whether or not they receive services, must be recertified every six months. This includes clients on a waiting list. The minimum activities for recertification include: Financial Eligibility determination. Ensuring that ADAP is the Payer of Last Resort Appropriate documentation (ie: financial/ insurance –or lack thereof/ denial of coverage)	MM/DD/YYYY	HAB ADAP Performance Measures
	What was the client’s enrollment status as of the end of the reporting period?	The status of an individual in the ADAP program as of the end of the reporting period. There are four possible options which are: The individual is enrolled in ADAP but did not need/request any services The individual is enrolled in ADAP but is on a waiting list The individual is enrolled in ADAP and received either ADAP-funded medications or insurance services during the reporting period The individual was disenrolled from ADAP	Enrolled, receiving services (skip to question #26) Enrolled, on waiting list (skip to question #26) Enrolled, services not requested (skip to question #26) Disenrolled	Description of clients served

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Enrollment and Certification: To describe client enrollment patterns and certification processes
	What was/were the reason(s) for disenrollment?	Please note the reasons for disenrollment/discharge. Select all that apply. If the reason is unknown, please report under “other”.	Ineligible, change in ADAP program FPL requirements Ineligible for ADAP, now eligible for Medicaid Ineligible, other reason Did not recertify Did not fill prescription Deceased Dropped out, no reason given Other/Unknown	To determine service utilization
ADAP Insurance Services Received: To describe ADAP-funded insurance assistance services and expenditures. ADAP-funded insurance assistance includes premiums, co-pays and deductibles. Co-pays and deductibles for medications should be reported in this section.
	Did this client receive any ADAP-funded insurance assistance during this reporting period, including Medicare Part D premiums?	This includes premiums, deductibles and co-payments for which ADAP funds were used. [If response to question #26 is no, go to #31]	No Yes	To describe service utilization
	Total amount of insurance Premium paid on behalf of this client during the reporting period [not including Medicare Part D].	The total amount of insurance premium paid on behalf of the client. This pertains to any premium paid during the reporting period, regardless of the time frame that it covers (i.e. if it extends outside the reporting period)	$$$	To describe service utilization and to determine annualized costs by type of insurance assistance
	For how many months of coverage was this insurance Premium during the reporting period?	The total number of months of coverage for which insurance premium in item #26 was paid. Please report all months even if they fall outside of the reporting period.	##	To describe service utilization and to determine annualized costs by medication type

Field #	Variable Description	Variable definition	Allowed Values	Rationale
ADAP Services Received: To describe ADAP-funded insurance assistance services and expenditures. ADAP-funded insurance assistance includes premiums, co-pays and deductibles. Co-pays and deductibles for medications should be reported in this section.
	Total amount of deductible and co-pays paid on behalf of this client during the reporting period.	The total amount of insurance deductibles and co-pays paid on behalf of the client, not including Medicare Part D. The amount reported should be based on the date that the deductible or co-pay was paid.	$$$	To describe service utilization and to determine annualized costs by medication type
	Total amount of Medicare Part D Co-Insurance, Co-Payment or donut hole coverage (true out of pocket expenses) paid on behalf of this client during the reporting period.	The total amount of Medicare Part D Co-Insurance, Co-Payment or donut hole coverage (true out of pocket expenses) paid on behalf of the client during this reporting period. The amount reported should be based on the date that the co-insurance, co-payment or donut hole coverage amount was paid.	$$$	To describe service utilization and to determine annualized costs by medication type

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Drugs and Drug Expenditures: To describe the ADAP-funded medications dispensed to clients and total expenditures for those services. This section is only for clients who were dispensed ADAP-funded medications paid in full by ADAP (i.e. not clients for whom only the co-pay or deductible was paid). This includes ARVs, Hepatitis B and Hepatitis C medications.
	Were any ADAP-funded medications dispensed to this client during this reporting period?	Whether or not ADAP-funded medications were dispensed to this client during this reporting period? ADAP-funded medications include any medication on your ADAP formulary which was paid for in full by ADAP funds.	No (skip to end) Yes	To describe service utilization
	Please list the ADAP-funded medication dispensed to the client during this reporting period.	The specific list of ADAP funded medications that were dispensed to the client during the reporting period. Please use the five-digit drug code (d-xxxxx) of the medication. Variables 32-35 will be reported for each ADAP-funded medication.	d#####	To describe service utilization and to determine annualized costs by medication type
	What is the start date of the ADAP-funded medication dispensed to the client during this reporting period?	List the start date for each ADAP funded medication listed in question #32.	MM/DD/YYYY	To describe service utilization and to determine annualized costs by medication type
	For how many days was the ADAP-funded medication dispensed?	The number of days for which the medication was dispensed for each ADAP funded medication listed in question #32. Number of days should be reported in 30-day increments (i.e. 30, 60, 90).Anything less than 30 days should be reported as 30 days.	##	To describe service utilization and to determine annualized costs by medication type
	What was the Total cost of the ADAP-funded medication dispensed to the client during the reporting period?	The total cost of each ADAP-funded medication dispensed during the reporting period. Include total costs of each ADAP-funded medication paid during the reporting period, even if the medication prescription period extended beyond the reporting period.	$$	To describe service utilization and to determine annualized costs by medication type
	Dispensing fees collected separately	Do you pay dispensing fees for medications separate from other fees such other administrative? [If yes, go to question 37)	No Yes	To describe service utilization and to determine annualized costs by medication type.

Field #	Variable Description	Variable definition	Allowed Values	Rationale
Drugs and Drug Expenditures: To describe the ADAP-funded medications dispensed to clients and total expenditures for those services. This section is only for clients who were dispensed ADAP-funded medications paid in full by ADAP (i.e. not clients for whom only the co-pay or deductible was paid). This includes ARVs, Hepatitis B and Hepatitis C medications.
	What is the total cost of all Dispensing Fees for medications paid on behalf of this client during the reporting period?	The total cost of all dispensing fees for medications paid on behalf of the client during the reporting period. Include all costs paid during the reporting period, even if the medication period extended beyond the reporting period.	$$	To describe service utilization and to determine annualized costs by medication type.

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