AIDS Drug Assistance Program (ADAP)
Acceptable Supporting Documentation Checklist

One item from each section is required unless otherwise indicated. Additional documents may be needed to determine eligibility.

Proof of Identity*

Proof of Identity and that client is 18 years old or older:

• Driver’s License
• State or local ID card (i.e., DMV issued ID, Municipal ID, student ID, or an ID from the Department of Corrections (CAL-ID))
• U.S. Passport
• Permanent Residence Card
• Employment authorization card
• Military ID card
• Photo ID issued by a foreign government (i.e., voter registration card, passport, or consulate ID card)
• Birth certificate (only if client does not have one of the ID’s listed above)
• Provider Verification of Identity form (PDF)
  

*Note: Expired cards may be used if no other form of picture ID is available. 

Proof of Residency*

These documents must be dated within 90 days, be in the client’s name, and include the client’s residential address:

• California rent or mortgage receipt
  
• Current utility bill with the service address listed in California (a cell phone bill is not acceptable)
• Employment paycheck stub.

These documents must be dated within one year, be in the client’s name, and include the client’s residential address:

• Rental/lease agreement or annual lease renewal documentation
• Voter registration card
• Vehicle registration (not expired)
• W-2 or 1099 (prior tax year documents will be accepted until February 15. After February 15, only current tax documents will be accepted.
• Social Security award letters (includes Supplemental Security Income (SSI) and Social Security Disability Income (SSDI))
• California Employment Development Department (EDD) award letter
• Filed State or Federal tax return
• Public housing letter on official letterhead from Housing and Urban Development (HUD) or a county agency
• Notice of Action (NOA) from the Department of Health Care Services (DHCS).

*Note: Clients who do not have the above residency documentation may prove residency by completing and submitting the Residency Verification Affidavit form (PDF). A letter from the client’s ADAP enrollment worker, on agency letterhead and containing the same information as found on the Residency Verification Affidavit form, is also acceptable.

HIV Labs*

New ADAP applicants at initial enrollment must provide proof of positive HIV status described below. Proof of positive HIV status must be provided. If no proof is provided, do not enroll.*

Proof of positive HIV Status (provide one of the following):

• HIV lab results (antibody test, qualitative HIV detection test, or detectable/ undetectable viral load)
• Letter of diagnosis from a physician or licensed health care provider on letterhead with the National Provider Identifier (NPI) number and the physician’s or licensed health care provider's signature verifying the client's HIV status
• ADAP Diagnosis Form (PDF) completed by the applicant’s physician or licensed health care provider
• Legible prescription for an antiretroviral drug listed on the ADAP formulary (excluding Truvada and Descovy), which includes the following:
• Client’s first and last name
• Name of antiretroviral drug
• Dated within the last 30 days.

*Note: Applicants can provide a positive rapid HIV test result to be granted a 30-day Temporary Access Period (TAP), pending a confirmatory HIV positive lab result. Once the confirmatory HIV positive lab result is provided, the 30-day TAP can be removed.

Proof of Income

Income documentation for all household members is required.

• Household members include:
  
• An applicant,
• An applicant’s spouse or registered domestic partner (RDP), and
• Any tax dependents of the applicant, spouse, or RDP.
• Preferred income documents for establishing Modified Adjusted Gross Income (MAGI) include:
• Federal tax returns (current and previous year only),
• Federal Tax Transcripts (current and previous year only), and
• State tax returns (current and previous year only).

In addition to state and federal tax returns, Internal Revenue Service (IRS) Form 2555 Foreign Earned Income must be submitted if applicable. If a federal or state tax return is not available to establish MAGI, then applicants may submit gross income documentation for all household members.

MAGI Documents:

• Filed Federal or State tax return with W-2, 1099 or Schedule C (ADAP will not accept a tax return without a W- 2, 1099 or Schedule C unless the return is signed, accompanied by proof of electronic submission, or the client’s income matches the data received from the California Franchise Tax Board (FTB)).
  
• Form SSA-1099 Social Security Benefit Statement may be accepted without additional accompanying documents for clients with SSI or SSDI.

Gross Income Documents:

• Pay stubs documenting three current consecutive months of income—
• Three consecutive months; of current paystubs, or
• One paystub showing Year-To-Date (YTD) earnings that includes at least three months of income, and the employment start date
• Payment/ weekly summaries or bank statements documenting three current consecutive months of income from clients who work for companies (i.e., Uber, Lyft, etc.) as independent contractors (self-employed). Payment/weekly summaries must clearly show the payment transactions are from the company the client works for and contain:
• The person’s first and last name and company name
• Dates covered and the gross income from profit/ loss
• Private disability award letter (dated within one year)
  
• Social Security award letters (includes SSI and SSDI) (dated within one year)*
  
• Bank statement showing direct deposit of Unemployment Insurance (UI), SSI/SSDI benefits. Statement must be dated within 90 days and clearly identify the deposit/income source (i.e.,, US Treasury, SSA)
• State Disability Insurance (SDI) award letter (dated within one year)
• Social Security Retirement Benefit award letter (dated within one year)
• Retirement/Pension award letter or three consecutive or monthly benefit statements, pay slips, or pay stubs (dated within one year)
• UI award letter (dated within one year)
• Spousal support court documentation
• Worker’s Compensation award letter (dated within one year)
• Investment income documentation (i.e., statement or portfolio summary dated within one month)
• Veteran’s Administration Benefits (VA) award letter (dated within one year)
• Rental income documentation (i.e., a signed rental agreement dated within the last year or three current bank statements showing rental income deposits)
• Employer statement (must be on company letterhead, signed by the employer and dated within 45 days of ADAP application, and include, name of employer or company, name and title of person writing the letter, employer or company address and phone number, date of the letter, start date and if applicable, the end date of the employee’s employment or pay and the two following statement: “I certify that [first and last name of person employed or receiving income: is/was an employee of [name of company]. [employee’s name]’s gross income for this pay period is/was $[Enter Amount] and frequency of pay is [weekly, every two weeks, twice a month, or monthly]. This letter does not guarantee employment or wages.” and “The information provided above is true and correct to the best of my knowledge.”)
• Self-employment Profit and Loss Statement or Ledger documentation (the most recent quarterly or year-to-date profit and loss statement, or a self-employed ledger.) (Form must include the client’s first and last name, company name, dates covered and the net income form profit/loss.)
• ADAP Self-Employment Affidavit (PDF) form (earnings for the past 3 months to present). This form can be used if clients are unable to obtain payment/weekly summaries from the company (i.e., Uber and Lyft) they work for as independent contractors (self-employed).
• ADAP Income Verification Affidavit (PDF) form (completed by the individual providing income support other than the applicant’s spouse/RDP) (dated within one month). This form can be used if clients are seasonal workers (i.e., farmers, actors) who work during certain times of the year and are ineligible for Medi-Cal.

* Clients receiving unearned income should always be screened for Medi-Cal, regardless if the unearned income amount is greater than 138% FPL. Please refer to the Proof of Income section of the ADAP Guidelines for details.

Proof of Medi-Cal Ineligibility*

ADAP applicants must provide proof that they are ineligible for Medi-Cal as described below. 

Proof of MAGI Medi-Cal ineligibility:

• Income documentation showing household income at or above 138% of the Federal Poverty Level (FPL)
• ID documentation (refer to Section I: Proof of Identity for a list of examples), showing client is aged 65 or older  
• NOA of Medi-Cal denial or termination will be reviewed and may be accepted on a case-by-case basis. NOA must be current and include a termination date. Unacceptable denial/termination reasons:
• Failure to comply
  
• Client lives in a facility (such as a long-term care, convalescent home, mental health facility, or jail)
• Withdrawal of application
• Loss of contact/unable to locate
• Denied reason of “Other.”
  

*Note: Individuals 19 years of age or older with income below 138% of the FPL regardless of immigration status qualify for MAGI Medi-Cal.

Proof of Non-MAGI Medi-Cal ineligibility (provide one of the following):

• Denial Letter for non-MAGI Medi-Cal, SSI or SSDI (dated within one year)
• Proof of employment (dated within thirty days)
• UI award letter (dated within one year).

*Note: Not applicable to clients who are currently enrolled in Medi-Cal or Medicare.

Additional Forms (provide all that apply)

• ADAP Consent Form (PDF) (required at initial enrollment and annual re-enrollment)
• Must be most current copy of the form with all fields filled out unless otherwise noted.
• ADAP Client Attestation (PDF) form (required at initial enrollment, annual re-enrollment, and any time an eligibility change or enrollment update is made using the electronic ADAP Enrollment System)
• Must be most current copy of the form with all fields filled out unless otherwise noted.
• ADAP-PrEP Enrollment Worker Attestation (PDF) form (required if enrollment worker enrolls a client over the phone who is unable to meet in person, cannot submit items electronically, and cannot mail the documents).
  

Office of AIDS Health Insurance Premium Payment (OA-HIPP) (If applicable) 

• Current health insurance billing statement(s) (for medical, dental, and/or vision-combination plans, as applicable)
• For plans purchased through Covered California:  Covered California Welcome Letter or Current Enrollment summary showing the health plan, premium amount, and how much Advanced Premium Tax Credit (APTC) the client qualifies for
• For family plans:  Documentation to substantiate the relationship between the client and all members on the insurance policy, such as:
• Marriage certificate
• Proof of registered domestic partnership
• Birth certificate
• Adoption documentation
• Most recent tax return identifying dependents on family plan
• Partial Payment Agreement (PDF) (only required if monthly premium is over $1,938.00). If a client and the spouse/RDP are both enrolled in ADAP, they are each eligible for a monthly medical, dental, and dental/vision premium threshold of $1,938.00. Therefore, their premiums can total up to $3,876 (Partial Payment Agreement is required if monthly premium is over). Note: A marriage certificate is required for verification purposes.
• Client Attestation Form (PDF)
• OA-HIPP Client Responsibilities (PDF) form 
  

Spousal/ Dependent Medical Out-of-Pocket Benefit (MOOP) (If applicable)

To qualify for the Spousal/Dependent MOOP Benefit, the spouse, registered domestic partner and/or dependents must be active ADAP clients and named as a family member on the health plan of a client enrolled in the OA-HIPP program. Submit all of the following:

• ADAP Consent Form (PDF) – (a separate form is required for both the primary client and the spouse/RDP/dependent)
• ADAP Client Attestation (PDF) form (select OA-HIPP or EB-HIPP) – (a separate form is required for both the primary client and the spouse/RDP/dependent)
• Acknowledgement of Policies and Responsibilities (PDF) 
• Family Plan Consent Form (PDF)
• Proof of family health coverage (must indicate that the spouse, registered domestic partner and/or dependents are covered under the family plan).
  

Medicare Premium Payment Program (MPPP) Program (If applicable) 

• Client Attestation Form (PDF)
• Fax coversheet (PDF) (if faxing)
• Most recent Medigap billing statement (if requesting Medigap premium assistance)
  

Employer Based Health Insurance Premium Payment (EB-HIPP) Program (if applicable)

• Client Attestation Form (PDF)
• Participation Agreement Form (completed by the client and the client’s employer)
• Initial enrollment and changes: One (1) month of consecutive paystubs (must be within the last three (3) months) to confirm premium amount. 
• Re-enrollment: One (1) paystub (must be dated within the last three (3) months).
• If the premium is not reflected on the paystubs, then a Benefit Enrollment Form, Benefit Statement, or a Benefit Summary Letter can be submitted in addition to confirm the premium amount.
• The Benefit Summary Letter must include the following:
• Must be on company letterhead or state the name of the company
• Must be signed by the employer (wet or approved digital signature)
• Must be no older than 45 days from the date received by ADAP
• Name of employer or company
• Name and title of person writing the letter
• Employer or company address
• Employer or company phone number
• Date of the letter
• Client’s name
• Insurance plan start date or premium change effective date
• Medical and dental monthly premium amount client is responsible for.
• Retirees only:
• In lieu of paystubs, retirees may submit a Benefit Enrollment Form, Benefit Statement, or Benefit Summary Letter to verify premium amount.
  
  • Client Attestation Form (PDF)
  • Participation Agreement Form (completed by the client and the client’s employer)
  • Initial enrollment and changes: One (1) month of consecutive paystubs (must be within the last three (3) months) to confirm premium amount. 
  • Re-enrollment: One (1) paystub (must be dated within the last three (3) months).
  • If the premium is not reflected on the paystubs, then a Benefit Enrollment Form, Benefit Statement, or a Benefit Summary Letter can be submitted in addition to confirm the premium amount.
  • The Benefit Summary Letter must include the following:
  • Must be on company letterhead or state the name of the company
  • Must be signed by the employer (wet or approved digital signature)
  • Must be no older than 45 days from the date received by ADAP
  • Name of employer or company
  • Name and title of person writing the letter
  • Employer or company address
  • Employer or company phone number
  • Date of the letter
  • Client’s name
    
  • Insurance plan start date or premium change effective date
  • Medical and dental monthly premium amount client is responsible for.
    

• Retirees only:
  
• In lieu of paystubs, retirees may submit a Benefit Enrollment Form, Benefit Statement, or Benefit Summary Letter to verify premium amount.
  

Notes:

• Paystubs will be reviewed to verify the monthly premium amount indicated on the Participation Agreement Form match the premium deduction on the paystubs.
• The employer listed on the Participation Agreement form must match the employer listed on the client’s paystub. If the employer’s name does not match, the application will be rejected.
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