Ryan White HIV/AIDS Program Part A Manual

The Ryan White HIV/AIDS Program, the largest Federal program focused exclusively on HIV/AIDS care, addresses the unmet health needs of persons living with HIV/AIDS (PLWHA) by funding primary health care and support services that enhance access to and retention in care. First enacted by Congress in 1990, it has been amended and reauthorized three times: in 1996, 2000, and 2006. The most recent reauthorization retitled the legislation as the Ryan White HIV/AIDS Treatment Modernization Act of 2006. Called the Ryan White HIV/AIDS Program by HRSA/HAB, the earlier title was the Ryan White CARE (Comprehensive AIDS Resources Emergency) Act.

Like many health problems, HIV/AIDS disproportionately strikes people in poverty, racial/ethnic populations, and others who are underserved by healthcare and prevention systems. HIV/AIDS often leads to poverty due to costly healthcare or an inability to work that is often accompanied by a loss of employer-related health insurance. Ryan White-funded programs are the "payer of last resort." They fill gaps in care not covered by other resources. Most likely users of Ryan White services include people with no other source of healthcare and those with Medicaid or private insurance whose care needs are not being fully met.

Ryan White services are intended to reduce the use of more costly inpatient care, increase access to care for underserved populations, and improve the quality of life for those affected by the epidemic. Ryan White works toward these goals by funding local and State programs that provide core medical services and support services; healthcare provider training; and technical assistance to help funded programs address implementation and emerging HIV care issues.

Ryan White provides for significant local and State control of HIV/AIDS healthcare planning and service delivery. This has led to many innovative and practical approaches to the delivery of care for PLWHA.

The Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) has lead responsibility for implementing the program. HRSA is an agency of the U.S. Department of Health and Human Services (HHS). HRSA/HAB provides funded programs with ongoing policy guidance (including Guiding Principles to address evolving challenges in HIV care) and technical assistance to enhance their operations.

The Ryan White HIV/AIDS Program is the largest Federal government program specifically designed to provide services for PLWHA. Its funding has grown along with the number of HIV/AIDS cases and treatment costs. Ryan White programs are classified under Parts and include:

• Part A – Local Areas
  
  Part A includes Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs), targeting resources to urban areas hardest hit by the HIV/AIDS epidemic. Eligibility is defined by the cumulative number of new AIDS cases reported in the most recent five year period, and the cumulative number of living cases of AIDS as of the end of the most recent calendar year for which data are available. EMAs/TGAs may use funds for HIV/AIDS primary care, other core medical services, and support services that enhance access to and retention in primary care. Grants are awarded to local governments. They, in turn, award funds to providers based on service priorities. These service priorities are established by the Part A planning council that is convened by the EMA/TGA to carry out HIV/AIDS planning. (Note: Planning councils are not required for the five new TGAs created as a result of the Ryan White legislation, although these areas must use a process for securing community input if a planning council is not formed.) Formula awards are based on the area's reported living cases of HIV and AIDS among all eligible areas as well as the yearly appropriation amounts available. Supplemental awards are based on demonstrated need as determined on an "objective and quantified basis."
  
  
• Part B – States
  
  States and territories are funded under Part B to improve access to primary care and support services that enhance access to and retention in primary care. Funding is available via: formula grants (Part B "base"), AIDS Drug Assistance Program (ADAP) Formula and ADAP Supplemental Grants, Emerging Communities Grants, and Supplemental Grants based on Demonstrated Need. Funds may also be used for early intervention services to move PLWHA into care. States have program flexibility to ensure a basic standard of care by providing support and services through consortia.

• Part C – Community-Based Programs
  
  Public and private nonprofit primary care providers receive competitive grants for outpatient early intervention services (i.e., comprehensive primary health care and other services, including HIV counseling, testing, and referral) and capacity development grants.
   
  
• Part D – Women, Infants, Children, and Youth with HIV/AIDS and Their Families
  
  Funds go to public and private nonprofit entities to coordinate services for women, infants, children, and youth, women and their families, to provide core medical and support services, and to enhance access to research.
   
  
• Part F – Special Projects of National Significance (SPNS)—Research Models
  
  Funds go to public and private nonprofit entities to develop innovative models of HIV/AIDS care.
   
  
• Part F – Dental Programs
  
  Two dental programs focused on dental services and training are funded under Ryan White: the Dental Reimbursement Program (to help cover the uncompensated costs of providing oral health care to PLWHA) and the Community Based Dental Partnership (for services at the community level along with training of dental providers).
   
  
• Part F – AIDS Education and Training Centers (AETC)—Provider Training
  
  Funds go to a network of regional and national entities to conduct multi-disciplinary HIV-related education and training for health care providers. The goal is to increase the number of trained HIV providers and to help prevent HIV transmission. AETCs also disseminate treatment information to health care providers and patients.
   
  
• Part F – Minority AIDS Initiative
  
  Funds go to Part A, B, C and D programs to evaluate and address disparities and the disproportionate impact of HIV/AIDS on access, treatment, care and outcomes for racial and ethnic minority groups as defined in the legislation.

The HIV/AIDS Bureau's (HAB) Ryan White programs are administered as follows:

• Office of the Associate Administrator for HIV/AIDS (OAA) provides the overall leadership and direction for the HIV/AIDS Bureau through the administration and management of its operations and policies.
  
• Division of Service Systems (DSS) administers Part A and Part B, including the AIDS Drug Assistance Program (ADAP).
  
• Division of Community Based Programs (DCBP) administers Part C, Part D, and Part F Dental Programs.
  
• Division of Science and Policy (DSP) administers the Part F SPNS Program; oversees research and evaluation studies related to the effectiveness of Ryan White programs; and analyzes service data submitted by funded programs. DSP also serves as the focal point for the Bureau's policy, regulatory, strategic planning, performance monitoring, document clearance, and program development activities.
  
• Division of Training and Technical Assistance (DTTA) administers the Part F AETC program; oversees HAB planning, training, and technical assistance activities; coordinates clinical quality management/improvement activities of HAB; and coordinates most HAB external meetings.

Although the epidemic has increased in recent years throughout the United States, the majority of reported HIV/AIDS cases continue to be in urban and suburban areas, particularly the Nation's largest metropolitan areas. The Part A program provides emergency relief grants to these areas.

Each eligible urban area encompasses an urban center plus surrounding counties and localities included within its Metropolitan Statistical Area (MSA) — a geographic area established by the U.S. Census Bureau that may cross State lines. Part A funds are awarded to local governments (grantees) who work with planning councils to assess the unmet needs of PLWHA in the area and determine how to address them. (Requirements for making this unique partnership work effectively are outlined below.)

There are two categories of eligibility for Part A funds. The first, Eligible Metropolitan Areas (EMAs) are defined as having over 2,000 cumulative new AIDS cases reported during the most recent five year period and 3,000+ living AIDS cases as of the most recent calendar year for which such data are available. The second category, Transitional Grant Areas (TGAs), are areas with 1000-1999 cumulative new AIDS cases reported within the most recent five years and at least 1,500 living AIDS cases as of the most recent calendar year for which such data are available.

Each EMA/TGA grant consists of a "formula" and "supplemental" part.

• The formula part is based on an area's reported living cases of HIV and AIDS among all eligible areas as well as the yearly appropriation amounts available.
• The supplemental part is based on the ability of the EMA/TGA to document demonstrated need for additional funding and capacity to use funds to meet community needs.

Part A supports a comprehensive continuum of quality, community-based care for low-income individuals and families with HIV/AIDS. Eligible service categories include core medical services and support services, as defined by the legislation.

EMAs/TGAs may award funds to public, nonprofit entities-or to private for-profit entities if they are the only available providers of HIV/AIDS care in the area. Eligible organizations include community-based organizations, ambulatory care facilities, community health centers, migrant health centers, homeless health centers, substance abuse treatment programs, mental health programs, hospitals, and hospices.

Part A funds are awarded to the chief elected official (CEO), usually the Mayor or County Executive of the city or county within the area providing outpatient and ambulatory services to the greatest number of people with AIDS living in the eligible area. CEOs are responsible for establishing planning councils. (Planning councils are required in EMAs and former EMAs but are optional in the five new TGAs that came into being in 2007. These five new TGAs must establish a process to secure community and consumer input into the planning process.) Planning councils share some duties with CEOs. Planning councils are broadly representative of the community.  They plan and set priorities for the allocation of funds. Grantees, in turn, must allocate funds according to these priorities and do so through their local procurement systems. Planning councils may not be directly involved in designating or selecting grant recipients or in administering Ryan White grants (i.e. participating in or sitting on panels that review funding applications for services in the area).

The CEO retains ultimate responsibility for submitting grant applications, ensuring that funds awarded are used appropriately, ensuring that the 75 percent core medical services requirement is met, and complying with reporting or other requirements. However, most CEOs delegate day-to-day responsibility for administering Part A awards to their local health departments.

Both the grantee and the planning council must establish their own grievance procedures for addressing grievances with respect to funding. These must include procedures for submitting-to mediation and binding arbitration-grievances that cannot otherwise be resolved. Grievance procedures must be consistent with HAB-developed models and must be approved by HAB.

In administering funds to ensure they are used appropriately and fairly, grantees must:

• Establish intergovernmental agreements (IGAs) with other jurisdictions within the EMA/TGA that provide HIV-related services and that account for at least 10 percent of the EMA's/TGA's reported AIDS cases. Allocation of funds and services to the other jurisdictions are based on these agreements.

• Ensure the delivery of services to women, infants, children, and youth with HIV/AIDS. Every EMA/TGA must allocate funds for each of these groups in an amount proportional to their representation among the area 's total AIDS cases. A waiver may be granted if the area can demonstrate to HRSA's satisfaction that one or more of these priority populations are receiving HIV-related health services through Medicaid, the State Children's Health Insurance Program, or other Federal/State programs, including other Ryan White programs. 
  
• Use grant funds to supplement, not replace, local funds provided for HIV-related services. Jurisdictions within an EMA/TGA that receive Part A funds must maintain their prior year's level of spending for HIV-related care and may not use Ryan White funds to replace these expenditures.
  
• Not use Part A funds to provide or support services that are reimbursable under any other program.
  
• Require organizations or entities that receive Part A funds to participate in an HIV community-based continuum of care, if such exists.
  
• Provide services regardless of an individual's ability to pay or health condition, in settings that are accessible to low-income persons with HIV/AIDS; outreach must be provided to inform them of the availability of services.
  
• Ensure that if providers charge a fee, a sliding scale is used that considers the patient's income level and limits charges to a fixed percent of an individual's yearly income.
  
• Establish a clinical quality management program to ensure that services provided are consistent with the most recent Public Health Service guidelines and that services are consistent with guidelines to improve access to and quality of HIV health services.
  
• Require providers receiving Part A funds to maintain "appropriate relationships with entities that constitute key points of access to the health care system."  Ryan White defines these points of access to include such entities as:

• Emergency rooms
• Substance abuse treatment programs
• Detoxification centers
• Adult and juvenile detention facilities
• Sexually transmitted disease clinics
• HIV counseling and testing sites
• Mental health programs
• Homeless shelters
• Public health departments
• HIV counseling and testing sites
• Federally qualified health centers, and
• Other specified health care points of entry.

• Expend Minority AIDS Initiative (MAI) funds received by the Part A grantee to serve disproportionately-impacted minority clients in a manner consistent with legislative intent and HRSA/HAB guidelines.

Funds used to administer the grant must be limited as follows:

• No more than 10 percent of funds may be used for grantee administration and monitoring. This category includes developing the annual funding application, developing reimbursement and accounting systems, preparing routine program and financial reports, meeting audit requirements, and carrying out activities related to awarding local contracts.
  
• Up to 5 percent of the grant, or $3 million (whichever is less) may be used for clinical quality management programs.
  
• Local providers and subcontractors and other entities may not collectively spend more than 10 percent of all funds for administrative expenses. This includes "usual and recognized" overhead, management, and oversight of programs, and program support activities such as quality assurance.
  
• No funds may be used for construction, land purchase, or cash payments to intended recipients of services.

Planning councils are diverse membership bodies that are established to plan and decide how to use Part A funds. They work in partnership with the grantee in carrying out needs assessment, comprehensive planning, capacity development, and services evaluation activities. Planning councils are required for current and former EMAs and are optional for the five new TGAs that were created in 2007. Planning council responsibilities (including duties shared with grantees, which are denoted by a "+" are to:

• Determine the size and demographics of the population with HIV/AIDS. +
  
• Determine the needs of that population. They must give special attention to identifying the needs of those who know their HIV status and are not in care and disparities in access and services among affected subpopulations and historically underserved populations. They must use a public process for obtaining community input on needs and priorities. +
  
• Develop a comprehensive plan for the organization and delivery of HIV services, compatible with existing State and local plans. +
  
• Participate in developing a Statewide Coordinated Statement of Need (SCSN), a mechanism for Ryan White programs to address key HIV/AIDS care issues and enhance coordination. +
  
• Coordinate with Federal grantees that provide HIV-related services. +
  
• Establish priorities for the allocation of funds. Decisions are to be based on needs assessment (with particular attention to the unmet needs of those with HIV/AIDS who are not in care), the cost effectiveness and outcome effectiveness of specific services, priorities of HIV-infected communities, and availability of other governmental and non-governmental resources.
  
• Assess the efficiency of the administering agency in rapidly allocating funds to areas of greatest need.

Planning Council Membership. Planning councils must include individuals from a variety of organizations and communities and reflect the local demographics of the epidemic. Particular consideration is given to members with specific areas of expertise as well as persons disproportionately affected and historically underserved populations. No less than 33 percent of the planning council's members must be PLWHA who receive HIV-related services from Part A providers. In the case of minors, these individuals can be their parents or other caregivers. These PLWHA representatives must not be affiliated with a service provider. This means that they may not serve as an employee or board member or be a consultant of any entity receiving Ryan White funds. 

Planning councils must also include representatives of the following:

• Health care providers, including Federally qualified health centers
• Community-based organizations serving affected populations and AIDS service organizations
• Social service providers (which are to include housing and homeless-services providers)
• Mental health providers
• Substance abuse providers
• Local public health agencies
• Hospital planning agencies or health care planning agencies
• Affected communities, including individuals with HIV/AIDS and historically underserved groups and subpopulations
• Non-elected community leaders
• State Medicaid agency
• State agency administering the Part B program
• Part C grantees
• Part D grantees (or, if no Part D grantee exists, representatives of organizations in the EMA with a history of serving children, youth, and families living with HIV/AIDS)
• Grantees under other Federal HIV programs (which are to include HIV prevention programs), and
• Formerly incarcerated PLWHA or their representatives.

Planning Council Procedures. Planning councils must have in place a variety of policies and procedures, including the following:

• Nominations for members based on an open process, with criteria clearly stated and publicized, including a conflict of interest standard
• Training for planning council members so they are able to fully participate 
• Leadership procedures ensuring that the planning council is not chaired solely by an employee of the grantee
• Planning council meetings that are open to the public and minutes that are publicly available and that protect the medical privacy of individuals
• Bylaws that establish how the planning council will conduct business
• Grievance procedures with respect to funding, including procedures for submitting grievances that cannot be resolved informally or by mediation to binding arbitration.

The legislation authorizes technical assistance (TA) to help programs comply with Ryan White requirements. This includes peer TA and assistance to planning councils.

The below chart summarizes important changes in the 2006 reauthorization of the Ryan White HIV/AIDS Program, in relation to earlier Ryan White HIV/AIDS Program provisions.