Ryan White HIV/AIDS Program Part A Manual

WHO ARE CEOs:

1. Mayor

2. County Executive

3. City Council or County Commission Chair/President

4. County Judge

5. Governor (Part B)

THE CEO AND THE GRANTEE

The Chief Elected Official (CEO) is the official recipient of Ryan White Part A or Part B funds and is ultimately responsible for administering all aspects of Ryan White Part A or B funds and ensuring that all legal requirements are met.

Grantee is the term used to describe the entity that receives Ryan White funds and has responsibility for administering the award. The CEO often delegates responsibility for Part A or Part B grant administration to an agency such as the health department-and in such cases it is referred to as the grantee.

. Services to Women, Infants, Children, and Youth
The CEO must ensure that funding for services to women, infants, children, and youth is proportionate to their representation among the EMA's/TGA's total HIV/AIDS cases. A waiver may be granted when an EMA/TGA can demonstrate that the needs of these populations are being met through other sources, such as Medicaid, the Children's Health Insurance Program (CHIP), or other Federal/State programs, including Ryan White programs. 

Ryan White defines these populations as follows:

• Women – 25 years and older

• Youth – 13-24 years old

• Children – 2-12 years old

• Infants – less than 24 months old

. Services to Women, Infants, Children, and Youth
The CEO must ensure that Part B funding for services to women, infants, children, and youth is proportionate to their representation in the State's HIV/AIDS cases. A waiver may be granted when a State can demonstrate that the needs of these populations are being met through other sources such as Medicaid, the Child Health Insurance Program (CHIP), or other Federal/State programs, including Ryan White programs. 

Ryan White defines these populations as follows.

• Women – 25 years and older

• Youth – 13-24 years old

• Children – 2-12 years old

• Infants – less than 24 months old

. Filling Gaps in Care and Maintenance of Effort
Part A CEOs must ensure that Ryan White funds are used only to fill gaps in care, not to pay for services covered by other available health care funding sources, such as Medicaid or Medicare. Grantees must ensure that PLWHA are enrolled in other health care programs for which they are eligible.  Further, CEOs must assure that grantees maintain their prior year's level of spending for Ryan White [HIV-related] core services and provide services regardless of an individual's ability to pay or his/her health condition.

Ryan White legislation specifies the following:

• No more than 10 percent of Part A funds may be used for administrative expenses, such as developing annual funding applications, program and financial reports, meeting audit requirements, reimbursement and accounting systems, awarding local contracts, planning council support, capacity development, and development of a clinical quality management program. Of this amount, up to 5 percent or $3 million, whichever is less, may be used for clinical quality management programs to ensure that HIV health services are consistent with Public Health Service guidelines and to monitor the improved health status of HIV-positive clients.

• Up to 5 percent or $3 million, whichever is less, may be used for clinical quality management programs to ensure that HIV health services are consistent with Public Health Service guidelines and to monitor the improved health status of HIV-positive clients.

• No more than 10 percent may be spent collectively by providers and subcontractors on administrative costs such as "usual and recognized" overhead, management and oversight of programs, and program support activities such as quality assurance, quality control and related activities.

• Funds may not be used for construction, land purchase, or cash payments to intended recipients of services.

Ryan White legislation authorizes the following administrative costs for Part B:

• Up to 10 percent of funds may be used for routine grant administration and monitoring activities. A maximum of 15 percent may be used to fund administration, planning, evaluation activities, capacity development, and development of a clinical quality management program.

• Up to 5 percent or $3 million, whichever is less, may be used for clinical quality management programs to ensure that HIV health services are consistent with Public Health Service guidelines and to monitor the improved health status of HIV-positive clients.

• No more than 10 percent may be spent collectively by providers and subcontractors on administrative costs, such as "usual and recognized" overhead, management and oversight of programs, and program support activities such as quality assurance, quality control, and related activities. 

• Funds may not be used for construction, land purchase, or cash payments to intended recipients of services.

ELIGIBLE SERVICES

• Core medical services (not less than 75 percent of grant funds unless a waiver is granted), defined as: outpatient and ambulatory health services; ADAP treatments; AIDS pharmaceutical assistance; oral health care; early intervention services; health insurance premium and cost sharing assistance for low-income individuals; home health care; medical nutrition therapy; hospice services; home and community-based health services; mental health services; substance abuse outpatient care; medical case management, including treatment adherence.

• Support services (defined as services "that are needed for individuals with HIV/AIDS to achieve their medical outcomes (such as respite care for persons caring for individuals with HIV/AIDS, outreach services, medical transportation, linguistic services, and referrals for health care and support services)."

• Administrative expenses.
  

ELIGIBLE PROVIDERS

Funding may be awarded to public or nonprofit entities, such as community-based organizations, hospices, ambulatory care facilities, community health centers, migrant health centers, homeless health centers, substance abuse treatment programs, mental health programs, hospitals, and hospices. Private for-profit entities are eligible to receive funding if they are the only available provider of high quality HIV care in the area.

CEOs must assure that planning bodies together with the administrative agency engage in planning to determine how to use Ryan White funds. The grantee or designee is required to engage in a participatory planning process, which includes public hearings to gain community input on the development of the comprehensive HIV plan. Participants in planning should reflect the same criteria as those for Part A (i.e., a broad and diverse input of key stakeholders, including PLWHA and historically underserved populations).

CEOs must assure that a Statewide Coordinated Statement of Need is developed and updated. Participants in development of the SCSN must include representatives of other Ryan White Parts operating in the State, PLWHA, staff of other public agencies, and HIV health service providers. The SCSN must be updated every three years.

. Part A Planning Councils
The planning council membership must reflect the demographics of the population of individuals with HIV/AIDS in the EMA/TGA. Special consideration must be given to historically underserved populations and those experiencing significant disparities in access to services. No less than 33 percent of planning council members must be PLWHA who receive Part A services (in the case of minors, this would include their caregivers) and who are unaligned with provider agencies that receive Part A funding. Alignment is defined to include board membership and employment and consulting arrangements with agencies receiving Part A funding.

In addition to the 33 percent PLWHA, planning council members must include:

• Health care providers, including Federally qualified health centers

• AIDS service organizations (ASOs) and community-based organizations (CBOs) serving affected populations

• Social service providers, including housing and homeless services providers 

• Substance abuse treatment providers

• Mental health providers

• Local public health agencies

• Hospital planning agencies or health care planning agencies

• Affected communities, including people with HIV/AIDS, members of a Federally recognized Indian tribe as represented in the population, individuals co-infected with hepatitis B or C, and historically underserved groups and subpopulations 

• Non-elected community leaders

• State Medicaid agency

• State agency administering the Part B program

• Ryan White or other programs serving women, children, youth and families

• Part C grantees

• Grantees under other Federal HIV programs, including but not limited to HIV prevention providers, and

• Formerly incarcerated PLWHA or their representatives.

. Part B Consortia
Part B funding can be used to establish HIV care consortia, which are associations of public and private health care and support service providers. Consortia conduct needs assessment and comprehensive planning activities with the broad input of key stakeholders, including PLWHA and historically underserved communities. Consortia may also be the providers of HIV services and care. Part B grantees must consult with providers of HIV services and consumers in making decisions about funding under Part B program areas.

Services provided through consortia are considered support services and do not count toward the 75 percent core services requirement.

. Planning Council Operations
CEOs must assure that planning councils 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 (Grantee applications need to include plans for training new members, including training timelines, goals, and budgets. The CEO and planning council chairs will need to submit signed assurances, along with the funding application, that such training will take place.
  

• 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, and
  

• Grievance procedures with respect to funding, including procedures for submitting grievances that cannot be resolved informally or by mediation to binding arbitration.

. Assessing Needs
Needs assessment is a collaborative activity of the planning council, grantee, and community, and is used as the basis for other Ryan White planning activities including priority setting and resource allocation and planning. Needs assessments determine needs in specific areas such as:

• PLWHA who know their HIV status but are not in care 
  

• Disparities in access to care for certain populations and underserved groups
  

• Coordination between care programs and providers of HIV prevention and substance abuse treatment services, and
  

• Outreach and early intervention services.

. Assessing Needs
CEOs must assure that needs assessments are conducted with broad community input to identify gaps in HIV services and the needs of specific communities. Needs assessments focus on the following:

• PLWHA who know their HIV status but are not in care
  

• Disparities in access to care for certain populations and underserved groups
  

• Coordination between care programs and providers of HIV prevention and substance abuse treatment services, and
  

• Outreach and early intervention services.

. Priority Setting and Resource Allocation
Based on the findings of the needs assessment, the planning council establishes priorities for the provision of HIV services in the local community. Service priorities are based on:

• The size and demographics of the population of individuals with HIV/AIDS and their needs, including those who know their HIV status but are not in care
  

• Compliance with the legislative requirement to use not less than 75 percent of funds to provide core medical services
  

• Cost effectiveness and outcome effectiveness of proposed services and strategies
  

• Priorities of PLWHA for whom services are intended
  

• Coordination of services with programs for HIV prevention and treatment of substance abuse
  

• Availability of other governmental and non-governmental resources in the service area, and
  

• Capacity development needs, resulting from disparities in the availability of services for underserved populations. 

Once service priorities are established, the planning council makes resource allocations, in accordance with the legislative requirement to use not less than 75 percent of funds to provide core medical services.  The priority setting and resource allocation process involves the planning council in determining how much funding will be dedicated to each service category. The planning council does not, however, select the providers to deliver services, or participate in the management of service provider contracts.

. Priority Setting and Resource Allocation
CEOs must assure that based on the findings of the needs assessment, Part B consortia or other planning bodies establish service priorities based on:

• The size and demographics of the population of individuals with HIV/AIDS and their needs, including those who know their HIV status but are not in care
  
  
• Compliance with the legislative requirement to use not less than 75 percent of funds to provide core medical services  
  
  
• Cost effectiveness and outcome effectiveness of proposed services and strategies
  
  
• Priorities of PLWHA for whom services are intended
  
  
• Coordination of services with programs for HIV prevention and treatment of substance abuse
  
  
• Availability of other governmental and non-governmental resources in the service area, and
  
  
• Capacity development needs to address disparities in access to services for underserved populations.

Note: Core services must be provided as Direct Services by the State to be counted as part of the 75 percent requirement.  Core services provided through consortia are considered Support Services.

. Comprehensive Plan
The CEO must assure that the planning council develops a comprehensive plan for services, which is compatible with other State, and local plans for the delivery of HIV services. This plan should be updated every three years.

Planning is done by a broad group of people representing the epidemic in the EMA/TGA, including PLWHA. Planning is based on needs assessment results. HAB/DSS expects EMAs/TGAs to develop multi-year comprehensive plans that will:

• Address disparities in HIV care, access, and services among affected subpopulations and historically underserved communities

• Ensure the availability and quality of all core medical services within the EMA/TGA

• Address the needs of those that know their HIV status and are not in care, as well as the needs of those who are currently in the care system.  

• Address clinical quality measures.

• Include strategies that:

  1. Identify individuals who know their HIV status but are not in care and inform these individuals of services and enable their use of HIV-related services

  2. Eliminate barriers to care and disparities in services for historically underserved populations

  3. Provide goals, objectives, and timelines (as determined by the needs assessment)

  4. Coordinate services with HIV prevention programs including outreach and early intervention services, and

  5. Coordinate services with substance abuse prevention and treatment programs.

. Comprehensive Plan
CEOs must ensure the development of a comprehensive plan for services that is compatible with the SCSN and any other State and local HIV service plans. The grantee must engage in a public advisory process, which includes public hearings, to develop the comprehensive plan. The comprehensive plan must be updated every three years. 

HAB/DSS expects States to develop multi-year comprehensive plans that will:

• Address disparities in HIV care, access, and services among affected subpopulations and historically underserved communities

• Ensure the availability and quality of all core medical services within the EMA/TGA
  
• Address the needs of those that know their HIV status and are not in care, as well as the needs of those who are currently in the care system. 

• Address clinical quality measures.

• Include strategies that:

  1. Identify individuals who know their HIV status but are not in care and inform these individuals of services and enable their use of HIV-related services

  2. Eliminate barriers to care and disparities in services for historically underserved populations

  3. Provide goals, objectives, and timelines (as determined by the needs assessment)

  4. Coordinate services with HIV prevention programs including outreach and early intervention services, and

  5. Coordinate services with substance abuse prevention and treatment programs.

. Coordination
The CEO must ensure that Part A programs coordinate their services with other Ryan White Parts and other Federal HIV programs operating in the EMA/TGA, including providers of EIS. This is necessary to ensure referral into care for those who are newly diagnosed with HIV and those who know their HIV status but are not participating in a system of care.  Another goal of coordination is to ensure that Ryan White funds are used to fill gaps in service, and that PLWHA are enrolled in non-Ryan White programs for which they are eligible.

Representatives of the Part A grantee and the planning council are required to participate in the SCSN process.

Prevention-Care Coordination
CEOs must assure that care-prevention coordination ensures that PLWHA enter care systems and receive ongoing treatment. Particular emphasis should be placed on identifying those who know their HIV status but are not receiving treatment. The anticipated long-term impact is to normalize screening for HIV in diverse social service and health care settings and help reduce barriers to care for the traditionally underserved by expanding the network of referrals. 

CEOs must assure that Ryan White providers maintain appropriate relationships with "key points of entry" into the health care system (e.g., HIV counseling and testing centers, emergency rooms, substance abuse treatment programs, STD clinics, homeless shelters). Since EIS can only be funded if other sources of funding are insufficient to meet current needs, needs assessment must document that EIS gaps exist prior to using Ryan White funds.

SCSN
The CEO must participate in the development and updating of the SCSN, for which Part B has lead responsibility. Representatives of the Part A grantee and the planning council are required to participate in the SCSN process.

. Coordination
CEOs must assure that Ryan White-funded providers participate in an HIV care continuum and that Ryan White providers coordinate their services with other HIV programs operating in the service area. Several types of coordination are required by Ryan White legislation.

Prevention-Care Coordination
CEOs must assure that care-prevention coordination ensures that PLWHA enter care systems and receive ongoing treatment. Particular emphasis should be placed on identifying those who know their HIV status but are not receiving treatment. The anticipated long-term impact is to normalize screening for HIV in diverse social service and health care settings and help reduce barriers to care for the traditionally underserved by expanding the network of referrals. 

CEOs must assure that Ryan White providers maintain appropriate relationships with "key points of entry" into the health care system (e.g., HIV counseling and testing centers, emergency rooms, substance abuse treatment programs, STD clinics, homeless shelters). Since EIS can only be funded if other sources of funding are insufficient to meet current needs, needs assessment must document that EIS gaps exist prior to using Ryan White funds.

SCSN
Part B convenes the SCSN process to ensure Statewide collaboration between Ryan White programs and providers.   Though this is not required, HAB/DSS encourages the use of the SCSN to support HIV planning Statewide.

Participants in SCSN development must include: representatives of all Ryan White Parts; PLWH; providers; and public agency representatives (e.g., maternal and child health Title V programs, mental health agencies, Medicaid, and local and regional health departments).

States must ensure the participation of required groups in the SCSN process.  They can use Part B funding to support the participation of PLWHA and historically underserved communities in the SCSN process.