Ryan White HIV/AIDS Program Part A Manual

For Ryan White HIV/AIDS Programs, the goal of coordination is to enhance access to a range of services in order to both achieve better client health outcomes and use Ryan White resources wisely. Coordination within the Ryan White community occurs through specific efforts of grantees to work together, such as joint planning under Parts A and B and the Statewide Coordinated Statement of Need (SCSN).

The Ryan White legislation contains requirements for coordination with non-Ryan White programs and payers from multiple sectors. Driving these changes is not only the funding represented by these entities but also the potential to coordinate planning and service delivery. The anticipated outcome is better services for people living with HIV/AIDS (PLWHA) with complex care demands, such as substance abusers and PLWHA who are not in care.

Among the non-Ryan White programs where coordination is required are Medicaid and Medicare. Both are much larger public sources of funding than Ryan White. Others—defined by their services as well as their payer status—include Veterans Affairs, substance abuse prevention and treatment services (funded extensively through State block grants and other public and private mechanisms), maternal and child health care, and HIV prevention. The latter includes Centers for Disease Control and Prevention (CDC) HIV prevention. CDC also funds outreach and early intervention services, both of which are also fundable under Ryan White but distinguishable because Ryan White must target PLWHA.

Private health insurance is yet another payer that has great potential to cover some of the service needs of Ryan White clients. Although many Ryan White primary care clients do not have private health insurance, mechanisms such as health insurance continuity payments and risk pools are potential payers of care.

Coordination—with both programs and payers—can occur in the following areas:

• Planning. Coordination in Ryan White planning involves consideration of other programs in such areas as assessment of needs, priority setting, and resource allocation. Required representation of other Federal programs on planning councils is designed to ensure their participation in Part A planning. To illustrate, needs assessments should determine existing resources, regardless of funding stream, as part of efforts to identify areas of unmet need. In setting priorities, other resources must be considered in terms of how they help meet service demands so that Ryan White resources can be used to fill gaps.
  
• Funding of Services. Ryan White grantees, including Part A programs, are required to coordinate their services and seek payment from other sources before Ryan White funds are used. This makes the Ryan White HIV/AIDS Program the “payer of last resort,” meaning that funds are to fill gaps in care not covered by other resources. Major payers include, for example, Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and private health insurance.
  
• Service Delivery. Ryan White requires coordination with specific services (i.e., outreach, substance abuse prevention and treatment, HIV counseling and testing, and early intervention services). Many are funded by other Federal, State, and local sources. For example, HIV prevention is funded through the CDC, while State substance abuse programs are supported partially through block grants from the Substance Abuse and Mental Health Services Administration (SAMHSA).

Section 2602(b)(2) of the Ryan White legislation identifies membership categories that must be represented on the planning council. Among them are Ryan White grantees from other Parts and multiple non-Ryan White entities, including:

• Health care providers, including federally qualified health centers
  
• Social service providers, including housing and homeless services providers
  
• Mental health providers
  
• Substance abuse providers, and
  
• Grantees of other Federal HIV programs, including HIV prevention programs.

Section 2602(b)(4)(C) states that Part A planning councils are required to “establish priorities for the allocation of funds within the eligible area, including how best to meet each such priority and additional factors that a grantee should consider in allocating funds under a grant based,” in part, on:

“(iv) coordination in the provision of services to such individual with programs for HIV prevention and for the prevention and treatment of substance abuse, including programs that provide comprehensive treatment for such abuse; and

“(v) availability of other governmental and non-governmental resources, including the State Medicaid plan under title XIX of the Social Security Act and the State Children’s Health Insurance Program under title XXI of such Act to cover health care costs of eligible individuals and families with HIV/AIDSs….” 

Section 2602 (b)(4)(D) requires the planning council to “develop a comprehensive plan for the organization and delivery of health and support services described in section 2604 that” in part:

“(ii) includes a strategy to coordinate the provision of such services with programs for HIV prevention (including outreach and early intervention) and for the prevention and treatment of substance abuse (including programs that provide comprehensive treatment services for such abuse); and

“(iii) is compatible with any State or local plan for the provision of services to individuals with HIV/AIDS….” Section 2602(b)(4)(H) requires that the planning council “coordinate with Federal grantees that provide HIV-related services within the eligible area.”

Section 2604(e)(1) permits the use of Part A funds for “early intervention services” for individuals with HIV/AIDS. It specifies entities “through which such services may be provided,” which include an array of substance abuse, mental health, homeless services, and other providers.

Section 2604(f)(1) discusses the provision of funds “for the purpose of providing health and support services to infants, children, youth, and women with HIV/AIDS, including treatment measures to prevent the perinatal transmission of HIV.” Such funds must total “not less than the percentage constituted by the ratio of the population involved (infants, children, youth, or women in such area) with acquired immune defi ciency syndrome to the general population in such area of individuals with such syndrome.”

Section 2604(f)(2) suggests coordination in determining use of Part A funds for these populations in allowing for a waiver of this requirement if “the population is receiving HIV-related health services through the State Medicaid program under title XIX of the Social Security Act, the State children’s health insurance program under title XXI of such Act, or other Federal or State programs.”

Section 2605(a) requires that a Part A application include “assurances adequate to ensure—(3) that entities…that receive funds under a grant under this part will maintain appropriate relationships with entities in the eligible area served that constitute key points of access to the health care system for individuals with HIV/AIDS.” These entities include an array of substance abuse, mental health, homeless services, and other providers.

The objective of coordination is to enhance access to the continuum of services. Ryan White grantees are required to build relationships with other Federal and State agencies, including State Medicaid agencies, CHIP, providers of HIV prevention and substance abuse prevention and treatment services, and incarceration facilities. Areas for coordination include planning; payment of services; and service delivery, as described below.

Planning with Other Programs

Grantees are required to collaborate with other publicly funded programs in the assessment of need, priority setting and resource allocation, and development of their comprehensive plans. Among the most important are Medicaid (by far the largest public payer of HIV care), Medicare (the second largest public payer of HIV care), CHIP, and private health insurance (a source of payment accessible to PLWHA through Ryan White via health insurance continuity payments, which can cover both continuation of existing policies and purchase of new ones). Also important are community health centers and providers of services to the homeless and substance abusers. Planning coordination is evident in the following requirements, each of which is covered in greater detail in other chapters in this manual.

• Planning Council Membership. Planning council membership must include representatives and providers of services from other Federal programs including:
  • HIV prevention programs
  • Substance abuse prevention and treatment providers
  • Mental health providers, and
  • Social service providers, including housing and homeless services providers.
    
• Needs Assessment. In order to adequately address priority setting and resource allocation and comprehensive plan requirements, needs assessments must address coordination with HIV prevention and substance abuse prevention and treatment. Coordination with these services can enhance efforts to identify individuals with HIV who know their status but are not receiving HIV/AIDS related primary health care and result in better attention to the range of their needs.
  
• Priority Setting and Resource Allocation. Part A planning councils are required to conduct priority setting with consideration to multiple factors, among which are:

Coordination in the provision of services to PLWHA with programs for HIV prevention and the prevention and treatment of substance abuse, including programs that provide comprehensive treatment for such abuse, and Availability of other governmental and non-governmental resources, such as State Medicaid and CHIP programs, to cover health care costs of eligible individuals and families with HIV/AIDSs.

• Comprehensive Plan. The comprehensive plan must include strategies to coordinate services with HIV prevention programs (including outreach and early intervention services) and substance abuse prevention and treatment programs. In addition, the comprehensive plan must be compatible with State or local plans for the delivery of HIV services.

Coordination of Payers

All Ryan White grantees are required to coordinate their services and seek payment from other sources before Ryan White funds are used, making the Ryan White HIV/AIDS Program the “payer of last resort.”

One specific area of payer coordination is services for women, youth, children, and infants. Each EMA/TGA must allocate funds for each group in an amount no less than the proportion that each is represented in the total number of living HIV/AIDS cases in the EMA/TGA. A waiver is provided when EMAs/TGAs can demonstrate that the needs of these populations are being met through other sources.

Private health insurance can also be coordinated in various ways with Ryan White funding, such as covering services not paid for by private insurance or paying health insurance premiums, if cost effective. For example, Part B grantees may purchase health insurance for clients as part of their AIDS Drug Assistance Programs (ADAPs) under the Health Insurance Continuity Program (HICP). HICP funds may only be used to purchase health insurance that includes the full range of HIV treatments and access to comprehensive primary care services and provides prescription coverage that is equivalent to the ADAP formulary. The total amount spent on insurance premiums cannot be greater than the annual cost of maintaining that same population on ADAP. Clients covered under HICP may continue to qualify for some Part A services that are not covered by their health insurance.

Each State has different insurance laws and regulations, and EMAs/TGAs should become familiar with them. For example, some States have existing insurance programs, like risk pools, and Ryan White dollars might be used to pay premiums. If qualified HIV providers—sometimes including Part A-funded providers—are on the preferred provider list for these insurance policies, such pools may offer opportunities for payer coordination.

Service Coordination

EIS and outreach services are intended to increase access to primary care services for PLWHA. In funding EIS, Part A grantees must demonstrate that other sources of funds for EIS are insufficient before spending Part A funds on EIS and must make this determination in their needs assessment (particularly the resource inventory). For outreach services, Ryan White outreach programs must focus on reaching PLWHA who are not in care.

Ryan White providers are required to maintain appropriate relationships with entities providing “key points of access” to both identify and link PLWHA into care. These include, for example, providers of early intervention services, family planning clinics, substance abuse treatment providers, sexually transmitted disease clinics, community organizations, and correctional institutions.

In order to work more effectively with other health programs, particularly Federal programs that provide services for PLWHA, Ryan White grantees should learn more about these payers. Among the most significant Federal programs that provide services for PLWHA are Medicaid, Medicare, CHIP, and private health insurance. Each of these programs and several other HHS programs are briefl y summarized below.

Medicaid

Medicaid, the joint Federal/State health program for low-income and disabled Americans, is the largest public payer of health care services for PLWHA. The Medicaid program is administered by the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA). To be eligible for Medicaid, a person must either be very poor, have children, and/or be disabled (based on the Social Security defi nition). Thus, most people living with HIV/AIDS are not eligible for Medicaid until they become impoverished and disabled. HIV-infected women and children covered by Medicaid are often eligible for reasons other than their HIV/AIDS.

Medicaid programs vary from State to State. While there are basic eligibility rules and a core benefi ts package (such as hospital, physician, and nursing services), each State may elect to provide optional services (prescription drug benefi ts, clinic services), modify eligibility rules above the minimum and place benefi ciaries in fee-for-services or managed care arrangements. Ryan White funds can be used to fill service and population gaps not covered by Medicaid. When a State’s Medicaid program does not cover a specific service, Ryan White funds can be used for payment.

Medicaid Managed Care

In the 1990’s, many States began enrolling Medicaid benefi ciaries in managed care. Managed care is designed to reduce costs by eliminating inappropriate and unnecessary services and relying more heavily on primary care and coordination of care. Managed care is characterized by formal enrollment of individuals in a managed care organization, contractual agreements between the provider and a payer, and some gatekeeping and utilization control.

For PLWHA, managed care systems can present some challenges to the receipt of appropriate services. These include:

• Access to primary care providers and specialists experienced in the treatment of HIV/AIDS, and
  
• Adequate coordination between medical and social services.
  Additionally, HIV/AIDS and other high-cost conditions present challenges to managed care plans and providers that contract with them where capitation rates do not refl ect the real costs of treating HIV/AIDS.

Medicare

Medicare is the second largest source of Federal financing of HIV/AIDS care. Most people 65 and older are entitled to Medicare because they are eligible for Social Security payments. Disabled persons who receive Social Security Disability Insurance (SSDI) cash payments (because they have sufficient work history to qualify) become eligible for Medicare after a two-year waiting period. Medicare covers a significant number of PLWHA in care.

Medicare covers such services as inpatient hospitalization, skilled nursing and home health visits, physician and outpatient hospital services, and outpatient prescription drugs. Many beneficiaries purchase supplemental insurance to help with Medicare’s cost-sharing requirements and fill gaps in the benefit package. Some opt to enroll in managed care organizations that typically have lower cost-sharing benefits.

A significant number of PLWHA are dually eligible for both Medicare and Medicaid. Despite coverage by both sources of public insurance, gaps in care may exist.

State Child Health Insurance Program

CHIP, administered by the CMS Center on Medicaid and State Operations, was enacted in 1997 and allows States to expand health insurance coverage for low-income children. Children cannot be excluded from eligibility due to a disability or pre-existing condition.

States have great discretion in the design of their CHIP programs. For example, States can choose how they will determine family income and have flexibility in determining which groups of low-income children to cover ( e.g., based upon age, disability status, where they live in the State). States also have flexibility to revise their child health plans over time.

Maternal and Child Health Bureau Programs

The Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB) addresses the health of mothers, infants, children and adolescents. A focus is on families with low income levels, those with diverse racial and ethnic heritages, and those living in rural or isolated areas without access to care.

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Substance Abuse and Mental Health Services Administration (SAMHSA) supports programs in substance abuse prevention, substance abuse treatment, and mental health services. It oversees State block grants that support HIV early intervention services in substance abuse or mental health treatment settings. In addition, SAMHSA provides HIV/AIDS grants to cities to enhance the effectiveness of outreach in urban areas highly impacted by substance abuse and HIV infection.

HIV/AIDS Prevention/Counseling and Testing

Publicly funded HIV counseling and testing services have been provided under grants from CDC through 65 local and State health departments since March of 1985. Both anonymous and confi dential voluntary HIV counseling, testing and referral services are available and have evolved to focus on individual, client-centered risk reduction counseling models. CDC Guidelines for HIV Counseling Testing and Referral include many recommendations to ensure that HIV-infected individuals (as well as those at risk) have access to appropriate medical, prevention, and psychosocial support services.