Tools for Grantees: Title I: Planning Council Primer

This primer explains what Title I planning councils do and how they work with Title I grantees.

Download the full version (pdf 76KB)

The Ryan White CARE Act and Its Titles
How Title I Works
Participants
Planning Council Duties
Grantee Duties
Glossary of CARE Act Terms

The Ryan White CARE Act and Its Titles TOP
The Ryan White CARE (Comprehensive AIDS Resources Emergency) Act is a Federal law that funds services for people living with HIV disease (PLWH) who cannot pay for the care they need. The CARE Act helps cities, States, and other areas pay for the high costs of HIV/AIDS care. It pays for care that is not covered by other programs like Medicaid and Medicare.

The CARE Act spells out who is eligible for services and describes how the money can be used. Most CARE Act funds go to pay for medical and support services for PLWH and their families. One goal is to get PLWH into care early and help them stay there and remain healthy.

Almost all CARE Act funds are grants, which go to local and State areas to address the needs of PLWH. Many decisions about how to use the money are made by local planning councils and State planning groups, who work as partners with their governments.

The Federal government agency that works with local and State areas that receive the grants is the HIV/AIDS Bureau (HAB), which is part of HRSA, the Health Resources and Services Administration. HRSA is within an even larger agency, the U.S. Department of Health and Human Services (DHHS).

The CARE Act awards grants under the five sections of the Act: Title I, Title II, Title III, Title IV, and Part F. Below is a short description of each.

Title I: Emergency Relief to Local Areas
Title I funds go to local areas that have been hit hardest by the HIV epidemic. These areas are called eligible metropolitan areas (EMAs).

Title I money goes to the chief elected official (CEO) of the major city or county government in the EMA. (The CEO is usually the mayor. In some EMAs it is the county executive, chair of the board of supervisors, or judge) The CEO is called the grantee and manages the grant by making sure the funds are used correctly. The CEO works with the Title I planning council in making decisions about how to use the funds.

Title I funds may be used for HIV primary medical care and support services (like case management) that help people stay in care. A limited amount of the money can be used for planning, managing, and evaluating programs.

Title II: Support to States
Title II is for States, the District of Columbia, Puerto Rico, and the U.S. territories. Title II funds can be used for medical and social support services. Because States differ so much, the CARE Act gives States flexibility to deliver these services under five different programs. These programs include (1) medications to treat HIV disease, (2) home care, (3) health insurance coverage, (4) consortia (groups of providers and community members that plan and deliver care), and (5) services provided by the State under its own programs.

The State often decides how to spend this money. States are required to conduct a needs assessment (to determine needs of PLWH). Based upon needs assessment results, States must set priorities and allocate resources to meet needs. States must also write a comprehensive plan, which is a guide on how to meet those needs.

Many States get input from Title II planning groups. Some are statewide groups. Others cover local areas (like several counties) and are called Title II consortia. They operate much like Title I planning councils, which are described later in this Primer. They are required to assess needed services and make decisions about how to use funds.Some consortia also deliver medical and support services.

Title III: Community Early Intervention Services
Title III funds individual agencies, like local public and private health clinics. The funds are used to reach people early in their HIV disease and to link them to care. These are called Early Intervention Services (EIS) (All CARE Act programs can provide EIS.) Title III funds can be used for HIV counseling and testing, medical care, support services, and referrals to services.

All CARE Act programs can provide EIS. Title III is unique because funds go directly to community agencies. Title III programs can operate in many areas, but their priority is to fund rural areas and locations that lack services. (Title I and Title II use local and State planning to decide what EIS to fund.) Some Title III funds (called planning grants) go to help agencies prepare to become EIS programs. Other Title III funds (called capacity grants) help agencies improve their operations so that they can deliver EIS.

Title IV: Services and Access to Research for Women, Infants, Children, Youth
Title IV funds go directly to local health care organizations or hospitals. The funds are used to link women, infants, children, and youth to different medical and social services. Title IV also lets clients know about clinical research trials and helps them learn how to participate if they wish.

Part F: SPNS, AETC, Dental Reimbursement
Part F funds support three programs:

Special Projects of National Significance (SPNS): SPNS funds go to organizations that are creating new and better ways of serving people living with HIV.

AIDS Education and Training Centers (AETCs): AETC funds go to regional and national centers that educate doctors, nurses, dentists, and other health professionals about HIV disease and current treatments.

HIV/AIDS Dental Reimbursement Program: These funds go to dental schools and other dental programs to help pay for dental care for people living with HIV.

How Title I Works TOP
The rest of this Primer describes the people who participate in Title I and what they do.

Participants TOP
Participants in the Title I grant include the following: (1) The CEO, also called the grantee, manages the grant by making sure funds are used fairly and appropriately. (2) The planning council conducts planning to decide how to use funds, in partnership with the CEO. (3) HAB/DSS is the Federal government entity in HRSA that makes sure the CARE Act is implemented correctly.

The Chief Elected Official (CEO)
The CEO is the person who officially receives the CARE Act funds. The CEO is the Chief Elected Official who is in charge of the major city or county in the EMA, such as a mayor, chair of the board of supervisors, county executive, or judge. The CEO is responsible for making sure that all the rules about using CARE Act funds are followed. The CEO usually picks an agency to manage the Title I grant – usually the county or city health department.

The Grantee
As the person who receives CARE Act funds, the CEO is the grantee. However, in most EMAs, the CEO gives responsibility for administering the grant to a local government agency (such as a health department) that reports to the CEO. This agency is sometimes also called the grantee. The word “grantee” means the person or organization that actually carries out CARE Act tasks, whether that is the CEO, the public health department, or another agency that reports to the CEO.

The Planning Council
Before the EMA can receive Title I money the CEO must appoint a planning council. The planning council (and its staff) must carry out many complex planning tasks.

The CARE Act requires planning councils to have members from various groups and organizations. At least one third (33 percent) of the planning council members must be people living with HIV who receive HIV-related services and are “unaligned.” This refers to consumers who do not have a conflict of interest, meaning they have no financial or governing interest in Title I funded agencies. (How the planning council is appointed is described below.)

HRSA/HAB Division of Service Systems
The HRSA HIV/AIDS Bureau’s (HAB) Division of Service Systems (DSS) is the office in the Federal government that is responsible for administering Title I and Title II throughout the country. The HAB/DSS office is located in Rockville, Maryland.

Each EMA is assigned a Project Officer who works in DSS. Project Officers help the grantee and the planning council do their jobs and make sure that they are running the local Title I program as the CARE Act says they should. Project Officers regularly contact both the grantee and the planning council chairs by telephone and through site visits to EMAs.

Planning Council Duties TOP
The planning council (and its staff) must carry out many complex tasks. Described below, the first step for planning councils is to set up rules to help the planning council to operate smoothly and fairly (planning council operations). This includes bylaws, open meetings, grievance procedures, and conflict of interest standards. Planning councils must also be trained in planning.

Once this is in place, the main planning task for the planning council is to find out what services are needed and what populations need care (needs assessment). Next, it decides what services to fund in the EMA (sets priorities) and then decides how much Title I money should be used for each of these services (resource allocations). The planning council then develops a plan on how to provide these services (comprehensive plan). The planning council also looks for ways that Title I services work to fill gaps in care with other CARE Act programs (through the Statewide Coordinated Statement of Need, SCSN) as well as other services like Medicaid (coordination). The planning council also evaluates how efficiently providers are selected and paid and how well their contracts are monitored. This is called assessing the efficiency of the administrative mechanism.

Set Up Planning Body Operations
Planning councils must have procedures to guide their activities. They are usually outlined in their bylaws. They cover such areas as:

Membership. Nominations for members must be based on an open process, and nomination criteria need to be clear and publicized. Nomination criteria must also include a conflict of interest standard so that people make decisions without personally benefiting.

Training. Members need to learn how to participate in CARE Act planning. The CARE Act requires training for planning council members, such as explaining the CARE Act and their role in planning.

Group Process. This includes rules for committee operations, meeting times, and locations. These are usually described in the bylaws.
Decision Making. Examples include voting and handling of grievances related to funding decisions and conflict of interest (see below). These are usually described in the bylaws.

Conflict of Interest. The planning council must define conflict of interest. They must outline a procedure to make sure that decisions about priorities and funding allocations are based upon community needs – not on the interests of individual planning council members. Planning council members who are involved with agencies that are competing for Title I funds may not make decisions related to that agency.

Grievance Procedures. The planning council must develop grievance procedures to handle complaints about how they make decisions about funding. The grievance procedures must specify who is allowed to file a grievance, types of grievances covered, and how grievances will be handled. The grantee must develop its own grievance procedures as well, although they should be written to work with those of the planning council.

Assess Needs
The planning council works with the grantee to identify HIV needs by conducting a needs assessment. This involves first finding out how many persons living with HIV disease (both HIV infection and AIDS) are in the area through an epidemiologic profile. Next they determine the needs of populations living with HIV disease through focus groups, surveys, or other methods. Special attention should be to determine: (1) needs of those who know their HIV status and are not in care; (2) differences in care (for affected subpopulations and historically underserved populations less likely to be in care); (3) capacity development needs of the EMA (like which agencies need help to improve their operations); and (4) how CARE Act services need to work with other services, like substance abuse services and HIV prevention agencies.

The needs assessment may be done by the grantee, the planning council, or an outside contractor. Regardless of who does this work, it is important to include many perspectives in deciding how to complete this work and analyze its results.

Set Priorities and Allocate Resources
The planning council next sets priorities. This means they decide which services to fund. The planning council makes these decisions about priorities for funding based on many factors: (1) the needs assessment; (2) information about the most successful and economical ways of providing services; (3) priorities of people living with HIV who will use services; (4) making Title I funds work well with other services like HIV prevention and substance abuse; (5) the amount of funds from other sources like Medicaid, Medicare, and the State Children’s Health Insurance Program; and (6) developing capacity for HIV services in historically underserved communities.

After they set priorities, the planning council must allocate resources, which means they decide how much funding will be used for these priorities. For example, the planning council can specify funding for primary care services for gay men of color. However, they cannot pick specific agencies to fund, and they cannot be involved in managing Title I contracts.

In addition to using funds for HIV/AIDS services, the planning council may decide to use some of the funds to pay for special projects like an evaluation of the HIV services in the EMA (program support) or to hire someone to help the planning council do its work (planning council support).

Develop the Comprehensive Plan
The planning council works with the grantee in developing a written plan that defines short- and long-term goals for delivering HIV services in the EMA. This is called a comprehensive plan. This plan is based, in part, on the results of the needs assessment. It is used to guide decisions – over several years – about how to deliver HIV/AIDS services for people living with HIV. This plan should be updated every three years, and it should work well with other existing local or State plans.

Coordinate With Other CARE Act Programs and Other Services
The planning council makes sure that Title I funds work well with other funds, as follows:

• The planning tasks described above (needs assessment, priority setting, comprehensive plan) require getting lots of input and finding out what other sources of funding exist. This helps avoid duplication in spending, and it reduces gaps in care. For example, the needs assessment should find out what HIV prevention and substance abuse services already exist.
• The Statewide Coordinated Statement of Need, called the SCSN, is a way for all CARE Act programs in a State to work together in planning how to use CARE Act funds and avoid duplication of services. Representatives of the planning council – and the grantee – must participate with other CARE Act programs in the State to develop a written SCSN.
  

Assess the Administrative Mechanism and Evaluate Services
The planning council is responsible for evaluating how well the grantee manages to get funds to providers. This means reviewing how quickly contracts with service providers are signed and how long the grantee takes to pay these providers. It also means reviewing whether the funds are used to pay only for services that were identified as priorities by the planning council and whether all the funds are spent.

The planning council may also decide to evaluate how well services funded by Title I are meeting community needs – or pay someone else to do such an evaluation.

Grantee Duties TOP
The grantee has Planning Duties, which include setting up the planning council and working with them in deciding how to use funds. The grantee also has Administration Duties, which means that they are responsible for making sure that Title I funds are fairly and correctly used. These duties are described below.

Planning Duties of the Grantee

Establish the Planning Council
The CEO must establish the planning council. The grantee must make sure that the planning council membership resembles the demographics of people living with HIV/AIDS locally (for example, race, ethnicity, exposure categories, age). This is called reflectiveness. In particular, attention should be paid to including those from disproportionately affected and historically underserved populations. Planning councils must also include people with specific expertise and backgrounds. This is called representation.

Planning councils must also have consumer participation. This means that at least 33% of the planning council must be PLWH members. They must be reflective of the demographics of PLWH locally. They must also be PLWH who receive HIV-related services and be “unaligned,” meaning they have no financial or governing interest in Title I funded agencies.

Choose Planning Council Members
The grantee and planning council must use a clear and open process to choose new planning council members and to replace members when a member’s term ends or the person resigns. Openness requires member vacancies to be widely advertised. The announcement should include the qualifications and other things that are considered when choosing members.

Once the planning council identifies candidates for vacancies, it should forward their names to the CEO for consideration for appointment. The CEO retains sole responsibility for appointment of all members to the planning council.

The planning council should form a Membership Committee to handle things like recruiting and selecting people to fill vacancies.

Support Planning Council Members
Both the planning council and the grantee have the responsibility to support the participation of people living with HIV disease on the planning council. Examples include reimbursing their travel and child care costs. The CEO must also train planning council members in planning so they can be effective members.
The grantee must cooperate with the planning council by providing information that the planning council needs to carry out its responsibilities, particularly information it needs to assess the efficiency of the administrative mechanism.

Assess Needs
As described above (page 11), the grantee works with the planning council to identify needs of communities affected by HIV/AIDS.

Distribute Funds According to Planning Council Priorities
The grantee must distribute Title I funds according to the priority setting and resource allocations decided by the planning council. (An exception is funds that the grantee decides to use for its own administrative expenses.) In addition, the grantee must follow planning council directives about “how best to meet” priority needs.

The grantee can only spend the amount of money that the planning council decides should be used for that priority.

Develop the Comprehensive Plan
As described above (page 12), the grantee and planning council work together to develop a comprehensive plan for the organization and delivery of HIV services. This plan must be compatible with existing State and local plans.

Coordinate With Other CARE Act Programs and Other Services
As described above (page 13), both the grantee and planning council work together to make sure that Title I funds work well with other funds. This occurs through planning. For example, the needs assessment and comprehensive plan need to find out what HIV prevention and substance abuse services already exist and work with them in serving PLWH. It also occurs through the Statewide Coordinated Statement of Need (SCSN), which is a way for all CARE Act programs in a State to work together in planning the use of CARE Act funds to provide services and avoid duplication.

Grantee Administrative Duties
Below are Title I grantee duties to make sure that funds are used fairly and appropriately.

Establish Intergovernmental Agreements (IGAs)
The grantee must make sure that Title I funds reach all communities in the EMA where need exists. Thus, they must establish formal, written agreements with cities and counties within the EMA that provide HIV-related services and also account for at least 10 percent of the EMA’s reported AIDS cases. This agreement is called an Intergovernmental Agreement (IGA.) An IGA should describe how Title I funds will be distributed and managed.

Ensure Services to Women, Infants, Children, and Youth With HIV Disease
The grantee must assure that the percentage of money spent on serving women, infants, children, and youth with HIV disease is at least in proportion to how much each group represents the total AIDS cases in the EMA. An exception is allowed when the grantee can show that their needs are met through other programs like Medicaid. The planning council must consider this when setting priorities.

Ensure that CARE Act Funds are Used to Fill Gaps
Title I grantees must ensure that funds do not pay for services that are funded by other sources and that Title I funds are not used to replace local spending on HIV/AIDS care. This is because the CARE Act is the payer of last resort.

Ensure Delivery of Quality Services
Title I grantees must ensure that Title I services are available, regardless of an individual’s health condition or ability to pay and in settings that are accessible to low-income people with HIV.

Outreach must be provided to inform people of the availability of services and to link them to care.

Providers receiving Title I funds must be required to work with other providers so that services are easier for clients to get. This network of providers is called a continuum of care. As part of this, providers should make it easier for clients to get into care as early as possible by maintaining “appropriate relationships with entities that constitute key points of access to the health care system.” Key points of access include, for example, emergency rooms, substance abuse treatment programs, and sexually transmitted disease clinics.

Finally, grantees must establish a quality management program that measures how providers are using standards of care for their services, like HIV/AIDS treatment guidelines. The quality management program should also determine if services are consistent with those guidelines. Grantees can use up to 5% of the award to conduct these programs.

Prepare and Submit Title I Applications
The grantee is responsible for preparing and submitting a Title I application to the Federal government. Although this is the grantee’s responsibility, the planning council should participate in the preparation of this application because the application requires information about the planning council and how it works. The chair(s) of the planning council must certify in writing to HAB/DSS that the priorities in the application are the ones developed by the planning council. They must also verify that the grantee spent funds in the past year according to the planning council’s decisions.

Limit Grantee Administrative Costs
The grantee may use up to 5% of the Title I grant for routine administrative duties. Examples include writing applications, preparing reports, and activities involving payout of Title I funds (including reviewing provider applications, negotiating and monitoring contracts, and paying providers).

Limit Contractor Administrative Costs
The grantee must ensure that local providers, subcontractors, and other entities, collectively, spend less than 10 percent of total Title I grant funds for administrative expenses.

Monitor Contracts
The grantee must make sure that the providers who receive Title I funds use the money according to the terms of the contract they signed with the grantee. The grantee monitors providers to determine how quickly they spend Title I funds, if they are performing the services, and if they are maintaining quality management standards.

Reallocate Funds
The grantee and the planning council must keep track of how rapidly Title I money is, or isn’t, being spent. If funds are not being spent in a timely fashion, there are two options: (1) the grantee may reallocate the funds to another provider within the same service priority, or (2) the planning council may reallocate funds to a different service priority. The grantee and the planning council must work together to share information and ensure that any changes are in agreement with the priorities established by the planning council.