Chapter 1
Overview of Title II  TOP

Introduction

The Title II program was created to make grants to States and territories "to enable them to improve the quality, availability, and organization of health care and support services for individuals and families with HIV disease." Eligible Title II grantees include the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and the following U.S. territories: American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. Since its inception, the Title II program has funded a range of primary medical care and support services, described below. Five program categories exist for States to deliver services, giving them flexibility to meet their diverse needs (see below, Title II Program Categories).

Eligible Services  TOP

Title II funds can be used to deliver the following services:

• Ambulatory (non-hospital) health care, including HIV specialty care; substance abuse and mental health treatment; oral health; home health; hospice; and
• Comprehensive treatment services including treatment education, antiretroviral therapies, and prophylaxis/treatment for opportunistic infections.
• Case management that prevents unnecessary hospitalization or delays in releases.
• Support services that "facilitate, enhance, support, or sustain the delivery, continuity, or benefits of health services for individuals and families with HIV disease."
• Outreach and early intervention services (EIS) to identify people with HIV disease who know their HIV status but are not receiving HIV-related services in order to bring them into care. EIS can be funded as long as the grantee can demonstrate that other sources of funds are insufficient to meet current needs.

Title II Program Categories  TOP

There are five mechanisms States and Territories can use to deliver Title II-funded services. They range from funds just for HIV-related drug costs to two programs-consortia and State Direct Services-that are much like Title I in such respects as planning and in providing a range of health and support services. This feature of Title II reflects how health care environments differ substantially from State to State and the flexibility they need to respond to unique needs.

1. AIDS Drug Assistance Program (ADAP). Primarily for medications that treat HIV disease but limited funds can be used to buy health insurance. States can also spend up to 5 percent of their ADAP award (and as much as 10 percent if they prove it is critical) on adherence support to help patients correctly follow complex drug regimens and on medical monitoring. States have considerable latitude in designing their ADAP programs in terms of drugs to cover and eligibility criteria. ADAP is the second largest CARE Act program, after Title I.

2. Consortia. Groups comprised of providers, consumers, and others who perform a planning and advisory function to regions, or the entire State, in determining needs and delivering essential health and support services (see below). Consortia identify service needs, plan how they can be met, and in some cases actually deliver services and in others do so through funding agreements.

3. State Direct Services. Health care and support services provided directly by the State or under contract. In some cases, States have opted to use this mechanism instead of directing funds through consortia but must document that this a more efficient way to deliver care.

4. Health Insurance Continuity Programs. State programs that provide coverage for eligible low-income people with HIV disease, either by helping them maintain existing health insurance coverage or purchasing new coverage. Funds may not be used for creating or administering a risk pool or to pay for State Medicaid assistance.

5. Home- and Community-based Services. Skilled health services provided according to a written care plan developed by a case management team of health professionals. Services do not include inpatient hospitalization, nursing home care, or placement in other long-term care facilities.

States may award funds to public, nonprofit entities and additionally to private, for-profit entities if they are the only available providers of quality HIV care in the area. Eligible organizations include, for example, community-based organizations, ambulatory care facilities, community health centers, substance abuse treatment programs, mental health programs, and faith-based programs.

Managing Title II Funds  TOP

States as the Title II grantees must ensure that funds are used appropriately-regardless of which of the above mechanisms they use to deliver services. States also decide how to use funds through planning with community and State planning groups as well as through coordination with other payers. Under Title II, States must also target resources to key groups. States must document their efforts and provide assurances in grant applications that they are meeting these requirements. Reports outlining how funds are used and who is being served are required. More specifically, these requirements include the following:

Planning. Community planning is used to determine use of Title II funds. It has evolved over the CARE Act's history to more closely parallel Title I in terms of requirements for broadly representative planning body membership and certain decision-making steps to follow. The Amendments of 2000 refine the requirement that States-and their consortia-assess needs, prioritize, and allocate funds on the basis of characteristics of their populations and subpopulations with HIV/AIDS. The legislation focuses on: people living with HIV disease who are not receiving care; disparities in access and services; and historically underserved communities.

Coordination. Ensuring the best use of Title II funds with other resources is particularly important for Title II in administering multiple programs and working with other Federal/State programs like Medicaid. Coordination requirements include the following:

• Consortia service plans must be consistent with State comprehensive plans.
• States must coordinate their overall Title II funds with other programs, including other CARE Act programs, outreach and early intervention services, prevention, substance abuse, and other public payers such as Medicaid. This is done by convening a meeting of the CARE Act community to develop a Statewide Coordinated Statement of Need (SCSN), which is a mechanism CARE Act programs use to address HIV/AIDS care issues and enhance coordination. The annual funding application must include a description of how the allocation and use of resources is consistent with the SCSN.
• Title II resources cannot be used to pay for services that are funded by other sources and cannot be used to replace local or State spending on HIV/AIDS care.

Targeting of Resources. Various requirements reinforce the need to target CARE Act funds to under-served groups, including provisions that Title II:

• Provide services regardless of an individual's ability to pay or health condition and in settings that are accessible to low-income people with HIV; outreach must be provided to inform them of the availability of services.
• Conduct outreach to HIV-positive individuals not in care who know their serostatus. Just as it did for EMAs under Title I, the Amendments of 2000 made early intervention services, such as HIV counseling and testing, fundable through Title II grants. Relatedly, funded entities must develop and maintain relationships with "key points of access" to facilitate early intervention for people newly diagnosed with HIV disease and for those who know of that they are HIV-positive but are not receiving care.
• Provide health and support services to women, infants, children, and youth with HIV disease, using dollar amounts proportional to their representation of the State's AIDS cases. A waiver is provided when grantees can demonstrate that the needs of a population group are being met through other sources, such as Medicaid or the State Children's Health Insurance Program.
• Take administrative or legislative action to ensure that good faith efforts are made to notify a spouse of a known HIV-infected patient that such spouse may have been exposed to HIV and should seek testing.

Quality of Care. Quality of care is increasingly important for CARE Act programs given effective—but complex—treatments. Title II must therefore establish a quality-management program that measures the extent to which providers are using the latest PHS treatment guidelines. They also must develop strategies for ensuring that services are consistent with those guidelines.

Funding  TOP

Title II funding comes in several forms: the formula grant based upon AIDS cases; ADAP funds for drug treatments (including supplemental ADAP grants); emerging communities grants; and requirements for States to match funds. In addition, Minority AIDS Initiative (MAI) funds are provided to target HIV related outreach and education services in communities of color hardest hit by HIV/AIDS.

• Title II "base" and ADAP awards are calculated on the basis of the estimated number of living AIDS cases in the State or Territory during each of the past 10 years. (In FY05 this will shift to funding based upon the prevalence of HIV disease-AIDS cases and HIV infections that have not yet progressed to AIDS—if such information is available.) For States with Title I Grantees, the formula is weighted so that 80 percent of the award is based on estimated living AIDS cases in the entire State or Territory, and 20 percent is based on the number of cases living outside Title I EMAs. The Amendments of 2000 set the minimum Title II base awards at the following levels:
  • $200,000 for States with fewer than 90 people living with AIDS
  • $500,000 for States with 90 or more people living with AIDS
  • $50,000 for U.S. Territories.
• Supplemental ADAP grants represent 3 percent of ADAP funding and are awarded to States demonstrating severe need for medications. Considerations in supplemental awards include the number of eligible persons living 200 percent below poverty and the State's ADAP and formulary eligibility standards.
• Emerging Communities, those with from 500 to 1,999 reported AIDS cases in the past 5 years, can receive a portion of the Title II base appropriation. The exact amount is calculated using a formula based on the increase in Title II base funds over the prior year. These grants are "formula" in that areas meeting eligibility criteria do not compete with one other for funds. Nonetheless, States must submit detailed applications that demonstrate local support and severe need and how funds will be spent.
• Matching funds are required from States with more than one percent of the total U.S. AIDS cases reported to the CDC during the previous 2 years. These matching funds can either be cash or in-kind resources, either directly or through donations to the State from public or private entities, in proportion to their Title II funding. (Puerto Rico is specifically excluded from complying with this requirement.) The match begins at $1 in State funds for every $5 Federal dollars and increases to $1 for every $2 in Federal funds in latter years. (Matching funds for ADAP supplemental treatment drug grants are required in an amount equal to $1 for each $4 of Federal funds provided in the supplemental grant.)
• Title II supplemental funds have been awarded since fiscal year (FY) 2001 under the Minority AIDS Initiative (MAI) to improve the quality of care and health outcomes in communities of color disproportionately impacted by the HIV epidemic. The MAI allocation is based on the relative distribution of minority AIDS cases in accordance with criteria established by Congress. Funds are to initiate, modify, or expand culturally and linguistically appropriate outreach and education services to improve minority participation in ADAP, primary care and HIV related support services.

Limits on Use of Funds  TOP

Funds used to administer Title II grants are limited as follows:

• States may not spend more than 10 percent of their grant for planning and evaluation activities or more than 10 percent for administration (including routine grant administration and monitoring); combined, expenses for these activities cannot exceed 15 percent of the total grant award.
• States must ensure that of the funds allocated to consortia, subcontractors, and other entities, no more than 10 percent of the aggregate amount will be used for administrative expenses.
• Up to 5 percent of the grant, or $3 million (whichever is less) may be used for quality management programs.
• Funds may not be used to make payments to recipients of services, except for reimbursement of appropriate out-of-pocket expenses associated with consumer participation in State or consortia activities.
• Funds may not be used to purchase or improve land, or to purchase, construct, or make permanent improvements to any building, except for minor remodeling.
• States that use Title II ADAP funds to purchase health insurance must assure that such costs, overall, will not exceed costs that would occur if services were purchased directly. Such insurance must also cover an array of drugs comparable to the State ADAP formulary.