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EFFECTIVE DATE: October 1, 2017



This policy establishes funding from The Resource Group (TRG) for HIV-related medical and support services as payment of last resort (PoLR). Subrecipients must establish and enact policies and procedures to assure that funds are used as PoLR for all consumers served under contacts from The Resource Group.



Administrative Agency (AA) – Entity responsible for ensuring a comprehensive continuum of care exists in their funded areas. This is accomplished through the management, distribution, and oversight of HIV care and treatment services funded by federal and state funds. The Resource Group is an AA.


CHIP – The Children’s Health Insurance Program (CHIP) is designed for low-income families who exceed the income limits for Medicaid.

Client File is a uniform term to describe the collection of documentation pertaining to a specific consumer used to provide a record of care/service delivery. The file may be physical or electronic in nature.


Consumer is an individual who receives services funded under TRG contracts.


Cost Sharing is an amount of money consumers are expected to contribute to the cost of their medical care. Cost sharing includes co-payment or co-insurance payments and deductible costs for health insurance or consumer fees charged by providers. Cost sharing requirements may be established through provider policy or be specified by the consumer's health insurance plan. Fees associated with cost-sharing requirements are subject to the limits on consumer contributions in this policy.


Federal Poverty Level (FPL) is a measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits. HIV Services are eligible services listed within the Ryan White Act and funded through contracts by TRG.


Medicaid is a state and federal insurance cooperative program that provides medical coverage to eligible low-income persons.


Medicare is a federal insurance program providing coverage primarily to people who are aged 65 and over and to those who are permanently disabled.


Modified Adjusted Gross Income (MAGI) is a calculation required by DSHS used to determine eligibility for Medicaid, CHIP, and for reduced-cost insurance on the Health Insurance Marketplace. Generally, MAGI is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income. Program eligibility considerations for DSHS-funded services should be based on household income (see Sliding Fee Discount Schedule below for determining a schedule of fees for services and the corresponding sliding fee discount schedule).


Household is defined as the applicant, the applicant’s legal or common law spouse, and minor dependent children (under the age of 18, may be biological, adopted, or step children) living 51% of the time or more in the applicant’s home. MAGI forms and requirements can be found at


The Patient Protection and Affordable Care Act (commonly called the Affordable Care Act or Obamacare) is the comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010.


The Affordable Care Act (ACA) is used to refer to the final, amended version of the law, which created guidelines for a new kind of marketplace for health insurance. Sliding Scale Discount Schedule are based on the cost of services received and consumer household income. Consumer charges are subject to the limits on consumer contribution specified in this policy.


Subrecipient is an agency that has entered into a contract with The Resource Group to provide services.


Texas HIV Medication Program (THMP) provides HIV treatment drugs directly to eligible uninsured or underinsured consumers through the AIDS Drug Assistance Program (ADAP); assistance with payments associated with Medicare Part D prescription drug plan through the State Pharmaceutical Assistance Program (SPAP); and assistance with medication copayments, coinsurance, deductibles, and premiums for employer-sponsored commercial health insurance through the piloted Texas Insurance Assistance Program (TIAP).



The funds contracted by TRG may not be used for any item or service for which payment has been made or can reasonably be expected to be made by any other payer. This requirement applies to all funding administered by TRG. Therefore, each Subrecipient that receives funding must screen every consumer for possible third party payment (TPP) sources. TTP sources include, at minimum, public or private health insurance coverage including Medicaid, Medicare, CHIP, ACA Marketplace and employer-based health insurance.


If a consumer is determined to have a TPP payment source, the Subrecipient must obtain documentation that allows that payment source to be billed for the service prior to utilization of The Resource Group’s funded grants. All Subrecipients must verify third party payer eligibility in accordance with requirements outlined in this policy. Additionally, Subrecipients should screen consumers for the ability to contribute to the cost of their care. The Subrecipient should establish a procedure to assess, obtain and track income generated via consumer contributions. This procedure should comply with the requirement outlined below. The procedure must comply with the requirements outlined below.



The Resource Group

1. Develops and assures compliance with requirements of its funders, and monitors Subrecipient billing of third party payers to determine compliance with PoLR requirements.

2. Provide education about the requirements of this policy.



1. Develop and implement policies and procedures to ensure that funds are used as PoLR. 2. Provide education to consumers about the requirements of this policy .

3. Provide education to consumers about their responsibilities under this policy.


1. Provide the requested information for income and TPP sources required under this policy

2. Report any changes in income and TTP sources to the Subrecipient within thirty (30) days of the change.


PROCEDURE: Affordable Care Act Essential Health Benefits Ambulatory Patient Services Emergency Services Hospitalization Maternity And Newborn Care Prescription Drugs Laboratory Services Mental Health & Substance Use Disorder Services (Including Behavioral Health Treatment) Rehabilitative & Habilitative Services & Devices Preventive/Wellness Services & Chronic Disease Management Pediatric Services (Including Oral & Vision Care) Medicaid/Medicare Reimbursable Service Categories Outpatient Ambulatory Medical Care Psychiatry Adult Day Care/Respite Care Oral Health Care Home Health Care Substance Abuse Treatment Hospice Transportation Mental Health Services Vision Services 


Screening for Other Payment Sources

1. Subrecipients are required to implement policies and procedures to certify eligibility for funded HIV services every six (6) months (at intake, six-month recertification and annual updates). Subrecipients must comply with the requirements of TRG Policy SG-1701 and DSHS Policy 220.001 to document eligibility for services and requirements for referral of consumers who may be eligible for public or private insurance or other medical benefit program. Subrecipients should meet standards for comprehensive eligibility review; timely referral; vigorous follow up; and documentation for these tasks.

2. Vigorous efforts to enroll the consumer in any health plan or program for which the consumer appears to be eligible must be documented in client file utilizing DSHS Attestation of Client Eligibility for Marketplace Plans and process, or approved local forms and processes.

3. If consumers are concerned about the affordability of job-related or Marketplace insurance, they should be counseled about the availability of health insurance assistance (HIA) services if such assistance is appropriate under local policies and guidelines (see TRG Policy HIA1701). Consumers who require assistance with Medicare Part D drug plans and eligible employer-based health insurance may be eligible for assistance through the piloted Texas Insurance Assistance Program (TIAP), a program of THMP.

4. While enrollment periods for Medicaid and CHIP are continuous, other programs have limited enrollment periods. If consumers appear eligible but are outside an enrollment period, they must receive counseling about opportunities for future enrollment and be referred to organizations or individuals that can further assist them. These efforts must be clearly documented in client file.

5. Consumers eligible for benefits through the Department of Veterans Affairs (VA) should receive education on the services available through the VA and be referred to VA health centers if they so choose. However, funded services must be made available to VA-eligible consumers who choose not to receive care through the VA systems. Such consumers are dually eligible for TRG-funded services and VA services and therefore exempted from the PoLR requirement. As with all efforts of vigorous pursuit, a consumer’s refusal for referral to VA services must be clearly documented in client file.


Verification of Coverage

1. Subrecipient must implement systems that allow for verification of TTP coverage for eligible services at every visit for a TTP reimbursable service (listed above). This verification must occur prior to utilization of TRG’s funded grants.

2. Subrecipients are encouraged to explore contracting of TTP coverage verification to entities that specialize in that service.

3. Documentation of this screening must be maintained within the client file.


Consumer Refusal to Enroll in TTP Coverage

1. Per HRSA HIV/AIDS Bureau (HAB) Policy Clarification Notice # 13-04, eligible consumers who refuse to enroll in programs or insurance plans must receive continued counseling on their eligibility at each recertification opportunity and may not be refused treatment services because of the refusal.

2. Vigorous efforts of benefit counseling and enrollment must be documented in the client file. 


Subrecipient Enrollment in TTP Sources

1. Health insurance plans cover some, but not all funded services. Eligible services typically covered by health plans include outpatient health services, outpatient mental health services, inpatient and outpatient substance abuse treatment, home health services, pharmaceuticals/drugs, home and community health services, home health services, and hospice services (listed above). Providers of these services who receive TRG funding must make reasonable efforts to enroll as participating or approved providers in the health plans carried by their consumers. No waivers are available. If an organization subcontracts the medical services listed above, the requirements below apply to their subcontractors.

2. Subrecipient who delivers Medicaid- eligible services must be enrolled as a Medicaid provider. Subrecipients must furnish Texas Medicaid ID numbers as demonstration of enrollment, or other documentation that establishes that the provider has initiated the application process. If the provider's application is denied, TRG may only use funds to contract with that provider if no other Medicaid-enrolled providers are available. Subrecipients who have been denied enrollment must continue to make good faith efforts to enroll, and must make evidence of these efforts available to TRG annually at time of renewal and upon request.

3. Subrecipients (including subcontractors) that deliver medical services typically covered by other public or private health plans must ensure they make good faith efforts to enroll as innetwork providers on the plans carried by their consumers. Subrecipients may prioritize their efforts to enroll in the plans carried by the greatest number of consumers. Subrecipients must provide documentation of their efforts to enroll annually to TRG. Subrecipients must show due diligence in their efforts to enroll, including requesting inclusion on the list of Essential Community Providers (ECP) compiled by the Center for Consumer Information & Insurance Oversight, informing health plans of their ECP status as 'write ins' if they are not included on the CCIIO list, and making health plans in their area aware of the unique services they provide.

4. Subrecipients who are not in-network or approved providers on a consumer's health insurance plan must refer consumers to appropriate providers that are in-network on a consumer's plan. If no such provider is available, the Subrecipient may deliver the service after obtaining a waiver in writing from TRG. The Request for Waiver must show proof of attempted billing to the consumer's health plan.

5. Subrecipients must make consumers aware of any limitations on health insurance assistance to consumers with out-of-network cost sharing obligations.

6. TRG funds may not be used to reimburse providers for denied claims that result from failure to follow plan requirements such as prior authorization or referral approval. DSHS funds may not be used to reimburse providers for rejected claims if the rejection is a result of provider error, including incomplete or late submission of claims. AAs must maintain and enforce policies to this effect.


Consumer Charges for Billable Services

1. DSHS-funded AAs must maintain policies requiring funded providers who deliver services typically billable to public and private health plans to maintain policies and procedures on consumer charges. For purposes of this policy, providers of Outpatient/Ambulatory Medical Care; Local Pharmacy Assistance Programs/AIDS Pharmacy Assistance Programs; Mental Health Services; Medical Nutrition Services; Home and Community-Based Health Services; Home Health; Hospice; Early Intervention Services (if such services are primarily associated with HIV testing and referral); and inpatient and outpatient Substance Abuse Treatment are considered to provide billable services.

2. To adhere to RWHAP legislation, all providers that deliver these services with DSHS funds must develop a sliding fee discount program that includes the following:

(1) a schedule of fees for services;

(2) a corresponding sliding fee discount schedule;

(3) a system/policy to waive or reduce fees to assure receipt of care;

(4) policies that prohibit refusal of services to consumers who are unable to pay fees or refuse payment of fees; and

(5) a limit on annual aggregate charges (cap on charges) based on the consumer's household income. "Aggregate Charges" applies to annual charges imposed for all services regardless of terminology (i.e. enrollment fees, premiums, deductibles, cost-sharing, co-payments, coinsurance, etc.) and applies to all service providers from whom individuals receive services. A simple application showing annual modified adjustable gross income (MAGI) of a household shall be used to establish the appropriate level of fees.

3. Providers must develop a fee schedule that is consistent with locally prevailing rates and is designed to cover reasonable costs. The fee schedule must be used as the basis for seeking payment from patients as well as third party payers.

4. The schedule may include a documented decision to impose only nominal charges. Such a charge may not be specific to RWHAP/SS consumers, and must be similar to charges for non-RWHAP/SS consumers. A nominal charge must be a fixed fee that does not reflect the true value of the service(s) provided and is considered nominal from the perspective of the patient. The nominal charge must be less than the fee paid by a patient in the first “sliding fee discount pay class” beginning above 100% of FPL.

5. Affected providers must also develop a SFDS based on the consumer's ability to pay. Eligibility for the SFDS is based on a percentage of FPL using only the HIV-positive consumer’s annual individual income calculated from Mock MAGI or MAGI worksheets. The SFDS must be revised annually, at a minimum, to reflect updates to the federal poverty guidelines. The provider must establish policies and operating procedures to assure that the SDFS is applied uniformly to eligible patients.

6. Providers of billable services must have supporting processes/operating procedures in place for assessing MAGI for all consumers, or must have a documented procedure for using the MAGI calculated during certification/re-certification for DSHS-funded services. If a consumer has had no changes in income, household composition, residence, immigration status, or insurance coverage since the previous full MAGI-based eligibility screening a selfattestation of ‘no changes’ may be used to satisfy eligibility determination requirements. If a consumer attests there have been no changes, the MAGI calculation from the previous eligibility screening should be used. Eligibility determination should be conducted in an efficient, respectful, and culturally appropriate manner to ensure that administrative operating procedures for such determinations do not themselves present a barrier to care. Patient privacy and confidentiality must be protected throughout the process. Once assessed, a patient who meets the income guidelines would receive a sliding fee discount based on the SFDS. As required by RWHAP, consumers with an individual annual income at or below 100% FPL must receive a full discount, meaning no charges may be assessed. Nominal fees may not be applied to this group. Regardless of consumer income, services cannot be refused based on the consumer's ability to pay, and this must be reflected in SFDS polices and operating procedures.

7. Consumers with health insurance coverage have incomes that would make them eligible for the SFDS established by the provider. Such consumers must use their insurance, but may be eligible to have the co-payment or co-insurance required by their insurance plan reduced based on the SFDS, subject to potential legal and contractual limitations. Such limitations may be specified by applicable federal and state law for Medicare and Medicaid and/or terms and conditions of private payer contracts. If this is allowed, the charge to these consumers is the maximum amount an eligible patient in that pay class is required to pay for a certain service regardless of insurance status. If the consumer receives HIA services, the reduced charge may be paid through these funds if the service is HIV-related and otherwise qualifies for payment by HIA. Providers may not seek reimbursement from RWHAP/SS for the difference between the insurance charge and the reduced charge collected from the payment. However, the terms of contracts that providers hold with health insurance plans may not allow discounting of consumer co-pays and co-insurance and discounting consumer cost sharing obligations may also be inappropriate for Medicare consumers. Providers may wish to consult with their third party payers or legal counsel and/or private legal counsel regarding the permissibility of discounting patients’ out-of-pocket costs. How a provider will approach the issues of cost sharing requirements and SFDS must be documented in policies on SFDS.

8. The SFDS must be publicly posted and must contain language that assures consumers that services are available regardless of ability to pay.

9. Service providers must make reasonable attempts to collect fees. The provider must establish policies on waiving consumer fees. The policy must include criteria for waiving charges, and should specify the staff with the authority to approve fee waivers. This policy must be consistently applied.

10. RWHAP legislation requires that consumers be charged no more than a maximum amount (cap) in a calendar year. The cap is based on the consumer's household MAGI as follows: • 5% for patients with incomes between 100% and 200% of FPL; • 7% for patients with incomes between 200% and 300% of FPL; • 10% for patients with incomes greater than 300% of FPL.

11. Provider policies must specify that once a consumer's annual aggregate charges reach the cap, no additional consumer charges may be made.

12. Providers must track consumer charges to assure that they do not exceed the aggregate caps specified in section 11.5. Providers are not responsible for tracking charges from other providers, but if consumers produce reasonable documentation for these charges they should be included in the tracked total. Examples of consumer out of pocket charges include consumer fees for services, drug co-payments or co-insurance payments, premiums, and enrollment fees.


Program Income

1. Income resulting from payments for HIV services by consumers or from insurance companies is considered program income. Service providers must retain program income derived from DSHS-funded services and must follow DSHS rules on reporting and use of  such income. Providers must also follow any additional requirements of DSHS-funded AAs specified in contract or policy.


Subrecipient Compliance

1. Upon receiving funding from The Resource Group, the Subrecipient must develop a screening procedure for all consumers to assess, obtain and maintain the documentation of Third Party Payers eligibility (including Medicare and/or Medicaid) that meet or exceed the requirements outlined in this policy. The screening process should include steps to:

a. Determine what employment-based medical insurances each consumer currently holds;

b. Determine what publically-funded medical insurance benefits (e.g. Medicaid) each consumer receives;

c. And, conduct a financial assessment to determine if the consumer is eligible for any publically-funded medical insurance benefit program.

2. The Subrecipient should incorporate the required screening elements into its client file layout. The documentation of the screening process should be present in each client file.

3. Documentation of eligibility for third party payment should always remain within the active client file. The documentation of eligibility should never be archived. Documentation of Third Party Payers should be documented where appropriate in the data collection system (ARIES/CPCDMS).

4. If the Subrecipient provides reimbursable services, it must maintain the ability to bill Medicaid/ Medicare or other third party (to assure that Ryan White is payer of last resort).

5. If the Subrecipient provides reimbursable services, the Subrecipient must establish and maintain a system for charging, collecting, and tracking consumer monies, including insurance co-payments and consumer contributions to their own medical care whether on a sliding scale or flat fee basis. This system should include financial systems to track services, billing and payments from third party payers.

6. Subrecipients must make a reasonable attempt to collect monies, however, services must be provided without regard to ability of the consumer to pay. Monies owed but not received from the consumer are not considered uncollected debt. Subrecipients should not track these amounts. Any monies received are considered program income for that month, regardless of when the services were provided.

7. The following Subrecipient systems will be reviewed:

a. Policy for the Third Party Payer Process

b. Documentation of staff training on Third Party Payer issues.

c. List of all public and private medical insurance plans held by consumers of the agency and status of agency’s efforts to become an approved provider under those plans.

d. Enrollment process with consumers who are potentially eligible for Medicaid and/or other publically-funded health insurance benefit program(s).

e. Subrecipient system for charging, collecting, and tracking consumer monies, including insurance co-payments and consumer contributions to their own medical care whether on a sliding scale or flat fee basis and evidence of compliance.

f. For clinic-based Subrecipients, the ability to bill Medicaid, Medicare and EmployerBased Insurance companies, etc. g. Subrecipient financial systems to track services, billing and payments from third party payers and evidence of compliance. 

8. Services rendered under The Resource Group’s funding for days on which a consumer was eligible for Medicaid, Medicare, or another third party payer will be recouped.

9. If the Subrecipient provides one of the above services through subcontract with another entity, the subcontracted entity must comply with the expectations of this policy.

10. A Subrecipient may establish thresholds of documentation that exceed these minimum requirements. However, no Subrecipient may establish thresholds of documentation that fail to meet these minimum requirements.

11. Compliance with this policy will be monitored as part of each Subrecipient’s annual quality compliance review and monthly reimbursement requests.

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