HOUSTON REGIONAL HIV/AIDS RESOURCE GROUP, INC.
POLICY AND PROCEDURE CLIENT
ELIGIBILITY FOR SERVICES (SR-0201-20)
EFFECTIVE DATE: SEPTEMBER 17, 2018
NOTE: This revision is a direct update to align with DSHS client eligibility requirements and Universal Monitoring Tool.
To outline the criteria that must be met to determine client eligibility for services for all funding from The Resource Group. Eligibility for services includes the determination of HIV Diagnosis, Residency, Income including (Income Calculation Worksheet), Third Party Screening, Consents and Acknowledgements, and Payer of Last Resort (POLR)1 .
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 or federal and state funds and under contractual agreement with the Department of State Health Services (DSHS).
AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV medication program, administered by the DSHS’ HIV/STD Prevention and Care Branch; a part of the Texas HIV Medication Program.
AIDS Regional Information and Evaluation System (ARIES) – Web-based, client-level software that RWHAP Part B /State Services-funded HIV providers use to report all RWHAP and State Services-funded services provided to RWHAP Part B-eligible clients.
Annual 12 - Month Eligibility Recertification – The process of screening and determining eligibility for a period of months. Clients must be screened for program eligibility every Six Months (no later than the last day of the clients’ Birth Month for the Annual 12-month Recertification and no later than the last day of the clients’ Half Birth Month for the 6-month Self-Attestation). Assessment includes: Documentation of Texas Residency, Income, and Proof of Insurance/(payor). This documentation is submitted by the last day of the applicant’s birth month.
Applicant – An individual requesting RWHAP Part B, State Services and/or THMP-funded services and undergoing the eligibility process.
1 Texas Health and Safety Code: Chapter 85, §§85.003, 85.013, 85.014 - 85.031; Ryan White HIV/AIDS Treatment Extension Act 2009; Health Resources & Services Administration (HRSA) Policy Clarification Notice (PCN) #16- 02; PCN #13-02
Client – An individual who has been determined to be eligible for Services, has successfully completed the eligibility process, and is receiving services (can be any agency services, not just those receiving Ryan White and/or State Services).
Contractor – The entity with whom the Department of State Health Services has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who provides the services.
Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas.
Federal Poverty Level (FPL) – A measure of income level determined by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2) that is updated periodically in the Federal Register and primarily used to determine eligibility for certain programs and benefits. FPL is the set minimum amount of gross income that an individual or a family needs for food, clothing, transportation, shelter, and other necessities. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines.
Half Birth Month – Half Birth Month is the month that is Six Months after the client’s birth month (e.g. birth month is January, half birth month is July, and so on). For purposes of this policy, the end of the Half Birth Month shall be considered the last day of the month it falls in, regardless of a client’s birth date.
Human Immunodeficiency Virus (HIV) – infection destroys some types of white blood cells and is transmitted through blood or bodily secretions such as semen and as further defined by the Centers for Disease Control and Prevention (CDC) and in accordance with the Health and Safety Code, §81.101.
HIV supplemental (confirmatory) test – a test that confirms the diagnosis of HIV after a preliminary positive test has been completed. HIV Service Delivery Area (HSDA) – Geographic service area set by the Department of State Health Services for the purposes of allocating federal and state funds for HIV medical and psychosocial support services.
HIV Services – Any of the social or medical assistance defined in the HIV Services Taxonomy (www.dshs.state.tx.us/hivstd/taxonomy/) paid for with Ryan White Part B and State Services funding streams disseminated through DSHS.
Initial Eligibility Determination Period – The 30-day period during which client undergoes initial eligibility assessment. Medicaid – Established by Title XIX of the Social Security Act, this program reimburses for health care services delivered to low-income clients who meet eligibility guidelines.
Medicare – A federal government insurance program providing coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria.
Modified Adjusted Gross Income (MAGI) – A figure used to calculate income eligibility for lower costs in Marketplace Health Plans as well as eligibility for Medicaid, Children’s Health Insurance Plan (CHIP), and RWHAP Part B/State Services-funded HIV medical and support services. Generally, modified adjusted gross income is adjusted gross income plus any taxexempt Social Security, interest, or foreign income an individual may have. MAGI must be calculated using the DSHS provided Income Calculation Form, which can be found on the DSHS MAGI documents page (http://www.dshs.texas.gov/hivstd/magi/).
New Eligibility Determination – The process of assessing an applicant’s eligibility upon entrance into RWHAP Part B, State Services, and/or THMP-funded services. Assessment includes: Documentation of HIV Diagnosis, Texas residency, Income (including the Income Calculation Worksheet), and Third-Party Insurance (payor).
Nucleic Acid Amplification Test (NAAT) – A laboratory test that amplifies the HIV RNA and detects viral genes instead of viral antibodies or antigens.
Payer of last resort (PoLR) – Ryan White or State Services funds cannot be used as a payment source for any service that can be paid for or charged to any other billable source. Subrecipients are expected to make reasonable efforts to secure other funding instead of Ryan White or State Services funding whenever possible.
Provider – A local organization, individual clinician, or group of clinicians who provide services to people living with HIV (PLWH).
Six-Month Self-Attestation – process of a client confirming no change in previous eligibility declaration and documentation. This process occurs by the last day of the half birth month, six months after the client’s birth month.
Subrecipient – A non-federal entity that receives a subaward from a pass-through entity or recipient (AA) to provide services to clients and implement policy.
Texas Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas.
Texas HIV Medication Program (THMP) – Provides medications for the treatment of HIV and its related complications for low-income Texans. The THMP is the official ADAP for the State of Texas. It also operates the SPAP and Texas Insurance Assistance Program (TIAP).
Texas Insurance Assistance Program (TIAP) – This program, which is operated by THMP, aids with premiums and out of pocket medication costs for low-income Texans with qualified insurance plans.
Texas Resident – An individual who resides within the geographic boundaries of the state. Veteran – A former member of the Armed Forces of the United States of America.
Veteran – A former member of the Armed Forces of the United States of AmericaVeterans are eligible to receive RWHAP Part B and State Services-funded services. Please see DSHS Policy 590.001 Payment of Last Resort (http://www.dshs.texas.gov/hivstd/policy/policies/590- 001.shtm) for more detailed guidance.
Viral Load – A laboratory test that measures the amount of HIV viral copies in a milliliter of blood.
Each Subrecipient that receives funding from The Resource Group must obtain and maintain documentation of HIV Diagnosis, Residency, Income (including Income Calculation Worksheet), Third Party Screening, and Consent for Acknowledgements for each client served. The Subrecipient should establish a procedure to obtain and maintain the acceptable documentation of HIV Diagnosis, Residency, Income (including Income Calculation Worksheet), Third Party Screening, and Consent and Acknowledgements that complies with the requirements outlined below. Clients must be screened for program eligibility every six months (no later than the last day of the clients’ birth month for the annual 12-month recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation) per Federal and State requirements. (NOTE: This applies to all funding administered by The Resource Group.)
1. Purpose of Funding:
a. The Ryan White HIV/AIDS Program and DSHS State HIV Services Program provides HIV-related services in the United States for those who do not have sufficient health care coverage or financial resources for coping with HIV disease. The program fills gaps in care not met by other payers.
b. DSHS Housing Opportunities for People with AIDS is to provide housing assistance and supportive services for income-eligible individuals living with HIV/AIDS and their families to establish or better maintain a stable living environment in housing that is decent, safe, and sanitary, to reduce the risk of homelessness, and to improve access to health care and supportive services.
2. Subrecipient Responsibilities
a. Subrecipients are responsible to meet the following requirements:
i. Develop policies and procedures to determine eligibility for services while ensuring Ryan White funds are used as payment of last resort;
ii. Develop policies and procedures to ensure that individuals seeking covered services are screened for eligibility using MAGI to participate in other payer sources such as the Marketplace, Medicaid and CHIP. Screening should occur as indicated in this policy. If individuals are determined potentially eligible for other benefits, refer them to the specific programs and assist them in completing the eligibility determination process.
iii. When providing emergency assistance to priority populations in crisis (e.g., an individual who is recently released from the criminal justice system who requires assistance in acquiring HIV medications), contractors must refer clients into appropriate program services and assist in obtaining any required eligibility documentation within 30 days of intake. Subrecipients should also ensure the proper documentation of all eligibility screening and intake activities in the respective client record (paper and/or electronic) and the client level data reporting system (e.g. ARIES).
3. Client/Caregiver Responsibilities:
a. The client and/or caregiver is responsible to meet the following requirements:
i. Provide the required documentation to determine eligibility for services under the specified funding;
ii. Provide any updated information for the six-month attestation;
iii. Provide updated information at the annual update.
4. Initial Eligibility Screenings
a. 30-day determination period for all Ryan White Part B and State funded services can be accessed by clients who are:
i. Newly diagnosed within the previous six months;
ii. New to the State of Texas/local HSDA and in need of medical services;
iii. Engaging in care for the first time after being diagnosed for longer than six months;
iv. Returning to medical care after an absence of six months or longer and/or; v. In need of early intervention services.
5. Documentation of HIV Diagnosis
a. A key objective in the National HIV/AIDS Strategy is to establish a seamless system to immediately link people to quality care when diagnosed with HIV. To accomplish this vision, all stakeholders (HIV testing staff, eligibility workers, linkage workers, case managers, RW clinical staff, etc.) must work together to reduce administrative and other barriers to clients accessing medical care. An individual must have an HIV diagnosis to be eligible for RW medical care. There are several different ways to document HIV Diagnosis; Documentation of HIV Diagnosis should include but not be viewed as a complete list:
i. Laboratory Documentation: Documentation of HIV Diagnosis may be found in laboratory test results that bear the client’s name. Some examples include: Positive result from HIV screening test (Multi-Spot, HIV 1/2 Combo Ab/Ag enzyme immunoassay [EIA]); Positive result from an HIV 1 RNA qualitative virologic test such as a HIV 1 Nucleic Acid Amplification Test (NAAT); or Detectable quantity from an HIV 1 RNA quantitative virologic test (e.g. viral load test)
ii. A signed statement from an entity with prescriptive authority attesting to the HIVpositive status of the person; or
iii. A complete THMP Medical Certification Form signed by a physician (required by THMP); or
iv. A hospital discharge summary documenting HIV infection of the individual
v. HIV testing technology is rapidly changing, and the standards of HIV confirmation continue to evolve. Subrecipient must stay informed of advances as these newer tests may also provide proof of HIV diagnosis.
b. Infants exposed to Maternal HIV can be served with documentation of the mother’s HIVpositive status up to the age of 18 months based upon the clinical protocols for managing infants born to women living with HIV.
c. Facilitating linkage with an HIV Preliminary Positive result:
i. A preliminary positive, is a positive result from an HIV screening test. Although a preliminary positive is not considered documentation of HIV Diagnosis (because it is not a confirmatory test in the current HIV testing algorithm), clients with such a result are very likely to have HIV diagnosis and would benefit from quick linkage to ongoing care. Having only a preliminary positive result from one HIV test should not be a barrier to linkage to medical care.
ii. The ability to utilize a preliminary positive test result to facilitate linkage to care does not negate the responsibility of the HIV testing site to conduct confirmatory testing and the receiving medical Subrecipients must be informed of the client’s unconfirmed preliminary positive HIV test result. Once the confirmatory results are received from the lab, HIV testing staff must provide these results to the client and if a Medical Release of Information is signed, to the HIV care Subrecipient. Clinics receiving such clients may choose to arrange an abbreviated first appointment, during which the client could receive counseling on HIV diagnosis, orientation to medical care, conduct eligibility, and/or begin laboratory work. Note: HIV medical Subrecipients may elect to conduct the HIV confirmatory test if a memorandum of understanding (MOU) is signed with the HIV testing agency.
iii. Subrecipients should contact their Administrative Agencies with questions about acceptable documentation of HIV diagnosis.
6. Documentation of Texas Residency
a. To be eligible for services paid by Ryan White/State Services, an individual must reside within the geographic boundaries of Texas and express intent to remain within the state, whether permanently or for an extended period, and not claim residency in any other state or country. Documentation of Texas residency should include:
i. Texas State Identification card or Driver License (including identification from criminal justice systems);
ii. Recent Social Security, Medicaid/Medicare or Food Stamp/TANF benefit award letters;
iii. IRS Tax Return Transcript, Verification of Non-Filing, W2, or 1099; iv. Current employment records (pay stub); v. Post office records;
vi. Official state mail;
vii. Current voter registration;
viii. Rent or utility receipts for one month prior to the month of client being eligible
ix. A mortgage or official rental lease agreement in the client’s name;
x. Valid (unexpired) motor vehicle registration;
xi. Proof of current college enrollment or financial aid;
xii. Property tax receipt;
xiii. A letter of identification and verification of residency from a verifiable homeless shelter or community center serving homeless individuals; or
xiv. A statement/attestation (does not require notarization) with client’s signature declaring that client has no resources for housing or shelter.
b. If none of the listed items are available, residence may be verified through:
i. Credit Card, Phone, or Cable Bill with address clearly indicated on document; or
ii. Bank brokerage statement with address clearly indicated on document; or
iii. Statement from landlord/neighbor/another reliable source;
iv. Submission of the DSHS-THMP Supporter Statement. (This is only accepted when no other proof of residency is available and must be accompanied by a signed statement on agency letterhead from the agency enrollment worker detailing steps that were taken to obtain proof of residency and why they were not successful);
v. Observance of personal effects and living arrangement (e.g., visit to residence).
c. Individuals do not lose their Texas residency status because of temporary absences from the state. For example, a migrant or seasonal worker may leave the state during certain periods of the year but maintain a home in Texas and return to that home after these temporary absences. Subrecipients should contact their Administrative Agencies with questions about acceptable documentation of Texas residency.
d. Students- Students from another state who are living in Texas to attend school may claim Texas residency based on their student status while they are residing in Texas.
e. There are no further proof of residency requirements (e.g. requirement for a photo ID, documentation of immigration status) other than those listed above. AAs, subrecipients and/or providers may not impose more stringent proof of residency requirements regarding eligibility for RWHAP and State HIV funded services than those listed
7. Documentation of Income including Income Calculation Worksheet:
a. Funding is targeted for the low-income individuals. Therefore, all clients must be screened for income. Subrecipients will use the client’s Modified Adjusted Gross Income (MAGI) to determine eligibility for Ryan White services. Generally, MAGI is the client’s adjusted gross income plus non-taxable social security benefits, tax-exempt interest and/or foreign income. For all client’s income eligibility is determined by using the Ryan White approved Income Calculation Worksheet.
b. The Income Calculation Worksheet is divided into ‘Section A’ and ‘Section B’.
c. Section A is used to calculate:
• Income for clients who do not have access to a ‘Tax Return Transcript’ or other standardized tax return forms (form 1040, 1040 EZ, etc.)
• Income for clients whose income has changed since filing taxes for the most recent year;
• Clients who are 'Married Filing Jointly'.
d. Acceptable Income Documents that may be used to complete Section A are outlined below:
• Pay Stubs (30 continuous days of payment within the last 60 days);
• Supporter Statement
• Employer Statement (on company letter head indicating weekly or monthly wages)
• Social Security Income (SSI) Award Letter;
• Social Security Disability Income (SSDI) Award Letter;
e. Other documents used to verify Income include:
• Benefits Letter for Unemployment
• Benefits Letter for Veterans Affairs “VA”
• Snap benefit letter (reflecting current income)
• Private disability/ Pension on company letterhead
f. If none of the items listed above are available, Income may be verified through:
• Bank statements (reflecting the 30-day window for the eligibility period).
• Agency Letter (Your agency can attest to an individual’s income; this is only accepted when no other proof of Income is available and must be on agency letterhead from the agency staff detailing steps that were taken to obtain Proof of Income and why they were not successful).
g. Section B is used to calculate income for clients who have access to (1) of the following:
• Standardized tax return forms (form 1040, 1040 EZ, Tax Return Transcript, etc.).
h. The Income Calculation Worksheet is self-calculating and produces the FPL percentage based on both household and individual income. A copy of the worksheet and supporting documentation must be kept in the primary client record
i. Income Calculation Worksheet is required by all Subrecipient but may be substituted if there is an internal form that is greater than or equal to the required Worksheet. Agency who decide to use a different form must provide a process and their form as an appendix to be approved by TRG. The substituted form is not yet official until it is approved by TRG and formal correspondence of approval has been sent
j. If none of the listed items are available, the Subrecipient may submit items for approval through the Request for Waiver Process within the thirty (30) day eligibility determination window. 8. Screening Clients for Third Party Payers (See TRG Policy SG-1602 Payer of Last Resort)
a. TRG funds should be the payer of last resort. Assessment of income is conducted to determine whether clients have a third-party payer who should be billed for the cost of services or whether the client can contribute to their services.
b. Subrecipients must screen individuals for ability to pay, as well as access to potential sources of payment for these services. Insurance Screenings should be accompanied by these supporting documentations:
i. Private/employer insurance (Copy of Insurance Card is needed)
ii. Medicare (including Part D prescription benefit)
iii. County Indigent Health Programs
iv. Patient Assistance Programs (PAP)
v. Medicaid vi. Children’s Health Insurance Programs (CHIP); or
vii. Other comprehensive healthcare plans
viii. Documentation of ineligibility/denial for Third Party reimbursement.
ix. TRG Approved Agency Screening Form: (this form will be used for individuals who attest to Third Party status and should be complete during the Initial and Birth Recertification period).
c. Programs/benefits must be used first and a Copy of Insurance Card for insured and underinsured should always be obtained.
9. Consent and Acknowledgements
a. The following are required TRG Consents and Acknowledgments for all clients and should be located in the client’s primary record:
i. Client Code listed/ correct in file
ii. ARIES (Data) Consent (signed and dated by client and completed annually)
b. Consents that should be signed and dated by the client and completed at a minimum of every 2 years:
i. Consent for Exchange/ Release of Information
c. Consents that should be signed and dated by the client and completed at a minimum of every 5 years:
i. Consent for Service
ii. Proof of Client Right and Responsibilities
iii. Proof of Grievance Procedure
iv. Proof of Confidentiality Policy
10. Failure to Document Eligibility
a. The thirty (30) day is designed to allow Subrecipients adequate time to work with the client to properly document eligibility for services. All eligibility should be verified and documented within the client file by the end of the determination window.
b. Failure of clients to provide the required eligibility documentation will result in the termination of services. c. Subrecipients that continue to serve clients beyond the thirty (30) day eligibility determination window will be required to repay any funds expended.
11. Half Birth Month “Six-Month Self-Attestation”
a. The Subrecipient will determine the system used to track clients’ status and renew eligibility (. While eligibility for services must be determined every six months for active clients, Subrecipients should be assessing changes in eligibility at the time of service. The Subrecipients’ policies and procedures must address how clients will be contacted regarding their six-month recertification, and how to determine if changes in eligibility have occurred at the time of service. Consult the table below for guidance on the recertification process and required documentation.
b. Subrecipients must screen clients for program eligibility every six months (no later than the last day of the clients’ Birth Month for the annual 12-month recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation). At any point if a client does not complete their Annual 12-month recertification by the end of their Birth Month or 6-month Self-Attestation by the end of their Half Birth Month, a complete a full recertification to determine eligibility must be complete.
c. Subrecipients may accept client Half Birth Month Self-attestations of no change in Income, Residency, and Insurance status (but Half Birth Month “Six-Month SelfAttestations” are not acceptable at the Birth Month “Annual/12-month recertification). Half Birth Month Self Attestation should be documented in the client’s primary record and updated in ARIES, even if there is no change (the date stamp in ARIES should reflect the most recent recertification date). If a client’s income, residency, or insurance status change at any time, documentation is required.
d. Recertification of HIV diagnosis after the Initial eligibility determination is not required.
e. If a waiver was granted for one of the required eligibility documents at the initial screening/annual/ 12-month recertification update, the Subrecipient must attempt to obtain the missing documentation from the client. If it is determined that documentation is not able to be obtained, the Subrecipient should use the “no changes” options for the Attestation.
f. Electronic acknowledgement of the Six-Month Self Attestation (Half Birth Month) is acceptable if it is clear and includes all the required data elements of the DSHS/TRG approved Self-Attestation form. It should be clearly noted that a client is attesting to changes/ no changes in income, residency, and insurance status.
12. Birth Month “(Annual) Twelve-Month Recertification”
a. The Subrecipient will determine the system used to track clients’ status and renew eligibility. While eligibility for services must be determined every six months for active clients, Subrecipients should be assessing changes in eligibility at the time of service. The Subrecipients’ policies and procedures must address how clients will be contacted regarding their Birth Month annual/ 12-month recertification (also called the annual update), and how to determine if changes in eligibility have occurred at the time of service. Consult the table below for guidance on the recertification process and required documentation.
b. Subrecipient must screen clients for program eligibility every six months (no later than the last day of the clients’ Birth Month for the annual 12-month recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation). At any point if a client does not complete their Annual 12-month recertification by the end of their Birth Month or 6-month Self-Attestation by the end of their Half Birth Month, a complete a full recertification to determine eligibility must be complete.
c. Half Birth Month “Six Month Self-attestations” are not acceptable at the Birth Month “12-month recertification”. d. Recertification of HIV diagnosis after the Initial eligibility determination is not required.
e. If a waiver was granted for one of the required eligibility documents at the initial screening/annual update, the Subrecipient must attempt to obtain the missing documentation from the client. If it is determined that documentation is not able to be obtained, the Subrecipient should obtain a new waiver.
f. Special Circumstance: Only if the client present one “1” month prior to their Birth Month (Annual Twelve- Month Recertification) to complete their ADAP application or due to scheduling of a medical visit; their rectification can be initiated. However, although the client presents early their eligibility window will not change.
13. Client’s Responsibility for Reporting Changes
a. A client should take immediate steps to report any changes in a timely manner that might affect their eligibility and ensure appropriate documentation is submitted and received by the service Subrecipient(s) within 30 days of the reported change.
b. Clients must also report any changes during the Birth Month “six (6) month attestation” of eligibility. Failure to provide the requested information will result in the client being ineligible for services until continued eligibility is determined.
14. Conflicting Eligibility Documentation
a. All documentation for eligibility must be consistent for the client that is being screened.
b. If the client presents documentation of eligibility that conflicts with previously or currently presented documentation (i.e. different name or address), the Subrecipient must resolve the conflict prior to considering the eligibility screening completed.
Initial Eligibility Determination
Birth Month (Annual Recertification)
Half Birth Month (6-months After Annual
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