Ryan White

Ryan White Program and Services for American Indians and Alaskan Natives 

Questions and Answers for Policy Notice 07-01 

• Are Federally-recognized American Indians (AI) and Alaskan Natives (AN) eligible to receive services funded under the Ryan White Program?

Yes. AIs/ANs can claim Ryan White Program services for which they are eligible where they choose, regardless of the availability of other services that may also be available to them (e.g., through Indian Health Service (IHS), tribal, or urban Indian health programs and services).

• What are the eligibility criteria?

Persons infected with the Human Immunodeficiency Virus (HIV) and those who have clinically defined Acquired Immune Deficiency Syndrome (AIDS) are eligible. Some States/Territories may require additional financial, residential, and medical criteria to establish eligibility. Non-infected individuals, in limited situations, may be eligible for services but only if these services have at least an indirect benefit to a person with HIV infection.

• Are AIs/ANs eligible for the AIDS Drug Assistance Program (ADAP) under Part B?

Yes. ADAP provides funding for medications for the treatment of HIV disease. Each State and territory establishes its own eligibility criteria. All require that individuals document their HIV status and meet established income eligibility criteria. ADAPs operate under either a pharmacy reimbursement model similar to Medicaid or may directly purchase and distribute drugs for and to enrollees. Clients can enroll in ADAP in one of two ways depending on the state of enrollment; either by applying directly through state ADAP offices or submitting applications through their case manager, physician, nurse, or other service provider.

• If Ryan White Program services are utilized by AIs/ANs, will services accessed through IHS and other providers be limited/restricted?

There are no restrictions that prohibit clients from tailoring their health care program utilizing various providers and services for which they are eligible to meet their individual health care needs.

• Will providing Ryan White Program services to eligible populations infringe upon existing resources meant for AIs/ANs?

Ryan White Program services cannot be denied to clients who are not AIs/ANs. By IHS law, IHS and tribal facilities who receive Ryan White Program funds, however, are not required to provide individuals whom are not AI/AN access to existing resources that are meant for AIs/ANs. As the Ryan White Program and IHS eligibility for services are separate health care programs, clients presenting for care are eligible for care/services as prescribed by each individual programs’ existing eligibility rules. Those clients, who are not AI/AN, who receive services not covered by the Ryan White program from IHS-operated, 638 contract, or Urban Indian Health Programs should follow the facilities’ established procedures for determining health care coverage and payment for these services.

• Can the Ryan White Program be used to provide additional services at facilities that already provide HIV related services?

Ryan White Program services must not supplant (replace a service already offered and available) other funded services but may be used to supplement services which are unavailable for clients who require the service.

• If an AI/AN receives Ryan White Program-funded services from a non-IHS provider, must they obtain a referral or purchase order from IHS or a 638 contract facility to cover the costs of services provided by the non-IHS provider or grantee?

No. The IHS is not obligated to reimburse a Ryan White Program grantee or provider for services provided to an AI or AN who requests those services. IHS services are a separate entitlement from Ryan White Program services. IHS facilities are also exempt from the “Payer of Last Resort” restriction for Parts A, B, and C.

• Who covers the cost of the services received at a Ryan White Program-funded service provider?

Ryan White Program funds cover the cost of the care. With the exception of programs administered by or providing services of the IHS under Parts A, B, and C, - who are exempt from payer of last resort restrictions - if a patient is eligible or has other health service coverage, e.g., Medicaid, the grantee or provider must seek payment from that payer first and should follow established procedures to determine health care coverage as it usually does under the payer of last resort program.

• What services are eligible for payment under the Ryan White Program?

The Ryan White Program can cover the cost of an array of HIV/AIDS health and related supportive services. Health services can include primary health care, including the ADAP, early intervention services, and dental services. In addition, the Ryan White Program covers critical health related support services needed for individuals with HIV/AIDS to achieve their medical outcomes. Support services might include respite care for persons caring for individuals with HIV/AIDS, outreach services, medical transportation, linguistic services, and referrals for health care and support services.

Payment for these services must be sought from all other sources, Medicaid, private insurance, and other third party reimbursement plans, prior to grantees seeking reimbursement from the Ryan White Program. With the exception of programs administered by or providing services of the IHS under Parts A, B, and C, - who are exempt from payer of last resort restrictions - Ryan White Program funding is the payer of last resort. Grantees must be capable of providing the HIV/AIDS Bureau (HAB) with documentation related to the use of funds as payer of last resort and the coordination of such funds with the tribes and with the IHS as applicable and other sources of payment (e.g., Medicaid, Medicare, Department of Veterans Affairs, State funded programs, etc.).

• How do IHS operated facilities, 638 contract facilities, and Urban Indian Health Programs differ in eligibility to receive Ryan White Program funds?

Ryan White Program	IHS Operated Facilities	638 Contract Facilities & Urban Indian Health Programs
Parts A & B	May only receive funds as a subcontractor	May only receive funds as a subcontractor
Parts C & D	May receive funds as a direct grantee or subcontractor	May receive funds as a direct grantee or subcontractor

• What is a 638 contract facility?

A 638 facility is operated by a tribal organization that is recognized by the Federal government, under a funding agreement with IHS

• How should a IHS operated facility, 638 contract facility, or Urban Indian Health program apply to become a Ryan White Program grantee?

Facilities, Tribes, and Urban Indian Health programs interested in applying as a direct grantee should periodically check http://www.grants.gov/ as all program guidances are released and applicants must apply electronically via this site.  Interested programs should also review the necessary steps on http://www.grants.gov/ to apply for grants and use the information provided to prepare themselves as a competitive applicant.

• What types of facilities and/or organizations can subcontract from a grantee to provide HIV related services?

Subcontractors can include hospitals (including Department of Veterans Affairs' facilities), community-based organizations, hospices, ambulatory care facilities, community health centers, migrant health centers, rural health centers, homeless health centers, substance abuse treatment programs, faith based organizations, and mental health programs that can provide HIV related services. Private for-profit entities may provide services as a subcontractor if they are the only available provider of quality HIV care in the specified area.

Facilities and/or organizations interested in providing services as a subcontractor, should directly contact Ryan White Grantees. For a list of current grantees under Parts A, B, C, and D, see the grantee lists at http://hab.hrsa.gov/programs.htm

	Ryan White Program Components
Part A	Eligible Metropolitan Areas (EMAs) with the largest numbers of reported cases of HIV/AIDS and Transitional Grant Areas (TGAs), to meet emergency service needs of people living with HIV disease.
Part B	All states, the District of Columbia, and eligible U.S. Territories (Guam, Puerto Rico, and the Virgin Islands) to improve the quality, availability, and organization of health care and support services for individuals living with HIV disease and their families (Part B includes funding for the ADAP program).
Part C	Public and private nonprofit entities to support outpatient early intervention HIV services for people living with HIV disease (PLWH).
Part D	Public and private nonprofit entities for the purpose of providing family-centered care involving outpatient or ambulatory care for women, infants, children, and youth with HIV/AIDS.
Part F	Special Projects of National Significance (SPNS) supports the development of innovative models of HIV/AIDS care to quickly respond to emerging needs of persons receiving assistance from the Ryan White Program, SPNS models are designed to be replicable and have a strong evaluation component; AIDS Education and Training Centers (AETC) conduct education and training for providers; the HIV/AIDS Dental Reimbursement Program assists accredited dental schools and post-doctoral programs with uncompensated costs incurred in providing oral health treatment to PLWH; Minority AIDS Initiative (MAI) to evaluate and address the disproportionate impact of HIV/AIDS on racial and ethnic minorities under Parts A, B, C, D and the AETCs under Part F; and, the Community Dental Program links Dental School programs and community dental providers to grants which fund dental services for PLWH.

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Links

Find a Ryan White Care Act Title I and Title II grantee
Click a state or territory below for a state Ryan White CARE Act profile and links to those grantee Web sites.

Ryan White Target Center
A technical assistance (TA) resource for Ryan White CARE Act grantees and HAB staff. Provides sources of TA, a TA helpdesk and links to links to Title I and Title II grantee Web sites.

Ryan White Program Fact Sheet (PDF - 179KB)
A technical assistance (TA) resource for Ryan White CARE Act grantees and HAB staff. Provides sources of TA, a TA helpdesk and links to links to Title I and Title II grantee Web sites.

Ryan White AIDS Drug Assistance Program (ADAP) Fact Sheet (PDF - 980KB)
A technical assistance (TA) resource for Ryan White CARE Act grantees and HAB staff. Provides sources of TA, a TA helpdesk and links to links to Title I and Title II grantee Web sites.

The Ryan White CARE Act (RWCA) was reauthorized (12/19/2006) as the “Ryan White HIV/AIDS Treatment Modernization Act of 2006 (RWMA)” (PDF - 2MB)
The language is particularly remarkable for the Indian Health Service (IHS) and AI/AN in that it establishes opportunity for more seamless access to HIV/AIDS care and treatment. Although the intent of previous RWCA language was to assist AI/AN in access and eligibility to treatment and care of HIV/AIDS, this specific and reauthorized language certainly aims and succeeds in clarifying that language. It is a privilege to note that this revised language is due in large part to the hard work, diligence, and passion of community members and organizations that came from within our AI/AN communities to advocate for these changes.

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The following RWCA provisions in the reauthorization affect the IHS and AI/AN population:

1. AI/AN individuals are/were always eligible for RWCA services if certain requirements were met (as any other person infected/affected by HIV/AIDS would need to meet various requirements – dependent upon the State of residence).
2. IHS federally operated Health Facilities will now be eligible to apply for services under Part C and Part D through the RWMA (in addition to previously authorized Urban Programs and 638 Tribal Facilities under RWCA). Thus, the changes of eligibility as a grantee for Titles III and IV affect our IHS sites, but did not affect the eligibility that was already offered to Urban and 638 facilities. Here are links to services provided under Part C and Part D: http://hab.hrsa.gov/programs/CapacityDevelopment/, http://hab.hrsa.gov/programs/PlanningGrant/, http://hab.hrsa.gov/programs/EarlyIntervention/, and http://hab.hrsa.gov/programs/women/. This, once again, enumerates eligibility, however funding for new programs will be through a competitive process.
3. IHS facilities are exempt from the “Payer of Last Resort” restriction for Parts A, B and CAlthough RWCA grantees are the payer of last resort, this amendment exempts I/T/U facilities from reimbursement, regardless of referral. In the past, RWCA grantees were asked to coordinate reimbursement of such funds with the tribes and with the IHS.
4. The new legislature supports access for all AI/AN under RWMA regardless of I/T/U utilization/affiliation or geographic location. (Previously, HRSA Policy 00-01 stated that AI/AN could not be turned away from RWCA services. RWCA grantees remain as Payers of Last Resort. If patients were referred from IHS, RWCA grantees could technically go back to IHS for funding (whether or not this actually happened). Now, the RWMA codifies (that IHS is exempt from the Payer of Last Resort restriction) this language into law.
5. Planning council representation under Part A should include members from federally recognized Indian tribes as represented in the population.
6. Language surrounding AIDS Education and Training Centers (AETCs) now specifically names “Native Americans” as person(s) to be trained. Previous language did not specify this; however we have been working with the AETC leads at HQ for quite some time and are continuing this activity by working on renewing a formal collaborative agreement.

We are working diligently with leadership from HRSA to discuss ramifications and implementation of this language and to disseminate the message of these changes to help with care of our AI/AN persons at risk and living with HIV/AIDS. Additionally, we hope to focus current and future initiatives and collaborations with HRSA around efficient models and linkages of care between our clients, I/T/U facilities, and Ryan White grantees, service providers, and services (i.e. RWCA Titles I, II (which includes the AIDS Drug Assistance Program), III, IV, etc.).

Although I/T/U sites are eligible for Titles III and IV, this does not mean I/T/U sites are automatically grantees; they must go through the application and approval process. For now, you may visit http://www.grants.gov/ for more information.

Given these new provisions, it is imperative that all AI/AN clients and facilities eligible for these provisions are made aware and assisted in removing any barriers to effective and seamless access and care. It may be advisable for each health facility to contact a RWMA grantee in your respective area/state to link this new language to an action plan and discuss potential linkages or improve existing ones.

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