Policy
Notice 07-01
Dear
Colleague:
Improving
access and care for American Indians (AIs)
and Alaska Natives (ANs) affected by HIV
disease remains important to the overall
objective of Title XXVI of the Public
Health Service Act as amended by the Ryan
White HIV/AIDS Treatment Modernization
Act of 2006 (Ryan White Program). The
following new language in the act highlights
the importance of providing access to
services for AI/AN:
To
incorporate the new language, we are revising
Policy Notice 00-01 and issuing Policy
Notice 07-01, The Use of Ryan White Program Funds for American Indians and Alaska Natives
and Indian Health Service Programs,
to further encourage and enhance health
care access and services for AIs and ANs
affected by HIV disease. A companion Question
and Answer guide is also attached to clarify
commonly asked questions raised by organizations
and AIs/ANs wanting to access the services
offered through the Ryan White Program.
Please
ensure that this policy is communicated
and distributed to all grantees and potential
providers of HIV related services for
AIs/ANs affected by HIV disease. If you
have further questions about this correspondence
or related policies, please visit the
Health Resources and Services Administration,
HIV/AIDS Bureau (HAB) website at or contact
your HAB project officer.
Sincerely,
Deborah
Parham Hopson, Ph.D., R.N.
Assistant
Surgeon General
Associate
Administrator
Policy
Notice 07-01: The Use of Ryan White Program
Funds for American Indians and Alaska Natives and Indian Health Service Programs
The
following policy establishes guidelines
for allowable expenditures under Title
XXVI of the Public Health Service Act
as amended by the Ryan White HIV/AIDS
Treatment Modernization Act of 2006 (Ryan
White Program): 1) to provide services
to American Indians and Alaska Natives
(AIs/ANs) and 2) for health care services
provided by the Indian Health Service
(IHS) programs directly or under contract
or compact. The purpose of all Ryan White
Program funds is to ensure that eligible
HIV-infected persons and families gain
or maintain access to medical care.
AIs/ANs
can claim Ryan White Program services
for which they are eligible where they
choose, regardless of the availability
of services that may also be available
to them (e.g., through IHS, tribal, or
urban Indian health programs and services).
This policy ensures that AIs/ANs have
direct and unfettered access to Ryan White
Programs. In addition, this policy clarifies
the circumstances under which the IHS
may and may not receive funds under the
Ryan White Program.
I.
Coverage of American Indians and Alaska
Natives under the Ryan White Program Who
are Eligible for Services Provided by
or Supported by the Indian Health Service
A.
Any AI or AN who is otherwise eligible
to receive Ryan White Program -funded
services from any Part may request and
must receive those services regardless
of whether or not they are also eligible
to receive the same services from the
IHS, and regardless of whether or not
those IHS services are available and accessible
to the AI or AN. A Ryan White program
grantee or provider cannot deny services
based on AI/AN status. However, individuals
must meet the same established eligibility
criteria as all other individuals receiving
care through a Ryan White Program funded
grantee or provider.
B.
AIs/ANs may seek care at a Ryan White
Program funded facility without referral
or a purchase order from the "IHS
operated" or "638 contract”
or compact facility. The Ryan White Program
funded facility or provider should follow
established procedures to determine health
care coverage as it usually does as the
payer of last resort program programs
administered by or providing services
of the IHS are exempt from the payer of
last resort restriction for Parts A, B,
and C. The IHS is not obligated to reimburse
a Ryan White Program grantee or provider
for services provided to an AI or AN who
requests services without a purchase order
referral from the IHS. However, the grantee
or provider must seek payment from other
payers (e.g. Medicaid) first.
II.
Eligibility of Indian Health Service or
Tribally Operated Facilities to Receive
Ryan White Program Funds
A.
"IHS-operated" facilities:
-
Are
not eligible to receive direct funds
under Part A or B of the Ryan White
Program but may apply and be awarded
funds under Parts C or D as a direct
grantee.
- Are
eligible to receive funds as sub-contractors
under Parts A, B, C, and D, as long as
the IHS-operated facility can demonstrate
that the provision of Ryan White Program
services to Ryan White Program eligible
individuals supplements and does not supplant
IHS-funded programs, and the IHS-operated
facility adheres to the requirements of
the grantee or provider from which the
sub-contract is awarded.
B.
"638 contract" facilities:
-
Parts
A and B: "638 contract" facilities
are not eligible to receive grant funds
as a direct grantee under Part A or
B of the Ryan White Program. However,
"638 contract" facilities are
eligible to receive funds as a subcontractor
under Parts A or B of the Ryan White
Program if they meet the statutory criteria
as appropriate entities. Financial assistance
(as a subcontractor) may be made "to
public or nonprofit private entities
or private for-profit entities if such
entities are the only available provider
of quality HIV care in the area ...”
(Section 2604(b)(2) of Title XXVI of
the Public Health Service Act).
- In
addition, if the tribe has (or receives)
nonprofit status, it is eligible as a
nonprofit private entity. A tribe is required
to produce a copy of its "638 contract"
with the IHS/DHHS to establish its status
as owner and operator of the facility.
In addition, a tribe claiming non-profit
status is required to produce a letter
from the appropriate Federal, State, or
local entity as proof of such status.
- Part
D: "638 contract" facilities are
eligible to receive direct and subcontractor
grant funds under Part D of the Ryan White
Program if they meet the criteria in Section
2671(a) of Title XXVI of the Public Health
Service Act as “public and nonprofit
private entities (including a health facility
operated by or pursuant to a contract
with the Indian Health Service) for the
purpose of providing family-centered care
involving outpatient or ambulatory care
(directly or through contracts) for women,
infants, children, an youth with HIV/AIDS.
- The
"638 contract" facilities and
services must meet established eligibility
criteria of the Ryan White Program. Thus,
for Ryan White Program services provided
to eligible individuals who present for
services, a "638 contract" facility
must serve those individuals without regard
to their status as non-AI or non-AN.
C.
Urban Indian Health Programs Designated
by the IHS:
-
Urban
Indian health programs designated by
the IHS are not eligible to receive
direct funds under Parts A and B.
- Urban
Indian health programs designated by the
IHS are eligible to receive direct funds
under Parts C and D. However, the Urban
Indian health programs must meet established
eligibility criteria of the Ryan White
Program. Thus, for Ryan White Program
services provided to eligible individuals
who present for services, an Urban Indian
health program must serve those individuals
without regard to their status as non-AI
or non-AN.
- Urban
Indian health programs designated by the
IHS are eligible to receive sub-contract
funds under Parts A, B, C, and D as long
as they meet the established Ryan White
Program criteria for those Parts, and
if they meet the statutory criteria as
appropriate entities. Financial assistance
(as a subcontractor) may be made "to
public or nonprofit private entities or
private for-profit entities if such entities
are the only available provider of quality
HIV care in the area ...” (Section
2604(b) (2) of Title XXVI of the Public
Health Service Act).
-
The
Urban Indian health programs must meet
established eligibility criteria of
the Ryan White Program. Thus, for Ryan
White Program services provided to eligible
individuals who present for services,
an urban Indian health program must
serve those individuals without regard
to their status as non-AI or non-AN.
With
the exception of programs administered
by or providing services of the IHS
under Parts A, B, and C, the Ryan White
Program must be the payer of last resort.
Grantees must be capable of providing
the 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.).
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.
|
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.
|
|