ADAP 101 (continued)

1. ADAP 101(continued) Nancy Abraham-Budds, ADAP/CHIC Administrator Illinois State Department of Health & Neal Carnes, Program Manager of HIV Medical Services Indiana State Department of Health

2. Presentation Overview • Client eligibility screening and documentation (verifiable and official) • Public Law 109-415: Ryan White • State/Territory-specific eligibility criteria • Policy setting & standardization • Confidentiality • HIPAA • Federal Reports: ADAP Quarterly & RDR • The hokey-pokey

3. Presentation themes • "Democracy means simply the bludgeoning of the people by the people for the people." Oscar Wilde • “If Columbus had an advisory committee he would probably still be at the dock.”  Arthur Goldberg • “A civil servant is sometimes like a broken cannon - it won't work and you can't fire it.” George S. Patton

4. Client eligibility screening • Public Law 109-415: Ryan White Treatment Modernization Act of 2006 requires covered clients/enrollees/patients/PEOPLE to be: • Living with HIV/AIDS • Low income • A State/Territory resident • “Payer of last resort” • States/Territories may have unique eligibility criteria, e.g. IN requires enrollment in Care Coordination

5. Documentation (verifiable & official) • Documentation proves the fundee (YOU) validated the enrollee meets established criteria for enrollment and you remain compliant with the law and program policies • Two questions: is the document official and can it be verified? • Anyone can say they are HIV positive, make less than established poverty threshold, etc but can they prove it; what is the documents source and can you check it’s validity?

6. Documentation (verifiable & official) • Why is this important? • If you are audited, and yes HRSA has the right and the responsibility to ensure the guidelines set out in the law and the criteria specified in the grant are being adhered to, then you will need to supply supporting documentation to prove valid enrollment • Fairness is also at play. Why should one client be allowed to supply, say a handwritten note stating there are 4 people in their household thus allowing them a greater income threshold yet another client gets only 1 household member, thus a lower income threshold?

7. Documentation (verifiable & official) • So what is accepted, not accepted? • PL 109-415 does not specify what a State/Territory can or cannot accept as proof of the applicants eligibility – this is left to the State • In IN we consider “verifiable” and “official” as our guide – can we contact the issuing agency to prove what is being supplied AND when we say official – is it an agency with some regulatory oversight and thus lacks a greater degree of vested interest

8. Documentation (verifiable & official) • Any questions so far? • Next we’ll look at specific examples based upon PL 109-415 requirements as well as State/Territory specific criteria

9. HIV status documentation • What is accepted in your State/Territory? • Lab reports • Everybody, no matter their HIV status, has a CD4 count. Any number of factors can impact a CD4 count, e.g. too much sugar, recent cocaine use, a cold – anything requiring an immune response can deflate one’s count • Viral load – what about those who are positive and showing an undetectable viral load • Example: IN requires a medical provider’s signature on a Physician Certification form (part of our application) in addition to recent lab results as a means of diagnosis along with the provider’s contact information (so we can validate) • Example – “…but he had a HAART pill bottle with him”

10. Low Income Status documentation • Does any State/Territory generate a non-FPL-based criteria when determining income? • We are allowed to set our own threshold, e.g. 150, 200, 300, 500…% of FPL • Do you consider gross or adjusted income? • Household membership is a factor, yet the FPL guidelines do not define household – how does your program? • Assets: what State/Territories consider assets, such as bank accounts, home ownership…? And how do you document? • Example: IN sets threshold at 300%, we consider household membership but not assets

11. Example: IN Income/Household documentation (from our manual) • Copy of Workforce Development earnings statement dated within 3 months of the application date • Copy of the previous year’s federal or state income tax return, • Copy of the previous year’s W-2(s), • Copy of a pay stub dated within 3 months of the application date and showing year-to-date earnings (as well as the employer’s name and address), • Copy of Unemployment Insurance benefits notification letter and the most recent check stub (must be dated within 3 months of the application date), • Copy of current (within 3 months of the application date) Social Security benefits notification letter or check, • Statement, dated within 3 months of the application signature date, from the employer (on company letterhead) documenting annual gross employment income, must be signed and dated by a company representative with contact information, • Food stamps, annuities, pensions, 401(k), rental property, etc payments count as income; an official print out from the payer to the payee is required as proof. • How do these meet the verifiable/official guidelines? • These are also comprise what is accepted for recertification

12. Example: IN Residency documentation (from our manual) • Copy of a valid – not expired, suspended, revoked, etc – Indiana Driver’s License, State Identification (ID) card,or an official BMV Driver Record printout, • Copies of utility bills or a print out from the utility company for the 12 consecutive months (one from each month) prior to the application date, • Copies of cancelled rent checks/mortgage payments or a print out from the property management/mortgage company for the 12 consecutive months (one from each month) prior to the application date, • Copy of Indiana Full Year Resident Income Tax return from the most recent tax year, • Postmarked medical bills or mail documenting 12 consecutive months of Indiana residency (one from each month), or • Notarized letter from HIV Care Coordinator attesting to 365 days of continuous Indiana residency and citing chronic homelessness. • Note on notary public: an officer who can administer oaths and statutory declarations, witness and authenticate documents, and perform certain other acts depending on the jurisdiction – check with your State/Territory to verify a notary public’s capacity when determining if you will or will not accept a notarized letter. • These also compromise what is accepted for recertification

13. Example: IN “Payer of last resort” documentation • IN requires all applicants to apply for Medicaid prior to their Ryan White Part B application – we do not wait for their denial, yet accept a Medicaid Application Verification form (unique to IN) to be signed and dated by a Medicaid Rep and submitted w/ their app • Our database interchanges w/ Medicaid’s and we are notified when one of our enrollees is Medicaid enrolled/eligible • We also require all applicants offered a private/employer-based insurance program to select this coverage as their primary. In cases where the policy is substandard we offer “wrap around coverage” • We also reserve the right to request the applicant/enrollee have a unique form be signed by an employer representative stating the client is not eligible for healthcare coverage – this can be verified and we do • All Medicare Part A and B eligible enrollees must elect this coverage – if they are not eligible for Part D we offer “wrap around” to pick up their pharmaceutical coverage – Medicare card must be submitted with app/recertification paperwork • We also require a private insurance rejection letter for applicants based on our high-risk insurance pool’s policy

14. Example: Care Coordination (CC) enrollment • Indiana HIV Medical Services requires all enrollees be enrolled in a State-sanctioned CC site – what unique criteria does your State/Territory apply? • IN documents CC enrollment via the application and recertification process – these documents must come from one of our funded sites, signed and dated by the client’s Care Coordinator

15. Criteria v policies • Many States/Territories adjust/set policies on-going; keep in mind that your location has submitted a grant application specifying the criteria you are considering for eligibility. If you want to make a change/adjustment you need to report them to HRSA and get approval prior to the adjustment • Consider: how do you plan to document this clarification/new policy? • If you are clarifying a policy it should relate to one of your established criteria…

16. Example: IN’s Incarceration Policy • On August 30, 2007 IN issued a policy clarification regarding enrollee’s who find themselves incarcerated during enrollment. The new policy stipulates those in a State or Federal facility are no longer eligible due to State and Federal law granting them access to healthcare coverage, re: “Payer of last resort.” Those in county facilities remain eligible for 90 days (a premium cycle) given they have someone who can get them meds

17. Standardization • What are standards? • How does your program standardize its criteria/policies? • Manual/program guidelines… • Why is it important to set standards? • Is it legal/fair to grant one set of standards to one person/group over another? • Allowance for exceptions? What is the basis? How do you document these exceptions? …

18. Confidentiality • PL 109-415, Sec. 304. states, “…the entity (meaning the State/Territory or other funded agency) agrees to ensure that information regarding the receipt of early intervention services pursuant to the grant is maintained confidentiality in a manner not inconsistent with applicable law.” It goes on to state, “…in testing an individual for HIV/AIDS, the applicant (your agency) will test an individual only after the individual confirms that the decision of the individual with respect to undergoing such testing is voluntarily made.”

19. Confidentiality • Upon application and recertification the client signs, dates and receives a copy of IN’s Certification of Understanding, which states, “I understand that my records are protected under the state law (16-41-8-1) relating to confidentiality of medical or epidemiological information involving a communicable disease (410 IAC 1-2.1) and/or under the federal regulations governing confidentiality of alcohol and drug use Patient Records, 42 CFR Part 2, and cannot be disclosed to any other entity except those referenced herein without my written consent.”

20. Confidentiality • Know your enrollees and your agencies' rights and responsibilities in light of what is law (State/Territorial & Federal) as well as any internal policies • Furthermore, we have an ethical (some would even say moral) responsibility to protect our enrollees identity/information

21. HIPAA • For those of us who are insurance-based or operate some portion of our program paying insurance-related costs, HIPAA is in play • HIPAA is not a CONFIDENTIALITY law, it is an insurance portability law with confidentiality clauses of which HIPAA-covered programs must verify enrollee identity or requesting parties capacity prior to disclosing personal health information (PHI) • When PHI can be disclosed: payment, treatment and/or program operations

22. Back to Nancy • Decision Tree • Pricing • I’ll be back in after these important topics to cover federal reports

23. Federal Reports • There are two primary federal reports: the ADAP Quarterly Report & the Ryan White HIV/AIDS Program Data Report (RDR, formerly the CADR) • ADAP Quarterly is due: • July 31 (April-June 30) • October 31 (July 1-September 30 • January 31 (October 1-December 31) • April 30 (January 1-March 31) • RDR is due March 24 by 6 pm EST

24. ADAP Quarter Report (AQR) • Required of all Part B funded grantees • Cover page (auto populated) • Section 1: Quarterly Submission, made up of: • Aggregated client, criteria, program limitation, funding, expenditure and ARV/OI/Hep B & C utilization data • Section 2: Annual Submission (due on the July 31st submission) made up of: • ADAP funding & formulary, eligibility requirement and cost savings aggregate data

25. ADAP Quarter Report (AQR) • Primary changes in the 2008 version: • Hispanic/Latino ADAP clients reported distinctly • Regimen differentiation (1-2, 3-4, more than 4) • Set formulary of medications reporting on and reporting on previous quarter not two quarters prior • Cost-savings per client accounting for rebates, etc

26. Ryan White HIV/AIDS Program Data Report (RDR) • Required of all Part A, B, C and D grantees • Reporting on previous calendar year data • Section 1: Grantee information – contact, functionality & funding • Section 2: aggregate clients served data • Section 3: core & support service data • Section 4: counseling & testing data • Section 5: outpatient/ambulatory medical provider data • Section 6: Part C & D (only) data • Section 7: health insurance programs data

27. Ryan White HIV/AIDS Program Data Report (RDR) • Primary changes in the works: CLIENT LEVEL DATA OVER AGGREGATE (Lord, God, Buddha, Isis, the Spirits, Mom… Help Us ALL!)

28. Statewide Coordinated Statement of Need &Comprehensive Plan • Statewide Statement is due Jan 5, 2009 • Combined statement of need – coordination of services across all Parts – regarding all Part grantees within your State/Territory • Another way to look at this is the barriers • Comp Plan is due Feb 1, 2009 • (basically the same thing as the Statement but in a unique document) • What you’re going to do about the barriers

29. Contact Information Neal Carnes Program Manager, HIV Medical Services Indiana State Department of Health 2 N Meridian St, 6-C Indianapolis, IN 46204 317-233-7450 (Direct) ncarnes@isdh.in.gov 37, 5’8”, 165 lbs of pure muscle, brown hair, blue eyes, great sense of humor, fabulous family, love kids (from a distance) and looking

30. Thank you And now for the hokey pokey