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Core Services. Area 15 Ryan White Program. HRSA Core Services.
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Core Services Area 15 Ryan White Program
HRSA Core Services • Core Services are a set of essential, direct health care services provided to persons living with HIV/AIDS and specified in the Ryan White Treatment Extension Act of 2009. The following core services are funded in Area 15 to eligible clients: • Primary Outpatient Medical Care • AIDS Drug Assistance Program (ADAP) • AIDS pharmaceutical assistance (local) • Oral Health • Health Insurance • Medical Nutrition Therapy • Mental Health Services • Substance Abuse Services- Outpatient • Case Management- Medical
Electronic PODatabase • In order for any core service (with the exception of case management) to be paid for by Part B funds, all providers must create a service request for each service being provided using the Electronic PO Database. All clients must have a Notice of Eligibility prior to initiating any service. • This service request is then approved by the Medical Services Specialist (MSS) at Project Response, if the client is eligible. • After the service has been delivered, the provider completes the service request in the Electronic PO Databaseby entering the date of service and reimbursement amount in order to receive payment. Back up documentation is then sent in to the Lead Agency (SLCHD) for reimbursement.
Primary Outpatient and Specialty Medical Care/ Laboratory Testing • HRSA Definition: Outpatient/Ambulatory medical care (health services) is the provision of professional diagnostic and therapeutic services rendered by a physician, physician's assistant, clinical nurse specialist, or nurse practitioner in an outpatient setting. • Primary and specialty HIV/AIDS health care. • Services include laboratory tests (such as viral loads tests and CD4 counts), other diagnostic tests (imaging, pathology), and routine GYN tests for women. • For eligible clients with private health insurance or Medicare, assistance with deductibles and co-pays may be available.
Access to Primary/Specialty Medical Care and Laboratory Testing • For clients in need of outpatient medical through Part B funds, the client must access one of the following medical clinics: • AIDS Research and Treatment Center • Associates in Infectious Disease • Coastal Primary Care • Florida Community Health Centers • Treasure Coast Infectious Disease
ADAP • HRSA Definition: AIDS Drug Assistance Program (ADAP treatments) is a State-administered program authorized under Part B of the Ryan White Program that provides FDA-approved medications to low-income individuals with HIV disease who have limited or no coverage from private insurance, Medicaid, or Medicare.
Access to ADAP • ADAP is administered by the local health departments. In order to enroll in ADAP, the client must provide the following documentation: • Notice of Eligibility • CD4 and Viral Load Labs less than 6 months old • Valid prescription(s) for medication on the ADAP Formulary • Insurance Documentation, if applicable • Case managers can assist clients in enrolling in ADAP.
Pharmaceuticals • HRSA Definition: AIDS Pharmaceutical Assistance (local) includes local pharmacy assistance programs implemented by Part A or Part B Grantees to provide HIV/AIDS medications to clients. This assistance can be funded with Part A grant funds and/or Part B base award funds. • Local pharmacy assistance programs are not funded with ADAP earmark funding.
Access to Pharmacy Services • For clients in need of pharmacy assistance through Part B funds, the client must access the following pharmacies: • Jackson Drugs • The Lead Agency provides the pharmacies and physicians with a comprehensive formulary each contract year, or as changes occur, that has been approved by the CNTC and reviewed by qualified medical providers.
Oral Health • HRSA Definition: Oral health care includes diagnostic, preventive, and therapeutic services provided by general dental practitioners, dental specialists, dental hygienists and auxiliaries, and other trained primary care providers.
Oral Health Access • For clients in need of oral health care through Part B funds, the client must access one of the following dental clinics: • Dr. Salomon Israel (Oral Surgery & Maxillofacial Surgery) • Treasure Coast Community Health Center • Florida Community Health Center • St. Lucie County Health Department – Research Treatment Alliance • Indian River County Health Department • Clients are allowed two dental cleanings within one contract year. • In addition eligible clients can receive up to $1300 of pre approved services located on fee schedule on an annual basis • Funds for Dentures are available as needed.
Health Insurance • Health Insurance Premium & Cost Sharing Assistance is the provision of financial assistance for eligible individuals to maintain a continuity of health insurance or to receive medical benefits under a health insurance program. • This includes premium payments, co-payments (for medications and medical appointments), and deductibles.
Access to Health Insurance Assistance • For those clients who have health insurance and need assistance with co-pays or deductibles, the service provider will complete the same process with the service request but will submit the invoice to the primary insurer first. • After the initial insurer has agreed upon the payment amount, the service provider will update the service request with the remaining amount owed for that date of service.
Mental Health • HRSA Definition: Mental health services arepsychological and psychiatric treatment and counseling services offered to individuals with a diagnosed mental illness, conducted in a group or individual setting, and provided by a mental health professional licensed or authorized within the State to render such services. This typically includes psychiatrists, psychologists, and licensed clinical social workers.
Access to Mental Health Services • In order for a client to receive Mental Health Services through Part B funds, the client must have a referral from a medical provider. • The medical provider submits the referral to the Project Response Case Manager for processing. The Case Manager arranges the first appointment or intake appointment for client with the provider. • The mental health provider then initiates the service request process.
Medical Nutrition Therapy • HRSA Definition: Medical nutrition therapy is provided by a licensed registered dietitian outside of a primary care visit and includes the provision of nutritional supplements. Medical nutrition therapy provided by someone other than a licensed/registered dietitian should be recorded under psychosocial support services.
Access to Medical Nutrition Therapy • In order for a client to receive Medical Nutrition Therapy through Part B funds, the client must have a prescription from a medical provider or nutritionist. • The client must have a medical evaluation, a BMI score and a new prescription written every 3 months in order to continue with this service. • The prescription is delivered to Project Response, where the service request will be initiated.
Case Management- Medical • HRSA Definition: Medical Case management services (including treatment adherence) are a range of client-centered services that link clients with health care, psychosocial, and other services. The coordination and follow-up of medical treatments is a component of medical case management. • These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client’s and other key family members’ needs and personal support systems.
Case Management- Medical continued • Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments. Key activities include (1) initial assessment of service needs; (2) development of a comprehensive, individualized service plan; (3) coordination of services required to implement the plan; (4) client monitoring to assess the efficacy of the plan; and (5) periodic re-evaluation and adaptation of the plan as necessary over the life of the client. It includes client-specific advocacy and/or review of utilization of services. This includes all types of case management including face-to-face, phone contact, and any other forms of communication. • Please refer to the Case Management PowerPoint for information on how to access this service.
Substance Abuse Services- Outpatient • HRSA Definition: Substance abuse services-outpatient is the provision of medical or other treatment and/or counseling to address substance abuse problems (i.e., alcohol and/or legal and illegal drugs) in an outpatient setting, rendered by a physician or under the supervision of a physician, or by other qualified personnel.
Access to Substance Abuse Services • In order for a client to receive Substance Abuse Services through Part B funds, the client must have a referral for substance abuse services from a medical provider. • The medical provider submits the referral to the Project Response Case Manager for processing. The Case Manager arranges the first appointment or intake appointment for client with the provider. • The substance abuse provider then initiates the service request process.
Newly Diagnosed • When clients present to medical providers and are newly diagnosed, these clients either meet with a case manger provided by the medical provider on site, or are referred to Project Response. • If assistance is required by the client in order to access these core services, the client MUST obtain a Notice of Eligibility from Project Response before receiving services.
