Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals

Service Standard

Health Insurance Premium and Cost Sharing Assistance for
Low-Income Individuals Service Standards print version

All health insurance payments should be reported in ARIES under the CARE/HIPP or SS/HIPP Programs. See Section 4 Health Insurance Programs (HIP).

Health Resources & Services Administration (HRSA) Description:

Health Insurance Premium and Cost Sharing Assistance (Health Insurance Assistance or HIA) provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. For purposes of this service category, health insurance also includes standalone dental insurance. The service provision consists of the following:

Paying health insurance premiums to provide comprehensive HIV Outpatient/Ambulatory Health Services (OAHS), and pharmacy benefits that provide a full range of HIV medications for eligible clients; and/or
Paying standalone dental insurance premiums to provide comprehensive oral health care services for eligible clients; and/or
Paying cost sharing on behalf of the client.

To use HRSA Ryan White HIV/AIDS Program (RWHAP) funds for health insurance premium and cost sharing assistance (not standalone dental insurance assistance), a HRSA RWHAP Part recipient must implement a methodology that incorporates the following requirements:

Clients obtain health care coverage that at a minimum, includes at least one U.S. Food and Drug Administration (FDA) approved medicine in each drug class of core antiretroviral medicines outlined in the U.S. Department of Health and Human Services’ Clinical Guidelines for the Treatment of HIV, as well as appropriate HIV Outpatient/Ambulatory Health Services; and
The cost of paying for the health care coverage (including all other sources of premium and cost sharing assistance) is cost-effective in the aggregate versus paying for the full cost for medications and other appropriate HIV OAHS.

To use HRSA RWHAP funds for standalone dental insurance premium assistance, a HRSA RWHAP Part recipient must implement a methodology that incorporates the following requirement:

HRSA RWHAP Part recipients must assess and compare the aggregate cost of paying for the standalone dental insurance option versus paying for the full cost of HIV oral health care services to ensure that purchasing standalone dental insurance is cost effective in the aggregate and allocate funding to HIA only when determined to be cost effective.

Program Guidance:

Traditionally, RWHAP Parts funding support health insurance premiums and cost sharing assistance. The following DSHS policies/standards and HRSA Policy Clarification Notices (PCNs) provide additional clarification for allowable uses of this service category:

DSHS Policy 260.002 (Revised 11/2/2015): Health Insurance Assistance
DSHS HIV/STD Ryan White Part B Program Universal Standards: Health Insurance Premium and Cost Sharing Assistance
PCN 07-05: Program Part B ADAP Funds to Purchase Health Insurance;
PCN 13-05: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Private Health Insurance;
PCN 13-06: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Medicaid;
PCN 14-01 (Revised 4/3/2015): Clarifications Regarding the Ryan White HIV/AIDS Program and Reconciliation of Premium Tax Credits under the Affordable Care Act;
PCN 16-02: Eligible Individuals & Allowable Uses of Funds and FAQ for Standalone Dental Insurance.

Language assistance must be provided to individuals who have limited English proficiency and/or other communication needs at no cost to them in order to facilitate timely access to all health care and services.

Subrecipients must provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services.

All AAs and subrecipients must establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.

Limitations:

HIA cannot be in the form of direct cash payments to clients.

HIA excludes plans that do not cover HIV-treatment drugs; specifically, the plan must cover at least one drug in each class of core antiretroviral therapeutics from the HHS clinical guidelines as well as appropriate primary care services.

Any cost associated with liability risk pools cannot be funded by RWHAP.

RWHAP funds cannot be used to cover costs associated with Social Security.

HIA funds may not be used to pay fines or tax obligations incurred by clients for not maintaining health insurance coverage required by the Affordable Care Act (ACA).

HIA funds may not be used to make out-of-pocket payments for inpatient hospitalization and emergency department care.

HIA funds may not be used to support plans that offer only catastrophic coverage or supplemental insurance that assists only with hospitalization.

HIA must not be extended for Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage if a client is eligible for other coverage that provides the required minimal level of coverage at a cost-effective price.

Services:

The provision of financial assistance for eligible individuals living with HIV to maintain a continuity of health insurance or to receive medical benefits under a health insurance program. This includes out-of-pocket costs such as premium payments, co-payments, coinsurance, and deductibles. Please refer to Texas Department of State Health Services (DSHS) Policy 260.002 (Health Insurance Assistance) for further clarification and guidance.

The cost of insurance plans must be lower than the cost of providing health services through grant-supported direct delivery (be “cost-effective”), including costs for participation in the Texas AIDS Drug Assistance Program (ADAP). Please refer to Texas Department of State Health Services (DSHS) Policy 270.001 (Calculation of Estimated Expenditures on Covered Clinical Services) for further clarification and guidance. Additionally, an annual cost-effective analysis can be located as an attachment to the aforementioned policy.

HIA may be extended for job or employer-related health insurance coverage and plans on the individual and group market, including plans available through the federal Health Insurance Marketplace (Marketplace). HIA funds may also be used towards premiums and out-of-pocket payments on Medicare plans and supplemental insurance policies if the primary purpose of the supplemental policy is to assist with HIV-related outpatient care.

Funds may be used for:

Purchasing health insurance (both job or employer-related plans and plans on the individual and group market) that provides comprehensive primary care and pharmacy benefits for clients that provide a full range of HIV medications;
Standalone dental insurance premiums when cost effective and/or cost sharing assistance when provided in compliance with requirements described in HRSA Policy Clarification Notice (PCN) 16-02, including the FAQ;
Paying co-pays (including co-pays for prescription eyewear for conditions related to HIV), deductibles, and co-insurance for medical and dental plans on behalf of the client;
Providing funds to contribute to a client’s Medicare Part D true out-of-pocket (TrOOP) costs; and/or
Certain tax liabilities.

Telehealth and Telemedicine is an alternative modality to provide most Ryan White Part B and State Services funded services. For the Ryan White Part B/SS funded providers and Administrative Agencies, telehealth and telemedicine services are to be provided in real-time via audio and video communication technology which can include videoconferencing software.

DSHS HIV Care Services requires that for Ryan White Part B or SS funded services providers must use features to protect ePHI transmission between client and providers. RW Providers must use a telehealth vendor that provides assurances to protect ePHI that includes the vendor signing a business associate agreement (BAA). Ryan White Providers using telehealth must also follow DSHS HIV Care Services guidelines for telehealth and telemedicine outlined in DSHS Telemedicine Guidance.

Service Standard and Measure

The following Standards and Measures are guides to improving healthcare outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard	Measure
Health Insurance Plans: The agency must ensure that clients are buying health coverage that, at a minimum, includes at least one drug in each class of core anti- retro viral treatment (ART) from the HHS treatment guidelines along with Outpatient/ Ambulatory Health Services (OAHS) and Oral Health Care that meet the requirements of the ACA law for essential health benefits. This must be documented in the client’s primary record.	Percentage of clients with documented evidence of health care coverage that includes at least one drug in each class of core ART from HHS treatment guidelines along with OAHS and Oral Health Care services that meet the requirements of the ACA law for essential health benefits as indicated in the client’s primary record.
Co-payments, Premiums, Deductibles, and Co-insurance: Otherwise, eligible clients with job or employer-based insurance coverage, Qualified Health Plans (QHP), or Medicaid plans, can be provided assistance to offset any cost-sharing programs may impose. Clients must be educated on the cost and their responsibilities to maintaining medical adherence. Education must be provided to clients specific to what is reasonably expected to be paid for by an eligible plan and what RWHAP can assist with to ensure healthcare coverage is maintained. Agencies will ensure payments are made directly to the health or dental insurance vendor within five (5) business days of approved request.	Percentage of clients with documented evidence of education provided regarding reasonable expectations of assistance available through RWHAP Health Insurance to assist with healthcare coverage as indicated in the client’s primary record. Percentage of clients with documented evidence of insurance payments made to the vendor within five (5) business days of the approved request.
Cost Sharing Education: Education is provided to clients, as applicable, regarding cost-sharing reductions to lower their out-of-pocket expenses. It must be evidenced in the client’s primary record that the individual must receive a premium tax credit and enroll in a silver level plan offered in the Marketplace. Clients who are not eligible for cost-sharing reductions (those under 100% FPL in Texas; those with incomes above 400% FPL; clients who have minimum essential coverage other than individual market coverage and choose to purchase in the marketplace; and those who are ineligible to purchase insurance through the marketplace) are provided education on cost-effective resources available for the client’s health care needs.	Percentage of clients with documented evidence of education provided regarding cost sharing reductions as applicable, as indicated in the client’s primary record.
Premium Tax Credits Education: Agencies have documented evidence in the client’s primary record of the enrollment in a QHP in the Marketplace, as applicable to the individual (clients that are between 100-400% FPL without access to minimum essential coverage). Education provided to the client regarding tax credits and the requirement to file income tax returns must be documented in the client’s primary record. Clients must be provided education on the importance of reconciling any Advanced Premium Tax Credit (APTC) well before the IRS tax filing deadline.	Percentage of clients with documented evidence of education provided regarding premium tax credits as indicated in the client’s primary record.
Prescription Eyewear: Agency must keep documentation from physician stating that the eye condition is related to the client’s HIV when HIA funds are used to cover co-pays for prescription eyewear.	Percentage of client files with documented evidence, as applicable, of prescribing physician’s order relating eye condition warranting prescription eyewear is medically related to the client’s HIV as indicated in the client’s primary record.
Medical Visits: Clients accessing health insurance premium and cost sharing assistance services are adherent with their HIV medical or dental care and have documented evidence of attendance of HIV medical or dental appointments in the client’s primary record. *Note:* For clients who use HIA to enable their use of medical or dental care outside of the RW system: HIA providers are required to maintain documentation of client’s adherence to Primary Medical Care (e.g., proof of MD visits) during the previous 12 months.	For clients with applicable data in ARIES or other data system used at the provider location, percentage of clients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. (HRSA HAB Measure)* OR For clients who use HIA to enable their use of medical care outside of the RWHAP system: Percentage of clients with documentation of client’s adherence to Primary Medical Care (e.g. proof of MD visits, insurance Explanation of Benefits, MD bill/invoice) during the previous 12 months. * For clients who use HIA for OAHS at RWHAP-funded providers and therefore have visit and lab data in ARIES or other data system.
Viral Suppression: Clients receiving Health Insurance Premium and Cost- Sharing Assistance services have evidence of viral suppression as documented in viral load testing.	For clients with applicable data in ARIES or other data system used at the provider location, percentage of clients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year. *(HRSA HAB Measure)*