260.002 Health Insurance Assistance

1.0 Purpose

This policy reviews eligibility requirements and allowable expenditures for Health Insurance Assistance (HIA) services supported with Texas Department of State Health Services (DSHS) funds and specifies the types of HIA policies and guidelines HIA-funded providers and Administrative Agencies (AAs) establish.

2.0 Scope of Policy

This policy provides guidance and requirements for the provision of HIA services to clients with health insurance plans. It does not address the specific eligibility requirements for public insurance programs, job-based coverage, or reduced-cost plans on the Health Insurance Marketplace. The factors that determine the best plan for a client and the final cost of the plan to a client are specific to each client and beyond the scope of this policy.

Clients should be referred to expert agencies, organizations, or navigators/individuals to assist them in choosing and enrolling in programs or health plans.

3.0 Background

The Ryan White HIV/AIDS Program (RWHAP) provides access to HIV-related outpatient and support services to low-income persons. HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort establishes the Ryan White Part B and State Services (SS) funds made available through DSHS as the payor of last resort. Sections 2605(a)(6), 2617(b)(7)(F), 2664(f)(1), and 2671(i) of the Public Health Service Act similarly require funds awarded through all Parts of the RWHAP awardees use as the payment of last resort.

Using grant funds, contracting providers directly provide access to HIV-related services, or clients receive financial support for health insurance coverage costs indirectly. HIA has been an RWHAP-eligible service from the initial authorization of the program. HIA-funded providers may also use RWHAP and SS funds to provide assistance to eligible clients in making payments associated with health insurance plans, including premiums, deductibles, copayments, or co-insurance payments as an alternative to making direct payment for health services. This policy refers to such payments as HIA payments.

4.0 Authority

Texas Health and Safety Code, Chapter, §85.003, §§85.014 - 85.031; Ryan White Treatment Extension Act 2009; Health Resources and Services Administration (HRSA) Policy Notices 13-01, 13-03, 13-04, 14-01, 16-02, 18.01, and 21-02.
 

5.0 Definitions

Administrative Agency (AA) – DSHS contracts with Administrative Agencies to disburse funds from DSHS through a subcontractor system to provide comprehensive services to HIV-positive individuals and those affected within the service planning area.

Copayment – A cost-sharing requirement for the insured to pay a specified dollar amount for each unit of service (e.g., $10 for each prescription dispensed).

Co-Insurance – A cost-sharing requirement for the insured to pay a percentage of costs for covered services and prescriptions (e.g., 10 percent of the prescription price).

Deductible – A cost-sharing requirement for the insured to pay a certain amount for health care or prescriptions before the insurance plans covers these costs.

Health Insurance Assistance (HIA) – Financial assistance provided to eligible people living with HIV to cover the costs associated with healthcare plans.

Job-Based or Employer-Based Insurance Coverage – A health insurance plan which includes individual employees or family members under one group policy provided by their employers.

Local Benchmark – The sum of the average AIDS Drug Assistance Program (ADAP) expenditure and the average local expenditure on covered clinical services is the total per client expenditure on directly delivered clinical services. AAs, DSHS, and HIA-funded providers use this in each HSDA as the comparison benchmark to judge the cost-effectiveness of HIA. Section policy 270.001, Calculation of Estimated Expenditures on Covered Clinical Services, describes the calculation of the benchmark.

Out-of-pocket (OOP) costs – Out-of-pocket costs are expenses for medical care not reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus costs for services not covered.

Qualifying Event – A change in status allowing an individual to change their insurance plan or enroll outside of open enrollment. For example, involuntary loss of insurance coverage, becoming or gaining a dependent, marriage or divorce, for persons between 100% and 150% of FPL, etc.

Premium – The amount paid by the insured to an insurance company to maintain an insurance policy.

Service Provider or Subcontractor – A local organization contracted by an Administrative Agency to provide services for Persons Living with HIV.

State Services (SS) – State general revenue funds provided for HIV-related services as a match requirement of the Ryan White HIV/AIDS Treatment Extension Act of 2009.

Supplemental Insurance – An insurance policy which covers expenses other insurance company may not cover. For example, a Medigap Policy helps pay for the “gaps” in coverage related to Medicare Part A and Part B. The individual may be responsible for the cost of services not covered by Medicare. Supplemental Insurance requires a payment of a premium.
 

6.0 Persons and Organizations Affected by this Policy

• DSHS HIV/STD Prevention and Care Unit Staff
• DSHS-funded AAs
• DSHS-funded HIA service providers

7.0 Responsibilities

7.1 DSHS

DSHS maintains HIA policy and provide technical assistance to AAs and monitor AA actions to ensure service providers comply with local HIA policies. DSHS collaborates with Part A Planning Councils, Part A AAs, and DSHS-funded AAs to clarify or modify the HIA policy as needed.

7.2 Service Providers

Service providers screen clients for potential third-party payers or other assistance programs, and appropriate referrals are made to the offices, organizations, or individuals who can assist clients in enrollment. Providers include the client's ability to contribute to this screening. Requirements for assessment of potential third-party payers and other assistance programs are available in HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort.

HIA providers obtain written approval from their AA before providing HIA for insurance coverage exceeding local benchmark service costs, providing payments for out-of-network charges, discontinuing HIA due to client conduct, or refusing HIA for a client who is eligible and for whom HIA provides a cost advantage over direct service delivery.

HIA-funded providers make HIA payments in a timely manner and make reasonable efforts to have coverage reinstated if client delays in assistance requests have caused coverage to lapse. Providers may maintain policies to discontinue HIA services for clients who habitually require such reinstatement assistance.

HIA-funded providers maintain communication with the client and with other relevant service agencies to ensure clients and other service agencies appropriately report information that would affect HIA. HIA-funded providers maintain communication with the AA regarding trends in the use of insurance monies to maximize best use of current funds.

7.3 Administrative Agencies (AA)

AAs develop the local policies and procedures required by this policy and other relevant DSHS policies and requirements, and ensure providers comply with these local policies and processes. AAs assure contractors use DSHS funds as payment of last resort. AAs provide requested adjudication for exceptional requests for assistance or denial of assistance from HIA service providers and on complaints from clients (subject to local procedures for resolving client complaints).

AAs or planning bodies for Part A EMAs develop reasonable and sufficient proposed annual allocations for HIA services, given the requirements of DSHS and HRSA policy for vigorous pursuit of cost-effective coverage.

8.0 Allowable Uses of HIA Funds

HIA-funded providers may make HIA payments for premiums, deductibles, copayments, or co-insurance payments. Providers and HIA-funded providers may also make payments for certain tax liabilities, as outlined below. DSHS-funded AAs maintain policies specifying the insurance-related costs HIA supports and specifying that HIA-funded providers inform clients of covered and non-covered costs.

HIA-funded providers may not use funds to pay fines or tax obligations incurred by clients not maintaining the health insurance coverage required by the ACA. HIA-funded providers may not use RWHAP funds and State Services funds to make OOP payments for inpatient hospitalization and emergency department care. HIA-funded providers may use HIA funds for payments for services delivered by providers outside a plan’s network of providers only after review by the AA (see Section 14). HIA-funded providers only make HIA payments for outpatient medical care. HIA-funded providers may never make payments to clients. HIA-funded providers makes premium payments directly to insurance companies and make OOP payments directly to the provider of services, such as a clinic, physician office, or pharmacy.

HIA-funded providers may only use HIA funds to pay a tax liability associated with the premium tax credit if AAs choose and if resources are available. AAs may permit the use of Ryan White Part B and State Services funds to pay the IRS additional tax liability a client may owe to the IRS solely based on the reconciliation of the premium tax credit. AAs take into consideration their decision to pay such additional tax liability for clients when determining how to operationalize a premium and cost-sharing assistance program. AAs and HIA service providers are responsible for establishing and maintaining policies and procedures for coordinating such payments to the IRS since HRSA and DSHS prohibit AAs and HIA service providers from making direct payments to clients. HIA providers make this payment to the IRS from funds available the year when the tax liability is due, even if HIA recipients incurred the premiums that generated the tax liability in a previous funding year.
 

9.0 Estimated Expenditure on Covered Clinical Services as Benchmark for Cost Comparison

To evaluate the cost effectiveness of health insurance coverage, DSHS coordinates with AAs and other Ryan White Part A, Part C, and Part D to benchmark local expenditures on clinical services typically covered by health insurance plans. Section policy 270.001, Calculation of Estimated Expenditures on Covered Clinical Services, describes the methods DSHS uses to estimate expenditures on covered clinical services. Policies on the use of DSHS funds for HIA reference this estimated cost in the development of eligibility guidelines and cost-control policies. DSHS-funded AAs and HIA-funded providers make the benchmark amounts publicly available to aid in decision making.

10.0 Allocations for HIA

Proposed Part B and State Services allocations process for HIA services must take into account the number of presently uninsured clients in the service area who are likely to qualify for low-cost health insurance plans based on client household income. DSHS confers with AAs and Part A Planning Councils to improve guidance on allocation based on estimates of true costs of health plans on the Marketplace, as areas gain more understanding of typical levels of expenditures associated with these plans.

11.0 Client Eligibility for HIA Services

Each DSHS-funded AA maintains policies specifying the criteria for client eligibility for HIA services. To be eligible for HIA services paid for by Part B or State Service funds, individuals must meet the general eligibility criteria described in HIV/STD Policy 220.001 – Eligibility to Receive HIV Services, as well as local eligibility requirements associated with residence, income, or other factors. Requirements for setting local eligibility criteria are available in HIV/STD Policy 220.001 – Eligibility to Receive HIV Services.

11.1 Considerations for the Use of Income Eligibility Criteria

Income eligibility guidelines for HIA should be consistent with the local income eligibility for Ryan White Part B and State Services funded Outpatient and Ambulatory Medical Care services.

Policies detail the expectation for client contribution, subject to provisions in HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort, and local policies on client contributions.

The AA or HIA provider bases local policies using income-based criteria on the household's modified adjusted gross income (MAGI) against the federal poverty levels (FPL) for that household size. AAs strongly consider using the same methods for annual income estimation as they used to determine Marketplace eligibility for premium tax credits and reduced OOP requirements, and strongly consider using income estimation methods consistently for service categories having income eligibility criteria.

Local HIA policies require HIA-funded providers to maintain referral relationships with organizations or individuals who can provide expert assistance to clients on their health insurance coverage options and available cost reductions. In addition, local policies for HIA ensure HIA-funded providers maintain referral relationships with organizations or individuals who can provide income tax preparation assistance. In areas with Part A Planning Councils, AAs coordinate and align HIA-related policies with the Planning Council's guidelines and policies. DSHS-funded AAs also make good faith efforts to coordinate policies and guidelines with Part C and Part D grantees in their area.

11.2 Lawfully present immigrants and Marketplace savings

1. A lawfully present immigrant can buy private health insurance on the Marketplace and may be eligible for lower costs on monthly premiums and lower out-of-pocket costs based on income. HIA-funded providers review the impact of immigration status on the cost of health insurance on the Health Insurance Marketplace (Marketplace). (See Health coverage for lawfully present immigrants).

12.0 Plans Eligible for HIA Payment

HIA-funded providers may offer HIA for job-related health insurance coverage and plans on the individual and group market, including plans available through the federal Marketplace. HIA-funded providers may also use DSHS funds towards premiums and OOP payments on Medicare plans and supplemental insurance policies, as long as the primary purpose of the supplemental policy is to assist with HIV related outpatient care. HIA-funded providers may not use DSHS funds to support plans offering only catastrophic coverage or supplemental insurance that assists only with hospitalization.

HRSA policies affecting all Parts of the RWHAP also exclude plans that do not cover HIV-treatment drugs; specifically, the plan covers at least one U.S. Food and Drug Administration (FDA) approved medicine in each drug class of core antiretroviral medicines outlined in the HHS clinical guidelines for the Treatment of HIV, as well as appropriate HIV outpatient/ambulatory health services.

HRSA policies affecting all Parts also specify HIA-funded providers may only make HIA payments when assistance with health insurance is cost neutral or offers a cost advantage when compared to estimated expenditure for covered clinical services. HIA-funded providers consider both premiums and reasonable estimates of out-of-pocket costs when making cost comparisons.

13.0 Considerations for Coverage Obtained through Group Policies

Access to health insurance coverage may be available to or currently carried by clients who are eligible for coverage due to their employment or membership in a group, such as a church, union, or professional organization. The person with the membership or employment qualifying them for the health insurance plan is the covered member or policyholder. The policyholder may be able to add a spouse or partner and dependents to their coverage.

DSHS-funded AAs and HIA-funded providers maintain policies on the assistance they can offer for clients covered under a group policy. Before extending assistance, providers determine the share of policy costs associated with the eligible client. For example, if the client is a dependent of the policyholder, HIA-funded providers can pay only the premium costs of adding dependents to a plan and the client's OOP payments. Extension of assistance is also dependent on meeting requirements for minimum levels of drug coverage and cost-effectiveness of the health plan. It is only allowable to assist an eligible client with the entire cost of a group policy that includes coverage for persons not eligible for HIA when the inability to cover these expenses would result in the eligible client losing health insurance coverage. In such circumstances, providers receive approval from their AA prior to extending HIA. 

13.1 COBRA Continuation Coverage

Clients may request assistance with COBRA continuation coverage if they have lost access to job-related insurance through job loss, reduction of work hours, or another qualifying event. COBRA continuation coverage is time-limited and is usually more expensive than the job-related coverage formerly available to the person electing to continue coverage under COBRA.

Before providing HIA support for COBRA insurance coverage, HIA-funded providers evaluate the cost of other options, such as enrolling on a spouse's job-based plan, enrolling in Medicaid, or getting coverage through the Health Insurance Marketplace. Loss of job-related insurance triggers a 90-day special enrollment period for the Marketplace, and people whose COBRA is running out are also eligible for special enrollment periods. However, persons already enrolled in COBRA are not eligible for special enrollment periods if they voluntarily end their COBRA coverage prior to its end date, although they can change to a Marketplace plan during open enrollment periods. Marketplace Navigators, Certified Application Counselors or insurance brokers may be helpful in helping the client determine eligibility for premium tax credits and reduced OOP requirements that reduces the costs of Marketplace coverage.

AA policy specifies HIA-funded providers do not offer HIA for COBRA coverage if a client is eligible for other coverage that provides the required minimal level of coverage at a cost-effective price. If the client has already elected COBRA continuation coverage, HIA for this coverage is subject to the conditions specified in this policy. Since clients with COBRA continuation coverage may enroll in Marketplace plans during open enrollment periods, HIA-funded providers reevaluate HIA support for COBRA plans during open enrollment.
 

14.0 Special Requirements for Plans Purchased on the Marketplace

If a client is eligible for a premium tax credit, the client takes this as an advance premium tax credit to receive assistance with premium payments. Clients who are eligible for plans with reduced cost sharing and reduced OOP payments must select a Silver Marketplace plan to receive assistance with OOP payments. HIA providers should assist clients not eligible for cost-sharing reductions with information about choosing cost-effective plans, including Gold and Platinum plans, that cover needed providers and medications.

Clients report changes in income, family size, tobacco use or residence promptly. These changes may affect the amount of premium tax credit or cost-sharing reductions. HIA or case management providers working with a client with Marketplace insurance who needs to make changes assist the client with making these changes or refer the client to an organization or individual that can help.

When forming policies for HIA assistance, providers refer to HRSA policy notices regarding client eligibility, RWHAP funds as payment of last resort, the use of RWHAP funds for premium and cost-sharing assistance, and reconciliation of advance premium tax credits.

15.0 Special Requirements for Medicare

Agencies may not pay for Medicare Part A (hospital insurance) premiums or cost sharing. Agencies may use HIA funds to pay for Medicare Part B (Outpatient Ambulatory Health Services) premiums and cost sharing in conjunction with paying for the Medicare Part D (medication) premiums or cost sharing.

Subrecipients may also use HIA funds to pay for Medicare Part C premiums and cost sharing assistance when the plan covers both outpatient ambulatory health services and at least one medication in each drug class of core antiretrovirals. If the Medicare Part C plan does not cover at least one medication in each drug class of core antiretrovirals, agencies must also pay for Medicare Part D premiums and cost sharing to meet the RWHAP requirement for health care coverage.

Agencies may not use HIA funds to pay premiums for Medicare Part D alone.

Medicare Costs Allowable in the RWHAP

16.0 Requests for HIA for Plans Exceeding Benchmark Costs

AAs develop procedures for reviewing requests to provide HIA for plans exceeding benchmark costs. AAs only approve requests for HIA exceeding the estimated cost of directly delivered services when circumstances exist making financial support of health insurance necessary to preserve the health of the client, or if it provides a cost savings over payment for direct services. For example, a client may have significant, costly to treat, co-morbidities and if left untreated limits the success of HIV treatment. Another common exemption may allow continued HIA support for policies exceeding local costs of care for clients who elected coverage prior to development of local eligibility criteria for HIA; such exemptions must be contingent on client enrollment in more cost-efficient coverage at the earliest opportunity. DSHS-funded AAs maintain policies outlining the procedures for obtaining a waiver under these circumstances, and these policies name the DSHS-funded AAs as the adjudicator for such requests. In areas with RWHAP Part A, C, D, and F grantees, DSHS-funded AAs collaborate with these grantees in the development of waiver policies.

17.0 Cost Control Policies for HIA

17.1 Annual Caps and Expenditure Limits

DSHS-funded AAs may develop local policies such as annual caps or expenditure limits for HIA for individual clients. DSHS advises AAs to base these caps or limits on local benchmark costs of direct delivery of covered clinical services. These policies may not restrict assistance for either premiums or out-of-pocket payments in such a way to render otherwise cost-effective, equivalent plans unaffordable for clients, such as placing monthly caps on OOP payments rather than annual caps on this type of assistance. In areas with RWHAP Part A, C, and D grantees, DSHS-funded AAs collaborate with these grantees in the development of these policies.

17.2 Restrictions on Out-of-Network Payments

DSHS-funded AAs develop polices restricting payment of co-pays or co-insurance costs when clients use out of network providers or fill prescriptions for drugs incurring higher co-pays or co-insurance because they are outside their health plan's formulary. The policy must make exception for payments for HIV-related care if an in-network provider is not available or appointment wait time for an in-network provider exceeds local standards for delivery of care. HIA funded providers may make payments for off-formulary drugs for a plan if the client makes use of the appeal process available under their policy. Case managers, clinical providers, and HIA funded providers may assist clients in these appeals, subject to their locally-described roles. The policy requires AA documented approval before the HIA funded provider makes a payment for out of network services.

17.3 Use of Drug Manufacturer Co-Pay Cards and Other Programs to Reduce OOP Payments

DSHS-funded AAs create policies and provide technical assistance to case managers and HIA staff, promoting the use of manufacturer co-pay cards and other programs that reduce OOP.

18.0 Revision History