2013.01 Ryan White Part B/State Funded Services in Special Care Facilities
|Effective Date||June 20, 2013|
|Subject Matter Expert||HIV Care Group Service Consultants|
|Approval Authority||TB/HIV/STD Section Director|
|Signed by||Felipe Rocha, M.S.S.W.|
The purpose of this policy is to define services that are allowable under Ryan White Part B and state services funds when a client is admitted to a Special Care Facility.
Ryan White Part B and state services funds may be used to support non-Medicaid/Medicare eligible services for HIV positive clients when admitted to a Special Care Facility for care as outlined in Texas Administrative Code Title 25 §125.
Administrative Agency – An administrative agency disburses funds from DSHS through a subcontractor system to provide comprehensive services to HIV positive individuals and those affected within the service planning area.
Contractor – An entity that contracts with the Department of State Health Services to provide services. The contractor is the responsible entity even if there is a subcontractor involved who actually provides the services.
Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas.
DSHS HIV/STD Prevention and Care Branch – a Branch within the TB/HIV/STD Section.
DSHS Regulatory Division – A Division within DSHS that establishes and administers rules and standards to maintain health care quality and consumer safety and is responsible for licensing, surveying, and inspecting providers of health care and consumer safety services.
Human Immunodeficiency Virus (HIV) – a virus that damages immune system by interfering with the body’s ability to fight the organisms that cause disease. HIV is a disease of the immune system caused by infection with the retrovirus HIV, which destroys some types of white blood cells and is transmitted through blood or bodily secretions such as semen. HIV can cause AIDS, a chronic, potentially life threatening condition.
HIV Services - Any of the social or medical assistance defined in the HIV Core and Support Service Categories paid for with Ryan White Part B/ State Services funding streams disseminated through DSHS.
Hospice Services – A provider that offers a coordinated program which includes palliative care for terminally ill residents and support services for a resident and a resident’s family.
Limited Care – Medical and nursing care, treatment and other services to residents who require staff attendance and supervision.
Medicaid – Title XIX of the Social Security Act, Medicaid reimburses costs for health care services delivered to low-income clients who meet eligibility guidelines.
Medicare - a federal government insurance program that provides health insurance coverage to people who are aged 65 and over; it also provides care to those who are under 65 and are permanently physically disabled or who have a congenital physical disability or to those who meet other special criteria.
Palliative Care - services that focus primarily on the reduction or abatement of physical, psychosocial, and spiritual symptoms of a terminal illness.
Payor of Last Resort – All medical care providers and case management facilities must bill third party payors before charging services to Ryan White and state services funds for all core medical care services. Ryan White or state services monies cannot be used to pay for client services that can be paid for or charged to any other billable source. Ryan White funds cannot be billed for any service where another payor is available. (HIV/STD Policy 590.001 Payor of Last Resort).
Resident – a person who lives in a special care facility.
Residential Board and Care – An array of services that includes medical and nursing care, treatment and other services for residents who do not require routine or continuous staff attendance and supervision.
Special Care Facility – facilities licensed under the Texas Health and Safety Code to provide medical care for improving life span and quality of life for comfort, for prevention and treatment of illness and for maintenance of bodily and mental function. Special Care Facilities can be designated as residential AIDS hospice to provide exclusively palliative care, bereavement services and support services to the residents’ families.
4.0 Persons Affected
DSHS HIV Care Services Group Staff
Residents with HIV living in a Special Care Facility
DSHS HIV Care Services Consultants – consultants will ensure that funds from Ryan White Part B and state services are the payers of last resort for services rendered through contracts with Administrative Agencies.
Administrative Agency – will develop policy for monitoring of Special Care Facilities to ensure compliance.
Contractor – will develop policies and/or procedures to ensure that individuals seeking services meet eligibility criteria as outlined in HIV/STD Policy 220.001 and that services rendered are within the facility’s occupancy classification.
DSHS HIV/STD Prevention and Care Branch – will review processes for contractor compliance with these requirements.
Special Care Facilities must adhere to all guidelines set forth in Texas Administrative Code Title 25 §125 Special Care Facilities.
Directors of Special Care Facilities will determine eligibility for use of Ryan White Part B and state services funds according to HIV/STD Policy 220.001 Eligibility to Receive HIV Services. Special Care Facilities will not use Ryan White Part B and/or state services funds to support care for residents who are eligible for Medicaid/Medicare covered services. Special Care Facilities will only use Ryan White Part B and/or state services funds for services not covered by Medicaid/Medicare.
Special Care Facilities will document in resident’s chart that an attempt has been made to place Medicaid/Medicare eligible clients in another facility prior to admission. Special Care Facilities will refer Medicaid/Medicare eligible clients to a hospice provider for medical, support and palliative care. Allowable services under Ryan White Part B and state services include, but are not limited to:
Assistance with activities of daily living
Transportation/coordination to medical appointments
Medical Case Management as outlined in the Ryan White Standards of Care
Medication Supervision/direct administration of medications
Medical management for pain and symptoms
These additional services are allowable when admitted to a Special Care Facility with a residential AIDS Hospice designation with physician certification of need.
Support services to include social, spiritual, and emotional care provided to a resident and the family
Residents seeking care for hospice within a Special Care Facility must first seek care from other facilities and denial must be documented in the resident’s chart.
The following are not allowable services:
HIV medications under hospice care unless paid for by the client.
Medical care for acute conditions or acute exacerbations of chronic conditions other than HIV for potentially Medicaid eligible residents.
In addition to the regularly scheduled monitoring performed by the DSHS Regulatory Division on Special Care Facilities, the Administrative Agencies will monitor Special Care Facilities on a quarterly basis to assess and confirm “payor of last resort” status and any other relevant quality of care issues.
7.0 Revision History
|9/1/2017||Changed "TB/HIV/STD Unit" to "TB/HIV/STD Section" to reflect new program designation||-|
|9/3/2014||Converted format (9/3/2014)||-|
|6/20/2013||This is a new policy||All|