• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: 737-255-4300

    Email the HIV/STD Program

    Email HIV, STD, Hepatitis C, and TB data requests to the Program – This email can be used to request data and statistics on HIV, STDs, Hepatitis C, and TB in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local health department.

    For information on HIV testing and services available to persons living with HIV, please contact your local HIV services organization.

2020.01

Quality Assurance for the Texas HIV Medication Program’s Eligibility Processes 

Policy
Procedure Number 2020.01
Effective Date November 2, 2020
Revision Date August 19, 2021
Subject Matter Expert THMP Manager
Approval Authority TB/HIV/STD Section Director
Signed by Felipe Rocha, M.S.S.W.


1.0 Purpose

This policy provides guidance on the processes the Texas HIV Medication Program (THMP) completes to ensure both reliable and accurate eligibility determination processes so that participants are not served after the end of the eligibility period. 


2.0 Authority

Texas Health and Safety Code: Chapter 85, §§85.003, 85.013, 85.014 - 85.031; Ryan White HIV/AIDS Treatment Extension Act 2009; Health Resources & Services Administration (HRSA) Policy Clarification Notice (PCN) #16-02; PCN #13-02.


3.0 Background

THMP is the state AIDS Drug Assistance Program (ADAP) for Texas. ADAP programs must follow the legislation and policy clarification notices (PCNs) released by the Health Resources & Services Administration’s (HRSA’s) HIV/AIDS Bureau (HAB).  DSHS Policy 220.001, Eligibility to Receive HIV Services, outlines the eligibility criteria both THMP and Ryan White (RW) Part B Care Services follow to ensure compliance with HRSA requirements. Quality assurance processes must be completed to ensure reliable and accurate eligibility determination processes. Additionally, because THMP is a direct service program, the program must also have a system in place that ensures that program participants are not served after the eligibility period ends. 


4.0 Definitions

ADAP Enrollment Workers (AEW)s – Workers at local community agencies that help THMP applicants by assisting with the completion of and submission of complete and accurate THMP applications. AEWs are also expected to follow up with participants due for renewal to help ensure continuous eligibility.

ADAP regional liaisons – Workers employed by Administrative Agencies (AAs) who are responsible for oversight of AEWs, including providing training, technical assistance, and compliance activities. ADAP regional liaisons are responsible for maintaining updated network information and acting as a liaison to ensure successful communication among local community agencies, THMP, and the AAs.

AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV Medication Program (THMP), administered by DSHS HIV/STD Prevention and Care Branch.

Annual 12-Month Eligibility Recertification – The process of screening and determining eligibility for a period of months. Participants must be screened for program eligibility every six months (no later than the last day of the clients’ birth month for the annual 12-month recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation). Assessment includes: documentation of Texas residency, income, and proof of insurance/(payor). This documentation is submitted by the last day of the applicant’s birth month.

Due Date – The date that a recertification or self-attestation application is due.

Eligibility Period – There are two eligibility periods within each 12-month period. The first eligibility period starts over two months after the applicant or participant’s birth month and ends on the last day of the month after the participant’s half-birth month. The second eligibility period starts over two months after the applicant or participant’s half birth month and ends on the last day of the month after the participant’s birth month. 

Participant – An applicant who has been determined to be eligible for services, has successfully completed the eligibility process, and is receiving services.

Half Birth Month – Half Birth Month is the month that is six months after the participant’s birth month (e.g. birth month is January, half birth month is July, and so on). For purposes of this policy, the end of the Half Birth Month shall be considered the last day of the month it falls in, regardless of a participant’s birth date.

Six-Month Self-Attestation – The process of a participant confirming any changes in previous eligibility declaration and documentation. This process occurs by the last day of the half birth month, six months after the participant’s birth month.

Texas Department of State Health Services (DSHS) – The agency responsible for administering public health-related prevention, treatment, and regulatory programs for the State of Texas.

Texas HIV Medication Program (THMP) – Provides medications for the treatment of HIV and its related complications for low-income Texans. The THMP is the official ADAP for the State of Texas. It also operates the State Pharmaceutical Assistance Program (SPAP) and Texas Insurance Assistance Program (TIAP).


5.0 Policy

THMP must ensure that initial eligibility is completed and that all participants enrolled in the program are recertified every twelve months, with a self-attestation check-in at the six-month mark and that the eligibility determination processes are accurate. The program has aligned recertifications and self-attestations with the participant’s birthdate, as outlined in  Policy 220.001, Eligibility to Receive HIV Services. The program must disenroll all ineligible participants if the participant no longer meets the eligibility criteria or does not renew or complete a self-attestation prior to the eligibility end date.


6.0 Procedures

6.1 Application Completeness Reviews: AEWs and other community agency workers who submit applications to THMP are expected to have applications reviewed for completeness by a second agency worker before submission. The application includes an area for both the worker and secondary reviewer to indicate this completeness review occurred. Additionally, ADAP regional liaisons monitor a sample of AEW submitted applications for completeness and timeliness. This provides information needed by ADAP regional liaisons to provide technical assistance and training to AEWs and community agencies that are having issues with complete and timely application submission.

6.2 Secondary Reviews: THMP completes a secondary review for all applications that are denied based on income ineligibility  and  where fraud is suspected. Applications that are denied due to residency or payer of last resort issues are subject to secondary review unless they are completed by a THMP regional coordinator or team lead.  Applications that cannot be processed due to the application being submitted without all the necessary components to determine eligibility are returned as incomplete and the applicant is asked to reapply.

6.3 Mentoring: THMP eligibility staff in training are assigned a mentor when they are ready to begin processing applications. During mentoring, 100% of eligibility determinations are reviewed and training is provided as needed. Staff are only released from mentoring when eligibility determination processes are reliable and valid.

6.4 Quarterly Reviews: THMP management conducts quarterly quality assurance checks of applications for THMP services. A randomly selected group of 20 approved and denied applications are reviewed each quarter. After the quarterly review, staff with identified issues in application processing receive training and counseling as needed.  If necessary, the eligibility determination will be changed. Additional applications by staff persons with recurring processing errors will be reviewed to ensure that that issues have been corrected.

6.5 Renewal Request and Tracking: Every month, the data system for THMP generates a mailing list for all participants who are due for a recertification or self-attestation by the end of the following month. Reminder letters and applications are sent out to these participants by the 15th of the month prior to the due date. The THMP data system is populated with due dates for recertification and self-attestation to alert program staff which specific enrollees are due for renewal and at the end of their eligibility period. These due dates will be no later than the last day of the participant’s birth month for the annual 12-month recertification and no later than the last day of the participant’s half birth month for submitting the self-attestation. These due dates may be extended in appropriate situations, for example as part of an emergency response.

Every month, the THMP data system automatically identifies and “drops” all participants who are past the end of the eligibility period. The eligibility period end dates are one month past the end of the enrollee’s birth month for recertification and one month past the end of the month six months after the birth month for self-attestation. This allows THMP staff one month to process applications received by the due date.

6.6 Quality Assurance: Every month, THMP staff will review enrollment data provided in a report for quality assurance. This tool allows staff to identify records that meet the following criteria:

  • Participant was not mailed recertification or self-attestation packet the month before the due date.
  • System did not populate due date or eligibility period dates appropriately for a recipient who was due for a recertification or self-attestation.
  • System did not deactivate a recipient who was no longer eligible for the program or who did not respond to a recertification or self-attestation due date.
  • A participant who was ineligible continues to be active for medications. The system is allowing medication orders on a recipient who should not be eligible to receive them.

Every month, THMP staff go into the THMP data system to investigate the identified data quality issues. Specifically, staff deactivate participants who are active in the system and still receiving medications but were found to be ineligible. Staff will also correct errors found in participant records and mail recertification or self-attestation packets when identified as having been missed in the mailing.


7.0 Revision History

Date Action Section
Revision History
8/19/2021 Revised throughout  All
11/2/2020 New policy -



Last updated August 19, 2021