220.001 Eligibility to Receive HIV Services

Policy Number  220.001
Effective Date  July 7, 2006
Revision Date  May 12, 2023
Subject Matter Expert HIV Care Services Group Manager
Approval Authority  HIV/STD Section Director
Signed by   

1.0 Purpose

The purpose is to outline the eligibility criteria for individuals to receive services funded through the Ryan White HIV/AIDS Program (RWHAP) Part B, State Services, and the State of Texas AIDS Drug Assistance Program (ADAP) which is known as the Texas HIV Medication Program (THMP).
 

2.0 Authority

3.0 Definitions

Administrative Agency (AA) – Administrative Agency (AA) - Entity responsible for ensuring a comprehensive continuum of care exists in their funded areas. AAs accomplish this through managing and overseeing HIV care and treatment services funded by federal and State of Texas funds under a contractual agreement with DSHS. For a list of AAs, their contact information, and coverage area see HIV Administrative Agencies.

AIDS Drug Assistance Program (ADAP) – A federally funded program which provides medications and other HIV-related services to low-income, uninsured, and underinsured people with HIV/AIDS. AIDS Drug Assistance Programs (ADAPs) services are available in all 50 states and U.S. territories.

Annual 12-Month Eligibility Re-certification – The process of screening and determining eligibility for a period of months. Clients are screened by TCT for program eligibility every six months (no later than the last day of the clients' birth month for the annual 12-month re-certification 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 (payer). The applicant submits documentation by the last day of the applicant's birth month.

Applicant – An individual requesting RWHAP Part B, State Services, and/or THMP-funded services and undergoing the eligibility process.

Client – An applicant who has been determined eligible for services, has completed the eligibility process, and is receiving services.

Federal Poverty Level (FPL) – A measure of income level determined by the US Department of Health and Human Services under the authority of U.S. Code Title 42, Chapter 106, 9902(2). The FPL is updated periodically in the Federal Register and primarily used to determine eligibility for certain programs and benefits. 

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

Human Immunodeficiency Virus (HIV) – HIV (human immunodeficiency virus) is a virus which attacks the body’s immune system. If HIV is not treated, it can lead to AIDS (acquired immunodeficiency syndrome). HIV is transmitted through blood or bodily secretions such as semen and as further defined by the Centers for Disease Control and Prevention (CDC) and by the Texas Health and Safety Code, §81.101.

HIV Confirmatory Test – A Food and Drug Administration-approved diagnostic test which confirms the diagnosis of HIV after the initial screening was reactive.

HIV Service Delivery Area (HSDA) – Geographic service area set by the Department of State Health Services to allocate federal and state funds for HIV medical and psychosocial support services.

HIV Services – Any social or medical assistance defined in the HIV Services Taxonomy paid for with RWHAP Part B and State Services funded through DSHS.

HIV Service Provider – Organization with a contractual agreement with AA to provide HIV-related medical and psychosocial support services to Person(s) Living with HIV (PLWH). At the sole discretion of DSHS, non-contracted providers of HIV services may use TCT.

Initial Eligibility Determination Period/Rapid Eligibility Determination Period – The 30 days during which the client undergoes initial eligibility assessment.

Initial Eligibility Determination – The process of assessing an applicant's eligibility upon entrance into RWHAP Part B, State Services, and/or THMP-funded services. Assessment includes documentation of HIV status, Texas residency, income, and insurance (payer).

Medicaid – Medicaid is a joint federal and state health insurance program for some people with limited income and resources. The purpose of Medicaid in Texas is to improve the health of people in Texas who might otherwise go without medical care for themselves and their children and the program is managed by Texas Health and Human Services.

Medicare – Medicare is a federal health insurance program for people who are 65 years old or older. Clients can sign up for Medicare three months before they turn 65. Persons may be eligible for Medicare earlier if they have disabilities or meet other special criteria. 

Modified Adjusted Gross Income (MAGI) – MAGI is a formula used for calculating income eligibility for Medicaid, CHIP, other financial help, and now Ryan White HIV/AIDS Program (RWHAP) services and Texas HIV Medication Program (THMP). MAGI is adjusted gross income plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.

Nucleic Acid Test (NAT) – Any one of the various laboratory tests used to detect the genetic material of a microorganism, such as HIV. The test can either tell if a person has HIV or tell how much virus is present in the blood (known as an HIV viral load test) and can detect HIV sooner than other types of tests. 

Payor of Last Resort (PoLR) – RWHAP or State Services funds cannot be used as a payment source for any service which can be paid for or charged to any other billable source. Providers make reasonable efforts to secure other funding instead of RWHAP Part B or State Services funding, whenever possible. AAs maintain policies requiring providers to verify third-party payer coverage for eligible services at every visit.

Provider – A local organization, individual clinician, or group of clinicians who provide services to Person(s) Living with HIV (PLWH).

Six-Month Self-Attestation – The process of a client confirming no change in previous eligibility declaration and documentation. This process occurs by the last day of the half-birth month, six months after the client's birth month.

Standard Deduction – THMP determines financial eligibility by subtracting the average monthly drug cost, annualized per THMP client from each applicant’s income for eligibility determination. This generates an adjusted FPL used for program eligibility determination. Each year, THMP adopts a new standard deduction amount based on the of the average monthly client drug cost, annualized, for the previous year.

State Pharmacy Assistance Program (SPAP) – The SPAP program, operated by THMP, aids with premiums and out-of-pocket costs associated with qualifying Medicare Part D prescription drug plans for low-income Texans.

Subrecipient – A non-federal entity receiving a subaward from a pass-through entity or recipient (AA) to provide services to clients and implement policy.

Take Charge Texas (TCT) – TCT is web-based software providers use to report all Ryan White and State Services provided to eligible clients. TCT serves as the Part B Uniform Reporting System (URS) for Texas.

Texas Department of State Health Services (DSHS) – DSHS is the agency responsible for administering physical and mental 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 SPAP and Texas Insurance Assistance Program (TIAP). For more information see the Texas HIV Medication Program-Frequently Asked Questions (FAQ).

Texas Insurance Assistance Program (TIAP) – TIAP, which is operated by THMP, aids with premiums and out-of-pocket medication costs for low-income Texans with qualified insurance plans. TIAP can also pay COBRA premiums for qualifying plans. Applicants may need to indicate they need assistance with insurance co-payments or COBRA in TCT. Clients who are interested in TIAP assistance with their co-payments, fill out the co-payment assistance section in TCT.

Texas Resident – An individual who resides within the geographic boundaries of the state of Texas

Veteran – A former member of the Armed Forces of the United States of America. Veterans are eligible to receive RWHAP Part B and State Services-funded services. Please see DSHS Policy 590.001 DSHS Funds as Payor of Last Resort for more detailed guidance.

Vigorous Pursuit – Making a reasonable effort to enroll a client into health care coverage or services for which they may be eligible via payer sources other than Ryan White.

  • The Health Resources Services Administration HIV/AIDS Bureau (HRSA HAB) requires grantees to maintain policies regarding the required process for the pursuit of enrollment in health insurance or non-Ryan White-supported services for all clients. 
     
  • Subrecipients document the steps during their pursuit of enrollment in health insurance and other services for all clients and establish strong monitoring and enforcement of subrecipient and contractor processes to ensure clients enroll in services, or health insurance paid by an organization other than Ryan White. 

Viral Load (VL) –The amount of HIV in a sample of blood. VL is a lab indicator on a standard lab report reported as the number of HIV RNA copies per milliliter of blood. An important goal of Antiretroviral Therapy (ART) is to suppress a person’s VL to an undetectable level, which is a level too low for most laboratory VL tests to detect the virus. The VL is a type of NAT.
 

4.0 Policy

Eligibility for an individual to receive assistance under RWHAP Part B, including the Texas HIV Medication Program (THMP) and/or State Services (SS) ensures appropriate client access to needed services while adhering to HRSA HAB PoLR requirements as reflected in PCN 21-02.
 

5.0 Persons Affected

  • DSHS HIV Care Services and THMP staff.
     
  • Administrative Agencies (AAs).
     
  • Subrecipients/Providers.
     
  • Applicants/Clients for HIV services funded by RWHAP Part B and State Services.
     

6.0 Responsibilities


6.1 DSHS HIV/STD Section

  • Ensures systems are in place to provide care and services to Texans who are eligible to receive these services through RWHAP Part B and State Services funding and ensures the use of these funds as payor of last resort. 
     
  • Staff assure AAs appropriately monitor eligibility documentation for these payer sources as well as conduct appropriate assessments to determine eligibility for other third-party payers using the module in TCT.
     
  • Develop guidelines for clients on how to complete eligibility processes via TCT for eligibility documentation.
     
  • Develop client, subrecipient, and AAs/data managers training to access TCT for eligibility documentation.
     
  • Provide a Help Desk to support users who are experience a challenge with the TCT system such as clients completing their eligibility application; subrecipients working on behalf of the client; and AAs/data managers who need assistance with accessing reports and/or managing import/data issues.
     

6.2 Administrative Agency (AA)

  • Develop a policy for the determination of eligibility as per PCN 21-02; use Modified Adjusted Gross Income (MAGI) to determine income if eligibility is determined outside of TCT using the DSHS MAGI form Ryan White HIV/AIDS Program MAGI Documents | Texas DSHS.
     
  • Determine the method of training providers on how to determine eligibility and monitor provider billing of third-party payers to determine compliance with PoLR requirements.
     
  • AAs submit their local Ryan White eligibility policy to their DSHS Care Services consultant for approval. All staff shall review this policy no less frequently than annually. AAs maintain this documentation onsite for review.
     

6.3 Subrecipient and Provider

  • Develop AA-approved policies and procedures to determine eligibility for services as per PCN 21-02.
     
  • Ensures the use of RWHAP Part B and State Services funds as payor of last resort.
     
  • Develop policies and procedures to ensure they screen individuals seeking covered services for eligibility using MAGI to identify other payer sources such as the Marketplace, Medicaid, and CHIP.
     
  • PoLR screenings occur as indicated in this policy and as per PCN 21-02.
     
  • If individuals are determined potentially eligible for other benefits, refer them to the specific programs and assist them in completing the eligibility determination process. When possible, service providers use eligibility documents located in TCT to reduce administrative burdens on clients. Service providers can maintain memorandums of understanding (MOUs) outlining this local process.
     
  • When providing emergency assistance to priority populations in crisis (e.g., an individual whom the criminal justice system has recently released and requires assistance in acquiring HIV medications, is pregnant, or has a CD4 of less than 200 cell/mm3), contractors refer clients into appropriate program services and assist in obtaining any required eligibility documentation.
     
  • Providers also ensure the proper documentation of any eligibility screening and intake activities are in the clients' respective charts —paper and/or electronic (e.g., TCT). All eligibility staff shall review this policy at least once a year.
     
  • RWHAP recipients and subrecipients conduct timely eligibility confirmations, by their policies and procedures, to assess if the client’s income and/or residency status has changed.
     

6.4 Applicant, Client, and Family

Provides the required documentation to determine eligibility for services funded under RWHAP Part B, State Services, and THMP and uploads as needed required documentation via the client portal in TCT or coordinates with the provider agency to access TCT via the agency portal
 

7.0 Initiating and Maintaining Eligibility for RWHAP Part B/State Services


7.1 Requirements to apply for Initial Eligibility and Maintain Program Eligibility

Upon initiation of services, providers determine whether an applicant meets the following RWHAP Part B/State Services eligibility criteria:

  • Have a documented diagnosis of HIV.
     
  • Provide documentation of Texas residency; and
     
  • Provide complete and accurate income documentation.

Following approval of initial eligibility, RWHAP recipients and subrecipients can accept a client’s self-attestation of “no change” when confirming eligibility, although HRSA HAB does not recommend recipients and subrecipients rely solely on client self-attestation indefinitely. TCT screens clients for program eligibility every six months to continue receiving assistance under RWHAP Part B. Retaining eligibility entails submitting the annual 12-month re-certification no later than the last day of the clients' birth month and submitting the self-attestation no later than the last day of the clients' half birth month. Subrecipients can accept a client’s self-attestation of “no change” when confirming their 6-month eligibility. In this case, the subrecipient can take the information over the phone and document the client’s information in the proper form to maintain in the client file and/or upload it to TCT. After the initial eligibility determination, re-certification requires documentation of Texas residency and income, but re-certification of HIV status is not necessary.

In addition to all the requirements and acceptable forms of documentation outlined in the policy language below, THMP can request additional information to verify an applicant's eligibility when needed.
 

7.1.1 Initial Eligibility Determination Period/Rapid Eligibility Determinations

Clients can access a 30-day determination period for all Ryan White Part B and State funded services when they are:

  • Newly diagnosed within the previous six months;
     
  • New to the State of Texas/local HSDA and in need of medical services;
     
  • Engaging in care for the first time longer than six months after diagnosis;
     
  • Returning to medical care after an absence of six months or longer; and/or
     
  • In need of early intervention services.

As providers link applicants to services, providers work to complete the eligibility process and collect required documents. An eligibility determination must be complete and entered in TCT within 30 days of program application initiation.

Providers have an established alternative source of funding if a client is ineligible for Ryan White Part B, or State funded services via TCT. The provider agency documents this in their policy and tracks this in the client file if applicable. The provider agency policy outlines the process for any necessary administrative adjustments if a cost is unallowable.

This initial determination period does not apply to clients applying to any THMP program. The service provider or applicant submits all required documentation with the THMP application via TCT.
 

7.1.2 Documentation of HIV-Infection Status

To be eligible for services paid for by RWHAP Part B/State Services/THMP, an individual must have a documented HIV diagnosis. Affected individuals (people who are not living with HIV) may be eligible for RWHAP services in limited situations; services for affected individuals always benefit PLWH. For further clarification on providing services to affected individuals, please see HRSA Policy Clarification Notice (PCN) #16-02 HRSA Policy Clarification Notice (PCN) #16-02, Eligible Individuals and Allowable Uses of Funds .

There are many ways to document an HIV diagnosis. Below are some examples of acceptable forms of documentation; however, this is not a complete list

Laboratory Documentation

Laboratory test results bearing the client’s name may show proof of HIV diagnosis. Some examples include:

  • Positive result from an initial (HIV-1 & 2 Antigen/Antibody Immunoassay (preferred test) with positive findings followed by an HIV1/HIV2-Antibody Differentiation Immunoassay with reactive results for HIV 1
     
  • Positive result from an HIV 1 RNA qualitative virologic test such as an HIV 1 Nucleic Test (NAT).
     
  • Detectable quantity from an HIV 1 RNA quantitative virologic test (e.g., viral load test)

HIV testing technology changes rapidly and standards of HIV confirmation continue to evolve. HIV service providers stay informed of advances in testing technology as newer tests may also provide proof of HIV diagnosis. For more information refer to the CDC’s website on HIV testing, laboratory testing, self-testing, testing in non-clinical settings, and screening in clinical settings.

Other Forms of Documentation - Some examples are:

  • A signed and dated statement from a medical provider with prescriptive authority attesting to the HIV-positive status of the person; or
     
  • A complete THMP Medical Certification Form signed and dated by a physician, physician assistant, or nurse practitioner; or
     
  • A hospital discharge summary documenting the HIV diagnosis of the individual

Serologic tests cannot be used to confirm a diagnosis of HIV in infants less than 18 months of age because the mother passively transfers maternal anti-HIV antibodies to the infant and persists for 12 to 18 months. Due to this condition, providers can serve infants with documentation of the mother's HIV-positive status up to the age of 18 months. Children older than 18 months meet the same criteria for proof of HIV as listed above to continue services

Facilitating with a reactive finding from an HIV screening test

In the case of a reactive (“preliminary positive”) result from a rapid test, the specimen is submitted for testing according to the 2018 recommended laboratory HIV testing algorithm, beginning with the combination antigen-antibody immunoassay.

  • A reactive HIV1/HIV2 antigen-antibody test requires a confirmatory test. Although the CDC does not consider a reactive finding proof of HIV status antigen/antibody tests can find 99% of people tested with HIV, with such a result from laboratory testing and being highly likely to have HIV, the client would benefit from quick linkage to ongoing medical care.
     
  • A preliminary positive result from one antigen-antibody HIV test without a reactive confirmatory test is not a barrier in linkage to medical care.

The ability to use a preliminary positive test result to facilitate linkage to care does not negate the responsibility of the HIV testing site to conduct or order a confirmatory (diagnostic HIV test). The lab results inform the receiving medical provider of the individual's reactive screening test result. Once the lab receives confirmatory findings (reactive) results, HIV testing staff provide these results to the individual and, if the client signs a release of information, to the HIV care provider.

Clinics receiving such individuals may choose to arrange an abbreviated first appointment, during which the individual could receive counseling on HIV, orientation to medical care, conduct eligibility screening, and/or begin laboratory work.

Note: HIV medical providers may elect to conduct the HIV confirmatory test as per the Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. If a medical provider with prescriptive authority determines that a client needs a confirmatory test, then the RWHAP will pay for that confirmatory test. When HIV medical providers elect to conduct an HIV supplemental test, an MOU between the medical provider and the outside testing agency must be in place. 

Application for THMP cannot use a reactive result from an HIV screening test without a reactive/positive confirmatory HIV test. For TCT documents for THMP, see THMP - Documents.

HIV care and services providers contact their AA with questions about acceptable documentation of HIV diagnosis.
 

7.1.3 Documentation of Texas Residency

To be eligible for services paid for by RWHAP Part B, State Services, or THMP, an applicant must reside within the geographic boundaries of Texas and express intent to remain within the state and not claim residency in any other state or country.

Acceptable proof of residency documents includes the applicant's full legal name and current residential address and be unexpired or dated within the same month or one month before the month of the application’s submission. The following list is not exhaustive. Providers contact their Administrative Agency or THMP with questions about acceptable documentation of Texas residency.

To expedite eligibility determination, use the following preferred source documents to show proof of Texas residency and upload them into TCT during the application process:

  • Valid (unexpired) Texas Driver's License;
     
  • Texas State identification card (including identification from criminal justice systems);
     
  • Recent Social Security, Medicaid/Medicare, Unemployment, or Food Stamp/TANF benefit award letters;
     
  • IRS Tax Return Transcript, Verification of Non-Filing, W2, 1040, or 1099;
     
  • Current employment records (pay stub);
     
  • Post office records;
     
  • Current voter registration;
     
  • A mortgage or official rental lease agreement in the client's name with signature page;
     
  • Valid (unexpired) motor vehicle registration or auto insurance;
     
  • Proof of current college enrollment or financial aid;
     
  • Property tax documents;
     
  • Any bill in the client's name for a service connected to a physical address (client's place of residency) dated within one month of the month of application (e.g., bills for rent, mortgage, electric, gas, water, trash, cable, landline phone, etc.);
     
  • A letter of identification and verification of residency from a verifiable homeless shelter or community center serving homeless individuals; or
     
  • A statement/attestation (does not require notarization) with the client's signature declaring the client has no resources for housing or shelter. For THMP, a letter from a shelter or agency worker attesting the individual has no resources for housing or shelter is acceptable.

If none of the preferred source documents listed above are available, Texas residency may be verifiable through one of the following:

  • Any piece of mail addressed to the client and meets all the following criteria:
     
    • Proof the item went through the mail system (stamped with a postmark or metered mark from the postal office). A person could send themselves a piece of mail or a case manager/service agency could send a piece of mail to the address simply to fulfill the residency verification requirement.
       
    • Date of postmark or date printed on contents of mail (e.g., date printed on letter or statement date of the bill) is within one month of the month of application,
       
    • An envelope having a clear window to display the client's address instead of the client's name and address printed directly on the envelope requires a return address, name, logo, or some means of identifying the sender matches the address, name, logo, etc. printed on the contents of the mail. This verifies the contents of the mail with the client's address are truly what came inside of said postmarked envelope.
       
    • For THMP applicants, mail from THMP is not acceptable as proof of residency.
       
  • Observance of personal effects and living arrangements (e.g., visit to the residence). For THMP, a signed statement on agency letterhead detailing this observance and why other forms of proof of residency were not available is acceptable.

A client can sign the attestation form stating they attest to living at a specific address with family/friends, or a case manager, outreach worker, or similar agency employee may make a field visit to the location where the client resides and document this in the primary record. The above are examples of an acceptable verification of residency.

There are no further proof of residency requirements (e.g., the requirement for a photo ID, and documentation of immigration status) other than those listed above. AAs, subrecipients, and/or providers may not impose more stringent proof of residency requirements regarding eligibility for RWHAP and State HIV-funded services than those listed in section 7.1.3 of this policy.

Individuals do not lose their Texas residency status because of a temporary absence from the state. For example, a migrant or seasonal worker may leave the state during certain periods of the year, but maintains a home in Texas, and returns to that home after this temporary absence. This individual does not lose their Texas residency status. For more details on situations in which THMP provides medication coverage for Texans temporarily residing in another state, refer to Policy 700.006, “Multi-Month and Special Circumstance Medication Supply and Coverage.”

Students

  • Students from another state who are living in Texas to attend school may claim Texas residency based on their student status while they are residing in Texas.
     
  • Students living out-of-state (living in a state other than Texas) to attend an educational institution but retain Texas residency based on their student status can continue receiving medication through the THMP if the ADAP in the state where the institution is located denies the student. In this situation, THMP requires the student to provide a denial from the other state's ADAP as well as documentation of school enrollment in addition to other required documents for approval.

If there are unique living situations or other issues regarding acceptable documentation of proof of residency, service providers contact their Administrative Agency or THMP as applicable.
 

7.1.4 Documentation of Income

To be eligible for services paid for by RWHAP Part B/State Services/THMP, an applicant submits proof of income and federal poverty level (FPL) via TCT. DSHS requires supporting documentation to complete the Income Calculation Worksheet. Subrecipients and providers use the TCT module.

Examples of acceptable documentation:

  • Pay stubs (30 continuous days of payment within the last 60 days).
     
  • Supporter statement;
     
  • Employer statement;
     
  • Social Security Income (SSI) Award Letter;
     
  • Social Security Disability Income (SSDI) Award Letter;
     
  • Veteran’s benefit statement;
     
  • Retirement benefits statement;
     
  • Alimony benefits statement;
     
  • Unemployment benefits letter;
     
  • Self-employment log (should include income from the last 30 days);
     
  • Agency letter;
     
  • Other income documentation;
     
  • Tax return transcript; or
     
  • Tax filing documents
     

7.1.5 Local Criteria for Eligibility Determination

  • AAs may impose additional criteria to determine eligibility, such as those based on income and county of residence. AAs may impose additional criteria if justified through a needs assessment or planning process which includes public input and comment. 
  • Additional eligibility criteria may vary depending on the service category. However, further eligibility determination applies to all individuals equally and cannot pose an undue hardship on individuals.
  • All RWHAP Part B and State-funded services must have an income limit not to exceed 500% of FPL. The current THMP financial eligibility criteria are available on the THMP website.
     

7.2 Screening Clients for Third Party Payers

AAs ensure their subrecipients/providers are coordinating benefits and the use of third-party reimbursement by:

  • Monitoring how subrecipients/providers determine client eligibility to ensure the RWHAP Part B and State Services programs are the payors of last resort; and
     
  • Monitoring the documentation showing clients have completed screening and enrollment in eligible programs before the use of RWHAP Part B and State Services funds; and
     
  • requiring and monitoring how subrecipients/providers use a third-party payer verification system.

Providers screen individuals for their ability to pay as well as their eligibility for other potential sources of payment for these services.

Programs/benefits used first include:

  • Private/employer insurance;
     
  • Medicare (including Part D prescription benefit);
     
  • County Indigent Health Programs;
     
  • Medicaid;
     
  • Children's Health Insurance Programs (CHIP); or
     
  • Other comprehensive healthcare plans.

Note: While waiting for THMP approval the agency worker or applicant can initiate a PAP application with the pharmaceutical company after applying for THMP. Additionally, THMP does not allow the use of co-payment assistance programs for those clients on TIAP or SPAP.
Acceptable documentation varies by region, subrecipient refers to Administrative Agency’s policies for details on this process. Examples of acceptable documentation of insurance verification include:

A client may be eligible for Ryan White or THMP services in addition to having other payers. Ryan White services may 'bridge' the gap when other payers cannot fully meet a client's needs. For more information on services or programs available to clients with other payers please contact your local administrative agency or the THMP program.

An agency worker files documentation of eligibility status in the client's primary record and uploaded into TCT.
THMP independently screens for third-party payers, which may result in denial from the program, the TCT database/client dashboard reflects this. 
Subrecipients should contact their AA for training on the local process of screening clients for third-party payers.
 

7.3 Six-month Self-Attestation (Half Birth Month)

To assess eligibility at the 6-month mark, providers may accept client self-attestations of changes/no changes in income, residency, and insurance status (self-attestations are not acceptable forms of documentation at the annual/12-month re-certification). The client or the provider may sign self-attestations with verbal affirmation from the client. This process occurs by the last day of the month, six months after the client's birth month.

RWHAP Part B providers transmit related communications confidentially. If a client has had a change in income, residency/address, or insurance status, they submit appropriate supporting documentation via TCT.

The applicant or agency worker documents self-attestations in TCT along with other supporting documentation.

For clients enrolled in the THMP, the applicant or agency worker uploads a copy of the self-attestation into TCT before the end of the half-birth month. THMP accepts self-attestation forms signed by the client or signed by the provider who spoke directly to the client, but the applicant or provider agency worker must upload them to TCT.

While eligibility for services is determined every six months for active clients, providers assess changes in eligibility at the time of service. The provider’s policies and procedures address how they contact clients regarding their 6-month re-certification, and how providers assess changes in eligibility at the time of service. Consult the table below for guidance on the re-certification process and required documentation.
 

Required Documentation Table

Eligibility Criteria (1) Initial Eligibility Determination (2) Annual 12-Month Recertification (by last day of Birth Month) (3) 6-Month Self Attestation (by last day of Half Birth-Month)
HIV status Only initial eligibility determination requires the uploading of documentation into TCT N/A N/A

Income

Applicant or provider agency worker upload income information into TCT for scenarios 1-3. 

Completing the client’s income information in TCT requires supporting documentation as indicated in 7.1.4.

Completing the client’s income information in TCT requires supporting documentation as indicated in 7.1.4.

Self-attestation of no change is acceptable. The applicant or provider agency worker documents the attestation in TCT. 
If there has been a change in income, provide backup documentation uploaded into TCT with the attestation.

Residency

Applicant or provider agency worker upload residency information into TCT for scenarios 1-3.

 Completing the client’s residency information in TCT requires supporting documentation as indicated in 7.1.3. Completing the client’s residency information in TCT requires supporting documentation as indicated in 7.1.3.

If the address has not changed, self-attestation of no change is acceptable. The applicant or provider agency worker document attestation in TCT.

If the address has changed, the applicant or agency worker should update documentation of residency in TCT and upload any supporting documentation into TCT with the attestation.

Insurance/Third Party Payer

The client or provider agency worker upload verification information for scenarios 1-3 into TCT.

The provider verifies the applicant’s enrollment in other health coverage and documents the status in TCT.

If the client is income eligible, provider agency workers pursue enrollment for Medicaid, CHIP, Health Insurance Marketplace plans, or various other health plans.

The Provider verifies the applicant’s enrollment in other health coverage and documents the status in the TCT client file.

If the client is income eligible, provider agency workers pursue enrollment for Medicaid, CHIP, Health Insurance Marketplace plans, or various other health plans.

If the client's insurance/third-party payer status has not changed, self-attestation of no change is acceptable. The applicant or provider agency worker documents attestation in TCT. 

If the insurance has changed, the applicant or provider agency worker uploads documentation of the client's insurance eligibility status into TCT with the attestation.


7.4 Client’s Responsibility for Reporting Changes

DSHS requires clients who do not have access to TCT to report any changes in income, residency, or insurance status to their agency provider and THMP to ensure the client meets eligibility requirements.

Clients who have access to the TCT client portal submit a “Change Request”, with supporting documents, via TCT for any changes which might affect their eligibility. Additionally, DSHS expects clients to report changes into TCT within 30 days of a change in circumstances. A client also reports any changes at the 6-month self-attestation and uploads the necessary supporting documentation into TCT. If a client fails to provide appropriate documentation of any changes, the client may experience delays in their services until the provider(s) can confirm eligibility. Clients who have access to the TCT client portal submit a “Change Request” via TCT for any changes which might affect their eligibility.

8.0 Revision History

Date Action Section
5/12/2023 Revised for TCT All
4/30/2022 Policy revised to reflect HRSA HAB PCN 21-02, October 19, 2021 All
4/30/2022 Policy revision to reflect the use of Take-Charge Texas web-based eligibility, service delivery, and grant management system All
3/18/2019 Changed infant exposure age from 12 months to 18 months to align with clinical panel recommendation and practice in the field.  7.1.3 
7/31/2018 Significant revisions throughout the policy. All
10/30/2017 Policy revised to align with THMP/ADAP eligibility certification schedule. All 
9/27/2016 Policy revised to add definitions; clarify documentation requirements for HIV Infection Status and Texas Residency; clarify Re-certification requirements; add requirement for MAGI for financial eligibility determination; and reflect advances in testing technology. All 
9/25/2014 Converted format (Word to HTML) -
1/15/2013 Policy revised to reflect HRSA issued Policy Clarification Notices relating to Implementation of the Affordable Care Act -
9/27/2012 Policy revised to clarify eligibility as it applies to HRSA’s “recertification” language and to give guidance for additional eligibility -
11/20/2011 Policy language revised to clarify documentation requirements -
6/25/2008 Policy revised to allow for testing technology advances All
HIV/STD Program

HIV/STD Program

HIV/STD Program Policies