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).

Eligibility for an individual to receive assistance under RWHAP Part B, State Services, or THMP-funded services ensures appropriate client access to needed services while adhering to RWHAP payor of last resort requirements as reflected in PCN 21-02.
 

2.0 Authority

• Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program: 
  • Title XXVI of the Public Health Service Act (42 U.S.C. §§ 300ff et seq.), Ryan White HIV/AIDS Program
  • Policy Clarification Notice (PCN) 16-02: Ryan White HIV/AIDS Program Services, Eligible Individuals & Allowable Uses of Funds; and
  • PCN 21-02: Determining Client Eligibility & Payor of Last Resort (PoLR) in the Ryan White HIV/AIDS Program
• THMP eligibility also follows requirements in the Texas Administrative Code Title 25, Chapter 98, Texas HIV Medication Program.
   

3.0 Definitions

AIDS Drug Assistance Program (ADAP) – A federally funded program that provides medications and other HIV-related services to low-income, uninsured, and underinsured people with HIV or AIDS. ADAP services are available in all 50 states and U.S. territories. THMP serves as the state's official ADAP.

Administrative Agency (AA) – An organization contracted with the Department of State Health Services (DSHS) to administer Ryan White Part B and State Services funds within a defined geographic service area. The AA ensures a comprehensive continuum of HIV care by overseeing fiscal management, program monitoring, and data quality. It also manages user access and enforces role-based access standards within the TCT application for its service network. For a list of HIV Administrative Agencies, including contact information and coverage areas, visit HIV Administrative Agencies.

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

Birth month and Half-Birth month Renewals –The process of screening and determining eligibility for a period of months. THMP and HIV Service Providers screen clients using TakeChargeTexas (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). The assessment includes documentation of Texas residency, income, and proof of insurance (payor). The client submits a complete renewal application and required documentation by the last day of the applicant's birth month. During the client’s half-birth month renewal, clients must provide documents if they are reporting changes in their income, where they live, or insurance.

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

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

HIV Service Provider – An organization with a contractual agreement with an AA to provide HIV-related medical and support services to PLWH. HIV service providers must comply with DSHS policies and RWHAP requirements. DSHS may grant non-contracted HIV service providers access to TCT at its sole discretion.

HIV Services – The core or supportive services defined in the HIV Core and Support Services Taxonomy and paid for with Ryan White Part B, State Services, or both funding streams that DSHS disseminates.

Human Immunodeficiency Virus (HIV) – HIV is a virus that attacks the body’s immune system. If left untreated, HIV can lead to acquired immunodeficiency syndrome (AIDS). HIV is transmitted through blood or bodily secretions such as semen, as further defined by the U.S. Centers for Disease Control and Prevention (CDC) and by the Texas Health and Safety Code 81.101.

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

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

Payor of Last Resort (PoLR) – Providers cannot use RWHAP or State Services funds as a payment source for services which they can pay for or charge to another billable source. Providers make reasonable efforts to secure other funding instead of RWHAP Part B or State Services funding, whenever possible. See HIV/STD Policy 590.001 – DSHS Funds as Payment of Last Resort.

Take Charge Texas (TCT) – The secure, web-based application administered by DSHS that streamlines eligibility determination for HIV Care Services (CARE) and the Texas HIV Medication Program (THMP), processes medication orders, and records client-level data for Ryan White and State Services programs. It supports case management, reporting, and data sharing. It serves as the Uniform Reporting System for HIV Care Services to ensure continuity of care while safeguarding protected health information (PHI), personally identifiable information (PII), and sensitive personal information (SPI).

Texas HIV Medication Program (THMP) – A state-funded program that provides HIV-related medications and pharmacy services for low-income Texans living with HIV. THMP is the official ADAP for the State of Texas. The program also operates the State Pharmacy Assistance Program and the Texas Insurance Assistance Program to help eligible clients access medications and maintain insurance coverage.

Texas Insurance Assistance Program (TIAP) –  THMP operates TIAP, which helps 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 interested in TIAP assistance with their co-payments should fill out the co-payment assistance section in TCT.

Texas Insurance Assistance Program-PLUS (TIAP-PLUS) – Provides premium payments, medication deductible payment assistance, and medication copayment assistance for eligible Marketplace or Off-Marketplace health insurance plan purchasing.

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 HIV services through DSHS. Please see HIV/STD Policy 590.001 – DSHS Funds as Payor of Last Resort for more detailed guidance.

Vigorous Pursuit – Reasonable efforts by providers to enroll clients in health care coverage or services funded by sources other than RWHAP or state services with required documentation of those efforts.
  

4.0 Persons Affected

• DSHS HIV Care Services and THMP staff
• AAs
• HIV Service Providers
• Applicants and Clients for HIV services funded by RWHAP Part B, State Services, and THMP
  
   

5.0 Responsibilities

5.1 THMP Staff

• Conducts timely eligibility confirmations to assess if the client’s income, residency, or insurance status has changed.
• Uses third-party verification, including residency, income, and third-party payer information to confirm eligibility during the application process and eligibility period. 
• Documents eligibility screening and intake activities in TCT.
• Notifies eligible participants of renewal deadlines and processes.
• Notifies applicants and participants of eligibility decisions and changes.
   

5.2 HIV Service Provider

• Ensures the use of RWHAP Part B and State Services funds as payors of last resort. 
• Refers individuals who are eligible for other benefits to specific programs and assists them in completing the eligibility determination process, when possible. HIV Service Providers can maintain memoranda of understanding (MOUs) outlining this local process.
• Documents eligibility screening and intake activities in the clients' respective charts—paper or electronic (e.g., TCT).
• Conduct timely eligibility confirmations, based on their policies and procedures, to assess whether the client’s income or residency status has changed.
• Notifies eligible participants of renewal deadlines and processes.
• Notifies applicants and participants of eligibility decisions and changes.
   

5.3 Applicant and Client

• Completes an application for eligibility and provides required documentation to determine eligibility for services funded under RWHAP Part B, State Services, and THMP.
• Submits the application for eligibility and any required documentation via the client portal in TCT, by mail, or with the assistance of an HIV Service Provider agency.
• Notifies THMP or their HIV Service Provider of eligibility changes within 30 days of a change in circumstances. Clients may complete this by submitting a “Change Request” in TCT or with the assistance of an HIV Service Provider agency.
• Renews eligibility during the birth month and half birth month.
• Authorizes THMP or the HIV Service Provider to verify eligibility through third-party verification, including residency, income, and third-party payer information, both to process the application and at any time in the future while enrolled in services to confirm continued eligibility.
• Ensures that contact information remains up to date and responds to requests for additional information promptly to maintain services.
    

6.0 Eligibility Requirements

6.1 Initial Eligibility

Upon initiation of services, HIV Service Providers determine whether an applicant meets the following RWHAP Part B, State Services, or THMP eligibility criteria:

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

Clients must follow payor of last resort requirements see HIV/STD Policy 590.001 – DSHS Funds as Payor of Last Resort.
 

6.2 Rapid Eligibility Criteria

Clients can access a 30-day determination period for RWHAP Part B and State Services-funded services. This rapid eligibility determination does not apply to clients applying to any THMP program.

6.2.1 Criteria for rapid eligibility determination:

• Newly diagnosed within the previous six months;
• New to the service area 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

6.2.2 Requirements for HIV Service Providers:

• HIV Service Providers must complete the eligibility determination within 30 days of the program application initiation
• An established alternative source of funding must be available if a client is ineligible for RWHAP Part B or State Services-funded services. HIV Service Providers must use this funding must cover ineligible services provided during the determination period.
• HIV Service Providers must track the determination period and outcome in the client's file.
• An agency policy outlining the process for necessary administrative adjustments if a cost is unallowable must be in place.
   

6.3 Birth Month Renewals

After determining initial eligibility, clients must complete birth month renewals annually. The first renewal will take place in the first birth month after initial eligibility determination, which may be less than 12 months.

To maintain program eligibility, the client must:

• Provide documentation of Texas residency; 
• Provide complete and accurate income documentation; and
• Follow payor of last resort requirements, see HIV/STD Policy 590.001 – DSHS Funds as Payor of Last Resort
   

6.4 Half-Birth Month Renewals

After determining the initial eligibility, clients must complete half-birth month renewals annually, no later than the last day of the client's half-birth month. The first renewal will take place the first half-birth month after initial eligibility determination, which may be less than 12 months.

The half-birth month renewal allows for a self-attestation of eligibility at the six-month mark between birth month renewals.

To maintain program eligibility, the client must complete the following steps when they have changes to report:

• Provide documentation of Texas residency;
• Provide complete and accurate income documentation; and
• Follow payor of last resort requirements, see HIV/STD Policy 590.001 – DSHS Funds as Payor of Last Resort
   

6.5    Eligibility Documents

6.5.1    Documentation of HIV Diagnosis Status

To be eligible for most services paid for by RWHAP Part B, State Services, or THMP, an individual must have a documented HIV diagnosis.

Affected individuals (people who are not living with HIV) are eligible for RWHAP services in limited situations; services for affected individuals always benefit PWH. For further clarification on providing services to affected individuals, please see HRSA Policy Clarification Notice PCN 16-02, Eligible Individuals and Allowable Uses of Funds.

Serologic tests should not 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, HIV Service 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.

There are many ways to document an HIV diagnosis. Below are examples of acceptable documentation; however, this is not a complete list. HIV testing technology changes rapidly, and standards of HIV confirmation continue to evolve. 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.

6.5.1.1 Laboratory Documentation

• Laboratory test results bearing the client’s name may show proof of an HIV diagnosis. Some examples include:
• Positive HIV immunoassay and positive HIV Western blot 
• Positive HIV immunoassay and detectable HIV RNA 
• Two positive HIV immunoassays (should be different assays based on different antigens or different principles) 
• Detectable quantity from an HIV 1 RNA quantitative virologic test (e.g., viral load test)

6.5.1.2 Other Forms of Documentation

• A signed and dated statement from a medical provider with prescriptive authority attesting to the HIV-positive status of the person
• A complete THMP Medical Certification Form signed and dated by a prescriptive authority. 
• A hospital discharge summary documenting the HIV diagnosis of the individual
• eHARS profile showing a client with an HIV diagnosis

6.5.1.3 Facilitating Linkage with a Reactive Finding from an HIV Screening Test

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

A reactive HIV-1/HIV-2 antigen and antibody test requires a confirmatory test. Although the CDC does not consider a reactive finding proof of HIV status, antigen and antibody tests can find 99 percent 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 and antibody HIV test without a reactive confirmatory test is not a barrier to 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 Service 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, or begin laboratory work.

Note: HIV Service 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 Service Providers elect to conduct an HIV supplemental test, an MOU between the medical provider and the outside testing agency must be in place.

An application for THMP cannot use a preliminary positive result without additional documentation. For required documents for THMP, see THMP - Documents.

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

6.5.2    Documentation of Texas Residency

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

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 maintain a home in Texas and return to that home after this temporary absence. This individual does not lose their Texas residency status.

Acceptable proof of residency documents must include the applicant's full legal name and current residential address, which are unexpired or dated within the same month or one month before the month of the application’s submission. The following list is not exhaustive. HIV Service Providers should contact their AA or THMP with questions about acceptable documentation of Texas residency.

6.5.2.1 Preferred Documentation

• Valid (unexpired) Texas Driver's License;
• Texas state identification card (including identification from the criminal justice system);
• Recent Social Security, Medicaid, Medicare, unemployment, or Temporary Assistance for Needy Families (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 a signature page;
• Valid (unexpired) motor vehicle registration or auto insurance;
• Proof of current college enrollment or financial aid;
• Property tax documents;
• A 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 homeless shelter or community center serving homeless individuals; or
• A statement or attestation (does not require notarization) with the client's signature declaring the client has no resources for housing or shelter or is living at a specific address with family or friends. For THMP, a letter from a shelter or agency worker attesting that the individual has no resources for housing or shelter is acceptable.
• For THMP, the supporter must sign a Supporter Statement showing they provide assistance with room, rent, or mortgage.

6.5.2.2 Other Acceptable Documentation

• A piece of mail addressed to the client and meeting all the following criteria:
  • Proof that the item has a stamped postmark or metered mark from the postal office. A person can send themselves a piece of mail, or a case manager or service agency can send a piece of mail to the address, simply to fulfill the residency verification requirement. For THMP applicants, mail from THMP is not acceptable as proof of residency.
  • The date of the postmark or date printed on the contents of the mail (e.g., the date printed on a letter or the 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 that the sender matches the address, name, logo, etc., printed on the contents of the mail. This verifies that the contents of the mail with the client's address came inside the postmarked envelope.
• Observance of personal effects and living arrangements (e.g., visit to the residence) and documentation in the primary record. THMP can accept a signed statement on agency letterhead detailing this observance and why other forms of proof of residency were unavailable.

If there are unique living situations or other issues regarding acceptable documentation of proof of residency, HIV Service Providers should contact their AA or THMP, as applicable.

6.5.3 Documentation of Income or Support

To be eligible for services paid for by RWHAP Part B, State Services, or THMP, an applicant submits proof of income or support. DSHS requires supporting documentation to complete the Income Calculation Worksheet. HIV Service Providers use the TCT module or a local client-level database.

6.5.3.1 Acceptable Documentation

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

6.5.4 Screening Clients for Third-Party Payors

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

Third-party payors include:

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

Examples of acceptable documentation for insurance verification include:

• Copy of their insurance card;
• Insurance coverage termination letter(s);
• Certificate of prior coverage; and
• Continuation of Health Coverage (COBRA) paperwork.

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

6.6 Other Criteria for Eligibility Determination

• AAs may impose additional criteria to determine eligibility, such as those based on income and county of residence. 
• Services are dependent on the availability of funding and may be restricted based on funding limitations. 
• See DSHS Guidelines for the Texas HIV Medication Program (THMP) for the current THMP financial eligibility criteria.
• Financial eligibility varies at local HIV Services provider. Local providers are listed here: HIV and STD Services in Texas.
• While waiting for THMP approval, the agency worker or applicant can initiate a Patient Assistance Program (PAP) application with the pharmaceutical company after applying for THMP. The client should not use PAPs or copayment assistance cards after receiving approval from THMP. 
   

7.0 Associated Policies

8.0 Revision History