Ryan White HIV/AIDS Treatment Extension Act- June 17, 2013 Kerry Hill, MSW

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1 Ryan White HIV/AIDS Treatment Extension Act- June 17, 2013 Kerry Hill, MSW US Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) Division of State HIV/AIDS Programs (DSHAP)

2 Welcome and Session Overview Overview of Ryan White Legislation HIV/AIDS Bureau/Division of State HIV/AIDS Programs Expectations Grantee Roles and Responsibilities Role of the Project Officer

3 Ryan White HIV/AIDS Treatment Extension Act Enacted as the Ryan White Comprehensive AIDS Resources Emergency Act in 1990 Amended in 1996, 2000, 2006, No longer an emergency act Unlike 2006, the current legislation does not sunset

4 Ryan White HIV/AIDS Treatment Extension Act Largest Federal government program specifically designed to provide services for people living with HIV/AIDS Third largest Federal program serving people living with HIV/AIDS after Medicaid and Medicare

5 Ryan White Appropriations FY

6 Ryan White Appropriations 2012 $900.0 $205.6 $34.6 $13.5 $77.3 $25.0 $672.5 $423.1 Part A 29% Part B 18% Part B ADAP 38% Part C 9% Part D 3% AETC 1% Dental 1% SPNS 1%

7 Revised Purpose of the Ryan White Legislation No longer emergency relief for overburdened health care systems Now: Revise and extend the program for providing life-saving care for those with HIV/AIDS Address the unmet care and treatment needs of persons living with HIV/AIDS by funding primary health care and support services that enhance access to and retention in care Early Identification of People Living With HIV/AIDS

8 Ryan White Part B Part B Grants: 59 States and Territories: 50 States District Columbia Puerto Rico Guam U.S. Virgin Islands Pacific Islands: Republic of Palau, American Samoa, Commonwealth of the Northern Mariana Islands, Marshall Islands and Federated States of Micronesia

9 Ryan White Part B Funding Awards Part B Base (X07) AIDS Drug Assistance Program (ADAP) Earmark Supplemental ADAP Award Emerging Communities Minority AIDS Initiative Funding TGA Closeout (CA, NJ, NY, PR), FY2013 Final year Part B Supplemental (X08) ADAP ERF (X09)

10 Details on the Ryan White Part B Awards - Formulas Part B Base is calculated using the number of living cases of HIV/AIDS in the State or Territory in the most recent calendar year as confirmed by Centers for Disease Control (CDC) Part B Base is used to fund core medical and support services provided through the following Part B program components: Contracts with HIV/AIDS Providers Provider Agreements Provision of Treatments Health Insurance Program State Direct Services HIV Care Consortia Home and Community-Based Care

11 Details on the Ryan White Part B Awards Formulas--ADAP ADAP funding is calculated using the number of living cases of HIV/AIDS in the State or Territory in the most recent calendar year as confirmed by CDC Eligible Services under ADAP: HIV/AIDS Medications Health Insurance with a prescription drug benefit Access, Adherence and Monitoring (5% cap)

12 Details on the Ryan White Part B Awards Formulas--ADAP ADAPs may provide ADAP-eligible PLWHA with assistance in paying for premiums, co-pays, deductibles, co-insurance, and True Out Of Pocket expenditures for private insurance, COBRA, Medicaid, Medicare Part D, Pre-Existing Condition Insurance Plan(PCIP), State High Risk Health Insurance, or Marketplace Insurance)

13 Detail on the Ryan White Part B Awards ADAP Supplemental ADAP Supplemental Up to 5% ADAP funding reserved for awards to areas with severe need Determined by the applicant s ability to demonstrate the need in the State based on an objective and quantified basis: Financial requirement of Federal Poverty Level (FPL) =<200% Limited formulary compositions for all core classes of antiretroviral medications Waiting list, capped enrollment or expenditures An unanticipated increase of eligible individuals with HIV/AIDS

14 Detail on the Ryan White Part B Awards ADAP Supplemental Eligible States will be notified in the annual Funding Opportunity Announcement under the ADAP Supplemental section Eligible States must have reported timely and accurate obligation of 75% of the Part B award from the prior year within 120 days of receipt of grant funds as reported on the Interim Financial Status Report ADAP Supplemental funds must be used to provide HIV/AIDS-related medications and must coordinate use of these funds with the ADAP Award in order to maximize drug coverage

15 Details on the Ryan White Part B Awards Formulas--MAI Minority AIDS Initiative funding is calculated based upon the number of living minority cases of HIV/AIDS cases in the State or Territory in the most recent calendar year as confirmed by CDC Minority AIDS Initiative (MAI) funding under Part B is used to increase minority enrollment into the AIDS Drug Assistance Program (ADAP) States must notify HRSA/HAB of their intent to be considered for MAI funding via annual Grant Application

16 Details on the Ryan White Part B Awards Formulas EC/TGA Emerging Communities is funding for areas located in States that have between cumulative AIDS Cases in the most recent 5 years Transitional Grant Area (TGA) Close Out is funding for States that lost Part A TGA due to the decrease in HIV/AIDS Four jurisdictions: (California--Santa Rosa, New York: -- Duchess County, New Jersey--Vineland, Puerto Rico-- Caguas) FY2013 is final year for TGA Close Out funding for these 4 jurisdictions

17 Detail on the Ryan White Part B Awards Part B Supplemental Funding for Part B Supplemental is derived from Unobligated Balances (UOB) from all Part B Grantees in most recent Fiscal Year Part B Supplemental competitive award intended to supplement the services otherwise provided by the State Part B Supplemental All 59 Part B Grantees are eligible except: States with more than 5% UOB of most recent fiscal year s Formula funds under Part B Base or ADAP

18 Detail on the Ryan White Part B Awards - Supplemental Part B Supplemental - Demonstrated need for this award is based upon use of quantifiable data on HIV epidemiology, co-morbidities, cost of care, the service needs of emerging populations, unmet need for core medical services, and unique service delivery challenges.

19 WICY Legislative Requirement: Part A and Part B grantees must spend a proportionate amount of their grant dollars to provide services to women, infants, children and youth (WICY) living with HIV/AIDS. Part A/B WICY Reports: The WICY Expenditure Report, Retrospective WICY Waiver Request (if applicable), and WICY Waiver Expenditures Documentation (retrospective) must be submitted as a component of the grantee s Annual Progress Report Separate guidance is issued to Part B Grantees for WICY reporting and waivers

20 Ryan White Part B: Maintenance of Effort Legislative Requirement HIV related core medical and support services Must maintain same level of support as the previous year (financial and or in-kind) Must have a methodology Must be auditable Data must be consistent year to year

21 Ryan White Part B: State Match States with more than 1% of the total HIV/AIDS cases in the US and PR are required to match Match applies to Part B Base, ADAP and EC Match varies, depending on length of match, but years do not need to consecutive, most states $1 for each $2 Match is based upon Award not expenditures ADAP Supplemental Match Required at $1: $4 by all grantees, unless request waiver Waiver permitted only if required to meet other match and grantee does meet the other matching requirement For both matches, grantee may request an amount less than they would otherwise be entitled to, up to the amount that they can match

22 Ryan White Part B: State Match Grantee must report expenditures not paid by the federal government May include non-federal funding for Ryan White HIV Program Contributions must be documented Contributions can be direct or in-kind Match cannot be funds identified by the State for matching other Federal Awards Must be verifiable in grantee records Amount of state match required is indicated on the NoA Grantees report match to HAB on the Federal Status Report (FSR or the SF 425) under Recipient Share

23 Limits on Non-Service Funding For Administration : 10% Cap For Planning and Evaluation: 10% Cap NOTE: The combined cap for Administration and Planning/Evaluation cannot exceed 15% (known as the 10+10=15 rule) For Clinical Quality Management there is a cap of 5% (or $3 million, whichever is less) -- assess quality of care and measure client level health outcomes

24 Ryan White Part B: Unobligated Balances Unobligated balances (UOB) provisions 2009 reauthorization. Implementation of the UOB provisions was simplified by providing the Secretary with the option to offset unobligated funds rather than cancel those funds Penalty trigger is 5% of unobligated formula funds as reported on FSR line H If triggered, grantees are subject, in a future year to: an offset of the amount of UOB less the amount of approved carryover, a reduction of the amount of UOB less the amount of approved carryover, and ineligibility for a supplemental award.

25 Ryan White Part B: Unobligated Balances Recent HAB policy clarified received rebate funds must be used first before grantees can draw down Ryan White Part B ADAP funds This could cause unobligated balances. However rebates are exempted from being reported as Program Income on Final FSR To avoid a UOB penalty due to expenditures of Rebates, Grantees must correctly indicate the amount and use of the rebate funds when reporting on the Final FSR

26 Comprehensive Plan Development of a comprehensive and responsive system of care that addresses the changing needs and challenges over time. Consultation and collaboration with the community, review of needs assessment data, review of existing resources to meet those needs, review of barriers to care Addresses programmatic initiatives: The National HIV/AIDS Strategy The Affordable Care Act Early Identification of Individuals living with HIV/AIDS Healthy People 2020 goals and objectives

27 Statewide Coordinated Statement of Need The purpose of the SCSN is to provide a collaborative mechanism to identify and address significant HIV care issues related to the needs of PLWHA and maximize coordination, integration, and effective linkages across the Ryan White HIV/AIDS Programs Important elements include: Describing the needs of individuals who are unaware of their HIV status The Early Identification of Individuals living with HIV/AIDS (EIIHA) National HIV/AIDS Strategy (NHAS)

28 Factors Affecting HIV/AIDS Services Nationally 1. Epidemic is growing among traditionally underserved and hard-to-reach populations 2. Because of available and emerging therapies, people with HIV/AIDS can live long and productive lives 3. Changes in the economics of health care affect the HIV/AIDS care network 4. Policy and funding increasingly are determined by clinical outcomes and administrative accountability 5. Treatment is Prevention 6. Implementation of the Affordable Care Act

29 Legislative Context: Factors and Major Themes 1. Ryan White Program has transitioned to a Chronic Care Model 2. Increased focus on getting people into primary medical care and keeping them in care 3. Increased focus on getting individuals tested and into care early (EIIHA) 4. Limits on non-service costs 5. Focus on ensuring all funds are used -- use or lose Part B funding

30 Chronic Care Model Key elements of The Chronic Care Model (CCM) include the community, the health system, self-management support, delivery system design, decision support and clinical information systems. The goal of a CCM is to foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. For Ryan White Programs, this shift is reflected in the NHAS Goals; EIIHAA; providing PLWHA assistance in navigating medical and support services; educating PLHWA about the importance of adherence to medications; and retention and maintenance in care.

31 Core Medical and Support Services Most recent reauthorizations have emphasized core medical services 75% of service funds must be spent on core medical services Up to 25% of service funds may be spent on support services 75/25 Core Medical Services waiver

32 Ryan White Core Medical Services 1. Outpatient and ambulatory health services 2-3. Medications: AIDS Drug Assistance Program (ADAP) and Local Pharmaceutical Assistance Programs (LPAP) 4. Oral health care 5. Early intervention services (EIS) 6. Substance abuse services outpatient 7. Mental health services 8. Medical case management including treatment adherence 9. Health insurance premium & cost sharing assistance 10. Home health care 11. Home & community-based health services 12. Medical nutrition therapy 13. Hospice services

33 Ryan White Part A and Part B Support Services 1. Case management (nonmedical) 2. Child care services 3. Emergency financial assistance 4. Food bank/home-delivered meals 5. Health education/risk reduction 6. Housing services 7. Legal services 8. Linguistics services (interpretation and translation) 9. Medical transportation services 10. Outreach services 11. Psychosocial support services 12. Referral for health care/supportive services 13. Rehabilitation services 14. Respite care 15. Substance abuse services residential 16. Treatment adherence counseling 17. Services Provided through Consortia*

34 Support Services Must be: 25% of total service expenditures Approved by the Secretary of HHS Needed to achieve medical outcomes Medical outcomes = outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS Support Services must be linked to funded support services that result in positive medical outcomes

35 Focus on Getting People into Care Unmet need = need for primary health care among PLWH/A who know they are HIV+ & are not receiving HIV-related primary care Major legislative emphasis on reducing unmet need New emphasis on the unaware population(early Identification of Individuals with HIV/AIDS EIIHA) Improved testing means more people will need primary care and medications

36 National HIV/AIDS Strategy Three Primary Goals: Reduce the number of people who become infected with HIV Increase access to care and optimize health outcomes for people living with HIV Reduce HIV-related health disparities

37 Priority Issue # 1: Access to Care and Treatment Grantee Roles and Responsibilities Early Identification of Individuals with HIV AIDS Development of realistic and tangible plans Allocation and expenditure of dollars for services that support EIIHA goals and expected outcomes Partnerships and collaborations that help you achieve the intended outcomes Addressing Unmet Need Continued efforts to reach those out of care Service models designed to support the elimination of barriers to care, and increase knowledge regarding HIV disease, and the availability of services

38 Priority Issue # 1: Access to Care and Treatment (cont.) Grantee Roles & Responsibilities Access and retention in care for special populations Identification of special populations for your jurisdiction Data to increase understanding of their unique service challenges Services designed to reach individuals and families within the context of their Cultural understanding of health care Revising and revamping systems of care Enrollment and Eligibility Services such as case management Models such as use of peers, closer ties with testing, partner notification, DIS Chronic care model SCSN & Comprehensive Planning Processes

39 Priority Issue # 2: Access to Medication Therapy Grantee Roles and Responsibilities Dialogue with Project Officers to understanding of the structure, function and enrollment issues of each ADAP Conference Calls Diagnostic and Comprehensive site visits Working with States to enhance cost cutting and cost saving strategies On site technical assistance TA conference calls Written and electronic materials

40 Priority Issue # 3: Changes in the Economics of Health Care (cont.) Grantee Responsibilities Understand how the National Economy and your State s economy is impacting health care Grant Applications Progress Reports Monitoring Calls On site technical assistance TA conference calls Written and electronic materials Increase coordination with Medicaid, Medicare and Third Party Payers Maximize ability to generate and use program income

41 Priority Issue # 3: Changes in the Economics of Health Care (cont.) Grantee Responsibilities Understand State s implementation of the Affordable Care Act Understand the role of the Ryan White Programs in the context of State s implementation of the ACA Continued opportunities Challenges Strategic and necessary changes Strengthening of partnerships

42 Priority Issue # 4:Accountability Administrative Accountability National Monitoring Standards (program and fiscal accountability) Subcontractor monitoring OIG/GAO Audits How demonstrate responsible stewardship of federal funds? Data Collection and Reporting Client level data Reporting to Congress Who our programs serve and what we do? Clinical Quality Management Programs Quantitative information on impact and continued efforts to improve What difference does the program make?

43 Project Officer Roles Track, review, feedback and approve Grant reporting requirements Conditions of Award Submission of grant request Provide technical assistant and facilitate TA requests Notice of Grant Awards (tracking) Work with Grantees to improve the system of care Needs Assessment Service Planning Service Delivery Service Evaluation Communicate Grantee activities and concerns

44 Summary Changes to the legislation, and the treatment of HIV disease Challenges to the delivery of the HIV services and the need to reach populations in need Changing landscape of healthcare delivery with arrival of ACA Outcomes and administrative accountability are important to HHS, Congress, and the future of HIV treatment

45 Contact Information Kerry Hill, MSW Public Health Analyst,NECSB Phone: (301)

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