• Contents
• Introduction
• Study 1: Ryan White CARE Act Reauthorization 2005: Title I and Title II Health Services Expenditure Patterns
• Study 2: Examination of Key Fiscal Issues Related to Grantees of the Ryan White Comprehensive AIDS Resources Emergency Act
• Study 3: Assessing the Impact of the Ryan White CARE Act Title II Emerging Communities Formula Grant Program

Study 2
EXAMINATION OF KEY FISCAL ISSUES RELATED TO GRANTEES OF THE RYAN WHITE CARE ACT

Julia Hidalgo AND Wendy Warcolik-Moody

Purpose of the Study

The HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA) contracted with Positive Outcomes, Inc. (POI) to (1) closely examine three legislatively mandated requirements of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act to provide HRSA with a clearer understanding of congressional intent to share HIV costs with grantees and the primary payers of HIV-infected persons’ care, including State, municipal, and other payers; and (2) provide HAB with a better understanding of whether and how these mandated requirements are being met by grantees during times of change in health care financing and during an economic downturn. The three fiscal requirements are maintenance of effort (MOE), matching funds, and payer of last resort (PLR).

Background

State and Local Funding Crisis

In recent years, the Ryan White CARE Act has operated in a highly dynamic, constrained financing environment. At the Federal level, HAB has experienced flattening in Congressional appropriations except for funds allocated to AIDS Drug Assistance Programs (ADAPs). At the same time, State and local taxes as a percentage of gross domestic product are at their lowest levels since the late 1980s. State, county, and local governments throughout the United States report significant fiscal crises. The National Association of State Budget Officers reports that beginning in fiscal year (FY) 2001, States experienced the worst budgetary situation in 60 years.1 From FY 2001, State revenues declined for eight consecutive quarters, with slight recent growth among some States. The decline of personal income tax and other State revenue sources contributed to the fiscal crisis. Although revenue appears to be improving among some States, other States project large budget shortfalls in FY 2005 because of decreased tax revenue. In 30 States with shortfalls, deficits range from $39 billion to $41 billion or about 7 percent to 8 percent of State expenditures. Current deficits were offset by one-time-only Federal Medicaid funds to help State governments cover sharply rising Medicaid expenditures. Although State tax revenue is projected to increase for some States, rising Medicaid expenditures are likely to continue to result in budget shortfalls without additional Federal funding intervention.

Although some States have raised taxes to offset their deficits, the principal solution taken by States has been to cut spending. Real per capita State spending dropped by $56.9 billion (5 percent) between 2001 and 2004. States have taken several approaches simultaneously. Many States have reduced spending through across-the-board cuts of all State programs. Other spending cuts have come in the form of elimination or significant reduction of funding for specific programs. Public health programs, including HIV/AIDS prevention, surveillance, and treatment, have experienced significant reductions in State funding. Most States also have reduced spending through one-time-only savings: layoffs, cutting vacancies, and reducing services. One-time-only savings help initially to reduce deficits, but they do not yield long-term solutions to insufficient revenue.

Medicaid programs, the fastest growing component of State budgets, have attempted to slow growth in expenditures by reducing the number of new and ongoing beneficiaries, eliminating optional benefits, or reducing payments to providers. Many Medicaid programs have narrowed eligibility criteria, eliminated programs, reduced benefits, lowered payments to providers, capped utilization, added or increased beneficiary cost-sharing, and expanded mandatory managed care enrollment. To reduce rapid growth in pharmaceutical expenditures, Medicaid programs have eliminated drugs from their formularies, capped the number of refills allowed, required use of generic medications, and restricted the number of retail pharmacies participating in Medicaid. At the same time, State-only health insurance programs have been cut or eliminated, including health insurance pools, medically needy or indigent programs, and pharmacy assistance programs (PAPs). Some States have also eliminated enrollment of parents from the State Children’s Health Insurance Program.

Although no single source of county and local public funding data is available, a survey conducted by the National Association of Counties in 2003 found that almost three-quarters (72 percent) of responding counties had budget deficits.2 Reductions in State funding for State-mandated programs were reported by 56 percent of responding counties. One-quarter of responding counties were planning to decrease public health funding. County and local governments depend heavily on Federal and State funding, so recent cuts in funding from those sources have exacerbated declines in local tax revenue. Hospital tax districts, the home of some CARE Act grantees, have also experienced sharp drops in tax revenue and Medicaid and other third-party reimbursement (TPR) while the number of their uninsured patients has risen rapidly.

CARE Act Fiscal Requirements

Since the authorization of the CARE Act in 1990, Congress has had an implicit expectation that State and local governments, other funders, grantees, and subgrantees3 would share the financial burden of HIV treatment and support services.4 The expectation that States would contribute financially to HIV services was underscored through the CARE Act maintenance of effort and match requirement. Congressional intent that the CARE Act be the PLR and that CARE Act clients with financial means contribute through copayments has been incorporated in the CARE Act since its authorization.

Table 1 illustrates that the three fiscal requirements have variable application to the titles of the CARE Act. While the match requirement relates only to Title II, the MOE requirement relates to Titles I, II, III, and the Dental Reimbursement Program (DRP). The PLR requirement relates to all Titles of the CARE Act but not to the DRP.

Table 1. Three CARE Act Fiscal Requirements, By Title and Part F

Fiscal Requirement	Title I	Title II	Title III	Title IV	Part F: Dental Reimbursement Program
Matching Funds*		+
Maintenance of Effort		+	+		+
Payer of Last Resort	+	+	+	+
* The matching fund requirement applies only to Title II grantees with more than one percent of the U.S. AIDS cases reported for the two most recent fiscal years.

When Congress authorized the CARE Act in 1990, it was impossible to predict that widespread financial downturns would trigger significant public funding crises at the State and local levels. Although many grantees are committed to ensuring State and local HIV services funding, the need to sustain basic public functions and address broad fiscal requirements has created substantial pressure on grantees to eliminate or reduce funding for HIV services. At the same time, grantees and subgrantees are more dependent than ever on CARE Act funding because other sources for support of HIV services are eroding. In moving toward reauthorization of the CARE Act in 2005, HAB staff wishes to have a comprehensive understanding of congressional intent of the CARE Act’s fiscal requirements and the challenges that grantees are encountering in meeting those requirements.

Project Goals

1. Examine three legislatively mandated requirements to provide HRSA with a clearer understanding of congressional intent to share HIV costs with grantees and primary payers of HIV-infected persons’ care.
2. Provide HAB with a better understanding of whether and how these mandated requirements are being met by grantees during times of change in health care financing and during an economic downturn.

Methodology

Qualitative case study methods were used to undertake an in-depth analysis of the impact of the three fiscal requirements on HIV-infected persons, their care, and the finance and delivery systems that undertake that care. Case study methods were used to identify and assess the contextual issues related to direct care, policies, and programmatic issues. These activities were conducted in 2003 and 2004.

Several approaches were undertaken, involving six steps:

1. A structured script was used to guide focus groups of approximately 70 Title I and II grantees at grantee meetings convened in July and August 2003.
2. An electronic mail solicitation requesting comments regarding the three fiscal requirements was transmitted to all CARE Act grantees.
3. Interviews were conducted with HAB staff responsible for the management of the titles of the CARE Act and the DRP.
4. Telephone interviews were conducted with State ADAP staff regarding supplemental ADAP funding.
5. Intensive case studies were conducted in six communities.
6. Interviews were conducted with representatives of the Department of Veteran Affairs (VA) and the U.S. Department of Housing and Urban Development.

The various routes available for CARE Act grantees to participate in the study made it difficult to compute a response rate among grantees or subgrantees or clearly define the denominator. As a result POI did not estimate the percentage of grantees or subgrantees that provided specific feedback.

The case studies broadly describe the impact of the three fiscal requirements on large populations of HIV-infected individuals and HIV care systems that receive CARE Act funding. Funds were available to conduct six case studies. The resulting case studies are illustrative of, but are not generalizable to, all CARE Act grantees and subgrantees throughout the United States. Composite economic indicators were developed by POI to identify communities in which there had been a recent documented downturn in the economy. The criteria used to select the case study sites include the following:

• Regional dispersion so that communities in the West, Southwest, Central, Southeast, and Northeast were included among the sites selected. Not all States within these regions experienced recent financial documented downturns, however, based on the economic indicators studied.
• Location in a State with more than 1 percent of the U.S. AIDS cases reported for the two most recent fiscal years.
• Location in a State with a Title II match requirement.
• Location in a State in which there has been a documented downturn in the economy, as based on composite economic indicators.
• Location in a metropolitan statistical area that qualifies as a Title I eligible metropolitan area.
• Title I, II, III, IV, and DRP funding in the community.
• Willingness of the Title I and Title II grantee lead agencies to participate in the case study.

To conduct the case studies, POI staff sent invitations to the Title I grantee’s lead agency in each of the communities initially selected for participation in the case studies. A similar invitation was sent to the State’s Title II program in which the community of interest is located. The invitations outlined the case study methods to be used and stressed the voluntary nature of participation in the assessment. Once the Title I and II grantees agreed to participate in the case study, key informants were identified. A representative from each of the CARE Act grantees was asked to participate in an onsite interview. The Title I, III, and DRP representatives were asked to address issues regarding MOE and PLR. The Title II representative was asked to address issues regarding match, MOE, and PLR. The Title IV representatives were asked to address PLR issues. If more than one Title III, Title IV, or DRP was operating in the community of interest, two grantees from each CARE Act program were randomly selected for participation in the case study.

Before the site visits, the HIV financing and delivery system of each case study community was assessed using secondary information from several sources:

• Match and MOE data for the 3 years of previous CARE Act grant applications were obtained for the selected communities, and trends were computed.
• The most recent grant applications were obtained from HAB. Titles I, II, III, and IV and DRP grantees operating in the selected communities provided their PLR policies and procedures before the site visits.
• A CARE Act Data Report (CADR) for each agency in the communities of interest funded by the CARE Act was obtained to gain background information regarding the insurance coverage of clients served, types of services provided that might be covered by third-party payers, and other client-based data.
• TPR data were obtained for the case study communities. A summary of the Medicaid State Plan was obtained from HRSA to identify which services are covered in the Medicaid fee-for-service program and managed care contracts. Information was also obtained from State-funded health insurance pools, hospital tax districts, county or local medical indigent pools, or other publicly funded programs.
• An Internet search of major local newspapers published in the communities of interest was conducted to identify current or recent crises in public financing.
• A structured interview instrument was used to conduct onsite or telephone interviews.

Limitations

Several limitations hampered this study:

• The State and local financing environments in which the CARE Act operates were highly volatile during the study period. While the funding of public financing systems stabilized in some communities, in others the economic environment continued to worsen. The absence of a nationwide State and local public financing monitoring system made it difficult to monitor closely the impact of the State and local financing system on CARE Act–funded systems.
• No “real time” data were available to monitor the extent to which CARE Act grantees were able to adhere to match and MOE requirements. Because grantees reported on expenditures that occurred 2 years previously, a grantee might not meet the match and MOE requirements in the most recent “reporting year” but may have subsequently met its match and MOE requirements.
• Enforcement of the PLR policies by CARE Act grantees and subgrantees is complex. Numerous third-party payers fund services for people who are HIV infected. Their eligibility requirements and covered benefits vary significantly, and rapidly shifting program modifications took place during the study period. State Medicaid programs greatly modified their eligibility, covered benefits, and payment policies, and HAB and the VA drafted a policy regarding the coverage of veterans by CARE Act grantees and subgrantees.
• Some grantees and subgrantees were reluctant to be interviewed because they were concerned about disclosing their inability to comply with certain HAB policies or considered the policies to be an impediment to meeting the needs of HIV-infected people in their communities. To address the concerns of grantees and subgrantees, POI agreed not to disclose the names of the States or communities in which they worked. This accommodation precluded POI from providing specific examples of policies and practices that might be of interest to readers of this report.

Major Findings

Title II Matching Funds

The Title II matching fund requirement was introduced in the 1990 CARE Act authorization. States and territories (except Puerto Rico) with greater than 1 percent of the aggregate number of total U.S. AIDS cases must match CARE Act Title II funds.5 The match ratio is $1 in non-Federal funds for every $5 in Title II grant funds in the first through fourth year of Title II funding. The match ratio increases to $1 in non-Federal funds for every $2 in Title II funds for the fifth and subsequent years. Matching funds may be in cash or in-kind fairly evaluated funds, including physical plant, equipment, or services.

States are asked to estimate how they will make their match in their proposed budget submission to HAB. However, in their final Financial Status Report (FSR), which is due 90 days after the end of the budget period, States must show their match expenditure in relation to the amount of federal funds expended. FSRs are submitted to the HRSA Grants Management Office for review. In addition, the match requirement is a component of the A-133 audit compliance requirements. The failure to meet this requirement should be noted in the A-133 audit compliance document that is submitted by all States to the Department of Health and Human Services Audit Center. If a State has not met its match requirement, this should have been reported to HAB. To date HAB staff are not aware of HAB receiving such a notification.

Through extensive interviews, focus groups, and electronic mail correspondence, many Title II grantees reported that the match requirement has been effective in either avoiding or minimizing cuts to State HIV budgets. Nonetheless, the match requirement did not prevent the cutting of State funds during recent financial crises. Grantees interviewed by POI reported that beginning in FY 2002, HIV expenditures dropped significantly as a result of across-the-board cuts and elimination or significant reduction of HIV program spending. Some State funds generated by the cuts were used to offset State deficits, while others were reallocated to Medicaid, education, and other State programs. Several other States reported that some HIV programs were specifically cut by incoming gubernatorial teams that were not supportive of HIV programs.

Some grantees reported, however, that during the past 12 to 24 months, they have experienced difficulty sustaining their matches. Growing State fiscal deficits have increased the need to continue across-the-board cuts or to initiate cuts of specific programs, such as HIV programs, that were not cut in earlier cost-cutting rounds. As ADAP earmark funds have increased, Title II grantees reported, it has become difficult to sustain and increase their matches because of State budgetary crises. State Title II grantee staff reported that they are not in control of their HIV program budgets or the budgets of Medicaid and other programs that contribute to the match. Grantee staff also reported that in negotiating with budget policy makers, their HIV budgets had to compete with education, Medicaid, public safety, and transportation programs. Community advocacy for HIV budgets is reported to have waned considerably, making it difficult to make the case during budget negotiations that HIV funding should be sustained while other budgets are cut.

States experiencing cuts in funding reported a significant reduction in their capacity to support HIV prevention, care, and surveillance programs. Loss of support for HIV and AIDS surveillance activities is likely to result in decreased case counts used to allocated CARE Act Title I and II funds. As a result, decreases in State and local funds could ultimately result in decreased CARE Act formula-based awards.

The CARE Act includes no provision for HAB to waive the match requirement for States unable to meet their matches. The penalty made available by Congress to enforce the match requirement is reducing the grantee’s award. In focus groups conducted by POI, some Title II grantees expressed concern that if the match requirement is not enforced, it will be difficult in the future to convince policy makers that the match requirement must be met. They expressed concern that a lack of enforcement of the match requirement may be seen by State officials as an opportunity to cut additional HIV funds, as they might believe no negative impacts would result.

Maintenance of Effort

The MOE requirement was introduced in the original CARE Act legislation in 1990. Grantees are required to maintain a level of HIV expenditures for services at an amount that is equal to the levels of expenditures in the preceding year. The MOE provision under Titles I, II, and III states that the Secretary “shall not make a grant under this subsection if doing so would result in a reduction of State funding allocated for such purposes.”3 Federal funding can be decreased, but not directly as a result of a reduction in other Federal funds, including reduction in CARE Act funds received by Title I, II, or III grantees.

Information regarding the method used to calculate the MOE was initiated by Title I and II grantees in 1997 and data submissions in 1998. The extent to which States, counties, and cities have invested in HIV infrastructure has changed considerably since that time. Although some grantees have adjusted their MOE figures, many have done so only slightly over the years or have reported the same amount of funds for the past 3 to 4 years. Moreover, some grantees claimed no MOE. Although those grantees and their jurisdictions may well support HIV-related activities with non–CARE Act funds, they have not reported an MOE because they do not want to be held to that expenditure level in future years.

Among State Title II grantees, the reported MOE amounts vary greatly (from $50,000 to $37 million). Three Title II grantees did not report an MOE. Many of the State Title II grantees that reported difficulty in sustaining their matches also reported having trouble sustaining their MOE. The exceptions were those States that initially reported low MOE in their first Title II grant application and did not significantly increase their MOE subsequently. Eight Title II grantees did not meet their MOE in their initial FY 2003 Title II applications, although several were able to restore their MOE in subsequent submissions to HAB.

Among Title I grantees, the MOE varies greatly (from $1,000 to $91 million); four grantees reported no MOE amount. Title I grantees reported using a process to determine the MOE that is similar to the mechanism used by Title II grantees in quantifying their MOE.

Many Title I grantees reported having difficulty in meeting their MOE. Many Title I grantee staff that POI interviewed reported that county and city governments were experiencing substantial deficits as a result of inadequate tax revenue, decreased Federal and State funding, and outlays for public safety related to homeland security. Many of the agencies contributing to Title I MOE, including hospital tax districts, also were reported to be experiencing deficits. Seven Title I grantees did not meet their MOE in their FY 2003 applications but did meet the requirements in their FY 2004 grant applications. Several additional Title I grantees reported that they would be unable to meet their MOE requirements in their FY 2005 Title I grant applications.

Because of growing deficits at the local government level, several grantees reported that agencies and jurisdictions contributing to the MOE effort had cost-shifted to reduce their deficits. Their MOE level appears to be sustained; however, the estimated figure includes costs for personnel that do not provide management, administrative, or direct services related to HIV programs. Such cost-shifting has been identified and discontinued in some but not all cases.

Some Title I and II grantees expressed concern that the MOE requirement is not an equal burden. In the current fiscal environment, grantees that have not contributed an MOE are unlikely to do so without a statutory requirement. Grantees with relatively high MOE levels reported that they are bound to expenditure levels that are difficult or impossible to sustain.

The CARE Act Title I and II MOE requirement was not accompanied by an enforcement mechanism. Therefore, HAB staff cannot directly penalize grantees that fail to meet their MOE requirement. HAB project officers do, however, contact grantees that fail to meet their MOE to determine the barriers to meeting the requirement. They advise them regarding possible funding streams that might be used to make up the shortfalls in reporting MOE figures.

MOE submissions are retrospective: Title I and II grantees report on expenditures that occurred 2 years previously. HAB staff reported that the retrospective nature of MOE reporting makes enforcing the requirement difficult. Moreover, the documentation provided regarding the sources of funds making up the MOE is limited and difficult to audit and evaluate. In reviewing the MOE documentation provided by Title II grantees, it appeared that some grantees have maintained their effort through supplanting of Federal funds. In turn, Title I submissions appear to document supplanting of Title I funds with State and CARE Act funds, including funds obtained through Titles II and III.

The Title III Early Intervention Services program and the DRP also have an MOE requirement that prohibits “any reduction in State funding allotted” to the DRP. These references constitute a technical error that may be addressed in 2005 CARE Act reauthorization language.

Payer of Last Resort

The PLR requirement was introduced in the initial authorization of the CARE Act and is found in Parts A, B, C, and F of the act. Implementation of this requirement has been addressed primarily in grant guidance and in additional instructions disseminated in December 2002 to CARE Act grantees.6 No specific enforcement mechanism is outlined in the CARE Act.

The PLR requirement was outlined in the December 2002 letter to CARE Act grantees from the HAB Associate Administrator. The letter covers HAB policies regarding billing to third-party payers and other sources, cost of billing third-party payers, retrospective billing for incurred costs, case management payments, use of TPR to support subgrantee programs, crediting of subgrantee budgets for TPR by subgrantees and retention of those revenues, use of TPR by subgrantees, Medicaid provider status, Medicaid professional credentialing requirements, allowable costs associated with development of billing capacity and credentialing of staff, and application of a sliding fee scale. In focus groups, numerous interviews, and electronic mail consultations with POI, CARE Act grantees and subgrantees reported that they were either unaware of the CARE Act PLR policies or unsure about how to implement them. CARE Act grantees tend to be notified of CARE Act PLR policies through grant guidance. For example, although Title III EIS grantees are instructed in grant guidance to participate in Medicaid and maximize reimbursement available from third-party payers, no specific mechanisms are provided to implement the policy. Grantees also reported that they do not provide specific requirements regarding implementation of the PLR by their subgrantees.

CARE Act grantees and subgrantees commonly receive funds from the Centers for Medicare and Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Housing Opportunities for Persons With AIDS program, the VA, the Centers for Disease Control and Prevention, and other Federal agencies. They also commonly receive State and local government funds. CARE Act grantees and subgrantees reported that these funders have informed them that they are the PLR and that CARE Act funds should be expended before their funds are used.

Grantees and subgrantees reported that cost-shifting occurs between CARE Act programs, each of which claims that they are the PLR. For example, some subgrantees reported that they have been told that they would no longer be eligible for Title I or Title II funds upon award of Title III or Title IV funds.

Grantees and subgrantees reported that they have received conflicting advice from HAB project officers and technical assistance providers regarding CARE Act TPR requirements. Subgrantees also reported that they receive conflicting advice from grantees regarding PLR policies.

Sliding Fee Scale

One component of the PLR is the assignment of copayments to CARE Act clients. The CARE Act specifies that if a direct service grantee (e.g., Titles III or IV) or subgrantee of Title I or II charges for services, it must do so using a sliding fee schedule that is made available to the public. Application of cost-sharing among Federally funded clients is consistent with other Federal health care programs.

CARE Act grantees or subgrantees may use their discretion in the case of clients subject to a charge, to assessing the amount to be charged, including imposing only a nominal charge for the provision of service. The grantee or subgrantee must take into consideration the medical expenses of clients in assessing the amount of the charge.

Individual, annual aggregate charges to clients receiving CARE Act services must conform to statutory limitations, applying to the annual charges imposed for all CARE Act services regardless of whether they are considered enrollment fees, premiums, deductibles, cost-sharing, copayments, coinsurance, or other charges. This requirement applies to all subgrantees from which a client receives CARE Act services. The grantee can waive the requirement for a subgrantee if it does not impose a charge or accept payment from any third-party payer, including payment under any insurance policy or any Federal or State health benefits program. The intent of the sliding fee scale is to establish a ceiling on the amount of charges to clients of services funded and to share the cost of services with clients who have financial means. To determine the amount to be paid by clients, a simple application requesting annual gross salary of the individual or family can be used to establish a baseline for establishing a fee cap.

CARE Act grantees and subgrantees described the act’s sliding fee scale policy as complex and burdensome. In interviewing CARE Act grantees and their subgrantees, POI learned that sliding fee scales rarely were applied in the manner outlined by Congress in the CARE Act. A small portion of HIV programs in agencies with mandatory sliding fee scales (e.g., federally qualified health centers, hospital tax districts, county health systems) did apply sliding fee scales, but the scales applied might vary from those specified by the CARE Act. Facilities commonly request out-of-pocket payments, collect the payments, and assign a patient to collections if he or she does not make the out-of-pocket payments on a timely basis. CARE Act grantees and subgrantees reported that some agencies with mandatory sliding fee scales have aggressive collection processes that often require intervention by case managers or legal aid attorneys.

In other community-based and CARE Act–funded agencies without a culture in which sliding fee scales are applied, the CARE Act sliding fee scale requirement was reported to be impractical and not used. No single point of eligibility determination or accounting for out-of-pocket payments is available to determine when the maximum amount is reached. Clients were reported to be unable to maintain the records necessary to document their out-of-pocket payments. Reception personnel were reported to feel uncomfortable asking for out-of-pocket payments, particularly from unemployed patients without health insurance.

Some CARE Act–funded grantees and subgrantees reported that they are structurally unable to collect out-of-pocket cash payments from clients. Their agencies’ policies prohibit them from handling cash, some reception staff have criminal records or are located at unsecured desks, or they have no secure means of transporting cash to the bank. HIV programs in large institutions reported that although their agencies can accept credit card payments, their accounting systems do not specifically track out-of-pocket payments made by their clients, and the funds are not returned to their budgets as grant income. These barriers are encountered in small and large institutions.

Several HIV programs have assessed the cost of implementing the CARE Act sliding fee scale policy. They reported that the additional costs associated with ensuring the physical security of employees handling cash, safe transport of cash to the bank, staff training, and accounting charges far outweigh the income projected to be generated by applying the sliding fee scale.

The CARE Act stresses that care should not be withheld from clients who do not have the means to pay their copayments based on the sliding fee scale. Several grantees and subgrantees interviewed by POI staff reported that some clients refuse to pay their copayments because they are aware that they cannot be refused services.

The CARE Act includes no enforcement mechanism to ensure application of the sliding fee scale policy. FSRs cannot be used to accurately estimate the amount of grant income that should have been generated by out-of-pocket payments resulting from the sliding fee scale. In addition, it is difficult to differentiate grant income generated by the sliding fee scale versus the cost-sharing mechanism of third-party payers (e.g., copayments and deductibles). Grantees and subgrantees do not submit data to HAB that would allow accurate calculation of the amount of grant income that should be generated. Similarly, it is difficult for grantees to assess whether their subgrantees are collecting sufficient out-of-pocket payments from eligible clients.

Eligibility Determination, Coordination of Benefits and Participation in Third-Party Reimbursement: Background

HAB’s policies regarding eligibility determination and participation in TPR systems were outlined initially in an August 10, 2000, policy letter. A subsequent letter from the HAB Associate Administrator outlined HAB’s policies in a question-and-answer format. Enforcement by HAB of these requirements is primarily through response to grant guidance. Review of grant income in FSRs and CADR data collected by HAB staff may also be used to assess whether grantees and subgrantees are adhering to these requirements. These data are insufficient to estimate the extent of TPR revenue that might be expected if grantees or subgrantees adhered to these requirements. Moreover, substantial variability exists between and among health care markets in health insurance enrollment among CARE Act clients, covered benefits, and payment levels. In Titles III and IV, periodic site visits by HAB staff and consultants assess TPR and other fiscal issues. These visits, however, are commonly spaced over several years and some grantees and subgrantees may not be visited very frequently. HAB staff may therefore be unable to assess the extent to which TPR policies are implemented.

Eligibility Determination

Policy: CARE Act grantees and providers should facilitate their clients’ enrollment in other TPR programs for which they may be eligible for benefits. To facilitate client enrollment, CARE Act–funded agencies should provide information about enrollment options and referral for eligibility determination.

Findings

Many CARE Act grantees and subgrantees reported that there commonly is no single point of eligibility determination information and assistance for their clients. Rather, clients and their case managers or other advocates must seek information from myriad agencies, many of which change their eligibility criteria on an annual or more frequent basis. Criteria for enrollment are highly variable and include such requirements as geographic residency; U.S. citizenship; legal residency status; age [e.g., Temporary Assistance to Needy Families (TANF); Medicare]; tribal membership (e.g., Indian Health Service); race/ethnicity (Minority AIDS Initiative); family composition (e.g., TANF); veteran status; previous financial contributions by the client [e.g., Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)]; employment status and employer insurance purchasing arrangements (for employer-based insurance plans); preexisting medical conditions, disability, and employability (e.g., SSI); income; assets; HIV serostatus; CD4 count; annual or lifetime utilization of benefits; and criminal convictions. The application materials required for enrollment are not always readily available and often require a reading level beyond the client’s capability.

Few CARE Act grantees reported establishing multiagency processes to ensure that all new clients enrolled in CARE Act services are uniformly and accurately screened for eligibility for public and commercial health insurance, income maintenance, and entitlement programs. None of the grantees interviewed has systematically identified key sources of eligibility determination and TPR in its community and communicated the contact information to its subgrantees. Rather, staff of CARE Act direct service grantees and subgrantees have established their own processes for screening, information gathering and referral, and helping clients gain eligibility. In discussing the processes used to screen and refer clients, CARE Act grantee and subgrantee staff reported that highly variable effort is made to assist clients. Some agencies act as advocates for their clients in their efforts to enroll in non-CARE Act programs. Among other agencies, program staff might suggest that a client seek enrollment in a program but provide little information about how to undertake an application. Interviews with many line staff in case study sites revealed a lack of knowledge about eligibility options for people living with HIV/AIDS and limited understanding of other non-HIV systems for which their clients might be eligible, such as HUD non-HIV housing programs, mental health and drug treatment programs, vocational rehabilitation, and food and nutrition programs.

In interviewing grantees and subgrantees throughout the United States, POI found that many grantees and subgrantees assume that CARE Act–funded case managers will help clients who are eligible with entitlement and other programs. Case managers reported, however, that their caseloads are far too large for them to be able to become familiar with the eligibility criteria and application procedures of the myriad programs for which their clients might be eligible. Many case managers reported that although they attempt to inform clients at initial intake that they may be eligible for a program, it is impossible to help actively all clients apply successfully to the programs for which they are eligible. Case managers also reported that rapidly growing caseloads hinder them from systematically redetermining clients’ changes in status that might trigger eligibility in another program. As a result, clients may experience significant changes in income, employment, or disability status but are not aware that the changes may make them eligible for public or commercial third-party insurance coverage or income assistance. Case managers also reported that they lack the time for and access to online eligibility verification systems (EVSs) to confirm that their clients are retaining their health insurance and other coverage. Some clients reportedly lose Medicaid benefits, for example, because they are unaware of redetermination appointments.

In conducting case studies across the United States, POI identified high rates of turnover among CARE Act–funded case managers. Because of low entry-level salaries, newly employed case managers tend to be relatively inexperienced and unfamiliar with the eligibility criteria for key health insurance, disability, and income maintenance programs. As a result of their high caseloads, new case managers commonly do not have the time available to receive training regarding benefits coordination.

Several CARE Act grantees pointed out that many of their subgrantees do not have the staff or expertise to undertake client eligibility screening for health insurance, income maintenance, or disability benefits. They suggested that the HAB policy puts an unrealistic burden on many CARE Act–funded agencies and that clients “fall through the cracks” because of the lack of coordination among CARE Act–funded programs, the absence of a single source of CARE Act eligibility determination, and the scarcity of communitywide, automated, CARE Act client–based information systems.

CARE Act grantees and subgrantees who participated in the interviews reported broad variations throughout the United States in the nature and frequency of their programs’ redetermination efforts. HAB policy requires the periodic redetermination of CARE Act clients, both to continue participation in the program and to identify other sources of third-party payment for which those clients might enroll. HAB has not recommended a uniform time period within which redetermination should take place; which agency or agencies are responsible for redetermination; or which “triggers” are highly suggestive of a change in disability, employability, or other factors pertinent to assessing eligibility for commercial disability insurance, SSI, or SSDI. Some CARE Act providers reported uniformly reassessing clients at each visit. Other clients are redetermined only on admission to a hospital for an initial AIDS-related opportunistic infection or other condition; hospital discharge planning staff initiate the determination.

State ADAPs eligible for supplemental funds and those with waiting lists were interviewed by POI staff. Most State ADAP staff reported that they rely heavily on community-based case managers to screen clients for eligibility for ADAP, Medicaid, and other programs. Few of the State ADAPs conduct routine training with community-based case managers regarding ADAP. ADAP staff also reported that they did not routinely communicate with community-based case managers to ensure that consistent, accurate, and timely screening, referral, and application preparation was taking place for enrollment in public or commercial health insurance or income maintenance programs.

Several case study participants observed that the number of HIV-infected, employed people seeking CARE Act services has increased because many employers no longer can purchase affordable health insurance for their employees. They also report that many employers are hiring employees who are not eligible for health insurance benefits. At the same time, some commercially insured people seek CARE Act services to avoid disclosure of their HIV serostatus to their employer-based health insurance plans.

CARE Act grantees and subgrantees throughout the United States expressed considerable confusion regarding application of PLR among veterans. As a result, some State ADAPs, CARE Act grantees, and subgrantees have denied CARE Act services to veterans. To clarify its position regarding veterans, HAB recently released a policy designed to clarify the HAB’s expectation that veterans should be able to access CARE Act programs.7 As with the coordination of benefits with third-party payers, it is likely that case managers and other staff of CARE Act grantees and subgrantees will have insufficient knowledge of the VA system to provide well-grounded information and referral. The responsibility for HIV-infected veteran information and referral services may be viewed by CARE Act grantees as an unfunded mandate for which they have insufficient resources and expertise.

Many CARE Act grantees reported that gaining enrollment in publicly funded disability programs, including SSI, is very difficult. The Social Security Administration (SSA) delegates the evaluation and processing of disability claims to States. State-by-state SSI denials by States for HIV-infected applicants are not made available by SSA. Based on POI’s case study interviews, however, the processing time and denial rates for SSI applications vary considerably. Numerous case managers, patient advocates, and legal aid staff reported that initial denial of SSI claims is common, and substantial legal intervention is required to contest claims. Several HIV care providers reported that State disability staff reported that clients may not submit a claim more often than once a year, an inaccurate interpretation of SSA policy. Denials for applications are often a result of what SSI determination personnel deem to be insufficient medical documentation of inability to sustain gainful employment due to disability and a sufficient level and duration of disability.

SSDI eligibility is triggered in part by documentation of a disability lasting in excess of 24 months, so documentation of the onset of disability in SSI applications is important. Despite the critical pathway to Medicaid and Medicare coverage and income maintenance that SSI afford, few ADAP or other CARE Act grantees reported that they have collaborated with State disability or SSA staff to increase the number of accepted SSI claims. At the Federal level, HAB staff reported that they have not collaborated with SSA to improve the award rates of SSI claims among HIV-infected people.

CARE Act grantees and subgrantees reported that many of their clients have benefited clinically from antiretrovirals and some clients are now able to return to employment. Many of those clients are reluctant to do so, however, because they do not want to lose their Medicaid or Medicare coverage.

The Ticket to Work/Work Incentives Improvement Act of 1999 (TWWIIA) includes an option for States to undertake demonstration projects to provide Medicaid to workers with potentially severe disabilities, such as HIV/AIDS, who are not yet disabled but whose health conditions could be expected to cause disability. Only two States have been awarded TWWIIA approval, and only one project has been implemented.

The client’s role in eligibility determination is not addressed well by many of the CARE Act grantees and subgrantees interviewed by POI. Some care providers assume that their clients are able to navigate the system, read, complete forms, and advocate for themselves. Determination processes that relied heavily on clients appeared to be unsuccessful, however. Paperwork that was viewed as important among providers often was not a high priority among clients who struggled with medical and personal challenges.

Policy: Until a CARE Act client is enrolled in Medicaid, grantees and subgrantees may provide services with CARE Act grant funds.

Findings

Among CARE Act grantees and subgrantees with access to Medicaid EVSs, this policy has been implemented successfully. The HIV programs closely follow the course of their clients’ applications and are commonly aware of the clients’ dates of application and enrollment (i.e., the period in which retrospective Medicaid billing may take place). Some grantees and subgrantees, however, do not have access to EVS.

Policy: Grantees and subgrantees are expected to explore out-stationing opportunities with State Medicaid agencies to place State eligibility workers at their sites.

Findings

Few CARE Act grantees or subgrantees participating in the case studies were aware that State Medicaid eligibility workers could be out-stationed at their programs. The few agencies that had arranged for out-stationed workers were in large institutions (e.g., hospitals, community health centers) that had arranged for eligibility workers for their business offices.

Policy: If a client is determined to be ineligible for Medicaid or other payers or if the services provided are not eligible for TPR, CARE Act grantees or subgrantees may use grant funds to provide those services without the need first to bill third-party sources, thus making the CARE Act grant the PLR.

Findings

For the most part, CARE Act grantees and subgrantees are aware of and adhere to this policy. However, several grantees in case study communities require as a condition of participation in CARE Act–funded services that HIV-infected clients receive a “notice of Medicaid rejection” letter before services can be initiated. Several State ADAPs also have adopted this approach in screening applicants. This process may take several months and HIV-infected clients may wait long periods before CARE Act–funded services are initiated.

In all the case study sites, an elimination or significant reduction in the capacity of publicly funded non-HIV housing, mental health, substance abuse treatment, and pantry and nutrition programs has occurred over the past 5 years. As a result, CARE Act clients are not able to obtain these services outside of the CARE Act system of care and supportive services. Many of the CARE Act grantees interviewed commented that significant and avoidable cost-shifting to the CARE Act has resulted.

Policy: Once a CARE Act client has been determined to be eligible for Medicaid enrollment, the grantee or subgrantee must bill Medicaid for any services rendered as of the client’s effective date of Medicaid enrollment.

Findings

CARE Act grantees without access to the Medicaid EVS reported that they sometimes are not aware of the outcomes of their clients’ applications to Medicaid. Clients are reported to sometimes be confused about the differences between Medicaid and CARE Act–funded services. As a result, clients do not make their CARE Act–funded HIV providers aware of changes in their insurance status.

Third-Party Reimbursement

Policy: If a CARE Act–funded agency does not provide a service covered by its State Medicaid program, there is no expectation that the grantee or subgrantee obtain a Medicaid provider number.

Finding

Several State Medicaid programs have placed a moratorium on issuance of additional provider numbers. Moratoriums are common for mental health and substance abuse provider numbers.

Policy: CARE Act funds may be used to pay for the costs of preparing to become certified as Medicaid providers. HAB considers this use of CARE Act funds to be an allowable cost for CARE Act grantees and subgrantees. CARE Act capacity development funds may be used for this purpose.

Findings

Several grantees and subgrantees interviewed by POI staff for the case studies reported that the costs incurred to become certified as Medicaid providers can be substantial. The agency and its staff must meet State licensing standards (as well as licensing requirements in county and city jurisdictions, in some cases). Other requirements include availability of telephone coverage on a 24-hour basis; numerous regulations; billing, accounting, and reporting systems that must be established or upgraded; malpractice and other liability insurance that must be obtained; quality assurance processes that must be put in place; capacity to enroll a defined number of clients that must be ensured; and Health Insurance Portability and Accountability Act and other electronic data transmission requirements that must be met. Several mental health and substance abuse programs interviewed, for example, would have had to terminate their line staff and supervisors to meet Medicaid credentialing requirements.

With flat or reduced CARE Act funding available for most grantees, many Planning Councils and consortia are unable to commit sufficient capacity development funds to assist subgrantees in becoming Medicaid providers. Among grantees allocating funds for this purpose, the amount of funding available has been insufficient to cover the costs required.

Policy: If an agency receives CARE Act funds for services that are eligible for TPR and grant funds, the agency must have a system in place to bill and collect from third-party payers.

Findings

Some grantees and subgrantees reported being confused as to what services are eligible for TPR from Medicaid or other third parties. Medicaid, Medicare, other publicly funded payers, and commercial payers vary considerably in their covered benefit packages. Even within programs such as Medicaid, covered benefits may vary by assistance category (e.g., TANF, SSI, etc.), by fee-for-service versus managed care programs, by county, and for waiver demonstration versus nondemonstration services.

Some community-based CARE Act–funded grantees and subgrantees tend to build billing systems. In several agencies, billing staff had insufficient management oversight and trained supervision. Many agencies interviewed have insufficient funds to employ credentialed billing personnel. Moreover, the volume of billings were insufficient to warrant employment of full-time claims-processing staff.

Policy: CARE Act grantees and subgrantees must bill all available sources of TPR and negotiate the best TPR rates possible if they provide covered services to clients enrolled in a third-party payer.

Findings

Some grantees and subgrantees acknowledged that they do not bill all available sources of TPR because the cost of generating the claim is greater than the expected payment amount. Additionally, some clients have requested that their employer-based insurance plans not be billed to prevent disclosure of their HIV infection. Other grantees and subgrantees reported that it is easier to draw upon grant funding to pay for the service than to seek TPR.

CARE Act–funded programs can bill for services only if they are contracted to participate in health insurance plans and managed care organizations (MCOs). Some CARE Act grantees and subgrantees reported unsuccessful attempts to enroll as providers in commercial indemnity insurance plans and Medicaid and commercial managed care plans. Those plans were reported to be concerned about adverse selection resulting from contracting with HIV care providers that might attract HIV-infected patients to enroll in their plans. In addition, HIV specialty clinics are viewed as being more expensive than community-based primary care physicians or infectious disease specialists. Nonparticipating HIV specialty clinics and other medical providers reported having insufficient capacity to serve referred patients seeking “out-of-plan” specialty care.

Many CARE Act grantees and subgrantees that provide billable services reported that they bill aggressively third-party payers but that payments are getting increasingly slower. They reported that payers tend to reject claims upon initial submission for nonexistent or spurious causes. In some cases, payers required substantial documentation for claims. Failure to document prior authorization or standing orders often is a rationale for rejecting claims, despite the completion of necessary paperwork at the time the service was provided. Although grantees and subgrantees reported that they routinely research and resubmit their claims, this process can extend the period between service and payment by many months.

Although HAB encourages CARE Act grantees and subgrantees to negotiate TPR rates, HIV care providers throughout the United States report that they have no bargaining power with Medicaid programs, health insurance plans, or MCOs. Moreover, Medicaid programs in several large States have rolled back reimbursement rates. In several other large States, Medicaid payment rates have not been increased in more than a decade. As a result, Medicaid rates no longer keep pace with steadily increasing personnel and operating costs.

In the past 15 years, State Medicaid programs, MCOs, and commercial insurance plans have established several model HIV reimbursement systems .Many of these programs have not been fully implemented, however, as a result of the absence of mandatory enrollment or because budget neutrality is no longer achievable, given sharp increases in HIV-related medication costs.

Despite HAB’s funding of TA and tool development, most of the CARE Act direct service grantees and subgrantees interviewed by POI were unaware of the actual cost of their services. Several grantees and subgrantees reported that they cannot access detailed overhead and related cost data from their institutions or that their accounting systems were not sufficiently flexible to report costs specific to their HIV program. As a result, grantees and subgrantees were unable to apply the tools developed by HAB.

Policy: CARE Act grantees and subgrantees are expected to bill third-party payers what it costs them to provide a particular service.

Findings

HAB expects that CARE Act grantees and subgrantees treat payment from third-party payers as payment in full. This policy has resulted in considerable concern among many of the HIV clinical providers interviewed by POI. Grantees and subgrantees in agencies ranging from large teaching hospitals to small, community-based organizations reported that TPR falls far short of their costs.

Most of the HIV medical providers interviewed report that they routinely perform services in medical visits for insured patients that that are not compensated by third-party payers. While an insurer may pay for a 15-minute medical examination, for example, the typical medical examination may take 30 to 60 minutes. Moreover, some medical services are outside the scope of their CARE Act contracts. Such services include medication education, adherence counseling, and secondary prevention counseling. Medical providers report that TPR falls far short in covering the expense of the medical visits as well as the complexity of the services provided.

Care Act–funded medical providers in case study communities reported that a new patient visit might well exceed 60 to 80 minutes, but third-party payers may pay only for a 30-minute visit. Third-party payers tend to pay clinical grantees and subgrantees at levels that are inadequate to compensate for highly intensive medical visits.

There was a lack of awareness among many CARE Act grantees and subgrantees paid by third-party payers that if a payer caps services, they might use CARE Act funds to purchase additional units of service. Examples of these capped services include home health visits and home hospice visits.

Most of the CARE Act–funded HIV clinics that attempted to adhere to TPR payment-in-full policies reported that their costs far exceeded their TPR revenue. Until recently, these clinics had benefited from considerable institutional support to make up the difference. As more institutions have experienced multidepartmental revenue loses, however, HIV clinics reported that institutional support has been cut or eliminated.

Many CARE Act–funded agencies interviewed by POI reported that TPR failed to keep pace with sharply rising costs, such as increasing salaries and fringe benefits. Similarly, throughout U.S. urban health care markets, collective bargaining and personnel shortages resulted in significant increases in nursing and ancillary personnel salaries.

Due to the financial pressures experienced by CARE Act subgrantees, several grantees reported allowing balance-billing by making up the TPR shortfalls with grant funds. In some case study communities, subgrantees were not routinely billing TPR because the cost of generating the bill exceeded the expected payment. In those situations, the subgrantees charged grant funds for the services instead.

In several case study communities, HAB’s recent announcement about essential core services has made implementation of the TPR requirements more complex.8 Core services include primary medical care, HIV-related medications, mental health treatment, substance abuse treatment, oral health, and case management. Except for case management, these services are commonly covered by Medicaid and other payers. Several unintended consequences were encountered. Among Title I and Title II programs in States with high rates of third-party enrollment among CARE Act clients, simultaneous implementation of core services funding and TPR as payment in full has contributed to budgetary shortfalls among providers. Because core services are the most likely services to be covered by TPR, grantees and subgrantees are expected to accept payment that is not offset by grant funds. At the same time, grantees may accrue large amounts of unexpended CARE Act funds. In contrast, in States with Medicaid programs that cover only the most indigent disabled or TANF populations or that offer narrow benefit packages, CARE Act core services are not covered and grantees and subgrantees can legitimately use CARE Act funds to pay for care.

Policy: CARE Act grantees and subgrantees may use CARE Act funds while Medicaid eligibility determination is pending. They must retroactively bill Medicaid for CARE Act–funded services provided to Medicaid beneficiaries during the retroactive enrollment period.

Findings

Many CARE Act clinical grantees and subgrantees reported that they adhered to this policy. For the most part, their billing systems allow retroactive billing. POI also found, however, that some State ADAPs and Title I PAPs do not have billing systems that can accurately execute retroactive billing.

Several State Medicaid programs had suspended retroactive billing for medications and other covered benefits in response to rapidly growing financial deficits.

Policy: HAB discourages CARE Act grantees from reducing grant funding for their subgrantees that collect TPR. Rather, grantees should encourage their subgrantees to maximize their CARE Act funds and collect TPR. Grantees and subgrantees are encouraged to use TPR grant income to expand or enhance HIV services to current clients and to identify and enroll new clients in the subgrantees’ service categories. TPR collected by CARE Act grantees and subgrantees should be used within the organization where the funds were collected if a broader range of services is needed, if existing clients need enhanced levels of service, or if new uninsured or other clients need services. Only when the subgrantee demonstrates no legitimate need should its CARE Act funds made up for by TPR be returned to the grantee or offset from its next award.

Findings

Most CARE Act grantees interviewed by POI reported that they adhere to this policy. Current flat or decreased grant awards to some CARE Act grantees, however, mean that TPR grant income is being used to sustain current capacity and meet the needs of existing clients. Losses in revenue and increased demand for services among existing clients have led some CARE Act grantees and subgrantees to be unable to initiate services for new clients on a timely basis. Waiting times for appointments for case management intake and new, nonurgent patient visits by some grantees and subgrantees exceed 6 weeks.

Policy: The parent institution or agency receiving a CARE Act grant must report TPR funds generated by the HIV program and return or credit these funds to the program’s budget. No legal authority exists to retain and spend CARE Act funds for purposes other than for approved HIV services. Where TPR is generated by CARE Act–funded services, those payments must be used for HIV-related services. TPR funds resulting from collection efforts by the CARE Act–funded grantee or subgrantee must be used to pay for HIV/AIDS services to eligible clients.

Findings

Some CARE Act–funded HIV programs in large institutions reported that they do not have separate accounting line items for their programs. As a result, TPR funds are returned to the general accounting system or to the department or program in which they are administratively assigned. As a result, programs are unable to determine if, when, and how much has been paid on their TPR claims. Moreover, some institutions were unwilling or unable to adjust their accounting systems to correct this problem.

Policy: CARE Act–funded grantees and subgrantees should staff their programs to ensure quality of care and maximize TPR. Existing programs should evaluate the costs and benefits of adjusting their staffing mix over time to determine whether staffing changes will, in the long term, be beneficial to the quality of care provided to clients.

Findings

As CARE Act–funded community-based HIV service organizations were established in many communities, they have tended to employ paraprofessional and nonprofessional staff to provide such services as mental health and substance abuse counseling. Although some of these services might otherwise be eligible for reimbursement by Medicaid and other payers, the absence of credentialed personnel precluded participation in provider networks.

Policy: If a CARE Act client is enrolled in Medicaid and Medicaid covers the type of case management the grantee or subgrantee provides, Medicaid should reimburse for those services. State Medicaid programs vary regarding the specific type of case management that is reimbursed, the frequency of services to be reimbursed, and the qualifications of case managers.

Findings

HAB recommends that grantees or subgrantees verify whether Medicaid reimburses for the type of case management they offer. Case management and other covered benefits may be identified by reviewing the State’s Medicaid plan on the CMS Web site.9 The State Medicaid Plans tend to be complex, however, and information regarding covered benefits is sometimes hard to identify.

References

1 National Association of State Budget Officers. The Fiscal Survey of State: April 2004. Washington, DC: National Governors Association; 2004.

2 Clark R. Counties in Crisis: A Survey of Current Budgetary Situations Facing America’s Counties. Washington, DC: National Association of Counties; 2004.

3 For the purposes of this report, subgrantees include agencies receiving funds from CARE Act grantees through contracts and fee-for-service reimbursement arrangements.

4 Public Health Service Act Section 2605(a)(6) applicable to Emergency Relief for Areas with Substantial Need for Services (Title I); Section 2617(b)(6)(F) applicable to CARE Grant Program (Title II); and Section 2664(f)(1) applicable to Early Intervention Services (Title III).

5 For the purposes of this report, “State Title II grantees” refers to States and territories receiving CARE Act Title II funds.

6 Managed Care and Health Services Financing Technical Assistance Center. Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Third Party Reimbursement (TPR) Frequently Asked Questions. Rockville, MD; 2002. Available at: http://www.hrsa.gov/tpr/TA-HIV-AIDS-Billing-FAQs.htm.

7 HIV/AIDS Bureau. Policy Notice-04-01 Ryan White CARE Act and Veterans. December 14, 2004. Available at: http://hab.hrsa.gov/law/0401.htm.

8 HIV/AIDS Bureau. CARE Act HIV Emergency Relief Grant Program Title I Eligible Metropolitan Areas Competing Continuation Awards, HRSA-05-010, CFDA No. 93.914, Program Guidance, Fiscal Year 2005. Rockville, MD: HRSA; 2004.

9 Available at: www.cms.gov/medicaid/tollfree.asp.

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