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HIV/AIDS BUREAU POLICY 13-05
Clarifications Regarding Use of Ryan White
HIV/AIDS Program Funds for Premium and Cost-
Sharing Assistance for Private Health Insurance
Policy Clarification Notice (PCN) #13-05 (Revised 6/6/2014)
Relates to HAB Policy #’s 10-02 and 7-05
Scope of Coverage: Ryan White Parts A, B, C, D, and Part F where funding
supports direct care and treatment services.
Purpose of PCN
This policy clarification notice reiterates HRSA policy regarding the use of Ryan
White HIV/AIDS Program (RWHAP) for premium and cost-sharing assistance for the
purchase and maintenance of private health insurance coverage. It also provides
RWHAP grantees and subgrantees with additional guidance on using RWHAP funds
for premium and cost-sharing assistance.
Background
Under the Affordable Care Act, beginning January 1, 2014, options for health care
coverage for PLWH have been expanded through new private insurance coverage
options available through Health Insurance Marketplaces (also referred to as
Exchanges) and the expansion of Medicaid in States that choose to expand. Health
insurers also will be prohibited from denying coverage because of a pre-existing
condition, including HIV/AIDS. An overview of these health care coverage options
may be reviewed at http://hab.hrsa.gov/affordablecareact/keyprovisions.pdf.
By statute, RWHAP funds may not be used “for any item or service to the extent
that payment has been made, or can reasonably be expected to be made…” by
another payment source.
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This means grantees must assure that funded providers
make reasonable efforts to secure non-RWHAP funds whenever possible for services
to individual clients. Grantees and their contractors are expected to vigorously
pursue enrollment into health care coverage for which their clients may be eligible
(e.g., Medicaid, CHIP, Medicare, state-funded HIV/AIDS programs, employer-
sponsored health insurance coverage, and/or other private health insurance) to
extend finite RWHAP grant resources to new clients and/or needed services.
Grantees and subgrantees must also assure that individual clients are enrolled in
health care coverage whenever possible or applicable, and informed about the
consequences for not enrolling.
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See Sections 2605(a)(6), 2617(b)(7)(F), 2664(f)(1), and 2671(i) of the Public Health Service Act.
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Under the Affordable Care Act, starting in 2014, if someone can afford it but doesn't have health insurance
coverage in 2014, they may have to pay a fee. See HealthCare.gov, What if someone doesn’t have health
insurance?, https://www.healthcare.gov/what-if-someone-doesnt-have-health-coverage-in-2014. Under no
circumstances may RWHAP funds be used to pay this fee for a client’s failure to enroll in minimum essential
coverage.
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HIV/AIDS BUREAU POLICY 13-05
As Affordable Care Act implementation continues, clients will become eligible for
and enroll in qualified health plans offered in the Marketplace. The RWHAP will
continue to be the payer of last resort and will continue to provide those RWHAP
services not covered, or partially covered, by public or private health insurance
plans. RWHAP grantees and subgrantees should consider helping individual clients
pay for premiums and/or cost-sharing, if cost-effective.
Requirements and Expectations for RWHAP Grantees and
Subgrantees
By statute, RWHAP funds awarded under Parts A, B, and C may be used to support
a Health Insurance Premium and Cost-Sharing Assistance Program, a core medical
service, for eligible low-income HIV positive clients.
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Consistent with the RWHAP
statute, “low-income” is to be defined by the EMA/TGA, State, or Part C grantee.
RWHAP Part D grantees may also use funds to purchase and maintain health
insurance, if cost-effective.
RWHAP funds may be used to cover the cost of private health insurance premiums,
deductibles, and co-payments to assist eligible low-income clients in maintaining
health insurance or receiving medical benefits under a health insurance or benefits
program, including high risk pools. However, RWHAP funds may not be used to pay
for any administrative costs outside of the premium payment of the health plans or
risk pools.
If resources are available, Part A planning bodies and Ryan White Part B, C and D
grantees may choose to prioritize and allocate funding to health insurance premium
and cost-sharing assistance for low-income individuals in accordance with Section
2615 of the Public Health Service Act. The grantee must determine how to
operationalize the health insurance premium and cost-sharing assistance program,
including the methodology used by the grantee to: (1) assure they are buying
health insurance that at a minimum, includes at least one drug in each class of core
antiretroviral therapeutics from the HHS Clinical Guidelines for the Treatment of
HIV/AIDS as well as appropriate primary care services; and (2) assess and compare
the aggregate cost of paying for the health insurance option versus paying for the
full cost for medications and other appropriate primary care services. The grantee
may consider providing the resource allocation to the Part B/AIDS Drug Assistance
Program (ADAP) which currently operates the health insurance continuation
programs in some States and, therefore, has the infrastructure to verify coverage
status and process payments to health plans for premiums, co-payments and
deductibles, and to pharmacies for medication co-payments and deductibles.
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See Section 2604(c)(3)(F), Section 2612(c)(3)(F), and Section 2651(c)(3)(F) of the Public Health Service Act.
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HIV/AIDS BUREAU POLICY 13-05
Requirements and Expectations Specific to Part B AIDS Drug
Assistance Program (ADAP)
ADAP funds may be used to cover costs associated with a health insurance policy,
including co-payments, deductibles, or premiums to purchase or maintain health
insurance coverage. In order to use Part B ADAP funds to purchase health
insurance, State ADAPs must be able to document for HRSA/HAB the methodology
used by the State to: (1) assure they are buying health insurance that at a
minimum, includes at least one drug in each class of core antiretroviral therapeutics
from the HHS Clinical Guidelines for the Treatment of HIV/AIDS as well as
appropriate primary care services; and (2) assess and compare the aggregate cost
of paying for the health insurance option versus paying for the full cost for
medications.
Grantees should refer to HAB Policy Notice 07-05, “The Use of Ryan White
HIV/AIDS Program Part B ADAP Funds to Purchase Health Insurance”
(http://hab.hrsa.gov/manageyourgrant/files/partbadapfundspn0705.pdf).
RWHAP Premium and Cost-Sharing Assistance and the
Affordable Care Act
The Affordable Care Act increases access to affordable health insurance by
establishing a Health Insurance Marketplace in every state where individuals may
purchase private health insurance. Many individuals may be eligible for premium
tax credits and cost-sharing reductions to help pay for private health insurance
offered in the Marketplace. Consequently, RWHAP grantees and subgrantees should
take into consideration other sources of premium and cost-sharing assistance when
determining how to operationalize a premium and cost-sharing assistance program,
as discussed below.
Use of RWHAP Funds for Clients Eligible for Advance Premium
Tax Credits
Many RWHAP clients with incomes between 100-400% of the federal poverty level
(FPL) without access to certain types of minimum essential coverage
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may be
eligible for premium tax credits to offset the cost of purchasing a qualified health
plan
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through their state’s Marketplace.
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The amount of the premium tax credit is
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“Minimum essential coverage” refers to the type of coverage an individual needs to have to meet the individual
responsibility requirement under the Affordable Care Act. This includes employer-sponsored coverage, Medicare,
Medicaid, CHIP, TRICARE, and certain other coverage as defined in Internal Revenue Code Section 5000(a).
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A qualified health plan is a health insurance plan that is certified by a Marketplace, provides essential health
benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum
amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in
which it is sold. See http://www.healthcare.gov/glossary/q/qhp.html.
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HIV/AIDS BUREAU POLICY 13-05
based on the individual’s income and the cost of the second-lowest cost silver plan
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available to them offered in the Marketplace. Once an individual enrolls in a
qualified health plan in the Marketplace, the individual can control how much of the
projected tax credit is used to help pay the monthly health plan premiums. The tax
credit is sent directly to the insurance company and applied to the individual’s
premium, so the individual pays less out of his/her own pocket.
Grantees and subgrantees may use RWHAP funds to pay for any remaining
premium amount owed to the health insurance company that is not already covered
by the RWHAP client’s premium tax credits. Grantees and subgrantees should take
the following into consideration when operationalizing their health insurance
premium and cost-sharing assistance program:
State-based Marketplaces have flexibility to implement a process for
premium payment aggregation. Grantees and subgrantees should work with
health insurance issuers and/or the State-based Marketplace to establish a
coordinated process that facilitates premium payments by the RWHAP for
individual clients.
In states with a Federally-Facilitated Marketplace, grantees and subgrantees
will need to work directly with health insurance issuers to facilitate premium
payments by the RWHAP for individual clients.
Use of RWHAP Funds for Clients Eligible for Cost-Sharing
Reductions
Many RWHAP clients with incomes between 100-250% FPL who receive the advance
premium tax credits may also be eligible for additional cost-sharing reductions to
lower their out-of-pocket expenses, such as co-payments and deductibles. In order
to receive cost-sharing reductions, individuals must receive a premium tax credit
and enroll in a silver level plan offered in the Marketplace.
As discussed above, RWHAP funds may only be used to purchase and maintain
health insurance that is cost-effective. In determining which qualified health plan in
the Marketplace is the most cost-effective for clients eligible for cost-sharing
reductions, grantees and subgrantees are encouraged to analyze the formulary
adequacy and other essential medical benefits, the cost of the premium, and the
effect of any cost-sharing reductions on the overall cost of the qualified health plan.
RWHAP grantees and subgrantees should inform clients regarding these analyses to
assist RWHAP clients in enrollment decisions.
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Legal residents with incomes below 100% FPL who have been in the United States for less than five years may
also be eligible for advance premium tax credits provided they are not eligible for Medicaid or other minimum
essential coverage.
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There are four types of coverage that will be offered in each Marketplace: bronze, silver, gold, and platinum. A
silver level qualified health plan (QHP) is a health plan offered in the Marketplace with an actuarial value (AV) of 70
percent. A bronze level QHP has an AV of 60 percent, a gold level QHP has an AV of 80 percent, and a platinum
QHP has an AV of 90 percent.
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HIV/AIDS BUREAU POLICY 13-05
Even if an individual is eligible for cost-sharing reductions, he/she may still incur
some cost-sharing in his/her health plan. RWHAP funds may be used to cover any
remaining costs of co-payments and deductibles if the grantee has established a
Health Insurance Premium and Cost-Sharing Assistance Program and be able to
document for HRSA/HAB the methodology used to determine if the program is cost-
effective.
Use of RWHAP Funds for Clients Not Eligible for Premium Tax
Credits and Cost-Sharing Reductions in a Health Insurance
Marketplace
Grantees and subgrantees should consider that some individuals are ineligible for
premium tax credits and cost-sharing reductions:
Clients under 100% FPL in states that do not implement Medicaid
expansion;
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Clients with incomes above 400% FPL;
Clients who have minimum essential coverage other than individual market
coverage (e.g., Medicaid, CHIP, TRICARE, employer-sponsored coverage, and
certain other coverage defined in Internal Revenue Code Section 5000(a))
available to them, but choose to purchase in the Marketplace; and
Clients who are ineligible to purchase insurance through the Marketplace.
If resources are available, RWHAP grantees and subgrantees are strongly
encouraged to use RWHAP funds for premium and cost-sharing assistance for these
individuals when it is cost-effective, as appropriate. As discussed above, the
grantee and subgrantee must ensure that use of RWHAP funds for premium and
cost-sharing assistance for these clients is cost-effective.
Conclusion
RWHAP funds may be used to help clients purchase and maintain health insurance,
if cost-effective and in accordance with RWHAP policy. It is important for grantees
and subgrantees to understand the new insurance options available to clients under
the Affordable Care Act. Many clients may also be eligible to receive advance
premium tax credits and/or cost-sharing reductions to help pay for private health
insurance in the Marketplace. RWHAP grantees and subgrantees must take into
consideration other sources of premium and cost-sharing assistance when
determining how to operationalize a premium and cost-sharing assistance program.
Grantees and subgrantees should also work directly with health insurance issuers
and/or the Marketplace to coordinate payment of premiums and cost-sharing for
clients.
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However, please note that legal residents with incomes below 100% FPL who do not qualify for Medicaid or other
minimum essential coverage may be eligible for premium tax credits and cost-sharing reductions.
