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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.
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.
See Section 2604(c)(3)(F), Section 2612(c)(3)(F), and Section 2651(c)(3)(F) of the Public Health Service Act.