No. 40846 (Amendment): Rule R388-805. Ryan White Program

(Amendment)

DAR File No.: 40846
Filed: 09/30/2016 10:59:49 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to clarify the name of the program as the "Ryan White Part B Program" rather than the "Ryan White Program"; to remove the $5,000 asset limit to be more aligned with HRSA guidelines, to reduce barriers to accessing care and determining eligibility; and to update information to align with program practice and references as needed.

Summary of the rule or change:

The changes remove the eligibility requirement of a $5,000 asset limit, update the program name, and remove eligibility requirements that are outdated.

Statutory or constitutional authorization for this rule:

• Section 26-1-18
• Section 26-1-5
• Section 26-1-15
• Subsection 26-1-30(2)(b)
• Subsection 26-1-30(2)(a)
• Subsection 26-1-30(2)(g)
• Subsection 26-1-30(2)(c)

Anticipated cost or savings to:

the state budget:

There are no anticipated costs or savings to the Program. This is a federally-funded program that provides services to people living with HIV/AIDS. The majority of the population served (60%) has no assets. Removing the asset test is not anticipated to increase Program utilization but rather reduce barriers to accessing care and determining eligibility.

local governments:

There are no anticipated costs or savings to local government because the program governed by this rule neither requires action from nor provides benefits to local governments.

small businesses:

There are no anticipated costs or savings to small businesses because the program governed by this rule neither requires action from nor provides benefits to small business.

persons other than small businesses, businesses, or local governmental entities:

The rule change will affect individuals that are over the $5,000 asset limit but under the 250% Federal Poverty Level. They will now be eligible for the Program if they exceed $5,000 in assets. It is anticipated that there will be no significant impact to the budget as the majority of individuals below the 250% Federal Poverty Level do not have assets exceeding $5,000. In the last 12 months, only 1 client had assets exceeding $5,000. The costs can range from $1,200 to $13,000 per person per year. The range depends upon whether or not a client is responsible for full pay or partial pay for their services. However, there are various variables that do not allow us to accurately assess the cost.

Compliance costs for affected persons:

There are no compliance costs for affected persons as the Program incurs all costs associated.

Comments by the department head on the fiscal impact the rule may have on businesses:

The amendment removes the $5,000 asset limit for eligibility, clarifies other eligibility requirements, and updates information to align with program practice. There will be no impact on business because the amendment addresses eligibility requirements and program practices.

Joseph Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Disease Control and Prevention; HIV/AIDS, Tuberculosis Control/Refugee Health
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Amelia Self at the above address, by phone at 801-538-6221, by FAX at 801-538-9913, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

11/14/2016

This rule may become effective on:

11/21/2016

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

R388. Health, Disease Control and Prevention; HIV/AIDS, Tuberculosis Control/Refugee Health.

R388-805. Ryan White Part B Program.

R388-805-1. Authority and Purpose.

This rule governs program eligibility, benefits, and administration by the Department for the Ryan White HIV/AIDS Treatment Extension[Modernization] Act of 2009[2006] Part B Program (Ryan White Part B Program). It is authorized by Section 26-1-5; Section 26-1-15; Section 26-1-18; and Section 26-1-30(2)(a), (b), (c), and (g).

 

R388-805-2. Definitions.

The following definitions apply to this rule:

(1) "HIV" means Human Immunodeficiency Virus.

(2) "Department" means the Utah Department of Health.

(3) "Client" means an individual who meets the eligibility criteria and is enrolled in the Ryan White Part B Program pursuant to the provisions of this rule.

 

R388-805-3. Nature of Program and Benefits.

(1) The Ryan White Part B Program provides reimbursement to providers for services rendered to HIV positive individuals who meet the eligibility requirements. The Ryan White Part B Program provides limited services as described in this rule. The Department provides reimbursement coverage under the program only for services for each program:

(a) as provided in law governing the Ryan White HIV/AIDS Treatment Extension[Modernization] Act of 2009[2006];

[(b) as described and limited in the Treatment and Care Program Comprehensive Plan, dated January 2009, which is adopted and incorporated by reference, and all applicable laws and rules;]

[(c)](b) to the extent that it has agreed to reimburse providers with whom it contracts to provide services; and

[(d)](c) as limited in [manuals that form part of ]its [Provider Agreements]agreements or contracts with providers.

(2) Within available funding, the Department provides Core Medical and Supportive Services as allowable under the legislation;[the following services under the Ryan White Program;]

(a) The AIDS Drug Assistance Program (ADAP) provides HIV related medications[;], health insurance premium, and cost-sharing assistance.

[(b) The Health Insurance Continuation Program pays for health insurance premiums and medication co-pays;]

[(c)](b) Supportive Services Program provides a variety of supportive services that enable the client to access medical care as well as to retain the client in medical care.

(3) The Department may adjust the services available to meet current needs and fluctuations in available funding.

(4) The Ryan White Part B Program is not health insurance. A relationship with the Department as the insurer and the client as the insured is not created under this program.

 

R388-805-4. Providers.

The Department reimburses only providers who contract with the Department to provide services under the program.

 

R388-805-5. Reimbursement.

(1) The Department shall reimburse only for services as limited in [the manuals that form part of ]its agreements or contracts with providers.

(2) The Department shall reimburse providers according to the fee schedule or budgets[schedules ]that are made part of its agreements or contracts with providers.

[(3) Payment for services by the Department and client co-payment, if any, constitutes full payment for services. A provider may not bill or collect any additional monies for services rendered pursuant to an agreement or contract to provide services under the Ryan White Program.]

[(4)](3) The Ryan White Part B Program is the payer of last resort. The Department does not pay for services under the Ryan White Part B Program for which an individual is eligible to receive under [Medicaid or ]any other primary payer source.

 

R388-805-6. Ryan White Part B Program Eligibility.

[(1) To receive services under the Ryan White Program, an individual must be a Utah resident and must have a medical diagnosis of HIV infection as verified by the individuals's physician.

(a) An individual may own one home and one registered vehicle but may not have any other assets over $5,000.00.

(b) If an individual owns a vehicle that is not registered and is considered an asset by Medicaid, which then prevents the individual from receiving benefits from Medicaid, the individual is also ineligible for services under the Ryan White Program.

(c) If an individual is ineligible for Medicaid due to failing Medicaid asset limits but otherwise meet Medicaid eligibility requirements, the individual is also ineligible for services under the Ryan White Program.

(2) To receive services under the AIDS Drugs Assistance Program, the Health Insurance Continuation Program and the Supportive Services Program, an individual must have income not exceeding 250% of the federal poverty level by providing any of the following:

(i) Immediate year Tax Return.

(ii) Immediate year W-2 Form(s).

(iii) Most recent pay Stub/Earnings Statement.

(iv) Most recent Social Security Disability Income Letter.

(v) Most recent Supplemental Security Income Letter.

(vi) Most recent Unemployment Statement.

(vii) Most recent General Assistance Letter from the Department of Workforce Services.

(viii) Most recent Disability Income Letter from a disability insurer.

(3) To be eligible to receive assistance from the AIDS Drug Assistance Program, an individual:

(a) must not be eligible for Medicaid and not covered for the medication requested through this program by any other public or private health insurance coverage;

(b) must have a prescription for the medication requested.

(4) To participate in the Health Insurance Continuation Program, an individual must currently take HIV anti-retroviral medications.

(5) To participate in the Consolidated Omnibus Budget Reconciliation Act (COBRA) Continuation program an individual must meet the following additional eligibility criteria:

(a) The individual must have a medical diagnosis of HIV disease or is a dependent with HIV disease who is covered under the health insurance of someone else;

(b) The policy covers HIV related costs and outpatient HIV related drugs;

(c) The policy can be converted under COBRA;.

(d) The individual has not previously been denied health insurance coverage for HIV disease related services;

(e) The individual must be ineligible for Medicaid or for group/individual health insurance from the individual's current employer;

(f) The individual must have begun the process of securing income support through the Social Security Disability Insurance (SSDI), or the Supplemental Security Income (SSI) or other disability programs if the individual is disabled, or have applied to receive public entitlement benefits.

(6) Clients must re-certify annually in order to continue program participation.]

(1) To receive services under the Ryan White Part B Program, an individual must physically reside in Utah, must have a medical diagnosis of HIV infection as verified by the individual's physician, and may not own more than one home and one registered vehicle.

(2) To receive Core Medical and Supportive Services, excluding Case Management services, an individual must not have gross annual household income exceeding 250% of the federal poverty level.

(3) To be eligible to receive assistance from the AIDS Drug Assistance Program, including health insurance premium and cost-sharing assistance an individual must have a prescription for the medication requested.

(4) Clients must re-certify semi-annually in order to continue program participation.

 

KEY: treatment and care, HIV/AIDS, ADAP, Ryan White Part B Program

Date of Enactment or Last Substantive Amendment: [December 30, 2009]2016

Notice of Continuation: October 18, 2011

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-1-15; 26-1-18; 26-1-30(2) (a), (b), (c), (g)

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