No. 30171 (New Rule): R388-805. Ryan White Program

DAR File No.: 30171
Filed: 07/03/2007, 12:14
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to document the Ryan White Program eligibility. The rule will apply program eligibility criteria to all eligible applicants.

Summary of the rule or change:

The rule establishes eligibility criteria for the Utah Ryan White Program.

State statutory or constitutional authorization for this rule:

Sections 26-1-5, 26-1-15, and 26-1-18; Subsections 26-1-30(2)(a), (b), (c), (g); and Sections 63-46a-3.5 and 63-46a-3

Anticipated cost or savings to:

the state budget:

There are no anticipated costs or savings to the State budget because this is a federally-funded program that provides services to persons living with HIV/AIDS.

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.

other persons:

There are no anticipated costs or savings to other persons. The program receives federal funding to provide services to persons living with HIV/AIDS. This rule does not change the amount or types of services previously provided by the program. A person who qualifies for the program would have cost savings in the amount of the service being provided to them.

Compliance costs for affected persons:

There are no compliance costs associated with this rule as no person is required to perform additional duties to qualify for services under the program.

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

Businesses serving persons eligible for services under the Ryan White program will continue to receive the same payments after this rule is adopted. Fiscal impact should be neutral. David N. Sundwall, MD, Executive Director

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

Health
Epidemiology and Laboratory Services; 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:

Jodie Pond at the above address, by phone at 801-538-6225, 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:

08/31/2007

This rule may become effective on:

09/07/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R388. Health, Epidemiology and Laboratory Services; HIV/AIDS, Tuberculosis Control/Refugee Health.

R388-805. Ryan White 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 Modernization Act of 2006 Part B Program (Ryan White Program). It is authorized by Section 26-805-5; Section 26-805-15; Section 26-805-18; and Section 26-805-30(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 Program pursuant to the provisions of this rule.

 

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

(1) The Ryan White Program provides reimbursement to providers for services rendered to HIV positive individuals who meet the eligibility requirements. The Ryan White 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 Modernization Act of 2006;

(b) as described and limited in the Treatment and Care Program Comprehensive Plan, dated January 2007, which is adopted and incorporated by reference, and all applicable laws and rules;

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

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

(2) Within available funding, the Department provides the following services under the Ryan White Program;

(a) The AIDS Drug Assistance Program (ADAP) provides HIV related medications;

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

(c) 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 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 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) The Department does not pay for services under the Ryan White Program for which an individual is eligible to receive under Medicaid or any other primary payer source.

 

R388-805-6. Ryan White 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 400% 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.

 

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

Date of Enactment or Last Substantive Amendment: 2007

Authorizing, Implemented, or Interpreted Law: 26-805-5; 26-805-15; 26-805-18; 26-805-30(2)(a), (b), (c), (g)