ESBD_383500_1732791775452_Appendix D - Program Requirements for HIV Contracts.docx

APPENDIX D:

PROGRAM REQUIREMENTS FOR HIV SERVICES CONTRACTS

A. DESCRIPTION OF SERVICE COMPONENTS

Federal and state funds awarded to local areas must provide comprehensive outpatient health and support services for individuals with HIV and to administer these funds. Eligible services to be provided or administered with state and federal resources allocated for medical and psychosocial support services are catalogued and defined on the Taxonomy at http://www.dshs.texas.gov/hivstd/taxonomy/default.shtm.

B. REQUIREMENTS FROM ADMINISTRATIVE AGENCIES TO SUBCONTRACTORS

The roles of the Subcontractors include administration, planning, evaluation, and quality management. All Subcontractors’ must provide all these services. These activities are defined as follows:

1. Administrative Functions

Through a contract with STDC, for available federal and State HIV services and HOPWA funds, including:

1. Respond, complete and submit funding applications and proposals by deadlines specified by STDC;

1. Establishment formal systems and fee for service agreements and/or Memorandums of Understanding (MOUs) at a minimum for the following:

· TB

· STD

· Substance Abuse

· Immunization

· HIV Prevention

· Partner Services

· Mental Health

· Intellectual Disabilities

· Housing

· Nutritional Therapy;

1. Execute Ryan White SD, State, and State Services contracts for the delivery of client services in accordance with HIV Services Taxonomy, http://www.dshs.texas.gov/hivstd/taxonomy/default.shtm;

1. Subcontractors shall maintain sustainable programs to increase availability and accessibility in order to provide services that are equitably available and accessible to all individuals diagnosed with HIV needing services and/or care within the identified service area;

1. Ensure that the service needs of all clients are provided in a manner that is culturally, ethnically, and linguistically sensitive appropriate, and assure that the care offered by vendor providers to these populations meet current standards of care and treatment of persons with HIV;

1. Compliance with contract conditions and audit requirements;

1. Subcontractor shall expend one hundred percent (100%) of the total contract budget, as show in Section VIII. BUDGET, by the end of the contract term and ensure that no more than ten percent of the funds provided in this Renewal Program Attachment are expended for administrative costs.

1. Subcontractor shall utilize all service delivery funds according to the service priorities and allocations established in its approved Table 1 and make reallocations only with the advance written approval of DSHS and STDC in accordance to the Reallocation Policy (at http://www.dshs.texas.gov/hivstd/policy/policies/241-006.shtm) and the reallocation form (at http://www.dshs.texas.gov/hivstd/policy/policies/241006a.xls). Subcontractor shall monitor the delivery of HIV services against the Estimated Units of Service shown in Table 1 of the contractor’s most recent application for delivery of these services. Subcontractors that request new subcategories line items to be open in TCT within the funded fiscal year must submit a revised Detailed Unit Cost Form to the Program Data Manager. The Detailed Unit Cost Form should have the new clients, units and amounts needed to open the line items in TCT. If the budget changes are needed for the primary service categories, then the subcontractors should submit a Reallocation Form to the AA Program Planner. The last reallocation request most occur at least 30 days prior to the end of the grant’s fiscal year.

1. Subcontractor shall meet and report supplemental performance measures required on Exhibit A to ensure delivery of these services.

1. Maintain proper accounting and financial management systems and prepare routine financial data and reports as required by STDC;

1. Comply with all quality and process improvement.

1. Subcontractor shall participate during on-site reviews. Subcontractor shall maintain and facilitate all the necessary required program documentation to STDC conducting desktop site reviews monitoring of clinical, case management, fiscal, and programmatic performance for the South Texas HSDA and Far West HSDA to assure compliance with the requirements found herein (e.g. programmatic and fiscal provisions) and compliance with the contracts executed between STDC and subcontractor, with an ongoing aim to improve the quality of care and client services delivery processes. Subcontractor shall also provide STDC with copies of any corrective action directives made by STDC to a subcontractor to address performance deficiencies cited during the site review, within thirty (30) days of the issuance of such directives. Subcontractor shall adhere and perform clinical and case management services in accordance with HIV Clinical and Case Management Services Standards (https://www.dshs.state.tx.us/hivstd/contractor/cm.shtm). Subcontractor shall also adhere to US Public Health Standards in the care and treatment of persons with HIV (https://www.dshs.state.tx.us/hivstd/contractor/hivmedical.shtm).

1. Subcontractor shall comply with the new Standards of Care revised on January 2024 which are accessible (http://www.dshs.texas.gov/hivstd/taxonomy/default.shtm). The subcontractor will implement and develop policies and procedures in adherence for all HIV Core and Support Service Categories. STDC will release an update upon completion of all appropriate DSHS updates to the Universal Standards, HIV Core, and Support Service Categories.

1. Submit a Strategic Plan to STDC for approval to cover the period of April 2025 through March 2026. An update needs to be sent to STDC on December 31, 2025 and June 30, 2026. The Plan will also include strategies for addressing the needs of individuals aware of HIV status but are not enrolled in HIV-related medical care. Subcontractors shall assure that efforts are in place to bring people who know their HIV status, but who are not receiving HIV-related medical care, into such care;

1. Subcontractor shall maintain current facility and individual licensure requirements as mandated by Texas Law and must be in good standing with the State of Texas. Subcontractor shall also ensure that vendor subcontractors maintain current facility and individual licensure requirements as mandated by Texas Law and that subcontractor are in good standing with the State of Texas. STDC and DSHS retain the right to deny any reimbursement for services rendered while licensure was not in good standing.

1. Subcontractors shall maintain appropriate relationships with mental health entities in the area being served that provide key points of access to the health care system for people living with HIV. These entities include, but are not limited to: emergency rooms, substance abuse treatment programs, detoxification centers, adult and juvenile detention facilities, mental health programs, homeless shelters, migrant health centers, community health centers, health services for the homeless, family planning grantees, comprehensive hemophilia diagnostic and treatment centers, and non-profit private entities that provide comprehensive primary care services to populations at risk for HIV; STD clinics/programs, DSHS Program’s HIV prevention contractors, and other venues where HIV transmission may be diagnosed, so that referrals can be made into the care system. STDC encourages linkages with hospital discharge planners.

1. Subcontractors’ staff is required to attend all required continuing education courses/training, conferences, technical assistance workshops and meetings as directed by STDC and DSHS Program to maintain licenses. Subcontractors shall ensure that direct service providers also attend required continuing education courses/training. All documentation to support current status shall be maintained at the Subcontractors’ site location and available for inspection upon request by STDC. Maintain complete, accurate and timely client-level programmatic data, including adhering to the minimum requirements for maintaining the Uniform Reporting System (URS), as required by STDC and DSHS. Subcontractor’s policies and procedures shall be consistent with the requirements herein and with DSHS’ policy on this subject [reference links http://www.dshs.texas.gov/hivstd/contractor/policy.shtm and http://www.dshs.texas.gov/hivstd/pops/default.shtm].

1. Report subcontractor financial and programmatic activities to STDC on a semi-annual and annual basis as noted in the Program Narrative Report Requirements section of the Contract.

2. Capacity Building

1. Capacity building to maintain sustainable programs to increase the availability and accessibility of services;

1. Technical assistance to fee for subcontractors and direct service providers;

1. Ensure that services are accessible to the populations to be served; and

1. Assure that the care offered meets current USPHS, standards of care and treatment of persons with HIV.

3. Needs Assessment/Planning/Evaluation Functions

1. Assessing service needs, barriers to services, services gaps, and unmet need for HIV-related medical care within the Health Service Delivery Area (HSDA).

1. Developing an annually updated strategic plan for delivery of HIV medical and psychosocial support services.

1. Periodic examination of utilization and expenditure data, requesting reallocations as necessary;

1. Collecting data on the outcomes of service delivery as specified by STDC;

1. Evaluation of the cost-effectiveness of the mechanisms;

1. Periodic evaluation of the success of the strategic plan in responding to identified needs;

1. Maintaining complete, accurate and timely client-level programmatic data, including adhering to the minimum requirements of maintaining the URS as required by STDC.

1. Providing in FSRs substantial explanation/ justification related to monthly service delivery trends and barriers.

1. Providing action plans for expending at least 95% of grant allowable budget two – three months prior to the end of the grant year.

1. Facilitating the introduction of outreach, peer to peer and supportive service activities as indicated in 2023-2026 Comprehensive Needs Assessment.

1. Requesting written consent from clients to be reached by STDC staff for service assessment and evaluation purposes.

4. Program Monitoring and Compliance

1. Comply with all quality and process improvement.

1. Subcontractor shall comply with scheduled onsite and desk-reviews performed by the Administrative Agency (AA) South Texas Development Council (STDC) within current fiscal year and yearly monitoring events conducted by both STDC and the Texas Department of State Health Services (DSHS), with the purpose of assessing compliance of DSHS HIV Core and support Service Categories, (https://www.dshs.texas.gov/hivstd/taxonomy/MasterServiceCategoryMonitoringTools.xls).

1. Subcontractor shall participate, maintain and facilitate all necessary required program documentation for one (1) full monitoring onsite review performed by the AA (STDC) per current fiscal year for compliance of DSHS HIV Core Service Category; Early Intervention Services (EIS), and DSHS HIV Support Service Categories; Emergency Financial Assistance (EFA), Food Bank/Home Deliveries, Home and Community Based Health Services, Medical Transportation (MT), Outreach Services, Psychosocial Support and any other service which may be deemed necessary to be added to the aforementioned.

1. Subcontractor shall provide the AA (STDC) with copies of any corrective action directives made to address performance deficiencies cited during onsite reviews within time period identified during the monitoring process under issuance of DSHS and STDC directives.

5. Quality Management Functions

Quality Management is a mandated function in the Ryan White Program. The standards apply to RWSD, SS, and MAI scopes of work. Subcontractor shall, from the effective date of this Program Attachment, continue to implement the quality management (QM Management Systems and plan which require):

1. Prepare and submit a current QM Plan to DSHS and STDC.

1. The presence of a documented, ongoing quality management system that is used to guide and continuously improve the program, which meets DSHS requirements. (Minimum of 4 times yearly)

1. A multi-disciplinary provider team which is used to guide and continuously improves the program. A QA/QI/PI committee/team function that includes documented membership, member roles, responsibilities, meeting frequency, and minutes of each meeting; Significant participation by physician and medical director in quality management functions;

1. Evidence of actions to measure, monitor and improve quality of care, including client utilization data and improvements in accessibility, availability, continuity, effectiveness, efficiency, patient satisfaction, timeliness of care, environmental safety, health disparities or other quality indicators of services;

1. Programmatic, financial, operational and other applicable data analysis in order to identify issues that impact the quality of services;

1. Agency client satisfaction surveys and follow up on all identified issues from the surveys with supported documentation of improvement and re-evaluation of those issues (Subcontractors are required to submit report and results of the Client Satisfaction Surveys annually on the date specified or upon request);

1. The identification of outcomes and efforts at improving them through the utilization of goals and measurable objectives with associated strategies (a QI/QM Improvement Plan) to accomplish the ongoing improvement, inclusive of a QI/QM work plan;

1. Identification, monitoring and correction of adverse outcomes;

1. Participate in quality improvement projects and report progress.

1. Subcontractor oversight compliance monitoring system, including documented corrective action, review, evaluation and follow up;

1. Subcontractor participation in the ongoing quality management system of the Administrative Agency meetings, conference calls and workshops, including a provider feedback loop;

1. Review, respond, and track client, staff and subcontractor compliant and grievances;

1. Participate in audits/site reviews and provide STDC, DSHS and its designated reviewers timely access to client records;

1. Complete corrective action requirements to the satisfaction of STDC and DSHS;

1. Evidence of programmatic and management improvements, including documented revisions to program administration, policies and procedures, committee actions and other applicable initiatives impacting quality of services;

1. A process for development and an annual review of clinical protocols and Standing Delegation Orders (SDO’s);

1. Subcontractor shall enter all required data into TCT to ensure compliance with HAB Group 1 and Group 2 Performance Measures;

1. An annual evaluation summary of the quality management system (internal);

1. An annual evaluation of agency policies and procedures;

1. Report Quality Management Program Activities, Progress and accomplishments in the required program reports to STDC; and

u) An Annual QM Program/System Summary is due annually on the date specified or upon request.

C. USE OF FUNDS

1. Allowable use of funds

Contract funds may be used for personnel, fringe benefits, equipment, supplies, staff training, travel, contractual or feebased services, other direct costs, and indirect costs. For the purposes of insurance assistance, contract funds may be used for the payment of insurance premiums, deductibles, co-insurance payments, and related administrative costs. Equipment purchases are allowed if justified and approved in advance. All costs are subject to negotiation with the STDC.

Subcontractors are required to adhere to federal principles for determining allowable costs. Such costs are determined in accordance with the cost principles applicable to the organization incurring the costs. The kinds of organizations and the applicable cost principles are set out in the STDC contract general provisions and in the Texas Grant Management Standards (TxGMS). Copies are available online at https://comptroller.texas.gov/purchasing/docs/grant-management-reader.pdf

If the Subcontractor expends $750,000 or more in total federal financial assistance during the Subcontractor's fiscal year, arrangements must be made for agencywide financial and compliance audits. The audit must be conducted by an independent certified public accountant and must be in accordance with applicable Office of Management and Budget (OMB) Circulars, Government Auditing Standards, State Audit Circulars, and the applicable Texas Grant Management Standards. Subcontractors shall procure audit services in compliance with state procurement procedures, as well as the provisions of TxGMS. If the Subcontractor is not required to have a Single Audit, DSHS will provide the Subcontractor with written audit requirements if a limited scope audit will be required.

The administrative agency will:

· Ensure that each subcontractor obtains a financial and compliance audit (Single Audit) if required by OMB Circular A-133 and/or TxGMS,

· Ensure that subcontractors who are required to obtain an audit take appropriate corrective action within six months of receiving an audit report identifying instances of non-compliance and/or internal control weaknesses, and

· Determine whether a subcontractor's audit report necessitates adjustment of the administrative agency's records.

2. Disallowances

Funds provided through RWSD, State, State Services or HOPWA contracts may not be used for the following:

· RWAA not authorized to use subcontractor’s service delivery funds for administrative expenses;

· To make cash payments to intended recipients of services, except for reimbursement of reasonable and allowable out-of-pocket expenses associated with consumer participation in planning activities;

· For acquisition of real property, building construction, alterations, renovations, or other capital improvements;

· To supplant other funding for services already in place; and

· Funds provided through the RWAA contract may not be used for direct client services.

3. Program Income

All fees collected for services provided by Ryan White and SS funds are considered program income. All program income generated as a result of program funding must be proportionately integrated into the program for allowable costs and deducted from gross reimbursement expenses on the voucher before requesting additional cash payments. All program income must be reported on the monthly financial reports. Subcontractor will adhere with Texas Grant Management Standards – Uniform Assurance, Standard Financial Management Conditions specific to Program Income. Additionally, Subcontractor will adhere with Policy Clarification Number (PCN) #15-03 – Clarifications Regarding the Ryan White HIV/AIDS Program and Program Income found at https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-15-03-program-income.pdf.

4. Payor of Last Resort (PoRL):

The costs of delivering services should be reasonably shared by the state and federal governments, private health insurers, and to the extent possible, by the client within the limitations set in the Charges to Clients for Services section below. To maximize the limited program funds, Ryan White CARE Act funds and State Services funds should be considered payor of last resort.

It is the responsibility of the subcontractor to ensure that:

Providers bill all potential third party payors for applicable services provided;

Costs incurred from the billing process are not be charged to the client in whole or in part;

Funds are not to be used to provide items or services for which payment already has been made or reasonably can be expected to be made by third party payors, including Medicaid, Medicare, other state or local entitlement programs, prepaid health plans, and/or employment-based health insurance;

Providers pursue the process to bill Medicaid, employment-based health insurances and other publicly-funded health insurance programs;

Providers screen all clients for employment-based health insurance, potential Medicaid and other publicly-funded health insurance benefits and actively promote successful client enrollment in Medicaid and other third party payor sources for which clients may be eligible (Medicare, CHIP, etc).

Providers who, with adequate justification, cannot bill a particular third party payor held within their client caseload applies for a waiver;

Note: Providers are subject to audit on this and other restrictions on use of funds.

This policy establishes funding from the South Texas Development Council for HIV-related medical and support services as payment of last resort (PoLR). It directs contracting service providers to establish and enact policies and procedures to assure that DSHS/STDC funds are used as PoLR. The process is as follows:

a). Screening for Other Payment Sources

DSHS Policy 220.001 - Eligibility to Receive HIV Services at https://www.dshs.texas.gov/hivstd/policy/policies/220-001.shtm requires service providers to implement policies and procedures to certify client eligibility for funded HIV services every six (6) months (no later than the last day of the clients’ birth month for the annual 12-months recertification and no later than the last day of the clients’ half birth month for the 6-month self-attestation). Providers should be guided by the requirements of this policy and local policies to document client eligibility for services and requirements for referral of clients who may be eligible for public or private insurance or another medical benefit program.

“Modified Adjusted Gross Income (MAGI) is a figure used to calculate income eligibility for lower costs in marketplace Health Plans as well as eligibility for Medicaid, Children’s Health Insurance Plan (CHIP), and RWHAP Part B/State Services funded HIV medical and support services. Generally, modified adjust gross income is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income an individual may have. MAGI must be calculated using the DSHS provided Income Calculation Form, which can be found on the MAGI documents page at https://www.dshs.texas.gov/hivstd/magi/. Because Ryan White (RW) is payer of last resort (PoLR), funded providers must make reasonable efforts to ensure eligible RW clients enroll in health insurance and secure non-RW funds whenever possible. MAGI supports coordination with eligibility determination process for insurance affordability programs for PoLR.

MAGI was implemented with three goals in mind:

1. To streamline eligibility guidelines among local agencies and with the THMP program.

1. To help ensure that agencies have access to reliable income documentation.

1. To reduce the client burden in that income information will often be required only once a year with a self-attestation being acceptable at the six-month recertification.

Additional Ryan White HIV-AIDS Program MAGI documents, information, and MAGI resources can be found at https://www.dshs.texas.gov/hivstd/magi/. As specified in policy 220.001, local areas may specify eligibility criteria in addition to those outlined in policy 220.001. Local eligibility determination and referral vary in terms of the processes used to determine eligibility, the titles of personnel who conduct eligibility screening, and the service categories under which eligibility determination and benefits coordination is completed. Regardless of these differences, service provider must assure that policies and procedures tailored to the local eligibility criteria and determination and recertification processes incorporate DSHS and local standards for comprehensive eligibility review; timely referral; vigorous follow up; and documentation for these tasks.

Vigorous efforts to enroll the client in any health plan or program for which the client appears to be eligible must be documented in client file utilizing DSHS Attestation of Client Eligibility for Marketplace Plans and process or approved local forms and processes.

b). Affordability and Health Insurance Assistance

If clients are concerned about the affordability of job-related or Marketplace insurance, they should be counseled about the availability of health insurance assistance (HIA) services if such assistance is appropriate under local policies and guidelines (see DSHS Policy 260.002). Clients who require assistance with Medicare Part D drug plans and eligible employer-based health insurance may be eligible for assistance through the piloted TIAP.

c). Special Considerations for Insurance Plans with Non-Continuous Enrollment

While enrollment periods for Medicaid and CHIP are continuous, other programs have limited enrollment periods. If clients appear eligible but are outside an enrollment period, they must receive counseling about opportunities for future enrollment and be referred to organizations or individuals that can further assist them. These efforts must be clearly documented in client file.

d). Special Considerations for Clients Eligible for Veterans Affairs Benefits

Clients eligible for benefits through the Department of Veterans Affairs (VA) should receive education on the services available through the VA and be referred to VA health centers if they so choose. However, funded services must be made available to VA-eligible clients who choose not to receive care through the VA systems. Such clients are dually eligible for RWHAP and VA services and therefore exempted from the PoLR requirement. As with all efforts of vigorous pursuit, a client’s refusal for referral to VA services must be clearly documented in client file.

e). Verification of Coverage

Service Providers must maintain policies that require verification of third-party payment coverage for eligible services. AA will verify at every site visit or upon request.

f). Client Refusal to Enroll

Per HRSA HIV/AIDS Bureau (HAB) Policy Clarification Notice # 13-04, Eligible clients who refuse to enroll in programs or insurance plans must receive continued counseling on their eligibility at each recertification opportunity and may not be refused treatment services because of the refusal. Vigorous efforts of benefit counseling and enrollment must be documented in the client file.

g). Service Provider Enrollment in Health Insurance Plans

Health insurance plans cover some, but not all RWHAP/SS-eligible services. Eligible services typically covered by health plans include outpatient health services, outpatient mental health services, inpatient and outpatient substance abuse treatment, home health services, pharmaceuticals/drugs, home and community health services, home health services, and hospice services. Providers of these services who receive DSHS funds must make reasonable efforts to enroll as participating or approved providers in the health plans carried by their clients. No waivers are available. If an organization subcontracts the medical services listed above, the requirements below apply to their subcontractors.

h). Enrollment in Texas Medicaid A contracting provider who delivers Medicaid- eligible services must be enrolled as a Medicaid provider. Contracting Service Providers must maintain and furnish Texas Medicaid ID numbers as demonstration of enrollment, or other documentation that establishes that the provider has initiated the application process. STDC will ensure that a provider not currently designated as a Medicaid provider must apply to be a Medicaid provider. If the service provider's application is denied, the AA may use DSHS funds to contract with that provider only if no other Medicaid-enrolled providers are available. Contracting providers who have been denied enrollment must continue to make good faith efforts to enroll and must make evidence of these efforts available to the AA or DSHS upon request. Examples of adequate justification include but are not limited to: evidence of denial by Medicaid, evidence that implementing this requirement would result in a loss of critical HIV/STD services to the community, or evidence that implementing this requirement would result in a substantial detriment to the health of a client with HIV/Stage 3.

i). Enrollment in Other Health Insurance Plans

AA will maintain and enforce policies that direct contracting providers (including subcontractors) that deliver medical services typically covered by other public or private health plans to make good faith efforts to enroll as in-network providers on the plans carried by their clients.

Providers may prioritize their efforts to enroll in the plans carried by the greatest number of clients. Providers must provide documentation of their efforts to enroll annually to the AA or DSHS. Providers must show due diligence in their efforts to enroll, including requesting inclusion on the list of Essential Community Providers (ECP) compiled by the Center for Consumer Information & Insurance Oversight, informing health plans of their ECP status as 'write ins' if they are not included on the CCIIO list, and making health plans in their area aware of the unique services they provide.

j). Referral to In-Network or Enrolled Providers

Providers who are not in-network or approved providers on a client's health insurance plan must refer clients to appropriate providers that are in-network on a client's plan. If no such provider is available, the provider may deliver the service but must show proof of attempted billing to the client's health plan. AAs will make providers aware of any limitations on health insurance assistance to clients with out-of-network cost sharing obligations.

k). Use of funds for Charges Denied by Health Plans

Funds may not be used to reimburse providers for denied claims that result from failure to follow plan requirements such as prior authorization or referral approval by DSHS and STDC. Funds may not be used to reimburse providers for rejected claims if the rejection is a result of provider error, including incomplete or late submission of claims. Service Provider must maintain policies to this effect.

l). Client Charges for Billable Services

Funded service providers who deliver services will maintain policies and procedures for services typically billable to public and private health plans on client charges. For purposes of this policy, service providers of Outpatient/Ambulatory Health Services; Local AIDS Pharmacy Assistance Programs; Mental Health Services; Medical Nutrition Services; Home and Community-Based Health Services; Home Health; Hospice; Early Intervention Services (if such services are primarily associated with HIV testing and referral); and inpatient and outpatient Substance Abuse Treatment are considered to provide billable services.

To adhere to RWHAP legislation, all service providers that deliver these services with DSHS/STDC funds must develop a sliding fee discount program that includes the following: (1) a schedule of fees for services; (2) a corresponding sliding fee discount schedule; (3) a system/policy to waive or reduce fees to assure receipt of care; (4) policies that prohibit refusal of services to clients who are unable to pay fees or refuse payment of fees; and (5) a limit on annual aggregate charges (cap on charges) based on the HIV-positive client's individual income. "Aggregate Charges" applies to annual charges imposed for all services regardless of terminology (i.e. enrollment fees, premiums, deductibles, cost-sharing, co-payments, coinsurance, etc.) and applies to all service providers from whom individuals receive services.

m). Fee Schedules/Charge Master

Service Providers must develop a fee schedule that is consistent with locally prevailing rates and is designed to cover reasonable costs. The fee schedule must be used as the basis for seeking payment from patients as well as third party payers. The schedule may include a documented decision to impose only nominal charges. Such a charge may not be specific to RWHAP/SS clients and must be similar to charges for non-RWHAP/SS clients. A nominal charge must be a fixed fee that does not reflect the true value of the service(s) provided and is considered nominal from the perspective of the patient. The nominal charge must be less than the fee paid by a patient in the first “sliding fee discount pay class” beginning above 100% of FPL.

n). Sliding Fee Discount Schedule (SFDS)

Affected providers must also develop a SFDS based on the client's ability to pay. Eligibility for the SFDS is based on a percentage of FPL using only the HIV-positive client’s annual individual income calculated from Income Calculation Worksheet. The SFDS must be revised annually, at a minimum, to reflect updates to the federal poverty guidelines. The provider must establish policies and operating procedures to assure that the SDFS is applied uniformly to eligible patients.

o). Determining Eligibility for Sliding Fee Discounts

Providers of billable services must have supporting processes/operating procedures in place for assessing MAGI for all clients or must have a documented procedure for using the Income Calculation Worksheet during certification/re-certification for funded services. If a client has had no changes in income, household composition, residence, immigration status, or insurance coverage since the previous full eligibility screening a self-attestation of ‘no changes’ may be used to satisfy eligibility determination requirements. If a client attests there have been no changes, the calculation from the previous eligibility screening should be used. Eligibility determination should be conducted in an efficient, respectful, and culturally appropriate manner to ensure that administrative operating procedures for such determinations do not themselves present a barrier to care. Patient privacy and confidentiality must be protected throughout the process. Once assessed, a patient who meets the income guidelines would receive a sliding fee discount based on the SFDS. As required by RWHAP, clients with an individual annual income at or below 100% FPL must receive a full discount, meaning no charges may be assessed. Nominal fees may not be applied to this group. Regardless of client income, services cannot be refused based on the client's ability to pay, and this must be reflected in SFDS polices and operating procedures.

p). Clients with Third Party Coverage Who are Also Eligible for SFDS

Clients with health insurance coverage have incomes that would make them eligible for the SFDS established by the provider. Such clients must use their insurance but may be eligible to have the co-payment or co-insurance required by their insurance plan reduced based on the SFDS, subject to potential legal and contractual limitations. If this is allowed, the charge to these clients is the maximum amount an eligible patient in that pay class is required to pay for a certain service regardless of insurance status. If the client receives HIA services, the reduced charge may be paid through these funds if the service is HIV-related and otherwise qualifies for payment by HIA.

Providers may not seek reimbursement from RWHAP/SS for the difference between the insurance charge and the reduced charge collected from the payment. However, the terms of contracts that providers hold with health insurance plans may not allow discounting of client co-pays and co-insurance and discounting client cost sharing obligations may also be inappropriate for Medicare clients. Providers may wish to consult with their third-party payers or legal counsel and/or private legal counsel regarding the permissibility of discounting patients’ out-of-pocket costs. How a provider will approach the issues of cost sharing requirements and SFDS must be documented in policies on SFDS.

q). Posting of Fee Schedule

The SFDS must be publicly posted and must contain language that assures clients that services are available regardless of ability to pay.

r). Collecting and Waiving Client Fees

Service providers will make reasonable attempts to collect fees. The service provider will establish policies on waiving client fees. The policy must include criteria for waiving charges and should specify the staff with the authority to approve fee waivers. This policy must be consistently applied.

s). Caps on Client Charges

RWHAP legislation requires that clients be charged no more than a maximum amount (cap) in a calendar year. The cap is based on the HIV-positive client's individual MAGI as follows:

· Equal to or below the official poverty line – No charges permitted;

· 5% for patients with incomes between 100% and 200% of FPL;

· 7% for patients with incomes between 200% and 300% of FPL;

· 10% for patients with incomes greater than 300% of FPL.

*The client should assure that the information provided is accurate.

Provider policies must specify that once a client's annual aggregate charges reach the cap, no additional client charges may be made. TCT automatically calculates the FPL based on the client’s household income.

t). Tracking Client Charges and Out of Pocket Expenditures

Service Providers must track client charges to assure that they do not exceed the aggregate caps. Service Providers are not responsible for tracking charges from other providers, but if clients produce reasonable documentation for these charges they should be included in the tracked total. Examples of client out pocket charges include client fees for services, drug co-payments or co-insurance payments, premiums, and enrollment fees.

u). Program Income

Income resulting from payments for HIV services by clients or from insurance companies is considered program income. Service providers must retain program income derived from funded services and must follow DSHS rules on reporting and use of such income. Providers must also follow any additional requirements by the AAs specified in contract or policy. See Section C. Use of Funds, Number 3. Program Income.

E. PROTOCOLS, STANDARDS AND TREATMENT GUIDELINES

Client services contractors are required to conduct project activities in accordance with the Quality Care: DSHS Standards for Public Health Clinic Services manual. A copy is posted on the DSHS website at https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/contract-mgmt/qmb-standards-health-clinic-svcs.pdf. Subcontractors are required to conduct project activities in accordance with various federal and state laws prohibiting discrimination. Guidance for adhering to non-discrimination requisites can be found on the following website .

Additionally, applicants who provide direct client services are required to adopt written protocols, standards and guidelines based on the latest medical knowledge regarding the care and treatment of persons with acquired or diagnosed with HIV. These include the standards found at the following links:

· DSHS Program’s HIV and STD Program Operation Procedures and Standards;

http://www.dshs.state.tx.us/hivstd/pops/default.shtm and http://www.dshs.state.tx.us/hivstd/policy/policies.shtm.

· Chapter 6A (Public Health Service) of Title 42 (The Public Health and Welfare) of the United States Code, https://www.govinfo.gov/content/pkg/USCODE-2014-title42/pdf/USCODE-2014-title42-chap6A.pdf as amended

· Chapter 81 and 85 of the Health and Safety Code – http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.81.htm http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.85.htm

· Department of State Health Services Standards for Public Health Clinic Services Revised – August 31, 2004 -https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/contract-mgmt/qmb-standards-health-clinic-svcs.pdf

· DSHS Program’s HIV/STD Clinical Resources Division Standards for Clinical and Case Management Services; https://www.dshs.texas.gov/hivstd/taxonomy/

· Department of State Health Services Standards for Public Health Clinic Services; Revised August 31, 2004 - https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/contract-mgmt/qmb-standards-health-clinic-svcs.pdf

· Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, April 29, 2009, or latest version; as revised by the Perinatal HIV Guidelines Working Group https://pubmed.ncbi.nlm.nih.gov/12489844/

· Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, December 1, 2009, or latest version; as developed by the DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents- a working Group of the Office of AIDS Research and Advisory Council (OARAC) https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/Adult_OI.pdf

· Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection; February 23, 2009, or latest version; as developed by the Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Francois-Xavier Bagnoud Center, UMDNJ, The health Resources and Services Administration (HRSA) and National Institutes of Health (NIH) https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/PediatricGuidelines.pdf

· Treating Opportunistic Infections Among Infected Adults and Adolescents.

Recommendations from the CDC, the National Institutes of Health, and the HIV Medicine Association/ Infectious Disease Society of America. https://www.cdc.gov/Mmwr/preview/mmwrhtml/rr5315a1.htm

· Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV 2002 Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. Center for Disease Control (CDC) Morbidity & Mortality Weekly Report (MMWR) June 14, 2002/ 51 (RR08) 1-46.

http://www.cdc.gov/MMWR/preview/MMWRhtml/rr5108a1.htm

· Updated guidelines on Managing Drug Interactions in the Treatment of HIV related Tuberculosis. February 1, 2008/ 54(04); 98. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5704a4.htm

· Perspectives in Disease prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Blood borne Pathogens. Center for Disease Control(CDC) Morbidity & Mortality Weekly Report (MMWR) June 24, 1988/ 37(24); 377-388, or latest version; http://www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm

· Incorporating HIV Prevention into the Medical Care of Persons Living with HIV. Center for Disease Control (CDC) Morbidity & Mortality Weekly Report (MMWR) July 18, 2003/ 52, RR 12; 1-24; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm

· DSHS Program’s Universal Precautions Preventing the Spread of HIV, Tuberculosis, and Hepatitis B in Employees of HIV/STD Funded Programs, HIV/STD Policy No. 800.001; https://www.dshs.texas.gov/hivstd/policy/policies/800-001.shtm

· DSHS Program’s STD Clinical Standards and Monitoring Guidelines;

https://www.dshs.state.tx.us/hivstd/healthcare/treatment.shtm

· Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Post exposure Prophylaxis, CDC MMWR, June 29, 2001/ Volume 50, RR 11; 1-42, or latest version; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm

· Updated Information Regarding Antiretroviral Agents Used as HIV Post Exposure Prophylaxis for Occupational HIV Exposures. CDC, Morbidity & Mortality Weekly Report (MMWR) December 14, 2007/ 56(49); 1291-1292; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5649a4.htm

· Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings, CDC, Morbidity & Mortality Weekly Report (MMWR) September 22, 2006 / 55(RR14); 1-17; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

The Clinical Guidelines for HIV/AIDS medical practice are available at https://clinicalinfo.hiv.gov/en/guidelines; and on the HIV/STD Clinical Resources Division at https://dshs.texas.gov/hivstd/contractor/hivmedical.shtm. PERFORMING AGENCY is responsible to maintain access to current standards and guidelines.

· Current, federally approved guidelines for clinical treatment of HIV and AIDS are available from HIVinfo | Information on HIV/AIDS Treatment, Prevention and Research | NIH at https://hivinfo.nih.gov/; and on the DSHS HIV/STD website at http://www.dshs.texas.gov/hivstd/. Subcontractor is responsible for maintaining access to current laws, standards and guidelines for its staff working on activities under this Program Attachment.

· These include the standards found at the following link: https://dshs.texas.gov/hivstd/contractor/hivmedical.shtm.

F. ASSURANCES AND CERTIFICATIONS

Subcontractors must submit with the application and maintain on file current, signed, and annually dated assurances adhering to the following:

· Nonprofit Board of Directors and Executive Officer Assurances, if the Subcontractor’s Agency is a nonprofit organization,

· HIV Contractor Assurances,

· Contractor Assurance Regarding Pharmacy Notification,

· Assurance of Compliance with Requirements for Contents of AIDS-Related Written Materials.

· Assurance From Sanctions for Client Abuse and/or Neglect

· Assurance of Compliance with from Sanctions for Evidence of Child Abuse and/or Neglect

· Assurance of Compliance with Training, Education, and Licensure

· Assurance of Compliance with Standing Delegation Orders

Copies of each form listed above are provided in this contract. Other assurances are included in the STDC contract general provisions. All Subcontractors must retain copies of the required assurances on file for review during program monitoring visits. Documents to support compliance with the assurances are to be kept on file with the Subcontractor and at each respective subcontractor site, and will be reviewed by STDC staff during site visits. Non-compliance with these Assurances could result in the suspension or termination of funding; therefore, it is imperative that the applicant read, understand, and comply with all these Assurances.

G. POLICIES OF THE HIV/STD PREVENTION AND CARE AND TB/HIV/STD EPIDEMIOLOGY AND SURVEILLANCE BRANCHES

The subcontractor must abide by all relevant polices of the HIV/STD Prevention and Care Branch and the TB/HIV/STD Epidemiology and Surveillance Branch. Subcontractors are required to provide pertinent policies to its service providers, when applicable. Policies may be found at https://www.dshs.texas.gov/hivstd/policy/policies.shtm. Subcontractors are encouraged to establish a policy manual to contain all STDC and DSHS policies.

H. FEDERAL RYAN WHITE POLICIES

Contractors and subcontractors are required to comply with HRSA’s HIV/AIDS Bureau Policies for the Ryan White CARE Act. To this end, the STDC recommends that all Subcontractors and their agents obtain and refer to the latest Ryan White Part B Manual. This manual can be downloaded at http://www.hab.hrsa.gov/ for a hard copy can be requested by contacting the HRSA Information Center at (888) ASK HRSA.

I. PROGRAM REPORTING

1. Uniform Reporting System

Take Charge Texas (TCT) is a web-based software that providers use to report on Ryan White and State funded services provided to eligible clients. TCT serves as the Ryan White Part B Uniform Reporting System (URS) of Texas. Subcontractors must enter required data into TCT to complete and produce client-level reports required by HRSA Ryan White HIV/AIDS Program Services Report (RSR). Subcontractors must demonstrate evidence of timely and routine entry of service delivery information. Subcontractors are required to participate in the new system quality assurance activities. Subcontractors must hire qualified personnel, as defined by STDC policy, to fulfill the required duties and standards described in the policy. This includes assisting providers in collecting and reporting of data, management, improvement, and assistance in the application of the TCT portal. All Ryan White eligible services provided by Ryan White, State Services and HOPWA eligible clients must be reported by STDC.

2. HIV Services Program Reports

Subcontractors are required to collect and maintain relevant data documenting the progress toward the goals and objectives of their project as well as any other data requested by the STDC and DSHS. Subcontractors must demonstrate in the data and program reports continuing efforts to assure that Ryan White and State Services monies is the payer of last resort through third party billing for all professional services, enrollment in available prescription plans and any other appropriate alternate payers.

Subcontractor shall utilize the HIV Services Reporting Forms, provided electronically by the STDC program. Subcontractor accepts responsibility and accountability for its agency’s compliance and timely submission of documentation required in the program narrative report and data reporting table. Subcontractor shall submit semi-annual and annual program reports to STDC on or before the fifteen (15th) day as indicated below. The progress toward meeting the program objectives must be reported for the report period as well as year-to-date. Data reporting information shall be reported as requested. The annual report will serve as the final program report. The program reporting format may be accessed at http://www.stdc.cog.tx.us. Failure to comply with deadlines and content requirements may result in an interruption of monthly reimbursements.

Ryan White Service Delivery, State and State Services providers use the same reporting form. The HOPWA Services are reported on the HOPWA semi-annual form. Reports are to be submitted as follows:

Email Ryan White SD/State/State Services semi-annual and annual reports to:

· John R. Keiser, Regional Programs Director, jrkeiser@stdc.cog.tx.us

· Maribel Rodriguez, Program Manager, mrodriguez@stdc.cog.tx.us and a copy to the following:

· Cindy R. Garza, Data Manager, crgarza@stdc.cog.tx.us

· Dora Inclan, Planner, dinclan@stdc.cog.tx.us

· Erika Garcia, Program Specialist, eagarcia@stdc.cog.tx.us

· Alma Briseño, Compliance Monitor, abriseno@stdc.cog.tx.us

If electronic…