Exhibit J - Subrecipient Manual.pdf

Developed for the Riverside/San Bernardino Transitional Grant Area

SUBRECIPIENT MANUAL

SECTION 1: PREFACE

1.1 Overview……………………………………………………………………………

1.2 Ryan White Program Background……………………………………………….

SECTION 2: ELIGIBILITY

2.1 Overview……………………………………………………………………………

2.2 Client Eligibility Requirements……………………………………………………

2.3 Service Inactivation………………………………………………………………..

2.4 Duplication of Services……………………………………………………………

SECTION 3: HCC

3.1 Overview……………………………………………………………………………

3.2 HCC Data Requirements……………………………………………………….

3.3 Timely Data Entry………………………………………………………………….

3.4 Case Notes……………………………………………………….………………..

3.5 Technical Lead…………………………………………………………………….

3.6 User and Staff Changes………………………………………….…………

3.7 Laptop Digital Certificates………………………………….…………………….

3.8 Interrupted Internet Service………………………………………………………

SECTION 4: REPORTS, TOOLS, AND FORMS

4.1 Overview…………………………………………………………………..……….

4.2 Self-Audits………………………………………………………………..……..…

4.3 Invoice Reporting………………………………………………………………….

4.4 EIS Reporting……………………………………………………………………..

4.5 New Client Classification…………………………………………….……………

4.6 Program Income Tracking and Usage………………………………………….

4.7 Required Tools and Forms List………………………………………………….

SECTION 5: MEDICAL AND NON-MEDICAL CASE MANAGEMENT

5.1 Overview……………………………………………………………………………

5.2 MCM and NMCM Levels of Coordination……………………………..………..

SECTION 6: PROGRAM MONITORING

6.1 Overview……………………………………………………………………………

6.2 Annual Program Monitoring Review…………………………………………….

SECTION 7: GRIEVANCE

7.1 Overview……………………………………………………………………………

7.2 Grievance Policy Requirement…………………………………………………..

TABLE OF CONTENTS

ADDITIONAL REFERENCES……………………………………………………………. 59

DEFINITIONS………………………………………………………………………………. 62

APPENDICES……………………………………………………………………………… 64

PREFACE

1.1 Overview

The purpose of this manual is to provide a consolidated resource for subcontractors (to be referred as subrecipients in this manual) of San Bernardino County Department of Public Health (SBCDPH) who provide Ryan White (RW) funded services to eligible clients in the Riverside/San Bernardino Transitional Grant Area (RSBTGA). It provides comprehensive guidance to the Ryan White Program (RWP) policies and procedures and includes references, guidelines, tools, and links to help subrecipients meet contract and program requirements as specified in:

• RWP Contracts,

• RWP Policies, − Program and HIV Care Connect System (HCC),

• HIV/AIDS1 Bureau (HAB) National Monitoring Standards (NMS),

• California Department of Public Health Office of AIDS (OA),

• Ryan White Services Report (RSR) Instruction Manual,

• Ryan White HIV/AIDS Treatment Extension Act Legislation,

• Inland Empire HIV/AIDS Planning Council (IEHPC) Standards of Care, and

• Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) policy notices.

This manual is organized into sections, with each section dedicated to a specific topic. To clearly specify which grant (Part A, Part B, and EHE) is relevant to a section block, grant identifiers have been systematically incorporated throughout the manual as follows:

Grant Identifier Part A A Part B B

EHE EHE

The beginning of each section provides an overview of the main topic and its subtopics.

Pertinent resources used are listed as references and linked after the overview block. The appendices section includes all the applicable forms, tools, and templates referenced in the manual. This structure ensures that the information is presented in a clear and organized manner, allowing subrecipients to find the information they need with ease.

RWP funding has various requirements to ensure it is the payer of last resort and that eligible individuals receive quality services that improve their health outcomes through RW funded services. Therefore, it is the RWP’s expectation that subrecipients be aware of the RWP policies and ensure staff understand and adhere accordingly. The referenced policies and procedures are part of the RWP compliance requirements to avoid findings, a corrective action plan (CAP) requirement, delay/denial of payment, or up to termination of contract. The RWP will conduct periodic Quality Assurance reviews and visit subrecipients’ sites annually, or as deemed necessary, to confirm compliance.

Please contact the RWP office for technical assistance, questions, or concerns regarding the content in this manual at (909) 387-6492.

1 Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome https://iehpc.org/images/DOWNLOADS/ABOUT_US/BYLAWS/Bylaws%20P%20&%20P%202020%201.2.3.4.pdf https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_hiv_data_systems.aspx https://ryanwhite.hrsa.gov/grants/manage/recipient-resources https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_program.aspx https://targethiv.org/library/rsr-manual https://ryanwhite.hrsa.gov/about/legislation https://www.iehpc.com/standards https://ryanwhite.hrsa.gov/grants/policy-notices https://ryanwhite.hrsa.gov/grants/policy-notices

1.2 Ryan White Program (RWP) Background

The SBCDPH RWP oversees the administration of the Ryan White Part A grant and Ending the HIV Epidemic (EHE) initiative grants for the RSBTGA. It also oversees the Ryan White Part B grant for San Bernardino County. Most of these grant funds are contracted out to various organizations throughout Riverside and San Bernardino counties who provide HIV medical care and support services to HIV+ clients. As the grant recipient, the RWP is responsible for overseeing the administration of in-house services and provides continuous technical assistance to contracted agencies to ensure service quality and compliance with federal and state requirements. The goal of the program is to be the payer of last resort and ensure access to quality services for HIV+ individuals who lack the health insurance and financial resources necessary to otherwise obtain the care and support services they need to improve their health outcomes, thereby improving the health of the community at-large.

The Ryan White HIV/AIDS Treatment Modernization Act (formerly called the Ryan White CARE2 Act) is a federal program that was enacted by Congress in 1990 with the purpose of improving the quality of life for those affected by HIV/AIDS. It was re-authorized in 1996, 2000, 2006, and 2009. The act was named after Ryan White, a teenager from Indiana who contracted HIV from a contaminated treatment of factor VIII and brought awareness of the epidemic through his struggle with HIV/AIDS and advocacy regarding AIDS-related discrimination. In 1994, the SBCDPH began receiving Ryan White HIV/AIDS Program (RWHAP) funding to support programs in the RSBTGA. The RWP currently has seven (7) HIV subcontractors (referred as subrecipients in this manual) that receive Part A, Part B, and/or EHE grants from SBCDPH and provide outreach and services to clients with the goal of reducing new HIV infections in the United States by at least 90% by 2030.

2 Comprehensive AIDS Resources Emergency

ELIGIBILITY

2.1 Overview

Subrecipients providing RW funded services under Part A, Part B, and/or EHE grant must first determine a client eligible to the RWP. The criteria and requirements in the RWP eligibility process, including the annual certification, are included in this section, but not limited to:

• Developing agency policies to address all requirements outlined,

• Submitting policies developed and any revisions to the RWP for review and approval,

• Collecting and maintaining all documentation verifying eligibility compliance,

• Performing targeted outreach for other payer sources, at least annually, and

• Completing intake and certification processes timely.

The RWP will monitor for compliance and enforce the referenced policies monthly in conjunction with invoice processing and annually through programmatic reviews. Eligibility requirements must be 100% compliant during the annual program review to prevent any findings and the need for a Corrective Action Plan (CAP) to the RWP.

References RWP Eligibility Policy

Service Inactivation Policy

Duplication of Services Policy

Policy Clarification Notice 07-01

Policy Clarification Notice 13-03

Policy Clarification Notice 13-04

Policy Clarification Notice 16-01

Policy Clarification Notice 21-02

OA HIV Care Program Memorandum Number 14-01

OA HIV Care Program Memorandum Number 14-02

Ryan White HIV/AIDS Program Legislation

IEHPC Common Standards https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/indian-salaskans-pn-0701.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-1303-eligibility-considerations.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-1304-private-insurance.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/clarification-services-veterans.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-21-02-determining-eligibility-polr.pdf https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/HCPMM14-01.pdf https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/HCPMM14-02.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/about-program/legislation-title-xxvi.pdf https://static1.squarespace.com/static/65aadbc337eb38508d8949e1/t/673558a2a520f5538d85779c/1731549346270/COMMON_STANDARDS__SEPTEMBER_2024.pdf

2.2 Client Eligibility Requirements

Eligibility entered in HCC

(A/B/EHE)

All eligibility information received from the client that is used by the agency to make an eligibility determination will be entered into HCC in a timely manner to ensure coordination of client services and support monthly invoice submissions.

For additional guidance related to HCC data entry policies, refer to:

• CDPH website,

• Data System Notice: No. 02, and

• HIV Care Connect FAQs

Note: Subrecipients are encouraged to upload eligibility documentation into HCC which can be shared amongst subrecipients in the TGA.

Eligibility requirements

(A/B/EHE)

Eligibility requirements are designed to ensure access to RW services, not to create barriers. While agencies must verify eligibility prior to providing RW-funded services, there is no legislative requirement for a “confirmed” HIV diagnosis prior to care (i.e., initial screening test results are sufficient).

However, a confirmatory test should be ordered during the first visit.

Category Requirement Part A Part B EHE HIV diagnosis Verification of HIV or AIDS diagnosis X X X Income Must meet RWHAP low-income definition X X

Residence Must live within the RSBTGA service area

Note: Part B within San Bernardino only.

X X

Other funding source screening

Documentation of screening, eligibility status, and/or verification

X X X

Statement of Need Documentation showing the client has a need for services

X X

Non-eligibility

While the following list of non-eligibility Consent/Notification forms is not necessary for a client to receive RW services. However, they are required for the annual program monitoring process conducted by the RWP. Therefore, they must be collected and kept on file for review for any client receiving RW-funded services under the Part A, Part B, and/or EHE, as outlined below.

Form Name Part A Part B EHE HCC Consent X X X HIPPA Notification X X X Service Consent X X Partner Service Notification X X

Continued on next page https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_hiv_data_systems.aspx https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/Complete_DSN02_ADA.pdf https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/HIV-Care-Connect-FAQs_ADA.pdf

2.2 Client Eligibility Requirements, Continued

Required documentation

The chart below outlines the acceptable documentary evidence and required frequency to verify a client’s eligibility for the RWP. If a client provides documentation that is not listed in the chart and the subrecipient wishes to use it for eligibility verification, they should contact the RWP office for technical assistance.

To minimize barriers, accommodate agency workflows, and support subrecipients in meeting compliance during program monitoring, there is a 30-day grace period from the date of service to ensure all eligibility documents have been collected and documented.

Element When to Document Documentary Evidence HIV diagnosis

(A/B/EHE)

One Time Only at initial eligibility

Note: Initial screening test results are sufficient, though confirmatory testing should be ordered on the first visit.

• Lab Results − Antibody test − Qualitative HIV detection test − Detectable viral load

• Diagnosis form CDPH 8440

• Letter from physician or licensed health provider, including:

− Letterhead, − National Provider Identifier

(NPI) number or driver license number, and

− Signature and date verifying HIV status.

Residence (A/B)

• Initial eligibility

• Annual certification

Note: A Residency Verification Affidavit signed and dated by the client is acceptable for clients with unstable housing.

• CA driver’s license or identification card

• Dated within the last 30-days:

− Rent or mortgage receipt − Current utility bill (cell phone excluded) − Paycheck stub

• Dated within one year:

− Rental/lease agreement − Voter Registration card − Unexpired vehicle registration − W-2 or 1099 − SSA, SSI, or SSD award letter − EDD award letter − Filed State/Federal tax return − Public housing letter − Notice of Action from DHCS − School record − Property tax receipt

• Letter from a shelter or social service agency verifying identity, length of residency, and location

Income • Initial eligibility • Current paystubs https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph8440.pdf

(A/B) • Annual certification − Three consecutive months − If employed more than one year, one paystub showing YTD earnings that includes at least three months of income

− If employed less than one year, one paystub showing YTD earnings that includes at least three months of income and start date

• Prior year tax documents

• Dated within one year:

− SSA, SSI or SSD award letter − Veteran’s benefit − SDI, Worker’s Comp or UIB − Retirement/Pension − Spousal support

• Current bank statement with clearly identified direct deposit

• Investment income

• Rental income

− Signed and dated rental agreement within the last year

− Three current bank statements showing deposits

• CDPH 8726 if self-employed and not filed taxes

• Letter from the income earned source signed and dated, including:

− Letterhead, if applicable, − Client name, − Rate/frequency of pay, and − Contact information.

• Letter of support signed and dated by the individual providing the support AND client self-attestation of zero income signed and dated.

• CDPH 8441, if no other method Other funding source screening

(A/B/EHE)

• Initial eligibility

• Copy of insurance card, including Medi-Cal BIC

• Dated insurance status screenshots from an official insurance system

• Denial/discontinuance letter from other available sources (e.g., Medi-Cal, CalFresh, HOPWA)

• “No insurance” statement from the client, as applicable, signed https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph8726.pdf https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph8441.pdf

Note: Whenever possible, verify a client’s ineligibility or lack of access to other funding sources at the point of service.

and dated; if employed, reason why insurance is not available through employer.

• Document verifying funds from the other source have exhausted.

• Signed and dated client statement indicating “no other funding resource available to obtain necessary/adequate service” AND agency documentation of other resources explored (i.e., referral to food bank) and reason they cannot support the need.

HCC Consent

(A/B/EHE)

• Initial eligibility

• Every 3 years

Form signed and dated

HIPPA Notification

(A/B/EHE)

Initial eligibility Form signed and dated

Service Consent (A/B)

Initial eligibility Form signed and dated

Statement of Need

(A/B/EHE)

• Initial eligibility

• When service needs change

Notes in client’s file indicating there is a need for services being received.

Partner Services Notification (A/B)

• Initial eligibility

Form signed and dated

Note: Documentation can take various forms, including emails, text messages, and digital signatures, as long as they comply with the agency’s client privacy policies. Ensure all received documents are dated upon receipt and initialed or signed by the receiving staff member.

Record keeping

(A/B/EHE)

Subrecipients must retain all current eligibility and non-eligibility documentation, including any documentation obtained from the client, whether ex-parte or used for determining eligibility. This documentation may be reviewed by the County during annual program monitoring or upon request.

Recertification (A/B)

HRSA HAB requires subrecipients to conduct annual recertifications at least once a year after the initial eligibility determination. This involves requesting supporting documentation similar to what was collected during the initial eligibility certification, unless they meet self-attestation criteria. Subrecipients must collect all required eligibility documents according to the specific grant requirements and documentation timeframes during the client’s annual recertification process, on the client’s birthdate following initial enrollment and every year thereafter.

Client Birthdate Initial

Enrollment Date

First Recertification

Occurs

Subsequent Recertifications

January 15

April 15, 2024

January 15, Every 12 months thereafter on birthdate

April 15 April 15, 2025 July 15 July 15, 2024 October 15 October 15, Note: Eligibility determinations may occur twice within the client’s first year of service as illustrated above.

Self-attestation criteria

(A/B/EHE)

To simplify the process and reduce administrative burden, self-attestation may be accepted in the following cases:

• Second eligibility determination within a client’s first year of service

• Clients with no changes in income, residency, or other funding sources

A self-attestation affidavit of no change may be used; however comprehensive documentation, similar to the initial eligibility certification, will still be required biennially (every two years).

RWP eligibility for clients with a SOC

(A/B/EHE)

Some Medi-Cal/Denti-Cal clients are required to meet a Share of Cost (SOC) each month before Medi-Cal/Denti-Cal will pay for services. Subrecipients will refer to the guidelines below when screening clients (Appendix 1) during each encounter prior to using RW funds for this client population.

• Recognize clients covered by Medi-Cal/Denti-Cal that are unable to pay the SOC and do not meet the payment requirement are considered no longer eligible for Medi-Cal/Denti-Cal.

Coverage will be denied, preventing the agency from billing Medi-Cal/Denti-Cal for services provided.

− RW funds can be used to provide services in the instance above. However, if a client has Medi-Cal/Denti-Cal without Medicare, AIDS Drug Assistance Program (ADAP) will pay for medication on the ADAP formulary up to the client’s Medi-Cal/Denti-Cal SOC amount. If so, the client’s SOC is met for the month and able to access other Medi- Cal/Denti-Cal covered services for the remainder of the month without any additional cost.

• Justify the use of RW funds for Medi-Cal/Denti-Cal by providing clear documentation of the client’s SOC situation and the steps taken to remedy the issue and specify the status of such efforts. Documentation must include the following:

− A Signed and dated Inability to Pay Share of Cost Affidavit (Appendix 2) or a RWP approved version, − A print-out of the Automated Eligibility Verification System (AEVS) or equivalent document indicating the SOC at the date of service, and This document must be obtained at each applicable encounter, attached to the

Inability to Pay Share of Cost Affidavit or other approved form, and maintained in the client’s chart for review.

− Keep continuous and dated case notes regarding efforts made to reduce or eliminate the SOC and any progress towards doing so.

• Educate clients about how ADAP can be used to eliminate and/or reduce SOC and refer to necessary services to assist with budget training and benefits counseling.

• Use RW funds to provide services only for a reasonable time while the SOC issue is remedied, not to exceed a reasonable amount of time.

Partial benefits through another payer source

(A/B/EHE)

RWP clients must exhaust their Medi-Cal, Denti-Cal, or private insurance benefits prior to utilizing RW services. If a RW service is comparable to a benefit the client has through another payer source (e.g., Medi-Cal, CalFresh, etc.) but there is a medical necessity for a service component beyond what their benefits offer, RW funds may be used to provide the service component.

RW funds cannot be used to pay for the balance of a service; only complete service components that are not available from another funding source. If RW funds are used for a service beyond what the client’s benefits offer documentation must be obtained and kept on file for justification, such as:

• Treatment plans or progress notes that describe the medical necessity of a service that is not covered by the client’s other payer source, and

• An outline of benefits from the other payer source that supports the need for RW funds to fill service gaps.

The inability to use RW funds to pay for the balance of a service restriction adheres to OA policy. Subrecipients must review the OA Management Memorandum #14-02, the associated Frequently Asked Questions (FAQ), and include the requirements into their agency’s policies and procedures.

Vigorous pursuit documentation (A/B)

Subrecipients must vigorously pursue eligibility for other funding sources (i.e., Covered California). The guidelines below outline compliance requirements for Vigorous Pursuit Documentation under PCN 21-02, applicable during both intake and recertification process.

(Only for OAHS, Oral Health, Mental Health, and Substance Abuse subrecipient providers)

Complete the following actions to ensure clients are assessed for available health coverage options:

• Make every reasonable effort to ensure all uninsured clients are assessed for private and public health care coverage, including Medi-Cal, Medicare, and any other private insurance.

• Check the RW clients who may qualify for Affordable Care Act (ACA) health insurance through the ACA Report or comparable RWP-approved report in HCC, at least once a year prior to Covered California’s November open enrollment, to facilitate targeted outreach to uninsured clients.

• Establish and uphold policies outlining the required process for health care coverage enrollment efforts.

− Policies must specify how subrecipients will document the enrollment process.

• Implement policies to confirm that clients are actively pursuing enrollment in health care, with documented efforts that HAB can monitor during site visits.

Provide clients with the following information regarding health care coverage:

• Those who may qualify for Medi-Cal must apply and receive an eligibility determination.

RW funds may only be used during the application period or under acceptable partial benefit circumstances. (Refer to Partial Benefits Through Another Payer Source)

• The consequences of not enrolling in available public or private health care coverage options.

• If, despite extensive documented efforts, they remain unable to enroll in health care coverage, they may continue to utilize RW services as otherwise eligible.

https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/HCPMM14-02.pdf https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/HCPMM14-02.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-21-02-determining-eligibility-polr.pdf https://www.healthforcalifornia.com/individual-and-family-quote?msclkid=f0340d8f62671ea84647682094cc6302&utm_source=bing&utm_medium=cpc&utm_campaign=Opt%20-%20Covered%20California&utm_term=california%20get%20covered&utm_content=Covered%20California%20New2%20-%20E&msclkid=f0340d8f62671ea84647682094cc6302&utm_source=bing&utm_medium=cpc&utm_campaign=Opt%20-%20Covered%20California&utm_term=california%20get%20covered&utm_content=Covered%20California%20New2%20-%20E&gclid=CODa5_yD9IMDFQGWxQIdSeoA5Q&gclsrc=ds https://www.dhcs.ca.gov/services/medi-cal/Pages/ApplyforMedi-Cal.aspx https://www.ssa.gov/medicare/sign-up

Vigorous pursuit documentation, (continued) If the client is ... Then ...

Eligible for comprehensive health care coverage but remains unenrolled

The subrecipient is required to do the following at the initial eligibility determination and each recertification:

• Screen for comprehensive health coverage through the ADAP

Enrollment System (AES) and attest that coverage options have been presented to the client and are aware that they may incur a fine for not having health insurance unless they meet an exemption (Appendix 3).

• Provide the client with the following information:

− Benefits of comprehensive health care coverage, including coverage purchased through Covered CA, − Medi-Cal and Covered CA eligibility criteria, including information for premium assistance and cost sharing subsidies, − Open enrollment dates for Covered CA, including special enrollment periods, − The ongoing availability of Medi-Cal enrollment, − Premium assistance offered through OA-HIPP3, − How to find a certified enrollment counselor for help with

Medi-Cal or Covered CA application, and − Whether their current provider is part of a Covered CA provider network and/or a Medi-Cal Managed Care Plan; if they receive OAHS, oral health, mental health, or substance abuse services.

• Document the screening outcome for comprehensive health coverage (or equivalent) in HCC in a timely manner.

• Enter detailed notes in the client’s file, tracking each step taken to assist with obtaining comprehensive health care coverage over time.

Eligible but opted to postpone or reject enrollment

The subrecipient must continue to:

• Carry out the actions under eligible for comprehensive health coverage but remains unenrolled.

• Help clients overcome enrollment barriers

− Document efforts in the client’s file at every encounter.

• Be aware that Covered CA open enrollment restrictions do not include special enrollment periods.

• Acknowledge that Medi-Cal has on-going enrollment and ensure the client is informed.

3 Office of AIDS’ Health Insurance Premium Payment Program https://www.coveredca.com/special-enrollment/ https://www.coveredca.com/special-enrollment/ https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_adap_hipp.aspx

2.3 Service Inactivation

Background RWP subrecipients requested the IEPHC relieve them of the service standard regarding clients that are not accessing specific RW services. The process of service inactivation permits subrecipients to develop and implement policies and procedures addressing service inactivation without affecting the client’s eligibility for other RWP services. Accessing one service is not a requirement for clients to access other RWP services.

Inactivation policy guidelines (A)

Subrecipients will refer to the IEHPC Common Standard and the guidelines below when developing and implementing their agency’s client service inactivation policy.

Step Action

1 Develop a service inactivation policy that defines the conditions in which a client may be placed on an “Inactive Status” list, while considering the following client factors:

• Attestation of no unmet needs or service gaps.

• Dropped due to lack of follow-up as determined by the service provider.

• Do not want to receive services.

2 Submit the policy to the RWP for review and approval prior to implementation.

3 Train staff and implement policy upon approval.

4 Following the service inactivation, enter detailed case notes in HCC documenting the factors of the service inactivation.

Review of inactivation policy (A)

RWP subrecipients are required to review their service inactivation policy at a minimum of every three years to determine if a revision is necessary.

If the policy ... Then ...

Requires revision, • Revise the policy as needed.

• Submit the revised policy to the RWP for review and approval.

• Update the Revision History section with the revision date.

• Train staff on the revised policy and implement it.

Does not require revision, • Update the Revision History section with the review date, indicating no changes required.

• Submit the unchanged policy with the updated revision date to the RWP.

2.4 Duplication of Services

Ryan White Care Act

(A/B/EHE)

Under the Ryan White CARE Act, duplication of services among subrecipients is not allowable. Subrecipients must make reasonable efforts and have policies in place to screen for and minimize duplication of services throughout the TGA, ensuring that funds are used as the “payer of last resort.”

Guidelines to avoid duplication of services

(A/B/EHE)

If a provider believes a client is accessing or attempting to duplicate services, subrecipients must:

• Maintain client confidentiality by not contacting other subrecipients to investigate, as this may violate privacy regulations

• Notify the RWP − The RWP has authority to review client records across the entire

TGA in HCC − The RWP will determine if the client is utilizing duplicate services.

• Enter client and service delivery data into HCC in a timely manner to improve monitoring across the TGA.

https://www.cdph.ca.gov/Programs/OLS/Pages/HIPAA-and-Your-Privacy-Rights.aspx

HIV Care Connect (HCC)

3.1 Overview

HCC was developed by the OA to collect, manage, and report on client data for RWHAP. The intent of HCC is to help service providers improve the quality of care and services they provide to people living with HIV/AIDS (PLWHA). RWP subrecipients will use HCC as the HIV/AIDS client management system to allow for coordination of client services and provide comprehensive data for program reporting and monitoring. The CDPH is currently developing requirements for various aspects of HCC, including guidelines for user and administrative tasks.

This follows the recent replacement of the previous system, ARIES. It is the subrecipients responsibility to:

• Review the guidelines as they are developed and ensure staff understanding and adherence,

• Collect the minimum set of data elements and enter them in HCC at every point of service

(POS).

• Develop agency policies to address all the requirements outlined, and

• Submit policies developed and any revisions to the RWP for review and approval.

The RWP will run various periodic reports and conduct Quality Assurance reviews throughout the grant year to ensure compliance with the policies referenced.

References

CDPH website Data System Notice: No. 02 HIV Care Connect FAQs https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_hiv_data_systems.aspx https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/Complete_DSN02_ADA.pdf https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/HIV-Care-Connect-FAQs_ADA.pdf

3.2 HCC Data Requirements

Data element collection expectations

(A/B/EHE)

All applicable data elements integrated in HCC should be collected and entered at the POS; prior to the client receiving any RW funded services.

Due to subrecipients’ varying workflow constraints, it is understood that this is not always possible and therefore the RWP has determined the minimum elements that must be collected at the POS.

Note: Adhere to the Interrupted Service Guidelines when it is anticipated that HCC will be unavailable for an extended duration.

Minimum data elements

Minimum data element development in progress.

Element Description HCC Data Forms

• Being designed to include screenshots of all relevant HCC screens to illustrate required elements

• Intended for use in collecting client information when direct access to HCC is unavailable

HCC Minimum Data Requirement

• First tab (under development):

− Will specify the minimum required data, to be updated as needed − Will feature a table outlining which elements require updates and their frequency

• Second tab (under development):

− Will contain the same information as the first tab − Will include elements necessary for reporting

Note: Data element entries are only required when they are applicable to the client (e.g., AIDS diagnosis date is only required if the client has been diagnosed with AIDS).

3.3 Timely Data Entry

Subrecipient responsibilities

(A/B/EHE)

Subrecipients are responsible for entering data in a timely manner into HCC to allow for coordination of services, accurate service utilization reporting and to meet reporting requirements (i.e., Monthly Invoice Reporting, etc.).

Timely data entry guidelines

(A/B/EHE)

RWP subrecipients will refer to the guidelines below when completing a timely client data entry into HCC.

• A new client record must be created within five business days of a client’s intake.

• All client information should be entered, including basic demographic and contact information to facilitate enrollment and service delivery to the client throughout the RSBTGA.

• Ensure data requirements and service delivery dates are entered and updated at the POS in real time, to:

− Streamline enrollment and service coordination across the RSBTGA, − Minimize duplication of services, and − Provide authorized access to the client’s record in HCC for the RWP and other subrecipients.

• For ongoing service delivery, subrecipient staff must complete “charting”

(entry) of service delivery dates in a timely manner after services are delivered.

− If there is a delay in data entry, subrecipients are to ensure that all required data, supporting their monthly invoice, is entered into HCC prior to submitting the invoice to the RWP for payment.

Example: If the November invoice is due to the RWP office by

December 20th, then the data supporting the November invoice must be completely entered into HCC before the 20th of December (Refer to Monthly Invoice Reporting).

Note: Data entry guidelines may be different for subrecipients who receive funding from the state.

Service dates in HCC

(A/B/EHE)

Service dates entries into HCC are required under timely data entry guidelines and should be completed at the POS. If there is a delay in the data entry process, The “Date of Service” under the “Services Section” is not affected.

Example: If the client received Home and Community Based Health Services on October 20th but the agency is not able to enter the service delivery information into HCC until November 20th, the date of “10/20/20YY” must be entered into the “Date of Service” field.

3.4 Case Notes

Case notes guidelines

(A/B/EHE)

Subrecipients serving eligible clients under the RWP within the RSBTGA must follow these guidelines when entering and maintaining case notes in

HCC:

• Case and service delivery data should be entered and maintained in HCC at the, in real time, whenever possible (Refer to Timely Data Entry and Reporting).

• For certain service categories (e.g., mental health, substance abuse), case notes must be signed and sealed by the end of each business day.

− A log report is available in HCC that can assist in determining if any case notes are unsigned at the end of the day.

• Case notes entered in HCC must not be deleted or altered in any way.

− If a “charting” mistake is discovered, an additional note must be entered that states the correction, whether paper or electronic.

Accessing the log report

(A/B/EHE)

Training on pulling the log report is currently being developed by CDPH and is not yet finalized.

3.5 HCC Technical Lead

HCC TL

requirement

Subrecipients are required to designate an individual at each agency site to act as the HCC Technical Lead (TL) who is responsible for ensuring effective utilization of the system and carrying out various tasks at the agency level.

The TL’s contact information must be submitted to the RWP. If there is a change in contact information or the previous TL has been replaced, the revised contact information must be submitted to the RWP within five business days.

TL

The TL must conduct and coordinate all tasks required to ensure the agency is able to effectively utilize HCC on a day-to-day basis and prevent unauthorized use. These activities include, but are not limited to:

• Submit HCC administrative questions to the RWP via email to <Beatrice.Garcia@dph.sbcounty.gov>,

• Update user accounts and reset passwords,

• Troubleshoot Information Technology (IT) issues and contact the HCC

Help Desk if issues cannot be resolved at the local level,

• Ensure HCC users adhere to the agencies Policy and Procedures (as approved by the RWP), and

• Mentor and train agency staff.

To prevent unauthorized use and access to HCC the TL will:

• Comply with all policy requirements, including the county contract, and

• Take reasonable precautions and due diligence when handling system data or using system resources and in the management and protection of system authentication controls (i.e., passwords, certificates, etc.).

Note: TLs are strongly encouraged to contact the RWP and/or the HCC Help Desk for assistance.

Ongoing trainings

(A/B/EHE)

As changes or updates to HCC occur, the RWP will conduct training to keep subrecipients informed and up to date. The TL is required to attend all HCC trainings provided by the RWP and responsible for delivering the information and knowledge to the rest of their agency staff. TL’s will also assist new users’ access OA online training to get familiarized with HCC.

mailto:%3cBeatrice.Garcia@dph.sbcounty.gov%3e

3.6 User and Staff Changes

Agency responsibility

(A/B/EHE)

As a measure to protect the privacy of staff and clients and prevent unauthorized use or access to HCC, subrecipients will report changes in staff who have HCC access to the RWP promptly.

Reporting

(A/B/EHE)

Subrecipients using HCC must notify the RWP in writing, within ten business days, when there is a change in staff and/or HCC user under the following circumstances:

• Leaves the subrecipient agency,

• Has a change in permission or user role level,

• Has a change in their contact information, and/or

• Will no longer be using HCC while at the agency.

3.7 Laptop Digital Certificates

Access request process

HCC laptop digital certificates are obtained from the RWP to allow subrecipient staff access to HCC on agency laptops and to ensure that HCC access is secure, and client data is not compromised. Laptop certificates are only approved for rare circumstances in which the staff member does not have access to a permanent computer workstation.

The agency HCC TL will refer to the step process below to request an HCC Laptop Digital Certificate from the RWP.

Step Action 1 Determine if a laptop digital certificate request is appropriate.

2 Complete and submit an HCC User Registration form to the

RWP office.

3 Provide a written justification explaining the need for the HCC laptop certification.

3.8 Interrupted Internet Service

Federal Paper Reduction Act of 1995

(A/B/EHE)

While one of the aims of HCC is to assist users in meeting the mandates set forth by the Federal Paper Reduction Act of 1995, this does not relieve the subrecipients of their responsibility to maintain paper records in sufficient quantity to meet the contractual requirements of the RWP.

Interrupted service guidelines

(A/B/EHE)

Subrecipients will refer to the guidelines below to reduce the risk of data loss caused by interrupted internet service, lack of internet access, or HCC being unavailable for any reason.

• Paper records may be created using one of the following methods:

− Print the HCC screen containing the desired data, and/or − Complete an agency form or document (typed or handwritten), and

• Once HCC is accessible, the subrecipient staff must enter data from the paper records into HCC.

https://www.govinfo.gov/content/pkg/FR-1995-08-29/pdf/95-21235.pdf

REPORTS, TOOLS, AND FORMS

4.1 Overview

To support and facilitate subrecipients compliance with their contractual agreement and program requirements, including “payer of last resort”, the RWP will request specific reports, tools, and forms that must be submitted to the RWP for review during the grant year. This section includes the required reports, tools, and forms as mandated in legislation and in the contract with the county for subrecipients receiving Part A, Part B, and/or EHE grants. It also includes optional reports, tools, forms, and guidelines that can be used to help meet compliance.

The RWP will conduct Quality Assurance reviews during the specified timeframes reports, tools, and forms are due which can include:

• On a specific due date,

• Monthly in conjunction with invoice processing,

• Mid-year through HCC data review, and/or

• Annually via programmatic onsite or virtual visit.

References Self-Audit Policy

Monthly Invoice Reporting Policy

Early Intervention Services Reporting Policy

New Client Classification Policy

Program Income and Tracking Usage Policy

Required Tools and Forms Policy

CFR: 45 CFR 75.302(b)(3) – Financial Management and Standards

CFR: 45 CFR 75.307(f) – Program income

Policy Clarification Notice 15-03

Policy Clarification Notice 15-04

Policy Clarification Notice 16-02 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.302 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-75/subpart-D/subject-group-ECFR911e5e1a30bfbcb/section-75.307 https://ryanwhite.hrsa.gov/grants/policy-notices https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/pcn-15-04-pharmaceutical-rebates.pdf https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/service-category-pcn-16-02-final.pdf

4.2 Self-Audits

Self-audit

(A/B/EHE)

The RWP requires subrecipients to conduct comprehensive programmatic self-audits at least once a year to determine compliance with all program requirements.

Note: Multiple self-audits are recommended; particularly for those agencies that have previously been cited with a finding and required to submit a CAP.

Self-audit

(A/B/EHE)

Subrecipients will refer to the guidelines below when completing their self-audits to remain in compliance with the RWP requirement.

Audit Part Activity Description When Conduct mid-grant self-audit in September/October and report the results of the RWP no later than the end of November.

• Subrecipients are strongly encouraged to conduct multiple self-audits throughout the GY; especially for those agencies that have previously been cited with deficiencies or subject to a CAP.

• If deficiencies are discovered, the report must include a CAP that includes the actions taken to rectify the deficiencies and methods to prevent any in the future.

Timeframe The audit must review criteria requirements related to the first six months of the grant year (March 1/April 1 – Aug 31/Sep 30; depending on the type of grant).

Sample size The adequate and random sample size of client’s records (who received RW Part A, Part B, and/or EHE funded services) to be reviewed is based on the subrecipient’s client population. Per the NMS response to FAQs, the RWP has established a random sampling methodology as part of the monitoring protocols. The adequate sample size based on the subrecipient’s client population is as follows:

Client Population % of Records to Review 50 or less 100%

51-100 40-50% 200-400 25%

500+ 10% 1000+ 3-5%

If a subrecipient has multiple sites, records at all sites must be reviewed according to the client population. In addition, efforts must be made to include records of all service categories to determine if any deficiencies are service-specific.

Note: Clients that received only EIS during the timeframe being reviewed may be exempt from eligibility requirements. However, EIS-specific requirements such as maintenance of EIS logs and the use of standardized forms remain.

4.2 Self-Audits, Continued

Self-audit guidelines, (continued)

Audit Part Activity Description What • All required elements should be reviewed for compliance on a regular basis.

− The elements are outlined in the resources listed in the Preface block at the beginning of this manual.

Some elements are general requirements that apply to all subrecipients.

Other elements are service-specific and only apply to the subrecipients that provide those services.

• The minimum elements required to be reviewed by subrecipients for compliance during self-audits are in relation to client eligibility and recertification. These elements include:

− HIV+ Documentation, − Residence in Riverside or San Bernardino County Verification, − Income Eligibility Verification, and − Other Funding Sources Screening.

Note: Refer to the Eligibility Requirements section for frequency and acceptable documentary evidence.

4.3 Invoice Reporting

Introduction The RWP requires subrecipients providing RW funded services to eligible clients to submit a timely and accurate Monthly Invoice Reporting (MIRP) monthly for payment.

MIRP policy

(A/B/EHE)

Subrecipients will develop and implement a policy using the steps below to ensure accurate and timely submission of the MIRP.

1 Develop a MIRP policy that assures the submission requirements are met.

2 Submit the policy to the RWP for review and approval.

3 Train staff on the policy once it has been approved.

4 Implement the policy.

5 Submit any policy revisions to the RWP.

Tracking and

(A/B/EHE)

HCC and/or another database must be used to clearly connect invoiced dollar amounts (including payroll) to allowable service delivery to eligible clients.

MIRP due date

The MIRP is due to the RWP every month, within 20 calendar days following the month in which services were provided, pursuant to the RWP Standard Contract. If the 20th falls on a non-business day, the due date will be the following business day.

MIRP contents

The MIRP must consist of the following forms and documentation:

• Document Transmittal Form (Appendix 4),

• RWP Monthly Invoice (Appendix 5),

• RWP Invoice back-up documentation:

− Proof of delivery of service, − Proof of delivery of goods, − Proof of payment, − Vendor invoices submitted for reimbursement, and − Proof that personnel were paid for the time being billed.

• EIS/Outreach Log (Appendix 6), if applicable, and

• Utilization Data Report (HCC printout – Provider Utilization by Primary

Service).

Note: Per the RWP contract, the county reserves the right to revise MIRP requirements to comply with updated program requirements.

4.3 Invoice Reporting, Continued

Submitting the

MIRP

(A/B/EHE)

Subrecipients will refer to the procedures below when submitting the MIRP to the RWP office.

1 Update the HCC Utilization Data Report or other tracking/documentation database system report being used.

2 Prepare the MIRP as outlined in the MIRP contents block.

Note: All required contents should be submitted to the RWP as one package.

3 Verify the MIRP is complete.

4 Send the MIRP to the RWP via US mail or email.

Supplemental invoices

(A/B/EHE)

In the interest of facilitating service delivery to eligible clients and to accommodate subrecipients who are unable to obtain the required back-ups to submit a MIRP timely, due to circumstances beyond their control, it has been the practice of the RWP to accept supplemental invoices. Supplemental invoices will be accepted:

• Quarterly in June, September, December, and March

• For border months, such as May, agencies may submit either in the June or September quarter, allowing two submission opportunities

• No later than 20 days following the end of the grant year.

Note: The RWP is not contractually required to accept invoices more than 20 days after the month in which services were provided.

Supplemental invoice documentation

(A/B/EHE)

Supplemental invoices must adhere to the same forms and documentation requirements outlined in the MIRP contents block. If a supplemental invoice is submitted due to revisions, all necessary supporting forms and documentation must be included.

Utilization data not captured in

HCC

(A/B/EHE)

Utilization data that cannot be captured in HCC via the Utilization Data Report (e.g., EIS/Outreach field encounters) must be documented in and tracked through other means (e.g. log). This separate must be attached to the appropriate service category invoice .

Note: Any changes to data submitted in previous months must be reported to the RWP and invoices should be adjusted accordingly.

4.3 Invoice Reporting, Continued

MIRP not accepted

(A/B/EHE)

A MIRP missing any information will not be accepted or processed until it is determined to be complete and correct. If an invoice contains unallowable costs billed as service expenses, it will need to be revised by the subrecipient and resubmitted.

Examples for a MIRP not being accepted or processed by the RWP include:

• Packet is missing any of the required forms or documentation (See MIRP contents).

• Invoice submitted without the corresponding Utilization Data Report.

• Incomplete areas or errors on the report or invoice.

• Back-up documentation and invoice information do not match.

• The report submitted is not in the format provided or previously approved by the RWP.

• The report contains client or utilization data for services for which the subrecipient is not contracted to provide under their RWP contract.

• Significant variances between invoice amount and HCC utilization data, as determined by the RWP staff.

MIRP

Procedures

(A/B/EHE)

MIRPs that are not accepted by the RWP will be returned to the subrecipient and may result in one of the following outcomes.

Outcome Description

1 Returned with an email requesting corrections, if the error can be fixed quickly, to facilitate invoice processing and avoid waiting until supplemental invoices are submitted.

2 Payments will be delayed/returned until all required documents have been received and determined to be complete by the RWP.

Note: This includes mathematical errors.

3 Subsequent MIRPs will not be accepted until the deficient report is corrected, received, and accepted by the RWP.

4 Invoices will be processed in order based on the date the RWP accepted the MIRP as correct and complete.

Note: A record of the subrecipient’s performance on the MIRP submission will be factored into the RWP Request for Proposals review process.

4.4 Early Intervention Services Reporting

Background

The goal of the United States Public Health is to inform all HIV positive individuals of their status, link them into care to improve their health status, prolong their lives, and slow the spread of the epidemic through enhanced prevention efforts.