Eligibility determination is a process of collecting information from an individual in order to provide access to appropriate sources of health insurance, services, and other benefits. Such determinations take place at initial intake but also at periodic intervals (recertification) to verify any changes in eligibility status. Ryan White HIV/AIDS Program eligibility determination and enrollment processes help ensure:
- Alignment of individuals with appropriate services and benefits under public and private health insurance and other service programs (e.g., substance abuse treatment, housing, social services).
- Coordination of benefits to maximize coverage while avoiding inappropriate coverage and payments.
- Compliance with program requirements (e.g., income eligibility, health status eligibility, Ryan White payer of last resort).
Ryan White eligibility determination processes entail collection of information on multiple criteria, most notably: HIV status, income (set as a percentage of federal poverty guidelines), residency, and eligibility/enrollment in other health insurance programs. Notably, eligibility determination processes are being enhanced via online systems that interface with insurance Marketplace systems established under the Affordable Care Act.
Guidelines and Manuals
HRSA HIV/AIDS BureauDecember 2016
HRSA's HIV/AIDS Bureau guidance and requrements for grantees of the Ryan White HIV/AIDS Program on such topics as eligibility, allowable use of funds, and clarifications of legislative requirements.
Webinars and Training
Webcast review of HRSA's insurance purchasing policy, the definition of MAGI, considerations for ADAPs, and a spotlight on Illinois ADAP.
This webinar explains eligibility determination (ED) and strategies to manage ED.
HRSA HIV/AIDS BureauMarch 2013
This webinar for Ryan White Part B Grantees provides an overview of Ryan White HIV/AIDS Program expectations for client eligibility assessment and recertification requirements.
HRSA HIV/AIDS BureauJuly 2012
Session for ADAP coordinators on ADAP intersections with patient assistance programs (PAPs), client access to PAPs, and NASTAD work to streamline the PAP eligibility and enrollment processes.
Training on meeting federal and state fiscal requirements, fiscal compliance assessment, implementing Ryan White payer of last resort policies, applying Federal Poverty Level guidelines to assess sliding fees, and financial sustainability.
Tools and Job Aids
HRSA HIV/AIDS Bureau, NASTADAugust 2016
The Common Patient Assistance Program (PAP) Application can be used to apply for any pharmaceutical assistance program (PAP) offered by pharmaceutical companies.
Oregon Health AuthorityJune 2016
Series of care plan forms to assess clients in terms of intake, assessment, medical case management (e.g., acuity), and care.
Idaho Department of Health and WelfareApril 2013
Resources submitted by Part B grantee.
Indianapolis TGA, MCHDJuly 2011
Tools used for quality and program monitoring by a Part A program.
Dallas EMAJanuary 2011
Program and service monitoring tools developed by a Part A grantee.
Hartford Department of Health and Human ServicesFebruary 2010
Form for staff to assess care plan needs of clients, every 6 months, in terms of case management, home health, respite, housing, mental health, substance abuse treatment, legal, and financial assistance.
Reports and Best Practices
Robust set of resources for Ryan White HIV/AIDS Program Part B programs and ADAPs to assist in their benefits management work
HRSA HIV/AIDS BureauDecember 2012
Series outlining cost-saving and cost-cutting strategies used by AIDS Drug Assistance Programs (ADAP).