PCN 16-02 RWHAP Services Eligible Individuals and Allowables

HIV/AIDS BUREAU POLICY 16-02

Ryan White HIV/AIDS Program

Services: Eligible Individuals &

Allowable Uses of Funds

Policy Clarification Notice (PCN) #16-02 (Revised 10/22/18)

Replaces Policy #10-02

Scope of Coverage: Health Resources and Services Administration (HRSA)

Ryan White HIV/AIDS Program (RWHAP) Parts A, B, C, and D, and Part F where

funding supports direct care and treatment services.

Purpose of PCN

This policy clarification notice (PCN) replaces the HRSA HIV/AIDS Bureau (HAB)

PCN 10-02: Eligible Individuals & Allowable Uses of Funds. This PCN defines and

provides program guidance for each of the Core Medical and Support Services

named in statute and defines individuals who are eligible to receive these HRSA

RWHAP services.

Background

The Office of Management and Budget (OMB) has consolidated, in 2 CFR Part 200,

the uniform grants administrative requirements, cost principles, and audit

requirements for all organization types (state and local governments, non-profit and

educational institutions, and hospitals) receiving federal awards. These

requirements, known as the “Uniform Guidance,” are applicable to recipients and

subrecipients of federal funds. The OMB Uniform Guidance has been codified by the

Department of Health and Human Services (HHS) in 45 CFR Part 75—Uniform

Administrative Requirements, Cost Principles, and Audit Requirements for HHS

Awards. HRSA RWHAP grant and cooperative agreement recipients and

subrecipients should be thoroughly familiar with 45 CFR Part 75. Recipients are

required to monitor the activities of its subrecipient to ensure the subaward is used

for authorized purposes in compliance with applicable statute, regulations, policies,

program requirements and the terms and conditions of the award (see

45 CFR §§

75.351-352).

45 CFR Part 75, Subpart E—Cost Principles must be used in determining allowable

costs that may be charged to a HRSA RWHAP award. Costs must be necessary and

reasonable to carry out approved project activities, allocable to the funded project,

and allowable under the Cost Principles, or otherwise authorized by the RWHAP

statute. The treatment of costs must be consistent with recipient or subrecipient

policies and procedures that apply uniformly to both federally-financed and other

non-federally funded activities.

HRSA HAB has developed program policies that incorporate both HHS regulations

HIV/AIDS BUREAU POLICY 16-02

and program specific requirements set forth in the RWHAP statute. Recipients,

planning bodies, and others are advised that independent auditors, auditors from

the HHS' Office of the Inspector General, and auditors from the U.S. Government

Accountability Office may assess and publicly report the extent to which an HRSA

RWHAP award is being administered in a manner consistent with statute, regulation

and program policies, such as these, and compliant with legislative and

programmatic policies. Recipients can expect fiscal and programmatic oversight

through HRSA monitoring and review of budgets, work plans, and subrecipient

agreements. HRSA HAB is able to provide technical assistance to recipients and

planning bodies, where assistance with compliance is needed.

Recipients are reminded that it is their responsibility to be fully cognizant of

limitations on uses of funds as outlined in statute, 45 CFR Part 75, the HHS Grants

Policy Statement, and applicable HRSA HAB PCNs. In the case of services being

supported in violation of statute, regulation or programmatic policy, the use of

RWHAP funds for such costs must be ceased immediately and recipients may be

required to return already-spent funds to the Federal Government. Recipients who

unknowingly continue such support are also liable for such expenditures.

Further Guidance on Eligible Individuals and Allowable Uses of

Ryan White HIV/AIDS Program Funds

The RWHAP statute, codified at title XXVI of the Public Health Service Act, stipulates

that "funds received...will not be utilized to make payments for any item or service

to the extent that payment has been made, or can reasonably be expected to be

made under...an insurance policy, or under any Federal or State health benefits

program" and other specified payment sources.

At the individual client-level, this

means recipients must assure that funded subrecipients make reasonable efforts to

secure non-RWHAP funds whenever possible for services to eligible clients. In

support of this intent, it is an appropriate use of HRSA RWHAP funds to provide case

management (medical or non-medical) or other services that, as a central function,

ensure that eligibility for other funding sources is vigorously and consistently

pursued (e.g., Medicaid, Children’s Health Insurance Program (CHIP), Medicare, or

State-funded HIV programs, and/or private sector funding, including private

insurance).

In every instance, HRSA HAB expects that services supported with HRSA RWHAP

funds will (1) fall within the legislatively-defined range of services, (2) as

appropriate, within Part A, have been identified as a local priority by the HIV Health

Services Planning Council/Body, and (3) in the case of allocation decisions made by

a Part B State/Territory or by a local or regional consortium, meet documented

needs and contribute to the establishment of a continuum of care.

HRSA RWHAP funds are intended to support only the HIV-related needs of

See sections 2605(a)(6), 2617(b)(7)(F), 2664(f)(1), and 2671(i) of the Public Health Service Act.

HIV/AIDS BUREAU POLICY 16-02

eligible individuals. Recipients and subrecipients must be able to make an

explicit connection between any service supported with HRSA RWHAP funds and

the intended client’s HIV care and treatment, or care-giving relationship to a

person living with HIV (PLWH).

Eligible Individuals:

The principal intent of the RWHAP statute is to provide services to PLWH, including

those whose illness has progressed to the point of clinically defined AIDS. When

setting and implementing priorities for the allocation of funds, recipients, Part A

Planning Councils, community planning bodies, and Part B funded consortia may

optionally define eligibility for certain services more precisely, but they may NOT

broaden the definition of who is eligible for services. HRSA HAB expects all HRSA

RWHAP recipients to establish and monitor procedures to ensure that all funded

providers verify and document client eligibility.

Affected individuals (people not identified with HIV) may be eligible for HRSA

RWHAP services in limited situations, but these services for affected individuals

must always benefit PLWH. Funds awarded under the HRSA RWHAP may be used

for services to individuals affected by HIV only in the circumstances described

below:

a. The primary purpose of the service is to enable the affected individual to

participate in the care of a PLWH. Examples include caregiver training for

in-home medical or support service; psychosocial support services, such

as caregiver support groups; and/or respite care services that assist

affected individuals with the stresses of providing daily care for a PLWH.

b. The service directly enables a PLWH to receive needed medical or support

services by removing an identified barrier to care. Examples include

payment of a HRSA RWHAP client’s portion of a family health insurance

policy premium to ensure continuity of insurance coverage that client, or

childcare for the client’s children while they receive HIV-related medical

care or support services.

c. The service promotes family stability for coping with the unique

challenges posed by HIV. Examples include psychosocial support

services, including mental health services funded by RWHAP Part D only,

that focus on equipping affected family members, and caregivers to

manage the stress and loss associated with HIV.

d. Services to affected individuals that meet these criteria may not continue

subsequent to the death of the family member who was living with HIV.

Unallowable Costs:

HRSA RWHAP funds may not be used to make cash payments to intended clients

of HRSA RWHAP-funded services. This prohibition includes cash incentives and

HIV/AIDS BUREAU POLICY 16-02

cash intended as payment for HRSA RWHAP core medical and support services.

Where direct provision of the service is not possible or effective, store gift cards,

vouchers, coupons, or tickets that can be exchanged for a specific service or

commodity (e.g., food or transportation) must be used.

HRSA RWHAP recipients are advised to administer voucher and store gift card

programs in a manner which assures that vouchers and store gift cards cannot be

exchanged for cash or used for anything other than the allowable goods or

services, and that systems are in place to account for disbursed vouchers and

store gift cards.

Other unallowable costs include:

• Clothing

• Employment and Employment-Readiness Services, except in limited, specified

instances (e.g., Non-Medical Case Management Services or Rehabilitation

Services)

• Funeral and Burial Expenses

• Property Taxes

• Pre-Exposure Prophylaxis (PrEP)

• non-occupational Post-Exposure Prophylaxis (nPEP)

• Materials, designed to promote or encourage, directly, intravenous drug use or

sexual activity, whether homosexual or heterosexual

• International travel

• The purchase or improvement of land

• The purchase, construction, or permanent improvement of any building or

other facility

Allowable Costs:

The following service categories are allowable uses of HRSA RWHAP funds. The

HRSA RWHAP recipient, along with respective planning bodies, will make the final

decision regarding the specific services to be funded under their grant or

cooperative agreement. As with all other allowable costs, HRSA RWHAP recipients

are responsible for applicable accounting and reporting on the use of HRSA RWHAP

funds.

Service Category Descriptions and Program Guidance

The following provides both a description of covered service categories and program

guidance for HRSA RWHAP Part recipient implementation. These service category

descriptions apply to the entire HRSA RWHAP. However, for some services, the

Store gift cards that can be redeemed at one merchant or an affiliated group of merchants for specific goods or

services that further the goals and objectives of the HRSA RWHAP are allowable as incentives for eligible program

participants.

General-use prepaid cards are considered “cash equivalent” and are therefore unallowable. Such cards generally

bear the logo of a payment network, such as Visa, MasterCard, or American Express, and are accepted by any

merchant that accepts those credit or debit cards as payment. Gift cards that are cobranded with the logo of a

payment network and the logo of a merchant or affiliated group of merchants are general-use prepaid cards, not store

gift cards, and therefore are unallowable.

HIV/AIDS BUREAU POLICY 16-02

HRSA RWHAP Parts (i.e., A, B, C, and D) must determine what is feasible and

justifiable with limited resources. There is no expectation that a HRSA RWHAP Part

recipient would provide all services, but recipients and planning bodies are expected

to coordinate service delivery across Parts to ensure that the entire

jurisdiction/service area has access to services based on needs assessment.

The following core medical and support service categories are important to assist in

the diagnosis of HIV infection, linkage to and entry into care for PLWH, retention in

care, and the provision of HIV care and treatment. HRSA RWHAP recipients are

encouraged to consider all methods or means by which they can provide services,

including use of technology (e.g., telehealth). To be an allowable cost under the

HRSA RWHAP, all services must:

• Relate to HIV diagnosis, care and support,

•

Adhere to established HIV clinical practice standards consistent with U.S.

Department of Health and Human Services’ Clinical Guidelines for the

Treatment of HIV

and other related or pertinent clinical guidelines, and

•

Comply with state and local regulations, and provided by licensed or

authorized providers, as applicable.

Recipients are required to work toward the development and adoption of service

standards for all HRSA RWHAP-funded services to ensure consistent quality care is

provided to all HRSA RWHAP-eligible clients. Service standards establish the minimal

level of service or care that a HRSA RWHAP funded agency or provider may offer

within a state, territory or jurisdiction. Service standards related to HRSA RWHAP

Core Medical Services must be consistent with U.S. Department of Health and

Human Services’ Clinical Guidelines for the Treatment of HIV, as well as other

pertinent clinical and professional standards. Service standards related to HRSA

RWHAP Support Services may be developed using evidence-based or evidence-

informed best practices, the most recent HRSA RWHAP Parts A and B National

Monitoring Standards, and guidelines developed by the state and local government.

HRSA RWHAP recipients should also be familiar with implementation guidance

HRSA HAB provides in program manuals, monitoring standards, and other

recipient resources.

HRSA RWHAP clients must meet income and other eligibility criteria as

established by HRSA RWHAP Part A, B, C, or D recipients.

RWHAP Core Medical Services

AIDS Drug Assistance Program Treatments

https://aidsinfo.nih.gov/guidelines

HIV/AIDS BUREAU POLICY 16-02

AIDS Pharmaceutical Assistance

Early Intervention Services (EIS)

Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals

Home and Community-Based Health Services

Home Health Care

Hospice

Medical Case Management, including Treatment Adherence Services

Medical Nutrition Therapy

Mental Health Services

Oral Health Care

Outpatient/Ambulatory Health Services

Substance Abuse Outpatient Care

RWHAP Support Services

Child Care Services

Emergency Financial Assistance

Food Bank/Home Delivered Meals

Health Education/Risk Reduction

Housing

Legal Services

Linguistic Services

Medical Transportation

Non-Medical Case Management Services

Other Professional Services

Outreach Services

Permanency Planning

HIV/AIDS BUREAU POLICY 16-02

Psychosocial Support Services

Referral for Health Care and Support Services

Rehabilitation Services

Respite Care

Substance Abuse Services (residential)

Effective Date

This PCN is effective for HRSA RWHAP Parts A, B, C, D, and F awards issued on or

after October 1, 2016. This includes competing continuations, new awards, and

non- competing continuations.

Summary of Changes

August 18, 2016 –Updated Housing Service category by removing the prohibition

on HRSA RWHAP Part C recipients to use HRSA RWHAP funds for this service.

December 12, 2016 – 1) Updated Health Insurance Premium and Cost Sharing

Assistance for Low-Income Individuals service category by including standalone

dental insurance as an allowable cost; 2) Updated Substance Abuse Services

(residential) service category by removing the prohibition on HRSA RWHAP Parts C

and D recipients to use HRSA RWHAP funds for this service; 3) Updated Medical

Transportation service category by providing clarification on provider

transportation; 4) Updated AIDS Drug Assistance Program Treatments service

category by adding additional program guidance; and 5) Reorganized the service

categories alphabetically and provided hyperlinks in the Appendix.

October, 22, 2018 – updated to provide additional clarifications in the following

service categories:

Core Medical Services: AIDS Drug Assistance Program Treatments; AIDS

Pharmaceutical Assistance; Health Insurance Premium and Cost Sharing

Assistance for Low-income People Living with HIV; and Outpatient/Ambulatory

Health Services

Support Services: Emergency Financial Assistance; Housing; Non-Medical Case

Management; Outreach; and Rehabilitation Services.

HIV/AIDS BUREAU POLICY 16-02

Appendix

RWHAP Legislation: Core Medical Services

AIDS Drug Assistance Program Treatments

Description:

The AIDS Drug Assistance Program (ADAP) is a state-administered program

authorized under RWHAP Part B to provide U.S. Food and Drug Administration (FDA)-

approved medications to low-income clients living with HIV who have no coverage or

limited health care coverage. HRSA RWHAP ADAP formularies must include at least

one FDA-approved medicine in each drug class of core antiretroviral medicines from

the U.S. Department of Health and Human Services’ Clinical Guidelines for the

Treatment of HIV.

HRSA RWHAP ADAPs can also provide access to medications by

using program funds to purchase health care coverage and through medication cost

sharing for eligible clients. HRSA RWHAP ADAPs must assess and compare the

aggregate cost of paying for the health care coverage versus paying for the full cost

of medications to ensure that purchasing health care coverage is cost effective in the

aggregate. HRSA RWHAP ADAPs may use a limited amount of program funds for

activities that enhance access to, adherence to, and monitoring of antiretroviral

therapy with prior approval.

Program Guidance:

HRSA RWHAP Parts A, C and D recipients may contribute RWHAP funds to the RWHAP

Part B ADAP for the purchase of medication and/or health care coverage and

medication cost sharing for ADAP-eligible clients.

See PCN 07-03:

The Use of Ryan White HIV/AIDS Program, Part B AIDS Drug

Assistance Program (ADAP) Funds for Access, Adherence, and Monitoring Services

See PCN 18-01: Clarifications Regarding the use of Ryan White HIV/AIDS Program

Funds for Health Care Coverage Premium and Cost Sharing Assistance

See also AIDS Pharmaceutical Assistance and Emergency Financial Assistance

AIDS Pharmaceutical Assistance

Description:

AIDS Pharmaceutical Assistance may be provided through one of two programs,

based on HRSA RWHAP Part funding.

1. A Local Pharmaceutical Assistance Program (LPAP) is operated by a HRSA

RWHAP Part A or B (non-ADAP) recipient or subrecipient as a supplemental

means of providing ongoing medication assistance when an HRSA RWHAP ADAP

https://aidsinfo.nih.gov/guidelines

HIV/AIDS BUREAU POLICY 16-02

has a restricted formulary, waiting list and/or restricted financial eligibility

criteria.

HRSA RWHAP Parts A or B recipients using the LPAP to provide AIDS

Pharmaceutical Assistance must establish the following:

• Uniform benefits for all enrolled clients throughout the service area

• A recordkeeping system for distributed medications

• An LPAP advisory board

• A drug formulary that is

o Approved by the local advisory committee/board, and

o Consists of HIV-related medications not otherwise available to the

clients due to the elements mentioned above

• A drug distribution system

• A client enrollment and eligibility determination process that includes

screening for HRSA RWHAP ADAP and LPAP eligibility with rescreening at

minimum of every six months

• Coordination with the state’s HRSA RWHAP Part B ADAP

o A statement of need should specify restrictions of the state HRSA

RWHAP ADAP and the need for the LPAP

• Implementation in accordance with requirements of the HRSA 340B Drug

Pricing Program (including the Prime Vendor Program)

2. A Community Pharmaceutical Assistance Program (CPAP) is provided by a

HRSA RWHAP Part C or D recipient for the provision of ongoing medication

assistance to eligible clients in the absence of any other resources.

HRSA RWHAP Parts C or D recipients using CPAP to provide AIDS Pharmaceutical

Assistance must establish the following:

• A financial eligibility criteria and determination process for this specific

service category

• A drug formulary consisting of HIV-related medications not otherwise

available to the clients

• Implementation in accordance with the requirements of the HRSA 340B

Drug Pricing Program (including the Prime Vendor Program)

Program Guidance:

For LPAPs: HRSA RWHAP Part A or Part B (non-ADAP) funds may be used to support

an LPAP. HRSA RWHAP ADAP funds may not be used for LPAP support. LPAP funds

are not to be used for emergency or short-term financial assistance. The Emergency

Financial Assistance service category may assist with short-term assistance for

medications.

For CPAPs: HRSA RWHAP Part C or D funds may be used to support a CPAP to

routinely refill medications. HRSA RWHAP Part C or D recipients should use the

Outpatient/Ambulatory Health Services or Emergency Financial Assistance service

HIV/AIDS BUREAU POLICY 16-02

categories for non-routine, short-term medication assistance.

See also AIDS Drug Assistance Program Treatments, Emergency Financial Assistance,

and Outpatient/Ambulatory Health Services

Early Intervention Services (EIS)

Description:

The RWHAP legislation defines EIS for Parts A, B, and C. See § 2651(e) of the

Public Health Service Act.

Program Guidance:

The elements of EIS often overlap with other service category descriptions; however,

EIS is the combination of such services rather than a stand-alone service. HRSA

RWHAP Part recipients should be aware of programmatic expectations that stipulate

the allocation of funds into specific service categories.

• HRSA RWHAP Parts A and B EIS services must include the

following four components:

o Targeted HIV testing to help the unaware learn of their HIV status and

receive referral to HIV care and treatment services if found to be living

with HIV

 Recipients must coordinate these testing services with other HIV

prevention and testing programs to avoid duplication of efforts

 HIV testing paid for by EIS cannot supplant testing efforts paid

for by other sources

o Referral services to improve HIV care and treatment services at key

points of entry

o Access and linkage to HIV care and treatment services such as HIV

Outpatient/Ambulatory Health Services, Medical Case Management,

and Substance Abuse Care

o Outreach Services and Health Education/Risk Reduction related to HIV

diagnosis

• HRSA RWHAP Part C EIS services must include the following four components:

o Counseling individuals with respect to HIV

o High risk targeted HIV testing (confirmation and diagnosis of the

extent of immune deficiency)

 Recipients must coordinate these testing services under HRSA

RWHAP Part C EIS with other HIV prevention and testing

programs to avoid duplication of efforts

 The HIV testing services supported by HRSA RWHAP Part C EIS

funds cannot supplant testing efforts covered by other sources

o Referral and linkage to care of PLWH to Outpatient/Ambulatory Health

HIV/AIDS BUREAU POLICY 16-02

Services, Medical Case Management, Substance Abuse Care, and other

services as part of a comprehensive care system including a system

for tracking and monitoring referrals

o Other clinical and diagnostic services related to HIV diagnosis

Health Insurance Premium and Cost Sharing Assistance for Low-Income

Individuals

Description:

Health Insurance Premium and Cost Sharing Assistance provides financial

assistance for eligible clients living with HIV to maintain continuity of health

insurance or to receive medical and pharmacy benefits under a health care

coverage program. For purposes of this service category, health insurance also

includes standalone dental insurance. The service provision consists of the

following:

• Paying health insurance premiums to provide comprehensive HIV

Outpatient/Ambulatory Health Services, and pharmacy benefits that provide

a full range of HIV medications for eligible clients; and/or

• Paying standalone dental insurance premiums to provide comprehensive oral

health care services for eligible clients; and/or

• Paying cost sharing on behalf of the client.

To use HRSA RWHAP funds for health insurance premium assistance (not

standalone dental insurance assistance), an HRSA RWHAP Part recipient must

implement a methodology that incorporates the following requirements:

• Clients obtain health care coverage that at a minimum, includes at least one

U.S. Food and Drug Administration (FDA) approved medicine in each drug class

of core antiretroviral medicines outlined in the U.S. Department of Health and

Human Services’ Clinical Guidelines for the Treatment of HIV, as well as

appropriate HIV outpatient/ambulatory health services; and

• The cost of paying for the health care coverage (including all other sources of

premium and cost sharing assistance) is cost-effective in the aggregate versus

paying for the full cost for medications and other appropriate HIV

outpatient/ambulatory health services (HRSA RWHAP Part A, HRSA RWHAP Part

B, HRSA RWHAP Part C, and HRSA RWHAP Part D).

To use HRSA RWHAP funds for standalone dental insurance premium

assistance, an HRSA RWHAP Part recipient must implement a methodology

that incorporates the following requirement:

• HRSA RWHAP Part recipients must assess and compare the aggregate cost

of paying for the standalone dental insurance option versus paying for the

full cost of HIV oral health care services to ensure that purchasing

standalone dental insurance is cost effective in the aggregate, and allocate

funding to Health Insurance Premium and Cost Sharing Assistance only

HIV/AIDS BUREAU POLICY 16-02

when determined to be cost effective.

Program Guidance:

Traditionally, HRSA RWHAP Parts A and B recipients have supported paying for

health insurance premiums and cost sharing assistance. If a HRSA RWHAP Part C

or Part D recipient has the resources to provide this service, an equitable

enrollment policy must be in place and it must be cost-effective.

HRSA RWHAP Parts A, B, C, and D recipients may consider providing their health

insurance premiums and cost sharing resource allocation to their state HRSA

RWHAP ADAP, particularly where the ADAP has the infrastructure to verify health

care coverage status and process payments for public or private health care

coverage premiums and medication cost sharing.

See PCN 14-01: Clarifications Regarding the Ryan White HIV/AIDS

Program and

Reconciliation of Premium Tax Credits under the Affordable Care Act

See PCN 18-01: Clarifications Regarding the use of Ryan White HIV/AIDS Program

Funds for Health Care Coverage Premium and Cost Sharing Assistance

Home and Community-Based Health Services

Description:

Home and Community-Based Health Services are provided to an eligible client in an

integrated setting appropriate to that client’s needs, based on a written plan of care

established by a medical care team under the direction of a licensed clinical

provider. Services include:

• Appropriate mental health, developmental, and rehabilitation services

• Day treatment or other partial hospitalization services

• Durable medical equipment

• Home health aide services and personal care services in the home

Program Guidance:

Inpatient hospitals, nursing homes, and other long-term care facilities are not

considered an integrated setting for the purposes of providing home and

community-based health services.

Home Health Care

Description:

Home Health Care is the provision of services in the home that are appropriate to an

eligible client’s needs and are performed by licensed professionals. Activities provided

under Home Health Care must relate to the client’s HIV disease and may include:

• Administration of prescribed therapeutics (e.g. intravenous and aerosolized

treatment, and parenteral feeding)

• Preventive and specialty care

• Wound care

HIV/AIDS BUREAU POLICY 16-02

• Routine diagnostics testing administered in the home

• Other medical therapies

Program Guidance:

The provision of Home Health Care is limited to clients that are homebound. Home

settings do not include nursing facilities or inpatient mental health/substance abuse

treatment facilities.

Hospice Services

Description:

Hospice Services are end-of-life care services provided to clients in the terminal

stage of an HIV-related illness. Allowable services are:

• Mental health counseling

• Nursing care

• Palliative therapeutics

• Physician services

• Room and board

Program Guidance:

Hospice Services may be provided in a home or other residential setting, including

a non-acute care section of a hospital that has been designated and staffed to

provide hospice services. This service category does not extend to skilled nursing

facilities or nursing homes.

To meet the need for Hospice Services, a physician must certify that a patient is

terminally ill and has a defined life expectancy as established by the recipient.

Counseling services provided in the context of hospice care must be consistent with

the definition of mental health counseling. Palliative therapies must be consistent

with those covered under respective state Medicaid programs.

Medical Case Management, including Treatment Adherence Services

Description:

Medical Case Management is the provision of a range of client-centered activities

focused on improving health outcomes in support of the HIV care continuum.

Activities provided under this service category may be provided by an

interdisciplinary team that includes other specialty care providers. Medical Case

Management includes all types of case management encounters (e.g., face-to-face,

phone contact, and any other forms of communication).

Key activities include:

• Initial assessment of service needs

• Development of a comprehensive, individualized care plan

• Timely and coordinated access to medically appropriate levels of health and

support services and continuity of care

• Continuous client monitoring to assess the efficacy of the care plan

HIV/AIDS BUREAU POLICY 16-02

• Re-evaluation of the care plan at least every 6 months with adaptations as

necessary

• Ongoing assessment of the client’s and other key family members’ needs and

personal support systems

• Treatment adherence counseling to ensure readiness for and adherence to

complex HIV treatments

• Client-specific advocacy and/or review of utilization of services

In addition to providing the medically oriented activities above, Medical Case

Management may also provide benefits counseling by assisting eligible clients in

obtaining access to other public and private programs for which they may be

eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs,

Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local

health care and supportive services, and insurance plans through the health

insurance Marketplaces/Exchanges).

Program Guidance:

Activities provided under the Medical Case Management service category have as

their objective improving health care outcomes whereas those provided under the

Non-Medical Case Management service category have as their objective providing

guidance and assistance in improving access to needed services.

Visits to ensure readiness for, and adherence to, complex HIV treatments shall be

considered Medical Case Management or Outpatient/Ambulatory Health Services.

Treatment Adherence services provided during a Medical Case Management visit

should be reported in the Medical Case Management service category whereas

Treatment Adherence services provided during an Outpatient/Ambulatory Health

Service visit should be reported under the Outpatient/Ambulatory Health Services

category.

Medical Nutrition Therapy

Description:

Medical Nutrition Therapy includes:

• Nutrition assessment and screening

• Dietary/nutritional evaluation

• Food and/or nutritional supplements per medical provider’s recommendation

• Nutrition education and/or counseling

These activities can be provided in individual and/or group settings and outside of

HIV Outpatient/Ambulatory Health Services.

Program Guidance:

All activities performed under this service category must be pursuant to a medical

provider’s referral and based on a nutritional plan developed by the registered

dietitian or other licensed nutrition professional. Activities not provided by a

HIV/AIDS BUREAU POLICY 16-02

registered/licensed dietician should be considered Psychosocial Support Services

under the HRSA RWHAP.

See also Early Intervention Services

Substance Abuse Outpatient Care

Description:

Substance Abuse Outpatient Care is the provision of outpatient services for the

treatment of drug or alcohol use disorders. Activities under Substance Abuse

Outpatient Care service category include:

• Screening

• Assessment

• Diagnosis, and/or

• Treatment of substance use disorder, including:

o Pretreatment/recovery readiness programs

o Harm reduction

o Behavioral health counseling associated with substance use disorder

o Outpatient drug-free treatment and counseling

o Medication assisted therapy

o Neuro-psychiatric pharmaceuticals

o Relapse prevention

Program Guidance:

Acupuncture therapy may be allowable under this service category only when, as

part of a substance use disorder treatment program funded under the HRSA

RWHAP, it is included in a documented plan.

Syringe access services are allowable, to the extent that they comport with current

appropriations law and applicable HHS guidance, including HRSA- or HAB-specific

HIV/AIDS BUREAU POLICY 16-02

guidance.

See also Substance Abuse Services (residential)

RWHAP Legislation: Support Services

Child Care Services

Description:

The HRSA RWHAP supports intermittent Child Care Services for the children living

in the household of PLWH who are HRSA RWHAP-eligible clients for the purpose of

enabling those clients to attend medical visits, related appointments, and/or HRSA

RWHAP-related meetings, groups, or training sessions.

Allowable use of funds include:

• A licensed or registered child care provider to deliver intermittent care

• Informal child care provided by a neighbor, family member, or other person

(with the understanding that existing federal restrictions prohibit giving cash

to clients or primary caregivers to pay for these services)

Program Guidance:

The use of funds under this service category should be limited and carefully

monitored. Direct cash payments to clients are not permitted.

Such arrangements may also raise liability issues for the funding source which

should be carefully weighed in the decision process.

Emergency Financial Assistance

Description:

Emergency Financial Assistance provides limited one-time or short-term payments to

assist an HRSA RWHAP client with an urgent need for essential items or services

necessary to improve health outcomes, including: utilities, housing, food (including

groceries and food vouchers), transportation, medication not covered by an AIDS

Drug Assistance Program or AIDS Pharmaceutical Assistance, or another HRSA

RWHAP-allowable cost needed to improve health outcomes

. Emergency Financial

Assistance must occur as a direct payment to an agency or through a voucher

program.

Program Guidance:

Emergency Financial Assistance funds used to pay for otherwise allowable HRSA

RWHAP services must be accounted for under the Emergency Financial Assistance

category. Direct cash payments to clients are not permitted.

Continuous provision of an allowable service to a client must not be funded

through Emergency Financial Assistance.

Food Bank/Home Delivered Meals

Description:

HIV/AIDS BUREAU POLICY 16-02

Food Bank/Home Delivered Meals refers to the provision of actual food items, hot

meals, or a voucher program to purchase food. This also includes the provision of

essential non-food items that are limited to the following:

• Personal hygiene products

• Household cleaning supplies

• Water filtration/purification systems in communities where issues of water

safety exist

Program Guidance:

Unallowable costs include household appliances, pet foods, and other non-essential

products.

See Medical Nutrition Therapy. Nutritional services and nutritional supplements

provided by a registered dietitian are considered a core medical service under the

HRSA RWHAP.

Health Education/Risk Reduction

Description:

Health Education/Risk Reduction is the provision of education to clients living with HIV

about HIV transmission and how to reduce the risk of HIV transmission. It includes

sharing information about medical and psychosocial support services and counseling

with clients to improve their health status. Topics covered may include:

• Education on risk reduction strategies to reduce transmission such as pre-

exposure prophylaxis (PrEP) for clients’ partners and treatment as prevention

• Education on health care coverage options (e.g., qualified health plans

through the Marketplace, Medicaid coverage, Medicare coverage)

• Health literacy

• Treatment adherence education

Program Guidance:

Health Education/Risk Reduction services cannot be delivered anonymously.

See also Early Intervention Services

Housing

Description:

Housing provides transitional, short-term, or emergency housing assistance to enable

a client or family to gain or maintain outpatient/ambulatory health services and

treatment, including temporary assistance necessary to prevent homelessness and to

gain or maintain access to medical care. Activities within the Housing category must

also include the development of an individualized housing plan, updated annually, to

guide the client’s linkage to permanent housing. Housing may provide some type of

core medical (e.g., mental health services) or support services (e.g., residential

substance use disorder services).

Housing activities also include housing referral services, including assessment, search,

HIV/AIDS BUREAU POLICY 16-02

placement, and housing advocacy services on behalf of the eligible client, as well as

fees associated with these activities.

Program Guidance:

HRSA RWHAP recipients and subrecipients that use funds to provide Housing must

have mechanisms in place to assess and document the housing status and housing

service needs of new clients, and at least annually for existing clients.

HRSA RWHAP recipients and subrecipients, along with local decision-making planning

bodies, are strongly encouraged to institute duration limits to housing activities.

HRSA HAB recommends recipients and subrecipients align duration limits with those

definitions used by other housing programs, such as those administered by the

Department of Housing and Urban Development, which currently uses 24 months for

transitional housing.

Housing activities cannot be in the form of direct cash payments to clients and cannot

be used for mortgage payments or rental deposits,

although these may be allowable

costs under the HUD Housing Opportunities for Persons with AIDS grant awards.

Housing, as described here, replaces PCN 11-01.

Legal Services

See Other Professional Services

Linguistic Services

Description:

Linguistic Services include interpretation and translation activities, both oral and

written, to eligible clients. These activities must be provided by qualified linguistic

services providers as a component of HIV service delivery between the healthcare

provider and the client. These services are to be provided when such services are

necessary to facilitate communication between the provider and client and/or

support delivery of HRSA RWHAP-eligible services.

Program Guidance:

Linguistic Services provided must comply with the National Standards for

Culturally and Linguistically Appropriate Services (CLAS).

Medical Transportation

Description:

Medical Transportation is the provision of nonemergency transportation that

enables an eligible client to access or be retained in core medical and support

services.

Program Guidance:

Medical transportation may be provided through:

See sections 2604(i), 2612(f), 2651(b), and 2671(a) of the Public Health Service Act.

HIV/AIDS BUREAU POLICY 16-02

• Contracts with providers of transportation services

• Mileage reimbursement (through a non-cash system) that enables clients to

travel to needed medical or other support services, but should not in any case

exceed the established rates for federal Programs (Federal Joint Travel

Regulations provide further guidance on this subject)

• Purchase or lease of organizational vehicles for client transportation

programs, provided the recipient receives prior approval for the purchase of

a vehicle

• Organization and use of volunteer drivers (through programs with insurance

and other liability issues specifically addressed)

• Voucher or token systems

Costs for transportation for medical providers to provide care should be categorized

under the service category for the service being provided.

Unallowable costs include:

• Direct cash payments or cash reimbursements to clients

• Direct maintenance expenses (tires, repairs, etc.) of a privately-owned

vehicle

• Any other costs associated with a privately-owned vehicle such as lease, loan

payments, insurance, license, or registration fees.

Non-Medical Case Management Services

Description:

Non-Medical Case Management Services (NMCM) is the provision of a range of client-

centered activities focused on improving access to and retention in needed core

medical and support services. NMCM provides coordination, guidance, and assistance

in accessing medical, social, community, legal, financial, employment, vocational,

and/or other needed services. NMCM Services may also include assisting eligible

clients to obtain access to other public and private programs for which they may be

eligible, such as Medicaid, Children’s Health Insurance Program, Medicare Part D,

State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient

Assistance Programs, Department of Labor or Education-funded services, other state

or local health care and supportive services, or private health care coverage plans.

NMCM Services includes all types of case management encounters (e.g., face-to-face,

telehealth, phone contact, and any other forms of communication). Key activities

include:

• Initial assessment of service needs

• Development of a comprehensive, individualized care plan

• Timely and coordinated access to medically appropriate levels of health and

support services and continuity of care

• Client-specific advocacy and/or review of utilization of services

• Continuous client monitoring to assess the efficacy of the care plan

HIV/AIDS BUREAU POLICY 16-02

• Re-evaluation of the care plan at least every 6 months with adaptations as

necessary

• Ongoing assessment of the client’s and other key family members’ needs and

personal support systems

Program Guidance:

NMCM Services have as their objective providing coordination, guidance and

assistance in improving access to and retention in needed medical and support

services to mitigate and eliminate barriers to HIV care services, whereas Medical Case

Management Services have as their objective improving health care outcomes.

Other Professional Services

Description:

Other Professional Services allow for the provision of professional and consultant

services rendered by members of particular professions licensed and/or qualified to

offer such services by local governing authorities. Such services may include:

• Legal services provided to and/or on behalf of the HRSA RWHAP-eligible

PLWH and involving legal matters related to or arising from their HIV

disease, including:

o Assistance with public benefits such as Social Security Disability

Insurance (SSDI)

o Interventions necessary to ensure access to eligible benefits, including

discrimination or breach of confidentiality litigation as it relates to

services eligible for funding under the HRSA RWHAP

o Preparation of:

 Healthcare power of attorney

 Durable powers of attorney

 Living wills

• Permanency planning to help clients/families make decisions about the

placement and care of minor children after their parents/caregivers are

deceased or are no longer able to care for them, including:

o Social service counseling or legal counsel regarding the drafting of

wills or delegating powers of attorney

o Preparation for custody options for legal dependents including standby

guardianship, joint custody, or adoption

• Income tax preparation services to assist clients in filing Federal tax returns

that are required by the Affordable Care Act for all individuals receiving

premium tax credits.

Program Guidance:

Legal services exclude criminal defense and class-action suits unless related to

access to services eligible for funding under the RWHAP.

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See 45 CFR § 75.459

Outreach Services

Description:

The Outreach Services category has as its principal purpose identifying PLWH who

either do not know their HIV status, or who know their status but are not currently in

care. As such, Outreach Services provide the following activities: 1) identification of

people who do not know their HIV status and/or 2) linkage or re-engagement of

PLWH who know their status into HRSA RWHAP services, including provision of

information about health care coverage options.

Because Outreach Services are often provided to people who do not know their HIV

status, some activities within this service category will likely reach people who are

HIV negative. When these activities identify someone living with HIV, eligible clients

should be linked to HRSA RWHAP services.

Outreach Services must:

1) use data to target populations and places that have a high probability of

reaching PLWH who

a. have never been tested and are undiagnosed,

b. have been tested, diagnosed as HIV positive, but have not received their

test results, or

c. have been tested, know their HIV positive status, but are not in medical

care;

2) be conducted at times and in places where there is a high probability that

PLWH will be identified; and

3) be delivered in coordination with local and state HIV prevention outreach

programs to avoid duplication of effort.

Outreach Services may be provided through community and public awareness

activities (e.g., posters, flyers, billboards, social media, TV or radio announcements)

that meet the requirements above and include explicit and clear links to and

information about available HRSA RWHAP services. Ultimately, HIV-negative people

may receive Outreach Services and should be referred to risk reduction activities.

When these activities identify someone living with HIV, eligible clients should be

linked to HRSA RWHAP services.

Program Guidance:

Outreach Services provided to an individual or in small group settings cannot be

delivered anonymously, as some information is needed to facilitate any necessary

follow-up and care.

Outreach Services must not include outreach activities that exclusively promote HIV

prevention education. Recipients and subrecipients may use Outreach Services funds

for HIV testing when HRSA RWHAP resources are available and where the testing

would not supplant other existing funding.

HIV/AIDS BUREAU POLICY 16-02

Outreach Services, as described here, replaces PCN 12-01.

See also Early Intervention Services

Permanency Planning

See Other Professional Services

Psychosocial Support Services

Description:

Psychosocial Support Services provide group or individual support and counseling

services to assist HRSA RWHAP-eligible PLWH to address behavioral and physical

health concerns. Activities provided under the Psychosocial Support Services may

include:

• Bereavement counseling

• Caregiver/respite support (HRSA RWHAP Part D)

• Child abuse and neglect counseling

• HIV support groups

• Nutrition counseling provided by a non-registered dietitian (see Medical

Nutrition Therapy Services)

• Pastoral care/counseling services

Program Guidance:

Funds under this service category may not be used to provide nutritional supplements

(See Food Bank/Home Delivered Meals).

HRSA RWHAP-funded pastoral counseling must be available to all eligible

clients regardless of their religious denominational affiliation.

HRSA RWHAP Funds may not be used for social/recreational activities or to pay for

a client’s gym membership.

For HRSA RWHAP Part D recipients, outpatient mental health services provided to

affected clients (people not identified with HIV) should be reported as Psychosocial

Support Services; this is generally only a permissible expense under HRSA RWHAP

Part D.

See also Early Intervention Services

Respite Care

Description:

Respite Care is the provision of periodic respite care in community or home-based

settings that includes non-medical assistance designed to provide care for an HRSA

RWHAP-eligible client to relieve the primary caregiver responsible for their day-to-

day care.

Program Guidance:

Recreational and social activities are allowable program activities as part of a

Respite Care provided in a licensed or certified provider setting including drop-in

centers within HIV Outpatient/Ambulatory Health Services or satellite facilities.

Funds may be used to support informal, home-based Respite Care, but liability

issues should be included in the consideration of this expenditure. Direct cash

payments to clients are not permitted.

Funds may not be used for off premise social/recreational activities or to pay for a

client’s gym membership.

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