Recommendations to Guide the 2005 Reauthorization of the Ryan White CARE Act

NASTAD's recommendations to enhance the ability of states to coordinate HIV/AIDS health systems focus on: SCSN and comprehensive planning, payer of last resort, and Title III grants.

Statewide Coordinated Statement of Need, Comprehensive Planning, and the Role of the States in Coordinating Services

The Statewide Coordinated Statement of Need (SCSN) and comprehensive planning processes are designed to achieve a goal of collaboration; however, they have become burdensome and duplicative. No additional funding has been provided for states to facilitate these efforts.

The CARE Act requires that each state periodically convene a meeting of persons living with HIV/AIDS, representatives of grantees under each title of the CARE Act, providers, and public agency representatives for the purpose of developing the SCSN.²¹ States are the only grantees under the CARE Act with the requirement to convene such a meeting, although all other titles are required to demonstrate in their applications consistency with the SCSN in their particular state.

• RECOMMENDATION #19 -- Revise coordination and planning requirements of the CARE Act.
  • RECOMMENDATION #19a -- (Legislative) Eliminate the SCSN requirement in the CARE Act. This requirement is duplicative of other requirements associated with the annual state application (which includes a comprehensive plan), public advisory and participatory planning requirements associated with the annual application, and Title I planning council and Title II consortia needs assessment and planning activities.

  • RECOMMENDATION #19b -- (Legislative) Require HRSA to consult with each state and other grantees within a particular jurisdiction prior to approving new grants. This requirement would improve state and grantee efforts to reduce duplication and allow new resources to be targeted to severe need jurisdictions (those with inadequate Title II base services or ADAPs that have inadequate formularies, low income eligibility levels, or other criteria, including presence of waiting lists). New projects should be consistent with the above collaborative planning processes and not duplicate existing programs, regardless of which title or other program is providing services.

  • RECOMMENDATION #19c -- (Legislative) Require documentation of collaborative efforts with the state in grant applications or progress reports for all CARE Act grantees, including AETCs and dental reimbursement programs. As part of each Title II application, the state will continue to report on the progress of the state's CARE Act grantee collaborative efforts and, where appropriate, document the participation of other grantees.

  • RECOMMENDATION #19d -- (Administrative) Eliminate the administrative requirement to submit a separate Comprehensive Plan from the Title II grant application. The current requirement is duplicative and unnecessary.

  • RECOMMENDATION #19e -- (Administrative) Provide states with maximum flexibility to determine the appropriate mechanism and timing of coordination efforts among the various CARE Act programs. The elimination of the SCSN does not eliminate the responsibility of all CARE Act grantees to actively participate in ongoing collaborative efforts within each state to ensure, to the greatest extent possible, access to coordinated client services across the state and reduced duplication of services. At its discretion, the Title II grantee in each state would be responsible for convening, planning, coordinating, and facilitating such efforts, with the assistance and input of the other grantees. Where a grantee's service area crosses over more than one state, the grantee should be required to participate in the collaborative process of each state in which they serve clients. New and/or additional funding should be provided to states in order to facilitate this process.

Payer of Last Resort

The CARE Act requires that CARE Act funds 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 any state compensation program, under an insurance policy, or under any federal, state or local health benefits program.²² This provision of the CARE Act is widely known and referred to as the "payer of last resort." While this is clearly understood with respect to most programs, HRSA's HIV/AIDS Bureau has generally been unable to clearly articulate a policy regarding payer of last resort. Some state Medicaid programs have also been unwilling to provide client eligibility data to ADAPs, making it difficult for ADAPs to fully comply with the payer of last resort provision.

• RECOMMENDATION #20 -- Revise the payer of last resort requirement in the CARE Act.
  • RECOMMENDATION #20a -- (Legislative) Provide explicit allowance within the CARE Act to wrap-around Medicaid and Medicare to help support payment of co-pays and other out-of-pocket expenses that provide necessary health care services to persons living with HIV/AIDS.

  • RECOMMENDATION #20b -- (Legislative) Enable states the flexibility to serve clients who have coverage for services through other payers that are also covered under the CARE Act if the services covered elsewhere are difficult to access (e.g., location of services is too far to enable the client access to the services).

  • RECOMMENDATION #20c -- (Legislative) Require Medicaid and Medicare to provide eligibility data to ADAPs to ensure the payer of last resort requirements are met.

  • RECOMMENDATION #20d -- (Legislative) Require Medicaid to reimburse states through a Medicaid Administrative Reimbursement process for staff time devoted to Medicaid coordination activities.

  • RECOMMENDATION #20e -- (Administrative) List the programs that are included with respect to the payer of last resort provision, including those of the Veterans' Administration, Medicaid, Medicare, Indian Health Services (IHS), State Children's Health Insurance Programs, and other federal, state and local programs, including other pharmacy benefits programs.

Title III Grants

The CARE Act includes language²³ giving priority for new Title III grants to "rural areas" and "underserved" areas. Of the programs funded under Title III during FY2003, approximately 44% were in urban areas, 36% were in rural areas and 19% were in mixed rural and urban areas. Of the grantees funded since 2000, 79% were rural and 21% were urban. It does appear that HRSA has responded appropriately to the CARE Act language regarding a preference for making new Title III awards in rural areas, however, it is unclear whether or not these Title III programs were within or near Title I EMAs.

• RECOMMENDATION #21 -- Revise the Title III provision of the CARE Act.

  • RECOMMENDATION #21a -- (Legislative) Prioritize new planning or Title III grants to underserved states that do not have access to Title I funding and as a secondary priority, underserved areas of states outside of existing Eligible Metropolitan Areas (EMAs).

  • RECOMMENDATION #21b -- (Legislative) Require HRSA to consult with each state and other grantees within a particular jurisdiction prior to determining new Title III projects within a particular area. This requirement would help to reduce duplication and allow new resources to be targeted to severe need jurisdictions (those with inadequate Title II base services or ADAPs that have inadequate formularies, low income eligibility levels, or other criteria, including presence of waiting lists). New projects should be required to coordinate services with the state, consistent with collaborative planning processes, and not duplicate existing programs, regardless of which title or other program is providing services.

  • RECOMMENDATION #21c -- (Administrative) Strengthen and enforce the provision of HIV services provided by community health centers that receive federal, but not CARE Act, support. In challenging fiscal times, it becomes increasingly important to maximize all resources available to provide services for persons living with HIV/AIDS.

  • RECOMMENDATION #21d -- (Administrative) Require HRSA to allow representatives from states in monitoring visits at Title III agencies and provide copies of subsequent reports to the states upon request. This requirement would increase collaboration between grantees and reduce duplication of services.