Eligibility Infrastructure

Staffing Models within Recipients/Subrecipients 

The size and makeup of the eligibility staff may vary considerably across RWHAP Part B systems of care and ADAPs. Eligibility staff most often consists of:

  • Eligibility Coordinator, who is responsible for overall oversight of eligibility determination/recertification processes.  The eligibility coordinator has oversight of all program-specific support staff and is responsible for documenting program rules, responsibilities, and decisions.
  • Eligibility Application Assister, who is responsible for meeting and working with each client to ensure that the application is submitted as accurately and thoroughly as possible.
  • Eligibility Determination staff, who is responsible for reviewing applications to determine programmatic eligibility.
  • Third-party Payer/Insurance Coordinator, who is responsible for reviewing all payer of last resort documentation for adequacy, affordability, and cost-effectiveness as programmatically defined.
  • Data Entry Staff, who is responsible for entering eligibility-related data into the recipient’s or subrecipient’s data system.

The titles and numbers of staff responsible for each of these roles and scopes of work may vary considerably between recipients and subrecipients. As well, the training and professional experience may differ based on the nature of the work and client need. For example, case managers may be well-positioned to serve as eligibility application assisters as they have strong interactions and rapport with clients and may gather much of the necessary eligibility information as part of their regular duties.

RWHAP Part B recipients and ADAP leadership may determine the staffing level and skill sets their program needs to optimize the efficiency and effectiveness of their eligibility determination and recertification processes by considering the following:

  • What is the acceptable and sustainable “working case load” (i.e., the ratio of applicants/clients to eligibility staff)?
  • Is the total pool of eligible clients manageable internally within the RWHAP Part B recipient and ADAP or should the program seek out additional assistance (e.g., contracting out eligibility determination/recertification)?
  • Will current staffing allow for all initial, annual, and six-month recertification applications to be processed on a timely basis? 
  • Does the RWHAP Part B recipient and/or ADAP have strategies to reduce and/or mitigate the impact of eligibility staff turnover?

Example:  Arizona

Prior to February 2019, the Arizona RWHAP Part B recipient and ADAP staffing model for addressing the needs of approximately 4,500 unique applicants per year consisted of five contractual  temporary eligibility review staff and one full-time state-employed “ADAP Retention Coordinator/Insurance Specialist,” all housed and supervised under the ADAP Operations Manager at the Arizona Department of Health Services. All RWHAP Part B and ADAP eligibility services transitioned on February 1, 2019 to the program’s pharmacy benefits manager (PBM) contract and the five contractual temporary staff became full-time employees of the PBM while performing the same duties as before. All other aspects of the eligibility determination process remained the same.

Example: Iowa

Iowa’s ADAP is responsible for 600-800 unique applicants annually. All applicants must apply for ADAP through a case manager. The ADAP staff consists of three staff:  an ADAP coordinator and a benefit/enrollment specialist employed by the state, and an additional benefit/enrollment specialist employed in a long-term temporary position through Iowa’s contract pharmacy.

Data Sharing and Other Data System Considerations

As noted in the RWHAP Part B Manual, HRSA HAB “expects to see collaboration, partnering and coordination between multiple sources of treatment, care and HIV testing, and HIV prevention service providers.” To contribute towards these efforts, RWHAP Part B programs and ADAPs are encouraged to establish data sharing arrangements with external entities (e.g., other RWHAP Parts in the jurisdiction, Medicaid) to assist in verifying clients’ income, residency, and/or third-party coverage as part of eligibility determination and recertification. In doing so, the RWHAP Part B program/ADAP may alleviate reporting burden on clients and providers.  They may also increase the completeness and accuracy of their data systems for purposes of reports (e.g., the RSR, the ADR) required as a condition of their federal awards.

Variables commonly shared between RWHAP Part B recipients and ADAPs and other entities for purposes of eligibility determination and recertification include:

  • HIV diagnosis (only at initial eligibility determination)
  • Income
  • Residency
  • Insurance status
  • Viral load date(s) and value(s) (Although not required as part of either annual or six-month recertifications, jurisdictions may choose to gather viral loads during recertification as part of ongoing program monitoring and meeting client-level reporting requirements)

The following are entities RWHAP Part B recipients and/or ADAPs commonly share data with as part of eligibility determination and recertification processes, and examples of the type of data shared:

  • State/local surveillance programs (e.g., HIV diagnosis, CD4 count, viral load, HIV risk category, hepatitis C (HCV) status)
  • Medicaid (e.g., Medicaid eligibility, income)
  • Other RWHAP Parts (e.g., income)
  • Pharmacy benefits managers (PBMs) and insurance benefits managers (IBMs) (e.g., ADAP eligibility, eligibility for other payers)

PBMs, IBMs, and Eligibility Determination/Recertification

As described in NASTAD’s PBM Toolkit, ADAPs often contract with third parties to provide pharmacy services to their clients, including PBMs for direct pharmacy services and IBMs for insurance benefit coordination services. PBMs and IBMs may perform a variety of administrative activities for ADAPs, including, but not limited to, claims adjudication and payment processing. ADAPs must therefore provide client eligibility data to any contracted PBMs and/or IBMs on a timely and regular basis so that they might appropriately process any associated claims, etc.

The mechanisms through which RWHAP Part B recipients and ADAPs share data with others vary widely based on the available data infrastructure, staff capacity, and  data privacy policies. Client information collected by RWHAP Part B recipients and ADAPs contain protected health information (PHI) which is subject to privacy and confidentiality standards, including the Health Information Portability and Accountability Act (HIPAA). Part B recipients  and ADAPs must follow federal, state, and local policies and laws regarding privacy and confidentiality. Part B recipients  and ADAPs may choose to leverage data sharing agreements (DSAs) to document expectations for how data is to be shared between them and their partners.

Example: Arizona

To implement a centralized eligibility system across RWHAP Parts A, B, and ADAP, the Arizona RWHAP Part B developed a unified data system statewide in 2017. This system, known as RWISE, is maintained via CAREWare and is the platform through which RWHAP eligibility is entered and transmitted. There is a DSA in place between the RWHAP Part B, Part A, and one of the three RWHAP Part C clinics in Arizona. All eligibility data is available to RWHAP Parts A and B providers, the participating Part C clinic, ADAP, the RWHAP-funded dental services provider and Arizona Part B program’s 340B pharmacy and its PBM. Finally, ADAP staff have access to their state surveillance system to obtain necessary lab data for eligibility-determination. Since launching RWISE, Arizona’s Part B program and ADAP staff have received consistently positive feedback from clients, who report less confusion, paperwork, and delays. Staff have experienced a less duplicative, burdensome, and inefficient workflow by collaborating with key partners.

Example: Colorado

In 2015, Colorado’s RWHAP ADAP signed a data sharing agreement with some of the RWHAP-funded providers in the state. Data exchanged between RWHAP ADAP and the participating RWHAP providers include: demographic data (e.g., date of birth, race, ethnicity, gender, HIV/AIDS status); the beginning and end of the clients’ ADAP certification period; most recently reported income and household size; insurance enrollment status; housing status; current residential/mailing address and phone number; and CD4 counts/viral loads. On a weekly basis, ADAP eligibility files are downloaded to a secure file transfer protocol (FTP) site from which participating RWHAP-funded providers can import them into other data systems. ADAP clients can opt-out if they do not want their information shared with other RWHAP providers. If they choose to opt out, clients must then complete RWHAP recertification with each provider separately, including ADAP. Since the launch of the data sharing agreement, all participating RWHAP providers accept a client’s current ADAP ID card as proof of RWHAP eligibility.  The ADAP ID card includes the date of expiration (i.e., the end of the ADAP recertification period), the region of the state the client lives, and the client’s prescription and medical billing information

Colorado’s ADAP uses their PBM’s data system to maintain all ADAP-related data, including client eligibility and claims processing. Providers that have data sharing agreement the ADAP are granted view-only access to check their clients’ eligibility in real-time. Individual pharmacies may also access the PBM data system in real-time. ADAP has shifted insurance navigation responsibilities away from case managers and towards regional insurance navigators spread across the state. If clients are eligible for ADAP-funded insurance, ADAP conducts eligibility assessments internally and then shares their record with the regional insurance navigators for viewing.

Example: Iowa

Iowa maintains RWHAP Part B program and ADAP client-level data within a CAREWare-based system, which is managed internally. Every two weeks, Iowa’s RWHAP Part B program/ADAP imports into CAREWare all viral load and CD4 information from the state’s Enhanced HIV/AIDS Reporting System (EHARS).

Example: Maryland

ADAP staff in Maryland check the state Medicaid enrollment system to ascertain if a client was enrolled in Medicaid in the past six months. The same system allows staff to verify wages reported to the state by employers.  If the client has income on the system that has not been reported to ADAP, the client and/or their case manager is called and asked for pay stubs for the newly identified employment.  Income is then recalculated to determine continued eligibility.

Example: Vermont

Vermont’s ADAP (VMAP) maintains a data sharing agreement with Medicaid and utilizes Medicaid’s PBM and data system. VMAP can verify residency in the Medicaid system for clients who are enrolled in an ADAP-funded QHP with premium tax credits, are on Medicaid, or are on the state pharmacy assistance program.