Documentation and Communication

Initial Eligibility Determination and Assessment

As stated in HRSA HAB PCN 13-02, RWHAP Part B recipients and/or ADAPs must gather documentation for each of the following in determining an individual’s initial eligibility to receive services:

  • HIV diagnosis or status
  • Income
  • Residency

The forms of documentation required by RWHAP Part B recipients and/or ADAPs are determined at the recipient level and may vary from state to state. In PCN 13-03, HRSA HAB recommends that jurisdictions align their RWHAP Part B and ADAP income calculations with Modified Adjusted Gross Income (MAGI), the standardized methodology used under the Affordable Care Act (ACA) to determine eligibility for Medicaid, private insurance within the ACA Marketplace, and the Children’s Health Insurance Program (CHIP). Also, although not technically a requirement for determining eligibility, many RWHAP Part B programs and ADAPs choose to gather data regarding clients’ insurance status (i.e., third-party coverage) as part of eligibility determination/recertification processes as a means of ensuring compliance with payor of last resort.

The RWHAP Part B and/or ADAP may find it helpful to provide documents to orient clients and providers to their program’s services and policies. For example, written documentation and language for eligibility staff (e.g., case managers) and clients that explains insurance and the role of RWHAP Part B programs/ADAPs in supporting access to it may be particularly helpful to clients who are new to health care coverage.

Per updates to HRSA HAB PCN 13-02 (revised 5/1/2019), eligibility determinations and six-month recertification processes may be conducted at the same time as testing and treatment. RWHAP Part B recipients, ADAPs, and any subrecipient agencies delivering services to individuals who are ultimately determined to be ineligible must assume the risk and responsibility for recouping RWHAP funds as necessary, charging the costs to another payment source, and/or otherwise returning funds to HRSA HAB.

 Example: Hawaii

Hawaii’s ADAP will accept self-attestation at enrollment of zero income for clients with no income and of residency for clients who lack documentation (e.g., homeless clients who have lost documentation), provided that such clients physically present to the intake worker and are under the care of an in-state medical provider.

Example: Michigan

Michigan’s ADAP requires that new and existing clients submit an annual application form. Clients receiving premium assistance must also submit a supplementary application. The ADAP uses supplemental forms to capture necessary information for specific situations related to eligibility determination.  These include:

  • An employment verification form, used when a client starts a new job and has not yet received pay stubs to submit as part of the regular application, or to confirm that a client’s  employer does not offer insurance;
  • A combined declaration form, which allows a third-party to confirm a client’s Michigan residency or the financial support of a client, used when a client does not have any state-issued identification or when a client has no income; and
  • A self-employment income statement, used when a client is self-employed to provide self-employment income and verification of business legitimacy. 

Example: New Hampshire

New Hampshire’s RWHAP Part B program and ADAP has established a rapid eligibility process to provide quicker, temporary access to services for persons awaiting a confirmatory result for a new HIV diagnosis and those who are not newly diagnosed but are re-engaging into medical care after not receiving medical care for over one year. At the time of rapid eligibility enrollment, an individual must submit a signed rapid-eligibility-specific application, a signed and dated release of information form, and self-attestation of income verification and New Hampshire residency. Verification of presumptive HIV status is required for clients awaiting a confirmatory HIV test result. Clients’ eligibility for RWHAP Part B services and ADAP is effective for 30 days to allow for submission of a full application and all required documentation. If after 30 days, the full application elements are not received, the client is dis-enrolled from the NH CARE program.

Annual and Six-Month Recertification Processes

As per HRSA HAB policy, clients must be recertified at least every six months (150 days or more apart) after their initial determination of eligibility to maintain eligibility for RWHAP services. The primary purposes of the recertification process are to ensure that an individual’s residency and income continue to meet the RWHAP Part B and/or ADAP eligibility requirements and to verify that the RWHAP Part B and ADAP continues to be the payor of last resort.  At least once a year, Part B and/or ADAPs are required to collect in-depth supporting documentation for, at minimum, the client’s income and residency for eligibility, and the client’s insurance status for payor of last resort.  At one of the two required recertifications during a year, Part B and/or ADAPs may accept client self-attestation (i.e., the client verifies if changes have or have not occurred to their income, residency and/or insurance status). Self-attestation can be completed by phone, e-mail, or in-person. If a client reports that their income, residency and/or insurance status has changed, the RWHAP Part B and/or ADAP must obtain corresponding documentation and determine whether the client is still eligible. In utilizing self-attestation, many RWHAP Part B recipients and/or ADAPs have observed significant reductions in reporting burden for clients.

There are variables that may also be gathered within eligibility and/or recertification applications that are helpful to the RWHAP Part B recipient and ADAP although not necessary for determining client eligibility or compliance with payor of last resort. For example, while viral load(s) are not required for eligibility determination, RWHAP Part B recipient and/or ADAPs may find it useful to include this in their applications to ensure that it is collected for clinical quality management (CQM) or HRSA HAB reporting purposes (e.g., the Ryan White Services Report (RSR) and the ADAP Data Report (ADR)).  Another example is variables that may inform eligibility for specific RWHAP services, such as housing status, to inform eligibility for Housing Services. Inclusion of such variables is at the discretion of the RWHAP Part B recipients and ADAP but should not be a barrier for access to core medical and support services.

Example: Hawaii

Hawaii’s ADAP utilizes self-attestation of no change in income, residency, and/or insurance for six-month recertifications. They rely on full recertification and documentation during the first six months of the calendar year to ensure that they have gathered documentation necessary for eligibility determination and for tax and premium purposes.

Example: Idaho

Idaho’s RWHAP Part B program and ADAP accept client self-attestation at their six-month recertification as detailed in their written policy and checklist documentation for providers. Clients’ recertification periods are determined based on the date of a client’s initial intake application. The six-month recertification self-attestation form includes: name, date of birth, contact information, household size, household income, and health insurance status. The form may be submitted in person or by mail. Clients must submit additional documentation in the event of any changes.

Example: Maryland

Maryland’s ADAP accepts client self-attestation for six-month recertification via a semi-annual verification notice form. The six-month recertification self-attestation form is prepopulated with information from the ADAP data system and includes: name, date of birth, last-four digits of social security number (SSN), citizenship, contact information, household size, household income, and health insurance status. The client either signs that the information provided is correct or provides updated information and corresponding documentation.  Once a client’s six-month verification notice form has been submitted, ADAP eligibility staff re-verify their income and Medicaid eligibility status by accessing the state’s Medicaid enrollment system. The vast majority of the ADAP’s six-month verification notice eligibility reviews result in no changes to clients’ ADAP enrollment status.

Example: Michigan

Michigan’s ADAP conducts self-attestation for six-month recertification via their online system and through paper forms. If there have been any changes in income, insurance, and/or residency, clients must submit supporting documentation to verify the change(s). In between six-month and annual recertifications, Michigan maintains a “change of status” form through which clients can submit any additional changes.

Example: Wisconsin

Wisconsin’s ADAP accepts client self-attestation at their six-month recertification via a two-page form in which clients can verify that their residency, address, household income, household size, and/or insurance coverage have not changed, or if they have changed, provide updated information and accompanying documentation. Once completed, the self-attestation form may be submitted to ADAP via mail or fax.