Strategies to Streamline Eligibility

Centralized and Consolidated Eligibility Across RWHAP Parts

RWHAP recipients, including RWHAP Part B and/or ADAP, may consider centralizing or consolidating eligibility for a variety of reasons, including but not limited to, improving client experience in receiving services across RWHAP Parts in their jurisdiction and reducing administrative burden on clients and staff. Some jurisdictions may choose to centralize or consolidate their eligibility across all RWHAP Parts jurisdiction-wide, while others may elect to do so for some but not all RWHAP Parts, or for Part B and ADAP only. For purposes of this toolkit, “centralized eligibility” is defined as a system in which eligibility criteria and documentation requirements are aligned across all participating RWHAP Parts and/or ADAP, with a single application used to document and determine eligibility and a single site or entity determining eligibility (e.g., the RWHAP Part B program). By contrast, “consolidated eligibility” is defined as a system in which eligibility criteria, documentation requirements, and application are the same across participating RWHAP Parts, but eligibility is determined by each RWHAP Part separately.

Centralizing or consolidating eligibility requires that all parties involved work collectively to convene, define goals, and find common ground.  While the goal of streamlining and consolidating eligibility is to achieve consensus on all aspects of eligibility, if there are any differences in eligibility criteria across the RWHAP Parts, the participating recipients need to ensure a client is eligible for the service requested.

RWHAP Parts participating in either a centralized or consolidated eligibility process should document the processing system and shared eligibility requirements in a living document that all parties can use as a point of reference for training new staff and providing transparency to clients. For centralized eligibility in particular, RWHAP Parts should also establish a mechanism to receive, process, share, and store all eligibility-related records electronically. This mechanism should be secure, timely, and accessible to all key stakeholders and staff.

Example: Arizona

Arizona maintains a statewide, centralized eligibility system for RWHAP Parts A and B (including ADAP) in which joint eligibility-related records are accepted, processed, corresponded, and stored in a web-based data system, the Ryan White Integrated Statewide Eligibility (RWISE). To accomplish this, RWHAP Parts A, B, and ADAP formed a joint eligibility workgroup to align many, eligibility criteria across the Parts. All decisions were memorialized in the Arizona Parts A, B, and ADAP Eligibility Guide and the Arizona Parts A, B, and ADAP Processing Guide.  These guides are resources to assist case managers and clients during the application submission process. Since instituting centralized eligibility, Arizona has observed reduced administrative burden on clients and staff, as well as improved data sharing across the Parts since all information and communications are easily accessible in real-time in a single repository. Arizona found the following to be critical to implementing and/or maintaining their centralized system:

  • Establishing fail-safes to ensure uninterrupted service delivery when or if an aspect of eligibility becomes unavailable (e.g., eligibility data system)
  • Maintaining a secure mechanism and server to exchange and store a large volume of data across RWHAP Parts
  • Securing sufficient and sustainable funding support permitting critical technology improvements as necessary
  • Ensuring consistent and clear communication between RWHAP Parts and clients
  • Seeking full buy-in and support from all parties involved, as documented in memoranda of understanding (MOUs) and contracts
  • Identifying and celebrating the achievement of a well-defined project vision, milestones, and goals.

Example: Colorado

In Colorado, RWHAP Parts A, B, C, D, and ADAP participate in consolidated eligibility in which they share a unified eligibility criterion for income at or below 500% of the federal poverty level (FPL). RWHAP Part B and ADAP applications are processed centrally within Part B. Applications for Parts A, C, and D are processed by each of the programs separately. Colorado’s consolidation process took two years to complete. One challenge they had to overcome as the concern of RWHAP clients and providers regarding names-based reporting and privacy/data security. To address this, all RWHAP Parts in Colorado collaborated to communicate the potential benefits of a consolidated eligibility process to clients and providers, and the systems that would be in place to ensure timely and secure exchanges of data.  Part B staff emphasized for providers that their administrative burden would be reduced and that the state’s ADR and RSR reports would be more accurate as a result of their centralized data sharing arrangement.  Parts A and Part B worked with their respective legal teams to ensure the necessary data sharing agreements were allowable. They then visited various AIDS Service Organizations (ASOs) and held public meetings about the process and its implementation. Colorado’s data sharing task force has, with input from community, since created a culture of trust and an avenue through which RWHAP programs can solicit feedback on broader topics (e.g., developing out-of-care lists).

Digital Tools to Optimize Enrollment and Eligibility Processes

RWHAP Part Bs and/or ADAPs may choose to invest in digital tools to bolster their infrastructure and streamline communications between recipient/subrecipient staff and clients. These tools might include:

  • An online application system (i.e., a web-based platform through which clients and/or RWHAP Part B and ADAP staff may input application data),
  • A digital storage system in which required eligibility/recertification documentation may be uploaded and saved, or
  • A platform through which relevant staff may send secure and timely text or e-mail communications to clients regarding upcoming recertifications, prescription refills, etc.

Each of these tools can benefit the program.  For example, an online application for RWHAP Part B and/or ADAP can increase the completeness and timeliness of applications; a digital storage system may ensure fast and secure transmission of necessary documentation for eligibility/recertification while reducing waste associated with paper-based systems; and sending alerts or messages to clients, regarding upcoming recertification dates, for example, may improve the rate of timely recertification for clients.

These tools require the RWHAP Part B recipient and/or ADAP to dedicate varying levels of funding and staffing for the initial implementation and on an ongoing basis for maintenance. The RWHAP legislation allows a limited amount of the grant award for the administrative costs of RWHAP services, including for example the implementation and maintenance of an online application system*. The legislative caps on administrative costs do not apply to the use of rebates or program income.  RWHAP Part Bs and/or ADAPs should consider ways to leverage their available funding to improve the efficacy and efficiency of their programs and their eligibility determination/recertification processes, including using one or more of these tools.

Example: Alabama

Alabama’s RWHAP Part B uses a shared eligibility system for RWHAP Part B and ADAP.  Alabama, in collaboration with its lead agency, United Way of Central Alabama (UWCA), launched an online application for ADAP on a web-based software program, ServicePoint, on November 1, 2016.  Alabama incorporated their RWHAP Part B program into the ServicePoint system in 2018.   The system allows case managers to apply for ADAP and RWHAP Part B services for new and returning clients, including uploading required documents. ServicePoint is also used for annual and six-month recertifications. The shared eligibility system enhances partnerships and collaboration among RWHAP providers and the state HIV central office. The improved system reduces barriers encountered by clients, reduces burden on providers, and coordinates streamlined eligibility systems and processes.

Example: Colorado

Colorado’s ADAP, in collaboration with their PBM (i.e., Ramsell), developed an online portal through which clients may enroll and submit eligibility and recertification applications as well as send updates to eligibility staff via secure messaging. Within the portal, clients can also print a temporary benefit card for medical and prescription co-payments, if eligible. They also receive prompts when their recertification date is approaching. The portal is also available in a mobile-friendly format. Since launching the portal, the ADAP has experienced expedited application processing and medication access for clients. In the future, Colorado hopes to integrate data from multiple platforms and sources into the portal to improve client health outcomes, including establishing an “eligibility-lookup” functionality for providers to confirm clients’ eligibility for RWHAP Part B and ADAP services.

Example: Oklahoma

Oklahoma’s ADAP maintains an online eligibility/enrollment system. The contract pharmacy, insurance benefits manager (IBM), and case managers have access to real-time approvals and client record information. The contract pharmacy and IBM upload client service utilization data into the system; the ADAP can then view the services provided to individual clients and run aggregate reports or queries as needed.

*RWHAP Part B recipients (i.e., states/territories) are allowed to use up to 10% of RWHAP Part B funding for the payment of administrative costs in any grant year, with a total of 15% used for the combination of administration, planning, and evaluation activities. Separately, the lesser of five-percent of the total grant or $3,00,000 may be used to fund CQM activities. The cost caps do not apply to rebate funds, but the costs must still be related to RWHAP allowable services.