HIV/AIDS Bureau
Division of State HIV/AIDS Programs (DSHAP)
Ryan White Part B
Technical Assistance Webinar
National Monitoring Standards
Update and Schedule of Charges
June 11, 2013
HAB DSHAP Mission
To provide leadership and support to
States/Territories for developing and
ensuring access to quality HIV
prevention, health care, and support
services.
Presenters:
Heather Hauck
Director, Division of State HIV/AIDS Programs
Harold Phillips
Deputy Director, Division of State HIV/AIDS
Programs
Agenda
Opening Remarks/ Announcements
Heather Hauck
Question and Answer Session 1
National Monitoring Standards Update and
Schedule of Charges
Harold Phillips
Questions and Answer Session 2
Closing Remarks
Heather Hauck
Announcements
Heather Hauck, Director
Division of State HIV/AIDS Programs
HIV/AIDS Bureau
Question and Answer Session
Division of State HIV AIDS Programs
Webinar Series
National Monitoring Standards and
Schedule of Charges
June 11, 2013
Harold J. Phillips, MRP
Deputy Director
Department of Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)
HIV/AIDS Bureau (HAB)
Divisions of States HIV AIDS Programs (DSHAP)
Presentation Agenda
• The Purpose of the National Monitoring
Standards (NMS)
• The Process of Implementation
• Recent Changes/Updates to Standards
• Resource Tools for Implementation
What are the NMS?
• Compilation of all major Ryan White Program documents used for
COMPLIANCE, OVERSIGHT & EXPECTATIONS
• Designed as a set of minimum expectations for use by all Part A &
Part B (including ADAP) grantees and subgrantees on
administration and program and fiscal monitoring
• Developed by HRSA/HAB and Expert fiscal and program
consultants
• Contributions and Involvement:
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HAB Legal Council
Government Accountability Office
HRSA Office of Communications
Part A & B grantee workgroups
• Dissemination:
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Draft in July of 2010
Published April 2011
Updated April 2013
Purpose of the NMS
• Clarify the oversight expectations of Ryan White
Part A & Part B Programs
• Design a specific set of minimum expectations for
monitoring
• Provide a single source for both program and fiscal
monitoring
• Specify the roles of HRSA and Grantees regarding
the monitoring of subgrantees
• Address concerns of HRSA, Congress and OIG
regarding oversight issues
Purpose of the NMS
• Designed to aid grantees in meeting minimal
expectations for:
• Fiscal and Program Management
• Monitoring providers/subgrantees
• Reporting
• Designed to streamline, standardize and improve
program efficiency and responsiveness.
Purpose of the NMS
• Compliance & Oversight & Expectations
• Ryan White Legislation
• Code of Federal Regulations
• HHS Grants Policy Manual
• HRSA/HAB Policies
• Parts A and B Program Guidance
• Part A and Part B Manuals (clarification, best practice)
• Program Terms and Conditions of Award
• OIG/GAO Reports and Recommendations
NMS Implementation Process
• National Monitoring Standards Packet for Ryan White
Part B contains:
Universal Monitoring Standards
Fiscal Monitoring Standards**
Program Monitoring Standards**
Frequently Asked Questions
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• Each individual monitoring standard
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Connected to a source which is cited
Has a grantee and/or sub grantee responsibility
Performance measure/method
Clearly stated performance measure and method
NMS Implementation Process
• Grantees are expected to comply with all of the
standards
• Grantees can develop their own ways to measure
compliance
• There is flexibility regarding how to implement the
monitoring standards
• Implementation is a process
• May require re-thinking, revising long-used practices with
regard to monitoring
• May require changes in tools, process, systems, procedures,
staffing patterns, fiscal and program management and
reporting
NMS April 2013 Updates
Item
Tracking Charges
(Provider or Client)
Change
Clarification
Source
Legislation
Rent as Administrative FAQ #55
Cost
Clarification
DMHAP/DSHAP Program letter: July
17, 2012 -Administrative Costs
Audits
FAQ #57 and
#58
Clarification, new
standard
DMHAP/DSHAP Program letter:
September 20, 2012 –Audits
Site Visit Exemption
FAQ #23
Clarification
DMHAP/DSHAP Program letter:
October 4, 2012 Site Visit Exemption
Eligibility
Determination
Limitation on Charges
(previously cap on
charges)
FAQ #34
New standard
Policy Clarification Notice (PCN) 13-02
Through out
Terminology Update Legislative language
Through out
Schedule of Charges
(previously Sliding Fee
Scale)
Terminology Update Legislative language
Through out
Terminology Update HAB Reorganization
Division Names
(DMHAP/DSHAP)
Location
FAQ #60 and
#62
Technical Assistance
• Work with your project officer
• Technical Assistance
• Consultant, Peer to Peer, HAB staff
• Cooperative Agreements
• Target Center Resources (tools, samples, AGM presentations)
• Please send copies of monitoring tools to PO’s to share with
other grantees
• Individualized conference calls
• National webinars/conference calls
Imposition of Charges and Application of
Sliding Fee Scale)
Assessment and Schedule of
Charges under Ryan White
Outline of this session
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A few definitions for clarity
Legislative Requirements Regarding Fees
Basics of RW Charges for Services/Fees
Eligibility Process
Federal Poverty Level
Sliding Fee Scale Requirements
Nominal Fees
Annual Limitation on Charges
How to Implement
How to Monitor
A Few Important Terms
• Costs are the accrued expenditures incurred by the
grantee/subgrantee during a given period requiring
the provision of funds for: (1) goods and other
tangible property received; (2) services performed by
employees, contractors, subgrantees,
subcontractors, and other payees.
• Charges are the imposition of fees upon payers for
the delivery of billable services
• Payments are the collection of fees from payers that
are applied to cover some aspect of costs of billable
services
Charges for Services
• Billable services are those for which there is
a payer
• Charges are the fees applied to billable
services
• Payers can include Medicare, Medicaid,
insurance companies and clients.
• Payments are the collection of fees from
payers that are applied to cover some
aspect of the costs of billable services
• Charge Master/Schedule of Charges is a
comprehensive listing of prices for billable
services and/or procedures
Legislative Requirements
Regarding Charges/Fees
• RW Schedule of Charges (Sliding Fee
Scale) Requirements have a historical
connection to Public Health Service Act
Section 330 -Health Center Programs such
as:
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Community health centers
Federally Qualified Health Centers and Look-Alikes
Migrant Health Centers
Health Care for the Homeless
Legislative Requirements
Regarding Charges/Fees
• Section 330 Programs and RW Programs are
required to have:
Schedule of fees for provision of service
Fees consistent with locally prevailing rates
Fees designed to cover reasonable costs
A schedule of discounts applied to fees
A discount system based on patient’s ability to pay
No patient denied care due to inability to pay
A system to waive or reduce fees to assure care
received
• Pursue payment from third party sources as
applicable
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Assessment of Client Charges
• Conflicts with Ryan White Sliding Fee Scale
(SFS) Requirements
• Community Health Center SFS Regulations –
a. allow for a minimum charge to persons with
incomes
below 100% of poverty.
b. do not allow for a SFS discount for persons with
incomes above 200% of poverty.
• In these cases at intake and eligibility its
important to clarify which program the client
is eligible for and being enrolled in and
comply with its requirements.
Basics of Ryan White Client Charges/Fees
• Eligibility Process
• Federal Poverty Level (FPL) used to determine
ability to pay fees/charges
• FPL is based on family size and Income @ 100% of
Poverty
• Nominal Fee for clients above 100% FPL
• Annual Limitation on Charges (Cap on Charges)
•Note: Designated free-clinics are exempt and can receive a waiver
Basics of RW Client Charges/Fees –
Eligibility Procedures
• The eligibility process is central to determination of how to
apply the sliding fee scale (determination of the discount on
charges)
• Eligibility Policies and Procedures that:
• Meet Ryan White Part B requirements (HIV status, residency, income,
and recertification every six months)
• Define household and/or individual
• Detail whether net or gross income will be used as part of the income
determination
• If using Modified Adjusted Gross Income (MAGI) Grantees can decide
what expenses to deduct
• Specify documentation required for proof of income/family Size
• Specify process for application of discount pending documentation,
retroactively or at the time of service.
Basics of RW Client Charges/Fees
Imposition of Charges
U.S. Poverty Guidelines
• Published Annually in
the Federal Register
• Health and Human
Services Posts them
on the Web
http://aspe.hhs.gov/poverty/index.shtml#latest
Federal Poverty Guidelines-2013
Annual Limitation on Charges
100% - 200%
200% - 300%
>300% of
At or below
of Poverty –
of Poverty –
Poverty –
100% of FPL –
No more than
No more than
No more than
5% of gross
7% of gross
10% of gross
annual income
annual income
annual income
0%
Annual Limitation on Charges
• Some examples of client charges for care
services that may count towards the annual
cap on client charges include:
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Enrollment Fees
Deductibles
Co-payments
Payments to other providers for care
Health Insurance Premiums
Co-insurance
Other cost sharing
Basics of Imposition and
Assessment of Charges
• How to Implement Process for Imposing
Charges
• Develop a sliding fee scale policy that correlates
with your eligibility process, includes discount
policy, nominal charges and caps on charges
• Develop discount mechanisms within the billing
system
• Develop patient education materials and notices
to be posted in client areas
• Implement staff training and acknowledge it may
be a cultural shift from either free or no
discounted service models
Basics of Imposition and
Assessment of Charges
How to monitor what Sub-grantees must have in place:
• Eligibility process and policy that define household and income
• Proof of Income and Family Size in client files
• Documented evidence of the use of FPL in determining ability to
pay
• Charge Master for billable services
• Discounted fee schedule
• Publicly posted signs indicating nominal fees including that
clients cannot be refused service due to inability to pay
• Be Medicaid certified if providing Medicaid billable services
• Contracts with third party providers
• System for charging payers including Medicaid if providing
Medicaid billable services
• Documented policy of not refusing service due to inability to pay
• Process for collecting from payers especially third party payers
• Proof of the use of program income to support HIV program
Question and Answer Session
Contact Information
Heather Hauck, Director
DSHAP
HHauck@hrsa.gov
Harold Phillips, Deputy Director
DSHAP
E-mail: hphillips@hrsa.gov
Thank You