Eligibility determination is a process of collecting information from an individual in order to provide access to appropriate sources of health insurance, services, and other benefits. Such determinations take place at initial intake but also at periodic intervals (recertification) to verify any changes in eligibility status. Ryan White HIV/AIDS Program eligibility determination and enrollment processes help ensure:
- Alignment of individuals with appropriate services and benefits under public and private health insurance and other service programs (e.g., substance abuse treatment, housing, social services).
- Coordination of benefits to maximize coverage while avoiding inappropriate coverage and payments.
- Compliance with program requirements (e.g., income eligibility, health status eligibility, Ryan White payer of last resort).
Ryan White eligibility determination processes entail collection of information on multiple criteria, most notably: HIV status, income (set as a percentage of federal poverty guidelines), residency, and eligibility/enrollment in other health insurance programs. Notably, eligibility determination processes are being enhanced via online systems that interface with insurance Marketplace systems established under the Affordable Care Act.
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Guidelines and Manuals
HRSA HIV/AIDS BureauFebruary 2015
HRSA HIV/AIDS Bureau's Affordable Care Act updates, policies, webinars, and documents.
Webinars and Training
Webcast review of HRSA's insurance purchasing policy, the definition of MAGI, considerations for ADAPs, and a spotlight on Illinois ADAP.
HRSA HIV/AIDS BureauMarch 2013
This webinar for Ryan White Part B Grantees provides an overview of Ryan White HIV/AIDS Program expectations for client eligibility assessment and recertification requirements.
HRSA HIV/AIDS BureauJuly 2012
Session for ADAP coordinators on ADAP intersections with patient assistance programs (PAPs), client access to PAPs, and NASTAD work to streamline the PAP eligibility and enrollment processes.
Training on meeting federal and state fiscal requirements, fiscal compliance assessment, implementing Ryan White payer of last resort policies, applying Federal Poverty Level guidelines to assess sliding fees, and financial sustainability.
Tools and Job Aids
HRSA HIV/AIDS Bureau, NASTADNovember 2013
The Common Patient Assistance Program (PAP) Application can be used to apply for any pharmaceutical assistance program (PAP) offered by pharmaceutical companies.
Idaho Department of Health and WelfareApril 2013
Resources submitted by Part B grantee.
Oregon Health AuthorityOctober 2012
Series of care plan forms to assess clients in terms of intake, assessment, and care. Forms include: intake, eligibility determination, residency verification, screening for care and psychological services, client rights and responsibilities, nursing assessment, and a care plan.
Indianapolis TGA, MCHDJuly 2011
Tools used for quality and program monitoring by a Part A program.
Dallas EMAJanuary 2011
Program and service monitoring tools developed by a Part A grantee.
Hartford Department of Health and Human ServicesFebruary 2010
Form for staff to assess care plan needs of clients, every 6 months, in terms of case management, home health, respite, housing, mental health, substance abuse treatment, legal, and financial assistance.
Reports and Best Practices
HRSA HIV/AIDS BureauDecember 2012
Series outlining cost-saving and cost-cutting strategies used by AIDS Drug Assistance Programs (ADAP).