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.