Health, Epidemiology and Laboratory Services; HIV/AIDS, Tuberculosis Control/Refugee Health

Rule R388-805

Ryan White Program

Notice of Proposed Rule

(Amendment)

DAR File No.: 33086
Filed: 10/22/2009 12:29:57 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule change is to change the eligibility requirements for services from 400% of the Federal Poverty Level (FPL) to 250% of the FPL due to projected shortfalls in the Program.

Summary of the rule or change:

In Subsection R388-805-6(2), reduces eligibility requirement from 400% of the FPL to 250% of the FPL. (DAR NOTE: A corresponding 120-day (emergency) rule that is effective as of 10/23/2009 is under DAR No. 33085 in this issue, November 15, 2009, of the Bulletin.)

State statutory or constitutional authorization for this rule:

• Section 26-1-18
• Section 26-1-15
• Section 63G-3-202
• Subsections 26-1-30(2)(a), (b), (c)

This rule or change incorporates by reference the following material:

• Updates: Ryan White Part B Comprehensive HIV/AIDS Care and Services Plan, 01/01/2009

Anticipated cost or savings to:

the state budget:

A portion of the state's budget can be considered a savings. This is a federally-funded program that provides services to people living with HIV/AIDS. It is anticipated that there will be a projected savings of up to $375,000 to ensure that the Program will stay within its budget. However, there are various variables that do not allow us to accurately project the savings.

local governments:

There are no anticipated costs or savings to local government because the program governed by this rule neither requires action from nor provides benefits to local governments.

small businesses:

There are no anticipated costs or savings to small businesses because the program governed by this rule neither requires action from nor provides benefits to small business.

persons other than small businesses, businesses, or local governmental entities:

The rule change will affect individuals who are over the 250% FPL. They will now have to pay the costs associated with their medications and/or health insurance premiums and other support services offered by this program such as dental and mental health services. It is anticipated that there will be a projected savings of up to $375,000 to ensure that the Program will stay within its budget. However, there are various variables that do not allow us to accurately access the savings.

Compliance costs for affected persons:

There are compliance costs associated with this rule change. There are numerous variables that can impact the costs such as if individuals decide to continue to take their medication or not paying for health insurance premiums that the Program was previously paying for. The Department estimates that this change will affect 90 people currently on the program and an estimated 120 people who would otherwise be eligible per year. The costs can range from $1,200 to $13,000 per person per year. The range depends upon whether or not clients are responsible for full pay or partial pay for their services.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule change is necessary to keep this program within available budget.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Epidemiology and Laboratory Services; HIV/AIDS, Tuberculosis Control/Refugee Health
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Jennifer Brown at the above address, by phone at 801-538-6131, by FAX at 801-538-9913, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/15/2009

This rule may become effective on:

12/22/2009

Authorized by:

David Sundwall, Executive Director

R388. Health, Epidemiology and Laboratory Services; HIV/AIDS, Tuberculosis Control/Refugee Health.

R388-805. Ryan White Program.

R388-805-3. Nature of Program and Benefits.

(1) The Ryan White Program provides reimbursement to providers for services rendered to HIV positive individuals who meet the eligibility requirements. The Ryan White Program provides limited services as described in this rule. The Department provides reimbursement coverage under the program only for services for each program:

(a) as provided in law governing the Ryan White HIV/AIDS Treatment Modernization Act of 2006;

(b) as described and limited in the Treatment and Care Program Comprehensive Plan, dated [January 2007] January 2009, which is adopted and incorporated by reference, and all applicable laws and rules;

(c) to the extent that it has agreed to reimburse providers with whom it contracts to provide services; and

(d) as limited in manuals that form part of its Provider Agreements or contracts with providers.

(2) Within available funding, the Department provides the following services under the Ryan White Program;

(a) The AIDS Drug Assistance Program (ADAP) provides HIV related medications;

(b) The Health Insurance Continuation Program pays for health insurance premiums and medication co-pays;

(c) Supportive Services Program provides a variety of supportive services that enable the client to access medical care as well as to retain the client in medical care.

(3) The Department may adjust the services available to meet current needs and fluctuations in available funding.

(4) The Ryan White Program is not health insurance. A relationship with the Department as the insurer and the client as the insured is not created under this program.

 

R388-805-6. Ryan White Program Eligibility.

(1) To receive services under the Ryan White Program, an individual must be a Utah resident and must have a medical diagnosis of HIV infection as verified by the individuals's physician.

(a) An individual may own one home and one registered vehicle but may not have any other assets over $5,000.00.

(b) If an individual owns a vehicle that is not registered and is considered an asset by Medicaid, which then prevents the individual from receiving benefits from Medicaid, the individual is also ineligible for services under the Ryan White Program.

(c) If an individual is ineligible for Medicaid due to failing Medicaid asset limits but otherwise meet Medicaid eligibility requirements, the individual is also ineligible for services under the Ryan White Program.

(2) To receive services under the AIDS Drugs Assistance Program, the Health Insurance Continuation Program and the Supportive Services Program, an individual must have income not exceeding [400%] 250% of the federal poverty level by providing any of the following:

(i) Immediate year Tax Return.

(ii) Immediate year W-2 Form(s).

(iii) Most recent pay Stub/Earnings Statement.

(iv) Most recent Social Security Disability Income Letter.

(v) Most recent Supplemental Security Income Letter.

(vi) Most recent Unemployment Statement.

(vii) Most recent General Assistance Letter from the Department of Workforce Services.

(viii) Most recent Disability Income Letter from a disability insurer.

(3) To be eligible to receive assistance from the AIDS Drug Assistance Program, an individual:

(a) must not be eligible for Medicaid and not covered for the medication requested through this program by any other public or private health insurance coverage;

(b) must have a prescription for the medication requested.

(4) To participate in the Health Insurance Continuation Program, an individual must currently take HIV anti-retroviral medications.

(5) To participate in the Consolidated Omnibus Budget Reconciliation Act (COBRA) Continuation program an individual must meet the following additional eligibility criteria:

(a) The individual must have a medical diagnosis of HIV disease or is a dependent with HIV disease who is covered under the health insurance of someone else;

(b) The policy covers HIV related costs and outpatient HIV related drugs;

(c) The policy can be converted under COBRA;.

(d) The individual has not previously been denied health insurance coverage for HIV disease related services;

(e) The individual must be ineligible for Medicaid or for group/individual health insurance from the individual's current employer;

(f) The individual must have begun the process of securing income support through the Social Security Disability Insurance (SSDI), or the Supplemental Security Income (SSI) or other disability programs if the individual is disabled, or have applied to receive public entitlement benefits.

(6) Clients must re-certify annually in order to continue program participation.

 

KEY: treatment and care, HIV/AIDS, ADAP, Ryan White Program

Date of Enactment or Last Substantive Amendment: [October 17, 2007]2009

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-1-15; 26-1-18; 26-1-30(2)(a), (b), (c), (g)