Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals

According to RWHAP statute, funds awarded under RWHAP Parts A, B, and C may be used to support the HRSA RWHAP core medical service “Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals,” regardless of the kind of health care coverage (public or private), in accordance with Section 2615 of the Public Health Service Act (Continuum of Health Insurance Coverage) and HRSA HAB PCN 16-02 Ryan White HIV/AIDS Program Services: Eligible Individuals and Allowable Uses of Funds.”

According to statute, funds awarded under RWHAP ADAP may be used to cover costs associated with health care coverage, including co-payments, deductibles, and premiums, in accordance with Section 2616 of the Public Health Service Act (Provision of Treatments) and HRSA HAB PCN 16-02, regardless of the kind of health care coverage (public or private). RWHAP Part D recipients may use funds to support the HRSA RWHAP core medical service “Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals,” in accordance with HRSA HAB PCN 16-02.

All RWHAP recipients must determine how to operationalize their health care coverage premium and cost sharing assistance programs and demonstrate that:

1. Clients obtain health care coverage that at a minimum, includes at least one U.S. Food and Drug Administration (FDA) approved medicine in each drug class of core antiretroviral medicines outlined in the U.S. Department of Health and Human Services’ Clinical Guidelines for the Treatment of HIV, as well as appropriate HIV outpatient/ambulatory health services; and
   
2. The cost of paying for the health care coverage (including all other sources of premium and cost sharing assistance) is cost-effective in the aggregate versus paying for the full cost for medications and other appropriate HIV outpatient/ambulatory health services (RWHAP Part A, RWHAP Part B, RWHAP Part C, and RWHAP Part D). RWHAP ADAP must determine the cost of paying for the health care coverage is cost-effective in the aggregate versus paying for the full cost for medications.
   

RWHAP Parts A, B, C, and D recipients may consider providing their health insurance premiums and cost sharing resource allocation to their state RWHAP ADAP, particularly where the ADAP has the infrastructure to verify health care coverage status and process payments for public or private health care coverage premiums and cost sharing.

RWHAP recipients must be able, upon request, to demonstrate the methodologies applied for determining compliance with these two requirements. As with other allowable costs, recipients are responsible for accounting and reporting on funds used for this purpose.

Health Insurance Premium and Cost Sharing Assistance provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. To use RWHAP funds for health insurance premium and cost-sharing assistance, a RWHAP Part recipient must implement a methodology that incorporates the following requirements:

• RWHAP Part recipients must ensure that clients are buying health coverage that, at a minimum, includes at least one drug in each class of core antiretroviral therapeutics from the Department of Health and Human Services (HHS) treatment guidelines along with appropriate HIV outpatient/ambulatory health services
  
• RWHAP Part recipients must assess and compare the aggregate cost of paying for the health coverage option versus paying for the aggregate full cost for medications and other appropriate HIV outpatient/ambulatory health services, and allocate funding to Health Insurance Premium and Cost Sharing Assistance only when determined to be cost effective
  

The service provision consists of either or both of the following:

• Paying health insurance premiums to provide comprehensive HIV Outpatient/Ambulatory Health Services and pharmacy benefits that provide a full range of HIV medications for eligible clients
  
• Paying cost-sharing on behalf of the client
  

Program Guidance:

Traditionally, RWHAP Parts A and B funding support health insurance premiums and cost-sharing assistance. If a RWHAP Part C or D recipient has the resources to provide this service, an equitable enrollment policy must be in place and it must be cost-effective and sustainable.

See also:

PCN 07-05: Program Part B ADAP Funds to Purchase Health Insurance

PCN 13-05: Revised 6/6/2014: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Private Health Insurance

PCN 13-06: Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance for Medicaid

PCN 14-01: Revised 4/3/2015: Clarifications Regarding the Ryan White HIV/AIDS Program and Reconciliation of Premium Tax Credits under the Affordable Care Act

PCN 16-02: Ryan White HIV/AIDS Program Services: Eligible Individuals & Allowable Uses of Funds

PCN 18-01: Clarifications Regarding the Use of Ryan White HIV/AIDS Program Funds for Health Care Coverage Premium and Cost Sharing Assistance

For the purposes of this document, need is based on the response of a consumer when asked if there was a service they needed. MMP interviews patients in care and asks consumers if they need a service and if they receive it. Client services unit data identifies needs at the time of initial intake.