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Health Insurance Premiums & Cost-sharing Asst.
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HRSA/HAB Category Definition:
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Health insurance premium and cost-sharing assistance is the provision of financial assistance for eligible individuals living with HIV to maintain a continuity of health insurance or to receive medical benefits under a health insurance program. This includes premium payments, risk pools, co-payments, and deductibles.
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Source: Definition provided by the U.S. Department of Health and Human Services, Health Resources and Services
Administration (HRSA), HIV/AIDS Bureau (HAB). 2009. Ryan White HIV/AIDS Treatment Modernization Act of
2006 Definitions for Eligible Services. Rockville, Md.: HRSA HAB, August 20.
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Category Notes:
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Clarifications
The following definition clarification is a result of a conference call involving representatives of the grantee (BCHD), Greater Baltimore HIV Health Services Planning Council (PC), PC support office (IGS) and HRSA on May 28, 2008 (IGS 2008).
EMA is allowed to be more restrictive in activities, so limiting this activity to funding co-pays is allowable: EMA cannot be less restrictive.
The following definition clarifications were distributed from HRSA on April 8, 2010 (HRSA 2010a):
Health Insurance Copayments and Deductibles
Funds awarded under Parts A, B, C of the Ryan White HIV/AIDS Program may be used to supports Health Insurance Premium and Cost-Sharing Assistance Program, a core medical service, for eligible low-income HIV positive clients.
Under this service category, funds may be used as the payer of last resort to cover the cost of public or private health insurance premiums, as well as the insurance deductible and co-payments.
The exception is that Ryan White HIV/AIDS Program funds may not be used to cover a client’s Medicare Part D “true out-of-pocket” (i.e. TrOOP or donut hole)” costs.
Consistent with the Ryan White HIV/AIDS Program “low income” is to be defined by the EMA/TGA,State or Part C Grantee.
Vision Care
Ryan White HIV/AIDS Program funds may be used for OAHS, which is a core medical service that includes specialty ophthalmic and optometric services rendered by licensed providers.
Funds also may be used for Rehabilitation Services that include low-vision training by licensed providers or authorized professionals.
Funds also may be used to purchase corrective prescription eye wear for conditions related to HIV infection, through either of these Allowable services:
• To cover the co-pay for prescription eye wear for eligible clients under a Ryan White HIV/AIDS Program supported Health Insurance Premium and Cost-Sharing Assistance;
• To pay the cost of corrective prescription eye wear for eligible clients through a Ryan White HIV/AIDS Program supported Emergency Financial Assistance Program.
History
Health insurance premium and cost-sharing assistance, as currently defined, first appeared in the 2004 HRSA definitions. The Baltimore EMA first funded it in 2007 to address ongoing medication co-payments (in place of emergency financial assistance, which was now only to be used for emergency or single-episode payments, not for continuing needs).
Current Directives
Ratified on July 12, 2006: Establish the service category health insurance specifically to pay for on-going or regular co-payments for prescriptions for Title I eligible clients. Amount of funding for first year should be FY 2006 annual cost of co-pays as determined by the administrative agent reporting (IGS 2011).
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