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OAHS — Specialty Laboratory Services
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HRSA/HAB Category Definition:
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Outpatient/ambulatory medical care includes the provision of professional diagnostic and therapeutic services rendered by a physician, physician's assistant, clinical nurse specialist, nurse practitioner or other healthcare professional who is certified in their jurisdiction to prescribe ARV therapy in an outpatient setting. Settings include clinics, medical offices, and mobile vans where clients generally do not stay overnight. Emergency room services are not considered outpatient settings. Services includes diagnostic testing, early intervention and risk assessment, preventive care and screening, practitioner examination, medical history taking, diagnosis and treatment of common physical and mental conditions, prescribing and managing medication therapy, education and counseling on health issues, well-baby care, continuing care and management of chronic conditions, and referral to and provision of specialty care (includes all medical subspecialties). Primary medical care for the treatment of HIV infection includes the provision of care that is consistent with the public health services (PHS) guidelines. Such care must include access to antiretroviral and other drug therapies, including a prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies.
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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 2009.
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Category Notes:
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Clarifications
The following definition clarifications are 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.
• HRSA suggested treating PMC Co-morbidity as a sub-activity under OAHS and consider mental-health and substance-abuse funding as line items under the activity PMC co-morbidity.
• It will be necessary for the actual expenditures and clients to be reported under the actual substance-abuse and mental-health categories.
• HRSA did acknowledge that it is confusing when there are service categories that can also be activities performed within other categories. Referral is an example of a stand-alone category and an activity performed within medical case management, outreach and non-medical case management.
• Planning council can fund activities such as referrals under the category in which the service is being provided.
• EMA is allowed to have a separate standard for pediatric primary medical care so long as the services follow public health guidelines and are not outside the scope of the OAHS definition.
• OAHS-pediatrics can be funded as a sub-activity under OAHS. Planning council should look at HRSA clinical performance measures for standards and outcomes.
The following clarification was distributed by HRSA on April 8, 2010 (HRSA 2010a).
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; or
• To pay the cost of corrective prescription eye wear for eligible clients through a Ryan White HIV/AIDS Program supported Emergency Financial Assistance Program.
Emergency Financial Assistance
Ryan White HIV/AIDS Program funds may be used to provide Emergency Financial Assistance (EFA) as an allowable support service.
The decision-makers deliberately and clearly must set priorities and delineate and monitor what part of the overall allocation for emergency assistance is obligated for transportation, food, essential utilities and/or prescription assistance. Careful monitoring of expenditures within a category of “emergency assistance” is necessary to assure that planned amounts for specific services are being implemented, and to indicate when reallocations may be necessary.
In addition, Grantees and planning councils/consortia must develop standard limitation on the provision of Ryan White HIV/AIDS Program funded emergency assistance to eligible individuals/households and mandate their consistent application by all contractors. It is expected that all other sources of funding in the community for emergency assistance will be effectively utilized and that any allocation of Ryan White HIV/AIDS Program funds to these purposes will be the payer-of-last-resort, and for limited amounts, limited use and limited periods of time.
History
Ambulatory/Outpatient medical care, so named in the Ryan White CARE Act of 1990, referred to a variety of health services such as substance-abuse treatment, mental-health treatment and comprehensive treatment services including prophylactic treatment for opportunistic infections and treatment education. The term primary medical care (PMC) was used in both formal and informal documents to mean specific HIV medical treatment. In the reauthorization of the CARE Act in 2000, the category was re-named outpatient/ambulatory health services, and the text continues to describe the same variety of health services as in 1999. In 2000, the act also describes outpatient and ambulatory support services including case management.
In 2002, the Health Recourses and Services Administration (HRSA) issued updated definitions for several service categories including PMC, which it formally titled “ambulatory/outpatient medical care” and described as HIV medical care and treatment provided by a physician, physician’s assistant, clinical nurse specialist or nurse practitioner in an outpatient setting. The text of the definition has remained the same since 2002.
In 2006, with the anticipated implementation of the Treatment Modernization Act, the planning council began planning for core medical and support services allocated along a 75-25 split. Since the text of the service definition for outpatient/ambulatory medical care (health services) remained static, it was used as the basis for planning to move other services that were clearly medical in nature and included in the services described in the definition.
In fiscal year 2007, the following services and their allocated funding were incorporated under the umbrella title of outpatient and ambulatory health services: primary medical care, centralized laboratory testing, viral-load testing, PMC co-morbidity, and emergency financial assistance for emergency medications, durable medical equipment, and professional services.
Current Directives
Emergency Financial Assistance (EFA), Early Intervention Services (EIS), Food Bank/Home-delivered Meals, Legal Services, Medical Case Management, and Outpatient Ambulatory Health Services.
Ratified on July 12, 2006: The administrative agent will require primary medical care providers to document twice annual syphilis screenings for those individuals most at risk i.e. MSM, sex workers, young women between the ages of 18 and 24 (IGS 2011a).
Ongoing 2006: Administrative agent to review the EFA system and determine whether there are significant differences in the amount per voucher and the number of vouchers a single consumer can access during a year. Administrative agent will report data from 2006 expenditures (IGS 2011a).
Ongoing 2006: The administrative agent and grantee will only award Title I EFA, In-Direct Transportation and Drug Reimbursement contracts to vendors that have in place a case management or client advocacy programs. COMPLETE. This directive is complete through contracts. There are no dollars for salaries in these categories. Providers receiving EFA, In-direct transportation and Drug Reimbursement funds must have either case management or client advocacy services in place (IGS 2011a).
Ongoing 2006: The administrative agent will identify the services that are funded as a sub-set of EFA and report client utilization and expenditures for each of the services.
Interim report is due that breaks out the use of EFA funds by sub category. The administrative agent will give a final report (IGS 2011a).
Ratified on October 16, 2007: The administrative agent will divide the allocation according to the percentage of those subset activities based on the service utilization percentage of each sub activity. The administrative agent will report out by total category performance and expenditure and by each subset performance and expenditure (IGS 2011a).
Ratified October 19, 2010: To fund OAHS Viral Load Testing vendor capable of providing electronic test results (IGS 2011a).
Primary Medical Care
Ongoing 2006: The administrative agent is to ensure that $4,000 added during priority setting is earmarked for geno/phenotypic STSC tests. The directive requires $4,000 to be set aside for genotypic/phenotypic testing and will end in February 2007 (IGS 2011a).
Primary Medical Care — Co-morbidity
Ratified on November 3, 2008: Offer bonus points to the applications of those providers offering Buprenorphine treatment and addiction counseling (IGS 2011a).
Ratified on November 3, 2008: Add five bonus points in the RFP for any substance-abuse counseling programs that provides Buprenorphine treatment (IGS 2011a).
Central Laboratory Services
Ratified on July 12, 2006 and updated on April 17, 2007: To increase genotypic testing dollars to allocate five hundred tests and to make reprogramming dollars for genotypic testing be a priority should the need be greater. Revised language: To allocate dollars for five hundred genotypic tests in FY 2007. Consideration for providing additional genotypic tests should be made after reviewing utilization and using PMC or reprogramming dollars (IGS 2011a).
Ratified October 16, 2007: The administrative agent will divide the allocation according to the percentage of those subset activities based on the service utilization percentage of each sub activity. The administrative agent will report out by total category performance and expenditure and by each subset performance and expenditure (IGS 2011A).
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