7Division of State HIV AIDS Programs National Monitoring Standards and Webinar SeriesNational Monitoring Standards andSchedule of ChargesJune 11, 2013Harold J. Phillips, MRP Deputy Director Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) Divisions of States HIV AIDS Programs (DSHAP)
8Presentation AgendaThe Purpose of the National Monitoring Standards (NMS)The Process of ImplementationRecent Changes/Updates to StandardsResource Tools for Implementation
9What are the NMS?Compilation of all major Ryan White Program documents used for COMPLIANCE, OVERSIGHT & EXPECTATIONSDesigned as a set of minimum expectations for use by all Part A & Part B (including ADAP) grantees and subgrantees on administration and program and fiscal monitoringDeveloped by HRSA/HAB and Expert fiscal and program consultantsContributions and Involvement:HAB Legal CouncilGovernment Accountability OfficeHRSA Office of CommunicationsPart A & B grantee workgroupsDissemination:Draft in July of 2010Published April 2011Updated April 2013
10Purpose of the NMSClarify the oversight expectations of Ryan White Part A & Part B ProgramsDesign a specific set of minimum expectations for monitoringProvide a single source for both program and fiscal monitoringSpecify the roles of HRSA and Grantees regarding the monitoring of subgranteesAddress concerns of HRSA, Congress and OIG regarding oversight issues
11Purpose of the NMSDesigned to aid grantees in meeting minimal expectations for:Fiscal and Program ManagementMonitoring providers/subgranteesReportingDesigned to streamline, standardize and improve program efficiency and responsiveness.
12Purpose of the NMS Compliance & Oversight & Expectations Ryan White LegislationCode of Federal RegulationsHHS Grants Policy ManualHRSA/HAB PoliciesParts A and B Program GuidancePart A and Part B Manuals (clarification, best practice)Program Terms and Conditions of AwardOIG/GAO Reports and Recommendations
13NMS Implementation Process National Monitoring Standards Packet for Ryan White Part B contains:Universal Monitoring StandardsFiscal Monitoring Standards**Program Monitoring Standards**Frequently Asked QuestionsEach individual monitoring standardConnected to a source which is citedHas a grantee and/or sub grantee responsibilityPerformance measure/methodClearly stated performance measure and method** Part A and B fiscal and program standards have differences that pertain to each of the unique program and fiscal requirements.
14NMS Implementation Process Grantees are expected to comply with all of the standardsGrantees can develop their own ways to measure complianceThere is flexibility regarding how to implement the monitoring standardsImplementation is a processMay require re-thinking, revising long-used practices with regard to monitoringMay require changes in tools, process, systems, procedures, staffing patterns, fiscal and program management and reportingThe monitoring standards are the basis for a conversation and the design/redesign of monitoring systems
15NMS April 2013 Updates Item Location Change Source Tracking Charges (Provider or Client)FAQ #60 and #62ClarificationLegislationRent as Administrative CostFAQ #55DMHAP/DSHAP Program letter: July 17, Administrative CostsAuditsFAQ #57 and #58Clarification, new standardDMHAP/DSHAP Program letter: September 20, 2012 –AuditsSite Visit ExemptionFAQ #23DMHAP/DSHAP Program letter: October 4, 2012 Site Visit ExemptionEligibility DeterminationFAQ #34New standardPolicy Clarification Notice (PCN) 13-02Limitation on Charges (previously cap on charges)Through outTerminology UpdateLegislative languageSchedule of Charges (previously Sliding Fee Scale)Division Names (DMHAP/DSHAP)HAB Reorganization
16Technical Assistance Work with your project officer Consultant, Peer to Peer, HAB staffCooperative AgreementsTarget Center Resources (tools, samples, AGM presentations)Please send copies of monitoring tools to PO’s to share with other granteesIndividualized conference callsNational webinars/conference calls
17Imposition of Charges and Application of Sliding Fee Scale) The RW Legislation does not mention a “sliding fee scale” which is the standard term for describing the discount applied to charges of clients receiving care under Public Health Service Act programs.
18Assessment and Schedule of Charges under Ryan White Outline of this sessionA few definitions for clarityLegislative Requirements Regarding FeesBasics of RW Charges for Services/FeesEligibility ProcessFederal Poverty LevelSliding Fee Scale RequirementsNominal FeesAnnual Limitation on ChargesHow to ImplementHow to MonitorWhen tasked with discussing the Ryan White Fee Scale, its difficult to discuss by itself as a stand alone item. So in reality this presentation covers the Imposition and Assessment of Charges under Ryan White Part B. So we will discuss eligibility, discounts, nominal fees and limitation or caps on charges, we will also cover how to implement and monitor these issues.
19A Few Important TermsCosts are the accrued expenditures incurred by the grantee/subgrantee during a given period requiring the provision of funds for: (1) goods and other tangible property received; (2) services performed by employees, contractors, subgrantees, subcontractors, and other payees.Charges are the imposition of fees upon payers for the delivery of billable servicesPayments are the collection of fees from payers that are applied to cover some aspect of costs of billable services
20Charges for ServicesBillable services are those for which there is a payerCharges are the fees applied to billable servicesPayers can include Medicare, Medicaid, insurance companies and clients.Payments are the collection of fees from payers that are applied to cover some aspect of the costs of billable servicesCharge Master/Schedule of Charges is a comprehensive listing of prices for billable services and/or proceduresThe Ryan White legislation speaks about both charges and payments. Cost is covered in OMB Costs Principles and Grants Policy. They are distinctly different. One example I use often in describing this is what my primary care doctor charges versus the payment the insurance company makes. Often in this scenario, there are two payers, me as the first payer and the insurance company.
21Legislative Requirements Regarding Charges/Fees RW Schedule of Charges (Sliding Fee Scale) Requirements have a historical connection to Public Health Service Act Section 330 -Health Center Programs such as:Community health centersFederally Qualified Health Centers and Look-AlikesMigrant Health CentersHealth Care for the HomelessThere are some similarities but our sliding fee scale is different and the presentation covers this later
22Legislative Requirements Regarding Charges/Fees Section 330 Programs and RW Programs are required to have:Schedule of fees for provision of serviceFees consistent with locally prevailing ratesFees designed to cover reasonable costsA schedule of discounts applied to feesA discount system based on patient’s ability to payNo patient denied care due to inability to payA system to waive or reduce fees to assure care receivedPursue payment from third party sources as applicableSchedule of fees is also called a charge master, Fees that are reasonable and necessary, discount of charges based on ability to pay is the sliding fee scale and no patient is denied care due to an inability to pay, POLR
23Assessment of Client Charges Conflicts with Ryan White Sliding Fee Scale (SFS) RequirementsCommunity Health Center SFS Regulations –a. allow for a minimum charge to persons with incomes below 100% of poverty.b. do not allow for a SFS discount for persons with incomes above 200% of poverty.In these cases at intake and eligibility its important to clarify which program the client is eligible for and being enrolled in and comply with its requirements.NOTE: BPHC is currently revising its guidance to grantees on sliding fee scales, client charges and discounts. When this information is available, DSHAP will make sure the information is shared with grantees on a future webinar.
24Basics of Ryan White Client Charges/Fees Eligibility ProcessFederal Poverty Level (FPL) used to determine ability to pay fees/chargesFPL is based on family size and 100% of PovertyNominal Fee for clients above 100% FPLAnnual Limitation on Charges (Cap on Charges)Note: Designated free-clinics are exempt and can receive a waiverSection D of the Part B Fiscal Monitoring Standards: Imposition and Assessment of Client Charges
25Basics of RW Client Charges/Fees – Eligibility Procedures The eligibility process is central to determination of how to apply the sliding fee scale (determination of the discount on charges)Eligibility Policies and Procedures that:Meet Ryan White Part B requirements (HIV status, residency, income, and recertification every six months)Define household and/or individualDetail whether net or gross income will be used as part of the income determinationIf using Modified Adjusted Gross Income (MAGI) Grantees can decide what expenses to deductSpecify documentation required for proof of income/family SizeSpecify process for application of discount pending documentation, retroactively or at the time of service.Note: Grantees/Subgrantees can decide whether they want to apply the discount pending documentation, at the time of service or retroactively.
26Basics of RW Client Charges/Fees Imposition of Charges U.S. Poverty GuidelinesPublished Annually in the Federal RegisterHealth and Human Services Posts them on the Web
27Federal Poverty Guidelines-2013 Apply the FPL and Group Patients by Poverty LevelEstablish discount using a sliding fees scale developed by the grantee/subcontractor.
28An example of a sliding fee scale and the imposition of a nominal charge. The fees are in dollars. The assessment of charges is at the discretion of the grantee including imposing a nominal fee. Clients with incomes above the official poverty level must be charged for the service.
29Annual Limitation on Charges At or below 100% of FPL – 0%100% - 200% of Poverty –No more than 5% of gross annual income200% - 300% of Poverty –No more than 7% of gross annual income>300% of Poverty –No more than 10% of gross annual incomeIt is not the responsibility of the grantee to track annual client charges from multiple providers, but it is the providers responsibility to track charges at the respective subgrantee agency. Clients are responsible for saving receipts and bills to document payments for services.
30Annual Limitation on Charges Some examples of client charges for care services that may count towards the annual cap on client charges include:Enrollment FeesDeductiblesCo-paymentsPayments to other providers for careHealth Insurance PremiumsCo-insuranceOther cost sharingAgain, it’s the client’s responsibility to track these across the system not the provider although some billing systems can do this. It is not a requirement that all of them do. Section D of the Part B Fiscal Monitoring Standards: Imposition and Assessment of Client Charges
31Basics of Imposition and Assessment of Charges How to Implement Process for Imposing ChargesDevelop a sliding fee scale policy that correlates with your eligibility process, includes discount policy, nominal charges and caps on chargesDevelop discount mechanisms within the billing systemDevelop patient education materials and notices to be posted in client areasImplement staff training and acknowledge it may be a cultural shift from either free or no discounted service models
32Basics of Imposition and Assessment of Charges How to monitor what Sub-grantees must have in place:Eligibility process and policy that define household and incomeProof of Income and Family Size in client filesDocumented evidence of the use of FPL in determining ability to payCharge Master for billable servicesDiscounted fee schedulePublicly posted signs indicating nominal fees including that clients cannot be refused service due to inability to payBe Medicaid certified if providing Medicaid billable servicesContracts with third party providersSystem for charging payers including Medicaid if providing Medicaid billable servicesDocumented policy of not refusing service due to inability to payProcess for collecting from payers especially third party payersProof of the use of program income to support HIV programSome subgrantees do refer clients to collection agencies in order to obtain payment. The Ryan White policy is silent on this issue it only speaks to the fact that clients cannot be refused service due to inability to pay.