1. HIV/AIDS Bureau Division of State HIV/AIDS Programs (DSHAP)
Ryan White Part B Technical Assistance Webinar
National Monitoring Standards Update and Schedule of Charges
June 11, 2013

2. HAB DSHAP Mission
To provide leadership and support to States/Territories for developing and ensuring access to quality HIV prevention, health care, and support services.

3. Presenters:
Heather Hauck Director, Division of State HIV/AIDS Programs Harold Phillips Deputy Director, Division of State HIV/AIDS Programs

4. Agenda Opening Remarks/ Announcements Heather Hauck
Question and Answer Session 1
National Monitoring Standards Update and Schedule of Charges
Harold Phillips
Questions and Answer Session 2
Closing Remarks

5. Announcements
Heather Hauck, Director Division of State HIV/AIDS Programs HIV/AIDS Bureau

6. Question and Answer Session

7. Division of State HIV AIDS Programs National Monitoring Standards and
Webinar Series
National Monitoring Standards and
Schedule of Charges
June 11, 2013
Harold 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)

8. Presentation Agenda
The Purpose of the National Monitoring Standards (NMS)
The Process of Implementation
Recent Changes/Updates to Standards
Resource Tools for Implementation

9. What are the NMS?
Compilation of all major Ryan White Program documents used for COMPLIANCE, OVERSIGHT & EXPECTATIONS
Designed 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 monitoring
Developed by HRSA/HAB and Expert fiscal and program consultants
Contributions and Involvement:
HAB Legal Council
Government Accountability Office
HRSA Office of Communications
Part A & B grantee workgroups
Dissemination:
Draft in July of 2010
Published April 2011
Updated April 2013

10. Purpose of the NMS
Clarify the oversight expectations of Ryan White Part A & Part B Programs
Design a specific set of minimum expectations for monitoring
Provide a single source for both program and fiscal monitoring
Specify the roles of HRSA and Grantees regarding the monitoring of subgrantees
Address concerns of HRSA, Congress and OIG regarding oversight issues

11. Purpose of the NMS
Designed to aid grantees in meeting minimal expectations for:
Fiscal and Program Management
Monitoring providers/subgrantees
Reporting
Designed to streamline, standardize and improve program efficiency and responsiveness.

12. Purpose of the NMS Compliance & Oversight & Expectations
Ryan White Legislation
Code of Federal Regulations
HHS Grants Policy Manual
HRSA/HAB Policies
Parts A and B Program Guidance
Part A and Part B Manuals (clarification, best practice)
Program Terms and Conditions of Award
OIG/GAO Reports and Recommendations

13. NMS Implementation Process
National Monitoring Standards Packet for Ryan White Part B contains:
Universal Monitoring Standards
Fiscal Monitoring Standards**
Program Monitoring Standards**
Frequently Asked Questions
Each individual monitoring standard
Connected to a source which is cited
Has a grantee and/or sub grantee responsibility
Performance measure/method
Clearly 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.

14. NMS Implementation Process
Grantees are expected to comply with all of the standards
Grantees can develop their own ways to measure compliance
There is flexibility regarding how to implement the monitoring standards
Implementation is a process
May require re-thinking, revising long-used practices with regard to monitoring
May require changes in tools, process, systems, procedures, staffing patterns, fiscal and program management and reporting
The monitoring standards are the basis for a conversation and the design/redesign of monitoring systems

15. NMS April 2013 Updates Item Location Change Source
Tracking Charges (Provider or Client)
FAQ #60 and #62
Clarification
Legislation
Rent as Administrative Cost
FAQ #55
DMHAP/DSHAP Program letter: July 17, Administrative Costs
Audits
FAQ #57 and #58
Clarification, new standard
DMHAP/DSHAP Program letter: September 20, 2012 –Audits
Site Visit Exemption
FAQ #23
DMHAP/DSHAP Program letter: October 4, 2012 Site Visit Exemption
Eligibility Determination
FAQ #34
New standard
Policy Clarification Notice (PCN) 13-02
Limitation on Charges (previously cap on charges)
Through out
Terminology Update
Legislative language
Schedule of Charges (previously Sliding Fee Scale)
Division Names (DMHAP/DSHAP)
HAB Reorganization

16. Technical Assistance Work with your project officer
Consultant, Peer to Peer, HAB staff
Cooperative Agreements
Target Center Resources (tools, samples, AGM presentations)
Please send copies of monitoring tools to PO’s to share with other grantees
Individualized conference calls
National webinars/conference calls

17. Imposition 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.

18. Assessment and Schedule of Charges under Ryan White
Outline of this session
A few definitions for clarity
Legislative Requirements Regarding Fees
Basics of RW Charges for Services/Fees
Eligibility Process
Federal Poverty Level
Sliding Fee Scale Requirements
Nominal Fees
Annual Limitation on Charges
How to Implement
How to Monitor
When 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.

19. A Few Important Terms
Costs 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 services
Payments are the collection of fees from payers that are applied to cover some aspect of costs of billable services

20. Charges for Services
Billable services are those for which there is a payer
Charges are the fees applied to billable services
Payers 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 services
Charge Master/Schedule of Charges is a comprehensive listing of prices for billable services and/or procedures
The 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.

21. Legislative 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 centers
Federally Qualified Health Centers and Look-Alikes
Migrant Health Centers
Health Care for the Homeless
There are some similarities but our sliding fee scale is different and the presentation covers this later

22. Legislative Requirements Regarding Charges/Fees
Section 330 Programs and RW Programs are required to have:
Schedule of fees for provision of service
Fees consistent with locally prevailing rates
Fees designed to cover reasonable costs
A schedule of discounts applied to fees
A discount system based on patient’s ability to pay
No patient denied care due to inability to pay
A system to waive or reduce fees to assure care received
Pursue payment from third party sources as applicable
Schedule 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

23. Assessment of Client Charges
Conflicts with Ryan White Sliding Fee Scale (SFS) Requirements
Community 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.

24. Basics of Ryan White Client Charges/Fees
Eligibility Process
Federal Poverty Level (FPL) used to determine ability to pay fees/charges
FPL is based on family size and 100% of Poverty
Nominal Fee for clients above 100% FPL
Annual Limitation on Charges (Cap on Charges)
Note: Designated free-clinics are exempt and can receive a waiver
Section D of the Part B Fiscal Monitoring Standards: Imposition and Assessment of Client Charges

25. Basics 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 individual
Detail whether net or gross income will be used as part of the income determination
If using Modified Adjusted Gross Income (MAGI) Grantees can decide what expenses to deduct
Specify documentation required for proof of income/family Size
Specify 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.

26. Basics of RW Client Charges/Fees Imposition of Charges
U.S. Poverty Guidelines
Published Annually in the Federal Register
Health and Human Services Posts them on the Web

27. Federal Poverty Guidelines-2013
Apply the FPL and Group Patients by Poverty Level
Establish discount using a sliding fees scale developed by the grantee/subcontractor.

28. An 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.

29. Annual Limitation on Charges
At or below 100% of FPL – 0%
100% - 200% of Poverty –
No more than 5% of gross annual income
200% - 300% of Poverty –
No more than 7% of gross annual income
>300% of Poverty –
No more than 10% of gross annual income
It 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.

30. Annual Limitation on Charges
Some examples of client charges for care services that may count towards the annual cap on client charges include:
Enrollment Fees
Deductibles
Co-payments
Payments to other providers for care
Health Insurance Premiums
Co-insurance
Other cost sharing
Again, 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

31. Basics of Imposition and Assessment of Charges
How to Implement Process for Imposing Charges
Develop a sliding fee scale policy that correlates with your eligibility process, includes discount policy, nominal charges and caps on charges
Develop discount mechanisms within the billing system
Develop patient education materials and notices to be posted in client areas
Implement staff training and acknowledge it may be a cultural shift from either free or no discounted service models

32. Basics of Imposition and Assessment of Charges
How to monitor what Sub-grantees must have in place:
Eligibility process and policy that define household and income
Proof of Income and Family Size in client files
Documented evidence of the use of FPL in determining ability to pay
Charge Master for billable services
Discounted fee schedule
Publicly posted signs indicating nominal fees including that clients cannot be refused service due to inability to pay
Be Medicaid certified if providing Medicaid billable services
Contracts with third party providers
System for charging payers including Medicaid if providing Medicaid billable services
Documented policy of not refusing service due to inability to pay
Process for collecting from payers especially third party payers
Proof of the use of program income to support HIV program
Some 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.

33. Question and Answer Session

34. Contact Information
Heather Hauck, Director
DSHAP
Harold Phillips, Deputy Director

35. Thank You