Ryan White is the payer of last resort. Always.
Ryan White providers and grantees are expected to help clients review eligibility and enroll in appropriate health insurance coverage (Medicaid, Marketplace plans, etc.)
- HRSA expects grantees to "vigorously pursue" enrollment in insurance for their clients.
- Ryan White grantees and planning councils should reconsider their priorities and allocations to include support for ACA-related outreach and enrollment activities.
- Outreach education, enrollment and benefits counseling can be provided under several Ryan White service categories: medical case management, early intervention services, care outreach, non-medical case management, health education and referral for health care and support services. More details from HRSA can be found here and here.
Ryan White will continue to offer "coverage completion" and "wrap around services" for Medicaid eligible consumers.
- Includes those currently eligible (covered) and those who will become eligible through the expansion of Medicaid eligibility in some states.
- Ryan White funds can cover services not covered or partially covered by third-party payers (Medicaid, private insurance, etc.). This means services, not money. If a provider can bill a third party for a service, then that is the reimbursement for that service. Ryan White cannot be billed for the same service. If the client's coverage has limits on the number of visits/units or specific activities, then Ryan White funds can pay for the services/activities not covered (the underinsured). The amount of third-party reimbursement does not affect "payer of last resort" requirements.
- Medicaid should be back-billed for eligible services. Any reimbursement received from Medicaid for services previously paid for Ryan White should be applied to HIV programming.
Clarifications about Ryan White client certification and re-certification requirements.
- Ryan White clients must be certified for eligibility for Ryan White services, with re-certification no less than every 6 months.
- Criteria for certification include low income as defined by the grantee and HIV+ status.
- Information required for certification process include: residency, HIV status, income, and insurance. HIV status does not need to re-confirmed after initial certification. Once a year a client can be re-certified without producing documented proof of income, residence, insurance status. However, any changes in status should be documented.
- Grantees should make an effort to align certification processes with Medicaid eligibility re-certification processes to reduce burden on clients and providers.
- More info on HRSA and CMS collaboration can be found here.
- More info on Ryan White client eligibility determination can be found in HRSA policy clarification 13-03