Eligibility determination is a process of collecting information from an individual in order to provide access to appropriate sources of health insurance, services, and other benefits. Such determinations take place at initial intake but also at periodic intervals (recertification) to verify any changes in eligibility status. Ryan White HIV/AIDS Program eligibility determination and enrollment processes help ensure:
- Alignment of individuals with appropriate services and benefits under public and private health insurance and other service programs (e.g., substance abuse treatment, housing, social services).
- Coordination of benefits to maximize coverage while avoiding inappropriate coverage and payments.
- Compliance with program requirements (e.g., income eligibility, health status eligibility, Ryan White payer of last resort).
Ryan White eligibility determination processes entail collection of information on multiple criteria, most notably: HIV status, income (set as a percentage of federal poverty guidelines), residency, and eligibility/enrollment in other health insurance programs. Notably, eligibility determination processes are being enhanced via online systems that interface with insurance Marketplace systems established under the Affordable Care Act.
Webinars and Training
HRSA HIV/AIDS Bureau (HAB)May 2019
The Imposition of Charges requirement is a term used to describe all activities, policies, and procedures related to assessing RWHAP patient charges as outlined in legislation.
ACE TA CenterJuly 2017
The Marketplace open enrollment period for 2018 plans runs from November 1 to December 15, 2017. This webinar will review what your organization can do to help clients be prepared for open enrollment.
Overview of Part B/ADAP eligibility, enrollment, and recertification practices.
Webcast review of HRSA's insurance purchasing policy, the definition of MAGI, considerations for ADAPs, and a spotlight on Illinois ADAP.
Tools and Job Aids
HRSA HIV/AIDS Bureau (HAB), NASTADJanuary 2019
Application and companion document on how to apply for any pharmaceutical assistance program (PAP) offered by pharmaceutical companies.
Decision tree for providers to illustrate and clarify the myriad treatment coverage options available to people living with HIV and HCV, including ADAP.
Indianapolis TGA, MCHDJuly 2011
Tools used for quality and program monitoring by a Part A program.
Reports and Best Practices
Robust set of resources for Ryan White HIV/AIDS Program Part B programs and ADAPs to assist in their benefits management work.