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).
The Ryan White eligibility determination processes contain a collection of information on multiple criteria:
- HIV status
- Income (set as a percentage of federal poverty guidelines)
- Residency, and eligibility/enrollment in other health insurance programs
The Eligibility Determination processes are being enhanced via online systems that interface with insurance Marketplace systems established under the Affordable Care Act.
Webinars and Training
- ACE TA CenterFour-part webinar series covered Medicare, Medicaid, and Medicare-Medicaid dual eligibility for Ryan White HIV/AIDS Program (RWHAP) clients.
- HRSA HIV/AIDS Bureau (HAB)
Webinars on HRSA HIV/AIDS Bureau (HAB) policy notices and program letters for Ryan White HIV/AIDS Program recipients.
Tools and Job Aids
- HRSA HIV/AIDS Bureau (HAB), NASTAD
Application and companion document on how to apply for many (but not all) pharmaceutical assistance program (PAP) offered by pharmaceutical companies.
- ACE TA Center
Overview of Medicare eligibility and coverage for RWHAP clients and other people with HIV.
- Indianapolis TGA
Tools used for quality and program monitoring by a Part A program.
Reports and Best Practices
Tools to assist ADAPs with benefits management activities to help clients obtain and maintain access to private and public insurance.
- NASTADToolkit for HRSA RWHAP Part B and ADAP recipients to guide design of systems and processes for eligibility determination and recertification.