HRSA Issues Numerous Guidance Letters Offering Patient Assistance

By: Ranier Simons, ADAP Blog Guest Contributor

The clients who qualify for and receive assistance through the Ryan White HIV/AIDS Program (RWHAP) are often representative of vulnerable populations. Providing a comprehensive means of providing HIV medications, healthcare, and related-services requires a whole-person approach. As such, Health Resources & Services Administration (HRSA) continues to evaluate and update its RWHAP endeavors to meet client needs. Systematic barriers exist that all to often challenge RWHAP clients’ ability to receive appropriate and consistent care. Recently, HRSA issued numerous guidance letters addressing those barriers.

HRSA has created patient assistance initiatives to enable a more seamless delivery service system aimed at addressing various socio-economic and systemic structural needs. Two of the program letters HRSA released in June 2024 address services for people living with HIV/AIDS (PLWHA) who have been involved in the criminal justice system, and those who are affected by housing insecurity.

PLWHA, who have been involved with the criminal justice system face barriers to access to care, among many other things. A person having legal involvement is defined as anyone who is engaged at any point along the continuum of the legal system as a defendant, including arrest, incarceration, and community supervision.[1] The HRSA HIV/AIDS Bureau (HAB) released guidance emphasizing how RWHAP funds may be used to support this demographic. RWHAP funds can be used to assist PLWHA who have been incarcerated or who are incarcerated and have an expectation of eligibility for RWHAP services upon release.[1] One effective means of support is assistance with the expungement of criminal records.

Photo Source: ADAP Advocacy | iStock Images

A criminal history is an obstacle to a person obtaining employment, housing, and education and subsequently affects access to healthcare. Expungement of criminal records improves the chances of successful reintegration into the community, reduces stigma, and protects privacy.[2] HRSA recognizes the importance of decreasing disparities to improve health outcomes for PLWHA. The expungement of criminal records facilitates obtaining gainful employment and securing housing, both of which translate into improving healthcare access. HRSA’s guidance informs providers that according to HRSA/HAB Policy Clarification Notice (PCN) #18-02, using RWHAP funds to help pay for expungement falls under the purview of allowable legal services because it is a matter “related to or arising from [an individual’s] HIV.”[1] Stipulations require any RWHAP recipients offering expungement services to research local laws, partner with legal counsel to create policies to determine how the services will be enacted, and ensure they are available to all eligible clients who seek help.[1]

In a related vein, in April 2024, HRSA announced new funding to support healthcare services for people transitioning out of incarceration. It earmarked $51 million to create funding opportunities for HRSA-funded health centers to develop innovative ways to give healthcare services to people in the 90-day period before their incarceration release.[3] Many people who are incarcerated have mental health conditions, substance abuse challenges, and chronic disease conditions such as HIV. The funding will enable HRSA-funded centers to provide care that ensures the continuity of medical services. This population needs case management services to help navigate things such as reinstating insurance eligibility, continuing access to medications and mental health counseling, reducing drug overdose risk, and even addressing housing and food insecurity.[3]

Regarding housing assistance, HRSA also released guidance educating providers, Policy Clarification Notice (PCN) #16-02, on an additional pathway RWHAP funds can be used to assist with housing instability. HRSA listened to clients who explained that statutory stipulations against using RWHAP funds to help pay housing security deposits for clients were a roadblock to helping them access stable and permanent housing.[4] As a result, HRSA/HAB issued guidance explaining that RWHAP funds can be used to pay for housing security deposits only if procedures are in place to ensure the security deposit is returned to the RWHAP service provider and not the RWHAP client.[4] It is not mandatory for RWHAP funds to be used for this purpose. Other funding sources, such as Ending the HIV Epidemic (EHE) funds, income generated from 340B program proceeds, and non-RWHAP grant awards, can also be used to help pay for housing security deposits.[4] This guidance is simply education on the existence of the option if needed.

HRSA has additional endeavors targeting the housing needs of PLWHA in the RWHAP. One of these is the SURE Housing initiative. SURE stands for Supporting Replication of Housing Interventions in the Ryan White HIV/AIDS Program. It is a program funded from 2022 through 2026 through HRSA’s RWHAP Part F Special Projects of National Significance Program.[5] Under this initiative, ten implementation sites are funded to create replicable effective interventions for rapid re-housing and housing stability for PLWHA who fall into one of three categories: those who have been involved with the legal system, those who identify as LGBTQ+, and young adults aged 18-24.[5]

With these guidance letters, HRSA/HAB has demonstrated its commitment to fostering an effective system, offering continuity of care and services for ADAP and RWHAP clients. HRSA continues to evaluate and modify current RWHAP offerings, communicate with recipients to investigate needs of new offerings, and examine how changing policy and legal landscapes affect funding rules and statutes. Housing instability and incarceration continue to complicate the lives of many PLWHA. It is imperative that government funding continues and scales with changing needs to ensure that no one falls through the cracks.

[1] HRSA HIV/AIDS Bureau. (2024, June 6). Ryan White Colleague Letter. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/hrsa-hab-expungement-program-letter.pdf

[2] Hamann, K., Riley, P., Bismuth, C. (2024, January 22).The evolving landscape of sealing and expungement statutes. Retrieved from https://www.americanbar.org/groups/criminal_justice/publications/criminal-justice-magazine/2024/winter/evolving-landscape-sealing-expungement-statutes/

[3] U.S. Department of Health and Human Services. (2024, April 10). Press Release: During Second Chance Month, HRSA Takes Policy Action, Releases First-Ever Funding Opportunity for Health Centers to Support Transitions in Care for People Leaving Incarceration. Retrieved from https://www.hhs.gov/about/news/2024/04/10/health-centers-to-support-transitions-in-care-for-people-leaving-incarceration.html

[4] HRSA HIV/AIDS Bureau. (2024, June 26). Ryan White Colleague Letter. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/hrsa-hab-security-deposit-program-letter.pdf

[5] Target HIV. (2024). SURE Housing Initiative. Retrieved from https://targethiv.org/spns/SUREHousing

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

HRSA Responds to Advocate Calls to Modernize ADAP Recertification

By: Jen Laws, Board Member, ADAP Advocacy Association, and HIV/transgender health advocate

For years, advocates, clients, case managers, and medical providers have all bemoaned the requirement for clients of the Ryan White HIV/AIDS Program (RWHAP), particularly for the State AIDS Drug Assistance Programs (ADAP), to “re-certify” their eligibility for the program every six months. The process was particularly grueling for clients and providers with difficult to manage fax systems, mail, and document gathering to prove income and residency. The initial qualification process, after all, requires a confirmed HIV diagnosis, documentation of living at or below 400% of the federal poverty level (in general – some states allow for up to 500% FPL), and proof of state residence. It is thorough, as it is cumbersome. The ADAP Advocacy Association has urged the Health Resources & Services Administration (HRSA) to improve the client eligibility recertification process.

Generally speaking, clients also have to prove they’ve sought any other assistance available to them, such as Medicaid or Supplemental Nutrition Assistance Programs, as Ryan White is required to be a payer of last resort. In a program document entitled, “Policy Clarification Notice (PCN) 13-02: Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements”, first implemented in 2013 and last updated in 2019, HRSA issued interpretive guidance. It included a particular timeframe for recertification of client eligibility, but no such timeframe is directed or defined in the statutory language of the program. Earlier this year, we published a blog detailing the ways in which HRSA could and should approach modernizing the recertification process in order to ensure recertification was not a barrier to care for low-income people living with HIV/AIDS.

On October 19th, after years of grassroots efforts to update the guidance, HRSA issued a long-awaited update to this policy, posted as “Policy Clarification Notice (PCN) 21-02: Determining Client Eligibility & Payor of Last Resort in the Ryan White HIV/AIDS Program”, accompanied by a “Dear Colleague” letter detailing some of the changes in the updated policy notice. My phone dinged when this posted…repeatedly. Advocates across the country were celebrating the win in what has long been viewed as an arbitrary and unnecessary barrier to care. Among the interpretive changes around recertification the PCN also reaffirms eligibility for Ryan White programs is not determined based on citizenship status, but residency. Some advocates cheered the acknowledgment and others wish to remain a bit quieter as certain political forces would fail to understand the public health value in ensuring a program meant curb the spread of an infectious disease is actually effective. 

The details provided in the PCN about what should replace the six-month recertification process are limited and that may be a concern for advocates as states evaluate what they may do with greater flexibility to ensure eligibility. HRSA notes recipients (most often states, affected urban areas, and community based organizations) and subrecipients should make every effort possible to reduce the administrative burden on clients and program staff, suggesting automated cross-checks may be available for determining income eligibility. The suggestion is strikingly similar to how many Medicaid programs are set up to cross-check state and federal tax reporting to determine income eligibility without requiring additional effort from clients in many situations. Non-reported income or support will, however, need to be documented with case managers according a recipient’s policies and procedures. HRSA cautions the currently available “self-attestation of no change” policy should not be allowed to go indefinitely. But…one could envision longer term, fix-income ADAP clients not necessarily needing to engage with any particular system of income or residency verification, especially as our population continues to age. HRSA specifically encourages recipients to seek ways to reduce the reporting burden for clients and establish systems of determining eligibility renewal that would verify a person’s eligibility “without requesting additional information from the individual.”

The PCN contains another statement of particular note: “RWHAP recipients and subrecipients should not disenroll clients until a formal confirmation has been made that the client is no longer eligible.” This directive, on its face, directly addresses an unfortunately common happenstance when clients faced situational barriers to gathering documentation or arranging logistics for recertification. It is not uncommon for case managers to face challenges when engaging particularly vulnerable clients, especially those facing houselessness. Just because one cannot get ahold of a client for several weeks doesn’t mean they should be booted off a system of support – rather it means that system needs to try harder to meet that client’s needs.

Photo Source: CU Today

In the space between HRSA’s words and the excitement advocates and clients feel, advocates need to be prepared to fight for and defend changes that reduce these administrative burdens on clients. Recipients are often loathe to make big changes or to make many changes with any kind of speed. The PCN was effective immediately upon publication. For advocates in states and localities are on a less than friendly basis with their advising community members, any lack of definition could easily be abused to impose stricter requirements on clients. Nothing in the PCN specifies any particular minimum standard from HRSA, nor is there an outlined process for community members and advocates to engage HRSA should they believe a recipient’s design does not best benefit their community. In this, HRSA should consider these documents may be directed at recipients but recipients and subrecipients are not the only members of the public engaging. Many advocates are intimately familiar with the rules because they’ve experienced the negative impacts of lax oversight and recipients with…other priorities.

Recipients and advocates alike should be prepared to quickly engage in a process of negotiating change that best suits their communities. This may look like a non-uniform program. I heard the concern of one ADAP that clients who need more personalized help may “fall out of care" due to a lack of standard engagement schedule. I suggested to one ADAP that’s unsure of change, starting with a more generous approach to recertification and issuing small pilot studies for particular client-types (i.e., those who need more “hand-holding” to manage applications for assistance but are fine in every other of care) to design a recertification process that fits the needs of their particular communities. The suggestion of a universal assistance portal in states makes a great deal of sense in a modern world. And, as we’ve seen with Covid-19 vaccine roll-outs, an online-only model doesn’t work for everyone. Benefits navigators will still be needed. 

Whatever the approach to considering this monumental and potentially beneficial change, recipients and sub-recipients should actively engage community members more now than ever. Regardless of the obstacles that may arise moving forward, I’d gently remind administrators and my colleagues, “We don’t have problem clients, we clients with problems and it’s our job to help them” (quote attributed to Joey Wynn, former ADAP Advocacy Association board member providing public comment at a Florida Comprehensive Planning Network meeting).

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.