• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (512) 533-3000

    E-mail the HIV/STD Program

    E-mail data requests to HIV/STD Program - This email can be used to request data and statistics on HIV, TB, and STDs in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local Health Department.

    For information on HIV testing and services available to Persons Living with HIV and AIDS, please contact your local HIV services organization.

220.001

Eligibility to Receive HIV Services

This policy is being revised. You can see the proposed revisions below.

Eligibility to Receive HIV Services: Proposed Policy (PDF : 803 kB)
Proposed Income Calculation Form (Excel : 21 kB)

print version (PDF : 398 kB)

Policy
Policy Number  220.001
Effective Date  July 7, 2006
Revision Date  September 27, 2016
Subject Matter Expert Manager, HIV Care Services Group
Approval Authority  Manager, HIV/STD Prevention and Care Branch
Signed by  Shelley Lucas, M.P.H.

1.0 Purpose

The purpose is to outline the eligibility criteria for individuals to receive services funded though Ryan White Part B and State Services.

 

2.0 Authority

Texas Health and Safety Code: Chapter 85, §§85.003, 85.013, 85.014 - 85.031; Ryan White Treatment Extension Act 2009; Health Services and Resource Administration (HRSA) Policy Clarification Notice (PCN) #16-02, Replaces Policy #10-02. Policy Clarification Notice (PCN) #13-02.

 

3.0 Policy

Eligibility for an individual to receive assistance under Ryan White Part B and/or State Services will be established to ensure appropriate client access to needed services while adhering to payer of last resort (PoLR) requirements.

 

4.0 Definitions

Administrative Agency (AA) – Entity responsible for ensuring a comprehensive continuum of care exists in their funded areas. This is accomplished through the management, distribution and oversight of federal and state funds and under contractual agreement with the Department of State Health Services (DSHS).

AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV Medication Program (THMP), administered by DSHS’ HIV/STD Prevention and Care Branch.

Applicant – An individual completing the eligibility process.

AIDS Regional Information and Evaluation System (ARIES) – Web-based, client-level software that Ryan White /State Services HIV Providers use to report all Ryan White and State services provided to Ryan White-eligible clients.

Client – An applicant who has been determined to be eligible for services, has successfully completed the eligibility process, and is receiving services.

Contractor – The entity with whom the Department of State Health Services has contracted with to provide services and implement policy.

Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas.

Determination Period – The 30-day period during which an individual undergoes initial eligibility screening and determination.

Eligibility Date – Date the individual submits accurate and complete documentation to the provider. The eligibility expiration date will be six months from the eligibility date.

Federal Poverty Level (FPL) – A measure of income level determined by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2) that is updated periodically in the Federal Register and primarily used to determine eligibility for certain programs and benefits. FPL is the set minimum amount of gross income that an individual or a family needs for food, clothing, transportation, shelter, and other necessities. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines.

Human Immunodeficiency Virus (HIV) – an infection that destroys some types of white blood cells and is transmitted through blood or bodily secretions such as semen and as further defined by the Centers for Disease Control and Prevention (CDC) and in accordance with the Health and Safety Code, §81.101.

HIV confirmatory test – a test that confirms the diagnosis of HIV after a preliminary positive test has been completed.

IV Services – Any social or medical assistance defined in the HIV Services Taxonomy paid for with Ryan White Part B and State Services funded through DSHS.

Medicaid – A joint federal and state health insurance program for some people with limited income and resources.

Medicare – A federal health insurance program for people who are 65 and older, certain younger people with disabilities, or to those who meet other special criteria.

Modified Adjusted Gross Income (MAGI) – A figure used to calculate income eligibility for lower costs in Marketplace Health Plans as well as eligibility for Medicaid, Children’s Health Insurance Plan (CHIP), and Ryan White/State Services funded HIV medical and support services. Generally, modified adjusted gross income is adjusted gross income plus any tax-exempt Social Security, interest, or foreign income an individual may have. MAGI and Mock MAGI worksheets and requirements can be found on the MAGI documents page

Nucleic Acid Amplification Test (NAAT) – A laboratory test that amplifies the HIV RNA and detects viral genes instead of viral antibodies or antigens.

Payor of last resort (PoLR) – Ryan White or State Services funds cannot be used as a payment source for any service that can be paid for or charged to any other billable source. Providers are expected to make reasonable efforts to secure other funding instead of Ryan White or State Services funding whenever possible.

Provider – A local organization, individual clinician, or group of clinicians who provide services to HIV-positive clients.

Re-certification for eligibility – The process of re-screening and determining eligibility for the next six months.

Self-Attestation – A client’s written statement/affirmation of change/no change in income, residency, and/or insurance status. Self-Attestation is to be completed during recertification for program eligibility.

Texas HIV Medication Program (THMP) – Provides medications for the treatment of HIV and its related complications for low-income Texans. The THMP is the official AIDS Drug Assistance Program for the State of Texas. It also operates the Texas HIV State Pharmaceutical Assistance Program, which provides assistance with out-of-pocket costs associated with Medicare Part D prescription drug plans.

Texas Resident – An individual who resides within the geographic boundaries of the state.

Veteran – A former member of the Armed Forces of the United States of America.

Viral Load – A laboratory test that measures the amount of HIV viral copies in a milliliter of blood.

 

5.0 Persons Affected

  • DSHS HIV Care Services staff
  • Administrative Agencies
  • Contractors/Providers
  • Applicants/Clients for HIV services paid for by Ryan White Part B and State Services funds.

 

6.0 Responsibilities

6.1 DSHS HIV Care Services Branch

Ensure that systems are in place to provide care and services to Texans who are eligible to receive these through Ryan White Part B and State Services, and ensure that these funds are used as payment of last resort. Staff will assure that Administrative Agents appropriately monitor eligibility documentation for these payment sources as well as conduct appropriate assessments to determine eligibility for other third party payers using MAGI.

 

6.2 Administrative Agency (AA)

Develop policy for determination of eligibility; use MAGI to determine income; determine how providers will be trained to determine eligibility; and monitor provider billing of third party payer to determine compliance with payer of last resort requirements.

 

6.3 Contractor and Provider

Develop policies and procedures to determine eligibility for services while ensuring Ryan White Part B and State Services funds are used as payment of last resort; develop policies and procedures to ensure that individuals seeking covered services are screened for eligibility using MAGI to participate in other payer sources such as the Marketplace, Medicaid and CHIP. Screening should occur as indicated in this policy. If individuals are determined potentially eligible for other benefits, refer them to the specific programs and assist them in completing the eligibility determination process. When providing emergency assistance to priority populations in crisis (e.g., an individual who is recently released from the criminal justice system who requires assistance in acquiring HIV medications), contractors must refer clients into appropriate program services and assist in obtaining any required eligibility documentation within 30 days of intake. Providers should also ensure the proper documentation of any and all eligibility screening and intake activities in the clients’ respective charts—paper and/or electronic (e.g., ARIES)

 

6.4 Applicant, Client, and Family

provides the required documentation to determine eligibility for services under Ryan White and State Services.

 

7.0 Requirements

7.1 Initial Screening for HIV status and residency

The provider must determine whether an applicant meets the following Ryan White/State Services eligibility criteria:

  • have a diagnosis of HIV infection;
  • be a Texas resident; and
  • provide complete and accurate income documentation

Eligibility for services must be determined at or within 30 days of intake into services. 

 

7.1.1 Documentation of HIV-Infection Status

A key objective in the National HIV/AIDS Strategy is to establish a seamless system to immediately link people to quality care when diagnosed with HIV. To accomplish this vision, all stakeholders (HIV testing staff, eligibility workers, linkage workers, case managers, RW clinical staff, etc.) must work together to reduce administrative and other barriers to clients accessing medical care.

To be eligible for services paid for by Ryan White / State Services, an individual must have a diagnosis of HIV infection. Affected individuals (people not identified with HIV) may be eligible for RW services in limited situations; services for affected individuals must always benefit people living with HIV. For further clarification on providing services to affected individuals please see HRSA Policy Clarification Notice (PCN) #16-02, Eligible Individuals and Allowable Uses of Funds.

There are a number of different ways to document HIV infection. Some examples of acceptable forms of documentation are provided below, however these should not be viewed as a complete list.

Laboratory Documentation

Proof of HIV infection may be found in laboratory test results that bear the client’s name. Some examples include:

  • Positive result from HIV screening test (Multi-Spot, HIV 1/2  Combo Ab/Ag enzyme immunoassay [EIA]);
  • Positive result from an HIV 1 RNA qualitative virologic test such as a HIV 1  Nucleic Acid Amplification Test (NAAT); or
  • Detectable quantity from an HIV 1 RNA quantitative virologic test (e.g. viral load test)

NOTE: HIV testing technology is rapidly changing and standards of HIV confirmation continue to evolve. Providers must stay informed of advances in testing technology, as newer tests may also provide proof of HIV infection.

Other Forms of Documentation

Some examples are:

  • A signed statement from a physician, physician’s assistant, advanced practice nurse, or registered nurse attesting to the HIV-positive status of the person; or
  • A complete THMP Medical Certification Form signed by a physician; or
  • A hospital discharge summary documenting HIV infection of the individual.

Facilitating linkage with an HIV Preliminary Positive result

A preliminary positive is a positive result from an HIV screening test. Although a preliminary positive is not considered proof of HIV status (because it is not a confirmatory test in the current HIV testing algorithm), individuals with such a result are very likely to have HIV infection and would benefit from quick linkage to ongoing care. Having only a preliminary positive result from one HIV test should not be a barrier in linkage to medical care.

The ability to use a preliminary positive test result to facilitate linkage to care does not negate the responsibility of the HIV testing site to conduct confirmatory testing. The receiving medical provider must be informed of the individual’s unconfirmed preliminary positive HIV test result. Once the confirmatory results are received from the lab, HIV testing staff must provide these results to the individual and if a Release of Information is signed, to the HIV care provider. Clinics receiving such individuals may choose to arrange an abbreviated first appointment, during which the individual could receive counseling on HIV infection, orientation to medical care, conduct eligibility screening, and/or begin laboratory work. Note: HIV medical providers may elect to conduct the HIV confirmatory test if a memorandum of understanding (MOU) is signed with the HIV testing agency.

Providers should contact their Administrative Agency with questions about acceptable documentation of HIV infection.

 

7.1.2 Documentation of Texas Residency

To be eligible for services paid for by Ryan White / State Services, an applicant must reside within the geographic boundaries of Texas and:

  • Express intent to remain within the state and not claim residency in any other state or country.

Students

  • Students from another state who are living in Texas to attend school can claim Texas residency based on their student status while they are residing in Texas
  • ADAP Only: Students living out-of-state (living in a state other than Texas), but who claim Texas residency based on their student status must provide a denial from that state’s ADAP in order to be allowed in the Texas ADAP.

Documentation of proof of Texas residency can be determined using one of the following:

  • Valid Texas Driver’s License;
  • Texas State identification card (including identification from criminal justice systems);
  • current voter registration;
  • rent or utility receipts for one month prior to the month of application in the client’s name;
  • a mortgage or rental lease agreement in the client’s name;
  • motor vehicle registration;
  • school records;
  • medical cards or other similar benefit cards;
  • property tax receipt;
  • a letter of identification and verification of residency from a verifiable homeless shelter or community center serving homeless individuals;
  • a statement/attestation with client’s signature declaring that client has no resources for housing or shelter (does not require notarization); or
  • submission of the DSHS-THMP Supporter Statement.

If none of the listed items are available, residence may be verified through:

  • Observance of personal effects and living arrangement (e.g., visit to residence), or statement from landlords, neighbors, or other reliable sources.

Individuals do not lose their Texas residency status because of a temporary absence from the state. For example, a migrant or seasonal worker may leave the state during certain periods of the year but maintain a home in Texas, and return to that home after this temporary absence. This individual will not lose their Texas residency status. 

Providers should contact their Administrative Agency with questions about acceptable documentation of Texas residency.

 

7.1.3 Documentation of Income

To be eligible for services paid for by Ryan White / State Services an applicant must submit documentation of income using the MAGI calculation.

Providers must use DSHS-provided MAGI and Mock MAGI worksheets to calculate an applicant’s income. These worksheets can be found online on the MAGI documents page.

The MAGI Eligibility process consists of three total worksheets:

  1. MAGI worksheet
  2. Mock MAGI worksheet
  3. Six month Self-Attestation form

MAGI Worksheet

The MAGI worksheet is used by tax filers or individuals who receive Social Security Income (SSI), or Social Security Disability Income (SSDI).

In order to complete the MAGI worksheet an individual must have one of the documents outlined below:

  1. Current year Tax Return Transcript - IRS (Preferred)
  2. Social Security Income (SSI) Award Letter
  3. Social Security Disability Income (SSDI) Award Letter

Mock MAGI Worksheet

The Mock MAGI worksheet is used by non-tax filers and members of special populations (homeless, undocumented residents, and recently released from incarceration).

Documents that may be used to complete the Mock MAGI worksheet are outlined below:

  • Verification of Non-Filing - IRS (preferred)
  • Pay stubs for the last 30 days
  • Other income documentation
  • Supporter statement
  • Employer statement
  • Agency letter

*IRS documentation is preferred and usually possible to obtain. A client and provider may opt to use a Mock MAGI worksheet if they are unable to obtain a tax transcript. The client and provider may opt to submit a Mock MAGI worksheet with no Certificate of Non-Filing if they are unable to obtain this documentation from the IRS. The provider must document in the client file if acquiring a tax transcript/Certificate of Non-Filing is burdensome or creates a barrier to care. Please note, required use of the MAGI worksheet vs. Mock MAGI worksheet and mandatory IRS documentation may vary locally; please verify specific requirements with your Administrative Agency.

Both the MAGI and Mock MAGI worksheets are self-calculating, and produce the Federal Poverty Level (FPL) percentage based on both household and individual income. A copy of the worksheet and supporting documentation must be kept in the client record.

Initial Eligibility screening verification flow chart.

Please note that the above graphic represents a household where the client’s income is the sole source of income. Adding spousal income may change the process.

For further clarification on the MAGI process, please reference the MAGI page on the DSHS website.

 

7.1.4 Local Criteria for Eligibility Determination

Administrative Agencies may impose additional criteria to determine eligibility, such as those based on income and county of residence. Additional criteria can be imposed if justified though a needs assessment or planning process that includes public input and comment. Additional eligibility criteria may vary depending on service category. However, further eligibility determination must be applied to all individuals equally, and must not pose an undue hardship on individuals.

 

7.2 Screening Clients for Third Party Payers

Administrative Agencies must ensure that their subcontractors/providers are coordinating benefits and the use of third party reimbursement by:

  • Monitoring how subcontractors/providers determine client eligibility to ensure that Ryan White HIV/AIDS program and State Services funds are the payers of last resort (PoLR); R)
  • Monitoring the documentation that shows clients have been screened for and enrolled in eligible programs prior to the use of Ryan White and State Services funds; and
  • Requiring and monitoring how subcontractors/providers utilize a third party payer verification system.

Providers must screen individuals for ability to pay, as well as access to potential sources of payment for these services. Programs/benefits that must be used first include:

  • private/employer insurance;
  • Medicare (including Part D prescription benefit);
  • County Indigent Health Programs;
  • Patient Assistance Programs (PAP’S);
  • Medicaid;
  • Children’s Health Insurance Programs (CHIP); or
  • other comprehensive healthcare plans.

Documentation of eligibility status must be filed in the client’s primary record(s).

 

7.3 Determination Period

The overarching goal of the Ryan White HIV/AIDS Program is to “quickly link persons with HIV into high quality medical care, consistent with the Early Identification of Individuals with HIV/AIDS as required in the Ryan White HIV/AIDS Program legislation (Sections 2603(b)(2)(a)(i-iii) and 2617(b)(8)(A-E) of the PHS Act) and the National HIV/AIDS Strategy.

  • A 30 day determination period for all Ryan White services can be accessed by clients who are:
    • Newly diagnosed clients within the previous six months;
    • New to the State of Texas/local HSDA and in need of medical services;
    • Engaging in care for the first time after being diagnosed for longer than six months;
    • Returning to medical care after an absence of six months or longer and/or;
    • In need of early intervention services.

As applicants are being linked to services providers should work to complete the eligibility process and collect required documents. The eligibility process and application must be complete within 30 days of program application initiation.

 

7.4 Recertification

The provider will determine and implement a system used to track clients’ status and renew eligibility. While eligibility for services must be determined every six months for active clients, providers should assess changes in eligibility at the time of service. The providers’ policies and procedures must address how clients will be contacted regarding their six-month recertification, and how changes in eligibility will be assessed at the time of service. Consult the table below for guidance on the recertification process and required documentation.

At the six-month client recertification, providers may accept client self-attestations of change/no change in income, residency, and/or insurance status (self-attestations are not acceptable forms of documentation at the annual/12-month certification).

Providers must make every reasonable effort to obtain a signed ‘Self-Attestation’ form. However, recertification is not required to be completed in person. Related communications from Ryan White Providers must be transmitted in a confidential manner. If a client has had a change in income, residency/address, or insurance status, they must submit appropriate supporting documentation.

Self-attestations should be documented in the client’s primary record and updated in ARIES, even if there is no change (the date stamp in ARIES should reflect the most recent recertification date). Supporting documentation must be kept in the client’s primary record.

Recertification of HIV status after the initial eligibility determination is not required.

Recertification Flow Chart

Required Documentation Table
Eligibility Criteria Initial Eligibility Determination & Annual 12 Month Period Recertification Recertification (6-months after annual certification)
HIV status Documentation is ONLY required for initial eligibility determination.
No documentation is required
Income

Supporting documentation is required to complete the MAGI/Mock MAGI process.

Acceptable documentation for the MAGI worksheet includes

  • Tax Return Transcript (Preferred)
  • Social Security Income (SSI) Award Lette
  • Social Security Disability Income (SSDI) Award Letter

Acceptable documentation for the Mock MAGI worksheet (not exhaustive list)

  • Pay stubs for last 30 days
  • Certificate of Non-Filing (Preferred)
  • Bank Statements
  • Supporter Statement
  • Income Verification Form
  • Student Loan Letter

Please note, required use of the MAGI vs. Mock MAGI worksheets and mandatory IRS documentation may vary locally; please verify specific requirements with your Administrative Agency.

Self-attestation of no change is acceptable.

Attestation must be documented in the client’s primary record and date stamped in ARIES.

If there has been a change in income complete the MAGI/Mock MAGI process.

Providers should assess changes in eligibility every time the client comes in to receive a service.

Residency Documentation is required

If address has not changed, self-attestation of no change is acceptable. Attestation must be documented in the client’s primary record and date stamped in ARIES.

If address has changed updated documentation of residency must be placed in the client file.

Providers should assess changes in eligibility every time the client comes in to receive a service.

Insurance/Third Party Payer

Provider must verify if applicant is enrolled in other health coverage and document status in client file. 

Enrollment must be pursued if client is income eligible for Medicaid, CHIP, Health Insurance Marketplace plans, or various other health plans.

If client’s insurance/third party payer status has not changed, self-attestation of no change is acceptable. Attestation must be documented in the client’s primary record and date stamped in ARIES.

Documentation of client’s insurance eligibility status must be filed in the client’s primary record(s).

Providers should assess changes in eligibility every time the client comes in to receive a service.


 

7.5 Client’s Responsibility for Reporting Changes

A client must immediately report any changes that might affect their eligibility to the provider(s). If a client has experienced a change in circumstances related to eligibility, they must submit appropriate documentation of the change to the provider(s) within 30 days of the reported change and ensure the provider(s) receives the documentation. A client must also report any changes at the six (6) month recertification of eligibility. If a client fails to provide appropriate documentation of the change, their services may be delayed until the provider(s) can confirm eligibility.

 

8.0 Revision History

Date Action Section
Revision History
9/27/2016 Policy revised to add definitions; clarify documentation requirements for HIV Infection Status and Texas Residency; clarify Re-certification requirements; add requirement for MAGI for financial eligibility determination; and reflect advances in testing technology. All 
9/25/2014 Converted format (Word to HTML) -
1/15/2013 Policy revised to reflect HRSA issued Policy Clarification Notices relating to Implementation of the Affordable Care Act -
9/27/2012 Policy revised to clarify eligibility as it applies to HRSA’s “recertification” language and to give guidance for additional eligibility -
11/20/2011 Policy language revised to clarify documentation requirements -
6/25/2008 Policy revised to allow for testing technology advances All

 


Last updated April 27, 2018