• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: 737-255-4300

    Email the HIV/STD Program

    Email HIV, STD, Hepatitis C, and TB data requests to the Program – This email can be used to request data and statistics on HIV, STDs, Hepatitis C, and TB 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, please contact your local HIV services organization.

Universal Standards

Standards

Universal Standards version (PDF)

The Universal Standards listed below are applicable to all service categories funded under the Ryan White Part B Program for direct care service providers. These Universal Standards are taken directly from the HRSA Standards listed in the Part B HIV/AIDS Bureau (HAB) Universal National Monitoring Standards and expanded to include DSHS program requirements for all Ryan White Part B and State Service sub-recipients. HRSA/HAB “expects recipients to monitor fiscal and programmatic compliance with all contracts and other agreements for HIV services in the State/Territory” and to report on “ongoing progress” of implementation of the National Monitoring Standards (NMS). [1]

Note: The Uniform Guidance, HHS Grants Policy Statement has not changed since January 1, 2007; Policy Clarification Notices, Program Letters, and the Notice of Grant Award are the Ryan White Part B grants management regulation and policy documents. [2]

 

Section A: Access to Care

NOTE: Recipients receiving Federal financial assistance take steps to ensure that people with limited English proficiency can meaningfully access health and social services. See EO 13166, August 11, 2000; FY 2017 NOA Standard Terms #9. Providers will ensure clients have access to the language line to ensure people can meaningfully understand their treatment plans and care goals.

HRSA/DSHS STANDARD

1. Structured and ongoing efforts to obtain input from clients in the design and delivery of services

PERFORMANCE MEASURE/METHOD

  1. Documentation of Consumer Advisory Board and public meetings – minutes, and/or
  2. Documentation of existence and appropriateness of a suggestion box or other client input mechanism, and/or
  3. Documentation of content, use, and confidentiality of a client satisfaction survey or focus groups conducted at least annually

SUB-RECIPIENT RESPONSIBILITY

  1. Maintain file of materials documenting Consumer Advisory Board (CAB) membership and meetings, including minutes and/or;
  2. Maintain visible suggestion box or other client input mechanism and/or;
  3. Regularly implement client satisfaction survey tool, focus groups, and/or public meetings, with analysis and use of results documented.

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section A.1 [3]; Program National Monitoring Standards (NMS), Section H.1a and H.1b; FY 2017 Part B Funding Opportunity Announcement (FOA), pp. 10-11; Part B Manual revised in 2015, p. 77; DSHS POPS 13.2.
  • Public Health Service (PHS) Act, 42 U.S.C. sections 2602(b)(6), 2605 (a)(7)(B), 2617 (b)(5), 2617 (b)(6), 2617(b)(7)(A), 2616(c)(4).

HRSA/DSHS STANDARD

2. Provision of services regardless of an individual’s ability to pay for the service

PERFORMANCE MEASURE/METHOD

Sub-recipients billing and collection policies and procedures do not:

  • Deny services for non-payment
  • Deny payment for inability to produce income documentation
  • Require full payment prior to service
  • Include any other procedure that denies services for non-payment

SUB-RECIPIENT RESPONSIBILITY

  1. Have billing, collection, co-pay, and sliding fee policies that do not act as a barrier to providing services regardless of the client’s ability to pay
  2. Maintain file of individuals refused services with reasons for refusal specified; include in file any complaints from clients, with documentation of compliant review and decision reached

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section A.2; Program Part B NMS, Section H.2b.
  • PHS Act sections 2605(a)(7)(A)(i), and 2617(b)(7)(B)(i)
  • DSHS Policy AA-5018 Section F.

HRSA/DSHS STANDARD

3. Provision of services regardless of the current or past health condition of the individual to be served

PERFORMANCE MEASURE/METHOD

Documentation of eligibility and clinical policies to ensure that they do not:

  • Permit denial of services due to pre-existing conditions
  • Permit denial of services due to non-HIV-related conditions (primary care)
  • Provide any other barrier to care due to a person’s past or present health condition

SUB-RECIPIENT RESPONSIBILITY

  1. Maintain files of eligibility and clinical policies
  2. Maintain file of individuals refused services

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section A.3; Program Part B NMS, Section H.2b
  • PHS Act sections 2605(a)(7)(A) and 2617(b)(7((B)(i)
  • DSHS Policy AA-5018

HRSA/DSHS STANDARD

4. Provision of services in a setting accessible to low-income individuals with HIV disease

PERFORMANCE MEASURE/METHOD

  1. A facility that is handicapped accessible, accessible by public transportation
  2. Policies and procedures that provide, by referral or vouchers, transportation if facility is not accessible to public transportation
  3. No policies that may act as a barrier to care for low-income individuals

SUB-RECIPIENT RESPONSIBILITY

  1. Comply with Americans with Disabilities Act (ADA) requirements
  2. Ensure that the facility is accessible by public transportation or provide for transportation assistance

LIMITATIONS

NO direct cash payments to clients can be made for transportation needs.

SOURCE CITATION

  • Universal National Monitoring Standards, Section A.4; Program Part B NMS, Section H.2c
  • PHS Act sections 2605(a)(7)(B), 2617(b)(7)(B)(ii), 2616(c)(4)

HRSA/DSHS STANDARD

5. Efforts to inform low income individuals of the availability of HIV-related services and how to access them

PERFORMANCE MEASURE/METHOD

Availability of informational materials about sub-recipient's services and eligibility requirements such as:

  • Newsletters
  • Brochures
  • Posters
  • Community Bulletins
  • Any other types of promotional materials

SUB-RECIPIENT RESPONSIBILITY

Maintain file documenting sub-recipient's activities for the promotion of HIV services to low-income individuals, including copies of HIV program materials promoting services and explaining eligibility requirements

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section A.5; Program Part B NMS, Section H.2d
  • PHS Act sections 2605(a)(7)(C), 2617(b)(7)(B)(iii), 2616(c)(3)

Section B: Eligibility Determination

HRSA/DSHS STANDARD

1. Eligibility determination and reassessment of clients to determine eligibility as specified by the jurisdiction (in this case State) or AIDS Drug Assistance Program (ADAP):

  • Eligibility determination of clients to determine eligibility for Ryan White services within a predetermined timeframe
  • Reassessments of clients every 6 months to determine continued eligibility

PERFORMANCE MEASURE/METHOD

  1. Documentation of eligibility required in client records, with copies of documents (e.g., proof of HIV status, proof of residence, proof of income eligibility based on the income limit established by the State, ADAP, or local area, proof of insurance, uninsured or underinsured), using approved documentation as required by the State
  2. Eligibility and Determination Enrollment forms for other third party payors such as Medicaid and Medicare
  3. Eligibility policy and procedures on file
  4. Documentation that all staff involved in eligibility determination has participated in required training
  5. Sub-recipient client data reports are consistent with eligibility requirements specified by funder
  6. Documentation of reassessment of client’s eligibility status every six months
  7. Training provided by the sub-recipient/ contractor to ensure understanding of the policy and procedures

SUB-RECIPIENT RESPONSIBILITY

  1. Initial Eligibility Determination & once a year/12 month period recertification documentation requirements:
    • HIV diagnosis (at initial determination)
    • Proof of residence
    • Low income (Not more than 500% of FPL)
    • Uninsured or underinsured status (insurance verification as proof)
    • Determination of eligibility and enrollment in other third party insurance programs including Medicaid and Medicare
    • For underinsured, proof this service is not covered by other third party insurance programs including Medicaid and Medicare
    • Proof of compliance with eligibility determination as defined by the State or ADAP
  2. Recertification (minimum of every six months) documentation requirements:
    • Proof of residence
    • Low income documentation (not more than 500% FPL)
    • Uninsured or underinsured status (insurance verification as proof)
    • Determination of eligibility and enrollment in other third party insurance programs including Medicaid and Medicare
    • Note: At six-month recertification one of the following is acceptable: full application and documentation, self-attestation of no change or self-attestation of change with documentation.
  3. Proof of compliance with eligibility determination as defined by the State or ADAP
  4. Document that the process and timelines for establishing initial client eligibility, assessment, and recertification takes place at a minimum of every six months
  5. Document that all staff involved in eligibility determination have participated in required training
  6. Sub-recipient client data reports are consistent with eligibility requirements specified by funder, which demonstrates eligible clients are receiving allowable services

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section B.1; FY 2017 FOA, pp. 15 & 43; Notice of Grant Award (NGA) dated 3/11/2016 for award #2 X07HA00054-26-00, Program Specific Terms (PST) #5; FY 2017 FOA Standard Terms #14 NMS: Frequently Asked Questions (FAQ), #35, 38-44.
  • PHS Act sections 2616(b)(12), 2617(b)(7)(B)(iv)
  • PCN #13-01 (rev 12/13/13), 13-02, 13-03 (rev 9/13/13), 16-02 (revised)
  • DSHS Policy HIV/STD 220.001

HRSA/DSHS STANDARD

2. Ensure military veterans with Department of Veterans Affairs (VA) benefits are deemed eligible for Ryan White services

PERFORMANCE MEASURE/METHOD

Documentation that eligibility determination policies and procedures do not consider VA health benefits as the veteran’s primary insurance and deny access to Ryan White services citing “payor of last resort.”

SUB-RECIPIENT RESPONSIBILITY

Ensure that policies and procedures classify veterans receiving VA health benefits as uninsured, thus exempting these veterans from the “payor of last resort” requirement.

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section B.2; NMS FAQ #43; PCN 16-01
  • DSHS HIV/STD Policy 220.001

HRSA/DSHS STANDARD

3. Payer of Last Resort: Ensure that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients.

PERFORMANCE MEASURE/METHOD

Ensure that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients. 

SUB-RECIPIENT RESPONSIBILITY

Agencies have written policies and/or protocols for ensuring RWHAP Part B and State Services funds are used as PoLR for eligible services and eligible clients. 

LIMITATIONS

N/A

SOURCE CITATION

  • Part B Program National Monitoring Standards, Section H.4c; FY 2017 FOA, pp. 14, 15, 43; PCN 07-01; PCN 16-01; PCN 16-02; Part B Manual, p. 63
  • PHS Act section 2617(b)(7)(F)
  • DSHS Policy 590.001 & 220.001

Section C: Anti-Kickback Statute

HRSA/DSHS STANDARD

1. Demonstrated structured and ongoing efforts to avoid fraud, waste and abuse (mismanagement) in any federally funded program

PERFORMANCE MEASURE/METHOD

  1. Employee Code of Ethics including:
    • Conflict of Interest
    • Prohibition on use of property, information or position without approval or to advance personal interest
    • Fair dealing – engaged in fair and open competition
    • Confidentiality
    • Protection and use of company assets
    • Compliance with laws, rules, and regulations
    • Timely and truthful disclosure of significant accounting deficiencies
    • Timely and truthful disclosure of non-compliance

SUB-RECIPIENT RESPONSIBILITY

  1. Maintain and review file documentation of:
    • Corporate Compliance Plan (required by CMS if providing Medicare-or Medicaid-reimbursable services)
    • Personnel Policies
    • Code of Ethics or Standards of Conduct
    • Bylaws and Board policies
    • File documentations of any employee or Board Member violation of the Code of Ethics or Standards of Conduct
    • Documentation of any complaint of violation of the Code of Ethics or Standards of Conduct and its resolution
  2. For not-for-profit contractors/sub-recipient organizations, ensure documentation of sub-recipient Bylaws, Board Code of Ethics, and business conduct practices

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section C.1; NGA, Standard Terms (ST) #7
  • PHS Act 42 U.S.C. 1320-7b(b)
  • AA Core Competencies

HRSA/DSHS STANDARD

2. Prohibition of employees (as individuals or entities), from soliciting or receiving payment in kind or cash for the purchase, lease, ordering, or recommending the purchase, lease, or ordering, of any goods, facility services, or items.

PERFORMANCE MEASURE/METHOD

Any documentation required by the Compliance Plan or employee conduct standards that prohibits employees from receiving payments in kind or cash from suppliers and contractors of goods or services

SUB-RECIPIENT RESPONSIBILITY

  1. Have adequate policies and procedures to discourage soliciting cash or in-kind payments for:
    • Awarding contracts
    • Referring clients
    • Purchasing goods or services, and/or
    • Submitting fraudulent billings
  2. Have employee policies that discourage:
    • The hiring of persons who have a criminal record relating to or are currently being investigated for Medicaid/Medicare fraud
    • Large signing bonuses

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section C.2; NGA, ST #7
  • PHS Act 42 U.S.C. 1320-7b(b)
  • AA Core Competencies

Section D: Recipient Accountability

HRSA/DSHS STANDARD

1. Proper stewardship of all grant funds including compliance with programmatic requirements

PERFORMANCE MEASURE/METHOD

Policies, procedures, and contracts that require:

  • Timely submission of detailed fiscal reports by funding source, with expenses allocated by service category
  • Timely submission of programmatic reports
  • Documentation of method used to track unobligated balances and carryover funds
  • A documented reallocation process
  • Report of total number of funded sub-recipients/contractors
  • A-133 or single audit
  • Auditor management letter

SUB-RECIPIENT RESPONSIBILITY

Meet contracted programmatic and fiscal requirements, including:

  • Provide financial reports that specify expenditures by service category and use of Ryan White funds as specified by Recipient
  • Develop financial and sub-recipient Policies and Procedures Manual that meet federal and Ryan White program requirements
  • Closely monitor any sub-recipients/contractor
  • Commission an independent audit; for those meeting thresholds, an audit that meet A-133 requirements
  • Respond to audit requests initiated by Recipient

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section D.1; NGA, PST #4; Part B Manual, p. 11; 45 CFR 75 - §75.300 (on compliance with regulations); 45 CFR 75 - §75.301 (Performance Measurement)
  • AA Core Competencies

HRSA/DSHS STANDARD

2. Recipient accountability for the expenditure of funds it shares with lead agencies (usually health departments), sub-recipients

PERFORMANCE MEASURE/METHOD

  1. A copy of each contract
  2. Fiscal, program site visit reports and action plans
  3. Audit reports
  4. Documented reports that track funds by formula, supplemental, service categories
  5. Documented reports that track unobligated balance and carryover funds
  6. Documented reallocation process
  7. Report of total number of funded sub-recipients/contractors
  8. Sub-recipient A-133 or single audit conducted annually and made available to the State every year an audit is conducted. (Note: State requires submission to the System Agency and Office of Inspector General within 30 calendar days of receipt of the audit reports every year an audit is conducted)*
  9. Auditor management letter

SUB-RECIPIENT RESPONSIBILITY

Establish and implement:

  1. Fiscal and general policies and procedures that include compliance with federal and Ryan White programmatic requirements
  2. Flexible fiscal reporting systems that allow the tracking of unobligated balances and carryover funds and detail service reporting of funding sources
  3. Timely submission of independent audits (A-133 audits if required) to the State
  4. Policies in place the ensure program income is documented per the Notice of Award using the “additive” method.
  5. Program income must be used for the purposes for which the award was made, and may only be used for allowable costs under the award.

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section D.2; FY 2017 FOA, pp. 22-23; Part B Manual, p. 47.
  • *Submission of audit to State: HHSC Uniform Terms and Conditions Section 4.03
  • PCN 15-03
  • Texas Health and Human Services Commission, HHSC Uniform Terms and Conditions-Grant, Version 2.13, Section 2.08 Program Income.

HRSA/DSHS STANDARD

3. Business management systems that meet the requirements of the Office of Management and Budget code of federal regulations, programmatic expectations outlined in the Recipient assurances and the Notice of Grant Award

PERFORMANCE MEASURE/METHOD

  1. Review of sub-recipient contracts
  2. Fiscal and program site visit reports and action plans
  3. Policies and Procedures that outline compliance with federal and Ryan White programmatic requirements
  4. Independent audits
  5. Auditor management letter

SUB-RECIPIENT RESPONSIBILITY

Ensure that the following are in place:

  1. Documented policies and procedures and fiscal /programmatic reports that provide effective control over and accountability for all funds in accordance with federal and Ryan White programmatic requirements

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section D.3; National Part B Fiscal Monitoring Standards, Sections E & K
  • 45 CFR 75
  • 45 CFR 75 - §75.302 (Financial management and standards for financial management systems)

HRSA/DSHS STANDARD

4. Responsibility for activities that are supported under the Ryan White Program as outlined by Office of Management and Budget, Code of Federal Regulations, HHS Grant Policy Statement Program Assurances, and Notice of Grant Award (NOA)

45 CFR 75 - §75.300 (b) The non-Federal entity is responsible for complying with all requirements of the Federal award. For all Federal awards, this includes the provisions of FFATA (FFATA – NOT for Ryan White), which includes requirements on executive compensation, and also requirements implementing the Act for the non-Federal entity at 2 CRF part 25 and 2 CFR part 170. See also statutory requirements for whistleblower protections at 10 U.S.C. 2324 and 2409, and 41 U.S.C. 4304, 4310, and 4712.

PERFORMANCE MEASURE/METHOD

Desk audits of budgets, applications, yearly expenses, programmatic reports; audit reports or on-site review when assessing compliance with fiscal and programmatic requirements

SUB-RECIPIENT RESPONSIBILITY

Ensure fiscal and programmatic policies and procedures are in place that comply with federal and Ryan White program requirements

LIMITATIONS

Activities do NOT support Trafficking Victims

SOURCE CITATION

  • RW Part B Universal National Monitoring Standards, Section D.4; FY 2017 NOA ST #10; Part B Manual, p. 11; DSHS Statement of Work
  • 45 CFR 75
  • 45 CFR 75 - §75.300 (on compliance with regulations)

Section E: Reporting

HRSA/DSHS STANDARD

1. Submission of standard reports as required in circulars as well as program-specific reports as outlined in the Notice of Grant Award

PERFORMANCE MEASURE/METHOD

Records that contain and adequately identify the source of information pertaining to:

  • Federal award revenue, expenses, obligations, unobligated balances, assets, outlays, program income, interest
  • Client level data
  • Aggregate data on services provided; clients served, client demographics and selected financial information

SUB-RECIPIENT RESPONSIBILITY

Ensure:

  1. Submission of timely sub-recipient reports
  2. File documentation or data containing analysis of required reports to determine accuracy and any reconciliation with existing financial or programmatic data. Example: Test program income final FFR with calendar year RDR.
  3. Submission of periodic financial reports that document the expenditure of Ryan White funds, positive and negative spending variances, and how funds have been reallocated to other line-items or service categories

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section E.1, NGA, PST #16 & #17, and Reporting Requirements; National Part B Program Monitoring Standards, Sections I & J; National Fiscal Monitoring Standards, Section K.10; Part B Manual, Section IV
  • 45 CFR 75

Section F: Monitoring

HRSA/DSHS STANDARD

1. Any recipient or sub-recipient or individual receiving federal funding is required to monitor for compliance with federal requirements and programmatic expectations at least annually

PERFORMANCE MEASURE/METHOD

Development and consistent implementation of policies and procedures that establish uniform administrative requirements governing the monitoring of awards

SUB-RECIPIENT RESPONSIBILITY

  1. Participate in and provide all material necessary to carry out monitoring activities at least annually
  2. Monitor any service contractors for compliance with federal and programmatic requirements at least annually

LIMITATIONS

N/A

SOURCE CITATION

  • Universal National Monitoring Standards, Section F.1; FY 2017 FOA p. 23; NGA, PST #6 and PST #22; Part B Manual, Section IV; PCN 16-02
  • 45 CRF 75
  • 45 CFR 75 - §75.351 and 75.352 (Sub-recipient Monitoring and Management)
  • DSHS Statement of Work

HRSA/DSHS STANDARD

2. Monitoring activities expected to include annual site visits of all Provider/Sub-recipients.

Note: 45 CFR 75 - §75.301 “Performance reporting frequency and content should be established to not only allow the HHS awarding agency to understand the recipient progress but also to facilitate identification of promising practices among recipients and build the evidence upon which the HHS awarding agency’s program and performance decisions are made.”

PERFORMANCE MEASURE/METHOD

Review of the following program monitoring documents and actions:

  1. Policies and procedures
  2. Tools, protocols, or methodologies
  3. Reports
  4. Corrective action plans
  5. Progress on meeting goals of corrective action plans

SUB-RECIPIENT RESPONSIBILITY

  1. Establish policies and procedures to ensure compliance with federal and programmatic requirements
  2. Submit auditable reports
  3. Provide the recipient access to financial documentation

LIMITATIONS