2020.01 Quality Assurance for the Texas HIV Medication Program’s Eligibility Processes

1.0 Purpose

This policy guides the processes the Texas HIV Medication Program (THMP) completes to ensure both reliable and accurate eligibility determination processes so participants are not served after the end of the eligibility period. 
 

2.0 Authority

Texas Health and Safety Code §85.003, §§85.013-85.031; Ryan White HIV/AIDS Treatment Extension Act of 2009; Health Resources and Services Administration (HRSA) Policy Clarification Notice (PCN) #21-02; PCN #13-02.
 

3.0 Background

THMP operates in accordance with federal AIDS Drug Assistance Program legislation to assist low-income individuals living with HIV with direct medication assistance for medications on the program formulary or costs associated with eligible health insurance policies including premiums and medication cost-sharing (deductibles, copayments, and coinsurance) and Medicare prescription drug plans. ADAP programs follow the legislation and policy clarification notices (PCNs) released by the Health Resources and Services Administration’s (HRSA’s) HIV/AIDS Bureau (HAB). DSHS Policy 220.001, Eligibility to Receive HIV Services, outlines the eligibility criteria both THMP and Ryan White (RW) Part B Care Services follow to ensure compliance with HRSA requirements. THMP staff complete quality assurance processes to ensure reliable and accurate eligibility determination processes. Additionally, because THMP is a direct service program, the program must also have a system in place which ensures program participants are not served after the eligibility period ends.
 

4.0 Definitions

ADAP Enrollment Worker (AEW) – Worker at local community agencies who helps THMP applicants by assisting with the completion and submission of THMP applications in the Take Charge Texas (TCT) system. AEWs also follow up with participants due for renewal to help ensure continuous eligibility.

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

ADAP Regional Liaisons – Workers employed by AAs who are responsible for oversight of AEWs. ADAP regional liaisons are responsible for maintaining updated network information and acting as a liaison to ensure successful communication among local community agencies, THMP, and the AAs.

AIDS Drug Assistance Program (ADAP) – Provides medications for the treatment of HIV and its related complications for low-income Texans who are uninsured or underinsured.

Annual 12-Month Eligibility Recertification – The process of screening and determining eligibility for a period of months. Assessment includes documentation of Texas residency, income, and proof of insurance (payor). The participant or AEW must submit this documentation to THMP by mail, fax, or through TCT by the last day of the participant’s birth month.

DSHS – Department of Health State Services

DSHS Automation Services – DSHS Automation Mailroom which physically creates mailout packets and mails them on a regular basis for DSHS programs.

Low-Income Subsidy – A federal program administered by the Social Security Administration that assists with the out-of-pocket costs associated with Medicare Part D. 

Full Low-income subsidy (Full-LIS) – The Social Security Administration waives both the deductible and Part D plan premium for applicants with income and assets below specified limits.

Eligibility Period – The time during which a THMP participant is eligible to receive medications through the program. 
Participant – An applicant eligible for services who completed the eligibility process and is receiving services.

Half Birth Month – The Half Birth Month is the month which is six months after the participant’s birth month (e.g., the birth month is January, and the Half Birth Month is July). For purposes of this policy, the end of the Half Birth Month is the last day of the month it falls in, regardless of a participant’s birth date.

Six-Month Self-Attestation – The process of confirming any changes to a participant’s previous eligibility declaration and documentation.

State Pharmacy Assistance Program (SPAP) – A Program, which is operated by THMP, that aids with premiums and out-of-pocket costs associated with qualifying Medicare Part D prescription drug plans for low-income Texans.

Take Charge Texas (TCT) – A web-based system allowing clients, pharmacists, local agency workers, and THMP staff to maintain Ryan White eligibility, demographic, and medication ordering information.

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

Texas HIV Medication Program (THMP) – Provides low-income Texans with medications for the treatment of HIV and its related complications. The THMP is the official ADAP for the State of Texas. It also operates the State Pharmaceutical Assistance Program (SPAP) and the Texas Insurance Assistance Program (TIAP).

Texas Insurance Assistance Program (TIAP) – This program, which is operated by THMP, aids with premiums and out-of-pocket medication costs for low-income Texans with qualified insurance plans.
 

5.0 Policy

THMP ensures the completion of initial eligibility and eligibility renewals. This includes both ensuring that all participants enrolled in the program recertify every twelve months and that participants complete a self-attestation check-in at the six-month mark. Furthermore, THMP ensures that the eligibility determination processes are accurate. The program has aligned recertifications and self-attestations with the participant’s birthdate, as outlined in Policy 220.001, Eligibility to Receive HIV Services. The program disenrolls all ineligible participants. Ineligible participants are those who no longer meet the eligibility criteria or do not renew or complete a self-attestation before the eligibility end date.
 

6.0 Procedures

6.1 Application Completeness Reviews: AEWs and other community agency workers who submit applications to THMP review applications for completeness before submission. Additionally, ADAP regional liaisons monitor a sample of AEW-submitted applications for completeness and timeliness. This provides information needed by ADAP regional liaisons to provide technical assistance and training to AEWs and community agencies having issues with complete and timely application submissions. THMP cannot process incomplete applications. THMP returns incomplete applications and asks the applicant to resubmit a completed one.

6.2 Secondary Reviews: THMP completes a secondary review for all applications denied based on income ineligibility and when THMP staff suspect fraud. Applications denied due to residency or payer of last resort issues are subject to secondary review unless a THMP regional coordinator or team lead completes them.

6.3 Mentoring: Management assigns a mentor to THMP eligibility staff in training who are ready to begin processing applications. During mentoring, the mentor reviews 100% of the trainee’s eligibility determinations and provides further training as needed. Management releases the trainee from mentoring when the trainee’s eligibility determination processes are reliable and valid.

6.4 Renewal Request and Tracking: Every month, data analysts generate a mailing list of all participants who are due for recertification or self-attestation. The THMP data system, TCT populates due dates for recertification and self-attestation. TCT alerts program staff when specific enrollees are due for renewal and are at the end of their eligibility period. These due dates are no later than the last day of the participant’s birth month for the annual 12-month recertification and no later than the last day of the participant’s Half Birth Month for submitting the self-attestation. THMP coordinates with DSHS Automation Services to send reminder letters and applications to these participants by the 15th of the month before their due date. THMP may extend due dates in appropriate situations as part of an emergency response.

Every month, the THMP data system automatically identifies and places all participants who are past the end of the eligibility period on a medication hold. The eligibility period end dates are one month past the end of the enrollee’s birth month for recertification and one month past the end of the month six months after the birth month for self-attestation. This allows THMP staff one month to process applications received by the due date.

6.5 Quality Assurance: Every month, THMP staff review enrollment data provided in a report for quality assurance. This report allows staff to identify records missing the following criteria:

• The participant was not mailed a recertification or self-attestation packet the month before the due date.
• The system did not populate the due date or eligibility period dates appropriately for a recipient who was due for recertification or self-attestation.
• The system did not place a participant who was no longer eligible for the program on a medication hold.
• A participant deemed eligible for the program is on a medication hold. The system is not allowing medication orders for a participant who should be eligible to receive them.
• A THMP staff member did not extend eligibility or update the application status on the task board when the participant completed the application.
• A THMP staff member extended eligibility for a participant who was not deemed eligible or updated the application status on the task board when the application was not completed.

Every month, THMP staff go into the THMP data system to investigate identified data quality issues. Specifically, staff place medication holds for participants who are active in the system and still receiving medications but are ineligible. Staff also correct errors found in participant records and mail recertification or self-attestation packets to participants who did not receive a recertification or self-attestation packet in error.

6.6 Quarterly Reviews: THMP management conducts quarterly quality assurance checks of applications for THMP services. Management selects a group of 20 total approved and denied applications to review each quarter. After the quarterly review, staff with identified issues in application processing receive training and counseling as needed. If necessary, THMP staff update TCT and correct the eligibility determination. Management conducts additional reviews and corrections of applications completed by staff who have recurring processing errors.
 

7.0 Revision History