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Health Insurance Premium and Cost Sharing Assistance

Service Standard

Health Insurance Premium and Cost Sharing Assistance Service Standard print version

Texas Department of State Health Services, HIV Care Services Group – HIV/STD Program | Texas DSHS

Subcategories Service Units
Dental Co-Insurance Per payment
Dental Co-Payment Per payment
Dental Deductible Per payment
Dental Premium Per month
Health Insurance Premium and Cost-Sharing Assistance Per payment
Medical Co-Insurance Per payment
Medical Co-Payment Per payment
Medical Deductible Per payment
Medical Premium Per month
Pharmacy Co-Payment Per prescription

Health Resources and Services Administration (HRSA) Description

Health Insurance Premium and Cost Sharing Assistance (HIA) provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. For purposes of this service category, health insurance also includes standalone dental insurance. The service provision consists of the following:

  • Paying health insurance premiums to provide comprehensive HIV Outpatient/Ambulatory Health Services (OAHS), and pharmacy benefits that provide a full range of HIV medications for eligible clients; and/or 
  • Paying standalone dental insurance premiums to provide comprehensive oral health care services for eligible clients; and/or
  • Paying cost sharing on behalf of the client.

To use HRSA Ryan White HIV/AIDS Program (RWHAP) funds for health insurance premium and cost-sharing assistance (not standalone dental insurance assistance), a HRSA RWHAP recipient must implement a methodology that incorporates the following requirements:

  • Clients obtain health care coverage that at a minimum, includes at least one U.S. Food and Drug Administration (FDA) approved medicine in each drug class of core antiretroviral medicines outlined in the U.S. Department of Health and Human Services Clinical Guidelines for the Treatment of HIV, as well as appropriate HIV Outpatient/Ambulatory Health Services; and 
  • The cost of paying for the health care coverage (including all other sources of premium and cost-sharing assistance) is cost-effective in the aggregate versus paying for the full cost of medications and other appropriate HIV OAHS.

To use HRSA RWHAP funds for standalone dental insurance premium assistance, a HRSA RWHAP Part recipient must implement a methodology that incorporates the following requirement: 

  • HRSA RWHAP Part recipients must assess and compare the aggregate cost of paying for the standalone dental insurance option versus paying for the full cost of HIV oral health care services to ensure that purchasing standalone dental insurance is cost-effective in the aggregate and allocate funding to HIA only when determined to be cost-effective.

Program Guidance

Traditionally, RWHAP Parts funding supports health insurance premiums and cost-sharing assistance. The following DSHS policies and standards and HRSA Policy Clarification Notices (PCNs) provide additional clarification for allowable uses of this service category: 

Limitations

HIA cannot be in the form of direct cash payments to clients.

HIA funds may not be used for any of the following:

  • Costs associated with liability risk pools
  • Costs associated with Social Security
  • Fines or tax obligations incurred by clients for not maintaining health insurance coverage required by the Affordable Care Act (ACA)
  • Out-of-pocket payments for inpatient hospitalizations and emergency department care
  • Insurance plans that offer only catastrophic coverage or supplemental insurance that assists only with hospitalization

Agencies may only use HIA for Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage if a client is not eligible for other coverage that meets the minimum required standards at a cost-effective price.

Services

HIA includes out-of-pocket costs such as premium payments, co-payments, coinsurance, and deductibles. Please refer to Texas Department of State Health Services (DSHS) Policy 260.002 (Health Insurance Assistance) for further clarification and guidance.

Agencies must determine that the cost of insurance plans is lower than the cost of providing health services through grant-supported direct delivery (“cost-effective”), including costs for participation in the Texas AIDS Drug Assistance Program (ADAP). Please refer to Texas Department of State Health Services (DSHS) Policy 270.001 (Calculation of Estimated Expenditures on Covered Clinical Services) for further clarification and guidance. Additionally, DSHS provides an annual cost-effective analysis as an attachment to this policy.

RWHAP-funded agencies may extend HIA for job or employer-related health insurance coverage and plans on the individual and group market, including plans available through the federal Health Insurance Marketplace (Marketplace). Agencies may also use HIA funds towards premiums and out-of-pocket payments on Medicare, Medicaid, and supplemental insurance policies if the primary purpose of the supplemental policy is to assist with HIV-related outpatient care.

Agencies may use HIA funds to pay for Medicare Part B (outpatient ambulatory health services) premiums and cost sharing but must also pay for the Medicare Part D (medication) premiums and cost sharing. Subrecipients may also use HIA funds to pay for Medicare Part C premiums and cost sharing assistance when the plan covers both outpatient ambulatory health services and at least one medication in each drug class of core antiretrovirals. If the Medicare Part C plan does not cover at least one medication in each drug class of core antiretrovirals, agencies must also pay for Medicare Part D premiums and cost sharing to meet the RWHAP requirement for health care coverage. Agencies may not use HIA funds to pay premiums for Medicare Part D alone.

RWHAP-funded agencies may use HIA funds for providing funds to contribute to a client’s Medicare Part D true out-of-pocket (TrOOP) costs, as well as certain tax liabilities. 

Universal Standards

Service providers for Health Insurance Premium and Cost-Sharing Assistance must follow HRSA and DSHS Universal Standards 1-52 and 79-83.

Service Standards and Measures

The following standards and measures are guides to improving healthcare outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard Measure

Health Insurance Plans: The agency must ensure that clients are buying health coverage that, at a minimum, includes at least one drug in each class of core anti-retro- viral treatment (ART) from the HHS treatment guidelines along with Outpatient Ambulatory Health Services (OAHS) and oral health care that meet the requirements of the ACA law for essential health benefits. This must be documented in the client’s primary record.

1. Percentage of clients with documentation of health care coverage that includes at least one drug in each class of core ART from HHS treatment guidelines, along with OAHS and oral health care services that meet the requirements of the ACA law for essential health benefits.

Co-payments, Premiums, Deductibles, and Co-insurance: Eligible clients with job or employer-based insurance coverage, qualified health plans (QHPs), or Medicaid plans can receive assistance to offset any cost-sharing these programs may impose. Agencies must educate clients on the cost and their responsibilities to maintaining medical adherence. 
 
Agencies must educate clients on reasonable expectations of eligible plan coverage and what HIA can assist with to ensure healthcare coverage is maintained. 

Agencies will ensure payments are made directly to the health or dental insurance vendor within 5 business days of an approved request.

2. Percentage of clients with documentation of education provided regarding reasonable expectations of healthcare coverage assistance available through HIA. 

3. Percentage of clients with documentation that insurance payments were made to the vendor within 5 business days of the approved request.

Premium Tax Credits Education: Agencies must document enrollment in a Marketplace QHP for clients that are between 100-400% of the FPL, without access to minimum essential coverage. 

Staff must provide education to the client regarding tax credits and the requirement to file income tax returns. Education must include  the importance of reconciling any advanced premium tax credit (APTC) well before the IRS tax filing deadline. Staff should document all education in the client’s primary record.

Cost-Sharing Reduction Education: Agencies must enroll clients who are eligible for cost-sharing reductions in a Silver Marketplace plan for these clients to receive assistance with out-of-pocket payments. Staff must provide education to eligible clients regarding cost-sharing reductions.

4. Percentage of clients with documentation of education regarding premium tax credits, as applicable.
 

5. Percentage of clients with documentation of education regarding cost-sharing reductions, as applicable.

Prescription Eyewear: When HIA funds are used to cover co-pays for prescription eyewear, agencies must keep documentation from the client’s medical provider stating that the eye condition is related to the client’s HIV or vision correction is necessary to support HIV treatment.

6. Percentage of clients receiving assistance for prescription eyewear with documentation from the client’s medical provider that vision services are related to HIV or necessary to support HIV treatment.

Medical Visits: Health insurance premium and cost sharing assistance should enable adherence to HIV-related medical or dental care. Documentation in the client’s chart should show attendance of HIV-related medical or dental appointments. 

For clients who use HIA for medical care outside of the RW system, HIA providers are required to maintain documentation of client’s attendance at primary medical care visits during the previous 12 months.

7. For clients with applicable data in TCT or other data system used at the agency’s location, percentage of clients who had at least one medical visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between medical visits. (HRSA HAB measure) 
 

8. For clients who use HIA for medical care outside of the RW system, percentage of clients with documentation of client’s adherence to primary medical care (e.g., proof of provider visits, insurance explanation of benefits, or provider bill or invoice) during the previous 12 months.

References

Division of Metropolitan HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part A Recipients. Health Resources and Services Administration, June 2022.

Division of State HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part B Recipients. Health Resources and Services Administration, June 2022.

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Clinical Info (HIV.gov), Department of Health and Human Services, September 2022. Accessed November 1, 2022.

Ryan White HIV/AIDS Program. Policy Clarification Notice 14-01: Clarifications Regarding the Ryan White HIV/AIDS Program and Reconciliation of Premium Tax Credits under the Affordable Care Act. Health Resources and Services Administration, 3 April 2015.

Texas Department of State Health Services. “260.002 Health Insurance Assistance.” Www.dshs.texas.gov, 2 Nov. 2015, dshs.texas.gov/hivstd/policy/policies/260-002. Accessed 7 Feb. 2023.

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