Health Insurance Premium Sharing Assistance Service Standards

Approved February 2, 2021

Prepared by

Service Standards and Integrated Care Plan Committee of the
Middlesex-Hunterdon-Somerset HIV Health Services Planning Council

HRSA Service Definition

2
Health Insurance Premium and Cost Sharing Assistance 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, 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.

TGA specific addendum; eligible consumers need to utilize state sponsored ADDP/HIPP programs for
pharmacy benefits and health insurance premiums. Consumers will receive assistance to cover insurance
outpatient medical care co-payments (medical visits). Consumers will receive assistance to cover co-
insurance for medical tests and procedures.
Ryan White HIV/AIDS Program Part recipient must implement a methodology that incorporates
the following requirements:
⮚ RWHAP Part recipients must assess and compare the aggregate cost of paying for the health
coverage option versus paying for the aggregate full cost for medications and other appropriate HIV
outpatient/ambulatory health services, and allocate funding to Health Insurance Premium and Cost
Sharing Assistance only when determined to be cost effective.
⮚ RWHAP Part recipients must ensure that clients are buying health coverage that, at a minimum,
includes at least one drug in each class of core antiretroviral therapeutics from the Department of
Health and Human Services (HHS) treatment guidelines along with the appropriate HIV
outpatient/ambulatory health services

(Clarifications Regarding Use of Ryan White HIV/AIDS Program Funds for Premium and Cost-Sharing Assistance
for Private Health Insurance Policy Clarification Notice (PCN) #13-05 (Revised 10/01/2016) Relates to HAB Policy
#’s 16-02, 2017.)

Staff Service Standards

(Health Insurance Premium Sharing Assistance)

Policy
Number
Activity/IssueMinimum Acceptable Threshold of Service

Accountability Mechanism
1.1Staff HiringAll staff will have the necessary skills and experience determined by:
*Written application
*Resume
*References
*Personal interview

Application, resume, and communication with personal references are documented in personnel files.
1.2Staff QualificationsAll staff have a diploma, certificate or license (if appropriate) or experience documented in personnel file100% of staff possesses a diploma, certificate or license (if appropriate) or experience documented in personnel file
1.2(a)Staff Qualifications
Peer Navigator

A member of the peer community living with HIV/AIDS with a high school diploma or GED, plus two years of social service experience. Peer must demonstrate understanding of HIV services and healthcare service navigation.
100% of staff possesses a diploma/GED with the required experience documented in personnel file

1.3Staff Job DescriptionsAll staff will be given a written job description. The job description includes definition of health insurance premium & cost sharing assistance services.
100% of staff have job description documented in personnel file.



1.4Staff TrainingAll staff are trained and knowledgeable on:
*HIV/AIDS and the affected community including disease process, co-morbidities and psychosocial effects of the disease.
*Cultural sensitivity.
*Entitlement programs, benefits to clients, and community resources/support services
*Client confidentiality, client rights, agency grievance procedures



100% of personnel files document training.

1.5Staff Continuing EducationAll staff have the opportunity to take advantage of continuing education training that is available and appropriate.

Staff attend at least one in-service or specialized training a year on topics related to their position.
100% of personnel files document training.

1.6Staff SupervisionAll supervisors are knowledgeable about RW HIV health insurance premium & cost sharing assistance services and procedures including fiscal and program

All staff will receive (at minimum) one hour supervision per week to develop skills
100% of supervisors are knowledgeable about the Ryan White program.




Supervision is documented in personnel file

1.6(a)Staff Supervision
Peer Navigator

All peer navigators will receive (at minimum) one hour supervision per week to include patient case conference, peer navigator job performance, and skill development.



Supervision is documented in personnel file.

1.7Policies and ProceduresSigned form is documented in the personnel file.

100% of staff agree to follow agency policies and procedures.
1.8Staff EvaluationStaff evaluations are documented in personnel files.100% of staff are evaluated on their performance annually.



1.9DocumentationAll staff will keep written documents of contact with clients in accordance with RW data collection procedures.
100% of all contacts are documented in client files.

Client Service Standards

(Health Insurance Premium Sharing Assistance)

Policy
Number
Activity/IssueMinimum Acceptable Threshold of Service

Accountability Mechanism
2.1Client EligibilityIn order to be eligible for services, individuals must meet the following:
*HIV positive
*Residing or receiving services in the Middlesex, Somerset, Hunterdon TGA
*Income no greater than 500% of the Federal Poverty Level.
*To receive premium cost-sharing reductions, individuals must receive a premium tax credit and enroll in one of the Affordable Care Act plans, ADDP and HIPP.
90% of clients have documentation of HIV positive status, residence, and income.

2.2Client AssessmentConduct an evaluation and assessment to determine the needs

The assessment will identify:
*Review of all other potential sources of assistance
*Copay cost
*Client income and expenses
90% of client files include an assessment to determine needs

2.3ReassessmentThe client’s eligibility for co-payment assistance will be reviewed at least once every six months.
90% of client files have documentation of copayment assistance review.

2.4Coordination of CarePatients receiving this service will be informed of other resources.90% of client files have documentation of assessment.
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