Systems to Sustainability TM

HRSA/HAB Site Visits:

Top Findings

Ryan White HIV/AIDS Program

Fiscal Health Series

INTRODUCTION

Sound fiscal management is critical for organizations to improve access

to health care, advance health equity, and build healthy communities.

In an ever-changing healthcare landscape, fiscal management,

including compliance with federal grants, is difficult to achieve. The

Sliding Fee Scales and Caps on Charges aims to strengthen Ryan

White HIV/AIDS Program (RWHAP)-funded organizations’ financial

management systems and compliance with fiscal aspects of the

RWHAP and other federal requirements. The topics covered in this

series are relevant to all RWHAP Parts and geared towards fiscal

administrators and program managers, though collaboration across

the organization is required to implement strong financial management

systems. This publication offers practical, financial management

infrastructure recommendations for nonprofit organizations, health

departments, and health clinics.

1

Site visits are a critical part of ensuring the fiscal compliance and sustainability of Ryan White HIV/AIDS Program (RWHAP) recipients and subrecipients. Despite the misconception of site visits resulting in punitive measures against recipients and/or subrecipients, in reality they offer important technical assistance opportunities during which recipients and subrecipients can strengthen areas of weakness and utilize the extensive knowledge of HRSA staff and consultants to improve the effectiveness and efficiency of organizations in delivering RWHAP services.

This brief consists of four sections to help you get ready for site visits with as little anxiety as possible. The first section, Preparing for a HRSA Site Visit: The Fiscal Module, outlines what you should do before your site visit. The next three sections, present checklists to assess compliance with three of the top site visit findings: Sliding Fee Scales and Caps on Charges, Time and Effort Reporting, and Program Income.

OVERVIEW OF HRSA/HAB SITE VISITS: TOP FINDINGS

2

Review references on legislative and programmatic requirements such as 45 CFR 75 (Uniform Guidance); HRSA/HAB Fiscal Monitoring Standards and Policy Clarification Notices; your Notice of Award, the FOA, and the Ryan White HIV/AIDS Program Site Visit Tool.

Prepare in advance for the pre-site visit conference call. Ask questions on the call and make sure you ask about documents you will need to prepare. If possible, ensure that a key staff person from each of the areas (clinical, fiscal, and administrative) is on the conference call.

Understand what is being assessed during a site visit. Each RWHAP Part (A - F) will be assessed differently.

Ensure all documents on the list are pulled in advance of the visit; determine if documents will be available in hardcopy or electronically.

Complete the Fiscal Module of the Site Visit Tool (if applicable to your RWHAP Part) as a self-assessment far in advance of the site visit to leave time to address any findings that arise. You likely won’t have time to “fix” any findings, but you can start amending any policies or procedures so that the consultants can provide feedback on your progress. Responding proactively to findings is viewed favorably.

All of your policies and procedures need to be documented, not described verbally. If you have a sliding fee scale in your clinic, you’ll need to show documentation, rather than tell the consultants, how it works.

Prepare staff for the visit by discussing expectations, the process, and roles and responsibilities so that the visit goes as smoothly as possible.

Decide subrecipients’ locations to be visited (if applicable).

Determine the location of the work areas for the site visit team.

Request technical assistance to address areas of expected findings or to ensure past findings have been resolved.

Acknowlegements: Juanita Farrow, MBA

TOP 10 RECOMMENDATIONS TO PREPARE FOR SITE VISITS

10

6

3

8

4

9

5

2

7

1

3

Source: HIV/AIDS Bureau, Division of State HIV/AIDS Programs National Monitoring Standards for Ryan White HIV/AIDS Program A Grantees: Fiscal – Part A; HIV/AIDS Bureau, Division of State

HIV/AIDS Programs National Monitoring Standards for RWHAP B Grantees: Fiscal – Part B

Determine the patient’s ability to pay using the updated Federal Poverty Level (FPL) at intake and through recertification every six months. Calculate each client’s out-of-pocket responsibility (nominal fee or discount) and cap on charges per calendar year based on the client’s individual income.

Determine fee discounts for RWHAP clients based on prevailing local rates and clientele’s ability to pay. One method is to mirror Medicaid co-pays.

Ensure RWHAP remains the payer of last resort by billing insurance when it is available and collecting payments based on the discount fee schedule.

Ensure that clients at or below the FPL are not charged for services.

Establish a system for notifying clients about the sliding fee scale.

Notify clients about their responsibility to keep track of charges from other RWHAP organizations.

Track RWHAP client charges at your organization through an accounting or billing system or manually.

Ensure that the billing system is notified when caps on charges are met and that the client is no longer charged.

Document policies, procedures, and charges to patients to comply with RWHAP legislation and requirements. See Fiscal Monitoring Standards for more information.

Ensure your patients know that they will continue to receive RWHAP services regardless of their ability to pay.

10 STEPS TO IMPLEMENT SLIDING FEE SCALES AND CAPS ON CHARGES

10

6

3

8

4

9

5

2

7

1

4

Source: 45 CFR 75.430(i), Standards for Documentation of Personnel Expense under Subpart E Cost Principles.Acknowlegements: Paul Calabrese, Rubino & Company, Chartered

There must be a system of internal controls to verify that records accurately reflect the work performed and that the actual time worked is consistent with the allocations of time and effort included in the Ryan White HIV/AIDS Program budget. There must be a written policy and procedure that allows organizations to review and adjust time and effort to ensure time reported matches actual hours worked.

Every employee should have a job assignment record, or a written description of their duties across federal and non-federal awards. This description should also provide a specific charge code representing each federal award and an estimate of the anticipated number of hours worked in each pay period. This description should be issued to new hires, for new awards, and at the beginning of each fiscal year.

New hires should be trained in proper timesheet preparation and refresher courses should be conducted if an employee does not comply.

Timesheets should be completed daily, or tracked daily until timesheets are submitted, to ensure accuracy.

There must be documentation to support the distribution of an employee’s salary if he/she works on: a. More than one federal award

b. A federal award and a non-federal award

c. An indirect cost activity and direct cost activity

d. Two or more indirect activities which are allocated using different allocation bases

e. An unallowable and a direct or indirect activity such as fundraising and lobbying

Time is computed on an actual hour basis, except for Institutes of Higher Education, which can record percentages of time.

RWHAP is a direct charge award or sub-award that is normally cost reimbursable or may be in the form of units of service. Organizations must track labor cost by service category, and direct or indirect administrative efforts.

Employees’ workload reports can be used to demonstrate Time & Effort. For example, if a provider is 0.2 FTE on a RWHAP grant, then her workload reports should reflect that allocation.

Estimates can only be used in the interim for accounting but do not qualify as support for charges to awards.

Understand the consequences of non-compliance and the implications of the False Claims Act, violations of which can result in criminal, civil, or administrative penalties.

TOP 10 TIPS FOR TIME AND EFFORT REPORTING

10

6

3

8

4

9

5

2

7

1

5

Know what is and isn’t program income. Program income is defined as gross income earned by the non-Federal entity (a recipient or subrecipient) that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance. In the RWHAP, program income could be insurance reimbursements, payments from clients for services, and money earned from 340B pharmacy programs. Rebates and refunds are NOT program income.

Program income must be reinvested in to the RWHAP and may only be used for allowable costs under the award. For example, paying for PrEP or clothing is not allowed under the grant, and is also unallowable for program income. See PCN 16-02 for allowable uses of funds.

The recipient must determine an allocation method to track program income. There is no set formula for allocation – the RWHAP-funded organization needs to be able to document the methodology used.

Subrecipients must follow the same regulations as recipients in using program income in that it can only use it for allowable and allocable costs.

Recipients should not report subrecipients’ program income on their Federal Financial Report (FFR). The recipient is responsible for monitoring the subrecipients’ use of program income to ensure they comply with allowable uses of funds under the grant.

To the extent that it is possible, recipients and subrecipients must use funds from program income, rebates, refunds, contract settlements, audit recoveries, and interest earned on funds before requesting additional cash payments.

Performance periods for Parts A and B are one year, but program income might not be received until the following year. For example, if a service was provided in a grant cycle that ends on June 30th, 2016 (FY16), but program income for that service was not received until July 20th, 2016 (FY17), the program income should be accounted for and used in the year it was received (FY17) and prior to requesting additional cash payments.

Program income can be used in excess of caps established by RWHAP, with exception to salary caps. For example, administrative costs are capped at 10% for recipient, but program income can be used in excess of the 10% cap. This is also true for caps related to clinical quality management and planning and evaluation.

Program income can be used to pay for any medically necessary services that Medicaid does not cover or only partially covers, as well as premiums, co-pays, and any other deductibles otherwise allowable under the RWHAP award.

Program income for the use of Maintenance of Effort (MOE), is discouraged because of how much it can vary from year to year.

Source: HIV/AIDS Bureau Policy Clarification Notice #15-03: Clarifications Regarding the Ryan White HIV/AIDS Program and Program Income

TOP 10 TIPS FOR TRACKING PROGRAM INCOME

10

6

3

8

4

9

5

2

7

1

@HealthHIV

www.Facebook.com/HealthHIV

http://www.YouTube.com/HealthHIV

http://tinyurl.com/HealthHIVLinked

Training@HealthHIV.org

202.232.6749

Systems to Sustainability TM

To Request Technical Assistance or to Participate in Training, Contact:

www.healthhiv.org

Fiscal Health: Systems to Sustainability is an education, training, and technical assistance (TA) program led by HealthHIV that addresses the fiscal sustainability of RWHAP organizations by building their fiscal management capacity. Through this HRSA/HAB-supported program, a diverse and culturally competent team of fiscal management experts designs and implements effective Regional Trainings and

individual TA, which focuses on fiscal requirements and grants management.