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Ryan White Services Division

Infectious Disease Bureau

Provider Manual

FY 2018

Ryan White HIV/AIDS

Treatment Extension Act

Part A

Ryan White HIV/AIDS Treatment Extension Act Part A Boston Eligible Metropolitan Area

Provider Manual Fiscal Year 2018 Edition March 1, 2018 - February 28, 2019

R y a n W h i t e S e r v i c e s D i v i s i o n I n f e c t i o u s D i s e a s e B u r e a u

B o s t o n P u b l i c H e a l t h C o m m i s s i o n

1 0 1 0 M a s s a c h u s e t t s A v e n u e , 2 n d F l o o r B o s t o n , M A 0 2 1 1 8

( 6 1 7 ) 5 3 4 - 4 5 5 9 ( p ) | ( 6 1 7 ) 5 3 4 - 2 4 8 0 ( f )

w w w . b p h c . o r g

Map of the Boston Eligible Metropolitan Area

INTRODUCTION From the Director PROGRAM OVERVIEW………………………………………………………………………..……………9 Program Rules (FY18) .................................................................................................................................................................... 11 Program Reporting Overview ...................................................................................................................................................... 13 Submission Dates ............................................................................................................................................................................ 14 Quarterly Report Instructions ...................................................................................................................................................... 15 Sample Program Narrative .................................................................................................................................................................... 16

Adding a New Client in e2Boston ............................................................................................................................................... 20 e2Boston - Client Utilization Form ............................................................................................................................................. 26 Sample Unit-rate Client Utilization Data, Fiscal Backup ...................................................................................................................... 28

Adding Services and Subservices to a Client Record ................................................................................................................. 29 Service and Subservice Definitions................................................................................................................................................ 30 AIDS Drug Assistance Program ........................................................................................................................................................... 30 Food Bank/Home-Delivered Meals ....................................................................................................................................................... 30 Medical Nutrition Therapy ..................................................................................................................................................................... 30 Housing .................................................................................................................................................................................................. 31 Medical and Non-Medical Case Management ......................................................................................................................................... 32 Medical Transportation .......................................................................................................................................................................... 33 Oral Health Care ................................................................................................................................................................................... 33 Psychosocial Support ............................................................................................................................................................................... 33 Substance Abuse —Residential .............................................................................................................................................................. 34 Outcome Measurement Reports ............................................................................................................................................................ 35

Adding Outcomes to a Client Record .......................................................................................................................................... 37 Ryan White HIV/AIDS RSR Reporting .................................................................................................................................... 40

FISCAL OVERVIEW .............................................................................................................................. 41 Fiscal Reporting Rules (FY18) ...................................................................................................................................................... 42 Sample Invoices ....................................................................................................................................................................................... 48

Budget Terms ................................................................................................................................................................................... 51 Sample Budgets ....................................................................................................................................................................................... 52 Budget Revision Guidance ............................................................................................................................................................ 55 Sample Budget Revisions ........................................................................................................................................................................ 56

MONITORING OVERVIEW ................................................................................................................ 59 Monitoring Visits ............................................................................................................................................................................ 60 Policy Maintenance ......................................................................................................................................................................... 62 Record Maintenance Guide ........................................................................................................................................................... 64

POLICIES AND PROCEDURES .......................................................................................................... 66 Payer of Last Resort Policy ...................................................................................................................................................................... 67 Federal Monitoring Standards ................................................................................................................................................................... 68 Sliding Fee Scale Policy for Ryan White Services ................................................................................................................................. 73 Client Eligibility for Ryan White Services ............................................................................................................................................... 76 Authorization to Obtain/Release Information ..................................................................................................................................... 84 Agency Incident Report Procedures ....................................................................................................................................................... 86 Contract Transition Policy ....................................................................................................................................................................... 88 Standards of Care ........................................................................................................................................................................................ 89 HRSA Policy Clarifications .................................................................................................................................................................... 106

GRANTEE ADMINISTRATION INFORMATION .......................................................................... 125 Staff Contact List FY 2018 .........................................................................................................................................................126 Internet Resources ........................................................................................................................................................................127 Agency Websites ..........................................................................................................................................................................128

Table of Contents

Introduction

Welcome to FY 2018 (Year 28) of the Ryan White Part A Program. This is the 9th year under the Ryan White HIV/

AIDS Treatment Extension Act of 2009 and the 28th year of Part A funding for the Boston Eligible Metropolitan Ar-

ea (EMA).

First, I would like to thank you for your commitment to serving over 5,000 people living with HIV across 10 counties

in Massachusetts and New Hampshire. The diverse array of services that all of you deliver ensure that individuals in

greatest need of support are able to obtain and maintain access to health care. Primarily, programs such as yours con-

tinue to provide an avenue for folks to obtain viral suppression, which is a key component to living a full, productive

life.

As we adapt each year to political and epidemiological changes, BPHC remains committed to administering “payer-of-

last-resort” Part A funds through programs such as yours. This grant will continue to support activities that address

unmet needs and fill unnecessary gaps in services. In doing so, our office is available to provide guidance.

We have put together this Provider Manual to provide all the information, tools, and instructions needed to meet our

agencies’ contractual requirements. This manual covers all federal and BPHC program and fiscal policies, and contains

instructions for completing all program, data, and fiscal reporting.

Whether you are a newly funded agency or one that has been funded for many years, it is important to thoroughly

review all sections of the manual. Policies and procedures are updated each year, and it is important that all subrecipi-

ents operate with the same up-to-date information. Please share this manual will all of your staff members associated

with Part A funding, including those responsible for administering the program, completing program reports, entering

and submitting program data, maintaining client files, and producing and submitting invoices. Questions about its

contents can be directed back to BPHC staff.

We will continue to work together to ensure that the system of care of PLWH adapts to the needs of the community.

Our shared goal is that PLWH have coordinated access to medical care and health-related support services. We look

forward to another year of partnership and collaboration between BPHC and HIV service subrecipients.

Thank you for your hard work, dedication, and service to people living with HIV.

Dennis Brophy

Director, Ryan White Services Division

FY 2018 Ryan White Provider Manual | 9

Program Overview

Program Rules (FY18) ................................................................................................................................................. 11 Program Reporting Overview ................................................................................................................................... 13 Submission Dates ......................................................................................................................................................... 14 Quarterly Report Instructions .................................................................................................................................. 15 Sample Program Narrative ........................................................................................................................................ 16 Adding a New Client in e2Boston ............................................................................................................................ 20 e2Boston - Client Utilization Form ......................................................................................................................... 26 Sample Unit-rate Client Utilization Data, Fiscal Backup ........................................................................................... 28 Adding Services and Subservices to a Client Record ............................................................................................. 29 Service and Subservice Definitions ............................................................................................................................. 30 AIDS Drug Assistance Program ............................................................................................................................... 30 Food Bank/Home-Delivered Meals ........................................................................................................................... 30 Medical Nutrition Therapy ......................................................................................................................................... 30 Housing ..................................................................................................................................................................... 31 Medical and Non-Medical Case Management ............................................................................................................. 32 Medical Transportation .............................................................................................................................................. 33 Oral Health Care ...................................................................................................................................................... 33 Psychosocial Support ................................................................................................................................................... 33 Substance Abuse —Residential .................................................................................................................................. 34 Outcome Measurement Reports ............................................................................................................................... 35 Adding Outcomes to a Client Record ...................................................................................................................... 37 Ryan White HIV/AIDS RSR Reporting .................................................................................................................. 40

10 |FY 2018 Ryan White Provider Manual


Program Rules FY 2018

Reporting 1. Reporting will be considered a deliverable under this agreement for purposes of determining fulfill-ment of the Subrecipient’s obligations. Failure to produce timely and adequate reports may jeopardize the Subrecipient’s funding during the current award period, as well as its eligibility or consideration for fund-ing in subsequent years, and will result in a delay in payment.

2. The Subrecipient must submit monthly statistical reports and narrative quarterly reports. Statistical re-ports must include, at a minimum, the submission of (1) Client Information: including a unique client code, client demographics, exposure category, diagnostic information, housing status, and insurance sta-tus, and (2) Client Utilization Data: including units of service delivered, dates of service, and number of units. Such submissions must be made via BPHC’s e2Boston System. Quarterly reports must include a description of the progress made and efforts undertaken to meet goals and objectives for each activity or service funded, including summary of services provided and those served (Program Utilization and Client Demographics), any problems, obstacles or barriers to meeting such goals and objectives, and any actions taken or to be taken to resolve such problems, obstacles, or barriers. Quarterly reports must include up-dates on personnel changes for Part A staff and a description of any program spending issues during the reporting period. The Boston Public Health Commission may request additional information at any time.

3. All quarterly reports must contain information that is concise and provides sufficient detail to allow evaluation of funded efforts. All tables included in the Quarterly Report template must be completed and narrative descriptions provided, where appropriate. The Subrecipient must include a description of the implementation and progress on any Plans of Corrective Action submitted to the Boston Public Health Commission. Furthermore, while funding through other sources that complement Part A funded activities may be cited, the application of Part A funds must be made explicit and documented separately in reports. The Boston Public Health Commission may provide specific formats for submitting reports, which the Subrecipient are required to follow. The Subrecipient must be required to adhere to new reporting re-quirements in submitting their quarterly reports subsequent to that date. 4. Quarterly reports must be submitted within fifteen (15) days after the end of the quarter. If applicable, annual reports must be submitted within fifteen (15) days of the close of the reporting period. All reports must be submitted to the Boston Public Health Commission.

5. Programs funded with unit-rate contracts must submit a combined fiscal and data report within fifteen (15) days after the end of each month, and a quarterly narrative report within fifteen (15) days of the close of each quarter.

6. Client level outcome measures have been developed for all service categories. Subrecipients must sub-mit outcomes data throughout the year through e2boston, according to the Client Clock Model.

7. All Subrecipients will be expected to complete the Ryan White Ryan White Services Report (RSR) each calendar year. Additional information will be provided prior to submission.

8. All Subrecipients will be expected to comply with the requirements detailed in the Standards of Care for Ryan White Services.


Program Performance The Boston Public Health Commission reserves the right to suspend, reduce, or terminate the Subrecipient’s contract if it determines the Subrecipient has failed to make substantial progress on its goals and objectives, that such failure is unreasonable, and the Subrecipient does not demonstrate an adequate strategy to address obstacles to that progress. The Subrecipient’s program performance will be assessed through; review of the Subrecipient’s program utiliza-tion, spending and reporting; evaluation of compliance regarding program and fiscal reporting requirements, and client file maintenance in relation to HRSA-mandated Part A site visits; and the Subrecipient’s demonstrated ef-forts to retain and maintain clients. Monitoring The Boston Public Health Commission or other entities on behalf of the Boston Public Health Commission will conduct site visits to test compliance with grant rules and regulations. The Subrecipient will receive no less than one (1) site visit during the period of performance. Site visits include a review of both fiscal and programmatic documentation. Key personnel involved in implementation of the Scope of Services at any and all locations where funded activities occur should be available for site visits, and must make all appropriate records available to BPHC staff.

Additional information may be requested prior to, at, or subsequent to the site visit. The Subrecipient will have a reasonable time to produce such information. The Subrecipient will also receive reasonable notice prior to each site visit. BPHC Site visit dates are communicated up to one year in advance to the Program Manager of the funded agency. While BPHC will attempt to accommodate agencies’ schedules within the assigned month, BPHC reserves the right to visit a funded program at a time of its choosing and without advance notice.

Client Eligibility The Subrecipient will be expected to comply with the Financial Eligibility Policy for Ryan White Services which requires funded subrecipients to screen HIV + clients for income eligibility, based on a threshold of 500% of the Federal Poverty Level (FPL) as determined by the U.S. Department of Health and Human Services (HHS). When applicable the Subrecipient will also adhere to the Ryan White Services Sliding Fee Scale Policies, as indicated by the Boston Public Health Commission (BPHC). In addition, Subrecipients must document client eligibility annually, and review every 6 months for changes to eligibility.


Program Reporting Overview BPHC monitors each program’s progress on meeting its contracted goals and objectives. Quarterly Report submis-sion requirements include: program targets (demographics and service utilization), unmet needs, and corrective plans. Each individually funded program must submit quarterly reports. If your agency is funded for multiple pro-grams (e.g., Medical Case Management, Psychosocial Support, and Housing), you must submit separate quarterly reports for each funded program. Reporting requirements differ for programs with unit-rate budgets and for those with cost reimbursement budgets. Substance Abuse - Residential is currently the only category with a unit-rate budget. Programs in all other service categories, including Minority AIDS Initiative (MAI), have cost reimbursement budgets unless specifically noted. Complete reporting requirements and instructions follow.

Reporting Requirements • Each Quarter, all Programs will submit a report that provides a detailed description of Part A funded activ-

ities during the quarter. (Quarterly Report must sent via email to your BPHC Program Coordinator.) • Each Month, all Programs will submit a fully completed electronic statistical report into the e2Boston Data Sys-

tem for all clients that received services. Unit-Rate Programs

Each Month, programs with unit-rate budgets will submit one signed original copy of combined fiscal and data report consisting of: One (1) copy of Fiscal Invoice AND One (1) copy of Utilization Summary Report. This service utilization data will serve as the data submission and as fiscal backup documentation for units billed. Unit-rate programs may submit utilization forms as a direct print out from the e2Boston data system or create their own spreadsheet. Spreadsheets must include the following: agency name, service category, client code in alpha or-der, unique client identifier, service code, date of service, number of units, unit-rate, and total cost. Programs should not submit duplicate versions of the same data. The one signed original copy of combined fiscal and data report is due within 15 days of the month’s end. Reports should be sent to: • Accounts Payable, Boston Public Health Commission, 1010 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, Or

• [email protected], CC: All Ryan White Fiscal Staff

Non-Compliance Agencies may be held in non-compliance at the end of each month if they do not meet the reporting requirements listed above. This includes non-submission of required information and incorrect or incomplete submission. If submitted reporting is incorrect and/or incomplete, it will be returned to the agency and the agency will be re-quired to submit new corrected information. Agencies are notified of non-compliance in writing. Payment will be held if complete data and quarterly reports are not received when due and/or if fiscal documentation is incom-plete. Non-compliance will be lifted as soon as all submissions are complete. Formal extensions of the deadlines for quarterly reporting are not granted under any circumstance.


FY 2018 Reporting Submission Dates

Submission Reporting Period Due Date

1st Quarterly Report Mar 1 - May 31 June 15, 2018

2nd Quarterly Report June 1 - Aug 31 Sept 15, 2018

3rd Quarterly Report Sept 1 - Nov 30 Dec 15, 2018

4th Quarterly Report Dec 1 - Feb 28 Mar 15, 2019

Unit-rate Programs – Submission of Fiscal Invoice and Client Utilization Data

Mar 1, 2018 - Feb 28, 2019 15 days after each month’s end (April 15, 2018 thru March 15,

2019)

Deadline for

Final Budget Revisions

Mar 1, 2018 - Feb 28, 2019 December 15, 2018

Outcomes Reporting Mar 1, 2018 - Feb 28, 2019

Rolling: Client outcomes must entered into e2boston within 6 months of last

service date.

HRSA RSR

(Client Level Data) Jan 1, 2019—Dec 31, 2019 February 15, 2019


Quarterly Report Instructions Subrecipients are expected to provide a detailed description of recent Part A funded activities in the program’s quarterly report. Subrecipients are required to complete a Quarterly Report for each funded service category. A template will be provided each quarter by your BPHC Program Coordinator. The following sections of the Quarterly Report must be completed to ensure Part A reporting requirements have been met. 1. Client Utilization Provide an update on your progress towards meeting the target utilization goal set in your Scope of Services. To complete the utilization table reference the program’s target utilization goals outlined in the scope, the actual number of units and the percentage completed for the quarter. Should the program not meet the expected percentage goal for the quarter, an explanation must be provided describing why the program was unable to meet the goal. Attach a copy of the client utilization report from e2Boston for the corresponding reporting period. Your Quarterly Report response regarding this section should utilize the data from this report. 2. Client Demographics: Attach a copy of the client demographic reports from e2Boston for the corresponding reporting period. 3. Personnel Provide an update on Part A program personnel, including any staff changes and/or TBD status of any open positions. If Part A funded staff attended any professional training during the quarter, complete the chart and include the date, the name of the training and the staff that attended. 4. Program Spending Provide an update on current program expenditures. To complete the program spending section reference the program budget and total amount billed to date to determine the percentage of funding billed out for the quarter. If there were under billed salary and program expense lines complete the table by including the salary/expense lines and the under billed amounts. Also, provide an explanation and plan for the reallocation of the underbilled dollars. Consult your fiscal staff if you require assistance in completing this section. 5. Service Specific Questions Respond to category specific questions regarding the program’s current efforts in providing services and support, implementing policies, and enacting strategies to ensure Ryan White Part A clients are engaged and retained in HIV care. These questions may differ each quarter, and will be included in the template provided by your BPHC Program Coordinator each quarter. Also, when responding to these questions, you may need to reference the programs client utilization, demographics, and outcomes when appropriate. 6. Other Program Update Provide any program updates such as new initiatives, program or agency expansion, or events the agency would like to highlight. 7. Unmet Need, Problems and Challenges Discuss any problems, obstacles and/or challenges faced internally by the program, how you met them, and how they affected your program. Include actions taken or planned to resolve them. Also, describe any training or technical assistance needs of program. 8. Plan of Corrective Action Describe your program’s progress in addressing the findings received at your last site visit. In answering the following questions, refer to your BPHC-approved Plan of Correction Action.

A sample Medical Case Management Quarterly Report can be found on the following page.

Quarterly Report Instructions


Sample Program Narrative

HELPFUL HINTS

Has there been any changes regarding program contacts such as a new contact , name/title change or new email address? Reference the e2Boston client utilization data to complete the chart and when describing any challenges in meeting the expected goals for the quarter you are reporting on.


HELPFUL HINTS

Have there been any personnel changes within the program such as, new hires, open positions, or vacancies? Include information regarding start and end dates of employment, plans for hiring new staff and any changes in supervisory structure. Are there any current or potential spending issues? Use this section to inform BPHC of these issues and how your program intends on resolving any issues. Consult your fiscal staff if you need assistance in completing this section.


HELPFUL HINTS When responding to service specific questions the answers should provide quantifiable and specific information. When applicable programs should reference the data submitted in their report. Are there updates such as future initiatives, program or agency expansions, or events the agency would like to highlight? Are there challenges that the program encountered in service delivery this quarter? Has your program developed and/or implemented strategies overcome them?


Adding a New Client to e2Boston

Intake Information This entire section highlights the re-quired data elements for a client’s rec-ord. However, we encourage you to fill in as much information as possible, such as Client’s Primary Language and Country of Birth. When you create a client record, you first enter infor-mation into the Client Intake page. This information is used to create a Unique Client Identifier (UCI) and a Client Code. e2Boston also uses this infor-mation to check if the client already exists in your system. Once you verify the client is new, you can move to Cli-ent Demographics.

Client Code/Unique Client Identifier Information

Last 4 Digits of SSN Enter the last 4 digits of the client’s Social Security Number. If this is un-

known, please enter “9999”.

Birth Date Enter the client’s date of birth in mm/dd/yy format.

Mother’s First Name Enter the first name of the client’s mother. If this is unknown, please enter

“XXX”.

Sex at Birth

& Current Gender

Indicate the client’s sex at birth (male or female) and also indicate the cli-

ent’s current gender (male, female, transgender, or unknown/unreported). If

the client’s current gender is “transgender”, please indicate whether the tran-

sition was from male to female, female to male, other, or unknown if the

client declined giving this information.



Demographics All pages in the client record, includ-ing Demographics, use red asterisks to indicate mandatory fields. On any given page, you must fill in all aster-isked fields before you can save the information. A majority of this de-mographic data is required for the Ryan White Services Report (RSR), which you submit to HRSA once a year. Completing data entry now for client race and ethnicity means you don’t need to do it later!

Client Contact Information

Street Address, City, State Enter the client’s street address, city, and state of residence.

Zip Code Enter the client’s 5-digit zip code. Do not enter “99999”. If the client’s housing is

unstable, enter the zip code where the client spends the most time or returns to

regularly and/or can receive messages and be contacted.

Intake and Activity Information

Date client first received services

Enter the date that the client first received HIV services at your agency in mm/dd/yy format.

Referral Source Indicate the way in which the client was initially referred to your agency for HIV ser-vices. If you choose “other”, please specify what the means of referral was.

Activity Status and Reason for Discharge (if inactive)

Indicate whether the client is an active client at your agency. If they are inactive, please indicate the reason for their discharge is known (please select only one and include the date of death in mm/dd/yy format if they are deceased.)

Race, Ethnicity, and Language Information

Client’s Ethnicity Please indicate whether the client is Hispanic or Latino/a or if the client is not Hispanic or Latino/a.

Race (select all that apply) Please select the racial categories that the client identifies as. The “Unknown” category in-cludes Latinos who do not identify with any race).

Ethnic Sub-group If a client is Hispanic or Latino/a, Asian, or Native American, an option will appear to mark

their Ethnic Subgroup. Please fill this out as it is now part of RSR Reporting.

Primary Language Please select the primary language spoken by the client.

Country of Birth Please indicate if the client was born in the United States, in a country with U.S. dependency,

or outside of the United States.



HIV Status This page contains info about the client’s HIV status, as well as orig-inal exposure category. Multiple exposure categories can be report-ed per client. The HIV status should be updat-ed if the client’s status changes, i.e. is diagnosed with AIDS.

HIV Verification

(select one)

Please indicate the client’s current HIV status by selecting one of the available options. If “AIDS, CDC defined” is selected, please provide the year of AIDS diagnosis in yyyy format. Important: HIV verification is required for any HIV positive clients

HIV exposure category (select all that apply)

Please indicate all applicable exposure categories for the client’s HIV status. You may

choose more than one.

Connection to Care

Please indicate whether the client currently has an HIV/AIDS medical provider. Also, please provide the date on which this information was updated.

Housing and Insurance Status This section of the client records contains income information, one of the main components of Ryan White Eligibility. This section must be updated each time a client is reas-sessed for eligibility. Once you have entered the client’s income, income type, and family size, use the “Calculate FPL” button for e2Boston to calculate the client’s FPL for you. This FPL number can be used on the Income Verification sheet so you don’t need to calculate it.

Source of Client Medical Insurance (check all that apply)

Please indicate the client’s source of primary medical insurance. If the client has more than

one source of insurance, select all applicable sources. Also, please indicate the date on

which this information was updated.

Housing Status (select one)

Please indicate the client’s housing status and provide the date on which this information

was updated. If “Permanent housing” is selected, another question will appear asking

whether or not the housing is owned or rented. If it is rented, also indicate whether it is

subsidized.



Medical This page contains information about the client’s medical history. You will need to go through each of the tabs outlined in the image to the right and complete the sec-tions titled, “General, Care Dates, CD4, and Viral Load.” The infor-mation completed in those sec-tions will then show up on the “Main” tab.

General Medical This section is to input data on the client’s first HIV/AIDS medical visit and the most recent visit. Please complete the question under “One-Time Data” on the first medi-cal visit that the client had at their current medical physician’s office. Next, under “General Medical” please put in an entry for the medi-cal visit referred to in the first sec-tion and complete the following questions. Click “save” when com-plete.

One-Time Data: Client’s first HIV/AIDS Medical

Visit

Please record the client’s first HIV/AIDS medical visit at the location which they are

currently receiving medical care. (If based on self-reported data, you may record this date

to the best of the client’s recollection)

General Medical: New Entry |General Medical

Please answer this section of questions based on the client’s previously mentioned HIV/

AIDS medical appointment.

Care Dates In this tab, please list the dates of all of the client’s HIV/Medical Care visit dates during the past calendar year. If they had more than one ap-pointment please list them all to the best of the client’s recollection.

CD4 Please enter the client’s most recent CD4 results with the date that the test was taken. If information is giv-en by self-report, record to the best of the client’s recollection.

Viral Load Enter the client’s most recent vi-ral load results with the date the test was taken. If information is given by self-report, record to the best of the client’s recollection. If the client’s viral load is <75 ppm, please check the box labeled “Viral Load Undetectable.”



Medical History This page contains information about the client’s medical history. You will need to go through each of the tabs outlined in the image to the right and complete the sec-tions titled, “General, Care Dates, CD4, and Viral Load.” The infor-mation completed in those sec-tions will then show up on the “Main” tab.

HIV Verification (select one) Please indicate the client’s current HIV status by selecting one of the available options. If “AIDS, CDC defined” is selected, please provide the year of AIDS diagnosis in yyyy format. Important: HIV verification is required for all clients

HIV exposure category (select all that apply)

Please indicate all applicable exposure categories for the client’s HIV status. You may

choose more than one.

Connection to Care

Please indicate whether the client currently has an HIV/AIDS medical provider. Also, please provide the date on which this information was updated.

Housing and Insurance Status This section of the client records contains income information, one of the main components of Ryan White Eligibility. This section must be updated each time a client is reas-sessed for eligibility. Once you have entered the client’s income, income type, and family size, use the “Calculate FPL” button for e2Boston to calculate the client’s FPL for you. This FPL number can be used on the Income Verification sheet so you don’t need to calculate it.

Source of Client Medical Insur-ance (check all that apply)

Please indicate the client’s source of primary medical insurance. If the client has more than

one source of insurance, select all applicable sources. Also, please indicate the date on

which this information was updated.

Housing Status (select one)

Please indicate the client’s housing status and provide the date on which this information

was updated. If “Permanent housing” is selected, another question will appear asking

whether or not the housing is owned or rented. If it is rented, also indicate whether it is

subsidized.



Medical II This page contains information about the client’s history of being screened for STIs and other infec-tious diseases. You will need to go through each of the tabs outlined in the image to the right and com-plete the sections titled, “Gonorrhea/Chlamydia, Hepatitis A/B/C, Syphilis, TB, and HPV Screenings.

Gonorrhea/Chlamydia

Please add a new entry for any screenings for gonorrhea or chlamydia that have been expe-rienced by the client. After clicking “New Entry,” please complete the following questions in that section and click “Save.” If the client has not had a screening for these then click through to the “Hepatitis A/B/C” tab.

Hepatitis A/B/C

Please respond to the questions in this section regarding screenings and treatment for hep-

atitis A, B, & C. As a reminder, all questions marked with an asterisk are required. Click

through to the “Syphilis” tab when complete.

Syphilis

Please add a new entry for any screenings for syphilis that have been experienced by the client. After clicking “New Entry,” please complete the following questions in that section and click “Save.” If the client has not had a screening for these then click through to the “TB” tab.

TB

Please respond to the questions in this section regarding screenings and treatment for. As a

reminder, all questions marked with an asterisk are required. Click through to the “HPV

Screenings” tab when complete.

HPV Screenings

Please add a new entry for any screenings for HPV that have been experienced by the cli-ent. After clicking “New Entry,” please complete the following questions in that section and click “Save.” If the client has not had a screening for HPV and all other Medical II data is complete you may move to the “Services” section of the intake.


Programs are required to use e2Boston to track service utilization for funded activities. BPHC uses the client code and unique client identifier to link service activities to specific clients. In addition to submitting an overview of utilization data with the quarterly reports, all programs must upload/import utilization data into e2Boston monthly. Client utilization data are entered or uploaded at least monthly for review and submitted quarterly for programs with cost reimbursement budgets. Likewise, programs with unit-rate budgets must submit client utilization data at least monthly. Reporting Requirements

• Cost Reimbursement: Programs with cost reimbursement budgets will submit client utilization data quarterly, incorporating data from e2Boston.

• Unit-rate: Programs with unit-rate budgets will submit a combined fiscal and data report consisting of a Fiscal Invoice and Client Utilization Data monthly. The monthly client utilization data will serve as fiscal backup documentation for units billed. Unit-rate programs are encouraged to create and submit their own spreadsheet or submit a print out from the e2Boston data system as their client utilization data fiscal backup. The submission should include the following: agency name, service category, client code in alphanumerical order, service code, date of service, number of units, rate, and total cost. Programs should not submit duplicate versions of the same data.

Instructions While the reporting deadlines and requirements vary for cost reimbursement and unit-rate programs, client activity itself is reported similarly for both types of programs. Client activity is recorded in one of three ways: by amount of time of service provided, upon completion of service, or by units of service provided. 1. Time-based Units of Service: If a client activity is measured in hours, it can be broken down into quarter-units. Examples:

• If a client meets face-to-face with his Case Manager for 30 minutes, the visit is recorded as 0.5 units. • If staff holds an individual psychosocial support session with a client for 90 minutes in her office, the

visit is recorded as 1.5 units. 2. Completion of Service: Not all units of client activity correspond to hours of time. Instead, they are reported as one (1) unit when the activity is completed, regardless of how long the activity took to complete. Examples:

• Phone calls that provide client-centered assistance are recorded as one (1) unit regardless of the length of the phone call.

• Case Management intakes are recorded as one (1) unit when they are completed. • Supported Referrals are recorded as one (1) unit when they are completed.

3. Units of Service: Some client activities are recorded in units of service provided. The units may be in the

form of discrete service units provided (e.g., meals, bed days). In some cases, they are client activities which

are defined as units.

e2Boston - Client Utilization Form


Examples: · A transitional housing program funded to provide bed days for clients would record each bed day provided for each client as one (1) unit. · A meals program funded to provide food bank packages for clients would record each package distributed to clients as one (1) unit. Refer to the Service Code Summary for complete service code definitions and reporting instructions.

Instructions for Completing Part A Unit-Rate Client Utilization Data Fiscal Backup

Reminder: Report service utilization only on clients whose services are paid for under Part A contracts.

For Cost Reimbursement and Unit-Rate programs, report utilization using Part A or Part A MAI codes listed in your Scope of Services only, as indicated in e2Boston.

1. Provider Name Enter the Provider name as indicated on the contract. If desired, the program

name may be entered after the Provider name.

2. Service Category Enter the service category for which utilization is being reported

3. Client Code

Enter the client code exactly as it was generated from the e2Boston Data

System. If the client code varies from the e2Boston Data System, the client

codes will need to be corrected.

4. Unique Client

Identifier

Enter the UCI exactly as it was generated from the e2Boston Data System. If

the UCI varies from the e2Boston Data System, the UCIs will need to be

corrected.

5. Date Enter the date the service was provided. Do not include dates that fall in

future or past quarters on the Client Utilization Data Fiscal Backup.

6. Number of Units

Enter the number of units of service provided for each service code listed.

Each service unit must be recorded using whole or partial units of service as

defined in the Service Code Summary.

7. Unit of Service

Description Describe the service provided as indicated in the Service Code Summary.


Unit-rate contracts must submit their client utilization data on a monthly basis via e2Boston and as fiscal backup with their unit-rate invoice. Below is a sample of a unit-rate client utilization data submission that is submitted monthly with the agency’s invoice. The submission serves as the fiscal backup documentation. Agencies that have a Substance Abuse - Residential unit-rate contract should submit a form like the one below on a monthly basis with their invoice. The form should list client codes in alphabetical order.

AIDS Service Organization Ryan White Part A Client utilization, Fiscal Backup Service Category: Substance Abuse — Residential

Month: March 2018

*Client discharged on March 31, 2018.

Sample Unit-Rate Client Utilization Data, Fiscal Backup

Client Code/UCI Dates of Services Subservice Unit # of units Rate Total

MAR0609547899/ RSCR0609542

03/01/18—3/31/18

Residential Recovery Services (RRS—Bed Day)

29 $100.08 $2,902.32

ASH0202566789/

JMBO0202561

03/03/18—3/31/18


27* $100.08 $2,702.16


Screenshot of e2Boston

Adding Services and Subservices to a Client Record

First, select the service date. Some services, such as Rental Assistance, have special conditions listed for services that will appear on screen if you enter the date wrong. Next, choose the Service Category and Subservice Category for the ser-vice rendered. The Program and Contract forms will automatically fill in based on the date of service you input. After you hit the Add Service button, the Service Details screen will appear underneath the Add Services field. The Provide the required details for the service and double check to make sure the information is correct. All Service Detail screens provide additional space to write Service Notes. You may use notes to include additional details about a visit or service for your own reference, or for BPHC to look at later. All services notes are saved in e2Boston and accessible in a client’s Service History.


AIDS Drug Assistance Program The AIDS Drug Assistance Program is a state-administered program to provide FDA-approved medications to low-income PLWH with limited or no health care coverage. Funds may be used to purchase health insurance for eligible clients and for services that enhance access to, adherence to, and monitoring of antiretroviral therapy. Programs must assess and compare the aggregate cost of health insurance versus the full cost of medications and other appropriate HIV medical services to prove cost-effectiveness.

Food Bank/Home-Delivered Meals & Medical Nutrition Therapy Food Bank/Home Delivered Meals is the provision of actual food items, hot meals, or a food voucher program for eligible PLWH. This also includes the provision of essential non-food items that are limited to the following: personal hygiene products; household cleaning supplies; water filtration/purification systems in communities with documented water sanitation issues. Medical Nutrition Therapy includes the following services for PLWH: 1)Nutrition assessment and screening, 2) Dietary or nutritional evaluation, 3) Food and/or nutritional supplements per a medical provider’s recommendation, and/or 4)Nutrition education and/or counseling. These services can be provided in individual or group settings, at community organizations or medical facilities. All MNT services must be pursuant to a medical provider’s referral and based on a nutritional plan developed by the registered dietitian or other licensed nutrition professional.

Service and Subservice Definitions

Subservice Definition

Prescription Please list using drug type code.


Home Delivered Food, by a

Professional

Number of meals/food delivered by a professional to the

home for clients and families who are incapacitated by HIV.

Home Delivered Food, by a

Volunteer

Number of meals/food delivered by a volunteer to the

home for clients and families who are incapacitated by HIV.

Meal, Congregate

Number of meals provided in a group setting that is not the

client’s home.

Assessment, Nutritional Enter one (1) when nutritional assessment is completed.

Visit, General Nutritional Counseling

A non-initial face-to-face session between counselor and

client where nutritional support services are provided. One

Unit = One Hour.

Food Bank Package

Withdrawal from food bank. Enter one (1) per can or

package.

Nutritional Supplement Enter one (1) per can or similar package.


Housing Housing services are the provision of transitional, short-term, or emergency housing assistance to enable a client or their

family to gain or maintain medical services. This may include housing referral services, transitional, short-term, or

emergency housing assistance.



Visit, Initial First face-to-face session between provider and client where

housing services are provided. One Unit = One Hour.

Visit, Follow-up Any non-initial session between provider and client where housing

services are provided. One Unit = One Hour.

Phone, Follow-up Enter one (1) for each telephone encounter which provides client-

centered assistance. One Unit = One Phone Call.

Placement, Temporary Enter one (1) when temporary placement is made.

Placement, Permanent Enter one (1) when permanent placement is made.

Assessment, Completed Enter one (1) when assessment is completed

Supported Referral Enter (1) for each active process of facilitating a client’s access to

HIV Support Services and any other services necessary to reduce

barriers to care.

Housing Support, Group Face-to-face session between an eligible provider and the client

participating in a group session with three or more individuals. One

Unit = One Hour.

Homelessness Prevention Enter one (1) for each unit (month of payment) of Homeless

Prevention delivered.

Rental Start Up Enter amount provided for first month, last month, or both time

periods.

Application Processed Enter one (1) for each Rental Assistance application reviewed.

Application Rejected Enter one (1) for each Rental Assistance application rejected or

denied.

Client Communication Enter one (1) for each non-initial communication to a client related

to rental assistance services. For example, One Unit = One Phone

Call.


Medical Case Management Medical Case Management is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be conducted by an interdisciplinary team that includes other specialty care Subrecipients. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, and any other forms of communication). Medical Case Management may also connect clients to relevant benefits, including but not limited to health insurance and pharmacy benefits. Medical Case Management services take place in or have a linkage with a medical setting where the client receives primary care to HIV care.

Non-Medical Case Management Non-Medical Case Management provides and improves access to medical, social, community, legal, financial, and other needed services. Non-Medical Case Management services may also include assisting eligible clients to obtain access to other public and private programs for which they may be eligible, such as insurance programs, drug assistance programs, and other state or local health care and supportive services.



Initial Intake, Started Enter one (1) when initial intake begins.

Assessment, Completed Enter one (1) when assessment is completed.

General Visit A face-to-face session between provider and client where case

management services are provided. One Unit = One Hour.

Home-Based Visit A face-to-face session between provider and client where case management

services are provided in a non-office based setting, including but not limited

to residential settings

Phone, Follow-up Enter one (1) for each non-initial telephone encounter which provides

client-centered assistance. One Unit = One Phone Call.

Reassessment/Follow-up

Service Plan, Completed

Enter one (1) when reassessment/follow-up service plan is completed.

Supported Referral Enter one (1) for each active process of facilitating a client’s access to HIV

Support Services and any other services necessary to reduce barriers to care.

Re-engagement in Care Unit of service that documents an attempt to contact, or successful contact,

with a client who has been out of care for the last 6-12 months. This may be

a phone call, email, or face to face visit.


Medical Transportation Medical Transportation services provide non-emergency transportation which allows an eligible client to be retained in core medical and support services. The goal of this service is to maintain clients connected to core and support services that contribute to positive health outcomes. Approved services include a voucher system, contract system with a taxi company, mileage reimbursement (non-cash), volunteer driver system, or approved purchase or lease of organization vehicle.

Oral Health Care

Oral Health Care services provide outpatient diagnostic, preventive, and therapeutic services by dental health care professionals, including general dental practitioners, dental specialists, dental hygienist, and licensed dental assistants to eligible clients. The goal of this service is to prevent and control oral and craniofacial diseases, conditions, and injuries, and improve access to preventive services and dental care



One-way Ride, Public One-way transportation by public transport system (subway or

bus passes) for client to access healthcare or support services.

One-way Ride, Taxi/

Transportation Company

One-way transportation by taxi or other similar company for

client to access healthcare or support services.

One-way Ride, Van One-way transportation by a funded agency vehicle for client to

access healthcare or support services.

One-way Ride, Volunteer One-way transportation by a volunteer for client to access

healthcare or support services.


Initial Intake, Started Enter one (1) when the initial intake begins.

Treatment Committed Enter one (1) when the treatment approval is made.

Treatment Claim Enter one (1) when the claim is completed.

Phone, Follow-up Enter one (1) for any non-initial telephone encounter which provides client-centered assistance. Phone calls should be reported only when successful contact is made; messages left should not be reported. One Unit = One Phone Call.


Psychosocial Support

Psychosocial Support services are group or individual counseling sessions between a PLWH and facilitator. The topic of

the session is a behavior or physical health concern, including but not limited to bereavement counseling, child abuse and

neglect counseling, HIV support groups, nutrition counseling and pastoral counseling services. Other relevant topics may

include substance use, domestic violence, coping with comorbidities, family support issues, among others.

Substance Abuse—Residential Substance Abuse Services — Residential programs provide services meant to treat substance use disorder in a

residential setting. These services include screening, assessment, diagnosis, and treatment.



Support Session, Group A regularly scheduled HIV support counseling meeting for three

or more people with HIV. One Group Unit = One Hour.‡

Support Session, Individual Any face-to-face counseling session between staff and a person

living with HIV. One Unit = One Hour.


Residential Recovery Services

Provision of services to a client enrolled in a residential sub-stance use program; greater than 8 hours and less than 24 hours.

Transitional Recovery Services

Provision of services to a client enrolled in a residential sub-stance use program; greater than 8 hours and less than 24 hours.


The Outcome Measurement Report is used to quantify and track the health of each client served; it is a tool to evaluate the impact of services on key indicators of health and wellness among clients. Outcomes reporting will be based on a “Client Clock” model; outcomes are assessed for each 6 month period during which the client received services. This model allows each client to have their own custom reporting period, which begins when the client receives a service at a Part A funded agency. Outcomes Descriptions and Definitions Subrecipients should use their professional assessment skills when completing the outcomes reporting forms. While each level for each outcome is defined, please keep in mind the broader status level categories (i.e., in crisis, poor, fair/good, and excellent).

• Access to Support Network: Support Networks may include friends, family, religious groups, or other peer groups from which the client obtains emotional, social, spiritual, or material support.

• Adherence to HIV Medication: Select whether the client always (0 missed doses in the last week), frequently (1-2 missed doses in last week), sometimes (3-4 missed doses in last week) or rarely (>4 missed doses in last week) adheres to prescribed HIV-related medical therapies. Subrecipients can use the criteria that they use in practice to measure adherence. Do not answer this question if the client is not on ART.

• Case Management Status: Record whether or not the client is receiving HIV case management services (social or medical) at any agency.

• Care Adherence: HIV-related appointments include medical appointments, mental health appointments, psychosocial support, case management, and anything else related to care completion and/or support.

• CD-4 Count: Choose the level for the most recent test result in the reporting period that you have seen or that he client has reported.

• Housing Status: This outcome aims to understand a client’s stability in housing, regardless of type of housing.

• Mental Health Status: Use information gathered from clients during intakes, assessments and regular interactions to evaluate client’s mental health status. This measure is not to be used as a mental health diagnosis.

• Primary Medical Care Engagement: Record the month and year in which the client was last seen by his/her HIV medical provider (the provider the client most commonly sees for their HIV medical care).

• Severity of Side Effects of HIV-Related Medications: This outcome measure aims to assess the client’s subjective experience of side effects from HIV medications. Wherever possible, this measure should be based on the direct report of the client. Do not answer this question if the client is not on ART.

• Viral Load: Record the actual value for the most recent test result in the reporting period that you have seen or that the client reported.

Outcome Measurement Reports


Rules for Custom Reporting Periods 1. An outcomes reporting period begins for a given client if the client receives a service at a given agency

AND a clock for that reporting period is not already going. 2. Once the outcomes reporting period begins, the provider has exactly 26 weeks (6 months) to complete an

outcomes form corresponding to the client. After this 6 month period has elapsed, the provider may no longer submit a form corresponding to that reporting period for that particular client.

3. After the outcomes reporting period ends, regardless of whether or not a corresponding outcomes form was submitted, the “next” outcomes reporting period starts for a particular client on the first day that they receive a service after the end of the preceding outcomes reporting period.

4. If an outcomes form is completed for a given client at any time during a given outcomes reporting period, the clock does NOT reset. Rather, the clock continues to run for 6 months. After the 6 month period is over, the next service that the client receives at the agency starts a new clock.

Reports 1. All reports involving Outcomes data will pull data SUBMITTED during the date range given in the report

unless otherwise specified. 2. The Outcomes Completion and Eligibility report will allow subrecipients to track clients that are in each of

the 4 submission states, particularly “Eligible for Submission” and “Submission Required”. This report will also allow BPHC and subrecipients to track how many missed outcomes reports a provider or a given client has.

Outcomes Instructions & Submission Process

• Resources can be found in the e2Boston Resource Center.

• Outcomes will only be accepted electronically via e2Boston. Once an outcome report is missed, there is no way to submit the data to BPHC. It is better to submit an INCOMPLETE outcome report than to submit nothing at all. Contact Information For technical assistance, policy and/or reporting requirement information, please contact your BPHC pro-gram coordinator.

Outcome Measurement Reports


Screen shot of e2Boston

Adding Outcomes to a Client Record


Ryan White RSR Reporting

Ryan White Services Report (RSR) ALL Ryan White funded subrecipients are required to complete the 2018 RSR, which covers the re-

porting period from January 1, 2018 to December 31, 2018. For FY 2018, agencies will be required to

use e2Boston to generate the appropriate XML file for their client-level data. Only information for

Part A clients can be entered into e2Boston, so subrecipients that are funded under multiple Ryan

White Parts will have to rely on other systems to track their non-Part A clients.

There are three components to the RSR:

• Grantee Report – to be completed by entities funded DIRECTLY by HRSA, including BPHC

as the Part A Grantee, DPH as the Part B Grantee, and all directly funded Part C and D pro-

viders.

• Service Provider Report – to be completed by ALL Ryan White funded subrecipients. This

report contains information about your agency and the services you provide under Ryan

White.

• Client Report – to be completed by ALL Ryan White funded subrecipients. This report con-

tains the Client Level Data (CLD) and is submitted electronically in an XML format with en-

crypted client identifiers.

More information, including instructions for completing the RSR and full Client Level Data compli-ance, is available at the following HRSA websites: http://hab.hrsa.gov/manageyourgrant and http://careacttarget.org/topics/rsr.asp.

http://hab.hrsa.gov/manageyourgrant/

http://careacttarget.org/topics/rsr.asp


Fiscal Reporting Rules (FY18) ................................................................................................................................... 42 Sample Invoices .......................................................................................................................................................... 48 Budget Terms ............................................................................................................................................................... 51 Sample Budgets .......................................................................................................................................................... 52 Budget Revision Guidance ......................................................................................................................................... 55 Sample Budget Revisions ........................................................................................................................................... 56

Fiscal Overview


Fiscal Reporting Rules FY 2018 All Part A contracted subrecipients are expected to expend 100% of their award in accordance with all federal, local, and BPHC policies. The Grantee will only reimburse subrecipients for deliverables that have been mutual-ly agreed on (see Scope of Services and Budget) and upon receipt of appropriate invoices and back-up docu-mentation. If the subrecipient wishes to revise the Scope of Services or allowable costs, they must submit a pro-posal to revise the Scope and/or Budget. In addition, it may be required that a subrecipient audit be submitted. Failure to meet these expectations may result in suspension or termination of your contract.

A. Invoicing General Information 1. A standard invoice including the approved budget must be submitted. Part A payments for cost reimburse-ment and unit-rate contracts are based on the approved budget. Invoices must be formatted by computer; hand written invoices are not acceptable. Please note there cannot be anything handwritten on an invoice. Only line item budgeted expenses are reimbursed. 2. All contracts must have their invoices signed by a program representative or a contract specialist before sub-mission to the Part A program.

3. Invoices are submitted monthly, within 15 days of the month's end. Each day thereafter will be considered late, therefore non-compliant. The final invoice is to be submitted by March 15, 2019. 4. Invoices must represent actual monthly expenses. Invoices without the required information or documenta-tion (including required data and reports) will not be processed. Instead, the Subrecipient will be informed of the deficiency to be corrected, and the invoice will be held for five business days. If there is no response after five business days, the invoice will be deleted and the agency will need to resubmit the invoice. 5. An invoice must be submitted to the BPHC for each month in the contract period. If no contracted activi-ties occurred in a given month, there are no reimbursable costs; an invoice with a $0 monthly total must be submitted. 6. Any revised or supplemental invoices are to be clearly labeled as such by including the word “Revised” or “Supplemental” within the “Invoice Number” notation. Retroactive billing may only occur when the expense is not billed to another funding source. Documentation of bills to other funding sources may be required. 7. Monthly invoices containing all required information will be paid within 30 days of receipt. Payment will be held if complete quarterly reports are not received when due and/or if fiscal documentation is incomplete; agencies are informed in writing.

Invoices are sent to:

• Accounts Payable, Boston Public Health Commission, 1010 Massachusetts Ave, 2nd Floor, Boston, MA 02118, Or • [email protected], CC: All Ryan White Fiscal Staff


Cost Reimbursement Invoicing

1. Appropriate supporting documents for monthly cost reimbursement invoices include: • Payroll registers and labor distribution reports • Purchase requisitions accompanied with vendor invoice copy • Cancelled checks • Copies of vendor invoices • Copies of reimbursement/voucher forms

2. The budget on the invoice must illustrate the exact approved contract budget. The name of each staff member must be noted next to each position on the budget. Actual monthly payroll expenses paid (not accrued) are billed on the invoice. The year-to-date amounts in the “Cumulative” billing column must be correct. Also, the salaries and FTEs which are billed must correspond to the approved contract budget. If any of these are incorrect on an invoice, it will not be processed. A budget revision request and/or revised invoice may be submitted.

3. The fringe rate must be the internally audited fringe rate. Verification of this rate is subject to audit. (Fringe is defined as government mandated and employer selected employee benefits including: social security, unemployment, workers’ and disability compensation, retirement programs, and health insurance).

4. The following is required for any invoices submitted for the purchase of client related travel, meals/food, and other client consumables in below line items on any program budget:

• Itemized receipts must include the merchant or provider name, service received or specific item purchased, date of service and amount of expense. • Itemized list indicating the client codes of those receiving the service and service utilization information (i.e., the dates and quantity of service provided to each client).

These are required at the time of billing for all (but not limited to) the following line items: • Bus and subway fare • Commuter rail • Contracted services rides • Food provided with client activities (e.g., Psychosocial Support group meals) • The Ride tickets • Taxi vouchers • Volunteer mileage

A sample itemized list for transportation and housing assistance:

Please note: RW funds cannot go directly to clients. Housing Assistance may not be used for mortgage payments, back rent, or security deposit. The itemized lists for Transportation must include to and from location and the purpose of the trip. Programs will be allowed to utilize resources to pre-purchase food, tokens, and taxi vouchers if done so by December 15, 2018.

Client Code/

UCI Date Unit of Service Amount Vendor

MAR0609547899/ RSCR0609542 03/03/18 Rental Start Up $300 Century 21

MAR0609547899/ RSCR0609542 03/10/18

One-Way Taxi to

Medical Appointment $22.50 Boston Taxi


5. The following must be submitted before billing for a consultant line:

• A resume and list of qualifications for any consultant hired. • A detailed description of the services/activities performed by the consultant. • The consultant’s last name must be indicated on the invoice cover sheet when an invoice is submitted.

6. Contracts can only include an “Indirect” line item (capped at 10%) if the Subrecipient has a certified HHS-negotiated indirect cost rate using the Certification of Cost Allocation Plan or Certification of Indirect Costs, or adhere to a 10% cap on administrative expenses. Administrative expenses must be clearly itemized on budgets.

7. Vehicle mileage is reimbursed at a per mile rate not to exceed the Internal Revenue Service’s standard mile-age rate, which is currently $0.545 per mile.

8. Travel outside of the EMA is not allowed and will not be reimbursed. Exceptions to this may be made with the written prior approval from the Ryan White Services Division, where travel outside the EMA is for neces-sary trainings.

Unit-Rate Invoicing

1. Unit-rate billing uses the non-personnel expense portion of the standard Part A invoice (bottom half).

2. Unit-rate billing documentation differs from Cost Reimbursement in that service utilization data serves as the fiscal backup documentation for units billed. Billing backup can be a direct print out from the e2Boston data system or prepared as shown in the example below.

Client Code/UCI Date Unit of Service # of units Rate Total

MAR0609547899/ RSCR0609542

03/03/18


29 $75 $2,175

B. Fiscal Compliance

1. Under the Ryan White HIV/AIDS Treatment Modernization Act of 2009, there are significant penalties to the EMA if there are unexpended dollars at the end of the fiscal year. This includes the need to return unex-pended dollars to the federal government. Therefore, all programs are expected to expend 100% of their con-tracted award. Contract expenses, as shown on invoices, are reviewed each quarter of the fiscal year. The Sub-recipient is informed after the first quarter, in writing, of any under billing. Any contract under billed through the second quarter may be reduced. If the under billing is due to a late start, the contract is reduced by the amount of the unspent funds to date. If the under billing is chronic, the contract is reduced by both the un-spent funds and the projected under spending to year-end. These unexpended funds are then reallocated to other provider contracts in accordance with the Ryan White Planning Council’s service priorities. Reallocations within individual categories and the resulting contract revisions do not require Planning Council approval. 2. In addition, the Subrecipient may be held in non-compliance at the end of each month if they do not meet the invoicing requirements. This includes non-submission of invoices, or late invoices. If the invoice is incor-rect and/or incomplete, it will be returned to the Subrecipient and the Subrecipient will be required to submit new corrected information. Subrecipients are notified of non-compliance in writing. Non-compliance shall be lifted as soon as all submissions are complete.


3. On a case-by-case basis, contract spending may differ from each personnel line item by no more than 10% monthly, for example if you are projected to bill a monthly salary of $500 (annual salary of $6,000), you may spend $550 within that line per month (therefore, cannot exceed $6,600 annually) with the sufficient back up. For below line items, e.g. if you are budgeted for a $1,000 office supply line for the year, you may spend up to $1,100 within that line (you many bill this in one month or it may divided between several months). Both of these stipulations apply as long as the total amount billed does not exceed the budget’s maximum obligation. Overspending will not be reimbursed. 4. Contract funding for a Part A fiscal year may not be used in a subsequent fiscal year. Fiscal years are dis-crete; the funding is separate and is not “carried over”.

C. Audits Agencies must perform audits of agency financial records (as described in the 45 CFR Part 75 Subpart F) if they receive more than $750,000 in federal funding. Subrecipients that receive less than $750,000 in federal funding are required to have annual audits and financial statements prepared by independent auditors. When completed, this audit must be sent to:

• William Kibaja, Controller, Boston Public Health Commission, 1010 Massachusetts Ave, 2nd Floor, Boston, MA 02118

In addition, this audit and all required fiscal records must be available at the program location for review dur-ing the on-site financial review.

D. Budget Revisions

1. Contract budgets are not changed without the approval of the Boston Public Health Commission. A revised budget request in the same format as the contract budget and accompanied by line item explanations of proposed revisions is required. If the budget revision does not match the most up to date contract budget, it will be returned to the agency. Complete instructions are available under the budget revision section of the manual.

2. Agency requests to revise contract budgets are sent via email to [email protected] or mailed to:

• Dennis Brophy, Director , Ryan White Services Division, Boston Public Health Commission, 1010 Massachusetts Ave, 2nd Floor, Boston, MA 02118

3. Budget revision requests must include the following: (1) a letter with a detailed explanation for making the proposed revision; (2) a current budget with the proposed changes made in the same format; and (3) a de-tailed line item budget explanation attached.

4. Generally, appropriate requests are those which propose using different means to accomplish the specific

program features which were approved and detailed in the original Scope of Services. In general, adding new line items is not an acceptable request. With prior approval, agencies are allowed to shift funds be-tween existing line items due to evolving service needs.

5. Budget revisions will not be accepted after December 15, 2018. Revisions submitted after this deadline will only be considered to fill vacant positions, and for legal name and position title changes.

6. Initial appeals of denied budget revision requests are made, in writing, to Dennis Brophy, Division Director. Further appeals may be submitted, in writing, to the Director of the Infectious Disease Bureau, Dr. Jenifer Jaeger.


E. Additional Funding Restrictions 1. Grant funds may not be used to supplant or replace current state or local HIV-related funding. 2. Funds may not be used to purchase or improve land or to purchase, construct, or make permanent improve-

ment to any building except for minor remodeling. 3. Funds may not be used to make payments to recipients of services.

4. Recipients of grant funds must participate in a community-based continuum of care. A continuum of care is

defined as: A comprehensive continuum of care includes primary medical care for the treatment of HIV infection that is consistent

with Public Health Service guidelines. Such care must include access to antiretrovirals and other drug thera-pies, including prophylaxis and treatment of opportunistic infections as well as combination antiretro-viral therapies. Comprehensive HIV care also must include access to substance-abuse treatment, men-tal-health treatment, oral health, and home health or hospice services. In addition, this continuum of care should include supportive services that enable individuals to access and remain in primary medical care as well as other health or supportive services that promote health and enhance quality of life.

5. The aggregate total of Part A Subrecipients administrative expenditures shall not exceed 10%

of the aggregate total of Part A funds awarded to the Subrecipients (without regard to whether any of these Subcontractors expend more or less than 10 percent for such expenses). For the purposes of the 10% aggregate cost cap, administrative activities include:

• Usual and recognized overhead activities, including rent, utilities, and facility costs.

• Costs of management oversight of specific programs funded under this title, including program coor-dination; clerical, financial, and management staff not directly related to patient care; program evalua-tion; liability insurance; audits; and computer hardware/software not directly related to

patient care. 6. If a particular service is available under the state Medicaid Plan, the political subdivision involved must either

provide the service directly or must enter into an agreement with a public or private entity to provide the ser-vice. The Subrecipient providing the service must enter into a participation agreement under the state Medicaid Plan and must be qualified to receive payment under the state Medicaid Plan.

7. Funds may not be used to provide items or services for which payment already has been made, or reasonably

can be expected to be made, by third-party payers, including Medicaid, Medicare, and/or other state or local entitlement programs, prepaid health plans, or private insurance. It is therefore incumbent upon Subrecipients of Part A funds to assure that eligible individuals are expeditiously enrolled in Medicaid and that Part A funds are not used to pay for any Medicaid-covered services for Medicaid-eligible PLWH. Part A Subrecipients are subject to audit on this and other restrictions on use of funds.

8. If the Part A Subrecipient charges for services, it must do so on a sliding-fee schedule that is made available to

the public. Individual annual aggregate charges to clients receiving Part a services must conform to statutory limitations. The intent is to establish a ceiling on the amount of charges to Part A service recipients.

Establishing a fee schedule should not result in a bureaucratic system to means-test individuals or families be-fore Part A-supported services are provided. A simple application that requests information on the annual gross salary of the individual/family should provide the baseline by which the caps on fees will be established.


Individual/Family Annual Gross Income Total Allowable Annual Charges

Equal to or below the official poverty line No charges permitted

101 to 200 percent above the official poverty line 5% or less of gross income

201 to 300 percent above the official poverty line 7% or less of gross income

More than 300 percent above the official poverty line 10% or less of gross income

Individual/Family Annual Gross Income And Total Allowable Annual Charges

9. Funds are to be used in a manner consistent with current and future program policies developed for Part A regarding allowable categories of services and eligibility for services. Please review all current HRSA/HAB and BPHC program policies.

10 All travel must be within the EMA and directly related to the services provided under the specific contract. 11. Funds may not be used for outreach programs which have HIV prevention education as their exclusive pur-

pose or broad-scope awareness activities about HIV services that target the general public. Sample cost reimbursement and unit-rate invoices can be found on the following pages.


Sample of Cost Reimbursement Invoice (Admin Cost Cap)


Sample of Cost Reimbursement Invoice (Indirect Rate)


Sample of Unit Rate Reimbursement


Budget Terms

Budgets cover a twelve month period and are presented in whole dollars (no cents). Cost Reimbursement

• The Core/Support Service Direct Cost column indicates the position title.

• The Personnel column indicates the name of the staff person occupying the position. Revisions should be submitted with staff first initial and last name (e.g., J. Smith). Enter TBD if the position is currently vacant. Program administration positions are funded, but only if their primary focus is the proposed service. Ryan White direct services dollars are not to be used to pay for Subrecipient’s administration.

• The Salary column reflects a Full Time Equivalent (1 FTE total) salary.

• The FTE column is the percentage of time (carried to no more than two decimals) that the position listed is paid for by Ryan White Part A funding. To meet audit requirements, employees cannot exceed a total FTE of 1.0 across all funding sources.

• The Months column is number of months the position listed will be occupied in the contracted period.

• The Annual column is the total salary amount that will be paid by Ryan White Part A in a twelve month budget period for the listed position based on the given FTE and Months. Annual = (FTE x Months x Salary)/12

• The Fringe rate must be the agency’s internal audited fringe rate, with a maximum of 50.70%. Verification of this rate is subject to audit. Fringe is defined as: government mandated and employer selected employee benefits including social security, unemployment, workers and disability compensation, retirement pro-grams, and health insurance.

• Non-personnel, expense line item titles should be specific (e.g., Food, Office Supplies, Staff Training) should be specific and listed under the Other Direct Costs column.

• The HHS Indirect Approve Rate line item is capped at 10%. Subrecipients who wish to use an indirect rate, must provided documentation of Certificate of Indirect Costs that is HHS-negotiated, signed by an individual at a level no lower than Chief Financial Officer.

• The Administrative Costs column should be specific. These costs include the usual and recognized over-head activities, including rent, utilities, and facility costs. It also applies to costs of management and over-sight of the specific program funded. It includes program coordination; clerical, financial, and management staff not directly related to patient care; program evaluation; liability insurance; audits; computer hardware/software not directly related to patient care. Administrative Costs are funded at a maximum rate of 10% of the total direct program costs. Subrecipients are responsible for preparing a project budget that meets ad-ministrative cost guidelines and provides expense reports that track administrative expenses.

• Service Award Total is the sum of the direct care total and the administrative or indirect rate cost total. Unit-Rate

• The Service refers to the activities the agency is funded to provide.

• The Unit represents the duration of the service activity.

• The Rate is the approved billable rate proposed per one unit of service. Rates may match but never exceed rates of reimbursement by other third-party payers (e.g., Medicare, Medicaid, Bureau of Substance Abuse Services) for same service activity. All current rates and documentation must be provided.

• The Volume represents the number of units to be delivered in a twelve month period.

• The Annual is the proposed rate times the volume. Annual = Proposed Rate x Volume Sample cost reimbursement and unit-rate budgets can be found on the following pages.


Sample Cost Reimbursement Budget (Admin)


Sample Cost Reimbursement Budget (Indirect)


Sample Unit-Rate Budget


Budget Revision Guidance

Appropriate budget revision requests are those which propose to use different means to accomplish the original agreed upon goals and objectives outlined in the Scope of Services. In general, adding new line items are not ac-ceptable requests. Subrecipients may be allowed to shift funds between existing line items due to evolving service needs. Service category budgets may only be revised with the written approval of the Director of the Boston Public Health Commission Ryan White Services Division. In order to receive written approval, agencies must submit a budget revision request, including a proposed budget in the appropriate format (see sample on the following page) and a line item budget justification via email to [email protected] or via mail to : Dennis Brophy, Director, Ryan White Services Division, Boston Public Health Commission, 1010 Massachusetts Ave, 2nd Floor, Boston, MA 02118

Budget revision requests must include the following:

• A current budget with the proposed changes, and final proposed annual amounts to the right of each person-nel and/or expense line item.

• A detailed explanation for each proposed change and how it will assist to meet contracted goals & objectives.

• For proposed staffing changes, please list both the prior and proposed staff on separate lines, detailing for

each the actual salary, FTE, and exact number of months on the contract. Personnel explanations should in-clude: the last name of the employee or, if vacant, the estimated date of hire and a brief description of the po-sition’s duties and responsibilities as they relate to Ryan White funding.

• For each new staff person a resume showing qualifications for the position, and proof of annual salary such as an offer letter or employee action form.

• For proposed expense item changes (e.g., food, program supplies, staff training, travel), explanations must incorporate quantities. Explain why an expense item is necessary and how it will be used. For example, travel expenses must specify who, where, when, and why the travel is necessary.

• For unit-rate changes, please provide the rationale and the calculation for the number of units proposed.

Any program proposing to add a consultant line or to move money into an existing consulting line must:

• Submit a resume and list of qualifications for any consultant hired as a condition of funding.

• Provided a detail description of the services/activities performed by the consultant with the budget revision and at the time of billing.

• Add the Consultant’s Last Name to the invoice coversheet, after approval of the consultant line.

If these conditions are not met, no payments on consultant lines will be allowed. Initial appeals of denied budget revision requests are made, in writing, to the Director of the Ryan White Services. Further appeals may be submitted, in writing, to the Director of the Infectious Disease Bureau, Dr. Jenifer Jaeger. Budget revisions will not be accepted after December 15, 2018. Revisions submitted after this deadline will only be considered to fill vacant positions, and for legal name and position title changes.


In this example, Medical Case Manager Doe has left the subrecipient after 3 months on the Part A contract. Case Manager Valdez has replaced Jones for the remaining 9 months of the fiscal year at a higher salary. The subrecipient has decided to decrease the new Case Manager's FTE from .80 to .75 on the Part A contract. In order to cover the additional dollars in Valdez’s line, the subrecipient had to reduce the Staff Training line to $800 and the Program Supplies line to $274. The subrecipient’s original budget is reflected in the first six columns. Staff names may be added if new staff has been hired. For example, a new line has been inserted to reflect the hiring of Medical Case Manager Valdez. Following are terms related to budget revisions. “Change” is the difference between the Annual and the New Annual (Change = Annual - New Annual). “New Salary” is the Full Time Equivalent (1 FTE total) sal-ary. If there is a salary adjustment from the original “Salary,” back-up documentation is required (e.g., hire letter). “New FTE” is the new percentage of time that the position listed will be paid through this contract. “New Months” indicates the new number of months that the employee will work; the number would differ from the original budget when a staff person is added or removed from a budget based on hiring or depar-ture. “New Annual” is the updated total salary amount that will be paid for by Part A based on changes made to the salary, FTE, or months in the budget revision. “New Annual” for a staff member who is being removed from a budget must be the actual amount expended based on monthly invoices submitted to date.

Sample Cost Reimbursement Budget Revision


Sample Unit-Rate Budget Revision

In this example, the subrecipient is requesting to move $5,020 from the RRS-Bed Day subservice line

and adding it to the TSS-Bed Day subservice line. In this case, the scope of service will be revised to

show the changes in the service volumes for both lines. Unit changes are reflected in the New Volume


Monitoring Visits ........................................................................................................................................................ 60 Policy Maintenance ...................................................................................................................................................... 62 Record Maintenance Guide ........................................................................................................................................ 64

Monitoring Overview


Monitoring Visits

Boston EMA Ryan White Part A Monitoring Visit Each Ryan White Part A subrecipient is required to participate in an annual, comprehensive, single-day monitoring visit. Monitoring visits are conducted to determine your program’s compliance with contractu-al obligations, program policies, service standards, and Federal legislation. This following summarizes what to expect during your annual monitoring visit. Scheduling Site visits are scheduled at the beginning of the calendar year. Your agency’s executive director and the program contact listed in our records will be notified of the site visit date. If the assigned date assigned is not feasible, you must formally respond to BPHC with a letter requesting a new date; it must include justi-fication for the request. Pre-Site Visit Preparation One month before your site visit, an assigned BPHC program coordinator will email you a confirmation packet. This coordinator will be your point of contact throughout the entire site visit process. Materials The confirmation packet includes the following items:

• Cover letter • Service Standards • Guidance Tool • Pre-Site Visit Assessment

Pre-Site Visit Assessment An assessment will be used to evaluate your program’s compliance with contractual obligations, as well as policies and standards. The due date of this form will be included within the confirmation packet. The assessment must be completed and returned prior to the site visit. The BPHC program coordinator may schedule a call to review the information that is requested in the assessment and to provide instruc-tion. Prior to the visit—24 to 48 hours—you will receive an encrypted email with a list of client codes: these will be the records reviewed during the monitoring visit. The BPHC coordinator will also review with you the logistics for the review and will discuss with you the completed assessment. Federal Requirements Monitoring visits are conducted according to uniform grant guidance for monitoring and evaluating feder-ally funded programs. Much of this language is included in your Part A contract. Programs can prepare for monitoring visits by familiarizing themselves with the basic concepts of grants management and responsi-bilities. A useful resource is the CFO Grants Training modules can be found at https://cfo.gov/grants/training The modules include guidance on cost principals, risk management, and administrative requirements, among others.


Day of the Monitoring Visit The program coordinator leading your visit will coordinate with your program contact to determine the logistics of the monitoring visit. The site visit will consist of the following activities:

Chart Review: A random sample of up to 50 client records will be reviewed to determine subrecipient com-pliance with contractual policies and service standards. Client records will not be removed from the prem-ises. Subrecipient will receive a client record list 24-48 prior to the visit. Morning briefing: At the beginning of the site visit, BPHC will discuss with your program staff the logistics and expectations for the day. Exit Conference: BPHC will discuss initial findings with your program staff at the end of the site visit. Facility Tour: BPHC may request to tour the facility, which will be determined prior to the site visit. For example, a tour will be required if your agency recently moved to a new location. Fiscal Records Review: Financial records and policies will be tested for compliance with contractual policies and federal legislation. This review is not an audit. Policies Review (Program and Fiscal): Your policies will be tested for compliance with contractual obligations, federal legislation, and service standards. For example, a client grievance and your program’s grievance policy may be reviewed together to determine consistency. Staff Interviews: Your program’s fiscal team and direct service providers will be interviewed to discuss their roles in providing Part A services. Space should be reserved at your agency that can accommodate a BPHC monitoring team for the whole day. During the exit conference, your site visit lead will discuss initial findings. Post Monitoring Visit You will receive a summary of your agency’s compliance with Ryan White Part A requirements. This sum-mary will include fiscal and programmatic observations and recommendations, and areas of noncompli-ance. Your program may be required to submit a Corrective Action Plan (CAP) that addresses areas of non-compliance. You may also request Technical Assistance in response to the findings. Corrective Action Plan The CAP must submitted to BPHC within 30 days of the findings. You will receive a letter of approval or denial for your CAP submission. If approved, the plan will be monitored until your next site visit. If de-nied, you must submit a revised CAP to BPHC within one business week.


Policy Maintenance

The following is a comprehensive list of policies that your program can expect to submit to BPHC during the annual site visit process. Many policies must be submitted prior to the day of the visit. The Program Co-ordinator assigned to lead your site visit will help you determine how to organize the submission of policies. Please familiarize yourself with this list and how each relates to your program and Ryan White Part A ser-vice category. Please note that some of your policies may be housed in the same document. Programmatic policies required (Numbers indicate where to reference in Standards of Care document)

• 2.1 Client Rights and Responsibilities Policy • 2.2 Confidentiality Policy • 2.3 Grievance Policy • 2.4 Intake and Assessment Policy and Procedure • 2.5 Transition and Discharge Policy • 3.1 Part A Staff Job descriptions and Resumes • 3.3 Evidence of Cultural Competency • 4.2 Client access to file Policy • 4.6 Archiving File Policy • 5.1 Safety • 5.2 Anti- Discrimination Policy • 5.3 Home Visit Safety Policy and Procedure • 5.4 Incident Reporting Policy

Fiscal policies required

Audits Non-audited interim financial statements Audited financial statement A-133 Audit Risk Assessment

Billable Services policies, including: Fee schedule Sliding fee schedule policy Cap on charges policy

Federal Property and Equipment Deposition of Federal Property policy Equipment management policy – Prevents loss, damage, theft Depreciation ledger policy

Financial Policies and Procedures manual Fixed Assets Policy Billing and Collection Policy Purchasing Policy Travel Policy


Fiscal policies required Fiscal Policies and Financial Reports

Accounting Policies and Procedures Manual Policy on revenue, including program income Policy and Procedure on selection of an auditor 12 -month report of program income Policy to determine reasonableness of costs Medicaid certificate Part A agreement and budget Chart of Accounts One month of invoices Agency income statement HHS indirect rate (if applicable) Summary of HIV funding Quarterly payroll tax report IRS agreement for payment of taxes in arrears (if applicable) Insurance Policies – Certificate of Liability, Worker’s Comp, Property Liability, Director’s and

Officers Liability, Automobile Liability HIV funding table

Ryan White Titles State, Local, Federal revenues

Human Resources Employee Handbook Organizational Chart Fiscal Document Retention and Destruction Policy Whistle Blower Policy Board Minutes (Most Recent) Governance that addresses insider transactions and conflicts of interest

Time and Effort policy and procedure One pay period payroll journal, time sheets, and effort reporting


Record Maintenance Guide Programs must maintain an on-site record for each client receiving Ryan White services, which includes the following documentation. Further clarification may be found in the Ryan White Standards of Care.

Certification Forms

HIV

VERIFICATION

Programs must have documentation of each client’s HIV status. Examples include:

• Lab slips.

• HIV test results.

• Medical provider statements acknowledging HIV status.

INCOME

VERIFICATION

FOR

FINANCIAL

ELIGIBILITY

Programs must have documentation of each client’s income. Examples include:

• Benefits statements.

• Pay stubs.

• Attestation letter written and signed by provider stating the client has no source of in-come.

Clients must be 500% of the Federal Poverty Level (FPL) or below to receive Part A services.

RESIDENCY

VERIFICATION

• Proof of residency can be in the form of:

• Driver’s license.

• Utility bills.

• Bank statement.

• Real estate tax bill or receipt.

• Current residential lease.

• Pay check or benefits statements.

• Signed case manager letter on the organization letter head verifying the town and postal code of residence.

INSURANCE STATUS

Programs must have documentation of each client’s insurance status. Types of insurance coverage can include public (Medicare, Medicaid/MassHealth, Commonwealth Care), pri-vate (employer-based, private non-group, COBRA, or subsidized private plans via Common-wealth Choice), or other types of coverage (VA Benefits). If a client is not eligible for any existing insurance plans, then the provider should document the reason and how the client will access medical services and prescription drugs.

AUTHORIZATION TO OBTAIN/RELEASE OF INFORMATION

Programs must have a release of information form that describes under what circumstances client information can be released. A release to multiple providers is allowable. A release of information should include:

• Name of agency/individual with whom the information will be shared.

• Information to be shared.

• Duration of the release consent.

• Client signature, date signed and expiration date.

GRIEVANCE

PROCEDURE

Programs must have a grievance procedure that includes:

• How to file a grievance.

• To whom the grievance should be addressed.

• An alternative addressee if the client does not choose to speak with first designee.

• How the grievance will be handled.

• Reasonable timeline for processing the grievance.

• Step-by-step filing process if grievance remains unresolved.


Service-Specific Certification Forms

HOUSING Programs must collect a letter indicating medical necessity of housing is on

file for each client.

SUBSTANCE ABUSE-RESIDENTIAL Programs must collect and document a clinical referral for each client.

MEDICAL

NUTRITION

THERAPY

Programs must include a referral from a medical provider and a nutritional

plan for each client.

Service Coordination

Initial Ongoing Discharge

INTAKE

Intake must include:

• Date of Intake,

• Referral Source,

• Age, Gender,

• Race/Ethnicity,

• Primary Language,

• Exposure Category,

• Diagnostic Infor-mation,

• Zip Code

PROGRESS NOTES

Programs must have progress notes which are related to the ser-vice care plan and show evidence of referrals and follow-up actions. Progress notes should be dated, legible, and organized appropriately and chronologically

Programs must have a policy detailing how clients are grad-uated, discharged, or trans-ferred from the program. When applicable, progress notes should provide details on the client’s discharge, grad-uation, or transfer from the program.

ASSESSMENT

Programs must have com-pleted assessments which include the following:

• Medical history

• Financial status

• Need concerning food, shelter, and transportation

• Need for legal assis-tance if necessary

6 MONTH UPDATE

Programs must recerti-fy the following items every 6 months for active clients:

• Income

• Residency

• Insurance

• Reassessment

• Updated Care Plan

QUALITY ASSURANCE

Programs must have evidence of a quality assurance review of client records. This may be noted through signed service care plans, signed progress notes and/or a signed review sheet that is maintained in the front of the client file.


1. Payer of Last Resort Policy ..................................................................................................................................... 67 2. Federal Monitoring Standards ................................................................................................................................. 68 3. Sliding Fee Scale Policy for Ryan White Services ................................................................................................ 73 4. Client Eligibility for Ryan White Services.............................................................................................................. 76 Sample Income Summary ........................................................................................................................................... 79 Sample Hardship Waiver/No Income Letter ............................................................................................................. 80 Sample Eligibility Letter for Exceeding Cap ................................................................................................................ 81 Sample Six-Month Recertification ............................................................................................................................... 82 Sample Self-Attestation Letter .................................................................................................................................... 83 5. Authorization to Obtain/Release Information ................................................................................................... 84 Sample Authorization to Release ................................................................................................................................. 85 6. Agency Incident Report Procedures ..................................................................................................................... 86 Sample Incident Report ............................................................................................................................................... 87 7. Contract Transition Policy ...................................................................................................................................... 88 8. Universal Service Standards ..................................................................................................................................... 89 9. Service Standards ....................................................................................................................................................... 96 10. HRSA PCN 15-01 10% Administrative Cap for Ryan White ....................................................................... 106 11. HRSA PCN 15-02 Clinical Quality Management ........................................................................................... 111 12. HRSA PCN 16-02 Eligible Individuals & Allowable Uses of Funds .......................................................... 121 Please refer to the Health Resources & Services Administration’s website for complete and additional policy clarifications and

program letters: https://hab.hrsa.gov/program-grants-management/policy-notices-and-program-letters

Policies and Procedures


Ryan White HIV/AIDS Program funds are the payer of last resort in relation to all other state and federal funding sources. This includes Medicaid. Specifically federal policy requires:

• Ryan White HIV/AIDS Program funds may not be used to pay for Medicaid covered services for Medicaid beneficiaries.

• Ryan White HIV/AIDS Program subrecipients who provide Medicaid covered services must be Medicaid certified.

• Ryan White HIV/AIDS Program subrecipients are expected to vigorously pursue Medicaid enrollment for individuals who are eligible for Medicaid coverage.

• Ryan White HIV/AIDS Program subrecipients must seek payment from Medicaid when they provide a Medicaid covered service for a Medicaid beneficiary.

• Ryan White HIV/AIDS Program subrecipients must back bill Medicaid for any Ryan White Act funded services provided to Medicaid eligible clients once Medicaid eligibility is determined.

Subrecipients are expected to exhaust mandatory Medicaid dollars before utilizing discretionary Ryan White HIV/AIDS Program funds. The Payor of Last Resort policy is currently part of all BPHC Part A provider contracts and is also restated on all program budgets. If you have questions regarding these policies please feel free to call our office.

1) Payer of Last Resort Policy


Based on HRSA issued monitoring standards, the following are all standards that must be adhered to by subre-cipients. Cost Principles

1. Payments made to subrecipients/subcontractors for services need to be cost-based and relate to Ryan White administrative, quality management, and core medical and support service costs in accordance with standards cited under OMB Circulars or the Code of Federal Regulations

a. Ensure that budgets and expenses conform to federal cost principles b. Ensure fiscal staff familiarity with applicable federal regulations

2. Payments made for services to be reasonable, not exceeding costs that would be incurred by a prudent per-son under the circumstances prevailing at the time the decision was made to incur the cost.

a. Make available to the grantee very detailed information on the allocation and costing of expenses for services provided

b. Calculate unit costs based on historical data c. Reconcile projected unit costs with actual unit costs on a yearly or quarterly basis

3. Written procedures for determining the reasonableness of costs, the process for allocations, and the policies

for allowable costs, in accordance with the provisions of applicable Federal cost principles and the terms and conditions of the award. Costs are considered to be reasonable when they do not exceed what would be incurred by a prudent person under the circumstances prevailing at the time the decision was made to incur the costs.

a. Have in place policies and procedures to determine allowable and reasonable costs b. Have in place reasonable methodologies for allocating costs among different funding sources and Ryan White categories c. Make available policies, procedures, and calculations to BPHC on request

4. Calculate unit costs based on an evaluation of reasonable cost of services; financial data must relate to per-

formance data and include development of unit cost information whenever practical a. Have in place systems that can provide expenses and client utilization data in sufficient detail to determine reasonableness of unit costs

5. When determining the unit cost of a service, unit cost cannot exceed the actual cost of providing the service

and includes only expenses that are allowable under Ryan White requirements a. Use the following formula to calculate unit cost: allowable administrative costs plus allowable program costs divided by number of units to be provided b. Have in place systems that can provide expenses and client utilization data in sufficient detail to calculate unit cost c. Have unit cost calculations available for BPHC review

Building a Healthy Boston

2) Federal Monitoring Standards


Unallowable Costs

All funded subrecipients must: 1. Maintain files with signed subrecipient agreement, assurances, and certifications that specify unallowable

costs 2. Provide and maintain budgets, expenditures, and related reports to BPHC with sufficient detail to document

that they do not include unallowable costs 3. Maintain on file policies and documentation consistent with the following cost prohibitions:

• Cash payments to intended recipients of RWHAP services • Clothing • Developing materials that may be perceived to promote or encourage injection drug use • Drug use and sexual activity • Employment and Employment Readiness • Funding liability risk pools • Funeral, burial, cremation or related expenses • Household appliances • International travel • Local or State personal property taxes (for residential property, private automobiles, or any other personal

property) • Off-premise social/recreational activities or payments for a client’s gym membership • Pet foods or other non-essential products • Pre-exposure prophylaxis and Non-Occupational Post-Exposure Prophylaxis • Purchase of land, construction, or renovations • Purchase or improve land, or to purchase, construct, or permanently improve (other than minor remodel-

ing) any building or other facility • Purchase Vehicles without Approval • Syringes

Property Standards

All funded subrecipients/subcontractors must: a. Develop and maintain a current, complete, and accurate asset inventory list and a depreciation

schedule that lists purchases of equipment by funding source b. Make the list and schedule available to the grantee upon request

1. Provider/Subcontractor tracking of and reporting on tangible nonexpendable personal property, including

exempt property, purchased directly with Ryan White Part A funds, and having a useful life of more than one year and an acquisition cost of $5,000 or more per unit

2. Implementation of adequate safeguards for all capital assets that assure that they are used solely for author-ized purposes.


3. Real property, equipment, intangible property, and debt instruments acquired or improved with federal

funds held in trust by subrecipients/subcontractors, with title of the property vested in BPHC but with the federal government retaining a revisionary interest.

a. Establish policies and procedures that acknowledge the revisionary interest of the federal government over property improved or purchased with federal dollars b. Maintain file documentation of these policies and procedures for BPHC review

4. Assurance by subrecipients/subcontractors that title of federally-owned property remains vested in the fed-eral government, and if the HHS awarding agency has no further need for the property, it will be declared excess and reported to the General Services Administration

5. Title to supplies to be vested in the recipient upon acquisition, with the provision that if there is a residual

inventory of unused supplies exceeding $5,000 in total aggregate value upon termination or completion of the program and the supplies are not needed for any other federally-sponsored program, the recipient shall retain the supplies for use on non-federally sponsored activities or sell them, and compensate the federal government for its share contributed to purchase of supplies

a. Develop and maintain a current, complete, and accurate supply and medication inventory list b. Make the list available to BPHC upon request

Income from Fees for Services Performed

1. Use of Part A and third party funds to maximize program income from third party sources and ensure that Ryan White is the payer of last resort. Third party funding sources include Medicaid, State, Children’s Health Insurance Programs (SCHIP), Medicare (including the Part D prescription drug benefit), and private insurance.

a. Have policies and staff training on the requirement that Ryan White be the payer of last resort and how that requirement is met

b. Require that each client be screened for insurance coverage and eligibility for third party programs, and helped to apply for such coverage, with documentation of this in client files

c. Carry out internal reviews of files and billing system to ensure that Ryan White resources are used only when a third party payer is not available

d. Establish and maintain medical practice management systems for billing 2. Ensure billing and collection from third party payers, including Medicare and Medicaid so that payer of last

resort requirements are met a. Establish and consistently implement:

• Billing and collection policies and procedures

• Billing and collection process and/or electronic system

• Documentation of accounts receivable 3. Ensure provider/subcontractor participation in Medicaid and certification to receive Medicaid payment

a. Document and maintain file information on grantee or individual provider agency Medicaid status b. Maintain file of contracts with Medicaid insurance companies c. If no Medicaid certification, document current efforts to obtain such certification


4. Bill, track, and report to the grantee all program income (including drug rebates) billed and obtained 5. Ensure service provider retention of program income derived from Ryan White-funded services. Funds may

be added to resources committed to the project or program and used to further eligible project or program objectives, and/or used to cover program costs.

a. Document billing and collection of program income b. Report program income documented by charges, collections, and adjustment reports or by the application of a revenue allocation formula

Imposition and Assessment of Client Charges

1. Subrecipient/Subcontractor policies and procedures must specify charges to clients for services, which may include a documented decision to impose only a nominal charge

a. Establish, document, and have available for review:

• Sliding fee discount policy

• Current fee schedule

• Sliding fee eligibility applications, in client files

• Fees charged and paid by clients

• Process for charging, obtaining, and documenting client charges through a medical practice information system, manual or electronic

2. No charges imposed on clients with incomes below 100% of the Federal Poverty Level (FPL)

a. Document that:

• Sliding fee discount policy and schedule do not allow clients below 100% of FPL to be

charged for services

• Personnel are aware of and following the policy and fee schedule

• Policy is being consistently followed

3. Charges to clients with incomes greater than 100% of poverty that are based on a discounted fee schedule and a sliding fee scale

a. Cap on total annual charges for Ryan White services based on percent of client’s annual income, as follows:

• 5% for patients with incomes between 100% and 200% of FPL

• 7% for patients with incomes between 200% and 300% of FPL

• 10% for patients with incomes greater than 300% of FPL b. Have in place a fee discount policy that includes a cap-on-charges policy and appropriate implementation, including:

• Annually evaluating clients to establish individual fees and caps

• Track of Part A charges or medical expenses inclusive of enrollment fees, deductible, co-payments, etc.

• Have a process for alerting the billing system that the client has reached the cap and should not be further charged for the remainder of the year

• Documentation of policies, fees, and implementation, including evidence that staff under-stand the policies and procedures


Limitations on Uses of Part A Funding 1. Adherence to 10% cap on Administrative Expenses. Appropriate subrecipient administrative activities include:

a. usual and recognized overhead activities, including established indirect rates for agencies; b. management oversight of specific programs funded under this Ryan White ; and c. other types of program support such as quality assurance, quality control, and related activities.

2. Inclusion of indirect costs

a. Indirect costs (capped at 10%) can be included only where the subrecipient has a certified HHS-negotiated indirect cost rate using the Certification of Cost Allocation Plan or Certificate of Indirect Costs

b. Subrecipients wishing to include an indirect rate must provide documentation of a current Certificate of Cost Allocation Plan or Certificate of Indirect Costs that is HHS-negotiated, signed by an individual at a level no lower than chief financial officer

c. If using indirect cost as part or all of its 10% administration costs, obtain and keep on file a federally approved HHS-negotiated Certificate of Cost Allocation Plan or Certificate of Indirect Costs

Submit a current copy of the Certificate to the Boston Public Health Commission (BPHC)

____________________________________ 1 The Division of Cost Allocation in HHS negotiates and approves indirect cost agreements for entities receiving funding through

the Department. This Division negotiates rates through its four regional field offices and the national headquarters. To obtain in-

formation from one of these offices go to: http//rate.psc.gov and click on Contact Information, then click on the appropriate link:

National Headquarters, Western, Central States, Mid-Atlantic, Northeastern. Contractors and subrecipients/subcontractors want-

ing to claim administrative costs in their Ryan White HIV/AIDS Program budget as indirect costs are allowed to do so only (1)

with an HHS-approved indirect cost rate in accordance with applicable cost principles; and (2) in accordance with the 10% legisla-

tive limitation on administration costs, (i.e., indirect costs are included in the definition of grantee administration under Part A and

B, as mandated by the legislation).


Purpose of the Policy : To guide the administration of the Ryan White Part A Program to ensure compliance with grant requirements related to charges to clients as per the following Health Resources Service Administration guidance:

• Ryan White Legislation: • §2605 (e)(F)(A) • §2605 (e)(1)(B) • §2065 (e)(1-4)(C-F)

• Part A Assurances • HRSA FOA • BPHC Ryan White Part A Contract

Important Terms:

• Costs are the accrued expenditures incurred by the recipient /Subrecipient during a given period requir-ing the provision of funds for: (1) goods and other tangible property received; (2) services performed by employees, contractors, Subrecipient, subcontractors, and other payees.

• Charges are the imposition of fees upon payers for the delivery of billable services. • Payments are the collection of fees from payers that are applied to cover some aspect of costs of billa-

ble services. • Billable services are those for which there is a payer source. • Charge Master/Schedule of Charges is a comprehensive listing of prices for billable services and/or

procedures. • Sliding fee means that costs change according to the patient’s income, lack of income, or ability to pay.

Policy and Procedures: If the Subrecipient charges health insurers for a service, the Subrecipient must impose the same charge and provide a discount to uninsured clients using the service. If an entity receiving Part A funds charges for services, it must do so on a sliding fee schedule that is availa-ble to the public and is based upon established fees that are reasonable and necessary. Establishing a fee schedule should not result in a bureaucratic system to means-test individuals or families before Part A sup-ported services are available. The sliding fee scale is intended to protect clients from becoming so over-whelmed by financial burdens they leave the system. The sliding fee scale/schedule of charges shall not per-mit charges to clients with an income ≤ 100% FPL and permits nominal fees for clients with income >100% FPL.

3) Sliding Fee Scale Policy and Cap on Charges for Ryan White Part A Services


The Sliding Fee Scale to be implemented is:

The schedule of charges must be displayed in a conspicuous location available to clients. Agency must have a written statement that no patient is denied care due to an inability to pay. Thus, clients can be charged but cannot be denied services if they have not been able to pay the charge. Individual, annual aggregate charges to clients receiving Part A services must conform to statutory limitations. The term, "aggregate charges," applies to the annual charges imposed for all such services under Part A with-out regard to whether they are characterized as enrollment fees, premiums, deductibles, cost sharing, co-payments, coinsurance, or other charges for services. This requirement applies to all service Subrecipients from which an individual receives Part A funded services. The intent is to establish a ceiling on the amount of charges to recipients of services funded under Part A. A. Annual limitation on the amounts of charges (i.e. caps on charges) for Ryan White services is based on

the percent of the client’s annual income, as follows:

B. The cap on charges must be displayed in a conspicuous locations available to clients. C. The client is responsible for keeping track of cumulative charges assessed across all the client’s service

Subrecipients and should ensure that the information provided is accurate. D. The client is responsible for keeping track of cumulative charges assessed across all the client’s service

Subrecipients and should ensure that the information provided is accurate.

E. Agency must have a written policy statement that no Ryan White Part A client is denied care due to an inability to pay. Agency shall have billing, co-pay, and collection policies and procedures that 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

Client FPL Fee

<100% No fee

101 – 200% 5% of fee

201 – 300% 10% of fee

301 – 400% 15% of fee

401 - 500% 25% of fee

>500% 100% of fee

Client FPL Cap on Out-of-Pocket Expenses

<100% N/A (No Out-of-Pocket Expenses)

101 – 200% Actual gross income multiplied by 5%

201 - 300% Actual gross income multiplied by 7%

>300% Actual gross income multiplied by 10%


F. The Subrecipient will establish and maintain a schedule of charges and a policy that includes a cap on charges with the following: • Responsibility for client eligibility determination to establish individual fees and caps. • Tracking of Part A charges or medical expenses inclusive of enrollment fees, deductibles, co-

payments, etc. • A process for alerting the billing system when the client has reached the cap and should not be fur-

ther charged for the remainder of the year.

The Subrecipient must ensure that personnel are aware of, and consistently follow, the policy for schedule of charges and the cap on charges. Monitoring

A. The BPHC Ryan White Services Division (RWSD) shall review the following Subrecipient policies for the compliance with legislative requirements: A) the schedule of charges and sliding fee scale and B) the cap on charges.

B. The RSWD shall review client records and documentation of actual charges and payments to ensure the policy is being correctly and consistently enforced and clients below 100% of FPL are not being charged for services.

C. The RSWD will review the accounting system and records of charges and payments to ensure compli-ance with sliding fee scale requirements and cap on charges requirements and review client records for eligibility determination to ensure consistency with policies and federal requirements.

D. The RWSD will verify that the schedule of charges, the sliding fee scale, and the cap on charges is dis-played in visible locations available to clients.

E. The RSWD shall review the policy indicating that Ryan White clients will not be denied services based on inability to pay and documentation reflecting annual acknowledgement of enrollment staff and fiscal staff of this policy.

F. The RWSD shall review:

• The accounting system for tracking patient charges and payments. • The process for alerting the billing system when the client has reached the cap and should not be

further charged for the remainder of the year. • The charges and payments to ensure that charges are discontinued once the client has reached his/

her annual cap. • Documentation reflecting annual acknowledgement of enrollment staff and fiscal staff of training

on policies related to schedule of charges and cap on charges.


4) Client Eligibility for Ryan White Services

Background The U.S. Health Resources and Services Administration (HRSA) establishes eligibility criteria for Ryan White Part A services to ensure that Ryan White services are reserved for people living with HIV with very limited fi-nancial resources. This policy was updated for FY 2018 to include clarifications regarding HIV verification, in-come, residency and insurance documentation requirements. With the exception of HIV verification, all eligibil-ity must criteria must be determined annually and recertified at six-months with a letter of self-attestation to no changes. Subrecipient monitoring will include the review of documentation of client eligibility. HIV Verification All Part A Subrecipients must maintain in client records primary documentation of positive HIV status. Exam-ples include:

• Any document with medical provider’s (MD, NP (ACRN), PA, RN, pharmacist) signature certifying HIV status Examples: letter from provider with letterhead

• Lab results indicating a positive HIV antibody test • Home-delivered meals certification

Income Threshold All Part A Subrecipients must screen HIV+ clients for income eligibility, based on a threshold of 500% of the current Federal Poverty Level (FPL) as determined by the U.S. Department of Health and Human Services (HHS), with an additional allowance for dependents based on the MassHealth dependent allowance formula. Individuals with incomes at or below this level will be eligible for RWSD and OHA services. Subrecipients may continue to serve individuals with incomes above this level and must not deny services to clients based on in-come. However, agencies may not use Ryan White funds to serve clients with incomes above the threshold. Subrecipients may implement a hardship waiver for clients with incomes over 500% of FPL whose out-of-pocket expenses have exceeded 10% of their income during the year. Subrecipients may continue to set lower financial eligibility levels for particular services in consultation with BPHC and MDPH. HHS updates poverty guidelines annually, typically in late January. The best place to find updated, accurate information is on the HHS website at https://aspe.hhs.gov/poverty-guidelines. Screening and Documentation Providers must screen for financial eligibility at intake and at six-month intervals thereafter, and must document sources of income and FPL range in the client’s record. Suitable documentation includes:

• At least two recent paystubs with pay periods indicated

• Copy of the most recent federal tax return

• W-2 for the most recent tax year

• 1099 form

• Documentation of SSDI, SSI, unemployment compensation, and any other government benefits or enti-tlements.

If there are no earnings, the client record should contain a signed letter from the medical case manager or health care provider stating that the client has no income and indicating how the client is being supported. Agencies may maintain their own processes to screen for and document financial eligibility. These processes should in-clude documents that obtain accurate, updated income information while ensuring low-threshold access to care and services.


Client Income Summary Agencies may use or adapt the BPHC and MDPH Client Income Summary form to record a client’s income and FPL. This form is intended to help facilitate access to other client services by communicating the results of finan-cial eligibility screens that are completed by one service provider so that other providers do not need to duplicate this work. If the Client Income Summary form is not used, another means of documenting client income and FPL range must be created. Agencies are required to record the exact percentage of FPL for each client every six months. Agencies may chose to take this figure from the demographics section of the e2Boston data base. The figure must be calculated based on the client’s most recent, up to date income verification. With appropriate releases of information, agencies working with common clients can coordinate ongoing six-month eligibility screens, share documentation of income and self attestation forms, and assess eligibility without requesting the same information directly from the same client. Agencies sharing Client Income Summaries and self-attestation documents do not need to share actual backup income documentation; however, agencies may request this documentation. Agencies should exchange contact information in order to facilitate communication and information-sharing. For example, two agencies might coordinate income eligibility screening processes and paperwork. The Medical Case Manager (MCM) screens a client for financial eligibility and works with the client to complete the Client Income Summary. The MCM then refers the client to a meals program with a completed Client Income Sum-mary to the meals provider along with a signed release of information. The agencies communicate about who will complete the financial eligibility screens every six months (in most cases, the MCM), exchange contact infor-mation, and decide how to share results and documentation on a routine basis. BPHC and MDPH may request the backup documentation used to determine financial eligibility during a monitoring visit. When the referring agency is also funded by Part A, and/or the client has signed the appropriate consent form for funder review, BPHC reserves the right to verify that appropriate eligibility review mechanisms are in place and that the related backup documentation is in the client file. Proof of Residency All service providers must document current residency in the Boston EMA for clients receiving Part A services. Documentation must be included in all client files. Proof of residency can be in the form of:

• A non expired driver’s license

• Utility bills

• Bank statement

• Real estate tax bill or receipt

• A current residential lease

• Proof of income in the form of a paycheck, or government issued benefits statement

• A signed case manager letter on letterhead verifying the town and postal code of residence. Proof of Insurance Subrecipients must maintain documentation of clients’ current health insurance status. An example of health in-surance status could include a current statement from a health insurance provider, an HDAP approval letter, a print out from an electronic medical record that indicates type of coverage, or a print out from the virtual gate-way indicating type of insurance coverage. Providers who are not located within a medical facility may collaborate with a client’s medical provider or nursing team to obtain current documentation of a client’s insurance. Subre-cipients are responsible for ensuring Ryan White Part A funds remain payer of last resort and for identifying cli-ents who may be underinsured or uninsured, and to assist those clients in applying for health coverage.


Six-Month Eligibility Recertification Client income, residency and insurance status must be verified and documented every 6 months for all ACTIVE clients receiving Ryan White Part A services. If the client reports CHANGES to any eligibility status, then the service provider must collect the documents which reflect those changes.

Self-Attestation If the client reports NO CHANGES to any eligibility status, the service provider is not required to collect documents. However, the service provider must complete a letter which attests to no changes at the time of recertification. The letter should be on agency letterhead, indicate the eligibility criteria which has not changed, signature of the provider and be maintained in the client file. The service provider can attest to no changes of the clients income and/or residence status ONCE PER YEAR.


Sample Income Summary

Client Income Summary The purpose of this form is to document financial eligibility for Ryan White HIV/AIDS Program services. The form

can be shared among service providers to verify income screening if the client has signed and dated a release of infor-

mation document. This form is valid for six months after the screening date.

Annual income:

To determine if the client’s gross annual income is less than 500% of the FPL, if the client provides a pay stub, the

gross year-to-date (“YTD”) is used to calculate gross annual income. If the pay stub does not show gross YTD, the

client must provide two pay stubs, so that yearly gross earnings can be calculated using the client’s average earnings

for the designated pay period. If the client is not working, but receives SSI, SSDI, or any other type of monetary bene-

fit, proof of this must also be shown. If the client is not working and has no income, or if he/she is working but cannot

provide proof of this, a letter from the client’s medical case manager is required. If the client does not have a medical

case manager, then a letter from his/her clinician is required. If a client is over-income, check to see if the client has

dependents. If so, documentation must be provided (usually a copy of page one from the most recent U.S. 1040 tax

return, if available), and an additional $4,320 (as of 2018) is then allowed for each dependent.

Documentation provided for client record (check all that apply): Pay stubs) ______ Social Security Administration (SSDI/SSI) letter ______ Private disability statement ______ Department of Transitional Assistance (TANF/EAEDC) letter _______ Veterans’ Benefits ___________ Other: _________________

Federal Poverty Level:

Consult the U.S. Department of Health and Human Services poverty guidelines for the current calendar year at http://

aspe.hhs.gov/poverty. Based on the client’s gross annual income, what is the applicable Federal Poverty Level (FPL)

range? FPL: %

Signatures:

Client: _______________________________________ Date: ________________

Agency staff (person completing the form): ______________________________ Date: ________________

Title: ____________________________________________________________

Agency name:

Agency address:

Agency phone number:

Client Name: Client Code:

Screening date: Expiration date (six months after screening):

CLIENT ANNUAL INCOME: $

http://aspe.hhs.gov/poverty

http://aspe.hhs.gov/poverty


[agency letterhead]

DATE

RE: patient/client name here

To Whom It May Concern:

The above-named patient/client is currently receiving [insert service type] from me. In accordance with your eligibility criteria and

to the best of my knowledge, this patient/client currently has zero income and is unable to afford to pay for [insert service type] due

to financial hardship. The patient/client is currently being supported by [insert type of support, do not include names].

If you have any further questions, please call me at 000-000-0000.

Thank you for your assistance.

Medical Case Manager /Health Care Provider Signature Here Date:

Medical Case Manager/Health Care Provider Printed Name Here

Agency Name Here

Patient/Client Signature Here Date:

Patient/Client Printed Name Here

Note: This letter must be completed on agency letterhead.

Sample Hardship Waiver / No Income Letter


[agency letterhead]

DATE

RE: patient/client name here


The above-named patient/client is currently receiving [insert service type] from me. This patient’s /client’s income is [insert in-

come], which is >500% of the FPL. His/her documented out-of-pocket expenses have presently exceeded 10% of his/her income,

therefore he/she is now eligible for Ryan White Part A and B services for the rest of the calendar year.

If you have any further questions, please call me at 000-000-0000.

Thank you for your assistance.

Medical Case Manager /Health Care Provider Signature Here Date:

Medical Case Manager/Health Care Provider Printed Name Here

Agency Name Here

Patient/Client Signature Here Date:

Patient/Client Printed Name Here

Note: This letter must be completed on agency letterhead.

Sample Eligibility Letter for Exceeding Charges Cap


Sample Six-Month Eligibility Recertification

This is an OPTIONAL FORM. Agencies may use or adapt this six month recertification summary form to record a client’s income, residency and insurance statuses. This form can be used by a service provider to facil-itate coordination of care to another Ryan White Part A funded service provider. With appropriate releases of information, agencies working with common clients can coordinate ongoing six-month eligibility screens, share income documents and other forms without requesting the information directly from the same client.

This form is valid for 6 months after screening date.

Agency Name:

Agency Address:

Agency Phone Number:

Client Name: Client Code:

Screening Date: Expiration date (six month after screening):

Financial

Client Annual Income $ % of Federal Poverty Level %

Pay Stubs (2 most recent)

Social Security (SSDI/SSI) Letter

Private Disability Statement

Department of Transitional Assistance (TANF/

EAEDC) Letter

Veterans’ Benefits

Medical Case Manager Letter

Other:______________

Residency

Pay Stub

Government Issued Check

Government Correspondence

Valid Driver’s License/MA ID

Utility Bill

Bank Statement

Real Estate Tax Bill

Current Residential Lease

Medical Case Manager Letter including town and zip

code

Other:_____________

Insurance

HDAP Approval Letter

Letter from Insurer

Premium Statement

Dated Print out from Exchange

Mass Health Approval Letter

Other:______________

Signatures

Client:______________________________________

Date:________

Agency Staff: ________________________________

Staff Title ___________________________________

Date:________


Sample Self-Attestation Letter

Agency Letterhead

Date __________________

RE: Patient/Client Name or Client Code


The above-named patient/client is currently receiving [insert service name] from me. This patient’s/client’s eligibility was last documented on [Insert Date of Last 6 Month Eligibility]. Since that time there has been no change to the clients’ eligibility for Part A service. This applies to the following: (check all that apply) Income: (income at last documentation) Residency: (town and zip code) Insurance: (type of insurance)

______________________________ Staff Signature

______________________________ Staff Name Printed

______________________________ Date

______________________________ Patient/Client Signature

______________________________ Patient/Client Name Printed

______________________________ Date


Authorization to obtain/release information must be documented for all communication with external partners. Programs must have a release of information form that describes under what circumstances client information can be released. This form must clearly document: the name of agency/individual with whom the information is being shared; the information to be shared; the client signature and date signed; and provide space for revocation of authorization. All authorizations to obtain/release information expire 12 months from the date of signature. Documentation of multiple external partners is allowable on one form. To ensure clear documentation of client authorization, clients must indicate by initialing next to each individual entity with whom information is to be shared. At any point in time, clients reserve the right to revoke authorization to obtain/release information. In an instance where one form contains documentation for multiple entities, all authorizations are revoked and a new form must be completed with the client’s initials next to each individual entity as well as a signature of authorization.

This form can be used as a living document. Over time clients may want to allow the release of information to additional entities. This is allowable so long as the agency ensures the client initials accordingly. There will be no change to expiration of one year. All releases will expire at the date listed on the bottom of the page. The date listed cannot be changed. There is no extension of the release of information. At the end of one year , the agency needs to work with the client to obtain a new signed and initialed form.

Required Elements of authorization • Client ID • Entity to be shared (specific staff person, when possible) • Contact information (phone/fax/address or location?) • Date signed • Date of expiration (No more than 12 months) • Staff Signature • Client Signature • Client Initials identifying each specific authorization to each individual external agency

Revoked Authorization

• Client Signature • Date • Staff Initials

Optional • Emergency Contact • Name • Relationship • Contact Information

5) Authorization to Obtain/Release Information


Sample Authorization to Obtain/Release


6) Agency Incident Report Procedures

BPHC requests that agency staff report major incidents separately from the narrative reports submitted quarterly, and as soon as possible after the incident. The report should include the following information: • Reporting staff name • Date of incident • A detailed description of what happened In addition to alerting Program Coordinators to situations which cause stress to clients and staff, and may temporarily limit the services provided by the agency, these reports will allow BPHC to offer support and guidance where appropriate. BPHC requests the program complete this form for BPHC’s internal tracking purposes only. Examples of Incidents which should be reported include, but are not limited to: • Physical harm or threat of physical harm to a client or staff member • Significant structural damage to agency premises (such as a fire or flood) • Involvement of external law enforcement or emergency personnel. The Incident Report Form can be found on the following page.


Sample Incident Report


Boston Public Health Commission Ryan White Services Division Contract Transition Policy

At the end of a contract period, every vendor holding a Ryan White contract with the Boston Public Health Commission (BPHC), Ryan White Services Division is responsible for ensuring that any outstanding contract related issues are resolved. This policy applies in all instances of contract termination, regardless of the reason for the termination. Clients/Client Records (applicable only if services will not continue at agency) A. The vendor shall notify all clients affected by the contract termination that services will no longer be

provided. Such notification shall be provided at least 30 days prior to the contract termination date. The vendor should make every effort to notify clients in person. If in-person notification is not feasible, clients should be notified in writing via certified mail with return receipt. If a return receipt is not delivered within two weeks, a follow-up notice should be sent via regular mail. The notice should include a list of other agencies in the same geographic area that provide the same or similar services.

B. Whenever practicable, the vendor should assist each client with registration for services at another agency of the client’s choosing. This will necessarily include transfer of client records, whether maintained on paper or in electronic media, which must be undertaken in accordance with the terms of the confidentiality agreement entered into at the time of contract execution.

C. If a client does not wish for his or her records to be transferred to another agency, the vendor is responsible for the confidential storage of these records, per State and Federal laws.

Data No more than 15 days after the contract termination date, vendors must submit all client level data collected for purposes of the contract (including data from subcontracted agencies) up to the contract termination date. Data submissions must be made in the same manner as they had been during the contract period. Reporting A. No more than 30 days after contract termination, unless the contract manager directs otherwise,

vendors must submit a final Progress Report covering the period between the previous submission and the contract termination date. This includes both narrative and data submissions.

B. Vendors must submit a Ryan White HIV/AIDS Program Services Report (RSR) covering the period between the previous RSR submission and the contract termination date. The submission date for the RSR is on an annual basis following the end of each calendar year. If this is impossible, the vendor must work with BPHC staff to ensure that information needed to complete the RSR is available to BPHC.

Fiscal No more than 15 days after the contract termination date the vendor will submit any final billing. Purchased Items A. Program supplies paid for under the contract remain the property of the vendor. B. Capital and equipment purchases made with funds allocated under the contract are the property of

BPHC, unless such capital items have fully depreciated, in which case they remain the property of the vendor. If an item has not fully depreciated, BPHC will determine whether the item must be returned to BPHC or transferred to another vendor.

7) Contract Transition Policy


8) Universal Standards of Care

The Standards of Care are the minimum requirements that programs are expected to meet when providing HIV/AIDS support services funded by Ryan White Part A. The Standards of Care establish the minimum standards in-tended to help agencies meet the needs of their clients. Subrecipients may exceed these standards. The objective of the Universal Service Standards is to help achieve the goals of each service type by ensuring that pro-grams:

• Have policies and procedures in place to protect clients’ rights and ensure quality of care;

• Provide clients with access to the highest quality services through experienced, trained, and when appropriate, licensed staff;

• Provide services that are culturally and linguistically appropriate;

• Meet federal and state requirements regarding safety, sanitation, access, public health, and infection control;

• Guarantee client confidentiality, protect client autonomy, and ensure a fair process of grievance review and advo-cacy;

• Comprehensively inform clients of services, establish client eligibility, and collect and store client information through an established process;

• Effectively assess client needs and encourage informed and active client participation;

• Address client needs effectively through coordination of care with appropriate subrecipients and referrals to need-ed services;

• Are accessible to all PLWH in the designated 10 counties that constitute the Boston EMA.

1. ELIGIBILITY The purpose of these measures is to ensure Ryan White funds are used only for individuals who qualify for the service. This applies to all Part A services, regardless of setting. The eligibility requirements are outlined by HRSA. Any subre-cipient of Part A funding that is found to provide a service to a person who is not eligible for that service will be found non-compliant. Subrecipients of Part A services in the Boston EMA are required to document the minimum eligibility, detailed below, for all clients who access a service and are reported to Part A. All Subrecipients are subject to annual compliance visits by the recipient. 2. POLICY & PROCEDURES The objectives of the standards for Policies and Procedures are to:

• guarantee client confidentiality, ensure quality care and provide a fair process to address clients’ grievances

• ensure that services are available to all eligible clients

• ensure that services are accessible for clients

• inform clients of their rights and responsibilities as consumers of HIV/AIDS services.

Clients who access any Part A service must be provided with a Client Rights and Responsibilities document that includes, at a minimum, the subrecipient’s confidentiality policy, the subrecipient’s expectations of the client, the cli-ent’s right to file a grievance, the client’s right to receive no-cost interpreter services, and the reasons for which a client may be discharged from services, including a “due process” for involuntary discharge. “Due process” refers to an es-tablished, step-by-step process for notifying and warning a client about unacceptable or inappropriate behaviors or actions and allowing the client to respond before discharging them from services.


Clients are entitled to access their files with some exceptions: agencies are not required to release psychotherapy notes, and if there is information in the file that could adversely affect the client (as determined by a clinician) the subrecipi-ent may withhold that information but should make a summary available to the client. Agencies must provide clients with their policy for file access. The policy must at a minimum address how the client should request a copy of the file (in writing or in person), the time frame for providing a copy of the file (cannot be longer than 30 days), and what information if any can be withheld. Confidentiality assures protection of release of information regarding HIV status, behavioral risk factors, or use of services. Each subrecipient will have a client confidentiality policy that is in accordance with state and federal laws. As part of the confidentiality policy, all agencies will provide a Release of Information Form describing the circumstances under which client information can be released (name of subrecipient/individual with whom information will be shared, information to be shared, duration of the release consent, and client signature). Clients shall be informed that permission for release of information can be rescinded at any time either verbally or in writing. Releases must be dated and are considered no longer binding after one year. For agencies and information covered by the Health Insurance Portability and Accountability Act (HIPAA), the release of information form must be a HIPAA-compliant disclosure authorization. A Grievance Procedure ensures that clients have recourse if they feel they are being treated in an unfair manner or do not feel they are receiving quality services. Each subrecipient will have a policy identifying the steps a client should follow to file a grievance and how the grievance will be handled. The final step of the grievance policy will include information on how the client may appeal the decision if the client’s grievance is not settled to his/her satisfaction within the subrecipient agency. 3. PERSONNEL STANDARDS The objectives of the standards personnel are to:

• Provide clients with access to the highest quality of care through qualified staff • Inform staff of their job responsibilities support staff with training and supervision to enable them to perform their jobs well Any subrecipient awarded Part A funding will submit job descriptions and resumes for staff who are selected to be on the Part A budget. All agencies will define supervisory roles and staff will receive a minimum amount of administrative supervision related to their job. Agencies are responsible for providing staff with supervision and training to develop capacities needed for effective job performance. At a minimum, all staff should be able to:

• Provide appropriate care to PLWH

• Appropriately document the services they deliver to clients

• Have relevant experience in the appropriate service/treatment modality

• Clinical staff must be licensed or registered as required for the services they provide. See the attached service-specific standards for additional competencies for some service categories.

Staff and program supervisors will receive consistent administrative supervision (minimum of two hours per month). Administrative supervision addresses issues related to staffing, policy, client documentation, reimbursement, schedul-ing, training, quality enhancement activities, and the overall operation of the program and/or agency. In addition to administrative supervision, direct care staff will receive consistent clinical supervision (minimum of one hour per month). Clinical supervision addresses any issue directly related to client care and job-related stress (e.g., boundaries, crises, and burnout). Clinical supervision can occur in a group setting and must be provided by a third party who is not associated with the funded Ryan White program. The clinical supervisor may be employed by the subrecipient organization but must be impartial to the services provided. Staff in need of clinical supervision must have two sepa-rate supervisors for clinical and administrative supervision. Any subrecipient that employs a staff member who delivers services that are billable to an insurance must explore and utilize other sources of payment before accessing Part A funding to satisfy the payor of last resort principal.


4. DOCUMENTATION AND DATA MANAGEMENT The objectives of the Standard for Documentation and Data management are to:

• Establish minimum reporting requirements both to the recipient and to HRSA for all subrecipients of Part A funding

• Establish minimum requirements for the storing and handling of client information, both electronic and paper

• Ensure all subrecipients are aware of the obligation of reporting as related to the specific service they deliver Any subrecipient that delivers HIV/AIDS services in the Boston EMA will meet their obligation to all mandatory re-porting standards. These reporting requirements include documenting all interactions between clients and service sub-recipients in progress notes, assessments, and the development of service plans for clients, as well as quarterly and annual data entry that includes outcomes measures. Once agencies have determined a client’s eligibility for Part A services, they will conduct and document an intake and initial assessment. For certain service categories, Subrecipients will create an individual service plan for each client and update the assessment and service plan every six months. Every subrecipient will establish a system for recording client utilizations in the form of progress notes. These notes will be stored in client files and will illustrate approved activities for the indicated service category. Clients will be allowed access to their files and the information stored in the file. For more information, see the Poli-cies and Procedures section. All subrecipients will protect client information by establishing a secure system to manage and store client infor-mation. All files should be protected by a lock or password, and access to the information should be limited to rele-vant staff who provide client services or supervise staff who provide services. 5. SAFETY The objectives of the Standards for Safety are to:

• Require each subrecipient to establish policies and procedures to protect the physical safety of staff and clients, both on-site and in the community

• Establish a minimum requirement that eliminates harassment in the workplace

• Define a process for staff to respond to emergencies that involve clients The care and safety of any client that receives Part A services must be prioritized both when a client is at a subrecipi-ent location, or when receiving services at their home or in the community. Additionally, any person employed by a subrecipient that delivers Part A services has an expectation of safety and support to manage any crisis that may occur during the workday.


# STANDARD MEASURE

1.1 Part A services are provided only to persons living with HIV.

All eligible clients present proof of HIV diagnosis. Acceptable forms should be on letterhead and signed by a medical professional with the ability to diagnose HIV. A lab report indicating viral load and CD4 count is acceptable.

HIV status filed and verified by subrecipient at time of site visit

1.2 Services will be provided to PLWH who earn < 500% Federal Poverty Level.

Subrecipient will document clients’ income and FPL at intake and every six months thereafter. Acceptable forms of income include benefits statements, pay stubs, income tax documents, or a docu-ment that quantifies how a client meets their basic needs.

Income verification filed and verified by subrecipient at time of site visit

1.3 Subrecipients will comply with payor of last resort principal.

Any billable service will be billed to client’s insurance. Services cannot be performed by a credentialed employee in a facili-

ty with billing capabilities without justification, or else program will be considered non-compliant.

Documentation of client’s current insurance status will be collected, filed, and updated every six months.

Proof of Insurance is filed and verified by subrecipient at time of the site visit.

1.4 Services will be provided to eligible persons who reside in the EMA

Subrecipients will collect documentation of clients’ address at intake and every six months thereafter. Proof of address includes any doc-ument with a formal, current address, including but not limited to: a lease, an energy bill, correspondence from insurance or other entity, valid state issued ID, or other appropriate justification of where a client resides.

Proof of address will be filed and verified by subrecipient at the time of the site visit.

1.5

Eligible persons will receive client-centered services that are appropriate to their needs

Subrecipients will deliver client-centered services as determined ap-propriate by an intake and needs assessment.

Should a client need a service not offered by subrecipient, an appro-priate referral will be made.


# STANDARD MEASURE

2.1 Rights and Responsibilities

Subrecipient develops policy and all clients are made aware of rights and re-sponsibilities upon intake. At minimum, policy includes:

Client right to access services

Client responsibility to respect staff and space

Client right to file a grievance

Signed document is stored in client file and reviewed by recipient at time of site visit.

Subrecipient right to refuse service and under what circumstances

Policy does not have to be specific to Part A program. Subrecipient may demonstrate an acceptable policy that covers all programming conducted at their agency.

2.2 Confidentiality

Subrecipient develops policy to protect the release of sensitive client infor-mation, including HIV status. Policy contains, at minimum:

Commitment to providing services in a confidential setting

Commitment to confidential storing of client files

Staff acknowledgment of confidentiality policy

Commitment to collect and document releases of information between other subrecipients

Signed document is stored in client file and reviewed by recipient at time of site visit.

Policy does not have to be specific to Part A program. Subrecipient may demonstrate an acceptable policy that covers all programming conducted at their agency.

2.3 Grievance Proce-dure

Subrecipient must develop a policy that includes, at minimum: How to file a grievance Who to direct grievance toward Timeline to resolve grievance Step-by-step process if grievance remains unresolved Client and staff signatures Signed and dated policy appears in client chart.

2.5 Intake and Ongo-ing Assessment

Subrecipient must define their process for determining eligibility, conducting an intake assessment, and ongoing needs assessments related to the service provid-ed.

Pertinent documents are stored in client file and updated every six months.

2.6 Transition and Dis-charge

Subrecipient has policy detailing how clients are graduated or discharged from the program. The policy must include language about termination of services if client is in violation of rules or poses threat.

Policy is signed by client and stored in file.


# STANDARD MEASURE

3.1 Proficiency and licen-sure

Staff possesses qualifications congruent with demands of job description.

Job descriptions, resumes, and licensure is on file and up-to-date.

3.2 Training and Onboarding

Subrecipient must develop and execute training that clearly outlines expecta-tions and requirements of Part A service subrecipients, including standards for the subrecipient’s specific funded service category.

3.3 Cultural Competency

Subrecipient’s physical space, recruitment, onboarding and training policies must reflect an intention to provide accessible services in a manner most ap-propriate to the population served.

Subrecipient will provide documentation, in the form of a mission statement or other document, that reflects a commitment to provide appropriate services to the target demographic.

3.4 Supervision

The supervision structure will be defined and documented in a policy by the subrecipient.

All staff will receive a minimum 0.05 FTE or two (2) hours of administrative supervision per month.

Direct care staff will receive 0.025 FRT or one (1) hour of clinical supervision per month. Clinical supervision may happen in a group setting.

Supervisors will conduct quality assurance reviews of client files. Supervisor’s signature and date indicates review. Supervision schedule will be made availa-ble upon request.

4.1 File Security Subrecipient maintains client records locked or password protected. Access to

records is limited to relevant staff.

Subrecipient will observe process for file security during monitoring activities.

4.2 Client Access to File Clients are granted access their records upon request and in accordance with

policy developed by subrecipient.

Policy is signed and dated by client and stored in client file.

4.3

Subrecipient will meet documentation re-quirements as ex-pected by recipient, HRSA, and the spe-cific service category.

Data entry and reporting requirements for recipient and HRSA are complete on schedule and with complete and accurate data.

Subrecipient staff will verify that all obligations have been met through e2Boston.

4.4 Progress notes Subrecipients will record and store progress notes related to all client encoun-

ters and congruent with approved activities for the service category. Notes will be reviewed at the time of a monitoring visit.

4.5 Chart Review Subrecipient will develop protocol for regular chart review for completion and

compliance with Part A standards.

4.6 Archiving Subrecipient will archive client files for a minimum of seven (7) years. Policy

must be documented and may include use of Iron Mountain or other archive systems.


# STANDARD MEASURE

5.1 Subrecipient must have documen-tation of a staff and client safety protocol for the site.

Policy is signed by staff members and made available to recipient.

5.2 Subrecipient has policies against bullying, discrimination, and sexu-al harassment

Policy is established and has language that protects staff and clients regardless of how they identify.

Policy is made available to recipient

5.3 Subrecipient has a policy for staff safety on community and home visits

Policy is signed by staff members and made available to recipient upon request.

5.4 Subrecipient has protocol for inci-dent reporting Protocol is made available to Subrecipient


6) Service Standards of Care

AIDS DRUG ASSISTANCE PROGRAM

FOOD BANK/HOME DELIVERED MEALS

# STANDARD MEASURE

1.1 Funding for this service must include: A medication formulary that meets the minimum requirements from all approved classes of medications according to HHS treatment guidelines *Guidelines can be found at: https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0

Subrecipient must provide documentation that the ADAP program meets HRSA/HAB requirements

1.2 If medication is stored on-site, the subrecipient must have policies and procedures for accessing and moni-toring medications in storage

Policy is on file

1.3 Subrecipient has a policy indicating Part A funds make up 5 - 10% of the state's total ADAP funding

Policy is on file

1.4 Subrecipient has a process to secure the best price available for all products, including 340B pricing or better for medications

Subrecipient reports on the number of individuals served, the medications provided, and the cost at which they were covered

2.1 Subrecipient has a policy to determine eligibility, including proof of client’s prescription drug coverage and proof of an attempt to receive medical coverage from other sources

Policy is on file

3.1 Subrecipients must obtain documentation of client ADAP eligibility at least every six months, including documentation of availability of other potential coverage options

Documented in client file

# STANDARD MEASURE

1.1 Allowable activities include provision of: • Personal hygiene products • Household cleaning supplies • Water filtration/ purification systems

Subrecipient will report only on approved items to be provided through this service

1.2 Unallowable activities include provision of: • Permanent water filtration systems • Household appliances • Pet foods • Other non-essential products

Subrecipient reports, invoices, and client rec-ords will not demonstrate the provision of these items

2.1 Subrecipient has policies that address the following: • Amount of food distributed per client • Frequency of food items/meals provided • Mechanism to assess need and ongoing needs as-

sessment

• Policy is on file • Mechanism to assess need is completed for

each client accessing services.

3.1 Subrecipient will develop internal documentation system to record and track services provided by type of service, number of clients served, quantity provided, date and time of service

Documentation system is available to recipient. Information is entered into database by the subrecipient as instructed by recipient.


HOUSING

# STANDARD MEASURE

1.1 Housing Assistance Eligibility A client must be eligible for Part A services, including proof of HIV status, income eligibility, and proof of residency in the Boston EMA. Policies Subrecipient develops policy with detailed algorithms that define: • Use of funds, including time limits, maximum amount per contract year,

and reapplication process • Reasonable assessment of urgent need related to imminent loss of hous-

ing or current state of unstable housing • Ryan White funds will not fund amount that exceeds Fair Market Rent

(FMR) for client's residence • Instructions on how award is to be applied and unallowable costs, includ-

ing any cost that can reasonably be covered by Emergency Financial As-sistance

• Payment process

1.2 Housing Search Ser-vices

Client records document: • Client eligibility determination • Housing Services including referral services provided • Individualized housing plans (4.3). • Housing referral services defined as assessment (3.2), search, placement,

and advocacy services must be provided by staff with comprehensive knowledge of local, state, and federal housing programs. (2.0)

2.1 Payment process • Subrecipient develops and follows specific payment procedures • Payments cannot be made directly to clients • Payment cannot be made for security deposit or mortgage payments

3.1 Program Application Completed program application is on file

3.2 Housing Needs Assess-ment

Detailed client budget is completed with staff member

3.3 Individual Service Plan Individual Service Plan must clearly detail budgeting and tenancy goals. Clients agree to be engaged in services for six months after award and update subrecipient on housing stability

3.4 Housing Certification A letter indicating medical necessity of housing is on file

3.5 Inactive Clients • Progress notes that document attempts to reach the client • Client records will become inactive for clients with no contact for six

months

3.6 Discharging Clients Subrecipient will have discharge policy for completion or termination of services


MEDICAL CASE MANAGEMENT

# STANDARD MEASURE

1.1 Needs Assessment • Complete initial intake and ongoing needs assessments are stored in client file. • Ongoing assessment of clients' needs, including minimum assessment of:

health care, mental health, transportation, risk reduction, substance use, legal needs, support systems, nutrition, housing, and insurance

1.2 Treatment Plan/Comprehensive Service Plan

• Subrecipient develops treatment plan with client format and informed by the needs assessment.

• Treatment plan is updated every six months and stored in clients’ file.

1.3 Coordination of Care

• Appropriate referrals and releases of information are filed. • Subrecipient links client to appropriate care as identified by needs assessment

1.4 Treatment Adher-ence Services

• Needs and appropriate referrals are documented. • Client is screened for barriers to treatment adherence

1.5 Coordination and follow-up of medi-cal treatments

• Documentation in the form of progress notes of clients' progress and change in need.

• Subrecipient follows clients’ needs and continues and identifies necessary re-ferrals and resources until clients’ needs are met.

1.6 Client-specific ad-vocacy and/or re-view of utilizations of services

• Treatment goals are marked as complete or updated indicating changes. • Subrecipient reviews clients' use of services and evaluates progress toward

goals on treatment plan.

2.1 Administrative and clinical supervision

• Policies are written and accessible • Subrecipient has written procedures for administering supervision • Staff receive one hour of administrative and one hour of clinical supervision

(direct care staff) per month

2.2 Caseload • Policies are written and accessible. • The subrecipient is responsible for creating a systematic approach to deter-

mine the appropriate levels of service and maximum caseload. • Subrecipient has a written procedure for managing and tracking caseload. • Subrecipient will have a policy for how to manage a wait list for services if

necessary.

2.3 Inactive/Discharge Policy

• Subrecipient has a written procedure, accessible to all relevant staff, for deter-mining when a client is inactive.

• Subrecipient has a clear discharge protocol and policy.

2.4 Quality Manage-ment

• Policies are written and accessible • Subrecipient has written procedures on file to evaluate medical case manage-

ment services • Subrecipient staff has a working knowledge of evaluation procedures • Subrecipient participates fully in EMA Quality Management activities includ-

ing data and chart review


MEDICAL CASE MANAGEMENT

# STANDARD MEASURE

3.1 Initial assessment of service needs • A completed initial assessment of client • Initial assessments completed within 14 days of initial

contact.

3.2 Development of a comprehensive Individual Service Plan. Individual Service plans should include: • Continuous client monitoring to assess the

efficacy of the Individual Service Plan • Timely and coordinated access to medically

appropriate levels of health and support services and continuity of care

• Ongoing assessment of the client’s and oth-er key family members’ needs and personal support systems

• Re-evaluation of the individual service plan with adaptations as necessary

• A completed individual service plan within a client’s files.

• Individual Service Plan completed within 30 days of initial contact

• Regular contact is maintained with the client • Re-evaluation completed at a minimum of 6 months

3.3 Service Components that may include: • A range of client-centered services that link

clients with health care, psychosocial, and other services

• Treatment adherence counseling to ensure readiness for and adherence HAART

• Client-specific advocacy and/or review of utilization of services

• Benefit applications on file • Progress notes that include: • Brief description of the encounter/communication • Type of encounter/communication • Duration of encounter/communication • Date of encounter/communication • Evidence that a trained Medical Case Manager led the

encounter/communication

3.4 Transferring Clients • A progress note indicating that the client has been transferred, and if necessary a release of information to document communication with the transferring subre-cipient.

• Clients who wish to transfer will be enabled to do so within 10 days

3.5

Discharging Clients

Clients will be discharged from case management if: • Client request discharge • Client transfers out of care • Client is referred to another case manager • All the client’s needs have been met • Client violates several program rules and regulations • Case manager is unable to make contact for more than

1 year. Documentation of the discharged must be included in the file.

3.6 Re-engagement Clients who have been discharged and/or inactive for an extended period, defined by the subrecipient, and are eligible for services are required to complete a full intake assessment.


MEDICAL NUTRITION THERAPY

MEDICAL TRANSPORTATION

# STANDARD MEASURE

1.1 Eligible activities include: • Nutrition assessment and screening • Dietary/nutritional evaluation • Food and/or nutritional supplements per med-

ical provider’s recommendation • Nutrition education and/or counseling

Subrecipients will only request funding for allowable service

1.2 Activities must be initiated by a referral from a medical provider and based on a developed nutri-tional plan

All client files must include a referral from a medical provider and a nutritional plan

1.3 Activities under this category not provided by a licensed nutritionist or registered dietitian are unal-lowable and must be delivered under the Psycho-social Support category. (See HRSA PCN 16-02)

Client files will contain evidence of services provided by a licensed nutritionist or reg-istered dietician

2.1 Staff are appropriately licensed and credentialed to pro-vide approved services

Copies of licenses and credentials to be kept in employee records.

3.1 • Recommended services and course of medical nu-trition therapy to be provided, including types and amounts of nutritional supplements and food

• The signature of the referring medical provider and each registered dietician who rendered service, the date of service

• Date of reassessment • Date of initiation and termination of medical nutri-

tion therapy • Any recommendations for follow up • Planned number and frequency of sessions

Subrecipient policy on file and copy of nutri-tion plan made available to the recipient upon request.

4.1 Subrecipient maintains nutritional plan for each client, updated every six months

Documentation in client record

# STANDARD MEASURE

1.1 Approved transportation methods will include: • Contract with transportation service, public or private • Volunteer drivers • Purchase of a vehicle, with pre-approved from recipient • Voucher system • Rideshare

Subrecipient will report on only approved methods of transportation services

1.2 Subrecipient will not provide funds for the maintenance or fees of a vehicle, including loan payments, registration or license fees.

Subrecipient will not invoice the recipient for any of the mentioned costs.

1.3 Subrecipient will not provide cash payments or cash reimburse-ment to clients for transportation.

Subrecipient will not invoice the recipient for cash reimbursements.


MEDICAL TRANSPORTATION

# STANDARD MEASURE

2.1 Transportation services are provided through approved methods.

Approved methods for providing services include:

• A contract or some other local procurement mechanism with a pro-vider of transportation services

• A voucher or token system that allows for tracking the distribution of the vouchers or tokens

• A system of mileage reimbursement that does not exceed the federal per-mile reimbursement rates

• A system of volunteer drivers, where insurance and other liability issues are addressed

Purchase or lease of organizational vehicles for client transporta-tion, with prior approval from HRSA/HAB for the purchase

2.2 Program provides transportation that is appropriate to client’s needs.

Procedure includes how to assess best method of transportation based on client’s needs.

2.3 All drivers contracted to transport clients are aware of their responsibil-ity in the event of an accident.

Signed dates forms on file that describe contracted driver’s responsibilities, obligations, and liabilities

2.4 Subrecipient has policy that details types of transportation to be provid-ed and how each method are docu-mented and administered

Policy and procedures are on record.

2.5 Program has policy that defines use of Part A transportation funds are reasonable and used as last resort.

Policy is on record.

3.1 Clients that cannot be accommodat-ed are referred for other transporta-tion options and Case Managers are notified.

Clients not provided transportation are referred to other transportation options with documented contact notifying Case Managers

3.2 Subrecipient maintains documenta-tion ensuring that their agency is meeting outlined contract require-ments about service delivery descrip-tion.

• Reimbursement methods do not involve cash payments to service recipients

• Mileage reimbursement does not exceed the federal reimbursement rate

• Use of volunteer drivers appropriately addresses insurance and other liability issues

• Documentation that prior approval has been received for the purchase of the vehicle

• Subrecipient does not invoice recipient for cost of vehicle repairs, insurance, or loan payments.

3.3 Transportation programs maintain required records and documentation.

For all transportation methods, maintain program records that document:

• The number of trips provided

• The reason for each trip and its relation to accessing health and sup-

port services

• Trip origin and destination

• Client eligibility

• The cost per trip The method used to meet the transportation need

3.4 Subrecipient has documentation regarding administration of vouchers

Staff who administer vouchers are identified and trained on procedure

• Written procedures regarding voucher administration exist and staff are properly trained on procedures

• Vouchers are stored in secure, confidential location


NON-MEDICAL CASE MANAGEMENT # STANDARD MEASURE

1.0 Service Components may in-clude:

• Benefits/entitlement coun-seling;

• Referral activities that assist clients access public and private programs for which they may qualify

All types of case management encounters and communications

• Client needs, as assessed by subrecipient, reflect the nature of referrals and linkages made.

• Benefit/Entitlement applications on file

• Progress notes that include:

Brief description of the encounter/communication

Type of encounter/communication

Duration of encounter/communication

Date of encounter/communication

Evidence that a trained non-medical Case Manager led the encounter/communication

1.2 Service Plan • Subrecipient develops service plan with client and informed by the needs as-sessment.

• Treatment plan is updated at least every six months and stored in clients’ file.

1.3 Continuous client monitoring to assess the efficacy of the care plan

• Subrecipient reviews clients' use of services and evaluates progress toward goals on treatment plan.

• Progress notes clearly indicate encounters between subrecipient and client as well as status of needs and goal completion.

1.4 Documentation of all referrals • Subrecipient will make and document all referrals to meet clients’ needs with-in 30 days of drafting the action plan.

• Documentation in the form of progress notes and referrals in client files.

2.1 Administrative and Clinical Su-pervision

• Policies are written and accessible

• Subrecipient has written procedures for administering supervision

• Staff receive one hour of administrative and one hour of clinical supervision

(direct care staff) per month

2.2 Case load • Policies are written and accessible.

• The subrecipient is responsible for creating a systematic approach to deter-mine the appropriate levels of service and maximum case load.

• Subrecipient has a written procedure for managing and tracking case load.

2.3 Inactive/Discharge Policy • Subrecipient has a written procedure, accessible to all relevant staff, for deter-mining when a client is inactive.

• Subrecipient has a clear discharge protocol and policy.

3.1 Initial assessment of service needs

A completed assessment within a client Initial comprehensive assessment is completed within 14 days of initial contact

with client

3.2 Development of a comprehen-sive Service Plan, including:

• Continuous client monitor-ing to assess the efficacy of the Individual Service Plan

• Ongoing assessment of the client’s and other key family members’ needs and per-sonal support systems

• Re-evaluation of the indi-vidual service plan with adaptations as necessary

• Individual Service Plan completed within 30 days of initial contact

• Individual Service Plan completed within 30 days of a re-evaluation.

• A completed individual service plan within a client files.

• Regular contact is maintained with the client

• Re-evaluation completed every 6 months

• Progress notes that include:

Brief description of the encounter/communication

Type of encounter/communication

Duration of encounter/communication

Date of encounter/communication

Evidence that a trained Medical Case Manager led the encounter/communication


NON-MEDICAL CASE MANAGEMENT

ORAL HEALTH

# STANDARD MEASURE

3.3 Inactive Clients Progress notes that document attempts to reach the client.

3.4 Transferring Clients • A progress note indicating that the client has been transferred, and if necessary a release of information to document communication with the transferring subrecipi-ent.

• Clients who wish to transfer will be enabled to do so within 10 days

3.5 Discharging Clients • Discharge is documented in clients file

• Clients will be discharged from a program if:

Client request discharge

Client transfers out of care

All the client’s needs have been met

Client violates program rules and policies

Case manager is unable to make contact for more than 1 year.

3.6 Re-engagement Clients who have been discharged and/or inactive for an extended period, defined by the subrecipient, and are eligible for services are required to complete a full intake assessment.

# STANDARD MEASURE

1.1 Administer current HIV/AIDS Treatment Guidelines Guidelines on file

1.2 Clinical decisions that are supported by the American Dental Association Dental Practice Parameters

Guidelines on file

1.3 Services fall within specified service caps, expressed by dollar amount, type of procedure, limitation on the number of proce-dures, or a combination of any of the above, as determined by the planning council or recipient.

ADAPP on file

2.1 Participating dentists possess appropriate license, creden-tials, and expertise

Policy on file

2.2 The program director has training experience in clinical aspects of oral hygiene, dental treatment planning and dental care

Completed forms in subrecipient’s personnel files; forms contain Board of Dentistry license number.

3.1 Program has written policy regarding waitlist of eligible prospec-tive clients

Resume in subrecipient’s personnel files

3.2 Program ensures that treatment is provided with the written con-sent of the client

Written policy on file with BPHC or MDPH

3.4 Program has policies and procedures to address client complaints of discrimination by participating dentists

Dentist has signed contract with Oral Health pro-gram including a statement that clients will pro-vide written consent for treatment

3.5 Recruitment and training of contracted dental providers. Subrecipient has procedure to recruit and onboard dental providers to offer Part A services at their practice.

4.1 Treatment Plan is developed based upon the initial examination of the client

Completed treatment plan in client file at the sub-recipient location, submitted by dentist, and re-viewed and approved by dental program director.

4.2 Treatment plan is reviewed and updated as deemed necessary by the dental provider or dental program director

Updated treatment plan in client file at the subre-cipient location, submitted by dentist, and revised and approved by dental program director.


PSYCHOSOCIAL SUPPORT

# STANDARD MEASURE

1.1 Unallowable costs include recreational activities, gym memberships, and nutri-tional supplements.

Invoices will not include purchases of unallowable services.

1.2 Pastoral counseling must be availa-ble to clients from all faiths.

Client's faith will not be a barrier to accessing services.

1.3 Services may be provided by those who are infected with or affected by HIV.

Subrecipient will have a written and posted policy that supports activities will be open to anyone infected with or affected by HIV.

2.1 Subrecipient will develop and docu-ment programming congruent with ser-vice category definition and reasonable for services they are able to provide.

Service delivery documentation will be stored in client records.

2.2 Group sessions will be defined as three or more people.

Subrecipient will report only sessions with 3+ people as a PS group

2.3 Group and individual PS sessions will have topic or curriculum

Subrecipient will develop system to record notes for individual and group counseling sessions that include, at minimum: • Topic • Duration of session • Name of peer

2.4 Group sessions will be facilitated by a person living with HIV OR a person with relevant/appropriate skills, experi-ence and knowledge.

Group facilitators will meet requirements of job description, and resume will be on file


SUBSTANCE ABUSE — RESIDENTIAL

# STANDARD MEASURE

1.1 Eligible programs will provide the following services: • Pretreatment • Harm reduction • Counseling • Relapse prevention • Medication assisted therapy and pharmaceuticals • Detox, where appropriate

Program policies and procedures detail allowa-ble activities Clients’ treatment plans will detail allowable services

1.2 Inpatient detoxification in a hospital setting is un-allowable under Part A

• Subrecipient will not report use Part A funds for inpatient detoxification services

• No invoices submitted to recipient will include detoxification in a hospital setting

1.4 Subrecipients are licensed or certified to provide sub-stance use services. Their skills will be congruent with the specified substance use treatment modality

• Resume and license will be on file • Training module will reflect ongoing education

1.5 Facility where services are delivered is licensed by an appropriate state agency to provide substance abuse services

• Subrecipient complies with statewide regula-tions, including licensing requirements, and is approved to provide substance use services.

• Licenses and appropriate accreditation made available upon request

2.1 Subrecipient collects and documents a clinical referral for each client served.

• Referrals are documented and on file. • Clinical referral may be submitted by a pro-

vider with any of the following qualifica-tions: MD, NP, PA, RN, LMHC, LICSW, LADC, CADAC


10) HRSA Policy 15-01


HRSA Service Category Descriptions and Allowable Costs can be found at:

https://hab.hrsa.gov/program-grants-management/policy-notices-and-program-letters http://bphc.org/whatwedo/infectious-diseases/Ryan-White-Services-Division/Pages/Funded-Providers.aspx Ryan White Standards of Care


Staff Contact List FY 2018 ...................................................................................................................................... 126 Internet Resources ..................................................................................................................................................... 127 Agency Websites ....................................................................................................................................................... 128

Grantee Administration


ADMINISTRATION

Jenifer Jaeger, MD Director, Infectious Disease Bureau [email protected]

Dennis Brophy Director, Ryan White Services Division [email protected]

PROGRAM

Cheryl Brickey Senior Program Coordinator [email protected]

Elizabeth Rios Senior Program Coordinator [email protected]

Nick Emard Program Coordinator [email protected]

Maya Haynes Program Coordinator [email protected]

Marcos Palmarin Program Coordinator [email protected]

Mahara Pinheiro Program Coordinator [email protected]

QUALITY MANAGEMENT

Katie Cobb Senior Program Coordinator [email protected]

Katherine D’Onfro Senior Program Coordinator [email protected]

FISCAL

Regis Jean-Marie Bureau Administrator [email protected]

Frantzsou Balthazar-Toussaint Fiscal Manager [email protected]

Monica Araujo Fiscal Coordinator [email protected]

Sheldon Ramdhanie Fiscal Coordinator [email protected]

DATA

Irina Neshcheretnaya Data Manager [email protected]

Boston Public Health Commission Infectious Disease Bureau, HASD Phone (617) 534-4559

1010 Massachusetts Avenue, 2nd Floor Fax (617) 534-2480

Boston, MA 02118 Web www.bphc.org

Staff Contact List FY 2018


Internet Resources

Local Resources

Boston Public Health Commission Ryan White Services Division http://www.bphc.org/whatwedo/infectious-diseases/Ryan-White-Services-Division/Pages/Ryan-White-Services-Division.aspx The Boston Public Health Commission Ryan White Services Division programs are integral to the distribution of Ryan White Part A funding within the Boston EMA, and the success of our funded agencies to promote health and enhance quality of life for PLWH. Included on the website are provider forms, quality management reports and resources, and pertinent links for HRSA-related information. Massachusetts Department of Public Health Office of HIV/AIDS | http://www.mass.gov/dph/aids The Massachusetts Department of Public Health Office of HIV/AIDS provides a variety of services throughout the Commonwealth of Massachusetts. Currently services range from prevention and education to HIV counseling and test-ing, client services, health, and support services.

Federal Resources HRSA — Health Resources and Services Administration |http://www.hrsa.gov HRSA administers programs that improve the nation's health by expanding access to comprehensive, quality health care for all Americans. HRSA is the federal grantee of Ryan White Act funding. Links include: HIV/AIDS Bureau, Ryan White Act History and Programs, Grant Opportunities, Tools for Grant Writers, as well as Education and Training Opportuni-ties. HRSA — Target Center | https://careacttarget.org/ The TARGET Center website is the central source of technical assistance and training resources for the Ryan White HIV/AIDS Program. The site is the one-stop shop for tapping into the full array of TA and training resources funded by HRSA HIV/AIDS Bureau, which administers Ryan White services. NQC — National Quality Center | http://nationalqualitycenter.org The National Quality Center (NQC) provides no-cost technical assistance to all Ryan White program grantees to improve the quality of HIV care nationwide. Funded through a cooperative agreement with the New York State Department of Health AIDS Institute, NQC serves the needs of Ryan White program grantees across all Parts and funded subrecipients, for technical assistance in quality improvement. CDC — Divisions of HIV/AIDS Prevention |http://www.cdc.gov/hiv/default.htm The CDC Division of HIV/AIDS Prevention mission is to prevent HIV infection and reduce the incidence of HIV-related illness and death in collaboration with community, state, national, and international partners. Links include: Basic Science, Surveillance, Prevention Research, Vaccine Research, Prevention Tools, Treatment, Funding, Testing, Evalua-tion, Software, Training, STD Prevention, and TB Prevention. SAMHSA — Substance Abuse and Mental Health Services Administration | http://www.samhsa.gov SAMHSA is improving the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illness. Links include: Grant Oppor-tunities, Contract Opportunities and Legislative Information. OMH — Office of Minority Health |http://minorityhealth.hhs.gov The mission of OMH is to improve the health of racial and ethnic minority populations through the development of ef-fective health policies and programs that help eliminate disparities in health. Links include: Minority AIDS Initiative, Con-ferences, Statistics and a Resource Center for funding opportunities. GRANTS.GOV | http://www.grants.gov


AIDS Project Worcester www.aidsprojectworcester.org

AIDS Response Seacoast www.aidsresponse.org

Beth Israel Deaconess Hospital—Plymouth www.bidplymouth.org

BMC Pediatric AIDS Program www.bmc.org/pediatrics-infectiousdisease/ ser

vices/pediatricAIDS.htm

Boston Health Care for the Homeless Program www.bhchp.org

BPHC Ryan White Dental Program www.bphc.org

Cambridge Health Alliance www.challiance.org

Casa Esperanza www.casaesperanza.org

Catholic Charitable Bureau of the Archdiocese of Boston www.ccab.org

Codman Square Health Center www.codman.org

Community Research Initiative of New England www.crine.org

Community Servings www.servings.org

Dimock Community Health Center www.dimockcenter.org

East Boston Neighborhood Health Center www.ebnhc.org

Edward M. Kennedy Community Health Center www.edwardmkennedychc.org

Father Bill’s & MainSpring www.helpfbms.org

Fenway Community Health Center www.fenwayhealth.org

Greater Lawrence Family Health Center www.glfhc.org

Harbor Health Services, Inc. www.hhsi.us

Justice Resource Institute www.jri.org

Lynn Community Health Center www.lchcnet.org

Massachusetts Alliance of Portuguese Speakers www.maps-inc.org

MGH Chelsea HealthCare Center & MGH Boston www.massgeneral.org

Merrimack Valley Assistance Program www.mvap.org

Montachusett Opportunity Council www.mocinc.org

New Hampshire Department of Health and Human Services www.dhhs.state.nh.us

Upham’s Community Health Center http://uphamscornerhealthcenter.org/

Southern New Hampshire HIV/AIDS Task Force www.aidstaskforcenh.org

Part A Subrecipients

R y a n W h i t e S e r v i c e s D i v i s i o n I n f e c t i o u s D i s e a s e B u r e a u

B o s t o n P u b l i c H e a l t h C o m m i s s i o n

1 0 1 0 M a s s a c h u s e t t s A v e n u e , 2 n d F l o o r B o s t o n , M A 0 2 1 1 8

( 6 1 7 ) 5 3 4 - 4 5 5 9 ( p ) | ( 6 1 7 ) 5 3 4 - 2 4 8 0 ( f )

w w w . b p h c . o r g

ryan white services division infectious disease bureau · sample program narrative ... thank you...

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