Imposition of Charges: Not Just an Imposition, It’s the Law!


Good afternoon everyone and welcome to the HAB webinar on Imposition of Charges this is Heather Hauck the Deputy Associate Administrator for the HIV/AIDS Bureau here at HRSA we have quite a bit of information that we will be covering today so please bear with us and pay attention to the intricacies of this particular topic we’re very happy to be able to provide this webinar today in today’s training we will cover a summary of the legislature from programmatic requirements related to the imposition of charges a review of the distinctions between schedule of charges nominal fee flat rate and sliding fee scale how to apply statutory and programmatic requirements to common recipient organizational scenarios such as comparing ways recipients and sub-recipients assessed charges track charges and calculate the cap on charges and lasts to identify resources to assist Ryan White HIV/AIDS program recipients and sub-recipients with this particular topic so why is it that we are covering imposition of charges today and a few other opportunities in the next couple of months the imposition of charges is a term that comes directly from statute and the Ryan White statute refers to it specifically as requirements regarding the imposition of charges for services so we are using this phrase imposition of charges to encompass all of the elements necessary to meet the requirements of the sections of this statute it’s all the activities in position of charges encompasses all the activities policies and procedures related to assessing Ryan White HIV/AIDS program patient charges as outlined in the statute so why is this topic important for a few reasons one of course is it is in the Ryan White HIV/AIDS program statute and we have the extended citation in the sub bullet in the second bullet it’s also because we have noted over the years during site visits that because this is such a complicated concept it does tend to be a finding during our site visits and so we wanted to have the opportunity to clarify what the components of imposition of charges are and and provide some technical assistance so that people can recipients and sub-recipients can be in compliance with the legislative and programmatic requirements around imposition of charges it’s also important to note a few key areas that we will be covering in more detail throughout the slide presentation but we wanted to go ahead and lay them out now because they are some of the common issues that people have identified as being challenging first it’s important to note that the imposition of charges is based on the income of the individual and not on the total household income or family income and we’ll talk more about the difference between imposition of charges being based on the income of the individual which may differ from your eligibility determination criteria which may be they based on total household income or family income it’s also important to note that in the imposition of charges provision it says clearly that no Ryan White program patient should be denied service due to that individuals ability to pay and we want to be very clear that that that it is not our requirement it’s not the statutory requirement that someone is turned away if they’re unable to pay and furthermore the statute does not require that patients or clients that fail to pay it’s failed to pay are turned over to debt collection agencies this may vary in terms of your state or your local laws or regulations but the statute itself does not require that an individual is turned over to debt collection if they’re not able to play exactly so we also wanted to cover a little bit about the legislation applicability and implementation so for Ryan White Parts A and B what the statute says is that imposition of charges applies to services with to services with assistance provided under the grant and in the Part C section of the statute it says early intervention services under the grant so it can be confusing to people in terms of what it is that we’re talking about in terms of what is assistance and what our early intervention services and how do I operationalize an imposition of charges on medical case management or emergency financial assistance or a referral to care because those are all different types of services and not all of them necessarily can be linked to an imposition of charge so for the purposes of our implementation what have is indicating is that imposition of charges applies to those services for which a distinct fee is typically build within the local healthcare market you might hear that phrased as a fee that is usual customary and reasonable and based on locally prevailing rates we determined that this would be a practical approach to imposition of charges it would be implementable for recipients and sub-recipients and certainly we were also cognizant of the fact that this better aligns with eight four agencies that are Multi multi funded as Dybbuk also follows this guidance so for those of you who receive have funds and pippick funds this better aligns with how it’s operationalized in in the BPHC Community Health Center programs as well the imposition of charges applies to all Ryan White Parts A B and C equally HAB does not apply the imposition of charges to Part D or ADAP and there are a few specific reasons for that for the ADAP program in particular it’s because the majority of ADAP programs don’t have a direct relationship with a patient and so would have no mechanism for implementing an ambitious imposition of charges so as I just said there are different there are different pieces of imposition of charges it’s important to note that if you’re an A or B recipient that means that most likely you are monitoring your sub-recipients practices and implementation of imposition of charges if you’re a part C or sub-recipient you’re actually implementing the imposition of charges so we outlined here and I’m not going to read everything on the slide because there’s a lot of information but we tried to outline what are the common pieces it’s just a difference in terms of the approach you’re either directly implementing it if you’re Part C or you’re monitoring if you’re Part A and Part B and what we’re going to do throughout the rest of the presentation is do a much deeper dive in terms of what are all these things that are on this slide and how do you actually operationalize them like fun so we also wanted to point out that there is a particular part of the statute that talks about a waiver it is very specific to only a limited set of types of clinics so recipients that are operating as a free clinic that might be a health care for the homeless clinic there’s actually a specific designation of free clinics in the Community Health Center program those are the only clinics that have the option to completely waive the imposition of charges on Ryan White patients so it’s for the majority the vast majority of you all a and B recipients sub recipients of a and B and C recipients and sub-recipients you are required to actually charge a Ryan White program patient who has an income over 100 percent of FPL for services rendered even if it is only a nominal fee which could be as little as $1 for that service so just a couple of things in terms of the agenda for today so the first section we’re going to cover quite a bit of terminology these slides are available to you so we certainly encourage you to download them and take notes because the terminology can be quite complex we’re also going to walk through federal poverty level in terms of what it is how it’s calculated and how its utilized in terms of imposition of charges we’re also going to walk through the statutory requirements of each of the compass that that are the totality what what we call imposition of charges and then we’re going to preview a little bit about what we are going to be doing in terms of presentations at the National Ryan White conference in December (2018) as well as other resources and and technical assistance that you all will be hearing about we know that this is a complicated requirement and the implementation of this requirement may seem daunting and that is why we are happy to be doing this webinar today as well as happy to be doing the follow up technical assistance and presentations that we’ll be doing over the next couple of months we want to be clear about the fact that we have definitely heard from you all recipients our project officers and other stakeholders for clarifications around this particular part of the statute for additional technical assistance as well as care where support and that is why again we are rolling this out today and over the coming months so that we have an opportunity to work with you all on how to better understand and implement the totality of what imposition of charges is in the Ryan White statute so I am now going to turn it over to the to the amazing team of have staff who are going to do the far more complicated job than what I just had to do of walking you through those various sections and the first person who is going to kick us off in in the next series of the presentation is Gail Glasser who is a Senior Project Officer in the Division of Community HIV/AIDS Programs here at HAB yep thank you so much Heather before we go and get into the weeds let’s go with some terminology that you’ll be seeing a lot of today by the way these terms are on the download let’s start off in the next three slides we’ll review seven terms we felt it was important to fully understand these terms and be able to distinguish these terms this is our introduction of terms and we’ll go over them in more detail throughout the training so don’t panic let’s start off with B schedule and that’s a complete listing of billable services and their associated fees based on locally prevailing rates or charges a fee schedule is different from a schedule of charges the fee schedule is not required by Ryan White legislation but having one in place is considered a best practice and by the way a requirement for health center grant recipients you can find fee schedules on the CMS website as they’re used by Medicare to pay doctors or providers or suppliers you can also google fee schedule and the city or state of of interest and find local and regional fee schedules on Google schedule of charges now is a term used in in our legislation and our requirement for our recipients it refers to fees imposed on the Ryan White patients for services based on the patient’s annual gross income a schedule of charges may take two different forms a varying rates such as a sliding fee scale or a flat rate next term we’re looking at nominal charge that is a charge greater than zero it’s important that we make this distinction if some providers have incorrectly interpreted nominal charge to be zero cap one charges is also requirement in legislation simply they law limits the annual cumulative charges to an individual for HIV related services based on the federal poverty level and the gross annual income during the calendar year and again annual income is income before taxes and other deductions are taken out once the cap is reached all HIV charges must be waived for the calendar year next term waiver as Heather did explained to you earlier on there is legislation language that says recipients may receive a waiver of the imposition of charges requirements the waiver is an exception and not frequently used a waiver can only be requested by recipients off as free clinics please note that only a handful of recipients are operating as free clinics therefore every other Ryan White recipient or sub-recipient should be charging patients over a hundred percent for services rendered even if it’s only a dollar. Federal poverty level is a measure of income issued every year by HHS and is used to determine eligibility from many federal programs programs like Medicaid, SNAP, CHIP. Ryan White eligibility and imposition of charges let’s look at the first annual gross income there are three approaches to determine income gross income is the amount of money you earn typically on a paycheck before payroll taxes and other deductions adjusted gross income is used to determine a taxpayers income bracket and refers to total income for the year – certain adjustments modified adjusted gross income equals total income for the year with certain adjustments added back into the total any of these forms of income can be used by Ryan wide providers for the purpose of imposition of charges and many providers opt to use the modified adjusted gross income since this is a measure used for Medicaid and CHIP programs after all what the provider is already using this for eligibility using it for imposition of charges helps to simplify processes and the imposition of charges processes in an agency however providers should keep in mind that the modified approach may not be representative of the clients most recent income and when it comes to imposition of charges using the most recent known income it’s very important for our presentation we’ll be referring to annual gross income as always means income earn during the calendar year the most important fact is that imposition of charges uses individual and not household income now now I’m going to turn it over to my colleague Kelley Weld Thank You Gail, I know some of you are already very familiar with federal poverty level either you use it for Ryan White eligibility and perhaps you use it for some other federal program but FPL is also fundamental to understanding and implementing the imposition of charges requirements as we go through this section I’m going to point out the differences and how FPL is used for Ryan White eligibility versus imposition of charges there are some important distinctions to be made between the two and this is an area that seems to be a point of confusion so we’re going to spend a little bit of time on that the SPL guidelines are what they sound like how the federal government defines poverty SPL guidelines are an economic measure of poverty based on income they vary based on family size and geographic location for example Alaska and Hawaii have higher federal poverty levels than the rest of the country there’s a bunch of modeling including several economic indicators like inflation that generates SPL but that’s a lot of math we’re not going to get into today as Gail mentioned poverty levels are commonly used to determine eligibility and benefits for programs such as Medicaid the Supplemental Nutrition Assistance Program (SNAP) Children’s Health Insurance Program (CHIP) and yes the Ryan White eligibility and imposition of charges requirements so the hurts of Ryan White legislation refers to the FPL guidelines to define who should not have a charge imposed who should have a charge imposed and the cap on charges or the maximum amount recipients may charge an individual during a calendar year we’ll get back to these three things in the coming slides also FPL guidelines are issued annually by HHS and providers are expected to update their systems each time there are changes in FPL in order to reflect the most recent guidelines so the table on the left of this slide shows the federal poverty guidelines for 2018 for the 48 states and DC the first thing to note he is that FPL is based on family or household size for example you can see by looking at this table that the poverty level for a household of one is twelve thousand one hundred and forty and the poverty level for a household of two is sixteen thousand four sixty and so on the second bullet states that imposition of charges is based on individual income as it relates to SPL this is where we get a lot of questions and you’ll hear a lot of references to individual income throughout the training I think part of the reason there’s so much confusion is that we get hung up on that term household size we just don’t think of individual income in terms of household but what if we want to know the federal poverty level for an individual what household size would you expect that to be it would be household of one in other words the poverty level for an individual is twelve thousand one hundred and forty which is highlighted on the slide this is the income threshold used to determine how much a patient is charged now you might be thinking what about the rest of the table well those have you familiar with Ryan White eligibility will know that recipients may use either individual income or household income to determine Ryan White eligibility and this slide attempts to show that visually providers when determining rainway eligibility have flexibility and you and they can use either individual income or household income which depending on family size can be based on any one of these poverty levels this is not the case with imposition of charges which is based only on individual income because both eligibility and imposition of charges require proof of income if providers are using individual income for eligibility no other documentation would be needed would need to be collected because you would have the individual income from the patient and you could use that for both your eligibility and imposition of charges however if you’re using family income for eligibility you would need to ask for and documents so individual and family income will touch on this again a little bit later but for now there are three things that I’d like you to keep in mind as we move on to the next slide one is that imposition of charges is based on individual income as it relates to the federal poverty level for a household of one and also the federal poverty level is an individual for an individual is a household of one and four 2018 that’s twelve thousand one hundred and forty the last thing I’d like you to take away from this slide and we haven’t talked about it yet is that when you hear the term a hundred percent FPL that is what the second column in this table represents 100 percent FPL in other words twelve thousand one hundred and forty is a hundred percent of the federal poverty level for an individual and sixteen thousand four hundred sixty is one hundred percent of the federal poverty level for a household of two and so on so if you slide the go I mentioned that FPL is referenced in statute with regard to imposition of charges to define three things you should not have a charge imposed who should have a charge imposed and what the annual cap on charges for an individual should be the blue italicized text to the right of each of these boxes is language taken directly from our legislation we’re going to go over the statutory language for each of these in greater detail later in the training so I’m not going to spend too much time on that here I just want to point out one thing on this slide note that there’s no mention of income at all in the blue italicized text instead the statute references a percentage of the FPL that is purposeful because poverty levels change every year and legislation of course cannot be updated each time new guidelines are released so that means that we have to translate this to income ourselves using the federal poverty guidelines and that’s what you see in the red text the income equivalent of the percent of FPL if you’re wondering how we came up with this numbers let’s take a look at the next slide you might recognize the first two columns of this table those are the FPL guidelines issued by HHS those of you who are responsible for eligibility determination whether that’s Ryan White Medicaid chip or other programs will be very familiar with this type of table for those who aren’t let’s talk about how you would construct a table like this it’s really simple actually so to calculate the numbers in the one hundred and fifty percent column you simply multiply the numbers in the one hundred percent column by 1.5 to calculate the numbers and the two hundred percent column you multiplied by two and so on and you can have up to as many columns as you would like on this table depending on your needs just keep in mind that since the federal poverty guidelines are updated annually this table too would need to be updated annually now we’re going to get to the fun part we’re going to do a little case study to help illustrate the intersection between eligibility and position of charges and FPL based on feedback from recipients most of the questions we receive center around this let’s imagine your clinics Ryan White low income eligibility cutoff is 300 percent and let’s assume it is based on household income meaning you are using the last column of this table to determine Ryan White eligibility based on family size now let’s determine or assume you have a female patient named Jane and Jane is married with three kids so she’s part of a household of five their income their household income is 80,000 so if we look at the row for household of five we can see that the cutoff for eligibility is eighty eight thousand two hundred and sixty that you can find that in the three hundred percent column since Jane’s household income is eighty thousand dollars that means that she would be eligible for Ryan White services but and this is a big but this is a key point of the imposition of charges requirement once Jane is enrolled in terms of in terms of imposing charges on her the clinic would use her own income and the poverty level of twelve thousand one hundred and forty the poverty level for an individual to determine how much Jane would be charged let’s suppose that her income is $10,000 because the poverty level for an individual is twelve thousand one hundred and forty she would not be charged since her income is below 100 percent FPL so the takeaway here again is that imposition of charges is based on individual income and not family or household income so we can sum up FPL and three points it’s used by recipients to define eligibility and some of you may use individual income to define eligibility some of you may use household income either approach is perfectly fine it might just mean that you need to collect both individual and household income from your Ryan white patients FPL is also used to determine how much to charge a Ryan White patient and it’s based on individual income only and FPL is used to determine the maximum maximum amount a patient can be charged in a calendar year that’s the annual cap on charges and this is also based on individual income as we continue through this training FPL will keep coming up as its central to imposition of charges so with that in mind I’m now going to turn things over to my colleague Connie Jorstad Connie great thanks Kelley so I have the great pleasure now that we have a pretty solid understanding of federal poverty level I get to introduce everybody to the statute and the statutory language so as we’ve already mentioned the imposition of charges requirement is a requirement from our federal statute and we have here a little math a little arithmetic to try to boil it down a little bit and of course it’s not exactly this simple as 1+1 but what we’re going to do breakdown the sections of the subsection that is called the requirements regarding imposition of charges for services that you’ll find throughout the statute we’re gonna break it down into these two big chunks the schedule of charges the cap on charges and then sort of bring it all back together as the imposition of charges so we recognize that the statute is wordy and it is not your run-of-the-mill wordy but legal wordy so we’re hoping that this little breakdown here will be helpful to everyone so starting off with the schedule of charges bear with me a moment as we’re going to go through the verbatim language in the statute so you see that here and it was already referenced a little bit by Kelley and so again where does the schedule of charges come from well we’ve established that it’s in statute and so here’s your proof in the case of the individuals with an income less than or equal to one hundred percent of the official poverty line the provider will not impose charges on any such individual for the provision of services under the grant great but I’m excited to tell you that there is still more in the case of individuals with an income greater than 100% of the official poverty line the the provider will one impose a charge on each such individual for the provision of such services and two will impose the charge according to a schedule of charges that is made available to the public and here’s where we see the schedule of charges specifically stated in statute and our first reference to publicly available but wait there’s still more here we have the legislative language around the nominal charge and here we see grantees may yadda-yadda-yadda assess the amount of the charge in the discretion of the grantee including imposing only a nominal charge for the provision of services subject to the provisions of such paragraph regarding public schedules and regarding limitations on the maximum amount of charges like I said it’s a lot of statutory language a lot of words so let’s break it down a little bit into some layman’s terms so we can all be on the same page right so as we said the schedule of charges is a term used in our statute you just saw it for yourself and as such the Ryan White recipients are required to have one your schedule of charges is basically as Gail had described is going to describe or define the fees that are to be imposed on your Ryan White patient for the Ryan White services they receive the statute does not state at all what your schedule of charges has to look like it may take the form of a flat rate or a varying rate which some people may better know as a sliding fee scale and the design of the schedule charges is really left up to this recipient the only specific statutory requirement related to the schedule of charges is that the patient’s your Ryan White patients at or below 100 percent FPL cannot be charged and those Ryan white patients with incomes above 100% FPL must be charged the statute also explains that you as Ryan White HIV/AIDS program recipients may impose a nominal charge so what is that you may recall Gail and Heather have both described nominal charges a fee greater than zero and again some folks may be defining a nominal charge as zero when in fact that is no not nominal all right so you’ll recall again that the the schedule’s charges describes the fees that are imposed on your Ryan white patients for Ryan White services your schedule of charges is an important required part of your imposition of charges policy to all of those policies and procedures that you have and your you know for your operations of your clinic or for your operations of your sub recipients that’s where all of this stuff is probably going to show up the schedule of charges requires that the Ryan White HIV/AIDS program recipients put into place a policy where they cannot impose a charge to Ryan white patients with income or below 100% FPL the schedule of charges again must include the imposition of charges to patients with incomes over 100 percent FPL so one hundred one percent and above the scheduled charges needs to be publicly available about publicly available we’ve heard from many recipients that they’ve been told or they’re under the impression that the that the publicly available means that the schedule of charges must be posted on a wall in your clinic and that that’s the only requirement like that’s the requirement the statute states that the scheduled charges is made available to the public and so publicly available is fairly wide ranging I mean it could be posting in the waiting room of a clinic it might also be as a handout at enrollment or at another time posting it on your clinic website your clinic uses an online patient portal you might want to have it there and certainly you know when Ryan White patient requests it you know you would you would be able to provide it it could be one approach it could be a combination approaches and there’s probably other approaches we haven’t even talked about here so we just expect that you guys know your patients best and how best to communicate with them and the broader communities that you serve all right so a few other things to think about related to schedule of charges if you don’t already have enough so one it applies to your uninsured Ryan White patients where you’re insured for my patients you are essentially billing or imposing the charge for the service to the insurance company using a fee schedule so again instead of applying the the imposing the charge on your clients you would be because they have insurance you would be imposing the charge on the insurance company the other payer as we mentioned before and we’ll mention again because it is one of the most misunderstood parts of our imposition of charges is that your Ryan White patient’s placement on the schedule of charges you how much they’re charged is based on individual annual growth income let me say that one more time just in case individual annual gross income each Ryan White HIV/AIDS program patients annual gross income is going to need to be documented even in household income is used to determine Ryan White eligibility keep in mind that a patient placement on your schedule of charges will change if there’s a change in either their annual gross income or changes in the FPL guidelines so we know already that annually the FPL guidelines are going to change and so that’s going to necessitate some sort of level of change and so for this reason it’s very important to regularly assess a patient’s status in terms of income because in some instances it’s in many instances it’s really in their best interest to have you guys know what their current income is so you can make sure they’re properly placed and they’re charged at the correct amount so again you need to have a schedule of charges for all your patients over 100 percent FPL and they you may choose to have a schedule of charges using that flat rate which is a single fee and can be nominal so for example a dollar or five dollars or a varying rates which is more commonly described as your sliding fee scale which is to say basically that the charges vary based on the patient’s income so let’s take a quick look at the differences in those types of schedules all right so we have three different examples of schedules of charges for three brilliantly named hypothetical clinics clinic a clinic B and clinic C remember you have the flexibility in how you set up your schedule charges as through these three clinics as long as you are not imposing a charge on your patients at or below a hundred percent and you are imposing a charge for those patients above 100 percent you have the flexibility and the number of FPL categories and you have and the type of schedule you choose to have so in the example that Kelley shared earlier there was a you know 150 percent FPL if you wanted to have categories from 100 to 150 152 to 203 you’re welcome to do that but that might make things a little more confusing so for the sake of simplicity we’re using the same FPL categories for all three schedules of charges so that you can actually do a better job an easier job of comparing so if clinic B wanted to have a 100 event yeah so they were so bad sorry so we went over how the schedule charges could be either a flat rate or a varying rate clinic a is using the flat rate the nominal fee of five dollars like I mentioned for anyone with an annual gross income over 100 percent FPL so anybody who’s Ryan White eligible that’ll come in for their services in clinic a that makes more than 100 percent FPL is charged $5 clinic B and clinic C are using those varying rates that we mentioned which is also referred to as a sliding fee scale where the fee varies based on the patient’s income level so clinic these sliding fee scale is nominal fee based on the patient FPL category so it’s kind of a combination of the nominal fee and the varying rate clinic sees sliding fee scale is based on a percentage of the fee schedule which is based on the and then the charge to the patient is based on the patient’s FPL category so here if the service is $100 and the patient is in the 101 to 200 percent FPL range they would be charged a ten ten dollars so you can see that a sliding fee scale is one way to do with scheduled charges it’s certainly not the only way it’s not a requirement under the Ryan White program but it is a requirement within the Community Health Center program and we’re going to get into that a little bit more a little later when we talk about the multi funded provider section in more detail all right so a quick synopsis of actors enrolled what is the responsibility as you’ll see recipients do need to have that schedule charges remember it is a statutory requirement and what it looks like is up to you the schedule charges needs to be publicly available again what that publicly available looks like is up to you but you need to make sure your patients can access this a part of this is probably going to involve how you communicate with your patients and how their charges are determined which then brings us around to just sort of the practically speaking you need to request and document your patients income why well you need the information to know where they fall on your schedule of charges and to let them know perhaps where they fall on that schedule of charges so that that publicly available schedule charges makes sense when you’re Ryan White patients receive services you then impose the charge which is to say you need to tell the patient what they owe you based on your schedule of charges and of course your Ryan White patients do have a part to play here which is primarily being responsive to the request being made of them yes we all understand that asking people for documentation and for income information and asking for money isn’t fun but it is necessary and ultimately the documentation really is in your patients best interest so after all of that I’m gonna hand you back over to Kelley and walk us through the next requirement of imposition of charges which is cap on charges take it away Thank You Kelley so the good news is that much of the cap on charges language and statute is very clear however we we know it’s much easier to spell it out and to implement it so let’s go through it this is the cap on charges language and statute it states that in the case of individuals with an income greater than a hundred percent of the official poverty line and not exceeding 200 percent of such poverty line the provider will not for any calendar year impose charges in an amount exceeding five percent of the annual gross income of the individual involved that is one of three pieces in legislation the other to define the other to FPL categories for example in the case of individuals with an income greater than 200 percent FPL the cap should the provider should impose charges in an amount exceeding 7 percent of the annual gross income of the individual involved and then finally in the case of individuals with an income greater than 300 percent of FPL the provider will not for any calendar year impose charges in an amount exceeding 10% of the annual gross income of the individual involved and those are the citations so what does all this mean in layman’s terms well earlier Gael defined cap on charges as the limitation on aggregate charges imposed during the calendar year based on a Ryan White patient’s annual gross income so in the XS that we just read legislation outlined specific FPL categories related to cap on charges the first one is 101 to 200 percent FPL patients whose income fall in this category are capped at 5% of their annual gross income the second 201 to 300% FPL patients in with incomes in this FPL category are capped at 7% of their income and those with incomes greater than 300% FPL would be capped at 10% also I want to point out that you don’t see the less than or equal to a hundred percent FPL category here although it’s mentioned in statute is if not mentioned in the cap on charges section specifically because it relates more to the schedule of charges that Kelley reviewed remember that providers cannot charge patients with incomes less than or equal to a hundred percent FPL therefore it goes without saying that they would not need a cap defined since they are not being charged so I’m going to walk you through an example of how to calculate the annual cap on charges for a patient whose annual gross income is $18,000 here in the gray table are the four FPL categories you’ll from earlier and their associated annual cap we’ve included the left-center equal to a hundred percent FPL category here so you can see that the cap is zero for that category the blue table shows the income equivalents for those FPL categories and if you recall when we did the FPL section earlier the large table with all the numbers that’s how you would get these figures you can also do some simple math and just multiply 100% by 2 to get 200% of FPL or the 100% FPL by 3 to get the 300% so it’s simple math so for this patient whose annual gross income is $18,000 if we look at the blue table we can see that eighteen thousand falls somewhere between twelve thousand one forty-one and twenty four thousand two eighty so that puts them in the 101 to 200 percent FPL category and since that category is capped is five percent of the patients annual gross income we can easily calculate the patient’s cap by multiplying 18,000 by 5% or 0.05 which is nine hundred dollars so this client would have an annual cap on charges of nine hundred dollars meaning once they are charged up to nine hundred dollars they would not be charged any further for the remainder of the calendar year remember if the patient’s income were to change or if the FPL guidelines were to change then this patient’s cap would need to be recalculated so let’s look at another piece of legislation statute it defines which services may count towards an individual’s annual cap and that states that the annual aggregate of charges imposed for such services during the calendar year without regard to whether they are characterized as enrollment fees, premiums, deductibles cost-sharing co-payments coinsurance and other charges that’s a lot to digest let’s take a look at what this means in layman’s terms so just for reference we took that the first bullet there is the statutory language from the previous slide just so that you have it after ready so what kinds of things can count towards the patient’s care if you look at the second bullet you can read this to mean any charge for services provided with assistance under the grant for which a distinct fee is typically billed in the local healthcare market imposed by both you the provider as well as other Ryan White providers we’re going to get into tracking charges in a moment and how it’s the patient’s responsibility to track these charges but for now just know that the cap can include more than just the charges that you impose you’ll notice in the first bullet there is a reference to other charges at the very end of the sentence other charges can include any charge for HIV related care to the extent the charge is in the context of or as a result of a Ryan White service these charges cannot include non HIV services but as long as the service is provided in connection with a Ryan White service it should be considered an HIV service if the recipient wishes it can including a list of charges that count towards the cap the patient’s out-of-pocket payments for items related to the patient’s HIV disease if that recipient explains this to the client so that was a lot of words this image is a simplified version of what counts towards your cap and it’s basically three things so the HIV related charges that you impose which is represented by the orange Ryan White HIV/AIDS program charges level the other Ryan White charges which would be HIV related charges your fellow Ryan White providers impose on that patient that same patient and then any of the patient’s out-of-pocket charges related to their HIV care that a patient reports to their provider which what are the requirements that recipients must meet in order to be in compliance with statute first providers must calculate each patient’s annual cap based on their individual annual growth income as if you haven’t heard enough today providers will also need to inform the patient of their cap as well as their responsibility to track all of their charges providers will also need to add up or track all applicable charges that is to say charges imposed by you and charges submitted by the client that were imposed elsewhere and then once that cap is met the provider should stop imposing charges at that time let’s now look at some things you should keep in mind about cap on charges some of this you’ve already heard is it relates also the schedule of charges but it applies here also the calculated cap on charges will change if there’s a change in an individual’s annual gross income or the FPL guidelines keep in mind that it’s important to use the most recent FDA guidelines and most recent income when determining a patient’s cap since cap on charges is based on individual income a patient’s income must be documented even if household income is used to determine eligibility and but unlike schedule of charges cap on charges applies to all Ryan White patients regardless of income or health care coverage and the cap is also based on charges imposed not the actual fee for service in other words in the case of a patient with a copay that Ryan White patient may only count the copay towards the cap not the total amount billed to the insurance company and the cap can only count when services are rendered not upfront this applies to bids paid for out-of-pocket for example if a Ryan White patient knows her total out-of-pocket costs for medication co-pays for the entire year for example when she sees the doctor at the end of June she can only submit six months worth of her out-of-pocket costs including those co-pays to her to count towards the cap because at that point that’s all she has spent thus far and the last thing to keep in mind is that the cap is based on the calendar year for example let’s say you have a Ryan White patient with an income a 200% FPL and they just met their cap this month if they come to see you again in November you would not charge them because they’ve met their cap however after January 1st they start all over again so they would be charged for any visit after January 1st until they met their cap again for that year so we talked about tracking charges earlier and that it’s the responsibility of the patient to track and report to you any charges encouraged whether that is from other Ryan White providers or any out-of-pocket costs related to their HIV disease but the provider also has a role to play here to start you’ll need to inform the patient of their responsibility to track and submit charges you should also let them know the types of charges that would count towards their caps you could provide them with a tracking sheet for instance to make it easier and remind them that is that it is in their best interest to track all their charges because it gets them to their cap quicker at which point they are no longer charged for services at all you’ll also need to review the documentation of HIV related charges that they submit to you to determine if they are allowable remember that for charges or payments to apply towards the cap they must be in the context of a Ryan White service third you’ll need to track the charges you impose on Ryan white patients and have a process in place outside of your existing financial management system that tracks other allowable HIV related charges as submitted by the patient these other charges combined with your own charges count towards the patient’s cap and finally you’ll need to have a process that will alert you to the fact that the patient has reached their cap and should not be further charged for the remainder of the calendar year in other words once the patient’s cap is met it’s your responsibility to waive any additional charges for the remainder of the year this may require this may require you to have two different systems that can talk to each other so as you can see this this would be a good example of where data sharing agreements would be extremely helpful now from a technical perspective we understand these two requirements are a bit complicated and as you know or might imagine a clinic doesn’t want to and should not have charges from other clinics mixed into their own billing system so this essentially means that you’ll want to have a conversation with the folks who manage your fiscal system to work out the logistics and and maybe you need to bring him a little something like chocolate or if they’re like me something salty can’t hurt right so seriously these are the ones these folks are the ones who are going to be in the best position to help you with this requirement so to wrap up cap on charges agencies must calculate a patient’s annual cap based on the individual income and if that income changes or the poverty levels change providers should recalculate their patients cab they should inform the patient of their tab and their responsibility to track and submit other Ryan White provider charges and any out-of-pocket payments related to their HIV and providers must press must have a process in place to ensure that each patient’s cap is not exceeded this means that agency should track these submitted charges aggregate them and once the cap is met with any additional charges for the remainder of the year and then it’s the patient’s responsibility in all of this to collect and track other charges and approved out-of-pocket payments and submit those to their provider so that wraps up cap on charges back to Gail thank you so much Kelley okay after hearing all that my job is to first of all tell you what should go into an imposition of charge policy clinic policy and procedure one of strategies you can do to implement all this there was a lot of pieces to all these requirements and all also for multi funded clinics how can you implement this I’m going to make some suggestions and recommendations that you can explore and again pursue with your project officer at a later point in time but trying to get some kind of realistic implementation next steps for you okay now that we’ve gone over schedule of charges and cap on charges you should have a pretty good idea about what to include in your written policy and procedure that outlines how you would implement the imposition of charges requirements again the following items should be included in that policy number one a schedule of charges that does not impose a charge to Ryan White patients with income at or below a hundred percent imposes a charge to all Ryan White patients with income over a hundred percent and limit aggregate charges during the calendar year for all Ryan white patients and that’s your cap on charges that we’ve been talking about include a process to capture documentation of the Ryan white patients annual gross income needed to determine placement on the schedule of charges and annual cap on charges a process to assess document and track the charges that the agency imposes on the Ryan white patients and also track the charges imposed on on their patient by other providers finally having a reliable system to alert the building system that a Ryan white patients cap has been reached and should not be further charged for the remainder of the year providers should make it to influences how do you educate your clients around that providers should make materials available to the Ryan white patients explaining the patient’s role in the imposition of charges again tracking charges across all providers and other out-of-pocket costs an imposition of Charge policy may be part of a larger organizational policy and it does not need to be a standalone policy providers should ensure staff are aware of and consistently follow the established policies and procedures examples of the kinds of staff that might be involved in this process include the receptionist intake staff case manager or billing staff recept recipients sub recipients should include these requirements in their provider agreements mo EES mo use contracts with their sub recipients here’s a portion of an actual policy Part C policy on imposition of charges given what we have just learned what two things should be updated to a better align with Habs implementation recommendations okay let me give you the answer the first correction to be made is in the first sentence charging Ryan white patients with income greater than a hundred percent is not optional it should read must be charged not can be charged the second correction would be the last sentence so again work with your project officer as you develop these policies and procedures so they’re in alignment with all the things that we’ve heard today this past table here looks at clinics that recipients that are multi funded it’s a lot here but again let’s look take pieces of this because this is a strategy for recipients who also received funding from vivek many of our recipients and sub-recipients thought it would be helpful to go over challenges faced by these multi funded clinics we know many people think requirements for health care centers are incongruent with those of Ryan White and that it’s not possible to have one schedule of charges that meets both programs requirements and we’re going to give you a suggested way to address that let’s go through the requirements and see how this can be achieved clinics funded by have and Didache need to implement requirements that have a slightly different focus remember we talked about terminology earlier and how important was the difference between a schedule of charges and a sliding fee scale with multi funded clinics those distinctions are even more important while the specific requirements in each program vary these requirements are not inherently in conflict they actually complement each other if it has a requirement similar to have imposition of charges called sliding fee scale discount program this table shows a side-by-side comparison of the two requirements multi funded clinics will need to implement both requirements which have a slightly different focus while the requirements aren’t identical they aren’t necessarily incompatible first let’s look at the similarities in terms of services that qualify both requirements apply to any service for which a distinct fee is typically billed for within the local healthcare market and both programs cannot deny a Ryan White patient service due to their inability to pay in addition we discussed earlier in the training about a fee schedule is not required of Ryan White recipients it’s good practice and it is a requirement of BPHC funded clinics the vivix fee schedules are based on the cost of services and local prevailing rates we’ve also discussed how providers must impose a charge on Ryan white patients based on a schedule of charges and providers have flexibility in what that schedule looks like flat rate or varying like a sliding fee scale however because the BPHC requirement necessitates a sliding fee scale for clinics that are multi funded it would make sense to use a sliding fee scale ideally the same sliding fee scale for all patients as long as it meets all the Ryan White’s requirements can be made now here is where we get into the differences patients eligible for reduced fees or just discounts under DivX are limited to income at or below 200% of FPL as eligible for discounts however all Ryan white patients even those at or above 200% can be eligible for reduced fees but it isn’t required that Ryan White patients at or above 200 percent receive a discount similarly Ryan White statue prohibits charging patients at or below a hundred percent of FPL however BPHC patients at or below 100 percent of FPL may be charged but it isn’t required that they may be charged there is there is actually a misconception by many BPHC recipients that they are required to have a nominal charge for patients at or below 100 percent FPL but that’s not true therefore as long as the multi funded clinic sliding fee scale there’s not charge for those at a hundred percent or below and does not offer a discount for those above two hundred percent the clinic will have a sliding fee scale that’s in compliance if both have and etic requirements one final difference is that Ryan white in position of charges requires an annual cap on charges whereas BPHC requirement does not this does not affect the amount patients are assessed but clinics who are multi funded we need to have a system in place that would track and your charge is imposed on the Ryan White patients so we see that requirements that are in direct conflict with one another practically speaking you may prefer to maintain two separate schedules of charges one for the health center funding and one for Ryan white that’s perfectly fine too it’s really up to your choice and what can work within your clinic setting and the ease with your staff [Applause] here are some take-home messages for multi funded clinics first the main difference in the Ryan White legislation and the biblical isolation is that it comes to this topic is that our legislation focuses on imposing charges and the payer of last resort whereas the big focus is on discounts and the second take-home message is that it is possible for multi funded clinics to meet the requirements of both have and vivid as long as the existing sliding fee scale is in compliance with the Ryan White legislation then they can utilize the existing sliding fee scale if it’s not in compliance with the Ryan White legislation for example patients at or below a hundred percent were being charged then modifications could be made to the sliding fee scale to be in compliance or you could elect to maintain a separate scheduled charges for Ryan White patients so the summit multi funded clinics you could be in compliance with both requirements as long as that sliding fee scale does not charge for those below a hundred percent and does not offer a discount to those above two hundred percent again this is a suggestion and for you to consider whether you’re a multi funded clinic or or not or just a Ryan White provider how do you engage your patient in this process it’s so important this is one requirement that requires a lot of knowledge on the part of the patient information resources and tools you provide to your Ryan White patients are up to you you know your patients and organizations better than we do so maybe a tracking tool you provide is in hardcopy electronic or maybe there is an app for that every patient counter really represents an opportunity to check in with the patient my my patient to see if there are any changes in their circumstances it’s in your patients best interest to keep track of the other charges that have been imposed upon them these all add up and could mean the patient’s reach their cap which means they’re no longer charged for the calendar year for example eligibility screening and recertification of eligibility are opportunities to assess we’re on a schedule of charges of buying weight patient falls and adjust the patient’s cap if necessary it’s also a good time to ask the patient about charges that may have been imposed by other providers or any other out-of-pocket expenses I could count towards the cap another opportunity is engagement across the her Ryan White service system coordination across multiple Ryan White recipients and sub-recipients within a jurisdiction is allowable it’s encouraged I guess it’s a lot easier said than done as I’ve heard more stories on the level at the ground level however well established coordination is a foundation for the next possible mechanism of easing imposition of charges and recertifications burden through data sharing when data sharing is in effect recipient sub recipients can look to the same data source for information in our documentation related to several program requirements remember the FPL and how you use it may and may be documented this might be a good example where davey sharing could help and your mo use could be a source for that that relationship being started and laying the groundwork for it data sharing is the means by which recipients and sub-recipients might facilitate their processes and procedures of Ryan White patients so the patient thoroughly understands that what you tell them that your clinic is the same across the Ryan White system given the potential to reduce burden on recipients and their sub recipients as well as patients another big plus for data sharing and coordination and I think that’s where we’re gonna now switch back to Connie to wind things down great thanks Gail so yeah we’re gonna wind down wrap up however you choose to look at it we want to talk a little bit about some of our next steps we want to assure you that this is not like a one-time deal we are planning to continue to offer some technical assistance related to imposition of charges and follow-up to this and we’ll get into a little more detail on that a few resources that are available to you and then of course we’re gonna get to some questions we suspect there may be some so looking forward like I said we’re gonna be providing some ongoing technical assistance this is not a sort of set it and forget it if you will this is something that habits truly committed to providing additional opportunities to help folks better understand imposition of charges and how to better implement it in their own programs fortuitously the National Ryan White conference is coming up in December if you haven’t registered you should make sure you do that and we’re gonna have a session there conveniently we also will have a session there on the enhanced CAREWare for those of you who use care where or maybe those of you who don’t but are thinking about it CAREWare six will be coming out soon and there have been some requests to you know can we work with CAREWare to enhance that so that there’s some capabilities built into that to help manage that sort of data element of imposition of charges we are very happy to say that we’ve been working in consultation with our data managed data management analysis branch within the division of policy and data within HAB and we’ve been talking to the folks that get to manage the care wear program and and so that is something that they have been working on to be able to put out in the new browser-based CAREWare six stay tuned we are also working with our colleagues in BPHC to develop a training for multi funded recipients you know it went over there’s a lot of complexity when you have to federally funded programs with each with their own set of requirements and and we know that those are the folks that are most likely the ones that are like you guys are having to do this every day so we want to we are working with it to identify some opportunities to provide some technical assistance specifically to you all we know that our project officers frequently receive questions from their recipients we’ve received several and many of those questions are actually common across all of the program parts like we said earlier you know Part A and B you do a lot of monitoring of folks that look very much like part C’s or part C’s it looks very much like sub recipients or who are both a sub recipient in a Part C so we do see a lot of the same questions come up over and over again and we suspect that we’re gonna see a few of those today and so we are working with our project officers or colleagues across here to look at those questions can we put those together identify some you know specific technical assistance areas and so we’ll keep taking those questions and so we’re also want to encourage you guys to take a look at the resources and tools that maybe you’re using related to your own imposition of charges policies and look at the TargetHIV website it’s recently been you know refreshed and rebranded so be sure to go check that out and so we’re thinking we can imagine folks might have eligibility letter templates or something that explains where your patients are going to be placed on the schedule of charges and many maybe you have some template language about the annual cap and tracking worksheets or whatever but we know that that it’s very helpful for folks to hear from each other about some time-tested products that that helps folks meet the requirements so some resources conveniently we have a couple of downloads available on this webinar we have the slides that are available for download we also have the glossary of terms that Gail was able to go over so we encourage you to take a look at that and you know keep that as a reminder or refresher we have recorded this webinar it will be available on target HIV and as I just mentioned we are taking this show on the road all the way to the National Ryan White Conference so let us know if you have any feedback on this presentation we would like to know especially from you guys if there is if there are areas within the presentation you would like more information on or those that you think we don’t need as much information on because you got it now so we are interested in that kind of feedback which you can provide now or through your project officers after the webinar and so I want to just express my profound thanks from my colleagues here it’s been a really great opportunity this this technical assistance webinar two years in the making and it’s required an incredible amount of work from a lot of people and I want to let you know that Dr. Cheever and Heather Hauck have done a really great job of encouraging all of us across the Bureau to work together on this because it is so complex it does affect so much of our program and it’s really been critical and I think our presentation is benefited from the input of the entire you know folks from across the Bureau so thank you to each of these folks as you’ll see we have folks from Part A Part B Part C plus D and from the Office of the Associate Administrator as well as OGC program support and OTCD so we’ve got you know our SPNS folks involved in this too and so we’ve reviewed a number of presentations to get to this point we’ve looked at site visit reports we’ve looked at policies and procedures that you know we’ve gotten as examples from some recipients and sub-recipients and and obviously we’ve taken a good hard look at the statute to make sure that the training that we’re able to provide we hope it’s clear it’s as concise as we could get it um and and we hope that it does fully explain the imposition of charges across the Ryan White program so many things include us all these folks and an extra special thank you to Heather, Gail, and Kelley my co-presenters here I’m very fortunate that I get to thank them out loud but also we have Alice Litwinowitz back in the studio who will be getting to read us some questions here in just a moment so getting back to this simple arithmetic generally speaking math is hard and we have accepted that imposition of charges is is also difficult and we know that it certainly isn’t as simple as yellow plus blue equals green and certainly there are intricacies in the everyday application of the requirement but we hope that by breaking down the statutory language into these two required components the schedule of charges and the cap on charges and explaining those relationships and how they relate and build into the imposition of charges the larger requirement we hope it’s a little bit easier to digest all of this and process it and apply it to your work so we’re getting ready for questions we’re going to get to as many of them as possible as well as those that were sent in previously previous to the webinar if we don’t get to your question today frets not we will respond after the webinar by email we’re also have talked a little bit about maybe putting together a frequently asked questions no okay so no but we’re going to be looking at the questions here and then we’ll be able to take in more questions at the national conference and again some of this is going to be really important to inform our additional technical assistance moving forward so let’s now open for our QA but first let’s hear from our operator operator thank you please send questions using the submit a question button towards the top of the window under the HRSA logo you can also ask a question by dialing eight eight eight nine seven two nine two four nine using the passcode webcasts please turn the sound down on your computer when asking a question Thank you that’s the cap on charges requirement apply to our clients living with HIV who are not eligible for the Ryan White program because their income is above our eligibility limit Gail could you take that one thanks Alice the Ryan White legislation speaks only to Ryan White cap on charges requirement applies to all Ryan White eligible patients thank you I have a second question we define low-income as four hundred percent of the federal poverty level for our program eligibility what is the income limit on the cap on charges for the requirement to apply I think of it next Kelley’s going to take that second question if I understand your question I if a patient is not eligible for Ryan White services because their income is greater than your FPL threshold used to determine eligibility then the cap on charges would not apply furthermore the cap on charges varies depending on income level so in the case of your clinic I think you had a 400% FPL threshold those with incomes at or below a hundred percent FPL are not capped because they are not charged those with incomes between 101 to 200 percent FPL are capped at five percent and those with incomes between two hundred and one to three hundred percent FC are capped at 7% and then the remainder which would be the 300 to 400 percent category which is up to your threshold limit those would be capped at 10% hope that answers your question oh thanks Kelley we’re going to go on to the third question about household income versus individual income so the question is how do we use household income versus individual income do we use household or individual income for our sliding fee scale what about the capital on charges is that individual or household and we’re going to rotate this one’s going to Connie so both the schedule of charges which again could be either the flat rate or the sliding fee failure reference and the cap are based on individual income and so remember for eligibility for the Ryan White program though you have a choice so with the imposition of charges though that we’ve been talking about today you don’t it’s not as clear and statute or excuse me it is clear in statute that individual income must be used and again that is statutory language that isn’t us making a random decision here at the table so it is statutory thanks Connie where do we use household income but we’re going to go back to Gail for this one well Connie look so I’ll be kind of dog telling your your answer household income would only be used for eligibility if your organization chooses to use household income or modified adjusted gross income to define low income eligibility for Ryan White services we have another question many of our Ryan White clients have dependents living with them the client is the only source of the income where do I place that client on the fee schedule is it based on their income level as an individual or do we figure that out when we look at their income as a family so it’s it’s based on their income as an individual the determination is made based on a patient’s income compared to the federal poverty level for for an individual which is the same as household of one if you’ll refer back to the federal poverty guidelines great this is going to be our last question hit here it goes once a client hits their cap on Ryan White charges where are the costs for any additional Ryan White services charged how are we supposed to keep track of the services we provide but the client no longer is charged for that is another great question so the services would be charged to the grant once the cap is reached so you as recipients would need to track these services just as you normally would your Ryan White cause as if there’s no charge to the patient for the service but if your question is specific to if you’re asking how a patient would track those services after they reach the cap there’s really no expectation that the patients would need to continue to track those services that was our last question thank you great so we just wanted to say that again if we didn’t get to your question today we are going to be reviewing all of the questions that came in through the the webinar today and again we’ve been looking over the questions that came in prior to the to the webinar so please feel free to sorry project officers but please send your questions to your project officers if you prefer you can email Kelley or myself but I will say this app tab at herceg of is considerably easier to spell than jorstad so you might want to consider that one too and there Kelley I both have access to that email address and when we do get those emails we do coordinate with project officers to make sure that you know the full context is taken into consideration so we want to make sure you complete the survey on this webinar let us know what you think and we do take all of your feedback seriously so please please do take the time to answer those few questions for us thanks a lot and thanks for joining us

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