Transcript Part B Core Services

Area 15 Ryan White Program
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Core Services are a set of essential, direct health care services
provided to persons living with HIV/AIDS and specified in the Ryan
White Treatment Extension Act of 2009. The following core services
are funded in Area 15 to eligible clients:
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Primary Outpatient Medical Care
AIDS Drug Assistance Program (ADAP)
AIDS pharmaceutical assistance (local)
Oral Health
Health Insurance
Medical Nutrition Therapy
Mental Health Services
Substance Abuse Services- Outpatient
Case Management- Medical
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In order for any core service (with the exception of case
management) to be paid for by Part B funds, all providers must
create a service request for each service being provided using
the TCHC Database. All clients must have a Notice of Eligibility
prior to initiating any service.
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This service request is then approved by the Medical Services
Specialist (MSS) at Project Response, if the client is eligible.
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After the service has been delivered, the provider completes the
service request in the TCHC database by entering the date of
service and reimbursement amount in order to receive
payment. Back up documentation is then sent in to the Lead
Agency (Health Council of Southeast Florida) for reimbursement.
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HRSA Definition: Outpatient/Ambulatory medical care (health
services) is the provision of professional diagnostic and
therapeutic services rendered by a physician, physician's
assistant, clinical nurse specialist, or nurse practitioner in an
outpatient setting.
◦ Primary and specialty HIV/AIDS health care.
◦ Services include laboratory tests (such as viral loads tests and CD4
counts), other diagnostic tests (imaging, pathology), and routine GYN
tests for women.
◦ For eligible clients with private health insurance or Medicare, assistance
with deductibles and co-pays may be available.
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For clients in need of outpatient medical through Part
B funds, the client must access one of the following
medical clinics:
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AIDS Research and Treatment Center
Associates in Infectious Disease
Coastal Primary Care
Florida Community Health Centers
Treasure Coast Infectious Disease
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HRSA Definition: AIDS Drug Assistance Program (ADAP
treatments) is a State-administered program
authorized under Part B of the Ryan White Program
that provides FDA-approved medications to lowincome individuals with HIV disease who have limited
or no coverage from private insurance, Medicaid, or
Medicare.
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ADAP is administered by the local health departments.
In order to enroll in ADAP, the client must provide the
following documentation:
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Notice of Eligibility
CD4 and Viral Load Labs less than 6 months old
Valid prescription(s) for medication on the ADAP Formulary
Insurance Documentation, if applicable
Case managers can assist clients in enrolling in ADAP.
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HRSA Definition: AIDS Pharmaceutical Assistance
(local) includes local pharmacy assistance programs
implemented by Part A or Part B Grantees to provide
HIV/AIDS medications to clients. This assistance can be
funded with Part A grant funds and/or Part B base
award funds.
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Local pharmacy assistance programs are not funded
with ADAP earmark funding.
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For clients in need of pharmacy assistance through Part
B funds, the client must access the following
pharmacies:
 Jackson Drugs
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The Lead Agency provides the pharmacies and
physicians with a comprehensive formulary each
contract year, or as changes occur, that has been
approved by the CNTC and reviewed by qualified
medical providers.
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HRSA Definition: Oral health care includes diagnostic,
preventive, and therapeutic services provided by
general dental practitioners, dental specialists, dental
hygienists and auxiliaries, and other trained primary
care providers.
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For clients in need of oral health care through Part B
funds, the client must access one of the following
dental clinics:
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Dr. Salomon Israel (Oral Surgery & Maxillofacial Surgery)
Treasure Coast Community Health Center
Florida Community Health Center
St. Lucie County Health Department – Research Treatment Alliance
Indian River County Health Department
 Clients are allowed two dental cleanings within one contract year.
 In addition eligible clients can receive up to $1300 of pre
approved services located on fee schedule on an annual basis
 Funds for Dentures are available as needed.
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Health Insurance Premium & Cost Sharing Assistance
is the provision of financial assistance for eligible
individuals to maintain a continuity of health insurance
or to receive medical benefits under a health insurance
program.
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This includes premium payments, co-payments (for
medications and medical appointments), and
deductibles.
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For those clients who have health insurance and need
assistance with co-pays or deductibles, the service
provider will complete the same process with the
service request but will submit the invoice to the
primary insurer first.
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After the initial insurer has agreed upon the payment
amount, the service provider will update the service
request with the remaining amount owed for that date
of service.
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HRSA Definition: Mental health services are
psychological and psychiatric treatment and counseling
services offered to individuals with a diagnosed mental
illness, conducted in a group or individual setting, and
provided by a mental health professional licensed or
authorized within the State to render such services.
This typically includes psychiatrists, psychologists, and
licensed clinical social workers.
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In order for a client to receive Mental Health Services
through Part B funds, the client must have a referral
from a medical provider.
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The medical provider submits the referral to the
Project Response Case Manager for processing. The
Case Manager arranges the first appointment or intake
appointment for client with the provider.
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The mental health provider then initiates the service
request process.
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HRSA Definition: Medical nutrition therapy is
provided by a licensed registered dietitian outside of a
primary care visit and includes the provision of
nutritional supplements. Medical nutrition therapy
provided by someone other than a licensed/registered
dietitian should be recorded under psychosocial
support services.
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In order for a client to receive Medical Nutrition
Therapy through Part B funds, the client must have a
prescription from a medical provider or nutritionist.
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The client must have a medical evaluation, a BMI score
and a new prescription written every 3 months in
order to continue with this service.
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The prescription is delivered to Project Response,
where the service request will be initiated.
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HRSA Definition: Medical Case management services
(including treatment adherence) are a range of clientcentered services that link clients with health care,
psychosocial, and other services. The coordination and
follow-up of medical treatments is a component of medical
case management.
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These services ensure timely and coordinated access to
medically appropriate levels of health and support services
and continuity of care, through ongoing assessment of the
client’s and other key family members’ needs and personal
support systems.
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Medical case management includes the provision of treatment
adherence counseling to ensure readiness for, and adherence to,
complex HIV/AIDS treatments. Key activities include (1) initial
assessment of service needs; (2) development of a
comprehensive, individualized service plan; (3) coordination of
services required to implement the plan; (4) client monitoring to
assess the efficacy of the plan; and (5) periodic re-evaluation
and adaptation of the plan as necessary over the life of the
client. It includes client-specific advocacy and/or review of
utilization of services. This includes all types of case
management including face-to-face, phone contact, and any
other forms of communication.
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Please refer to the Case Management PowerPoint for
information on how to access this service.
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HRSA Definition: Substance abuse services-outpatient
is the provision of medical or other treatment and/or
counseling to address substance abuse problems (i.e.,
alcohol and/or legal and illegal drugs) in an outpatient
setting, rendered by a physician or under the
supervision of a physician, or by other qualified
personnel.
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In order for a client to receive Substance Abuse Services
through Part B funds, the client must have a referral for
substance abuse services from a medical provider.
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The medical provider submits the referral to the Project
Response Case Manager for processing. The Case Manager
arranges the first appointment or intake appointment for
client with the provider.
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The substance abuse provider then initiates the service
request process.
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When clients present to medical providers and are
newly diagnosed, these clients either meet with a case
manger provided by the medical provider on site, or
are referred to Project Response.
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If assistance is required by the client in order to access
these core services, the client MUST obtain a Notice of
Eligibility from Project Response before receiving
services.