Health Insurance Premium and Cost- Sharing Assistance Service

Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024

Health Insurance Premium and Cost-

Sharing Assistance Service Standard

Texas Department of State Health Services, HIV Care Services Group — HIV/STD

Program | Texas DSHS

Subcategories

Service Units

Dental Co-Insurance

Per payment

Dental Co-Payment

Per payment

Dental Deductible

Per payment

Dental Premium

Per month

Health Insurance Premium and Cost-Sharing Assistance

Per payment

Medical Co-Insurance

Per payment

Medical Co-Payment

Per payment

Medical Deductible

Per payment

Medical Premium

Per month

Pharmacy Co-Payment

Per prescription

Health Resources & Services Administration (HRSA)

Description:

Health Insurance Premium and Cost Sharing Assistance (HIA) provides financial

assistance for eligible clients living with HIV to maintain continuity of health

insurance or to receive medical and pharmacy benefits under a health care

coverage program. For purposes of this service category, health insurance also

includes standalone dental insurance. The service provision consists of the

following:

● Paying health insurance premiums to provide comprehensive HIV

Outpatient/Ambulatory Health Services (OAHS), and pharmacy benefits that

provide a full range of HIV medications for eligible clients; and/or

Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024

● Paying standalone dental insurance premiums to provide comprehensive oral

health care services for eligible clients; and/or

● Paying cost sharing on behalf of the client.

To use HRSA Ryan White HIV/AIDS Program (RWHAP) funds for health insurance

premium and cost-sharing assistance (not standalone dental insurance assistance),

a HRSA RWHAP recipient must implement a methodology that incorporates the

following requirements:

● Clients obtain health care coverage that at a minimum, includes at least one

U.S. Food and Drug Administration (FDA) approved medicine in each drug

class of core antiretroviral medicines outlined in the U.S. Department of

Health and Human Services Clinical Guidelines for the Treatment of HIV, as

well as appropriate HIV Outpatient/Ambulatory Health Services; and

● The cost of paying for the health care coverage (including all other sources of

premium and cost-sharing assistance) is cost-effective in the aggregate

versus paying for the full cost of medications and other appropriate HIV

OAHS.

To use HRSA RWHAP funds for standalone dental insurance premium assistance, a

HRSA RWHAP Part recipient must implement a methodology that incorporates the

following requirement:

● HRSA RWHAP Part recipients must assess and compare the aggregate cost of

paying for the standalone dental insurance option versus paying for the full

cost of HIV oral health care services to ensure that purchasing standalone

dental insurance is cost-effective in the aggregate and allocate funding to

HIA only when determined to be cost-effective.

Program Guidance:

Traditionally, RWHAP Parts funding supports health insurance premiums and cost-

sharing assistance. The following DSHS policies and standards and HRSA Policy

Clarification Notices (PCNs) provide additional clarification for allowable uses of this

service category:

● DSHS Policy 260.002 (Revised 11/2/2015): Health Insurance Assistance

● PCN 18-01: Clarifications Regarding the Use of Ryan White HIV/AIDS

Program Funds for Health Care Coverage Premium and Cost-Sharing

Assistance

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Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024 
●  PCN 16-02: Eligible Individuals & Allowable Uses of Funds and Standalone 
Dental Insurance Frequently Asked Questions  
●  PCN 14-01 (Revised 4/3/2015): Clarifications Regarding the Ryan White 
HIV/AIDS Program and Reconciliation of Premium Tax Credits under the 
Affordable Care Act 
Limitations:  
HIA cannot be in the form of direct cash payments to clients.  
HIA funds may not be used for any of the following: 
●  Costs associated with liability risk pools 
●  Costs associated with Social Security 
●  Fines or tax obligations incurred by clients for not maintaining health 
insurance coverage required by the Affordable Care Act (ACA) 
●  Out-of-pocket payments for inpatient hospitalizations and emergency 
department care 
●  Insurance plans that offer only catastrophic coverage or supplemental 
insurance that assists only with hospitalization 
Agencies may only use HIA for Consolidated Omnibus Budget Reconciliation Act 
(COBRA) coverage if a client is not eligible for other coverage that meets the 
minimum required standards at a cost-effective price. 
Services: 
HIA includes out-of-pocket costs such as premium payments, co-payments, 
coinsurance, and deductibles. Please refer to Texas Department of State Health 
Services (DSHS) Policy 260.002 (Health Insurance Assistance) for further 
clarification and guidance. 
Agencies must determine that the cost of insurance plans is lower than the cost of 
providing health services through grant-supported direct delivery (“cost-effective”), 
including costs for participation in the Texas AIDS Drug Assistance Program 
(ADAP). Please refer to Texas Department of State Health Services (DSHS) Policy 
270.001 (Calculation of Estimated Expenditures on Covered Clinical Services) for 
further clarification and guidance. Additionally, DSHS provides an annual cost-
effective analysis as an attachment to this policy. 

Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024

RWHAP-funded agencies may extend HIA for job or employer-related health

insurance coverage and plans on the individual and group market, including plans

available through the federal Health Insurance Marketplace (Marketplace). Agencies

may also use HIA funds towards premiums and out-of-pocket payments on

Medicare, Medicaid, and supplemental insurance policies if the primary purpose of

the supplemental policy is to assist with HIV-related outpatient care.

Agencies may use HIA funds to pay for Medicare Part B (outpatient ambulatory

health services) premiums and cost sharing but must also pay for the Medicare Part

D (medication) premiums and cost sharing. Subrecipients may also use HIA funds

to pay for Medicare Part C premiums and cost sharing assistance when the plan

covers both outpatient ambulatory health services and at least one medication in

each drug class of core antiretrovirals. If the Medicare Part C plan does not cover at

least one medication in each drug class of core antiretrovirals, agencies must also

pay for Medicare Part D premiums and cost sharing to meet the RWHAP

requirement for health care coverage. Agencies may not use HIA funds to pay

premiums for Medicare Part D alone.

RWHAP-funded agencies may use HIA funds for providing funds to contribute to a

client’s Medicare Part D true out-of-pocket (TrOOP) costs, as well as certain tax

liabilities.

Universal Standards:

Service providers for Health Insurance Premium and Cost-Sharing Assistance must

follow HRSA and DSHS Universal Standards 1-52 and 79-83.

Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024

Service Standards and Measures:

The following standards and measures are guides to improving healthcare outcomes for people living with HIV

throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard

Measure

Health Insurance Plans: The agency must ensure that

clients are buying health coverage that, at a minimum,

includes at least one drug in each class of core anti-retro-

viral treatment (ART) from the HHS treatment guidelines

along with Outpatient Ambulatory Health Services (OAHS)

and oral health care that meet the requirements of the ACA

law for essential health benefits. This must be documented

in the client’s primary record.

1. Percentage of clients with documentation of health care

coverage that includes at least one drug in each class of

core ART from HHS treatment guidelines, along with

OAHS and oral health care services that meet the

requirements of the ACA law for essential health

benefits.

Co-payments, Premiums, Deductibles, and Co-

insurance: Eligible clients with job or employer-based

insurance coverage, qualified health plans (QHPs), or

Medicaid plans can receive assistance to offset any cost-

sharing these programs may impose. Agencies must

educate clients on the cost and their responsibilities to

maintaining medical adherence.

Agencies must educate clients on reasonable expectations

of eligible plan coverage and what HIA can assist with to

ensure healthcare coverage is maintained.

Agencies will ensure payments are made directly to the

health or dental insurance vendor within 5 business days of

an approved request.

2. Percentage of clients with documentation of education

provided regarding reasonable expectations of

healthcare coverage assistance available through HIA.

3. Percentage of clients with documentation that insurance

payments were made to the vendor within 5 business

days of the approved request.

Premium Tax Credits Education: Agencies must

document enrollment in a Marketplace QHP for clients that

4. Percentage of clients with documentation of education

regarding premium tax credits, as applicable.

Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024

are between 100-400% of the FPL, without access to

minimum essential coverage.

Staff must provide education to the client regarding tax

credits and the requirement to file income tax returns.

Education must include the importance of reconciling any

advanced premium tax credit (APTC) well before the IRS tax

filing deadline. Staff should document all education in the

client’s primary record.

Cost-Sharing Reduction Education: Agencies must enroll

clients who are eligible for cost-sharing reductions in a

Silver Marketplace plan for these clients to receive

assistance with out-of-pocket payments. Staff must provide

education to eligible clients regarding cost-sharing

reductions.

5. Percentage of clients with documentation of education

regarding cost-sharing reductions, as applicable.

Prescription Eyewear: When HIA funds are used to cover

co-pays for prescription eyewear, agencies must keep

documentation from the client’s medical provider stating

that the eye condition is related to the client’s HIV or vision

correction is necessary to support HIV treatment.

6. Percentage of clients receiving assistance for

prescription eyewear with documentation from the

client’s medical provider that vision services are related

to HIV or necessary to support HIV treatment.

Medical Visits: Health insurance premium and cost sharing

assistance should enable adherence to HIV-related medical

or dental care. Documentation in the client’s chart should

show attendance of HIV-related medical or dental

appointments.

For clients who use HIA for medical care outside of the RW

system, HIA providers are required to maintain

documentation of client’s attendance at primary medical

care visits during the previous 12 months.

7. For clients with applicable data in TCT or other data

system used at the agency’s location, percentage of

clients who had at least one medical visit in each 6-

month period of the 24-month measurement period,

with a minimum of 60 days between medical visits.

(HRSA HAB measure)

8. For clients who use HIA for medical care outside of the

RW system, percentage of clients with documentation of

client’s adherence to primary medical care (e.g., proof

of provider visits, insurance explanation of benefits, or

provider bill or invoice) during the previous 12 months.

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Texas Health and Human Services ● hhs.texas.gov ● Revised: 01/2024 
References: 
Division of Metropolitan HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White 
HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part A 
Recipients. Health Resources and Services Administration, June 2022. 
Division of State HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White 
HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part B 
Recipients. Health Resources and Services Administration, June 2022. 
Panel on Antiretroviral Guidelines for Adults and Adolescents. “Guidelines for the 
Use of Antiretroviral Agents in Adults and Adolescents with HIV.” Clinical Info 
(HIV.gov), Department of Health and Human Services, 21 Sept. 2022, 
clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-
arv/whats-new-guidelines. Accessed 1 Nov. 2022. 
Ryan White HIV/AIDS Program. Policy Clarification Notice 14-01: Clarifications 
Regarding the Ryan White HIV/AIDS Program and Reconciliation of Premium Tax 
Credits under the Affordable Care Act. Health Resources & Services Administration, 
3 Apr. 2015. 
---. Policy Clarification Notice 18-01: Clarifications Regarding the Use of Ryan White 
HIV/AIDS Program Funds for Health Care Coverage Premium and Cost Sharing 
Assistance. Health Resources & Services Administration, 30 Aug. 2018. 
---. Policy Notice 16-02: Eligible Individuals & Allowable Uses of Funds. Health 
Resources & Services Administration, 22 Oct. 2018. 
---. Standalone Dental Insurance Frequently Asked Questions. Health Resources & 
Services Administration, 13 June 2017. 
Texas Department of State Health Services. “260.002 Health Insurance Assistance.” 
Www.dshs.texas.gov, 2 Nov. 2015, www.dshs.texas.gov/hivstd/policy/policies/260-
002. Accessed 7 Feb. 2023. 
 