591.000 Limitations on Ryan White and State Services Funds for Incarcerated Persons in Community Facilities

1.0 Purpose

To provide guidance to Administrative Agencies (AA) and subrecipients on the use of Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program (RWHAP) Part B and State Services (SS) program funds to provide core medical services and support services: 1) on a transitional basis to people living with HIV (PLWH) who are incarcerated in Federal and State prison systems; and 2) on a short-term and/or transitional basis to PLWH who are incarcerated in other correctional systems (e.g., local prisons and jails).
 

2.0 Background

In the provision of treatment for HIV infection, both federal and state program funds must be used as a payment of last resort (PoLR). Federal law and policy prohibit use of federal Ryan White (RW) Program funds for payment of treatment and care services where another entity is reasonably or legally required to provide or pay for such treatment. The policy similarly treats SS funds as the payor of last resort. See Policy 590.001 DSHS Funds as Payment of Last Resort for further guidance on PoLR.
 

3.0 Authority

Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87); Health Resources and Services Administration (HRSA) Policy Clarification Notice (PCN) #18-02; Texas Code of Criminal Procedure Article 104.002 (a); Texas Attorney General (AG) Opinion Letter 98-072 (1998); AG Opinion DM-380 (1996); AG Opinion JM-643 (1987).
 

4.0 Definitions

Allowable Services – A general term that encompasses the combination of core medical services and support services that are approved to be funded with RWHAP money. Together, these services assist in the diagnosis of HIV infection, linkage to and entry into care for PLWH, retention in care, and the provision of HIV care and treatment. To be considered an allowable service, the service must: relate to HIV diagnosis, care and support; adhere to established HIV clinical standards consistent with U.S. Department of Health and Human Services’ Clinical Guidelines for the Treatment of HIV and other related or pertinent clinical guidelines; and comply with state and local regulations, and provided by licensed or authorized providers, as applicable. Core Medical Services are listed in Section 2604(c)(3) of the Public Health Service (PHS) Act. Support services allowed under RWHAP Part B are limited to services that are needed for PLWH to achieve their medical outcomes, as defined by the RWHAP. HRSA RWHAP core medical and support services are further described in PCN 16-02 Ryan White HIV/AIDS Program Services: Eligible Individuals and Allowable Uses of Funds.

Community Medical Provider – A local community-based organization, community health clinic, or hospital clinic that provides HIV-related Outpatient/Ambulatory Health Services (OAHS) or other RWHAP Core Medical Services to RWHAP-eligible clients.

Incarceration – Refers to the involuntary confinement of an individual in connection with an alleged crime. It includes involuntary confinement, either where a sentence has been determined or where the individual is detained pending adjudication of the case.

Community Facility – A facility providing involuntary confinement of an individual under custody outside of the prison or jail system; generally includes pre-release facilities, half-way houses, home detention and substance use disorder treatment centers.

HIV Service Delivery Area (HSDA) – Geographic service area set by the Department of State Health Services for the purposes of allocating federal and state funds for HIV medical and psychosocial support services.

Local Jail – Any city, county or other municipality jail system.

Outpatient/Ambulatory Health Services (OAHS) – Outpatient/Ambulatory Health Services provide diagnostic and therapeutic-related activities directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings may include clinics, medical offices, mobile vans, using telehealth technology, and urgent care facilities for HIV-related visits.

Transitional basis – Refers to the time-limited provision of appropriate core medical and support services for the purpose of ensuring linkage to and continuity of care for incarcerated PLWH that will be eligible for HRSA RWHAP services upon release, when such release is imminent. HRSA HAB defers to recipients/subrecipients for a determination of the time limitation, generally 180 days or fewer.

Short-term basis – Refers to the time-limited provision of core medical and support services that are not prohibited by the statutory payor of last resort requirements. HRSA HIV/AIDS Bureau (HAB) defers to recipients/subrecipients for a determination of the time limitation. HRSA HAB recognizes that, in some instances, the time limitation will be commensurate with the duration of incarceration.
 

5.0 Policy

Texas Department of State Health Services (DSHS) AAs and subrecipients may provide core medical services and support services to PLWH incarcerated in Federal and State prison systems on a transitional basis only. The nature of these services must be defined by AAs and subrecipients in collaboration with the Federal or State prison system. Additionally, AAs’ and subrecipients’ definitions of transitional services must be based on the HIV-related needs and anticipated release date of the incarcerated person.

DSHS AAs and subrecipients may also provide core medical services and support services to PLWH incarcerated in other correctional systems including those under community supervision on a short-term and/or transitional basis. The nature of these services must be defined by AAs and subrecipients in collaboration with the correctional institution to ensure there is no duplication of services. If core medical services and support services are provided on a short-term basis, DSHS recommends that recipients and subrecipients also provide services on a transitional basis.

RW/SS funds are intended to support only the HIV-related needs of eligible individuals. To be an allowable cost, DSHS AAs and subrecipients must be able to make an explicit connection between any service supported with RW/SS funds and the HIV care and treatment of the incarcerated person and must adhere to established HIV clinical practice standards consistent with U.S. Department of Health and Human Services’ Clinical Guidelines for the Treatment of HIV.
 

5.1 Fiscal Responsibility for Medical Care

Texas law mandates that a county is liable for all expenses incurred in the safekeeping of prisoners confined in the local jail. This includes all medical expenses. In certain circumstances, counties can seek reimbursement, but this does not alleviate the underlying legal responsibility for the county to provide care. The Texas Department of Criminal Justice (TDCJ) is likewise responsible for all medical expenses for inmates within the state prison system.

There may be scenarios wherein a local jail transports inmates to a RW/SS-funded community provider to receive OAHS. While the local OAHS provider may provide this care, the local jail remains responsible for the cost. RW and SS funds cannot be used to pay for this service.

Among PLWH who are incarcerated, RWHAP Part B and SS funding may only be used to fund transitional and support services for individuals in this population who are expected to be eligible for RW/SS funded services upon their release. RW and SS funds may not be used to pay for medical care or medications for any person while he or she is detained in a state or federal prison, or a local jail.

RWHAP Part B and SS funding may be used to provide core medical services and support services for individuals who have been released from incarceration but are subject to community supervision, such as parole or home detention, only if the services and care cannot be provided by any other source.
 

5.2 Limited Transitional Medical Services for Persons Residing in Community Facilities Not Part of the Correctional System

RW and SS funds cannot be expended for medical care or medications if medical care or services are available within the community facility for any type of medical condition or disease.

RW and SS funds can be used to provide OAHS or HIV medications for eligible persons if no medical care or medical services are provided and are not reasonably expected to be available within the facility. Details about the services and care provided using RW and SS funds must be carefully documented by the subrecipient and AA and requires prior approval by DSHS. AAs must obtain written approval from the Care Services Branch to permit a subrecipient entity to provide limited transitional medical services for PLWH residing in community facilities [which are] not part of the correctional system. The prior approval request shall be submitted to the Care Services Branch Consultant assigned to the respective HIV service delivery areas (HSDA).

Examples of these facilities include half-way housing and drug treatment centers. In these situations, transitional medical services cannot exceed 180 days.
 

5.3 Allowable Transitional Support Services

RW and SS funds can be used to provide transitional support services to establish or re-establish linkages in the community. Non-medical case management or similar service linkage (e.g. outreach, referral for health and supportive services that links a soon-to-be released inmate with Outpatient Ambulatory Health Services is an example of appropriate transitional support service). Transitional support services may not exceed 180 days.
 

6.0 Unallowable Uses

The HRSA RWHAP Part B and SS funds generally cannot be used pay for services for which payment has been made or can reasonably be expected to be made by Federal or State sources. DSHS AAs and subrecipients cannot use RW and SS funds to pay for core medical services and supportive services provided to PLWH in Federal or State prison systems on a short-term basis, because such services are generally provided by the Federal and State prison systems. Similarly, if Federal and State prison systems provide services that are equivalent to core medical services and supportive services to PLWH on a transitional basis, DSHS AAs and subrecipients cannot pay for these services.

DSHS AAs and subrecipients cannot use RW and SS funds to duplicate payment for core medical services and supportive services provided to PLWH in other correctional systems or subject to community supervision programs if these services are provided by the other correctional system or community supervision program. RW and SS funds cannot pay for services for incarcerated persons who retain private, State or Federal health benefits during the period of their incarceration.
 

7.0 Additional Expectations

Familiarity with Federal and State Prison Systems, Other Correctional Systems, and Community Supervision Programs: DSHS AAs and subrecipients shall become familiar with Federal and State prison systems, other correctional systems, and community supervision programs and the established pre-release procedures applicable to these systems to the extent they wish to provide core medical services and support services to PLWH, as described in this policy. DSHS AAs and subrecipients shall work with the appropriate corrections administrators and staff to determine:

1. What health services are legally expected to be provided within the correctional system;
2. How, and whether, the correctional system addresses the transitional needs of PLWH who are incarcerated, including: discharge planning, continuity of treatment, and community linkages, and;
3. What services will be provided with the RW and /or SS funds.

Communication: DSHS AAs and subrecipients must ensure communication between the correctional system, the recipient or subrecipient, and/or qualified provider follows all applicable laws and regulations regarding privacy.

DSHS AAs and subrecipients that provide core medical services and support services to eligible incarcerated PLWH should establish clear expectations with the correctional system administrators and staff regarding communication of release dates to ensure continuity of care for newly released eligible PLWH. Specifically, recipients should know what services are provided in the correctional system and who is delivering them to ensure compliance with the DSHS statutory payment of last resort requirements and to ensure there is no duplication of effort.
 

8.0 Programs Not Affected

This policy does not affect projects or programs using funds from the Centers for Disease Control and Prevention (CDC) for delivery of testing or provision of immunizations or STD medications in local jails.
 

9.0 Revision History