Payor of last resort 

Ryan White HIV/AIDS Program (RWHAP) funds may only be used as the payor of last resort, meaning they are used to cover HIV care and treatment services only when no other payor, such as Medicaid, Medicare, private insurance, or another state or local program, has paid or can reasonably be expected to pay. RWHAP funds may also be used to fill coverage gaps for individuals who are uninsured, underinsured, or whose existing insurance does not fully cover needed services, even when those services are provided at the same visit. 

RWHAP recipients and subrecipients must ensure that reasonable efforts are made to use non-RWHAP resources whenever possible, including establishing, implementing, and monitoring policies and procedures to identify any other possible payers to extend f inite RWHAP funds. “Reasonable” may mean that the RWHAP agency has a documented process (like to vigorously pursue) that the client was thoroughly screened for other benefits and has documented denial of coverage. Before using RWHAP funds, recipients and subrecipients must make and document reasonable efforts to confirm that other payor options have been pursued. 

Examples of reasonable efforts may include:

• Screening clients for eligibility for Medicaid, Medicare, marketplace plans, or employer-based coverage during intake or timely eligibility confirmation.
• Helping clients complete or renew applications for public health coverage or private health insurance.
• Checking existing coverage databases or eligibility systems to confirm a client’s current health coverage status. 
• Documenting client self-attestations when they report that they are not eligible for other health coverage coverage. 

Note: RWHAP funds may be used to fill coverage gaps, including services that are only partially covered for individuals who are either underinsured or uninsured to maintain access to care and services as allowable and defined by RWHAP.

Vigorously pursue 

To vigorously pursue refers to establishing, implementing, and monitoring policies to identify other possible payors such as Medicaid, Medicare, Marketplace insurance, or private insurance through individual plans and employers. RWHAP recipients and subrecipients must “vigorously pursue” those other coverage options if clients are eligible for them and if those coverage options provide comprehensive and affordable HIV care and treatment services. These efforts should be ongoing, timely, and well-documented.

Ongoing efforts to vigorously pursue 

A person’s eligibility for health coverage is not static, and may change several times throughout the year, depending on factors such as income, family size, and employment status. Vigorously pursuing health coverage should not be considered a one-time activity, and programs should conduct periodic checks to determine if a client’s health coverage or eligibility has changed, as this may affect whether RWHAP remains the payor of last resort. 

Timely efforts to vigorously pursue 

Although there is never a wrong time to vigorously pursue health coverage for RWHAP clients, program staff should leverage existing appointments and keep in mind health coverage enrollment timelines. For example, RWHAP recipients have implemented activities such as screening clients for health coverage eligibility during their ADAP eligibility appointment/application and screening for Marketplace eligibility during open enrollment (beginning November 1st, annually). They also ensure that clients who are aging or who receive disability benefits have a note in their case file of when they will become eligible for Medicare, and program staff ensure timely enrollment during applicable Medicare open enrollment periods.

Well-document efforts to vigorously pursue 

RWHAP recipients and subrecipients are expected to establish, document, implement, and monitor policies and procedures that describe how staff identify and assist clients in pursuing other coverage options before using RWHAP funds. 

Policies should be updated regularly to confirm that they are followed consistently and continue to align with federal and state program requirements. These may include:

• Defining staff roles—such as case managers or benefits counselors—responsible for screening and assisting clients with coverage applications.
• Documenting outreach, application support, and follow-up efforts in client files. 
• Conducting periodic checks to confirm whether a client’s coverage or eligibility status has changed. 
• Allowing clients to self-attest to “no change” in coverage, with follow-up verification as appropriate.
• Requesting denial or determination documentation when feasible (not as a universal prerequisite).
• Outlining limited exceptions for clients who decline coverage options, with documentation of the rationale and continuation-of-care plan. 

In addition to documenting the process of vigorously pursuing healthcare coverage, program staff working directly with clients should document when, how, and the result of their efforts. For example, RWHAP case managers should note within a client’s file if they screened them for Medicaid eligibility, when that took place, and the result of the eligibility screening. This practice supports an organizational culture that prioritizes payor of last resort requirements, and can help demonstrate program compliance. 

Note: services do not need to be delayed while vigorously pursuing; RWHAP funds can be used to provide services as long as programs document their efforts.  

Resources:

• Health Resources and Services Administration HIV/AIDS Bureau (HRSA/HAB), PCN 21-02, Determining Client Eligibility & Payor of Last Resort in the Ryan White HIV/AIDS Program 
• RWHAP legislation signed into law, including statutory Payor of Last Resort Requirements