Administrative Overview for New Title III Administrative Staff

1
Administrative Overview for New Title I/II
Administrative Staff

• All Titles Meeting Washington, DC
• Harold Phillips/Phillips Solutions, Boston, MA
• August 28, 2006

2
Presentation Overview

• Importance and Challenges CARE Act
• Grantee roles and responsibilities
• Stewardship program and fiscal monitoring
• Quality Management
• HRSA/HAB What Do They Want?

3
Importance of Ryan White CARE Act

• The CARE Act continues to provide primary care
  and essential support services to low-income,
  uninsured, and underinsured people living with
  HIV/AIDS.
• The CARE Act is still the largest federal program
  specifically designated to provide primary care
  and support services for people living with
  HIV/AIDS.

4
Importance of Ryan White CARE Act

• The CARE Act supports a continuum of care that
  reaches over 571,000 people a year.
• The demand for outpatient HIV services continues
  to grow.

5
Federal Funding for HIV/AIDS Care,
FY 2005
(In millions)
11,652 Million
NOTE Funding from states is also significant,
particularly for Medicaid. Estimated state
Medicaid spending on HIV/AIDS care in FY 2005 is
4.9 billion States provided 171.9 million to
ADAPs in ADAP FY 2003 States provided
approximately 400 million in Title II HIV Care
Grant matching funds in Title II FY
2002. SOURCES Kaiser Family Foundation, Fact
Sheet Federal Funding for HIV/AIDS The FY 2006
Budget Request, February 2005 DHHS, Office of
Budget/ASBTF, February 2005 SSA, Office of the
Actuary, February 2005 CMS, Office of the
Actuary, February 2005 NASTAD/Kaiser Family
Foundation, National ADAP Monitoring Project, May
2004 NASTAD, FY 2002 Ryan White CARE ACT Title
II HIV Care Grants (Proposed), February 2002.
6
Federal Funding for HIV/AIDS Care by Program,
FY 2006
(In millions)
12,302 Million
Notes Data are estimates only Medicaid is
jointly financed by the federal government and
the states and the federal government matches
state spending at a rate ranging from 50 to 77.
In FY 2006, state Medicaid spending on HIV/AIDS
is estimated to total 5.1 billion. Source
Kaiser Family Foundation analysis of data from
the White House Office of Management and Budget,
Congressional Appropriations bills, HHS Office of
Budget, Centers for Medicare and Medicaid
Services, and Congressional Research Service.
7
Presidents Reauthorization Principles

• Several guiding principles used to strengthen the
  CARE act
• Focus on primary care and treatment
• Increase flexibility to target resources
• Ensure accountability using sound fiscal
  management and tools to evaluate program
  effectiveness

8
Challenges of the CARE Act

• Increases in the number of uninsured and
  underinsured.
• Crisis among other safety-net programs.
• Need to balance primary care and life saving
  treatments with vital support services.
• Rising rates of infection among minority
  communities

9
Challenges of the CARE Act

• Need to measure success and evaluate outcomes.
• Address capacity development with few new
  resources and the rising costs of care.

10
Key Challenges Around Strengthening the CARE Act

• Administration of the Program HRSA recognizes
  that stewardship of CRE Act funds is the key to
  assuring that, regardless of appropriations
  levels, the Department is utilizing Federal funds
  in the best way possible.

11
Key Challenges Around Strengthening the CARE Act

• As administrators of the CARE Act, HRSA and
  Titles I II Grantees can work more effectively
  to ensure
• Improved planning, quality and evaluation of care
  treatment and support services
• Consistency in defining expectations and costs
• Sound fiscal management and stewardship

12
Title I II Grantee Roles Responsibilities

• Administrative Oversight of Grant
• Procurement developing and implementing a process
  for selecting subcontractors and awarding funds.
• Program Monitoring assessing the quality and
  quantity of the services being provided by
  contractors.
• Fiscal Monitoring assessing how efficiently a
  contractor uses the CARAE Act funding and whether
  they are used for approved purposes

13
Title I II Grantee Roles Responsibilities

• Administrative Oversight of Grant
• Services to Women, Infants, Children Youth
  ensure that funding is proportionate to their
  representation among AIDS cases.
• Payor of Last Resort funds may not be used to
  pay for services covered by other health care
  sources, including Medicaid Medicare

14
Title I II Grantee Roles Responsibilities

• Planning and Coordination
• Access to Services Must provide services
  regardless of individuals ability to pay
• Require provider participation in HIV/AIDS
  continuum of care with key points of entry to
  assure referral to care

15
Title I Grantee Responsibilities

• Planning and Coordination
• Coordinate with the planning council by providing
  data in easy to use formats
• Work with the planning council to ensure data
  based decision making
• Ensure they are aware of HRSA/HABs policies
  regarding allowable use of funds

16
Title II Grantee Roles Responsibilities

• Evaluation/Quality Management
• QM is the purview of the Grantee
• Part of contractual agreement with Providers
• Input and Buy-in from stake holders is essential
• Grantee should collect and share aggregate data
  by service category for planning purposes

17
Title II Grantee Roles Responsibilities

• Planning and Coordination
• Engage in a public advisory planning process that
  includes public hearings concerning the intended
  use and distribution of Title II funds
• Coordinate the development of the Statewide
  Coordinated Statement of Need (SCSN)

18
Title II Grantee Roles Responsibilities

• Evaluation
• Periodic independent review to assess the quality
  and appropriateness of health and support
  services.
• Quality Assurance that includes service standards
  or standards for the quality of care.
• Review/Evaluation of a statewide comprehensive
  plan for the delivery of HIV/AIDS services.

19
Flow of Title I Decision-Making and Funds
20
Flow of Title II Funds Decision Making
Federal government
State Agency Designated by Governor
State Administered Services
Local HIV Care Consortia
AIDS Drug Assistance Program
Providers, Public Private Community Based
Organizations
Continuation of Health Insurance Program
People Living With HIV/AIDS
Direct Health and Support Services
21
DSS Expectations of Grantees

• Stewardship of grant funds
• Program and fiscal monitoring
• Adherence to Reporting Requirements
• Quality Management Program
• Appropriate membership of Planning bodies

22
Stewardship of Grant Funds

• Allowable, proper, authorized, reasonable and
  necessary costs
• Ensuring that funds are used for Care Act
  purposes.
• Monitoring spending patterns
• Verification of payor of last resort
• Monitoring of cost caps
• Adequate documentation
• No supplanting

23
Fiscal Monitoring

• Ability of grantees to document and account for
  all grant funds
• Assure that funds are expended according to
  federal requirements
• Initiation of corrective action when necessary
  and appropriate

24
Fiscal Monitoring CARE Act

• Costs costs caps defined in legislation
• Aggregate administrative costs
• Allowable administrative costs
• Allowable subcontractor costs
• Grantee administrative cost caps
• Caps for first-line entities
• Quality management program costs

25
Fiscal Monitoring CARE Act

• Other Fiscal Requirements in Legislation include
• Payor of Last Resort
• Maintenance of Effort
• Audit Requirements
• State Match

26
Audit Requirements CARE Act

• Audit Requirements, Section 2675
• Pursuant to OMB Circular A-133, grantees and
  sub-grantees that expend 500,000 or more federal
  funds shall have audits made by an independent
  auditor in accordance with generally accepted
  government auditing requirements covering
  financial audits.
• OMB Circular A-133
• Audits of States, Local Governments, and
  Nonprofit Organizations

27
OMB Circulars - Relevant Information

• Federal grant administration
• OMB Circular A-102
• Grants and Cooperative Agreements with State and
  Local Governments. (45 CFR Part 92)
• OMB Circular A-110
• Uniform Administrative Requirements for Grants
  and Other Agreements with Intuitions of Higher
  Education, Hospitals, and Other Non-Profit
  Organizations. (45 CFR Part 74)

28
OMB Circulars - Relevant Information

• They cover
• Standards for financial management systems
• Purpose of Property standards
• Procurement
• Reports and records
• Termination and enforcement
• Close out procedures

29
OMB Circulars - Relevant Information

• Establishing Cost Principles and Standards
• OMB Circular A-122
• Cost Principles for Nonprofit Organizations
• OMB Circular A-87
• Cost Principles for State, Local and Indian
  Tribal Governments
• OMB Circular A-21
• Cost Principles for Educational Institutions

30
OMB Circulars

• For more information
• Office of Federal Financial Management, Office of
  Management and Budget
• www.whitehouse.gov/omb/circulars

31
Other Reporting Requirements with Fiscal
Components

• Implementation Plan
• Budget and Revisions
• MAI Plan
• Final MAI Report
• WICY Plan
• WICY Final Report
• Final Financial Status Report
• Planned Allocations Table

• Local Pharmacy Assistance Report
• ADAP Quarterly Report
• Interim FSR 75 Obligation
• Contract Review Certification CRC
• Use of Carry Over Funds

32
DSS Goals for Fiscal Accountability

• Goals
• A. To assure that each grantee has in place an
  effective fiscal management system to manage and
  account for all grant funds, including funds
  awarded to contract providers.
• B. To assure each grantee has an effective
  fiscal management system in place to monitor
  contractor expenditures, unit costs, allowable
  costs, and all other fiscal requirements.

33
Major Fiscal Accountability Monitoring Objectives

• 1. Ensure each assigned grantee clearly documents
  its system for monitoring contractor compliance
  with fiscal requirements including fiscal
  reporting requirements, on-site fiscal monitoring
  reviews, audit requirements, and corrective
  action procedures
•  2. Understand each assigned grantees fiscal
  monitoring procedures, including fiscal reporting
  requirements, auditing requirements, and
  corrective action procedures for contractors

34
Major Fiscal Accountability Monitoring Objectives

• 3. Understand how each assigned grantees assures
  that its contractors only expend grant funds for
  allowable costs (improper payments)
•  
• 4. Ensure that assigned grantees inform (alert)
  DSS about any actual or potential fiscal problems
  with contractors that may appear in the media

35
Improper Payments and OIG Concerns

• What are Improper Payments?
• Unallowable cash payments or services received by
  eligible recipients or
• Allowable cash payments or services by ineligible
  recipients

36
Improper Payments and OIG Concerns

• What does this mean for Title I and Title II
  grant programs?
• For Title I and Title II Improper payments are
• Unallowable services received by eligible clients
  (services not allowed by CARE Act legislation or
  HAB Policies)
• Allowable services received by ineligible clients
  (clients that are not low-income or who are in
  not HIV positive)

37
Definition of Program Accountability

• Assessment of the quality and quantity of the
  services provided by a particular contractor
• Contract monitoring includes program and fiscal
  monitoring

38
Definition of Program Accountability (cont.)

• Verify the delivery of services un compliance
  with
• CARE Act legislation
• Federal requirements
• HAB policies and procedures
• Scope of work
• Local contract requirements
• Approved budget

39
Successful Program Monitoring Includes

• Program reports
• Site visits
• Reviewing client records or charts
• Reviewing client satisfaction surveys
• Capacity development/technical assistance (best
  practices)

40
Contract Monitoring

• Program Monitoring
• Progress reports
• Data reports
• Monthly reports
• quarterly report
• Fiscal Monitoring
• Monthly invoicing
• Quarterly expenditure review
• Redistribution of funds (sweeps)
• Annual Agency Financial Audit Review

41
ADAP Insurance HAB Policy Notice 99-01, January
1999

• Allows for the use of Title II ADAP funds to
  purchase of health insurance services that
  include the full range of HIV treatments as well
  as access to comprehensive primary care services
• Prescription coverage must be equivalent to the
  ADAP formulary
• Aggregate costs cannot be greater than the cost
  of maintaining the same population on ADAP

42
ADAP Insurance (cont.)

• Grantees can purchase health insurance premiums
  and pay co-pays and deductibles
• States have utilized High Risk Health Insurance
  Pools, State-sponsored health insurance COBRA,
  and private insurance policies
• States can collect rebates on co-pays and
  deductibles (Policy Memo dated April 29, 2005)

43
ADAP Flexibility Policy- HAB Policy Notice 00-02
(July 2000)

• Purpose to fund support services directly tied
  to
• Gaining Access to medications
• Increasing Adherence to medication regimens,
  and
• Monitoring clients progress in taking
  HIV-related medication

44
Quality - Definition

• The degree to which a health or support service
  meets or exceeds established professional
  standards and user expectations
• Evaluations of quality should consider
• Quality of personnel resources available
• Quality of the service delivery process and
• Quality of outcomes

45
Goals of Quality Management Program

• Assure that funded medical services at a minimum,
  adhere to the established HIV clinical practice
  standards in the PHS guidelines
• Ensure that inclusion of effective supportive
  services in achieving access to primary medical
  care. Implement Standards of Care for all
  services
• Monitor outcomes for specific services to improve
  their effectiveness and the effectiveness of the
  system of care

46
Characteristics of QM Programs

• Systemic process with identified leadership,
  accountability, and identified resources
• Uses data and measurable outcomes to determine
  progress toward relevant, evidence-based
  benchmarks
• Focus on linkages, efficiencies and provider and
  client expectations in addressing outcome
  improvement
• Continuous adaptive process that fits within the
  framework of other activities

47
2004 OIG Reports

• Titles I II grantee monitoring of sub grantees
• Set standards for monitoring to include contract
  or formal agreement, program report, fiscal
  report and consider regular site visits.
• Report on monitoring in every application
• Increase efforts to monitor grantees oversight
  of sub grantees

48
2004 OIG Reports

• HRSA monitoring of Titles I II grantees
• Specify and enforce PO standards for monitoring
  grantees
• PO training
• Standardize corrective action process address
  grantee issues more formally
• Insure frequency and comprehensiveness of site
  visits

49
OIG/DSS Project Monitoring Expectations

• Detailed written documentation pertaining to
  contractor performance maintained and available
  for review at any time
• Progress reports
• Site visit reports
• Payment and expenditure data
• Memos/written notes of verbal discussions
• Written correspondence

50
DSS Expectations June 5, 2001

• Program and fiscal monitoring are grantee
  responsibilities under Title I II
• Establish sound and effective business management
  systemsar
• Meet minimum requirements as detailed in
• OMB Circular A-102
• OMB Circular A-110

51
DSS Expectations (cont.)

• Grantees are responsible for providing
  subgrantees with clarification on allowable
  activities
• Grantees are expected to be well versed
• The relevant OMB Circulars
• The Grants Policy Statement
• CARE Act
• HAB Policies

52
DSS Expectations (cont.)

• Assessments should include the quality and
  quantity of services being provided
• Grantee staffing levels should be maintained to
  enable the performance of programmatic and fiscal
  oversight responsibilities
• Staff is expected to be trained and have clear
  knowledge of covered services

53
DSS Expectations (cont.)

• Administrative policy and procedures manuals
  outlining covered services are expected to exist
• All grantees expending more than 500,000 in
  Federal funding in a year must have a fiscal
  audit performed by a certified auditing firm
• Title I should be included in the auditors
  sampling at least once every 3 years

54
HRSA/HAB Expectations Quality Management

• QM to lead to improved client health status
• Outcomes focus
• Health status outcomes for primary medical care
  and core services at a minimum

55
Grants Policy Statement on Fraud and Abuse

• Those who become aware of fraud and abuse are
  encouraged to call the Inspector Generals
  Hotline or write
• Grantees must immediately notify Project Officers
  and GMO of illegal acts, misappropriation of
  funds and improprieties

56
Key Monitoring Activities for Project Officers

• Assess and understand each assigned grantees
  fiscal and programmatic monitoring systems by
  review of application and progress reports
• Discuss fiscal and programmatic monitoring
  systems with grantees during monitoring calls
• Discuss contractor compliance issues with
  grantees during monitoring calls ask about any
  contractor fiscal issues that may appear in the
  media
• Review fiscal and programmatic monitoring
  procedures during site visits
• Discuss how allowable costs are assured
• Discuss corrective action procedures for
  disallowed costs

57
Be The Project Officer

• In light of the project officer monitoring goals,
  take 10 minutes and review the following budgets
• Be ready to report to your Branch Chief and
  recommend, approval, return to grantee,
  disapproval

58
Important Tools for Grantees

• CARE Act legislation
• Title I II Manuals
• OMB Circulars
• HAB Policies and Procedures
• QM Manual National Quality Center
• Developing Primary Care Outcomes
• Project Officer
• TA

59
Summary

• Internal and external forces demanding greater
  accountability of federal programs
• Challenges of the CARE Act also increase the need
  for Quality Management
• Focus on CARE Act, Conditions of Award, OMB
  Circulars, OIG Reports
• View Project Officer differently