Department of Health and Human Services
OFFICE OF 
   
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
THE CO  RE MEDICAL SERVICES 
 
R R
EQUIREMENT IN THE  YAN 
 
 
W P  
HITE  ROGRAM
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
October 2009 
OEI-07-08-00240   
 
 
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.   
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVE
 
1.  To determine the extent to which Ryan White grantees expended 
grant funds on core medical services, as required. 
2.  To describe effects of the core medical services requirement on 
grantee operations. 
3.  To assess the Health Resources and Services Administrations 
(HRSA) guidance on and project officers oversight of the core 
medical services requirement. 
BACKGROUND 
Enacted in 1990, the Ryan White CARE Act (the Act), as amended, 
established the Ryan White program to provide funding to grantees to 
develop, organize, coordinate, and operate effective and cost-efficient 
health care and support services for people with HIV and AIDS.  
Administered by HRSA, the Ryan White program had a budget of 
$2.1 billion in 2008.   
The Ryan White HIV/AIDS Treatment Modernization Act of 2006 
changed how Ryan White funds may be used, emphasizing life-saving 
and life-extending services for people living with HIV/AIDS.  A key 
change made by this law provided more funds for direct health care 
services for Ryan White clients and established a requirement that 
certain grantees spend at least 75 percent of awarded grant funds on 
core medical services unless they receive waivers of this requirement.  
The requirement went into effect in 2007.  Section 703 of the law 
repealed the entire Ryan White program effective October 1, 2009, 
unless it is again reauthorized.  In late 2009, Congress was holding 
hearings on reauthorization of the program. 
Ryan White grantees must submit financial and performance reports 
throughout the grant period, and each grantee is assigned a HRSA 
project officer to oversee and assist with the proper use of grant funds.   
This evaluation is based on grantee interviews, grantee expenditure and 
allocation information, project officer interviews, and a review of HRSA 
guidance. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  i   
   
E X E C U T I V E   S U M M A R Y  
FINDINGS 
Almost all grantees complied with the core medical services 
requirement; grantee expenditures for core medical services 
changed little from 2006 to 2007.  Ninety-six percent of Part A 
grantees complied with the requirement in 2007, and 98 percent 
allocated their grant funds in compliance with the requirement in 2008.  
All Part B and Part C grantees were in compliance with the 
requirement based on 2007 expenditure and 2008 allocation reports.  
Even though grantee expenditures on core medical services changed 
little from 2006 to 2007, 55 of the 92 grantees responding to the 
question reported that they could better serve the goals of their 
programs and meet the needs of their clients if more flexibility were 
built into the requirement (e.g., more local control over funding, options 
to adjust the percentage spent on core medical services).  Additionally, 
71 of the 121 grantees that responded to the question provided 
suggestions for Congress to consider during the next reauthorization.   
The core medical services requirement affected support services 
and administrative processes for some grantees.  When compared to 
Part B and C grantees, a higher percentage of Part A grantees reported 
that the core medical services requirement had a significant effect on 
support services provided to their clients.  When asked, 14 percent of all 
grantees reported that the core medical services requirement increased 
their administrative burden.  
HRSA guidance was helpful, but project officer turnover created 
program management difficulties.  Of the 81 percent of grantees that 
received guidance from HRSA, 95 percent found HRSA guidance helpful.  
However, 71 percent of grantees reported experiencing project officer 
turnover in recent years that created program management difficulties.  
Further, OIG found that issues with project officer oversight continue to 
cause vulnerabilities within the Ryan White program. 
CONCLUSION 
The Ryan White HIV/AIDS Treatment Modernization Act of 2006 
emphasized providing funds for direct health care services for people 
living with HIV/AIDS by establishing a requirement that certain 
grantees spend at least 75 percent of their grant funds on core medical 
services.  OIG found that, overall, those grantees complied with the core 
medical services requirement in 2007 and allocated their funds in 
compliance with the requirement in 2008.  There was little change in 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  ii   
   
E X E C U T I V E   S U M M A R Y  
grantee spending on core medical services after the requirement went 
into effect.  However, some grantees reported that the core medical 
services requirement affected their delivery of support services and 
increased their administrative burden.  Further, when asked, just over 
half of the grantees we interviewed would welcome the opportunity to 
provide input as Congress considers reauthorization of the Ryan White 
program in 2009.  Lastly, while over 90 percent of grantees found HRSA 
guidance helpful, OIG found that project officer oversight continues to 
be a vulnerabilty in the Ryan White program.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
HRSA concurred with our findings.  Regarding the finding pertaining to 
turnover among project officers affecting oversight of grantees, HRSA 
further commented that it has lost a number of experienced project 
officers in recent years, and is currently hiring new staff.  HRSA also 
noted that in response to the complex requirements mandated by the 
Act, impending reauthorization of the Act, and the influx of new project 
officers, it will be intensifying training in the coming weeks.  We did not 
make any changes in response to HRSAs comments.   
 
 
 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  iii   
 
 
 T A B L E   O F   C O N T E N T S  
 
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
   
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 
 
 
   
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 
 
Almost all grantees complied with the core medical services 
requirement; grantee expenditures for core medical services  
 
changed little from 2006 to 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 
 
The core medical services requirement affected support services  
and administrative processes for some grantees. . . . . . . . . . . . . . 10 
 
HRSA guidance was helpful, but project officer turnover created 
 
program management difficulties . . . . . . . . . . . . . . . . . . . . . . . . . 11 
 
 
  CONC LUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 
Agency Comments and Office of Inspector General Response . . . 14 
 
 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 
 
  A:  Point Estimates and Confidence Intervals. . . . . . . . . . . . . . . . 15 
 
B:  Five Highest-Funded Core Medical Service Categories by  
  Grantee Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 
  C:  Grantee Ratings of the Difficulty of Implementing the Core 
Medical Services Requirement. . . . . . . . . . . . . . . . . . . . . . . . . 19 
 
  D: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 
 
 
   
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 
 
 
 
 
   
   
 I N T R O D U C T I O N  
OBJECTIVES 
1.  To determine the extent to which Ryan White grantees expended 
grant funds on core medical services, as required. 
2.  To describe effects of the core medical services requirement on 
grantee operations. 
3.  To assess the Health Resources and Services Administrations 
(HRSA) guidance on and project officers oversight of the core 
medical services requirement. 
BACKGROUND 
Enacted in 1990, the Ryan White CARE Act (the Act), as amended, 
established the Ryan White grant program to provide funding to 
develop, organize, coordinate, and operate effective and cost-efficient 
health care and support services to people with HIV and AIDS.  
Administered by HRSA, the Ryan White program is the largest 
federally funded program dedicated to providing services to people with 
HIV/AIDS, with funding of $2.1 billion in 2008.1  The Ryan White 
program serves nearly half a million people annually.  
The Ryan White HIV/AIDS Treatment Modernization Act of 2006, the 
most recent reauthorization of the Ryan White program, changed how 
Ryan White funds may be used, emphasizing life-saving and 
life-extending services for people living with HIV/AIDS.  A key change 
made by this law established a requirement that certain grantees spend 
at least 75 percent of awarded grant funds on core medical services 
unless they receive waivers of this requirement.2  Examples of core 
medical services include outpatient health services, home health care, 
mental health services, and medications.  Section 703 of the law 
repealed the entire Ryan White program effective October 1, 2009, 
unless it is again reauthorized.3  In late 2009, Congress was holding 
hearings on reauthorization of the program. 
 
1 HIV/AIDS Policy Fact Sheet, The Ryan White Program.  The Henry J. Kaiser Family 
Foundation, June 2008.  Available online at  http://hab.hrsa.gov/reports/funding.htm.  
Accessed on June 30, 2009.   
2 The 2006 reauthorization also renamed various Titles of the Act:  Title I became Part A, 
Title II became Part B, and Title III became Part C. 
3 Ryan White HIV/AIDS Treatment Modernization Act of 2006, P.L. No. 109-415 
(Dec. 19, 2006).    
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  1   
   
I N T R O D U C T I O N  
The Act is divided into six parts, and the core medical services 
requirement applies to funds provided under Parts A, B, and C; the  
majority of Ryan White grant funds are allocated to these three parts.  
Grants and grantees are referred to based on the part of the Act under 
which their grants are awarded; for example, an organization receiving 
a grant under Part A of the Act would be referred to as a Part A 
grantee.  Part A grants are awarded to metropolitan areas for 
HIV-related services.  Part B base grants, along with supplemental 
funds, are awarded to States and Territories to improve the quality, 
availability, and organization of health care and support services.4  
Finally, Part C Early Intervention Services (EIS) grants are made to 
public and private nonprofit organizations to fund comprehensive 
primary health care in an outpatient setting for people living with 
HIV.5    
Core Medical Services Requirement 
The 2006 reauthorization of the Act established a requirement that 
Parts A, B, and C grantees spend at least 75 percent of their funds, after 
deducting funds for administration and quality management services, 
on core medical services (hereinafter referred to as the requirement).6  
Grantees may seek waivers of the requirement under circumstances 
specified by statute.   
 
4 Many of the supplemental funds associated with Part B grants are earmarked for the 
AIDS Drug Assistance Program (ADAP).  ADAP provides medications for the treatment of 
HIV.  States may also use ADAP program funds to purchase health insurance for eligible 
clients and for services that enhance access to, adherence to, and monitoring of drug 
treatments.  HRSA, Part B:  Grants to States and Territories.  Available online at  
http://www.hab.hrsa.gov/treatmentmodernization/partb.htm#ADAP.  Accessed on 
July 14, 2009. 
5 Part C includes two categories of grants:  EIS grants, which fund comprehensive 
primary health care in an outpatient setting; and Planning and Capacity Development 
grants, which support organizations in planning for service delivery and in building 
capacity to provide services.    
6 Sections 2604(c), 2612(b), 2620(e), and 2651(c) of the Act (42 U.S.C.  300ff-14(c), 
300ff-22(b), 300ff-29a(e), and 300ff-51(c)). 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  2   
   
II NN TT RR OO DD UU CC TT II OO NN      
TThhee  rreeqquuiirreemmeenntt  aapppplliieess  ttoo  tthhee  ffoorrmmuullaa  ffuunnddiinngg,,  mmoosstt  ssuupppplleemmeennttaall  
ffuunnddiinngg,,77  aanndd  MMiinnoorriittyy  AAIIDDSS  IInniittiiaattiivvee  ((MMAAII))  ffuunnddiinngg  rreecceeiivveedd  bbyy  
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ffuunnddiinngg  aawwaarrddeedd  uunnddeerr  PPaarrtt  CC,,  iinncclluuddiinngg  MMAAII  ggrraannttss..99  
TThhee  ccoorree  mmeeddiiccaall  sseerrvviicceess  ssppeecciiffiieedd  iinn  tthhee  AAcctt  aarree::  
  oouuttppaattiieenntt  aanndd  aammbbuullaattoorryy  hheeaalltthh  sseerrvviicceess;;  
  pphhaarrmmaacceeuuttiiccaall  aassssiissttaannccee,,  iinncclluuddiinngg  mmeeddiiccaattiioonnss  pprroovviiddeedd  tthhrroouugghh  
AADDAAPP;;  
  oorraall  hheeaalltthh  ccaarree;;  
  eeaarrllyy  iinntteerrvveennttiioonn  sseerrvviicceess;;  
  hheeaalltthh  iinnssuurraannccee  pprreemmiiuumm  aanndd  ccoosstt--sshhaarriinngg  aassssiissttaannccee  ffoorr  
llooww--iinnccoommee  iinnddiivviidduuaallss;;  
  hhoommee  hheeaalltthh  ccaarree;;  
  mmeeddiiccaall  nnuuttrriittiioonn  tthheerraappyy;;  
  hhoossppiiccee  sseerrvviicceess;;  
  hhoommee  aanndd  ccoommmmuunniittyy--bbaasseedd  hheeaalltthh  sseerrvviicceess;;  
  mmeennttaall  hheeaalltthh  sseerrvviicceess;;  
  oouuttppaattiieenntt  ssuubbssttaannccee  aabbuussee  ccaarree;;  aanndd  
  mmeeddiiccaall  ccaassee  mmaannaaggeemmeenntt,,  iinncclluuddiinngg  ttrreeaattmmeenntt  aaddhheerreennccee  sseerrvviicceess..1100  
  
77  TThhee  ccoorree  mmeeddiiccaall  sseerrvviicceess  rreeqquuiirreemmeenntt  ddooeess  nnoott  aappppllyy  ttoo  tthhee  ssuupppplleemmeennttaall  ggrraannttss  
awarded under Part B for Emerging Communities.  Section 2621 of the Act 
(42 U.S.C.  300ff-30a); HRSA HIV Care Grant Program Part B Program Guidance, FY 
2008, p. 38 (November 30, 2007). 
8 HRSA awards MAI grants to Parts A, B, C, D, and F grantees through a competitive 
process.  The goal of these grants is to reduce HIV-related health disparities among 
minority populations.  Section 2693 of the Act (42 U.S.C.  300ff-121).  When a Part A, B, or 
C grantee receives MAI funding, the requirement applies to the total combined award.   
HRSA Announcement No. 07-135, Part A Minority AIDS Initiative Grant Program, 
Application Guidance for New Competing Discretionary Grants, 2007.  HRSA 
Announcement No. HRSA 5-H3M-08-001, Part A Minority AIDS Initiative Grant Program, 
Non-Competing Continuation Discretionary Grants, 2008.  HRSA Announcement No. 
07-136, Part B Minority AIDS Initiative Grant Program, Application Guidance for New 
Competing Discretionary Grants, 2007.  HRSA Announcement No. HRSA 5-G24-08-001, 
Part B Minority AIDS Initiative Grant Program, Non-Competing Continuation 
Discretionary Grants, 2008.   
9 Only Part C EIS grantees are subject to the core medical services requirement.  
Hereinafter, we refer to Part C EIS grantees as simply Part C grantees.  HRSA 
Announcement No. 5-H76-07-002, Ryan White Title III:  Categorical Grant Program for 
Outpatient EIS, Non-Competing Continuation Application, 2007.  HRSA Announcement 
No. 5-H76-08-001, Ryan White Part C (Title III):  Categorical Grant Program for 
Outpatient EIS, Non-Competing Continuation Application, 2008. 
10 Sections 2604(c)(3), 2612(b)(3), 2620(e), and 2651(c)(3) (42 U.S.C.  300ff-14(c)(3), 
300ff-22(b)(3), 300ff-29a(e), and 300ff-51(c)(3)). 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  3   
   
II NN TT RR OO DD UU CC TT II OO NN      
GGrraanntteeeess  mmaayy  ssppeenndd  uupp  ttoo  2255  ppeerrcceenntt  ooff  tthheeiirr  RRyyaann  WWhhiittee  ggrraanntt  ffuunnddss  
oonn  ssuuppppoorrtt  sseerrvviicceess  nneeeeddeedd  ffoorr  iinnddiivviidduuaallss  wwiitthh  HHIIVV//AAIIDDSS  ttoo  aacchhiieevvee  
tthheeiirr  ddeessiirreedd  mmeeddiiccaall  oouuttccoommeess  ((ee..gg..,,  oouuttrreeaacchh,,  mmeeddiiccaall  
ttrraannssppoorrttaattiioonn,,  lliinngguuiissttiicc  sseerrvviicceess,,  rreessppiittee  ccaarree,,  aanndd  rreeffeerrrraallss  ffoorr  
hheeaalltthh  ccaarree  aanndd  ssuuppppoorrtt  sseerrvviicceess))..  
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ttoo  ssppeenndd  lleessss  tthhaann  7755  ppeerrcceenntt  ooff  tthheeiirr  RRyyaann  WWhhiittee  ggrraanntt  ffuunnddss  oonn  ccoorree  
mmeeddiiccaall  sseerrvviicceess..    TToo  qquuaalliiffyy  ffoorr  aa  wwaaiivveerr,,  tthheerree  mmuusstt  bbee  nnoo  AADDAAPP  
wwaaiittiinngg  lliisstt  iinn  tthhee  ggrraanntteeeess  SSttaattee  aanndd  ccoorree  mmeeddiiccaall  sseerrvviicceess  mmuusstt  bbee  
aavvaaiillaabbllee  ttoo  aallll  iinnddiivviidduuaallss  iiddeennttiiffiieedd  aanndd  eelliiggiibbllee  ttoo  rreecceeiivvee  sseerrvviicceess  
uunnddeerr  tthhee  AAcctt..1111    GGrraanntteeeess  aappppllyyiinngg  ffoorr  wwaaiivveerrss  iinn  ggrraanntt  yyeeaarrss  22000077  aanndd  
22000088  sseellff--cceerrttiiffiieedd  tthhaatt  tthheeyy  mmeett  tthheessee  rreeqquuiirreemmeennttss..1122  
AAccccoorrddiinngg  ttoo  HHRRSSAA,,  55  ooff  tthhee  5566  PPaarrtt  AA  ggrraanntteeeess  aanndd  33  ooff  tthhee  5599  PPaarrtt  BB  
ggrraanntteeeess  rreecceeiivveedd  wwaaiivveerrss  ooff  tthhee  rreeqquuiirreemmeenntt  ffoorr  tthhee  22000077  ffuunnddiinngg  ccyyccllee..    
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wwaaiivveerrss,,  33  ooff  wwhhiicchh  aallssoo  rreecceeiivveedd  wwaaiivveerrss  iinn  22000077..    NNoo  PPaarrtt  CC  ggrraanntteeeess  
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wwaaiivveerrss..  
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HHRRSSAA  rreeqquuiirreess  RRyyaann  WWhhiittee  ggrraanntteeeess  ttoo  ssuubbmmiitt  rreeppoorrttss  tthhrroouugghhoouutt  tthhee  
ggrraanntt  ppeerriioodd,,  iinncclluuddiinngg  ppeerrffoorrmmaannccee  rreeppoorrttss  aanndd  ffiinnaanncciiaall  rreeppoorrttss  aatt  tthhee  
eenndd  ooff  eeaacchh  aannnnuuaall  ggrraanntt  ppeerriioodd..1133    HHRRSSAA  aallssoo  rreeqquuiirreess  ggrraanntteeeess  ttoo  
ssuubbmmiitt  aa  nnuummbbeerr  ooff  ssttaannddaarrddiizzeedd  rreeppoorrttss  aannnnuuaallllyy  oonn  cclliieennttss,,  sseerrvviicceess  
pprroovviiddeedd,,  aanndd  eexxppeennddiittuurreess..    TThheessee  rreeppoorrttss  aarree  iimmppoorrttaanntt  ffoorr  
ddeetteerrmmiinniinngg  ggrraanntteeeess  ccoommpplliiaannccee  wwiitthh  tthhee  rreeqquuiirreemmeenntt..1144      
HHRRSSAA  pprroojjeecctt  ooffffiicceerrss  hhaavvee  pprriimmaarryy  rreessppoonnssiibbiilliittyy  ffoorr  oovveerrsseeeeiinngg  
ggrraanntteeeess..    EEaacchh  ggrraanntteeee  iiss  aassssiiggnneedd  aa  pprroojjeecctt  ooffffiicceerr  ttoo  oovveerrsseeee  aanndd  
aassssiisstt  wwiitthh  tthhee  pprrooppeerr  uussee  ooff  ggrraanntt  ffuunnddss..    PPrroojjeecctt  ooffffiicceerrss  uussee  ggrraanntteeeess  
  
1111  SSeeccttiioonnss  22660044((cc))((22)),,  22661122((bb))((22)),,  22662200((ee)),,  aanndd  22665511((cc))((22))  ((4422  UU..SS..CC..    330000ffff--1144((cc))((22)),,  
300ff-22(b)(2)), 300ff-29a(e), and 300ff-51(c)(2)).  Some States have more people needing 
medications than their ADAP funding can provide for; these States have had to institute 
waiting lists of people needing medications. 
12 FY 2007 Interim Waiver Eligibility Guidance; 72 Fed. Reg. 66181 (November 27, 
2007); 73 Fed. Reg. 33097 (June 22, 2008).  
13 Requirements for grantees to submit performance and financial reports are found at 
45 CFR  92.40(b)(1) and 92.41(b)(3) (for governmental grantees) and 45 CFR  74.51(b) 
and 74.52 (for nongovernmental grantees). 
14 Grantees receiving ADAP funds must submit the quarterly ADAP report; MAI funds 
are included on the allocation and expenditure reports.   
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  4   
   
I N T R O D U C T I O N  
performance and financial reports to determine compliance with 
spending requirements.  Project officers also give feedback in response 
to grantees reports, including acknowledging receipt of the documents, 
providing clarifying information, and asking grantees to make any 
necessary budget revisions.     
Previous Office of Inspector General Work 
A previous Office of Inspector General (OIG) report found that 
53 percent of Titles I and II (now known as Parts A and B) Ryan White 
expenditures in 1992 were for medical services and pharmaceuticals.15  
In 2004, an OIG report found that project officers were not adequately 
monitoring the Ryan White grantees studied and that HRSA provided 
little support to its project officers.16  OIG made recommendations to 
improve the monitoring of Ryan White grantees, including:  specifying 
and enforcing standards and guidelines for how project officers should 
monitor grantees; addressing ongoing training for project officers; 
standardizing a corrective action process and addressing grantee issues 
more formally; increasing frequency and comprehensiveness of site 
visits; and improving project officer continuity.  HRSA agreed to make 
changes in its monitoring of grantees in response to those 
recommendations.   
In May 2008, HRSA informed OIG that it had taken a variety of steps to 
implement the recommendations.  These steps included enhancing 
training for project officers, developing a site visit protocol for onsite 
monitoring, and increasing the number of grantee site visits.  
Additionally, HRSA reported that it has consolidated its grants 
management offices, relocated all Title II (Part B) monitoring 
responsibilities from regional offices to headquarters, and redefined the 
Office of Field Operations as the Office of Performance Review.17  
METHODOLOGY 
We limited our grantee population for this study to grantees located in 
the 50 States, the District of Columbia, and Puerto Rico.  This 
 
15 The Ryan White Care Act:  Fiscal Year (FY) 1992 Title I and Title II Expenditures, 
OEI-05-93-00331, April 1994. 
16 Monitoring of Ryan White CARE Act Title I and Title II Grantees, OEI-02-01-00640, 
March 2004. 
17 Compendium of Unimplemented Office of Inspector General Recommendations, 
Department of Health and Human Services OIG, May 2009, p. 87. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  5   
   
I N T R O D U C T I O N  
population included all 56 Part A grantees, 52 of 59 Part B grantees, 
and 361 of the 363 Part C grantees.  Our sample consisted of all 
56 Part A grantees, all 52 Part B grantees, and a simple random sample 
of 90 of 361 Part C grantees.  This study also included all 
HRSA-identified project officers responsible for working with the Ryan 
White Parts A, B, and C grantees.  We requested responses to a 
structured interview guide from all Part A, all Part B, and sampled 
Part C grant officials through in-person interviews, telephone 
interviews, or email.  For all grantees included in this study, we 
requested, in writing, the grantees expenditures for FYs 2006 and 2007 
and their allocated expenditures for FY 2008.18  We also sent an 
electronic structured survey to all HRSA-identified project officers.  
Additionally, we reviewed HRSA-developed guidance documents. 
Grantee Interviews 
We requested responses to a structured interview guide from all Part A, 
all Part B, and sampled Part C grant officials responsible for 
administering each of the Ryan White grants.  In their responses, 
grantees provided us with information regarding their experiences with 
the core medical services requirement and any changes in operations 
resulting from the requirement.  Grantee responses also provided 
information regarding why they did or did not apply for waivers and 
about their guidance and oversight experiences with HRSA.  Grantee 
response rates were 98 percent for Part A grantees (55/56), 85 percent 
for Part B grantees (44/52), and 80 percent for Part C grantees (72/90).   
Grantee Expenditure and Allocation Report Review 
We requested that all Part A, all Part B, and sampled Part C grant 
officials complete a form to provide us with Ryan White grant 
expenditures for 2006 and 2007 and allocated expenditures for 2008.19  
We analyzed the information provided to determine whether each 
grantee complied with the requirement in 2007 and whether each 
allocated at least 75 percent of its 2008 funds to core medical services, 
 
18 We requested information on grantees total Ryan White funds, including their 
Parts A, B, and C base grants and any supplemental funding, such as ADAP or MAI 
funding they received in each year. 
19 The grant year for Part A and Part C funds is March 1 to February 28; for 
Part B funds, April 1 to March 31; and for Part F funds, August 1 to July 31.  We requested 
that grantees provide expenditures and allocations for the 2006, 2007, and 2008 grant years 
for Parts A, B, and C grants. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  6   
   
II NN TT RR OO DD UU CC TT II OO NN   
after deducting funds for administration and quality management.20  
We also analyzed the information provided to determine whether and 
how grantee expenditures on core medical and support services changed 
from 2006, prior to the implementation of the requirement, to 2007 and 
2008.  Rates of response to our request for grantee expenditures in 2006 
and 2007 and allocated expenditures in 2008 varied among Part A, 
Part B, and Part C grantees; see Table 1.   
Table 1:  Percentage of Grantees Responding to Requests for 
Expenditure and Allocation Information 
Allocation 
Grantee Type  Expenditure Information Information 
  2006  2007  2008 
  Part A  89.9  98.2  98.2 
  Part B  86.5  86.5  86.5 
  Part C  78.9  81.1  78.9 
Source:  OIG analysis of grantee expenditure and allocation information. 
 
HRSA Project Officer Interviews and HRSA Guidance Review 
We reviewed HRSA-developed guidance regarding Ryan White grant 
requirements.  We also requested responses to a structured interview 
guide from all 42 HRSA Ryan White project officers for Parts A, B, and 
C grants in early 2009.  The interviews included questions about the 
training and guidance project officers received, project officers 
interactions with grantees, project officers oversight of grantees, 
implementation of the requirement, and waivers of the requirement.  
The project officer interview response rate was 100 percent.   
Limitations 
This evaluation did not assess the accuracy of expenditure and 
allocation information provided by grant officials.  We also did not 
determine grantees compliance with HRSAs policies and practices used 
to oversee grantees. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency.
 
20 Because data collection occurred during FY 2008, final expenditure reports were not 
yet available. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  7   
   
 F I N D I N G S  
Almost all grantees complied with the core  Overall, Parts A, B, and C 
medical services requirement; grantee  grantees collectively spent an 
average of 93 percent of their 
expenditures for core medical services changed 
Ryan White grant funds on core 
little from 2006 to 2007 
medical services in 2007.  Part A 
grantees average spending on core medical services in 2007 
and their allocated expenditures in 2008 were 82 percent.  Part B and 
Part C grantees each had average spending on core medical services in 
2007 of 94 and 95 percent, respectively; their allocated expenditures for 
core medical services in 2008 were both 94 percent.  The five Part A and 
three Part B grantees that received waivers of the requirement spent 
between 54 and 99 percent of their grant funds on core medical services.  
Point estimates and confidence intervals for selected statistics are 
presented in Appendix A.  Appendix B shows that the proportion of 
funds devoted to core medical service categories changed little from 
2006 to 2008.   
Overall, Parts A, B, and C grantees complied with the core medical services 
requirement in 2007 and 2008   
Ninety-six percent of Part A grantees complied with the requirement in 
2007, and 98 percent allocated their grant funds in compliance with the 
requirement in 2008.  The two grantees that did not have waivers and 
spent less than 75 percent on core medical services in 2007 spent 71.0 
and 73.9 percent, respectively.21  At the time of our review, only one 
grantee expected to spend less than 75 percent of its grant funds on core 
medical services in 2008.22  All Part B and Part C grantees were in 
compliance with the requirement based on 2007 expenditure reports 
and 2008 allocation reports.23  
 
21 These grantees reported that difficulties with midyear implementation and budget 
changes contributed to their noncompliance with the requirement.  HRSA project officers 
reported that they anticipated that these two grantees would comply with the requirement 
in 2008. 
22 One Part A grantee allocated only 69.0 percent of its grant funds to the core medical 
services in 2008.  However, at the time of our data collection, 2008 final expenditure reports 
were not due.  Therefore, we cannot report how grantees actually spent their funds in 2008. 
23 While all 71 responding Part C grantees were in compliance with the core medical 
services requirement, we estimate with 95-percent statistical confidence that between 
94.1 and 100 percent of all Part C grantees were in compliance in 2007 and between 
95.9 and 100 percent of all Part C grantees were in compliance in 2008.   
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  8   
   
F I N D I N G S  
Parts A, B, and C grantees expenditures for core medical services changed 
little from 2006 to 2007 
Our analysis of grantees 2006 expenditures showed that they were 
already spending a high proportion of their grant funds on core medical 
services prior to implementation of the requirement.  From 2006 to 
2007, Part A grantees average spending on core medical services 
changed from 74 percent to 82 percent, Part B grantees average 
spending changed from 95 percent to 94 percent, and Part C grantees 
average spending remained at 95 percent. 24   
Even though there was little change in grantee spending on core 
medical services, 55 of the 92 grantees that responded to the question 
reported that they could better serve the goals of their program and 
meet the needs of their clients if more flexibility were built into the 
requirement (e.g., more local control over funding, options to adjust the 
percentage spent on core medical services).  Further, when asked, 71 of 
the 121 grantees that responded to the question provided suggestions 
for Congress to consider during the next reauthorization.25 
The most common suggestions included:  expanding the definitions of 
the core medical service categories to include case management, 
inpatient substance abuse treatment, and transportation; and seeking 
provider and consumer input during the next reauthorization.  One 
grantee stated, The distribution of funds formula should be 
reconsidered, including those [living] with HIV as well as those 
[diagnosed] with AIDS, as the trend of the epidemic is that people with 
HIV are surviving and improving.  Another grantee offered that 
. . . during [the] last reauthorization, there was very little chance for 
communities and consumers to provide input.  [We] encourage Congress 
to provide more opportunities for input from people who use and run the 
program. 
 
24 These estimates are based on grantee-reported expenditure information. 
25 Because of the low rates of response to these interview questions, we could not project 
the number of grantees in the population that reported that they could better serve the 
goals of their programs and meet the needs of their clients if more flexibility were built into 
the requirement or that provided suggestions for Congress to consider during the next 
reauthorization. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  9   
   
FFF III NNN DDD III NNN GGG SSS    
  
The core medical services requirement affected  The circumstances of 
support services and administrative processes  individual grantees and 
their clients needs played a 
for some grantees  
role in the degree to which 
the requirement affected their programs.  Part A grantees reported that 
the requirement had a significant effect on the provision of support 
services to their clients more often than Part B or C grantees.  Although 
Parts A, B, and C grantees rated implementing the requirement as 
easy, they also indicated that the requirement and other changes 
established in the reauthorization created additional burdens on 
administrative practices.   
The core medical services requirement affected the delivery of support 
services for 27 percent of Part A grantees, 7 percent of Part B grantees, and 
1 percent of Part C grantees 
Twenty-seven percent of Part A grantees reported that the requirement 
had a significant effect on support services provided to their clients, 
compared to only 7 percent of Part B and 1 percent of Part C grantees.  
Because the requirement imposed a minimum percentage for spending 
on core medical services and a maximum percentage for spending on 
support services, grantees that devoted a greater percentage of their 
funds to support services either made greater changes to how they spent 
their grant funds and the services they provided to clients or sought 
waivers of the core medical services requirement.   
One Part A grantee reported that the limitations placed on how Ryan 
White funds could be spent reduced funding for transportation in their 
rural area and caused clients difficulty in obtaining services, saying, 
Many support services are just as important as core [medical services] 
in some ways.  How can [a client] go to work when going to the doctor 
takes all day on the bus?  Another grantee noted the lack of funds for 
food assistance, saying, Food is critical to [the] success of medications; 
sometimes food banks dont have food that patients can eat or that will 
help them absorb their medications.  Finally, one grantee reported that 
as a result of their own evaluation, they found that these [support] 
services were absolutely critical as part of health outcomes, which put a 
lot more pressure on the county to provide [support] services. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  10   
   
F I N D I N G S  
The core medical services requirement increased the administrative burden 
for 14 percent of all grantees  
When we asked grantees to rate the degree of difficulty they 
experienced with implementing the requirement on a 5-point scale, 
where 1 indicated easiest and 5 indicated most difficult, the most 
common rating was 1 (see Appendix C for further information on 
grantees ratings).  However, when we asked grantees whether the 
requirement affected their administrative practices, 14 percent reported 
that it increased their administrative burden.  Examples of changes 
made to administrative practices included:  modifying program policies 
and practices, changing strategic planning practices, allocating and 
budgeting funds, reporting and tracking program expenditures, 
renegotiating contracts with providers, and identifying additional 
community resources.   
Other changes established by the reauthorization also affected grantees 
administrative practices.  For example, prior to the reauthorization, 
MAI funds were applied for and disbursed in conjunction with Parts A, 
B, and/or C grant funds; now these funds are applied for and disbursed 
separately.26  Grantees reported that these activities lessened their 
focus on service delivery to clients.  As one grantee stated, We spend so 
much time on reporting and completing grant applications that it leaves 
little time to think about service delivery.   
 
HRSA guidance was helpful, but project officer  Eighty-one percent of Ryan White 
turnover created program management  grantees reported receiving 
guidance from HRSA on the 
difficulties
requirement, and 95 percent of 
grantees that received guidance indicated that they found the guidance 
helpful.  However, grantees also reported that the turnover in and 
limited experience of Ryan White project officers contributed to 
inconsistent grantee oversight.  Grantee and project officer responses 
about the difficulties caused by turnover indicate that consistent 
grantee monitoring by project officers continues to be a vulnerabilty 
 
26 In a Government Accountability Office report on the implementation of the 
requirements of the Act for MAI grants, HRSA officials said that they changed the MAI FY 
for 2007 so that HRSA could complete the new guidance necessitated by the changes made 
by the Act.  The FY for MAI funding is from August 1 to July 31.  Ryan White Care Act:  
Implementation of the New Minority AIDS Initiative Provisions,  GAO-09-315, 
March 2009, p. 19. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  11   
   
F I N D I N G S  
within the Ryan White program, as previously identified in a 2004 OIG 
report.27  
Eighty-one percent of grantees reported receiving guidance on the core 
medical services requirement 
According to grantees, HRSA provides guidance through written 
materials, conference calls, and electronic mail, as well as in-person 
meetings and telephone conversations with project officers.  Of the 
grantees that received guidance from HRSA, 95 percent found it helpful.  
However, 21 percent of all grantees reported that some of the core 
medical services definitions were unclear.  Specifically, grantees 
reported that the definitions of medical case management, 
transportation, and early intervention services were unclear.  
Thirty-eight percent of project officers confirmed that grantees seek 
additional information and clarification on service definitions. 
Turnover affects project officer oversight of grantees 
At the time of our review, 71 percent of grantees reported experiencing 
project officer turnover in recent years.  Of these, 62 percent reported 
that project officer turnover created program management difficulties.  
Twenty-eight percent of the grantees that reported turnover said that 
they have to repeatedly train project officers on both the Ryan White 
program and the individual grantees unique organizations and 
processes.  Further, 26 percent of these grantees reported experiencing 
varying project officer expectations, and 23 percent of grantees reported 
a lack of consistency in project officer interactions.  Grantees offered the 
following comments about project officer turnover and oversight: 
  In my 10 years, we have had eight project officers.  Continuity is 
an issue.  We [the grantee] have to retrain them. 
  We have had three different project officers in the past year.  Each 
has had different expectations and . . . differing methods to monitor 
[the] program. 
  [Project officer] turnover has occurred without notification, and 
sometimes submissions [reports] appear to have been lost in the 
shuffle.  
 
27 Monitoring of Ryan White CARE Act Title I and Title II Grantees, OEI-02-01-00640, 
March 2004. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  12   
   
F I N D I N G S  
  Our new project officer has to consult with others constantly and 
never makes decisions on her own.  She is not familiar with the 
program . . . her relative inexperience creates a lot of trouble.  
Project officers generally agreed with the grantees assessments of high 
turnover within their ranks, explaining that HRSA has experienced 
staffing shortages in the past few years.  As HRSA project officers turn 
over, grantees are reassigned among the available staff.  Project officers 
noted problems resulting from turnover similar to those that grantees 
reported, including difficulties establishing relationships with grantees, 
inconsistent project officer expectations of grantees, and differing 
project officer approaches for grant oversight.  Of the forty-two project 
officers we interviewed, 21 reported that the frequent reassignment of 
grantees affected their ability to effectively oversee their grantees.  
Twenty-one project officers reported having no Ryan White experience 
prior to becoming Ryan White project officers, and 31 reported having 
no prior project officer experience.  Further, 19 project officers also 
reported that they came to their positions with limited prior experience 
and had only recently joined HRSA.  
 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  13   
   
FC IO NN DC ILNUGS SI  O N  
 C O N C L U S I O N  
 
The Ryan White HIV/AIDS Treatment Modernization Act of 2006 
emphasized providing funds for direct health care services for people 
living with HIV/AIDS by establishing a requirement that certain 
grantees spend at least 75 percent of their grant funds on core medical 
services.  OIG found that, overall, those grantees complied with the core 
medical services requirement in 2007 and allocated their funds in 
compliance with the requirement in 2008.  Our analysis of grantees 
2006 expenditures showed that most grantees were already spending a 
high proportion of their grant funds on core medical services in 2006, 
prior to the implementation of the requirement.  Therefore, there was 
little change in grantee spending on core medical services since the 
requirement went into effect.   
Despite the small amount of change in spending, a higher percentage of 
Part A grantees reported being affected by the core medical services 
requirement in the delivery of support services, compared to Part B and 
Part C grantees.  Additionally, 14 percent of all grantees reported that 
since implementation of the requirement, they have experienced an 
increase in their administrative burden.  Further, when asked, just over 
half of the grantees we interviewed would welcome the opportunity to 
provide input as Congress considers reauthorization of the Ryan White 
program in 2009.  Lastly, while 95 percent of the grantees who received 
guidance from HRSA found it helpful, grantee and project officer 
responses about the difficulties caused by turnover indicate that project 
officer oversight continues to be a vulnerabilty in the Ryan White 
program.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
HRSA concurred with our findings.  Regarding the finding pertaining to 
turnover among project officers affecting oversight of grantees, HRSA 
further commented that it has lost a number of experienced project 
officers in recent years, and is currently hiring new staff.  HRSA also 
noted that in response to the complex requirements mandated by the 
Act, impending reauthorization of the Act, and the influx of new project 
officers, it will be intensifying training in the coming weeks.  We did not 
make any changes in response to HRSAs comments.  For the full text of 
HRSAs comments, see Appendix D. 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  14   
   
 A P P E N D I X   ~   A  
Point Estimates and Confidence Intervals 
Grantee  Sample  Point  95% Confidence 
Statistic Description
Type Size  Estimate Interval*
Estimates from expenditure and allocation reports
All 171 92.9 92.093.7
Average percentage of grantee funds expended on   A 55 81.7 -
core medical services in 2007 B 45 93.5 -
C 71 94.9 93.896.1
All 169 93.3 92.594.2
Average percentage of grantee funds allocated for  A 53 81.5 -
core medical services in 2008 B 45 93.9 -
C 71 95.4 94.396.5
A 55 96.4 -
Grantees in compliance with the core medical 
B 45 100.0 -
services requirement in 2007
C 71 100.0 94.9100.0
A 53 98.1 -
Grantees in compliance with the core medical 
B 45 100.0 -
services requirement in 2008
C 71 100.0 94.9100.0
A 50 74.3 -
Average percentage of grantee funds expended on 
B 45 95.0 -
core medical services in 2006
C 70 94.8 93.496.1
Estimates from interview responses
A 49 26.5 -
Percentage of grantees reporting significant effects 
B 43 7.0 -
on service delivery
C 71 1.4 0.03.8
All 172 13.5 8.918.2
Percentage of grantees reporting significant effects  A 47 19.1 -
on administrative processes B 42 28.6 -
C 83 10.8 5.016.7
* Statistics presented for Parts A and B grantees are descriptive population statistics and therefore have no confidence interval.
 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  15   
   
A P P E N D I X   ~   A  
Point Estimates and Confidence Intervals (continued) 
Grantee  Sample  Point  95% Confidence 
Statistic Description
Type Size  Estimate Interval*
Percentage of grantees reporting receiving guidance 
All 171 80.9 74.787.0
on the core medical services requirement
Percentage of grantees that received guidance 
All 141 94.8 91.697.9
reporting finding the guidance helpful
Percentage of grantees reporting that the core 
All 171 21.4 15.427.4
medical service definitions are unclear
Percentage of grantees reporting project officer 
All 170 70.5 64.276.9
turnover
Percentage of grantees with project officer turnover 
All 96 61.7 51.971.5
reporting that turnover created difficulties
Percentage of grantees with project officer turnover 
reporting that turnover resulted in need to help  All 96 28.0 19.136.8
project officer understand program
Percentage of grantees with project officer turnover 
reporting that turnover resulted in experiencing  All 96 26.3 17.535.2
varying project officer expectations
Percentage of grantees with project officer turnover 
reporting that turnover resulted in lack of consistency  All 96 23.4 15.331.5
in project officer interactions
* Statistics presented for Parts A and B grantees are descriptive population statistics and therefore have no confidence interval.
Source:  Office of Inspector General analysis of grantee survey responses, expenditure reports, and allocation reports, 2009.
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  16   
   
 A P P E N D I X   ~   B  
Five Highest-Funded Core Medical Service Categories by Grantee Type 
 
Proportions of Part A Grantees' 2006 and 2007 Expen ditures and 2008 
Allocations
s  
d
n
u
F 50%
ant  40% 2006
Gr 30%
of  20% 2007
e  10% 2008
g
a
nt 0%
Perce O utp atieCnats e M a n a g e m e nt A D A P M e ntal H e alth Oral Oth er*
M e dical 
Five Highest-Funded Core Medical Service Catagories
* "Other" includes early intervention services, premium assistance, home health, nutrition, hospice, home- and 
community-based services, and substance abuse.
Source:  Office of Inspector General (OIG) analysis of Part A Ryan White grantees' expenditures and allocations.
Proportions of Part B Grantees' 2006 and 2007 Expenditures and 2008 
Allocations 
s
d
un 90%
F 80%
nt  70%
ra 60% 2006
G 50% 2007
of  40%
e  30% 2008
g
a 20%
nt 10%
e
c 0%
Per A D A P MO uetdpiactiale Cnta s e M a n g e mPreenmtiu m A s sista n ce Oral Oth er*
Five Highest-Funded Core Medical Service Catagories
* "Other" includes substance abuse, home health, nutrition, hospice, home- and community-based services, early intervention 
services, and mental health.
Source:  OIG analysis of Part B Ryan White grantees' expenditures and allocations.
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  17   
   
A P P E N D I X   ~   B  
Five Highest-Funded Core Medical Service Categories by Grantee Type 
(continued)  
 
Proportions of Part C Grantees' 2006 and 2007 Expenditures and 2008 
  Allocations
s
d
  n
u 70%
F
  nt  60%
a 50%
Gr 40% 2006
  of  30% 2007
e  20%
g 10% 2008
  a
nt 0%
e
   Perc E aOrluyt Ipnattieernvte ntioMne dSiecravli cCeass e M a n a g e m e nt Oral M e ntal H e alth Oth er*
 
Five Highest-Funded Core Medical Service Categories
 
* "Other" includes ADAP, premium assistance, home health, nutrition, hospice, home- and community-based services, 
 
and substance abuse.
  Source:  OIG analysis of Part C Ryan White grantees' expenditures and allocations.
 
Point Estimates and Confidence Intervals Relating to Part C Grantees 
Expenditures and Allocations
95% 
Fiscal  Sample  Point 
Statistic Description Confidence 
Year Size  Estimate
Interval
2006 72 57.6 47.667.6
Part C grantees' expenditures on outpatient services 2007 71 54.5 47.062.1
2008 73 52.9 45.660.3
2006 72 21.3 13.828.7
Part C grantees' expenditures on early intervention 
2007 71 22.8 14.930.6
services
2008 73 22.4 14.730.2
2006 72 9.0 6.611.4
Part C grantees' expenditures on medical case 
2007 71 7.9 5.610.1
management
2008 73 8.5 6.410.6
2006 72 5.5 3.47.6
Part C grantees' expenditures on oral health services 2007 71 5.6 3.67.6
2008 73 6.7 4.39.1
2006 72 3.5 2.54.6
Part C grantees' expenditures on mental health 
2007 71 4.1 2.95.2
services
2008 73 4.5 3.06.0
2006 72 5.6 3.97.3
Part C grantees' expenditures on all other core 
2007 71 5.2 3.76.7
medical services
2008 73 4.9 3.56.4
Source:  OIG analysis of Part C Ryan White grantees' expenditures and allocations, 2009.
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  18   
   
 A P P E N D I X   ~   C  
Grantee Ratings of the Difficulty of Implementing the Core Medical Services 
Requirement 
We asked grantees to rate the difficulty they experienced in 
implementing the core medical services requirement on a scale from 
1 to 5, with 1 being the easiest and 5 being the most difficult.  The chart 
below illustrates how each type of grantee responded. 
Ryan Whit e Grantees' Rating of the Difficulty of Implementing 
the Core Medical Services Requirement
 
50  
of  40   1
Percentage Grantees 123000    234
5
0
 
A B C
  Grantee Type
Source:  Office of Inspecto r General (OIG) analysis of grantee responses, 2009.
 
Point Estimates and Confidence Intervals Relating to Part C Grantees Ratings of 
Difficulty
95% 
Grantee  Sample  Point 
Statistic Description Confidence 
Type Size  Estimate
Interval
1 - 37.3
2 - 21.6
A 51 3 - 17.6 -
4 - 19.6
5  -  3.9 
1 - 36.4
Percentages of grantees rating the difficulty of  2 - 20.5
implementing the core medical services requirement  B 44 3 - 29.5 -
(1=easy through 5=difficult) 4 - 9.1
5 - 4.5
1 - 47.1 36.957.4
2 - 24.3 15.433.1
C 70 3 - 18.6 10.626.6
4 - 8.6 2.814.3
5 - 1.4 0.03.9
Source:  OIG analysis of grantee survey responses, 2009.
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  19  A  P PEN  D  x  D 
Agency Comments 
i11l<!i11h f!f!!ic.m:..s, end $~ 
Mni'llstr.atlofl 
OCT  1 2099 
FROM:  Adminisfrator 
oro 
SUBJECt:  OTllfi Report: ''TheCore MediCllJ SlTI'i.<lCB Rcquin;ment ill thcR~11 White 
Progr,lml" (OEJ.07.Q8><QQ240) 
This ls in fCSlJQ1111<l to Ole OIG's request fw commcl1(ij em tbe draft roport. "The CORE Medical 
Scrvi:s.Roquinmlc:nl. in the Ryan White Program" (O~I~7~fI,.OO2Mi).  Auaclled atO the Health 
ResCMlrces and S1l:rvicGS Adl11inistrwol]'~  comments.. Ifyou have any quesHcns. please contact 
Patricia A. R~&c in mSA'sOffice of FalmLl A9Sismncc Management at (30 t) 4430l70. 
Milry K. Wllkefield, Pn.D., R.N. 
Altachmel1t 
OEI070800240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  20  A P PEN D  x  D 
Health Re_ourcu and ~s AdmillJiltrllltlo.os Commeots 00 tile OlG Dl'aftRepon 
'VCbe CON M~BI Stlitvku Requlre1lilent III dteR,yo White Program" 
(m(j..OO'~OO14lJ, 
The ReQh'l1 ResollfCes and. Slmit~ Adminitr:amm.hBs ~the 0(1'1$ dm:ft repon lIIld hl\i$ 
the following oommei1lg, 
In poerat lhe ExecWvj,l Sl.IlliUUary,liItmdw:tioo, Mcthodo1Qgy and FlllltilJjlI BectiQn~ ofthe 
report are clear ome) tcebnitally llllCllJrllie. RRSA ~WIl1mr.mtl> witb l~t t<}I'heifullowillj 
specifIc nndinp: 
p, 3 QJGF!pding: 
Almon aD grnnteelioompUell db tile core medlelll ilIrvl~ nqulre1lileotsl fiJ1l.lItee 
expenditures til' COR mdl<Bl servkesehllnged little from 2006-2007. 
RRSA Rem>lID,lU;: 
HRSA OOtlCllfil willi J!IliB filJlding, 
Tbl! (:1;lJI1l Jmlldh::al $tlM'lee requirment idf~ted i$UPport swvillel and adIlllnlBtrnlive 
P~mlS for some grll111ees. 
HRSA collUT$ with this fmding. 
P. 11 QjQ Findi!lJl: 
HRSAgoild:llnfJe WIIS l1elpl'lIl, but pr!JJeet ofllce:r mmover' enAted proal'lim mauage:mem 
diffh:ultWs. 
HRSA ().onoors wi6l d,liS findins, HRSA hllll>1011t a number of experlencedproject t!iffit:el'S In 
ret1entyem, Ha~. WI.!' Me :nOM' 1m. tbe proOOli15ol'biringncwstllff'to fill tbisvoid, 
OE 1-0 7-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  21   
   
A P P E N D I X   ~   D  
 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  22   
   
 A C K N O W L E D G M E N T S  
This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the Kansas 
City regional office.  
Michala Walker served as the lead analyst for this study.  Other 
principal Office of Evaluation and Inspections staff from the Kansas 
City regional office who contributed to the report include Rae 
Hutchison, Amber Meurs, Dennis Tharp, and Deborah Walden; central 
office staff who contributed include Talisha Searcy and Kevin Farber.  
 
  OEI-07-08-00240  THE CORE MEDICAL SERVICES REQUIREMENT IN THE RYAN WHITE PROGRAM  23