Joint CMCS and HRSA Informational Bulletin 
 
 
DATE:   May 1, 2013 
 
FROM:   Cindy Mann, Director  
Center for Medicaid and CHIP Services  
 
Mary Wakefield, Administrator  
Health Resources and Services Administration  
 
SUBJECT:   Coordination between Medicaid and Ryan White HIV/AIDS Programs   
 
The Affordable Care Acts expansion of Medicaid provides tremendous opportunities to improve 
the health of the uninsured, especially for those with complex and chronic health conditions 
including people living with HIV/AIDS (PLWH).  With the transition to health coverage, there 
are opportunities and challenges for coordinating care and services for PLWH through the 
Medicaid and Ryan White HIV/AIDS Programs.  At the federal level, the Centers for Medicare 
& Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA) are 
working together to provide support and technical assistance to Medicaid agencies and Ryan 
White HIV/AIDS Programs as they plan for transitions ahead.  To facilitate coordination at the 
state level, this Information Bulletin outlines some program information and upcoming activities.  
We look forward to working with you on our shared goal of ensuring that PLWH will have 
access to quality, comprehensive health care through the coverage that will become available 
under the Affordable Care Act.    
 
Background 
 
In the United States, approximately 50,000 people become infected with HIV each year, and 
there are more than 1.1 million Americans living with HIV.  Currently,  Medicaid is the most 
significant source of coverage for PLWH, but still many PLWH currently lack healthcare 
coverage. The Affordable Care Act seeks to increase access to health care coverage for PLWH 
through a number of health insurance reforms, including the ban on exclusion based on pre-
existing conditions, the new Marketplace through which individuals will be able to purchase 
insurance with premium tax credits and cost sharing reductions for eligible individuals, and the 
expansion of Medicaid to low-income adults with incomes up to 133 percent of the Federal 
Poverty Level (FPL) in states that adopt the new adult group.   
 
As new coverage opportunities become available to individuals with HIV/AIDS, it is important 
to consider how these coverage programs interact with the Ryan White HIV/AIDS Program.  
Ryan White HIV/AIDS Programs can play an important role in helping people enroll in the 
coverage that will be available to them. In addition, by statute, the Ryan White HIV/AIDS 
Program is the payer of last resort, meaning that the Ryan White funds may not be used for  Informational Bulletin  Page 2 
any item or service for which payment has been made, or can reasonably be expected to be 
made, by any other payer.  Grantees are required to assess every client for eligibility for other 
payers at least every six months, and use effective strategies to coordinate with third party 
payers, including Medicaid, that are responsible for covering the cost of services provided to 
eligible or covered persons. As eligible individuals begin to enroll in Medicaid or private 
insurance, coordination around eligibility, provider/pharmacy network adequacy, prescription 
drug formularies, and availability and provision of services will be critical to ensure that PLWH 
continue to receive health care and treatment.   
 
Ryan White HIV/AIDS Programs (RWHAP) and AIDS Drug Assistance Programs (ADAP) 
 
The RWHAP, as amended by the Ryan White HIV/AIDS Treatment Extension Act of 2009 
(Public Law 111-87), provides grants to states and U.S. Territories, eligible metropolitan areas, 
and clinics to improve the quality, availability, and provision of HIV/AIDS health care and 
support services. Congress designates a portion of the RWHAP appropriation for ADAP funds, 
which are awarded to states and territories based on a formula of reported living HIV/AIDS 
cases in the most recent calendar year. ADAP provides medications for the treatment of HIV 
disease. Program funds may also be used to purchase health insurance for eligible clients if the 
health insurance is cost effective and has a formulary that is equivalent to the states ADAP 
formulary.  It is particularly important to ensure a seamless transfer for eligible individuals 
between ADAP and Medicaid because of the vital role prescription drugs play in the 
management of and prevention of HIV, as well as the significant financial impact of prescription 
drugs expenditures on state programs. 
 
Coordination between the RWHAP/ADAP and Medicaid has always been a critical, complex 
undertaking.  Eligibility for and enrollment in Medicaid and the RWHAP can be fluid: 
individuals may transition from the RWHAP/ADAP to Medicaid temporarily; the RWHAP may 
continue to provide support for limited or uncovered Medicaid services;  individuals may receive 
retroactive Medicaid eligibility status, and then RWHAP/ADAP may need to back-bill Medicaid 
for Medicaid-reimbursable services or medications.  Under the Affordable Care Act, in states 
that adopt the new adult coverage group in Medicaid, Medicaid eligibility should be more stable, 
but still key coordination challenges will exist.    
 
 
CMS and HRSA coordination activities for Medicaid and Ryan White HIV/AIDS 
Programs  
 
As we work on promoting seamless transitions of care for PLWH, CMS and HRSA have 
identified a set of topics that may be useful for providers, states and others to learn more about.  
These topics include:  eligibility, enrollment, essential community providers, best practices in 
managed care, and integrated care models in context of HIV/AIDS. We are planning a series of 
webinars on these topics for states, providers and stakeholders (where applicable) that we hope 
will inform and facilitate communication and collaboration within states, with providers and 
stakeholders, as we encourage these entities to coordinate with one another.  With consistent 
collaboration by all parties, we can help ensure that beneficiaries with HIV and AIDS reap the 
full benefits of the Affordable Care Act while preserving the protections and benefits of the Ryan 
White program.   
  Informational Bulletin  Page 3 
Please visit http://hab.hrsa.gov/affordablecareact to register for email updates and view resources 
produced jointly by HRSA and CMS, including notices of webinars in this series.  Additional 
resources about the Affordable Care Acts changes to Medicaid can be found on CMSs website, 
http://www.medicaid.gov/ , and resources on the Ryan White program can be found on the 
HRSA website, http://hab.hrsa.gov/ .