GAO 

United States Government Accountability Office

Report to Congressional Requesters

RYAN WHITE CARE 

ACT 

Health Resources and 

Services 

Administration’s 

Implementation of 

Certain Provisions 

Hampered by Lack of 

Timely and Accurate 

Information 

September 2009 

GAO-09-1020 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 2009

RYAN WHITE CARE ACT

Health Resources and Services Administration’s

Implementation of Certain Provisions Hampered by 

Highlights of GAO-09-1020, a report to Lack of Timely and Accurate Information 

congressional requesters 

Under the CARE Act, funds are 

made available to assist over 

530,000 individuals affected by 

HIV/AIDS. Grantees directly 

provide services to individuals 

(clients) or arrange with service 

providers to do so. The Department 

of Health and Human Services’s 

(HHS), Health Resources and 

Services Administration (HRSA), 

which administers CARE Act 

programs, is required to cancel 

balances of grants that are 

unobligated after one year and 

redistribute amounts to grantees in 

need. HRSA began to collect clientlevel data in 2009. Under the CARE 

Act, states and territories receive 

grants for AIDS Drug Assistance 

Programs (ADAP), which provide 

HIV/AIDS drugs. GAO was asked 

to examine elements of the CARE 

Act. In this report, we review: 

(1) HRSA’s implementation of the 

unobligated balance provisions, 

(2) HRSA’s actions to collect clientlevel data, and (3) the status of 

ADAP waiting lists. GAO reviewed 

reports and agency documents and 

interviewed federal officials, 

officials from 13 state and 5 local 

health departments chosen based 

on location and number of cases, 

and other individuals 

knowledgeable about HIV/AIDS. 

What GAO Recommends

GAO recommends that HRSA take 

action to ensure it obtains timely 

and accurate information on 

grantees’ unobligated balances. 

HHS reviewed a draft of the report, 

but did not comment on the 

recommendations. 

The lack of timely and accurate information reporting by grantees has delayed 

HRSA’s distribution of certain grants and has placed at risk HRSA’s ability to 

obligate these funds. The late submission of actual unobligated balances for 

the 2007 grant year delayed HRSA’s ability to determine grantees’ unobligated 

balances and redistribute these funds to other grantees. A number of grantees 

were late in their submissions. For example, 21 of the 56 metropolitan areas 

submitted their information beyond the date initially set by HRSA. 

Additionally, some grantees reported inaccurate unobligated balances, which 

required HRSA staff to correspond with grantees and request revised 

information, creating additional delays. HRSA is authorized to obligate fiscal 

year 2007 funds for a 3-year period and is at risk of losing the authority to 

make grants from these funds. HRSA officials said they have made changes to 

how they implement the unobligated provisions in an effort to avoid these 

issues in the future. 

HRSA has taken actions to collect client-level data by implementing a new 

data collection and reporting system. However, some grantees and service 

providers did not submit the initial reports by HRSA’s deadline. HRSA set a 

July 31, 2009, submission deadline for grantees’ initial reports, but 100 of 638 

grantees did not meet this deadline. Client-level data includes information 

such as the dates clients were served, the types of services provided, and the 

clients’ health status. HRSA has implemented a system to collect data on the 

number of unique clients from grantees and service providers that will allow 

HRSA to determine the services each client received and the outcomes of 

these services. In order for HRSA to collect this information, grantees and 

service providers must first collect the data using their own systems, and 

HRSA has provided technical and financial assistance so that they can develop 

these systems. For example, under a project initiated in 2009, HRSA awarded 

approximately $4 million to CARE Act grantees for the development of their 

own client-level data collection systems. 

The number of ADAPs with waiting lists and the number of individuals on 

those lists is increasing. In the first quarter of grant year 2008 (April 1, 2008, 

through June 30, 2008), 2 ADAPs had waiting lists with a total of 55 people on 

those lists; this grew to 3 ADAPs and a total of 112 people in the fourth quarter 

of the year, and increased to 4 ADAPs and 136 individuals in August 2009. 

Kentucky, Montana, Nebraska, and Wyoming were each maintaining a waiting 

list for ADAP services in August 2009; Nebraska had the largest number of 

individuals (71), and Wyoming had the smallest number (5). ADAP officials 

expressed concern that they will have to establish or expand waiting lists or 

implement other cost-control measures, such as limiting the number of drugs 

they make available. 

View GAO-09-1020 or key components.

For more information, contact Marcia Crosse 

at (202) 512-7114 or crossem@gao.gov. 
Page i GAO-09-1020 

Contents 

Letter 1

Background 6 

Lack of Timely, Accurate Information Places at Risk Certain 

Funds, and HRSA Has Unsuccessfully Attempted to Obtain 

Needed Information 13 

HRSA Has Taken Actions to Collect Client-Level Data, but Some 

Grantees Did Not Submit Initial Reports by the Deadline 17 

The Number and Size of ADAP Waiting Lists Is Increasing 23 

Conclusions 25 

Recommendations for Executive Action 25 

Agency Comments 26 

Appendix I Comments from the Department of Health and 

Human Services 27 

Appendix II GAO Contact and Staff Acknowledgments 30 

Tables 

Table 1: Number of Grantees Submitting Late FSRs by Amount of 

Time 14 

Table 2: Description of Data Submitted for Ryan White HIV/AIDS 

Program Services Reports 22 

Table 3: ADAPs with Waiting Lists and the Number of Individuals 

on Those Lists, Grant Year 2008 First Quarter, Grant Year 

2008 Fourth Quarter, and as of August 10, 2009 23 

Figure 

Figure 1: Timeline for 2007 Part A and Part B Grants and 

Unobligated Balance Provisions 10 

 Implementation of CARE Act Provisions 
Abbreviations 

ADAP AIDS Drug Assistance Program 

AIDS acquired immunodeficiency syndrome 

CARE Act Ryan White Comprehensive AIDS Resources Emergency 

 Act of 1990 

CDC Centers for Disease Control and Prevention 

DGMO Division of Grants Management Operations 

EMA eligible metropolitan area 

FSR Financial Status Report 

HAB HIV/AIDS Bureau 

HHS Department of Health and Human Services 

HIV human immunodeficiency virus 

HRSA Health Resources and Services Administration 

NASTAD National Alliance of State and Territorial AIDS Directors 

RDR Ryan White HIV/AIDS Program Data Report 

RSR Ryan White HIV/AIDS Program Services Report 

RWTMA Ryan White HIV/AIDS Treatment Modernization Act of 2006 

SPNS Special Projects of National Significance 

TGA transitional grant area 

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page ii GAO-09-1020 Implementation of CARE Act Provisions
Page 1 GAO-09-1020 

e, 

 

United States Government Accountability Office

Washington, DC 20548 

 

September 29, 2009 

The Honorable Michael B. Enzi 

Ranking Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Richard Burr 

United States Senate 

The Honorable Tom A. Coburn 

United States Senate 

The Honorable Lisa Murkowski 

United States Senate 

It has been more than 28 years since the first cases of acquired 

immunodeficiency syndrome (AIDS) in the United States were reported in 

June 1981. Since that time, approximately 1.7 million Americans have been 

infected with human immunodeficiency virus (HIV), including more than 

580,000 who have died.1

 The Centers for Disease Control and Prevention 

(CDC) estimates that approximately 1.1 million people were living with 

HIV infection in the United States at the end of 2006, and that there were 

56,300 new HIV infections in that year.2

The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 

(CARE Act), administered by the Department of Health and Human 

Services’s (HHS) Health Resources and Services Administration (HRSA), 

was enacted to address the needs of jurisdictions, health care providers, 

and people with HIV/AIDS and their family members.3

 Each year CARE 

Act programs provide assistance to over 530,000 mostly low-incom

1

HIV is the virus that causes AIDS. In this report, we use the common term HIV/AIDS to 

refer to HIV disease, inclusive of cases that have progressed to AIDS. When we use these 

terms alone, HIV refers to the disease without the presence of AIDS, and AIDS refers 

exclusively to HIV disease that has progressed to AIDS. 

2

These were the most recent estimates available at the time of this report. 

3

Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff through 300ff121). The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless 

otherwise indicated, references to the CARE Act are to the current title XXVI. 

 Implementation of CARE Act Provisions 
 

underinsured, or uninsured individuals living with HIV/AIDS. Under the 

CARE Act, approximately $2.2 billion in grants were made to states, 

localities, and others in fiscal year 2009. CARE Act programs have been 

reauthorized three times (1996, 2000, and 2006) and are scheduled to be 

reauthorized again in 2009.4

 The Ryan White HIV/AIDS Treatment 

Modernization Act of 2006 (RWTMA) reauthorized CARE Act programs for 

fiscal year 2007 through fiscal year 2009. 

Part A of the CARE Act provides for grants to selected metropolitan 

areas—known as eligible metropolitan areas (EMA) and transitional grant 

areas (TGA)—that have been disproportionately affected by the HIV/AIDS 

epidemic.5

 Part B provides for grants to states, the District of Columbia, 

and territories and associated jurisdictions to improve quality, availability, 

and organization of HIV/AIDS services,6

 including grants specifically for 

AIDS Drug Assistance Programs (ADAP).7

 ADAPs provide medications for 

the treatment of HIV/AIDS. Program funds may also be used to purchase 

health insurance for eligible clients and for services that enhance access 

to, adherence to, and monitoring of drug treatments. ADAP grants 

accounted for about 37 percent of the total $2.2 billion in CARE Act grants 

awarded in fiscal year 2009. ADAPs and other programs funded through 

CARE Act grants serve as the payers of last resort for eligible individuals 

who have no other private or public sources available for the services they 

need. Some ADAPs have struggled to meet the demand for their services 

and have established waiting lists for eligible individuals who will be 

served when space in the program becomes available and have taken other 

measures that restrict access and control costs. For example, in the past 

 

4

CARE Act programs were previously reauthorized by the Ryan White CARE Act 

Amendments of 1996 (Pub. L. No. 104-146, 110 Stat. 1346), the Ryan White CARE Act 

Amendments of 2000 (Pub. L. No. 106-345, 114 Stat. 1319), and the Ryan White HIV/AIDS 

Treatment Modernization Act of 2006 (Pub. L. No. 109-415, 120 Stat. 2767). 

5

EMAs are areas that have a population of 50,000 persons or more and had a cumulative 

total of more than 2,000 new AIDS cases during the most recent 5-year period. TGAs are 

areas that have a population of 50,000 persons or more and had a cumulative total of 1,000 

to 1,999 new AIDS cases during the most recent 5-year period. Prior to RWTMA, all 

metropolitan areas that received Part A funding were classified as EMAs. In fiscal year 

2009, there were 24 EMAs and 32 TGAs according to HRSA. 

6

These territories and associated jurisdictions are American Samoa, the Commonwealth of 

the Northern Mariana Islands, the Commonwealth of Puerto Rico, the Federated States of 

Micronesia, Guam, Palau, the Republic of the Marshall Islands, and the U.S. Virgin Islands. 

7

The ADAP in each state, the District of Columbia, territory, and associated jurisdiction is 

eligible for this funding. 

Page 2 GAO-09-1020 Implementation of CARE Act Provisions
 

ADAPs have required that individuals make a copayment in order to 

receive a drug and have placed caps on expenditures per enrollee.8

Most CARE Act funding is distributed to grantees either as base or 

supplemental grants. Base grants are distributed by formula, and HRSA 

uses a grantee’s share of living HIV/AIDS cases to determine the amount of 

base grants. Supplemental grants are generally awarded through a 

competitive process based on the demonstration of severe need and other 

criteria. Grantees may deliver services directly to individuals (clients) or 

arrange with service providers to provide client services.9

RWTMA added provisions regarding the obligation of funds by Part A and 

Part B grantees. In the past, some CARE Act grantees did not obligate all 

of their funds in some years, while others obligated all of their funds.10

RWTMA provided that base and supplemental grants were available for 

obligation by the grantee for a 1-year period beginning on the date 

awarded funds first became available to the grantee (i.e., the grant year). It 

also required HRSA to cancel any unobligated balances at the end of the 

grant year, recover funds that had been disbursed to grantees, and 

redistribute these funds to grantees in need as supplemental grants.11

Under appropriations acts enacted since RWTMA, funds for these grants 

 

8

GAO, Ryan White CARE Act: Improved Oversight Needed to Ensure AIDS Drug 

Assistance Programs Obtain Best Prices for Drugs, GAO-06-646 (Washington, D.C.: 

Apr. 26, 2006), 16-17. 

9

A service provider is an agency that provides direct services to clients and their affected 

family members or provides support such as administrative or technical services to 

grantees. Service providers may be directly funded through one or more CARE Act parts; 

through agreements with one or more grantees; or through subcontracts with a grantee’s 

fiscal intermediary (i.e., an administrative agent of the grantee). 

10Grantees obligate funds when they commit them for a specific purpose that will require 

payment during the same period of time when the funds were committed or a future period 

of time. Funds that have not been so committed by grantees are unobligated. 

11The unobligated balance provisions do not apply to Part A and Part B Minority AIDS 

Initiative grants. These grants are available to all Part A and B grantees as competitive, 

supplemental funding. For more information on Minority AIDS Initiative grants, see GAO, 

Ryan White CARE Act: Implementation of the New Minority AIDS Initiative Provisions, 

GAO-09-315 (Washington, D.C.: March 27, 2009). 

Page 3 GAO-09-1020 Implementation of CARE Act Provisions
 

are available for obligation by HRSA for a 3-year period. For example, 

fiscal year 2007 appropriations are available until September 30, 2009.12

In 2009, HRSA began requiring the collection of client-level data from 

grantees and service providers. Client-level data refers to information on 

each client receiving CARE Act-funded services, such as the dates services 

were received, the types of services provided, and current health status. 

Previously, grantees and service providers submitted only aggregate data 

to HRSA on those being served. To help ensure the accountability of CARE 

Act funds, HRSA has begun to collect client-level data. Implementing a 

client-level data collection and reporting system can allow HRSA to obtain 

accurate information on the medical and support services received by 

each unique client served with CARE Act funds. HRSA requires grantees 

and service providers to complete specified reports and transfer these 

reports electronically to HRSA. 

As Congress prepares to reauthorize CARE Act programs, you asked us to 

examine various elements of CARE Act programs. In this report, we 

review (1) HRSA’s first year implementation of the unobligated balance 

provisions; (2) the actions taken by HRSA to collect client-level data, and 

(3) the number and size of ADAP waiting lists. 

To examine the first year implementation of the unobligated balance 

provisions, we reviewed all grant year 2007 Part A and Part B carryover 

requests that were provided to us by HRSA,13 including those based on 

grantees’ estimated unobligated balances and those based on grantees’ 

actual unobligated balances. We also reviewed all grant year 2007 Part A 

and B financial status reports provided to us by HRSA. We reviewed HRSA 

documentation on grantees’ carryover requests and financial status reports 

as well as HRSA documentation on grantees’ unobligated balances at the 

end of grant year 2007. We interviewed HRSA officials and asked follow-up 

questions related to the calculation of unobligated balances, discrepancies 

in the carryover requests and financial status reports, grantee estimates of 

their unobligated balances that differed from their actual unobligated 

balances, and information provided by grantees that we found to be 

 

12We also examined the unobligated balance provision in a previous report. See GAO, Ryan 

White CARE Act: Effects of Certain Funding Provisions on Grant Awards, GAO-09-894 

(Washington, D.C.: Sept. 18, 2009). 

13Carryover requests are also referred to as waivers of the cancellation of unobligated 

balances. 

Page 4 GAO-09-1020 Implementation of CARE Act Provisions
 

incorrect. We determined that the information provided to us by HRSA 

was sufficiently reliable for our purposes. 

To examine the actions taken by HRSA to collect client-level data, we 

reviewed statements, manuals, and other materials on the implementation 

of client-level data collection by HRSA, grantees, and service providers. 

We focused on 2009, the first year grantees and service providers were 

required by HRSA to submit client-level data, including deadlines for data 

submission. In addition, we interviewed officials at HRSA as well as 

officials from 12 state and 5 local health departments who are 

knowledgeable about the CARE Act and the client-level data that grantees 

and service providers must collect.14 We also interviewed officials from the 

Henry J. Kaiser Family Foundation, the National Alliance of State and 

Territorial AIDS Directors (NASTAD), and other organizations 

knowledgeable about client-level data. 

To examine the number and size of ADAP waiting lists, we obtained and 

reviewed the ADAP Quarterly Data Reports submitted to HRSA by 

ADAP grantees covering the first quarter of grant year 2008 (April 1, 2008, 

through June 30, 2008) and the fourth quarter of grant year 2008 

(January 1, 2009, through March 31, 2009).15 These reports contain 

information on waiting lists. We reviewed the ADAP Quarterly Data 

Reports and asked HRSA officials follow-up questions about the accuracy 

of the data, and determined that the data were sufficiently reliable for our 

purposes. We also obtained updated data from HRSA on ADAP waiting 

lists as of August 10, 2009, and determined that the data were sufficiently 

reliable for our purposes after discussing the data with HRSA officials. We 

 

14We interviewed officials from 12 state health departments and 5 local health departments. 

We interviewed the following state health departments: California, Delaware, Florida, 

Hawaii, Indiana, Missouri, Nebraska, North Carolina, Ohio, Pennsylvania, Rhode Island, 

and Washington. We interviewed the following local health departments: Harris County, 

Tex.; Maricopa County, Ariz.; Memphis, Tenn.; New York, N.Y.; Sacramento County, Calif. 

We selected health departments to achieve a range in geographic locations and the number 

of HIV cases among jurisdictions. 

15We reviewed and analyzed ADAP Quarterly Data Reports if the grantee submitted reports 

for both the first and fourth quarters of the 2008 grant year. Consequently, we reviewed the 

reports of 52 of the 59 grantees. Louisiana did not submit an ADAP quarterly report for the 

first quarter of grant year 2008 and the U.S. Virgin Islands did not submit a report for the 

fourth quarter of grant year 2008. American Samoa, the Commonwealth of the Northern 

Mariana Islands, the Federated States of Micronesia, and the Republic of the Marshall 

Islands did not submit reports for either the fist or fourth quarters of grant year 2008. Palau 

also did not submit a report for either quarter, but it also did not receive any ADAP funding 

in grant year 2008. 

Page 5 GAO-09-1020 Implementation of CARE Act Provisions
 

reviewed published information on ADAPs. We interviewed HRSA officials 

knowledgeable about ADAPs and interviewed officials from 13 states, 

which we chose based on their geographic location, size, and number of 

HIV/AIDS cases, about their ADAPs.16 In addition, we interviewed officials 

from the Henry J. Kaiser Family Foundation, NASTAD, and other 

organizations knowledgeable about ADAPs. 

We conducted this performance audit from April 2009 through September 

2009 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives. 

RWTMA includes provisions related to unobligated balances, client-level 

data, and ADAPs. Background 

Unobligated Balance 

Provisions and Impact on 

Funding 

RWTMA includes provisions to encourage grantees to obligate their 

grant funds in the year in which they were awarded. RWTMA provides that 

Part A and Part B grant funds are available for obligation for a one-year 

period beginning on the date funds first become available (referred to as 

the grant year for the award).17 RWTMA requires HRSA to cancel the 

unobligated balance of grant awards at the end of a grant year and to 

require grantees to return any amounts from such balances that have been 

disbursed to them. However, in the case of base grants, a grantee may 

submit a request to carry over the unobligated balance prior to the end of 

the grant year. If HRSA approves the request, the unobligated balance that 

is approved for carryover (carryover funds) is available to the grantee for 

 

16We interviewed officials from the following ADAPs: Arizona, California, Delaware, 

Florida, Hawaii, Indiana, Missouri, Nebraska, North Carolina, Ohio, Pennsylvania, Rhode 

Island, and Washington. 

17Provisions establishing a one-year period for the obligation of funds apply to Part A base 

and supplemental grants to metropolitan areas, and all Part B grants to states and 

territories and associated jurisdictions—that is, Part B and ADAP base grants, Part B and 

ADAP supplemental grants, and supplemental grants for emerging communities. (Emerging 

communities are those metropolitan areas that do not qualify as EMAs or TGAs, but have 

500-999 cumulative reported AIDS cases during the most recent 5-year period. Emerging 

community grants are distributed to states, which then pass them through to emerging 

communities.) 

Page 6 GAO-09-1020 Implementation of CARE Act Provisions
 

expenditure for a one-year period beginning upon the expiration of the 

grant year (referred to as a carryover year). Under the RWTMA 

unobligated balance provisions, HRSA is required to cancel any 

unexpended balance of carryover funds at the end of the carryover year. 

HRSA must make the canceled balances from the grant awards (that is, 

funds that were not eligible or approved for carryover and carryover funds 

that remain after the carryover year) available as supplemental grants for 

the first fiscal year beginning after the fiscal year in which HRSA obtains 

the information necessary for determining the balance available. Part A 

grantees with greater than 2 percent of their base grant awards 

unobligated at the end of the grant year and Part B grantees with greater 

than 2 percent of their Part B and ADAP base awards unobligated at the 

end of the grant year incur a penalty. RWTMA requires HRSA to reduce the 

amount of those grants by the same amount as the unobligated balance for 

the first fiscal year beginning after the fiscal year in which HRSA obtains 

the information necessary for determining the unobligated balance. The 

grant funds that become available as a result of these reductions are also 

to be made available as supplemental grants.18

RWTMA’s authorization of appropriations for base and supplemental 

grants under Parts A and B provided that amounts appropriated for a fiscal 

year would be available for obligation until the end of the second 

succeeding fiscal year. Further, under appropriations acts enacted since 

RWTMA, funds for grants under Parts A and B, to which the unobligated 

balance provisions apply, are available for obligation for a 3-year period.19

In fiscal year 2007, for example, funds were made available for obligation 

until September 30, 2009—the end of the 2009 federal fiscal year. Thus, as 

HRSA recognized in its guidance regarding the unobligated balance 

provisions, the initial obligation of funds, cancellation of unobligated 

balances, return of amounts disbursed to grantees, and the recompetition 

and redistribution of supplemental grants would need to occur within the 

3-year window. 

 

18The availability of funds for supplemental grants is subject to hold-harmless provisions 

that protect grantees’ grant amounts at specified levels. 

19Revised Continuing Appropriations Resolution, 2007, Pub. L. No. 110-5, § 2, 121 Stat. 8, 31; 

Consolidated Appropriations Act, 2008, Pub. L. No. 110-161, div. G, title II, 121 Stat. 1844, 

2170; Omnibus Appropriations Act, 2009, Pub. L. No. 111-8, div. F, title II, 123 Stat. 524, 

763-64. 

Page 7 GAO-09-1020 Implementation of CARE Act Provisions
 

In order to implement the RWTMA unobligated balance provisions, HRSA 

created a multistep process for grantees and issued a policy notice to 

grantees explaining this process.20 HRSA’s process for implementing the 

unobligated balance provisions in grant year 2007 included five steps. 

First, a grantee wishing to carry over funds was required to submit a 

carryover request to HRSA with an estimated unobligated balance of base 

grant funds 60 days prior to the end of the grant year. In addition to the 

estimated unobligated balance, the initial carryover request also had to 

contain a viable plan and detailed budget for the use of the funds, and a 

description of the grantee’s capacity to utilize the funds within one-grant 

year. Part A grantees had to submit their initial carryover request to HRSA 

by January 1, 2008. Part B grantees had to submit their initial carryover 

request to HRSA by February 1, 2008. 

The second step of the 2007 grant year process was the evaluation of the 

initial carryover requests. HRSA authorized grantees that obtained 

approval before the end of the 2007 grant year to carryover 50 percent of 

the amount they requested in this initial carryover request. To authorize 

the use of the carryover funds, HRSA issued these grantees a notice of 

grant award that explained to the grantees that HRSA had effectively 

transferred the carryover funds from their grant year 2007 account into 

their grant year 2008 account, though balances remained, in effect, 

available to the grantees for obligation until the end of grant year 2007.21

HRSA officials explained that they did not authorize the full amount of the 

initial carryover request because they believed it was possible that the 

grantees that requested waivers would incur obligations greater than 

anticipated in the 60-day estimate. HRSA officials stated that they wanted 

to authorize the carryover of a portion of the unobligated balance so that 

grantees with approved carryover requests would have a longer period of 

time to obligate the carried over funds. 

 

20Department of Health and Human Services, Health Resources and Services 

Administration. HIV/AIDS Bureau. Policy Notice 07-09: The Unobligated Balances 

Provision (2007). http://hab.hrsa.gov/law/0709.htm 

21HRSA accomplished this by deobligating funds from the grantees’ 2007 grant year 

accounts and reobligating the funds to their 2008 grant year accounts. For grantees that 

incurred 2007 grant year obligations for which the use of CARE Act funds was appropriate, 

HRSA adjusted the accounts through a similar process at the end of the grant year, 

effectively transferring funds back to the grant year 2007 accounts. 

Page 8 GAO-09-1020 Implementation of CARE Act Provisions
 

For step three of HRSA’s 2007 grant year unobligated balance process, 

grantees were required by HRSA to submit a Financial Status Report 

(FSR) 90 days after the end of the grant year. The FSR contains, among 

other things, a grantee’s actual unobligated balance. For Part A grantees, 

FSRs were due on June 1, 2008. For Part B grantees, FSRs were due on 

June 30, 2008. HRSA can extend the deadlines for grantees for submission 

of their FSRs and granted extensions for 30 to 180 days. 

For step four of the process, although not required by HRSA for grant year 

2007, grantees could submit a final carryover request based on their actual 

unobligated balances. Those grantees that had their initial carryover 

requests approved and had been authorized by HRSA to carry over 

50 percent of their unobligated balances at that time, could apply for the 

remaining funds (the difference between the 50 percent they had already 

been authorized to carry over by HRSA and their actual unobligated 

balance). HRSA then authorized the use of the additional amount of 

carryover funds by issuing a notice of grant award. 

For step five of this process, grantees with unobligated balances of greater 

than 2 percent of their grant year 2007 Part A, Part B, and ADAP base 

grants were assessed a penalty. This penalty was a corresponding 

reduction in grant year 2009 funds.22 In addition, Part A and B grantees 

with unobligated balances of greater than 2 percent for grant year 2007 

were ineligible to receive supplemental grants in grant year 2009. For 

Part A grantees this meant that they were not eligible to receive grant year 

2009 Part A supplemental grants. For Part B base grantees this resulted in 

ineligibility to receive grant year 2009 Part B supplemental grants. For 

Part B ADAP grantees, an unobligated balance of greater than 2 percent 

does not result in ineligibility for ADAP supplemental grants. Instead, 

ineligibility for the ADAP supplemental grant occurs when a grantee has 

 

22Grantees are not penalized in the year immediately following the year in which they have 

unobligated balances in excess of 2 percent. Because the grantee submits the actual 

unobligated balance on the FSR 90 days after the grant year ends, grants for the next year 

have already been made by the time HRSA has received the information necessary to 

determine which grantees have an unobligated balance greater than 2 percent. As a result, 

there is a one-year lag time between when the unobligated balance occurs and when the 

penalty is assessed. For example, if a grantee had an unobligated balance of three percent 

in grant year 2007, the grantee’s FSR would have been filed in grant year 2008, and the 

dollar amount of the 2007 unobligated balance would have been deducted from the 

grantee’s award in grant year 2009. 

Page 9 GAO-09-1020 Implementation of CARE Act Provisions
 

not obligated at least 75 percent of its ADAP grant award within 120 days 

of the award.23

Figure 1 shows a timeline for Part A and B grant distribution and the 

unobligated balance provisions. 

distribution and the 

Figure 1: Timeline for 2007 Part A and Part B Grants and Unobligated Balance Provisions 

Source: GAO analysis of HRSA guidance.

J

F

M

A

M

J

J

A

S

O

N

D

J

F

M

A

M

J

J

A

S

O

N

Federal 

fiscal 

year ...........................2007............ ...........................2008........................... ...........

J

F

M

A

M

J

J

A

S

O

N

D

J

F

M

A

M

J

J

A

S

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N

Part A 

grant 

year

............... ...........................2007........................... .......2008...........................

April 1: Grantee receives the grant award. The 12-month period to obligate funds begins.

July 1: 90 days after the grant year ends, grantees must file a Financial Status Report (FSR), which includes 

the actual amount of the grantee’s unobligated balance. Any unobligated balances at this point are cancelled 

and amounts disbursed are returned to HRSA, unless the grantee has submitted a carryover request and it 

has been approved. The FSR is the basis for determining the applicability of the unobligated balance 

provisions.

February 1: 60 days prior to the end of the grant year, grantees file their estimated unobligated 

balance. Grantees may file an initial carryover request to retain any unobligated base grants.

J

F

M

A

M

J

J

A

S

O

N

D

J

F

M

A

M

J

J

A

S

O

N

Part B 

grant 

year

.......... ...........................2007........................... ............2008........................... June 1: FSR due.

January 1: Carryover request due.

March 1: Grantee receives grant.

HRSA cancelled and recovered $13,764,295 in combined grant year 2007 

Part B base and supplemental unobligated balances from 16 Part B 

grantees with unobligated balances of greater than 2 percent. In addition, 

these 16 grantees’ grant year 2009 awards were reduced by a total of 

$19,677,483 as a penalty for incurring an unobligated balance of greater 

 

23Since its inception, the CARE Act has required Part B grantees to obligate 75 percent of 

their entire Part B grant within certain time frames and repay any unobligated balance to 

HRSA for reallocation to Part B grantees. States had 150 days to meet this requirement in 

the first year of the program and have had 120 days in subsequent years. HRSA requires 

Part B grantees to report this obligation within 150 days on an FSR. In addition, grantees 

that do not obligate this 75 percent are ineligible for ADAP supplemental grants. 

Page 10 GAO-09-1020 Implementation of CARE Act Provisions
 

than 2 percent in grant year 2007. Of this, $4,441,865 was from Part B base 

grants and $15,235,618 was from ADAP base grants. 

Client-Level Data Prior to RWTMA, HRSA used the Ryan White HIV/AIDS Program Data 

Report (RDR) to collect information on CARE Act services from grantees 

and their service providers. However, RDR was unable to collect clientlevel data with unique identifying information. Consequently, there was no 

way of knowing if the clients counted as being served by one provider 

were also included in the counts of those being served by other providers. 

Therefore, totaling the number of clients receiving services across 

providers could result in clients being counted more than once. 

Additionally, the lack of client-level data meant that HRSA was unable to 

assess the quality of care given to clients or sufficiently account for the 

use of CARE Act funds. 

HRSA now collects client-level data to help ensure accountability of CARE 

Act funds. A client-level data collection and reporting system contains 

information unique to each client receiving CARE Act-funded services, 

such as their socio-demographic characteristics, the services provided, 

and each client’s current health status. Because the system collects clientspecific information rather than only aggregate-level data, HRSA can 

obtain a more accurate measure of the number of clients being served than 

was available using RDR. 

ADAP Funding and 

Activities 

Each ADAP is given broad authority under the CARE Act to design its own 

program. The scope of an ADAP’s coverage—who and what is covered—is 

determined by each ADAP’s program design, which includes criteria such 

as the number and types of drugs it will provide to its clients, and the 

income levels to qualify for services. However, RWTMA required that each 

grantee establish an ADAP formulary that covers all core classes of 

antiretroviral medications.24

 

24A formulary is a drug list that establishes the number of drugs available within a 

therapeutic class for purposes of drug purchasing, dispensing, and reimbursement. 

Antiretroviral medications are used to combat the reproduction of the HIV virus and to 

slow the progression of HIV-related disease. ADAPs must cover at least one drug from each 

of the six antiretroviral drug classes. 

Page 11 GAO-09-1020 Implementation of CARE Act Provisions
 

ADAP grants totaled approximately $821 million in fiscal year 2009. Of this 

amount, $780 million was provided to grantees as ADAP base grants, 

which are awarded by formula and are based on a grantee’s share of living 

HIV/AIDS cases. The remaining $41 million was distributed to grantees as 

ADAP supplemental grants.25 These grants are distributed to ADAPs that 

demonstrate a severe need to increase the availability of HIV/AIDS drugs.26

ADAPs must balance client need with available resources. In previous 

years, many ADAPs have had to institute waiting lists and other cost 

containment measures because of insufficient funds to provide services to 

all individuals who qualify. In our 2006 report, we found that in fiscal year 

2004, 14 ADAPs had waiting lists of individuals they determined were 

eligible for assistance but they were unable to serve.27 According to 

NASTAD and the Henry J. Kaiser Family Foundation, since 2002 a total of 

20 different ADAPs have had waiting lists at some point. The largest 

number of individuals on waiting lists across all grantees at any time was 

1,629 in May 2004. However, they reported that there were no individuals 

on waiting lists as of September 2007.28 NASTAD, the Henry J. Kaiser 

Family Foundation, and others have cited several factors that contributed 

to the elimination of waiting lists as of September 2007. These reasons 

included HRSA’s awarding $39.5 million in ADAP supplemental grants in 

September 2007, states’ increasing their contributions to ADAPs,29 and the 

continued implementation of Medicare Part D prescription drug 

coverage.30

 

25Annual appropriations acts specify the total amount of funding for ADAPs. Five percent 

of this funding is reserved for ADAP supplemental grants. 

26Severe need is when a grantee is unable to provide medications consistent with Public 

Health Service guidelines. 

27GAO-06-646, 28. 

28National Alliance of State and Territorial AIDS Directors and the Henry J. Kaiser Family 

Foundation, National ADAP Monitoring Project Annual Report (Washington, D.C.: 2009) 

10. 

29In addition to federal funding, ADAPs can also receive funding from other sources such as 

state budgets. 

30The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 added a 

new prescription drug benefit, Part D, to the Medicare program. Some ADAP clients were 

eligible for Medicare Part D benefits and thus, ADAPs were able to reduce costs because 

they no longer had to pay all the prescription drug costs for these individuals. 

Page 12 GAO-09-1020 Implementation of CARE Act Provisions
 

The lack of timely and accurate information has delayed HRSA’s 

distribution of unobligated balances as supplemental grants and places at 

risk HRSA’s ability to obligate these funds. HRSA has attempted to develop 

timely information on grantee obligations but was unsuccessful doing so 

for grant year 2007. 

Lack of Timely, 

Accurate Information 

Places at Risk Certain 

Funds, and HRSA Has 

Unsuccessfully 

Attempted to Obtain 

Needed Information 

The Lack of Timely, 

Accurate Information Has 

Delayed HRSA’s 

Redistribution of Funds 

and Places at Risk HRSA’s 

Ability to Obligate Funds 

in the Required Time 

Frame 

The lack of timely and accurate information in grantees’ FSRs regarding 

grant year 2007 unobligated balances has delayed HRSA’s distribution of 

Part B supplemental grants, and places at risk HRSA’s ability to 

redistribute these funds by September 30, 2009, after which it will no 

longer have the authority to redistribute the funds. Because of late FSR 

submissions, as of September 14, 2009, HRSA had not yet redistributed 

funds that it canceled and recovered from grantees’ 2007 unobligated 

balances. However, as HRSA recognized in its guidance regarding the 

unobligated balance provisions, the entire process for canceling and 

recovering grant funds and making the corresponding awards of 

supplemental grants must occur within the 3-year period of availability of 

those Part B funds.31

For HRSA’s grant year 2007 process, Part A grantees were required to 

submit their FSRs by June 1, 2008, and Part B FSRs were to be submitted 

to HRSA by June 30, 2008. The FSR contains, among other information, a 

grantee’s actual unobligated balance. HRSA uses the grantees’ actual 

unobligated balances, as reported on their FSRs, to determine the total 

amount of unobligated balance funds that will be available for 

redistribution through supplemental grants. Without complete, accurate, 

and timely information from grantees about their unobligated balances, 

 

31HRSA’s entire unobligated balance process includes the initial obligation of funds, 

cancellation of unobligated balances, return of amounts disbursed to grantees, and the 

recompetition and redistribution of supplemental grants. 

Page 13 GAO-09-1020 Implementation of CARE Act Provisions
 

HRSA is unable to redistribute unobligated balance funding through the 

Part A and Part B supplemental grants.32

Many Part A and B grantees submitted their FSRs late, and some 

submitted their FSRs more than 120 days after the deadline. Of the 56 

Part A grantees, 21 submitted FSRs after the June 1, 2008, deadline. Of the 

59 Part B grantees, 24 submitted FSRs after the June 30, 2008, deadline. 

Table 1 shows the number of days after the deadline that Part A and Part B 

grantees submitted their FSRs. 

Table 1: Number of Grantees Submitting Late FSRs by Amount of Time 

30 to 60 

days after 

deadline

61 to 90 

days after 

deadline

91 to 120 

days after 

deadline 

121 days or 

more after 

deadline

Total 

late final 

FSRs

Part A Grantees 3 5 3 10 21

Part B Grantees 3 7 10 4 24

Source: GAO analysis of HRSA data. 

HRSA officials stated that grantees were often delayed in submitting their 

FSRs because of their end-of-the-year workload, which includes the need 

to submit grant applications and multiple reports for their formula and 

supplemental funding. HRSA officials stated that grantees normally 

request extensions for submitting their FSRs, and 60-day extensions are 

typically granted. HRSA officials stated that in grant year 2007, due to the 

new process HRSA implemented to address the unobligated balance 

provisions, grantees had to implement separate tracking of the 

expenditure of current grant year base grant and supplemental funds, and 

the expenditure of carryover funding from previous years. HRSA officials 

also stated that grantees had difficulty implementing the separate tracking 

of these funds. HRSA officials stated that due to grantees’ difficulty 

tracking funds separately, some grantees’ FSRs reported inaccurate 

unobligated balances, which required HRSA staff to correspond with 

grantees and request revised information, creating additional delays. 

 

32The Part B supplemental grant program is a new program established by RWTMA. It 

provides for grants in fiscal years in which appropriations for Part B exceed a specified 

amount and serves as a mechanism for redistributing (1) carryover funds that are not 

expended by the end of the carryover year, (2) unobligated balances that grantees do not 

request to carryover, and (3) funds HRSA obtains through penalties assessed on grantees 

who exceed the 2 percent threshold for unobligated balances. No funds had been 

distributed as of September 14, 2009, under this program. Grant year 2009 is the first year 

funds will be available through this program. 

Page 14 GAO-09-1020 Implementation of CARE Act Provisions
 

According to HRSA officials, in addition to experiencing difficulty tracking 

funds, grantees were dealing with other factors including late receipt of 

final invoices from contractors, delays in receipt of ADAP rebates, and 

staff vacancies.33

While HRSA has typically approved grantees’ requests for extensions in 

submitting their FSRs, the tardiness of grantees’ FSR submissions and 

HRSA’s need to correspond with grantees to address their inaccuracies 

has delayed HRSA’s ability to determine the amount of unobligated 

balances available for redistribution to grantees through Part B 

supplemental grants. In April 2009, HRSA officials stated that they planned 

to distribute Part B supplemental grants in May 2009. However, as of 

September 14, 2009, HRSA had not distributed the 2009 Part B 

supplemental grants. As a consequence, HRSA had not yet fully 

implemented the unobligated balance provisions for the first time. HRSA 

officials stated that they plan to implement changes to improve the 

timeliness of their process. For example, HRSA officials also stated that 

beginning in grant year 2009 they will no longer approve grantees’ requests 

for extensions for their FSR submissions. Additionally, beginning in grant 

year 2009, FSRs will be due 30 days after the end of the grant year instead 

of the grant year 2007 deadline of 90 days after the end of the grant year. 

In Its 2007 Process, HRSA 

Attempted to Develop 

Timely Information on 

Grantees’ Unobligated 

Balances but Was 

Unsuccessful 

In its 2007 process, HRSA tried to develop timely information on grantees’ 

unobligated balances, but these efforts were unsuccessful. For grant year 

2007, in order to gain information on grantees’ unobligated balances so 

that it could begin to determine how much funding would be available for 

distribution as supplemental grants and so that it could provide grantees 

with a full year to obligate carryover funds, HRSA requested that grantees 

submit estimates of their unobligated balances 60 days before the end of 

the 2007 grant year. Because unobligated balance funds that grantees 

decide not to carry over and unobligated balance funds from carryover 

requests that are not approved by HRSA are available for redistribution 

through supplemental grants, HRSA officials needed to complete 

processing of the carryover requests before they could determine the 

 

33Twenty-seven Part B grantees purchase drugs exclusively through a federal drug discount 

program, under which they pay full price and receive a rebate at some point in the future. 

Federal regulations generally applicable to state and local government grantees require 

them to disburse these rebates before requesting additional cash payments. Thus, grantees 

receiving drug rebates must prioritize spending these funds and several grantees said that 

this makes it more difficult to obligate grant funds in the grant year. See GAO-09-894. 

Page 15 GAO-09-1020 Implementation of CARE Act Provisions
 

amount of funding that and could be made available as supplemental 

grants. 

Many grantees’ estimates of their unobligated balances in advance of the 

end of the grant year differed from their actual unobligated balances at the 

end of the grant year. In accordance with HRSA’s requirements, many 

Part A and Part B grantees submitted estimates of their unobligated 

balances with requests to carryover these funds 60 days before the end of 

the grant year, but their estimates proved to be substantially different from 

the actual unobligated balances reported on their FSRs. Of the 29 Part A 

grantees that submitted initial carryover requests, compared to the actual 

unobligated balances they submitted on their FSRs, 25 overestimated their 

unobligated balances, two grantees underestimated their unobligated 

balances, and two grantees correctly estimated their unobligated balances. 

Among the grantees that overestimated their balances were nine grantees 

that were ultimately able to obligate all of their funding by the end of the 

grant year and therefore did not need to carry over any funds. Of the 24 

Part B grantees that completed initial carryover requests, compared to the 

actual unobligated balances they submitted on their FSRs, 18 

overestimated their unobligated balances. Two of these grantees, New 

York and New Jersey, overestimated their unobligated balances by more 

than the amount they received from HRSA based on their initial carryover 

requests and had to request that HRSA return the grant year 2007 

carryover funds that the grantees had previously requested be transferred 

into their grant year 2008 accounts.34 Six grantees underestimated their 

unobligated balances. Nine grantees that overestimated their balances 

were ultimately able to obligate all of their funds by the end of the grant 

year and did not need to carryover any unobligated balances. 

 

34According to HRSA, New York submitted an initial carryover request for $2,491,742. 

HRSA approved its request for 50 percent of the funding, which was $1,245,871. New York 

then submitted its final FSR with an actual unobligated balance of $0 and requested that 

the carryover funds be deobligated from the grant year 2008 account and reobligated into 

the grant year 2007 account, because New York had been able to obligate the entire 

$2,491,742 for CARE Act purposes. Similarily, according to HRSA, New Jersey submitted an 

initial carryover request for $911,621. HRSA approved its request for 50 percent of the 

funding, which was $455,810. HRSA deobligated this amount from New Jersey’s 2007 grant 

and reobligated these funds to New Jersey’s 2008 grant. New Jersey then submitted its final 

FSR with an actual unobligated balance of $169,057 and requested that $286,574 in 

carryover funds be deobligated from grant year 2008 and reobligated to the grant year 2007, 

because New Jersey had been able to obligate all but $169,057. 

Page 16 GAO-09-1020 Implementation of CARE Act Provisions
 

The process of approving grantees’ initial carryover requests sometimes 

extended into the 2008 grant year. As a result, grantees were not 

authorized to use carryover funds at the expiration of the 2007 grant year 

as provided for by RWTMA. HRSA officials stated that the implementation 

of procedures to process, approve, and authorize carryover funding 

required significant staff time from the HRSA project officer, grants 

management staff, and program managers. The HRSA process called for 

staff to review these initial carryover requests, approve them, and 

authorize carryover funding to be transferred from the grantees’ 2007 

accounts into their 2008 accounts. HRSA officials stated that the multiple 

grantee submissions, which often included revised proposals, resulted in 

processing delays and confusion for HRSA staff. On average, it took HRSA 

staff 3 months to complete processing of Part A grantees’ initial 

unobligated balance carryover requests and 4 months for Part B grantees. 

Because grantees were only given until the end of grant year 2008 to 

expend carry over funds, grantees who received authorization to carryover 

funds after the start of the grant year did not have the entire grant year to 

expend these funds. 

In light of HRSA’s difficulty implementing procedures related to the 

submission of initial carryover requests and the differences between 

grantees’ estimated and actual unobligated balances, HRSA has decided to 

discontinue its process of approving initial carryover waiver requests 

based on estimated unobligated balances. 

HRSA has taken actions to collect client-level data by implementing a new 

data collection and reporting system. It has also provided financial and 

technical assistance to grantees and service providers implementing their 

own client-level data and reporting systems. In addition, HRSA developed 

a timeline for the submission of reports covering the initial reporting 

period using client-level data, but some grantees did not submit the initial 

reports by the deadline. 

HRSA Has Taken 

Actions to Collect 

Client-Level Data, but 

Some Grantees Did 

Not Submit Initial 

Reports by the 

Deadline 

Page 17 GAO-09-1020 Implementation of CARE Act Provisions
 

HRSA has taken actions to collect client-level data from CARE Act 

grantees and service providers. Beginning in December 2007, after the 

initial design and development of a client-level data collection and 

reporting demonstration project, HRSA held meetings with CARE Act 

grantees, national organizations, and federal agencies to discuss collecting 

and reporting client-level data. Topics discussed included data collection 

and reporting barriers, data elements to be collected, how the data would 

be used, and the technical assistance that would be available from HRSA. 

Using information from these sessions, HRSA finalized the Ryan White 

HIV/AIDS Program Services Report (RSR), its client-level data collection 

and reporting system. RSR consists of three reports: the Grantee Report, 

the Service Provider Report, and the Client Report. RSR was submitted to 

the Office of Management and Budget for approval in November 2008, 

which granted approval for HRSA to collect data from grantees and 

service providers using RSR in March 2009. 

HRSA Has Taken Actions 

to Collect Client-Level 

Data by Implementing a 

New Data Collection and 

Reporting System 

HRSA stated that RSR will improve information on the clients served, the 

services provided to clients, and the outcomes of the services provided. 

RSR is designed to provide HRSA with a more accurate measure of the 

number of unique clients receiving CARE Act-funded services by assigning 

each individual an encrypted Unique Client Identifier thereby allowing the 

tracking of individuals who receive services from multiple providers.35

Because RSR will contain client-specific data, HRSA will be able to 

determine the services each client received and the outcomes of these 

services. 

RSR is part of a process through which HRSA plans to collect information, 

including client-level data, from grantees and service providers funded 

under CARE Act Parts A, B, C, D, and F.36 First, the grantees and service 

providers collect data using their own data collection systems. Second, the 

 

35HRSA has stated that there will still be some degree of duplication due to error, and has 

estimated the total error rate will be 8.8 percent. Duplication will occur when two different 

clients receive the same identifier because of a recording error, such as a mistake in 

recording a client’s date of birth. An error may also occur when a client receives two 

different identifiers. For example, this might occur when a client changes his or her last 

name. 

36Part C provides for grants to public and private nonprofit entities to provide early 

intervention services, such as HIV testing and ambulatory care. Part D provides for grants 

to public and private nonprofit entities for family-centered comprehensive care to children, 

youth, and women and their families. Part F provides for grants for demonstration and 

evaluation of innovative models of HIV/AIDS care delivery for hard-to-reach populations, 

training of health care providers, and for Minority AIDS Initiative grants. 

Page 18 GAO-09-1020 Implementation of CARE Act Provisions
 

grantees and service providers report the data to HRSA in specified 

reports using RSR.37 HRSA has stated that it intends to use the data 

collected through RSR to generate reports on the use of CARE Act funds 

and the providers that receive them. HRSA reports are expected to provide 

client-level information on the characteristics of the clients served, the 

types of services they received from the provider, and their current health 

status. Additionally, HRSA has stated that it intends to conduct detailed 

analyses of national and regional information about clients and services. 

HRSA Has Provided 

Financial and Technical 

Assistance to Grantees to 

Develop Their Own ClientLevel Data Collection and 

Reporting Systems 

HRSA provided financial assistance to CARE Act grantees to develop or 

adapt their client-level data collection and reporting systems so that they 

could submit the required information to RSR. There are grantees who 

must develop new systems while other grantees’ systems require 

modification to enable them to generate data compatible with the 

requirements of RSR. HRSA administered a Special Projects of National 

Significance (SPNS) initiative in fiscal year 2008 and another in fiscal year 

2009 to provide funds to support CARE Act grantees in developing clientlevel data systems that could be used to report information to RSR.38

Under the fiscal year 2008 SPNS initiative, HRSA awarded 17 grants 

ranging from $87,000 to $200,000 to all 17 CARE Act Parts A and B 

grantees that applied for funding. Under the fiscal year 2009 SPNS 

initiative, HRSA awarded a total of approximately $4 million to all 57 

Parts C and D grantees that applied for funding. Officials from 4 of the 17 

health departments we interviewed stated that they received financial 

assistance from HRSA to develop and implement a client-level data 

collection and reporting system. Two of these health departments received 

$200,000 each. One of these health departments used the funding to help 

 

37A grantee or service provider can use a customized client-level data collection system, a 

vendor-distributed client-level data collection system, or HRSA’s CAREWare to collect 

client-level data. A customized client-level data collection system is created by a grantee or 

service provider to collect client-level data. A vendor-distributed client-level data collection 

system is created by a vendor. On its Web site, HRSA maintains a list of vendors whose 

data systems meet HRSA’s reporting requirements or are progressing toward meeting these 

requirements. CAREWare is a free, comprehensive electronic health information system 

that is available to grantee and service providers through HRSA’s Web site. CAREWare 

generates data for RDR and is also capable of collecting the needed client-level data for 

RSR. 

38According to HRSA, the SPNS initiatives fund innovative models of care and support for 

HIV/AIDS care. RWTMA authorized SPNS funding to assist CARE Act grantees in 

developing their own standard electronic client-level information data systems so that they 

could report their client-level data to HRSA. 

Page 19 GAO-09-1020 Implementation of CARE Act Provisions
 

build its own new system while the other department used the funding to 

adapt its current system to be compatible with CAREWare, a free, data 

collection system available through HRSA’s Web site. In addition to the 

SPNS funds, HRSA has made other funding available for infrastructure 

development. In 2008, HRSA provided a total of more than $1 million to 15 

CARE Act Part C grantees that included funds for them to develop their 

client-level data systems. As of April 2009, HRSA was reviewing 72 

applications for infrastructure development grants. 

HRSA also provided technical assistance to CARE Act grantees and 

service providers to develop client-level data collection and reporting 

systems. HRSA established the Technical Assistance Resources, Guidance, 

Education & Training Web site to provide information and resources, such 

as help desk support. HRSA conducted training sessions and webcasts to 

provide information on issues relating to implementing a client-level data 

system. Additionally, HRSA established the RSR Triage Committee to 

monitor and address the technical assistance needs of grantees. The 

committee meets weekly to discuss technical assistance concerns of 

grantees and monitors contractors charged with addressing technical 

concerns on behalf of HRSA. Officials from 7 of the 17 health departments 

we interviewed told us that they received technical assistance from HRSA 

to develop and implement a client-level data collection and reporting 

system. For example, one state grantee told us that HRSA provided a 2-day 

training session on CAREWare in November 2008. The HRSA official 

returned in March 2009 to provide assistance in implementing the 

CAREWare system.39

The state and local health departments that we interviewed have taken 

steps to implement a client-level data collection and reporting system that 

can report client-level data to RSR. Officials from all 17 health 

departments we spoke with stated that they either already had a clientlevel data system or were implementing such a system. Officials from six 

health departments indicated that they either currently use or plan to use 

CAREWare. The other eleven said they will use or plan to use a 

customized or vendor-distributed client-level information data system. 

Officials from 8 of the 17 departments stated that they had a system to 

 

39HRSA also consulted with vendors to make sure that their client-level data software was 

compatible with RSR. 

Page 20 GAO-09-1020 Implementation of CARE Act Provisions
 

collect client-level data before HRSA’s requirement to implement such a 

system.40

Officials from 10 of the 17 health departments we interviewed had 

concerns or challenges with implementing a client-level data collection 

and reporting system and reporting client-level data to HRSA. For 

example, officials from three health departments stated they were 

concerned about how to train service providers and other partners to 

collect client-level data. An official from 1 of these 3 health departments 

mentioned that it had been a challenge for his state to train the 100 case 

managers in the state to report client-level data in a consistent manner. 

Additionally, officials from three departments stated that they were 

concerned with potential breaches in the confidentiality of client 

information when data are entered into the RSR system. 

HRSA Developed a 

Timeline for Submitting 

the Initial Reports to RSR, 

but Some Grantees Did 

Not Submit Initial Reports 

by the Deadline 

HRSA developed a timeline for grantees to submit their initial reports to 

RSR, but some grantees did not submit initial reports. The initial RSR 

reporting period covered January 1, 2009, through June 30, 2009; however, 

the deadlines varied for the different reports.41 Table 2 provides a 

description of the reports to be submitted to RSR by grantees and service 

providers and the deadline for the initial reporting period for each report. 

 

40While some grantees already had client-level data collection and reporting systems in 

place, HRSA officials told us that they still needed to assist these grantees in making the 

systems compatible with RSR. 

41After the initial reporting period of January 1, 2009, through June 30, 2009, grantees and 

service providers must also submit reports for the entire 2009 calendar year. In subsequent 

years, grantees and service providers will only submit reports on an annual basis. HRSA 

officials said that they anticipate that grantees and service providers will continue to report 

aggregate data using RDR for calendar years 2009 and 2010 to allow HRSA to monitor the 

CARE Act services provided to clients while transitioning to RSR. 

Page 21 GAO-09-1020 Implementation of CARE Act Provisions
 

Table 2: Description of Data Submitted for Ryan White HIV/AIDS Program Services 

Reports 

Report 

Party responsible 

for completing 

the reporta

Description of data 

collected 

Deadline for initial 

reporting periodb

Grantee 

report 

CARE Act Part A, 

B, C, D, or F 

granteesc

Information about the 

grantee organization and 

the service providers that it 

funded 

July 31, 2009 

Service 

provider 

report 

Service providers 

who provide CARE 

Act-funded 

services 

Information about the 

service provider and the 

CARE Act services it 

delivers 

September 15, 2009 

Client report Service providers 

that deliver and/or 

pay for direct client 

services with 

CARE Act funds 

Information about each 

client that receives services 

funded by the CARE Act 

such as demographic data, 

HIV clinical information, 

and medical and support 

services received at the 

service provider 

September 15, 2009 

Source: GAO analysis of HRSA data 

a

For the initial reporting period of January 1, 2009, through June 30, 2009, and the first annual 

reporting period of January 1, 2009, through December 31, 2009, only service providers receiving 

CARE Act funds to provide outpatient/ambulatory medical care and/or case management services will 

be required to submit a Client Report. All service providers will eventually be required to submit Client 

Reports. 

b

The submission deadline for Grantee Reports is July 31, 2009. Grantees must approve the Service 

Provider Reports and the Client Reports entered by service providers by September 15, 2009. 

c

Only Part F Minority AIDS Initiative grantees must complete this report. 

While most grantees submitted a Grantee Report to HRSA by the July 31, 

2009 deadline, some did not do so. For the initial RSR reporting period, 

538 of 638 (about 84 percent) CARE Act grantees submitted Grantee 

Reports to HRSA by the deadline. According to HRSA officials, as of 

August 13, 2009, of the 100 grantees and service providers that had not 

submitted their required reports, 50 had started the submission process 

and 50 had not begun. HRSA officials told us that they are contacting the 

grantees to determine the cause of the reporting delays. HRSA officials 

also stated that they are aware that some grantees have had problems 

generating data in the RSR-required format. 

Page 22 GAO-09-1020 Implementation of CARE Act Provisions
 

The number of individuals on ADAP waiting lists increased during grant 

year 2008 and has continued to increase in 2009. In the first quarter of 

grant year 2008 (April 1, 2008, through June 30, 2008), 2 ADAPs had 

waiting lists with a total of 55 people on those lists. In the fourth quarter of 

grant year 2008 (January 1, 2009, through March 31, 2009), there were 3 

ADAPs with waiting lists, but the number of individuals on the lists had 

increased to 112. By August 10, 2009, the most recent date for which data 

were available at the time of our analysis, these numbers had grown to 136 

individuals on 4 ADAP waiting lists. Overall, this represents an increase of 

147 percent (from 55 to 136) in the number of individuals on waiting lists 

from the first quarter of grant year 2008 to August 2009. Kentucky, 

Montana, Nebraska, and Wyoming all had waiting lists in August 2009. 

Nebraska had the largest ADAP waiting list with 71 individuals while 

Wyoming had the smallest list with 5 individuals. Five ADAPs had waiting 

lists at some point during the time period we examined. Montana had a 

waiting list at all three points while Kentucky and Wyoming had a waiting 

list at one of those times. Indiana and Nebraska had a waiting list at two 

points. Table 3 lists the grantees with ADAP waiting lists and the number 

of individuals on those lists. 

The Number and Size 

of ADAP Waiting Lists 

Is Increasing 

Table 3: ADAPs with Waiting Lists and the Number of Individuals on Those Lists, 

Grant Year 2008 First Quarter, Grant Year 2008 Fourth Quarter, and as of August 10, 

2009 

Number of individuals on waiting lists 

Grantee 

Grant year 2008

first quarter

Grant year 2008

fourth quarter August 10, 2009a

Indiana 50 51 0

Kentucky 0 0 36

Montana 5 19 24

Nebraska 0 42 71

Wyoming 0 0 5

Total 55 112 136

Source: GAO analysis of ADAP Quarterly Reports and HRSA. 

a

Waiting list information as of August 10, 2009 was the most recent data available at the time of our 

analysis. 

Page 23 GAO-09-1020 Implementation of CARE Act Provisions
 

We also found that the total number of individuals enrolled in ADAPs 

increased during grant year 2008.42 In the first quarter of grant year 2008, 

164,849 individuals were enrolled in ADAPs. The number enrolled by the 

fourth quarter of grant year 2008 was 177,746, an increase of 7.8 percent. 

Similarly, the number of individuals receiving at least one medication from 

an ADAP increased. In the first quarter of grant year 2008, 121,075 received 

at least one medication while 134,019 individuals received at least one 

medication in the fourth quarter of grant year 2008, an increase of 

10.7 percent. 

The increase in the number and size of ADAP waiting lists, as well as the 

increase in the number of individuals enrolled in and receiving 

medications through ADAPs, indicates increased financial pressure on 

ADAPs as ADAPs balance client needs with available resources. HRSA 

officials told us that because of financial pressures they are closely 

monitoring five ADAPs—Arizona, Arkansas, California, Kentucky, and 

Iowa—for the initiation or expansion of waiting lists or other cost-control 

measures. For example, Arkansas is considering establishing an ADAP 

waiting list while Kentucky projects that additional individuals will be 

added to its waiting list. Arizona’s ADAP reduced the number of drugs on 

its formulary effective July 1, 2009, because of a budgetary shortfall.43

Additionally, Arizona’s ADAP still anticipates a budgetary shortfall this 

grant year even with the reduced number of drugs on its formulary and is 

considering additional cost-control measures. 

ADAP officials we interviewed also indicated that ADAPs were under 

increasing financial pressure. For example, Hawaii officials expressed 

concern that they will have to establish a waiting list. They stated that they 

are facing higher drug prices and an increasing number of people enrolled 

in their ADAP. Washington state officials noted that they are facing ADAP 

budget constraints. An advisory committee has developed a number of 

possible cost-control measures to stay within budget, including reducing 

the number of drugs on the ADAP formulary and reducing payments to 

pharmacies and medical laboratories. 

 

42Individuals who are enrolled in an ADAP are eligible to receive medications through the 

program; however, they may not actually receive ADAP medications. For example, this 

could occur if an individual was receiving medications from another source. 

43Because fewer drugs are covered, reducing the number of drugs on a formulary may 

reduce costs. 

Page 24 GAO-09-1020 Implementation of CARE Act Provisions
 

HRSA has been working to implement the unobligated balance provisions 

of RWTMA since its enactment in December 2006. As a result of the 

requirement to cancel unobligated balances and, in some cases, penalize 

grantees, HRSA implemented complex processes that have been difficult 

for grantees to comply with, thus delaying HRSA’s first implementation of 

the requirement. To implement the unobligated balance provisions, HRSA 

has required information on the amount of unobligated balances at the end 

of the grant year that some grantees either did not provide in a timely 

manner or that was inaccurate, or both. Three years after enactment of 

RWTMA, HRSA was continuing to develop its process for implementing 

the provisions and making adjustments based on some grantees’ continued 

inability to comply with the process that HRSA established. In addition, at 

least one key provision, the use of Part B supplemental grants to 

redistribute unobligated funds, has yet to occur for the first time. Because 

funds for these grants are only available until September 30, 2009, HRSA is 

at risk of losing the authority to make these grants. 

HRSA officials told us that, for grant years 2008 and 2009, they have 

changed their process for implementing the unobligated balance 

provisions in order to alleviate the burden on staff and to ensure that 

HRSA has the information it needs to implement the unobligated balance 

provisions in a timely manner. However, even with a changed process, 

HRSA will continue to depend upon grantees to provide useful information 

on their unobligated balances in a timely manner. This will not be achieved 

if grantees continue to provide information after the deadline by which it 

is required. HRSA must have complete, accurate, and timely information 

from grantees to complete the entire process to redistribute unobligated 

balances as supplemental grants within the period given for obligation of 

funds for Part A and Part B of the CARE Act. 

To help ensure that HRSA is able to implement the unobligated balance 

provisions in a timely manner, we recommend that the Secretary of HHS 

instruct the administrator of HRSA to take the following two actions to 

obtain timely and accurate information on grantees’ unobligated balances: 

Conclusions 

Recommendations for 

Executive Action 

• Identify the causes of grantees’ difficulties in providing a timely and 

accurate accounting of their unobligated balances. 

• Ensure that grantees adhere to deadlines for submission of their 

unobligated balances by developing steps to assist them in overcoming the 

causes of difficulties identified in accounting for unobligated balances. 

Page 25 GAO-09-1020 Implementation of CARE Act Provisions
 

HHS reviewed a draft of the report, but did not comment on our 

conclusions and recommendations. HHS’ comments are reprinted in 

appendix I. We incorporated HHS comments and technical comments as 

appropriate. 

Agency Comments 

We are sending copies of this report to the Secretary of Health and Human 

Services. The report is also available at no charge on GAO’s Web site at 

http://www.gao.gov. 

If you or your staffs have any questions, please contact me at (202) 512-

7114 or crossem@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may found on the last page of this report. 

Other staff who made major contributions to this report are listed in 

Marcia Cross

appendix II. 

e 

Director, Health Care 

Page 26 GAO-09-1020 Implementation of CARE Act Provisions
Appendix I: Comments from the Department Appendix I: Comments from the Department of Health and Human Services 

of Health and Human Services 

Page 27 GAO-09-1020 Implementation of CARE Act Provisions 
Appendix I: Comments from the Department 

of Health and Human Services 

Page 28 GAO-09-1020 Implementation of CARE Act Provisions
Appendix I: Comments from the Department 

of Health and Human Services 

Page 29 GAO-09-1020 Implementation of CARE Act Provisions
Appendix II: 

A

GAO Contact and Staff 

cknowledgments 

Page 30 GAO-09-1020 

Appendix II: GAO Contact and Staff 

Acknowledgments 

Marcia Crosse, (202) 512-7114 or crossem@gao.gov 

In addition to the contact above, Thomas Conahan, Assistant Director; 

Robert Copeland, Assistant Director; Leonard Brown; Romonda McKinney 

Bumpus; Cathleen Hamann; Sarah Resavy; Rachel Svoboda; and Jennifer 

Whitworth made key contributions to this report. 

 Implementation of CARE Act Provisions 

GAO Contact 

Acknowledgments 

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