An Overview
of Key Changes to the Ryan White CARE Act
Adopted in the Ryan White CARE Act Amendments of
2000
Legislation reauthorizing
the Ryan White CARE Act (S. 2311) unanimously passed both houses of
Congress on October 5, 2000 and was signed into law by President Clinton
on October 20th. Enactment of S. 2311 guarantees uninterrupted federal
support for medical services for low-income, uninsured and underinsured
people living with HIV disease. The former CARE Act legislation expired on
September 30, 2000.
This document
provides a general overview of the key changes to the CARE Act that are
included in S. 2311. The complete text and additional legislative
information regarding the final version of the CARE Act can be found on
"Thomas, Legislative Information on the Internet" at thomas.loc.gov. If you would like additional
information regarding reauthorization of the CARE Act, please contact the
San Francisco AIDS Foundation Public Policy Department at
415-487-3080.
Common Themes Throughout the CARE Act Amendments
- Improving Quality of
Care: Adopts measures to ensure that
medical services funded by the CARE Act are consistent with the most
recent U.S. Public Health Service (PHS) HIV treatment guidelines and
that grantees implement improvements in access to and quality of medical
services.
- Improving Collaboration
between Medicaid and State Children’s Health Improvement Programs
(SCHIPs): Requires states and eligible
metropolitan areas (EMAs) to establish formal linkages with these
programs.
- Enhancing Access to
Early Intervention Services: Supports service funding, program
linkages and co-location of HIV testing and counseling services and
CARE-funded medical care in an effort to reduce the length of time
between HIV diagnosis and entry into care.
- Reaching Individuals
with HIV Disease Who Are Not Receiving Care: The Health Services and Resources
Administration (HRSA) will work with the Center for Disease Control and
Prevention (CDC) to develop a method to estimate the number of people
living with HIV disease who are not in care. State planning consortia
and Title I planning councils will be required to use this method to
identify individuals living with HIV currently not receiving care and to
prioritize funding for services to these targeted
individuals.
- Enhancing Existing
Quality Management: Requires that CARE Act grantees
establish or enhance quality management systems for CARE Act funded
programs. These systems must include quality of care standards (Public
Health Service HIV treatment guidelines as a minimum). The new law
allows Title I and Title II grantees to expend 5% (but no more than $3
million) of the annual grant on such efforts.
- Linking Support
Services to Medical Care: Requires that support services
funded under the CARE Act facilitate, enhance, support, or sustain the
delivery, continuity, or benefits of health services for individuals or
families with HIV. All CARE providers will be required to have formal
medical health care referral relationships, regardless of the service
they provide.
Key Changes to CARE
Act by Title
The following guide
highlights the key changes adopted in the Ryan White CARE Act
reauthorization amendments by CARE Act Title.
Title I: Funding to High-Incidence Eligible Metropolitan
Areas (EMAs)
1.
Planning Councils
The new Act requires that
planning councils include HIV prevention providers, housing and homeless
service providers, and HIV positive former prisoners or their
representatives. These seats are in addition to the current list of
required memberships, which include social service, mental health and
substance abuse providers, public health agencies, hospital and/or health
care planning agencies and affected communities including historically
underserved groups. One-third of planning council members must now be HIV
infected or affected family members of Title I service consumers who are
unaffiliated with any entity that receives Title I funding (i.e., these
consumers cannot be officers, employees, or consultants of such entities).
Planning Council meetings must comply with Federal Advisory Council Act
(FACA) regulations that require all meetings of the planning council to be
open to the public and be conducted only after proper public notice. The
Planning Council must also establish a process that provides public access
to non- personnel related materials distributed to planning council
members, including reports, meeting minutes, meeting agenda and any other
documents distributed to the full planning council. The Department of
Health and Human Services (HHS) will also be required to provide Title I
communities with materials to train all planning council
members.
2. Use of HIV Data in Formula Funding
Currently, amounts awarded
for the Title I formula grants are calculated using a 10-year weighted
AIDS case band count to estimate the number of people living with AIDS in
a given area. The new law will require that the most recent year of HIV
case data be incorporated into the 10-year weighted case count beginning
in 2005 unless the Secretary of HHS determines that HIV case data are not
yet available throughout the country. The new law also requires an
Institute of Medicine study of HIV case surveillance to determine if it is
adequate for use in formula funding.
3.
Allowable Reductions in Title I Formula Funding (Hold Harmless
Provision)
Former law limited allowable reductions in Title I formula funding to
Eligible Metropolitan Areas (EMAs) by 1% per year, for a total of 5%
during the five-year period the legislation was authorized. The CARE Act
Amendments of 2000 adopt a graduated reduction of Title I formula funding
as follows: 2% in the first year the hold harmless is needed, 3% in the
second year, 3% in the third year, 3% in the fourth year, and 4% in the
fifth year, for a total maximum reduction of 15% over the five years. If
HIV data are incorporated into the formula calculation for Title I funding
in FY 2005, the reduction for the fifth year will be lowered to 2%, for a
total reduction of 13%. Reductions are based on the affected EMA’s Title I
formula allocation from the preceding fiscal year. The graduated reduction
begins anew if there is an intervening year in which an EMA does not need
the hold harmless provision.
Title II: Funding to States for Medical and Support Services
(including the AIDS Drug Assistance Program)
1.
Use of HIV/AIDS Data in Formula Funding
The changes in the formula
related to the use of HIV data to determine Title II awards are identical
to the changes included in Title I (see #2 above).
2.
Allowable Reductions in Title II Funding
The new law maintains the provision that ensures that no state will
suffer more than a one percent cut per year in non-ADAP Title II base
funding. This means that states will receive no less than 99% of their
base year award in the first year. It will continue to allow only an
additional 1% reduction per year in the following years (for a maximum
total reduction of 5% over the five years of the reauthorized Act).
3.
Supplemental Grants for "Emerging Communities"
The CARE Act Amendments of
2000 create a new supplemental grant to states to provide services to
"emerging communities" that are not currently eligible for Title I
funding. This provision will not take effect until Title II appropriations
(exclusive of ADAP-specific funds) exceed FY 2000 funding levels by at
least $20 million. After this threshold has been met, fifty percent of any
Title II funds above the FY 2000 funding level will be set aside to fund
the new supplemental grants. Once this funding measure has been triggered,
HHS will be required to ensure that at least $10 million is made available
for these "emerging communities" every year. To be eligible, communities
must have a population base of 500,000 and have reported between 500 and
1,999 AIDS cases in the past five years. In FY 2005, if HIV data are used
in addition to AIDS data to calculate the formula allocations in Title I
and II, the same will be used to calculate eligibility for the Title II
supplemental.
Eligible areas with between
500 and 999 reported AIDS cases over the most recent five year period
shall receive a minimum grant of $5 million or 25% of new Title II funds.
Eligible areas with between 1,000 and 1,999 reported cases shall receive a
comparable allocation of $5 million or 25% of new Title II
funds.
4.
Competitive Grants for ADAP Funds
The Act creates
a new provision that sets aside three percent of all Title II
ADAP-specific funds for a competitive grant program to increase access to
HIV drugs for individuals who live in selected states with (a)
demonstrated need for improved drug access, and (b) a significant number
of consumers living at or below 200% of the federal poverty level. The
provision requires that no state can receive a reduction in ADAP funds as
a result of this new set-aside (i.e., holds states harmless from reduction
that could occur due to this program). Eligible states must match the
award at a rate of one dollar for every four federal dollars that they
receive. States must also agree not to impose limitations on eligibility
requirements or scope of benefits that are more restrictive than such
requirements that were in effect on January 1, 2000. The criteria for
awarding of grants will be developed by the Secretary of
HHS.
5.
Partner Notification Programs
The law creates
a new $30 million annual authorization that would enhance existing partner
notification, counseling and referral service programs. To be eligible,
states must implement partner notification programs and reporting of those
who test HIV-positive to the state public health officer in a manner
recommended and approved by the CDC. Grant preference will be given to
states with HIV reporting systems that are "sufficiently accurate and
reliable" for Title I and Title II formula allocation.
6.
Pregnancy and Perinatal Transmission of HIV -- Mandatory Testing of
Newborns
The new law
authorizes $30 million to address the issue of perinatal HIV transmission.
The former grant program was funded through a $10 million annual
allocation from the budget of the CDC. New language establishes a $30
million authorization of which $10 million will continue to be transferred
from the CDC and the other $20 million will be subject to annual
appropriations. The $20 million authorization will be available each year
to (a) states with a mandatory testing requirement for all newborns or for
newborns for whom the mother’s HIV status is unknown, or (b) states
demonstrating the most significant reductions in the rate of new cases of
perinatal HIV transmission. A special rule for FY 2001 will reserve a
minimum amount ($4 million) from new Title II funds for this
purpose.
An increasing
proportion of this funding (i.e., the amount appropriated in a fiscal year
above the original $10 million) will be provided to states with mandatory
testing requirements. The specific proportions are 33 percent in FY 01, 50
percent in FY 02, 67 percent in FY 03, and 75 percent in FY 04 and FY 05.
The remainder of these funds will be provided to states based on such
criteria as reductions in perinatal transmission and the incidence of HIV
and AIDS among women of childbearing age. Individual grants to states from
this set- aside will not exceed $4 million.
The Institute of
Medicine will be asked to assess the number of HIV-positive infants born
and the possible barriers that prevent the mother’s obstetrician from
offering her an HIV test in each state, and make recommendations to each
state on methods to reduce the incidence of perinatal HIV transmission. In
response to these recommendations, each state must submit a report to HHS
by 2004 that describes the actions it has taken toward meeting the
recommendations.
Title III: Direct Grants to Organizations for Early
Intervention and Primary Care Services
1.
Preferences in Awarding New Title III Funds
The Secretary will give grant preference in two tiers to service
providers who (1) provide early intervention services in rural areas and
(2) provide early intervention services in areas that are underserved.
2.
Increasing the Allowable Administrative Costs for Title III
The new law increases the amount of Title III grants that can be spent
on administrative costs from 7.5% to 10% to more accurately reflect the
actual administrative costs associated with service provision.
3.
Establishing New Title III Capacity Development Grants
Capacity development grants of up to $150,000 will be created for rural
and/or underserved areas to expand capacity, preparedness, access to and
expertise in the delivery of HIV primary care in these areas. These grants
are not to exceed three years in duration.
4.
Partner Notification & Counseling
Modifies
existing Title III HIV counseling guidelines with a provision that
requires providers, during post-test counseling for HIV infected
individuals, to state that "it is the duty of infected individual to
disclose their status" to partners and "emphasize that it is the
continuing duty of the individual to avoid any behaviors that would expose
others to HIV."
Title IV: Programs for Women, Infants, Children and Youth
1.
Grants for Coordinated Services and Access to Research for Women, Infants,
Children, and Youth
The requirement to
enroll "significant numbers" of women and children in research projects is
eliminated, but the new law requires that grantees provide enhanced
information and education to their clients on opportunities to participate
in HIV/AIDS- related clinical research. Requires the HHS Secretary,
through the National Institutes of Health, to examine the distribution and
availability of ongoing and appropriate HIV/AIDS- related research
projects, particularly in communities that are underserved by such
projects.
2.
Limitation on Administrative Expenses
A new provision
is included that requires the Secretary of HHS to conduct a review of the
administrative and indirect costs associated with Title IV grants in an
effort to establish a standard. This review is to be completed no later
than 12 months after the CARE Act is reauthorized. No later than 180 days
following the 12-month period for the review, HHS will be required to
report on the relationship between the administrative cost of service
delivery and recommend a standard for administrative and indirect costs.
After this determination is completed, grantees will be required to cap
administrative expenses.
Part F: Miscellaneous Provisions
1.
AIDS Education and Training Centers – Prenatal and Gynecological Care
A new provision
is included that requires the development and distribution of protocols
for women with HIV disease, including prenatal and other gynecological
care. Such treatment protocols must be developed and disseminated within
90 days of reauthorization of the CARE Act.
2.
Authorizing Appropriations for Expanded Dental Reimbursement
Program
The Act expands the definition of eligible dental entities to include
accredited schools of dental hygiene. It also expands grants to dental
schools to include those dental schools and dental hygiene programs that
partner with community-based dental programs in underserved areas.
Subtitle B: General Provisions
1.
Coordination of Federal HIV Programs
The law creates a new requirement that the HHS Secretary must submit a
plan to Congress every two years describing barriers to HIV program
integration and a strategy for eliminating such barriers and enhancing the
continuity of care and prevention services.
2.
Plans Regarding Release of Prisoners Living with HIV
Disease
A new provision
requires HHS to develop a plan for the medical case management and
delivery of support services to individuals living with HIV disease who
are to be imminently released from either federal or state penal systems.
The plan must be submitted to Congress no later than two years after
reauthorization.
3.
Selected Audits
A new provision
allows the Secretary of HHS to reduce the Title I or Title II grant to any
grantee if it fails, in two consecutive grant years, to produce audits
required of all federal grantees. Annually, the Secretary of HHS will be
required to select a representative sample of grantee audits, summarize
them and provide them in a report to be submitted to
Congress.
4.
Administrative Simplification: Coordination of Title I and Title II Grant
Years
A new provision
requires the Secretary of HHS, no later than 18 months after enactment of
the bill, to develop a plan for coordinating the distribution of
appropriated Title I and Title II funding for grant making purposes. No
later than two years after the plan is submitted to Congress, the
Secretary of HHS shall implement this plan regardless of any other
provision of law.
5.
Administrative Simplification: Biennial Application Process and
Simplification
A new
requirement states that no later than two years after enactment of the
bill, the Secretary of HHS must determine whether the administration and
efficiency of Title I and Title II CARE grants would be improved by a
biennial rather than annual federal grant making process. The HHS
Secretary is required to submit a plan for simplifying the process for
applying for Title I and Title II funding within 18 months after CARE Act
reauthorization and to implement the plan no later than two years after
the plan has been submitted to Congress.
Title V: General Provisions
1.
Institute of Medicine Studies
The Secretary
of HHS – in conjunction with the Institute of Medicine – must complete the
following studies:
Health Care
Financing: Identify and provide for use by health planners
epidemiological measures and their relationship to the financing and
delivery of primary care and health-related support services for
low-income, uninsured, and under-insured individuals living with HIV. The
study will consider availability and utility of health outcomes measures,
the effectiveness and efficiency of service delivery, existing and needed
epidemiological data and other tools for resource planning and allocation
decisions, and other relevant factors. The study will include an
assessment of the financial impact of reforming the Social Security Act to
provide Medicaid eligibility to those in earlier stages of HIV disease.
State
Surveillance Systems: The study must include a determination of
whether the HIV surveillance system of each of the states provides
adequate and reliable information on the number of individuals in that
state that are diagnosed with HIV and whether such information is
sufficiently accurate to be used for formula funding purposes.
Recommendations will be issued to those states where the reporting
mechanism is deemed insufficient.
The study on state
surveillance systems must be completed no later than three years from the
date of enactment. The study on health care financing must be completed
within two years of enactment.
2.
Development of Rapid HIV Test
The NIH is
directed to expand, intensify and coordinate research to develop an HIV
test that can be rapidly administered and the results rapidly obtained.
Within 90 days after the CARE Act is reauthorized, the Secretary of HHS
must submit a report to Congress on the progress made towards (and the
barriers to) the development and availability of such rapid HIV tests. As
soon as commercial distribution of a rapid HIV test occurs, the Secretary
of HHS will establish guidelines that include recommendations regarding
the availability of rapid HIV tests for administration to pregnant women
who are in labor (or in the late stages of pregnancy) and whose HIV status
is not known to the physician.
Page last updated 2 November
2000 | 
