Ryan White HIV/AIDS Program

Medical Case Management

The provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. In addition to providing the medically oriented services above, Medical Case Management may also provide benefits counseling by assisting eligible clients in obtaining access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care and supportive services, and insurance plans through the health insurance Marketplaces/Exchanges).

Referral for Health Care and Support Services

Referral for Health Care and Support Services directs a client to needed core medical or support services in person or through telephone, written, or other type of communication. Activities provided under this service category may include referrals to assist HRSA RWHAP-eligible clients to obtain access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, and other state or local health care and supportive services, or health insurance Marketplace plans).

Service Providers

Substance Abuse Outpatient Care is the provision of outpatient services for the treatment of drug or alcohol use disorders. Services include:

• Screening
• Assessment
• Diagnosis
• Treatment of substance use disorder
• Pretreatment/recovery readiness programs
• Harm reduction
• Behavioral health counseling associated with substance use disorder
• Outpatient drug-free treatment and counseling
• Medication assisted therapy
• Neuro-psychiatric pharmaceuticals
• Relapse prevention
• Residential

Service Providers

Mental Health Services are the provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment, and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers.

Service Providers

Outpatient/Ambulatory Health Services are diagnostic and therapeutic services provided directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings include clinics, medical offices, and mobile vans where clients do not stay overnight. Emergency room or urgent care services are not considered outpatient settings.

Service Providers

Psychosocial Support Services provide group or individual support and counseling services to assist eligible people living with HIV to address behavioral and physical health concerns.

Service Providers

Oral Health Care activities include outpatient diagnosis, prevention, and therapy provided by dental health care professionals, including general dental practitioners, dental specialists, dental hygienists, and licensed dental assistants.

Service Providers

Medical Nutrition Therapy includes:

• Nutrition assessment and screening
• Dietary/nutritional evaluation
• Food and/or nutritional supplements per medical provider’s recommendation
• Nutrition education and/or counseling

Early intervention services (EIS) for Parts A and B include identification of individuals at points of entry and access to services and provision of HIV testing and targeted counseling, referral services, linkage to care, and health education and literacy training that enable Clients to navigate the HIV system of care. Part A funds are only used as necessary for HIV testing to supplement, not supplant, existing funding. EIS services must include the following four components:

• Targeted HIV testing to help the unaware learn of their HIV status and receive referral to HIV care and treatment services if found to be HIV-infected.
• These testing services must be coordinated with other HIV prevention and testing programs to avoid duplication of efforts.
• HIV testing paid for by EIS cannot supplant testing efforts paid for by other sources.
• Referral services to include HIV care and treatment services at key points of entry.
• Access and linkage to HIV care and treatment services such as HIV Outpatient/Ambulatory Health Services, Medical Case Management and Substance Abuse Care.
• Outreach services and Health Education/Risk Reduction related to HIV diagnosis.

Service Providers

Housing assistance is provided through the Housing Opportunity for People Living with AIDS (HOPWA). The HOPWA Program helps increase housing stability, reduce risk of homelessness and increase access to care for people with HIV who have an income at or below 80% of area median income. Services include:

• Housing Case Management
• Short-Term Rent, Mortgage, Utilities (STRMU)
• Permanent Housing Placement (PHP)
• Tenant-Based Rental Assistance (TBRA)
• Short-Term Housing
• Facility Based Housing

Please visit HOPWA page for more information.

Service Providers

Medical Transportation services are available to Ryan White Eligible Clients and can be obtained through Case Management. Clients must be enrolled in Ryan White services, and not eligible for Medicaid, Medicare, or Advantage Transportation. Clients who meet the eligibility criteria may be eligible for a 30 day buss pass, 1 day buss pass, or door-to-door transportation. Eligibility for the 30 day buss pass and a 1 day buss pass depends on the number of service appointments a Client has within a 30 day period. For door-to-door transportation a Client must be farther than ¾ mile from a bus route and/or not physically able to use a bus.