Performance Measure: Timely Payment of Health Insurance Premiums

National Quality Forum #: None

Description: Percentage of health insurance policies terminated due to late health care premium payment or lack of health care premium payment by the AIDS Drug Assistance Program (ADAP)

Numerator: Number of health insurance policies from the denominator that were terminated due to late premium payment or lack of premium payment by ADAP

Denominator: Number of health insurance policies for which ADAP made at least one payment in the measurement year

Exclusions: Clients who died or became ineligible¹ for ADAP services in the measurement year

Data Elements: Does the client, regardless of age, have a diagnosis of HIV? (Y/N)

1. If yes, did the client receive at least one payment from ADAP towards a health insurance policy in the measurement year? (Y/N)
   
   1. If yes, was the client's insurance policy terminated at any time during the measurement year? (Y/N)
      
      1. If yes, was the termination due to a late payment made by ADAP or
      2. Lack of payment by ADAP?

Data Sources: Recipient's ADAP data system

National goals, targets, or benchmarks for comparison

The HIV Quality Measures (HIVQM) Module is a tool within the RSR portal that allows recipients to enter aggregate data specific to the HRSA HAB Performance Measures. The HIVQM Module allows recipients to conduct point-in-time benchmarking across Ryan White HIV/AIDS Programs that use the module.

Basis for selection

The Ryan White HIV Treatment Modernization Act of 2006 (P.L. 109-415) requires that the Ryan White HIV/AIDS Program (RWHAP) be the payor of last resort. HIV/AIDS Bureau, Policy Clarification Notice 21-02: Determining Client Eligibility and Payor of Last Resort in the Ryan White HIV/AIDS Program (PDF - 68 KB) specifies that "Once a client is eligible to receive RWHAP services, the RWHAP is considered the payor of last resort, and as such, funds may not be used for any item or service "to the extent that payment has been made, or can reasonably be expected to be made under. . . any State compensation program, under an insurance policy, or under any Federal or State health benefits program... or by an entity that provides health services on a pre-paid basis."²

Department of Health and Human Services Clinical Practice Guidelines

None

References/notes

¹ For the purposes of this measure, ineligible means those clients who are deemed ineligible for ADAP services for any reason.

² Sections 2605(a)(6), 2617(b)(7)(F), 2664(f)(1) of the Public Health Service (PHS) Act. See also 2671(i) of the PHS Act. The Indian Health Service is statutorily exempted from the payor of last resort provision.