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Review of the Puerto Rico Health Department's Compliance With the Ryan White CARE Act Payer-of-Last-Resort Requirement

For grant years 2002-2004, we estimated that Puerto Rico claimed $24.3 million in unallowable Federal funds under Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990. These claims did not comply with the payer-of-last-resort requirement that Title II funds not be used to pay for HIV/AIDS drugs or services that are eligible for coverage by other Federal, State, or private health insurance. The CARE Act, which is administered by HRSA, funds health care and support services for more than 500,000 individuals each year who have HIV/AIDS and who have no health insurance or are underinsured. Of the 100 prescriptions that we sampled, 57 prescriptions were incorrectly claimed for patients who had other health insurance that would have covered the drugs.

We recommended that Puerto Rico refund $24.3 million and develop procedures to bill HIV/AIDS drugs to the Federal, State, or private health insurance plans with primary payment responsibility. Puerto Rico did not directly address our recommendations but disputed some of our error determinations. Based on additional documentation provided to us, we revised four of our original error determinations and the refund amount.

Filed under: Centers for Medicare and Medicaid Services