26 Tex. Admin. Code § 354.3 - Definitions
The following words and terms, when used in this chapter, will have the following meanings unless the context clearly indicates otherwise.
(1) Administrative review--A
process that allows applicants, clients, and providers the opportunity to
request an informal review of any intended program action that would suspend,
modify, deny, or terminate their eligibility for enrollment, benefits
participation in the program, or reimbursement for allowable
products.
(2) Allowable
products--Blood factor replacement products indicated for the treatment of
hemophilia and approved for payment by the program.
(3) Applicant--A person making an initial
application or re-application for the program.
(4) Approved health plan--An insurance plan
that provides coverage for hemophilia medical treatment.
(5) Attestation--A statement by a person or
the person's legally authorized representative attesting that:
(A) the person does not have access to
private health care insurance that provides coverage for the benefit, service,
or assistance; or
(B) the person
has access to private health care insurance that provides coverage for the
benefit, service, or assistance.
(6) CHIP--The Children's Health Insurance
Program administered by the Commission under Title XXI of the Social Security
Act.
(7) Claim--A request for
payment or reimbursement of services or insurance premiums.
(8) Client--A person who has applied for
program services and who meets all program eligibility requirements and is
determined to be eligible for program services, and may include:
(A) a person who has applied to the program
for the first time and is determined to be eligible for program
services;
(B) a person who has
re-applied to the program (after a lapse in eligibility) and is determined to
be eligible for program services; or
(C) a person who has applied to the program
and is determined to be eligible for program services and is currently on the
program's waiting list.
(9) Commission--The Health and Human Services
Commission.
(10) CSHCN Services
Program--Children with Special Health Care Needs Services Program.
(11) Date of service--The date the allowable
products are dispensed.
(12)
Denial--An action by the program that disallows program eligibility, benefits,
or administrative review requests.
(13) Department--Department of State Health
Services.
(14) Eligibility date for
program benefits--The effective date of client eligibility for program benefits
is the date of receipt of a complete, approved application.
(15) Exclusion--The federal and state offices
of Inspector General maintain lists that exclude certain people or businesses
from participating as service providers for federal and state health care
programs.
(16) Factor--A substance
that is injected into the vein of a person with hemophilia to replace the
missing blood clotting factor and allow the blood to clot properly.
(17) Fair hearing--The informal hearing
process the department follows in accordance with §§ 1.51- 1.55 of
title 25 (relating to Fair Hearing Procedures).
(18) Family--In order to determine family
size for the calculation of the applicant's percentage of the Federal Poverty
Level for program eligibility, the family includes the following persons who
live in the same residence:
(A) the
applicant;
(B) any persons who have
a legal responsibility to support the applicant;
(C) children under age 18 or wards of the
applicant; and
(D) children under
age 18 or wards of any persons who have a legal responsibility to support the
applicant.
(19) Federal
Poverty Level guidelines (FPL)--The minimum income needed by a family for food,
clothing, transportation, shelter, and other necessities in the United States,
according to the United States Department of Health and Human Services, or its
successor agency or agencies. FPL varies according to family size, and after
adjustment for inflation, is published annually in the Federal
Register.
(20) Filing
deadline--The last date that a claim may be received by the program and still
be considered eligible for payment of benefits.
(21) Hemophilia Assistance Program
(program)--A state funded program that provides limited financial assistance to
persons age 18 and older who have been diagnosed with hemophilia and meet other
program eligibility requirements for blood factor replacement products that are
administered or dispensed by program-approved providers or insurance premium
payment assistance.
(22)
Hemophilia--A human physical condition characterized by bleeding, resulting
from a genetically determined deficiency of a blood coagulation factor or an
abnormal or deficient plasma procoagulant that prevents the blood from clotting
properly. The diagnoses covered by the program include:
(A) congenital factor VIII disorder
(Hemophilia A);
(B) congenital
factor IX disorder (Hemophilia B); and
(C) congenital factor XI disorder (Hemophilia
C).
(23) Income--The
gross income, either earned or unearned, before deductions over a given period
of time for each family member.
(24) Incomplete claim--A request for payment
or reimbursement of services or insurance premiums that is missing required
information.
(25) Insurance premium
payment--A payment made to an approved health plan.
(26) Medicaid--A program of medical care
authorized by Title XIX of the Social Security Act and the Human Resources
Code.
(27) Medicare--A federal
program that provides medical care for people age 65 or older and the disabled
as authorized by Title XVIII of the Social Security Act.
(28) Other Coverage--Coverage, in addition to
benefit coverage as referenced in §
354.7 of this title (related to
Benefits and Limitations), to which a person is entitled for payment of the
costs of services or insurance premiums included in the scope of coverage of
the program, but not limited to, benefits available from:
(A) an insurance policy, group health plan,
health maintenance organization, or prepaid medical plan;
(B) Title XVIII, Title XIX, or Title XXI of
the Social Security Act (42 U.S.C. §§
1395 et seq., 1396 et seq., and 1397aa et
seq.), as amended;
(C) the United
States Department of Veterans Affairs;
(D) the TRICARE program of the United States
Department of Defense;
(E) workers'
compensation or any other compulsory employers' insurance program;
(F) a public program created by federal or
state law or under the authority of a municipality or other political
subdivision of the state, excluding benefits created by the establishment of a
municipal or county hospital, a joint municipal-county hospital, a county
hospital authority, a hospital district, a county indigent health care program,
or the facilities of a publicly supported medical school; or
(G) a cause of action for the cost of care,
including medical care, dental care, facility care, and medical supplies,
required for a person applying for or receiving services from the department or
a settlement or judgment based on the cause of action if the expenses are
related to the need for services provided under this chapter.
(29) Physician--An individual
licensed by the Texas Medical Board to practice medicine in the
state.
(30) Prior
Authorization--The process of getting approval from the program, before a
product is dispensed, to determine if it can be considered for
reimbursement.
(31) Program--The
Hemophilia Assistance Program.
(32)
Provider--Any individual or entity, as defined in §
354.9, of this title (relating to
Providers) approved by the program to provide allowable products to
clients.
(33) Recertification of
Program Eligibility--Upon request of the program, clients must submit the
information required in order to determine their continuing eligibility for
program services.
(34)
Reimbursement--Payment of a claim for insurance premiums submitted by a client
or allowable products administered or dispensed to a client submitted by a
program provider.
(35)
Reimbursement rate--The program payment rate for allowable products, determined
annually for the following fiscal year.
(36) Social Security Administration (SSA)--A
United States government agency that administers the social insurance programs
in the United States. The agency covers a wide range of social security
services, such as disability, retirement and survivors' benefits.
(37) Social Security Disability Insurance
(SSDI)--A payroll tax-funded, federal insurance program managed by the SSA,
that provides income to people who are unable to work because of a
disability.
(38) State--The State
of Texas.
(39) Texas resident--A
person who:
(A) is physically present within
the geographic boundaries of the state:
(i)
intends to remain within the state;
(ii) maintains an abode within the state
(i.e., house or apartment, not merely a post office box);
(iii) has not come to the state from another
country for the purpose of obtaining medical care with the intent to return to
the person's native country; and
(B) does not claim residency in any other
state or country; or
(C) is a
person residing in the state who is the legally dependent spouse of a Texas
resident; or
(D) is an adult
residing in the state, and plans to continue to reside, with a parent(s),
managing conservator, guardian of the adult's person, or caretaker who is a
Texas resident.
Notes
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