26 Tex. Admin. Code § 354.7 - Benefits and Limitations
An eligible client may receive either blood factor replacement products or insurance premium payment assistance in the same fiscal year, but not at the same time.
(1)
Blood Factor Replacement Products. The program provides limited reimbursement
to program providers for blood factor replacement products indicated for the
treatment of hemophilia and prescribed to eligible clients for use in medical
or dental facilities, or in the home.
(2) Program benefits for allowable products
are limited to those prescribed by a physician and dispensed by a program
provider.
(3) The program will pay
for allowable products based upon:
(A)
available funds;
(B) established
limits for allowable products by type or category; and
(C) the reimbursement rates established by
the department.
(4)
Eligible clients with private or group health insurance for which the program
does not provide insurance premium payment assistance must exhaust all benefits
prior to receiving program benefits for allowable products.
(5) Insurance Premium Payment Assistance. The
program may assist eligible clients in obtaining public or private health
insurance by providing insurance premium payment assistance if paying for such
health insurance can reasonably be expected to be cost effective for the
program.
(6) The program is payer
of last resort. Applicants and currently eligible clients are no longer
eligible when they become eligible for the CHIP, SSDI, or Medicaid.
(7) To meet budgetary limitations, the
department may:
(A) adjust the reimbursement
rates established by the department;
(B) restrict allowable products and insurance
premium payments paid for under the program;
(C) adjust the annual benefit limits;
or
(D) establish a waiting list of
persons eligible for the program. Appropriate information will be collected
from each applicant who is placed on a waiting list. The information will be
used to facilitate contacting the applicant and to allow efficient enrollment
of the applicant when benefits become available. Eligibility must be maintained
while on the waiting list.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.