(a) Benefits.
(1) Outpatient drugs and supplies listed on the current
KHC formulary.
(2) Transportation reimbursement for ESRD-related medical
services.
(3) Medical benefits, including:
(A) access surgery-related services; and
(B) chronic maintenance dialysis.
(4) Medicare Part A and B premium payment. To qualify
for this benefit, clients must:
(A) be 65 years of age or older;
(B) be accepted for Medicare hospital and medical insurance;
(C) be obligated to pay the Part A premium;
(D) not be eligible for the following types of Medicare
savings programs:
(i) QMB;
(ii) SLMB; or
(iii) QI; and
(E) promptly submit all Medicare premium due notice
statements to the program for payment.
(5) Medicare Part B immunosuppressive drug co-insurance
amounts. To qualify for this benefit, clients must:
(A) be eligible for program drug benefits;
(B) be accepted for Medicare hospital and medical insurance;
(C) enroll in a Texas Medicare Part D Stand-Alone Plan;
(D) not be enrolled in a Medigap plan;
(E) not be enrolled in a Medicare Advantage Plan with
drug coverage; and
(F) not be eligible for the QMB Medicare Savings Program.
(6) Limited Medicare Part D out-of-pocket expenses.
To qualify for this benefit, clients must:
(A) be eligible for program drug benefits;
(B) be accepted for Medicare Part D benefits;
(C) enroll in a Texas Medicare Part D stand-alone plan;
(D) not be eligible for LIS from Medicare that covers
full premium and deductible amounts; and
(E) not be enrolled in a Medicare Advantage Plan with
drug coverage.
(7) Benefits are payable beyond the Medicare three-month
qualifying period for eligible clients who have applied for and have
been denied Medicare coverage based on ESRD. Clients must submit a
copy of the official Social Security Administration Medicare denial
notification (based on chronic renal disease) to the department.
(b) Limitations.
(1) Only enrolled providers may be reimbursed for covered
services and allowable drugs.
(2) Covered services are limited to a maximum allowable
amount based upon:
(A) available funds;
(B) established limits for covered services by type
or category;
(C) an agreement between the department and the enrolled
provider;
(D) the reimbursement rates established by the department;
(E) any co-payment or co-insurance applied to client
service benefits; and
(F) any third-party liability.
(3) Clients eligible for drug coverage under Medicaid,
Medicare Advantage Plan, individual or group insurance, Veterans programs,
or any other health benefits coverage are not eligible to receive
program drug benefits. A client that has exhausted drug coverage under
Medicaid, Medicare Advantage Plan, individual or group insurance,
Veterans programs, or any other health benefits coverage may be eligible
to receive drug benefits from the program.
(4) Access surgery benefits are payable only if the
services are performed on or after the date Texas residency is established
and not more than 180 days prior to the client's program effective
date.
(5) Program medical benefits are payable during the
Medicare three-month qualifying period. Benefits are payable for services
received on or after the client's program effective date. The three-month
qualifying period is calculated from the first day of the month the
client begins chronic maintenance dialysis. When a client becomes
eligible for Medicare during the three-month period, program medical
benefits are not payable from the date of Medicare eligibility.
(6) Transportation reimbursement is available from
the first day of the month following the program effective date for
in-center dialysis clients or from the program effective date for
transplant and home peritoneal dialysis clients.
(7) Clients eligible for coverage under Medicaid, Medicare,
individual or group insurance, Veterans programs, or any other health
benefits coverage which cover the treatment of ESRD are not eligible
to receive program medical benefits.
(8) Clients receiving services, including access surgery,
dialysis, or drug benefits through the Veterans Administration (VA)
or the military may not be eligible to receive these services through
the program, depending on the client's access to VA or military services.
(9) The program is the payor of last resort. All third
parties must be billed prior to the program. The Commissioner may
waive this requirement in individually considered cases where its
enforcement will deny services to a class of ESRD patients because
of conflicting state or federal laws or regulations, under the Texas
Health and Safety Code, §42.009.
(10) If budgetary limitations exist, the department
may:
(A) restrict or categorize covered services. Categories
will be prioritized based upon medical necessity, other third party
eligibility and projected third party payments for the different treatment
modalities, caseloads, and demands for services. Caseloads and demands
for services may be based on current or projected data. In the event
covered services must be reduced, they will be reduced in a manner
that takes into consideration medical necessity and other third party
coverage. The department may change covered services by adding or
deleting specific services, entire categories or by making changes
proportionally across a category or categories, or by a combination
of these methods; or
(B) establish a waiting list of eligible applicants.
Information will be collected from each applicant who is placed on
a waiting list to facilitate contacting the applicant when benefits
become available and to allow efficient enrollment of the applicant
for benefits.
|
Source Note: The provisions of this §365.5 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421 |