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 this
title (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 §37.114 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 §37.115, 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.
Cont'd... |
