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RULE §354.3Definitions

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.

  (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.

Source Note: The provisions of this §354.3 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981

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