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RULE §354.5Program Eligibility

(a) Client Requirements. In order to be determined eligible for program benefits, applicants must meet the medical, age, residency, financial, and other criteria in this section, and submit a complete application for program benefits.

  (1) Medical criteria. A physician must certify that the applicant has a diagnosis of hemophilia.

  (2) Age. The applicant must be 18 years of age or older.

  (3) Residency. The applicant must be a Texas resident.

  (4) Financial criteria. Financial criteria are determined at least annually or as directed by the program. Financial criteria are based upon the determinations of income and family size. Income must be at or below 200% of the FPL.

  (5) Other criteria. The applicant must not be eligible for Medicaid or the Children's Health Insurance Program (CHIP). The program may require an applicant currently not enrolled in Medicaid, Medicare, CHIP, SSDI, or the CSHCN Services Program to apply for any of these applicable programs when the applicant's age, income, or medical disability determination meets the eligibility criteria for any of these programs and, if eligible, to participate in those programs.

  (6) Health Insurance. All health insurance coverage insuring the applicant must be attested to on the application. Noncompliance with this requirement may result in the termination of program benefits.

    (A) The program may require an applicant currently not enrolled in a health insurance plan to apply for an available insurance plan that is accessible and provides comprehensive coverage. The program may provide program benefits for ongoing clients during insurance application, enrollment, or limited or excluded coverage periods.

    (B) Before canceling, terminating, or discontinuing existing health insurance or electing not to enroll in available health insurance, the client, or person who has a legal responsibility for the client, must notify the program 30 days prior to cancellation, termination, discontinuance, or end of the enrollment period, whenever possible.

  (7) Application.

    (A) To be considered by the program, a complete application must be made on forms required by the department. The application must have the signature or mark of the applicant, or the applicant's legally authorized representative, and the physician's signature.

    (B) The program will make the determination of an applicant's eligibility using the information provided with the application. The program will verify information on the application, including required documentation of diagnosis, income, attestation of other coverage, date of birth, and residency.

    (C) The program may request additional documentation to verify information provided by the applicant to establish eligibility. The program will notify the applicant, or the applicant's legally authorized representative, in writing when specific documentation is required. It is the responsibility of the applicant, or the applicant's legally authorized representative, to provide the required documentation.

    (D) The program will determine eligibility when a completed application is received.

  (8) Eligibility Date. The effective date of eligibility for program benefits is the date of receipt of a complete, approved application.

  (9) Program Termination. If program coverage is terminated, the eligibility date for any subsequent eligibility period will be the date on which the program receives a subsequent completed application for program benefits.

(b) Determination of continuing eligibility for program benefits. Income criteria, residency, and attestation of other coverage must be documented annually or as directed by the program for the recertification of program eligibility and benefits.

  (1) Clients are notified of program deadlines for recertification of eligibility.

  (2) If an ongoing client does not meet program deadlines for submitting information required for the determination of continuing eligibility, the client's eligibility for the program will end.

  (3) If a former client re-applies to the program, a new medical certification is not required, and their new eligibility date is determined to be the date the completed application is received.

Source Note: The provisions of this §354.5 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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