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
(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
(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
(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.
|Source Note: The provisions of this §354.7 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