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RULE §354.7Benefits and Limitations

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 upon:

    (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 allowable products.

  (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 department;

    (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

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