(a) A person must meet all of the following requirements
to be eligible for program benefits:
(1) have a diagnosis of ESRD; and
(A) require a regular course of chronic renal dialysis
treatments; or
(B) have received a kidney transplant;
(2) satisfy the Texas residency criteria as specified
in subsection (b) of this section and not be:
(A) in the custody of or incarcerated by a city, county,
state, or federal entity; or
(B) a ward of the state;
(3) not be eligible for drug, transportation, and medical
benefits under the Texas Medicaid Program;
(4) submit a complete application for benefits; and
(5) satisfy the financial criteria as specified in
subsection (c) of this section.
(b) Residency Requirements.
(1) The following conditions must be met by an applicant
and maintained by a client to satisfy the residency requirements in
this section:
(A) physically reside within the state; and
(B) maintain a home or dwelling within the state.
(2) If the applicant is residing with a person establishing
residency on behalf of the applicant (such as a parent, legal guardian,
managing conservator, sibling, adult child, or spouse), then that
person must meet all of the requirements of paragraph (1) of this
subsection.
(3) All documents acceptable to meet residency requirements,
as specified by the program, must be in the applicant's name, or in
the name of the person establishing residency for the applicant, provide
some verification of a Texas address or domicile, and be in English
or be accompanied by an accurate English translation.
(c) Financial Criteria. The applicant or the person(s)
who has a legal obligation, as defined by state law, to support the
applicant must have an annual gross income of less than $60,000. Income
reported as "joint income" is considered as one income.
(d) Maintenance of Benefits Eligibility.
(1) A client must meet the following requirements within
the first 3 months of program eligibility:
(A) apply for medical, drug, and transportation benefits
and Medicare Savings Plans (QMB, SLMB and QI) under Title XIX, Social
Security Act (Medicaid);
(B) apply for Medicare hospital and medical benefits
under Title XVIII, Social Security Act (Medicare);
(C) enroll in Medicare Part D benefits and apply for
Low Income Subsidy under the Medicare Prescription Drug Improvement
and Modernization Act of 2003, if Medicare eligible;
(D) provide authorization for Medicare premium payments
by the program as specified in §61.5 of this title (relating
to Benefits and Limitations), if obligated to pay the Part A premium.
(2) A client must meet the following requirements to
continue benefit eligibility:
(A) continue premium payments to health insurance plans
under Medicare, individual or group health insurance plans, and prepaid
medical plans, where enrollment was effective prior to program eligibility;
(B) re-apply for LIS as required by the Social Security
Administration;
(C) re-apply for Medicaid benefits as requested by
the program if there are changes in the client's status that would
make the client potentially eligible for Medicaid benefits;
(D) re-apply for Medicare hospital and medical benefits
as requested by the program if there are changes in the client's status
that would make the client potentially eligible for Medicare benefits;
and
(E) notify the program within 30 days of changes in
the following:
(i) permanent home address;
(ii) treatment status;
(iii) coverage under Medicaid, Medicare, individual
or group insurance, Veterans programs, or any other health benefits
coverage;
(iv) location of treatment; and
(v) income.
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Source Note: The provisions of this §365.3 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421 |