Texas Register, Volume 29, Number 5, Pages 727-1096, January 30, 2004 Page: 773
727-1096 p. ; 28 cm.View a full description of this periodical.
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(1) Complete application. A complete application is re-
quired before any eligibility determination will be made. A complete
application shall consist of all of the following:
(A) a complete Application for Benefits, with the appli-
cant's, or the applicant's representative's, original signature or "mark";
(B) a diagnosis of hemophilia certified by a licensed
physician;
(C) documentation of Texas residency as required by
37.113 of this title (relating to Residency and Residency Documenta-
tion Requirements);
(D) applicant financial data. Acceptable data to estab-
lish the applicant's financial qualifications shall be submitted with the
application. If the applicant, or person(s) who has a legal obligation
to support the applicant is currently approved to receive benefits from
Texas Medicaid, Temporary Assistance for Needy Families (TANF), or
Food Stamps, no verification of income is required. Changes in income
or financial qualifications that would affect the applicant's eligibility
shall be reported to the HAP.
(i) The applicant, or the person(s) who has a legal
obligation to support the applicant, may submit any of the following
documents to verify income:
(I) copy of the most recent paycheck;
(II) copy of the most recent paycheck stub or
monthly employee earnings statement;
(III) employee's written verification of gross
monthly income;
(IV) pension/allotment award letters;
(V) a copy of the IRS individual income tax re-
turn form and supporting schedules for the most recently completed tax
year; or
(VI) any other documents considered valid by
HAP.
(ii) If the applicant, or person(s) who has a legal
obligation to support the applicant, is unemployed, a statement of
termination from the employer, or other documentation acceptable to
HAP, is required.
(2) Incomplete applications. Any application which does
not meet all of the requirements of paragraph (1) of this subsection is
incomplete. Incomplete applications may be returned to the submitting
person for correction or completion.
(3) Eligibility date for HAP benefits. The HAP eligibility
date will be either:
(A) the date HAP receives a completed application; or
(B) the date of conditional authorization for allowable
products, if all written information to establish eligibility is received
within 30 days of the date of conditional authorization.
(4) Eligibility date for reinstatement of HAP benefits. If
HAP benefits are terminated, the eligibility date for any subsequent
benefit period will be the date on which HAP receives a subsequent
completed application for HAP benefits.
(5) An applicant whose eligibility for benefits is denied
may appeal HAP' s decision under the procedure contained in 1.51 -
1.55 of this title (relating to Fair Hearing Procedures).
37.115. Financial Criteria.Financial need is established on the basis of income legally available
to the applicant or the person(s) who have a legal obligation to support
the applicant.
(1) The income used to determine eligibility is the com-
bined gross income of the applicant and of all persons who have a legal
obligation to support the applicant.
(2) Income includes earned wages, pensions or allotments,
alimony, or any monies received on a regular basis for support pur-
poses. Supplemental Security Income (SSI) for the disabled applicant
is not included as income. Verification of income data will be required
as set out in 37.114(1)(D) of this title (relating to Applications and
Eligibility Date).
(3) The income level for eligibility is based on a percent-
age of the Federal Poverty Level Guidelines currently published by the
U.S. Health and Human Services and adopted by the Texas Department
of Health (department). Priority levels are based on available funds and
may be adjusted by the department in order to meet budgetary limita-
tions. Priority levels are as follows.
(A) Priority 1 - 100% or below;
(B) Priority 2 - 101% - 115%;
(C) Priority 3 - 116% - 130%;
(D) Priority 4 - 131% - 145%;
(E) Priority 5 - 146% - 160%;
(F) Priority 6 - 161% - 185%; or
(G) Priority 7 - 186% - 200%.
37.116. Limitations and Benefits Provided.
(a) The Hemophilia Assistance Program (HAP) provides
limited reimbursement to participating providers for blood derivatives,
blood concentrates, and manufactured pharmaceutical products
indicated for the treatment of hemophilia and prescribed to eligible
recipients for use in medical or dental facilities or in the home.
(b) All HAP benefits are limited to those prescribed by a li-
censed physician and received in Texas from a participating provider.
(c) Depending on the recipient's eligibility status, HAP will
pay for allowable products based upon:
(1) available funds;
(2) established limits for allowable products by type or cat-
egory of product; and
(3) the reimbursement rates established by the Texas De-
partment of Health (department).
(d) Recipients eligible for coverage of allowable products un-
der a private/group health insurance plan are not eligible to receive HAP
benefits. A recipient that has exhausted this coverage may be eligible
to receive benefits from HAP.
(e) To meet budgetary limitations, the department may:
(1) adjust the priority level for receipt of benefits, as out-
lined in 37.115(3) of this title (relating to Financial Criteria);
(2) adjust the reimbursement rates established by the de-
partment;
(3) restrict the allowable products paid for under the HAP;
(4) adjust the established limits for allowable products;
(5) adjust the limits established based on the inhibitor sta-
tus of the recipient or applicant;PROPOSED RULES January 30, 2004 29 TexReg 773
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Texas. Secretary of State. Texas Register, Volume 29, Number 5, Pages 727-1096, January 30, 2004, periodical, January 30, 2004; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth101101/m1/45/: accessed May 4, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.