Texas Register, Volume 34, Number 33, Pages 5445-5614, August 14, 2009 Page: 5,471
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(19) Fair hearing--The informal hearing process the depart-
ment follows under 1.51 - 1.55 of this title (relating to Fair Hearing
Procedures).
(20) Filing deadline--The last date that a claim may be re-
ceived by the program and still be considered eligible for benefit.
(21) Final decision--A decision that is made by a decision
maker after conducting a fair hearing under 1.51 - 1.55 of this title.
(22) Interim approval--The status given by the program to
an outpatient dialysis facility, free-standing or hospital-based, which
has applied for participation as a KHC provider but has not executed
an agreement with the program.
(23) KHC--Kidney Health Care.
(24) KHC formulary--A list of general therapeutic cate-
gories of drugs, over-the-counter products, and limited diabetic sup-
plies that are covered for reimbursement by the program.
(25) Low Income Subsidy (LIS)--The subsidy provided
under the Medicare Prescription Drug, Improvement and Modern-
ization Act (MMA) of 2003 for Medicare Part D plan premiums
and related costs, at varying levels, for some low-income Medicare
beneficiaries.
(26) Medical benefit--Any medical treatment or procedure
approved by the program as a covered service.
(27) Medicare Advantage Plan--A Medicare health plan
that is similar to a health maintenance organization, participating
provider organization, or other Medicare health plan, and includes
medical, drug coverage and other benefits.
(28) Medicare Part A--Hospital insurance for people age
65 or older, or under age 65 with certain disabilities, that helps cover
inpatient hospital stays, care in a skilled nursing facility, hospice care,
and some home health care.
(29) Medicare Part B--Health insurance for people age 65
or older, or under age 65 with certain disabilities, and any age with
ESRD, that helps cover medically necessary services, such as doctors'
services and outpatient care, and some preventive services.
(30) Medicare Part D--Established by the Medicare Pre-
scription Drug, Improvement, and Modernization Act of 2003 (MMA),
it provides members with prescription drug coverage, expanded health
plan options, improved health care access for rural Americans, and pre-
ventive care services.
(31) Medicare Part D out-of-pocket expenses--Include pre-
miums, deductibles, and co-insurance amounts.
(32) Medicare Part D Premium--The amount paid monthly
under a Medicare Part D contract to insure coverage.
(33) Medicare Prescription Drug Plan (PDP)--A
stand-alone drug plan offered by insurers and other private companies
to individuals eligible for Medicare Part D.
(34) Medigap plan--A Medicare supplement insurance pol-
icy sold by private insurance companies to fill "gaps" in Medicare cov-
erage.
(35) Modification--A change made to a client's record that
affects a program benefit or eligibility status.
(36) Program--Kidney Health Care Program.
(37) Provider--Any individual or entity approved by the
program to furnish covered services to KHC clients including:
(A) outpatient dialysis facilities;(B) out-of-state outpatient dialysis facilities;
(C) hospitals and ambulatory surgical centers (ASCs)
located in Texas and operating in compliance with applicable law;
(D) out-of-state hospitals and ASCs;
(E) military or Veterans Administration hospitals
located in Texas which have a renal unit approved by the Joint Com-
mission on Accreditation of Healthcare Organizations or the American
Osteopathic Association;
(F) pharmacies approved as Texas Medicaid providers
and licensed to operate within the United States and its territories, in-
cluding mail order pharmacies;
(G) physicians and certified registered nurse anes-
thetists (CRNAs) licensed in Texas;
(H) out-of-state physicians and CRNAs; and
(I) Medicare Prescription Drug Plan (PDP) and Medi-
care Advantage Plan (MA-PD) providers.
(38) Qualified Individual (QI)--A Medicaid program for
beneficiaries who need help in paying for Medicare Part B premiums.
The beneficiary must have Medicare Part A and limited income and
resources and not be otherwise eligible for Medicaid. For those who
qualify, the Medicaid program pays full Medicare Part B premiums
only.
(39) Qualified Medicare Beneficiary (QMB)--A Medicaid
program for beneficiaries who need help in paying for Medicare ser-
vices. The beneficiary must have Medicare Part A and limited in-
come and resources. For those who qualify, the Medicaid program
pays Medicare Part A premiums, Part B premiums, and Medicare de-
ductibles and coinsurance amounts for Medicare services.
(40) Reimbursement--Payment of a claim for allowable
services or transportation.
(41) Reimbursement rate--The KHC payment rate for al-
lowable products, services, and transportation determined annually for
the following fiscal year.
(42) Specified Low Income Medicare Beneficiary
(SLMB)--A Medicaid program that pays for Medicare Part B premi-
ums for individuals who have Medicare Part A, a low monthly income,
and limited resources.
(43) Suspension--Eligibility for benefits which is held
without final action pending satisfaction of a program request or
requirement.
(44) Termination--A final action by the program, which
ends client or provider participation in the KHC program.
61.3. Client Eligibility Requirements.
(a) A person shall meet all of the following requirements to be
eligible for KHC 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 sub-
section (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;PROPOSED RULES August 14, 2009
34 TexReg 5471
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Texas. Secretary of State. Texas Register, Volume 34, Number 33, Pages 5445-5614, August 14, 2009, periodical, August 14, 2009; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth90865/m1/26/: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.