Texas Register, Volume 38, Number 26, Pages 4053-4242, June 28, 2013 Page: 4,152
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(2) does not qualify for assistance or receives less than full
coverage for approved program medication(s) under any State com-
pensation program or under any other state or federal health benefits
program;
(3) meets the program's payer of last resort criteria [is not
eevered under an insurance policy or is otherwise underinsured for pre-
seription drugs]; and
(4) has an annual gross income (minus the adjustments de-
scribed in subsection (b) of this section) that does not exceed 200% of
the most recently published federal poverty income guidelines.
(b) Formula for adjusting annual gross income.
(1) An applicant's annual gross income (if single), or the
combined annual gross income of the applicant and his or her spouse,
minus the program's annualized cost of the prescribed medication(s).
(2) For a minor child, the (combined) annual gross income
of the child's parent(s), minus the program's annualized cost of the pre-
scribed medication(s). Only the income of the parent(s) living in the
same household as the child at the time of application or recertification
will be used to determine financial eligibility.
(3) For an emancipated minor, financial eligibility is deter-
mined as set forth in paragraph (1) of this subsection.
(c) The department shall periodically verify the financial sta-
tus of a recipient to determine if the recipient continues to meet the
financial eligibility criteria of the program.
98.110. Application Process; Verification; Renewal.
(a) Persons meeting the aforementioned eligibility re-
quirements must submit a complete application for benefits to the
department, on the form specified by the department, accompanied by
the required supporting documentation. A complete application shall
consist of all of the following:
(1) a complete Application for Services, with the original
signature of the applicant, or the person legally responsible for the ap-
plicant, certifying that the statements made within the application are
factual and true;
(2) documentation of current Texas residency;
(3) documentation acceptable to the department to estab-
lish the applicant's financial qualifications;
(4) verification that the applicant has a diagnosis of HIV
disease and is under the care of a physician licensed to practice
medicine in the United States of America, who prescribes drugs for
that person.
(b) Any application that does not meet all of the [abee] re-
quirements in subsection (a) of this section is considered incomplete.
Incomplete applications will not be processed further, and the applicant
will be contacted concerning the insufficiency of the application.
(c) To request an application packet, call toll-free 1-800-255-
1090 or write to: Department of State Health Services, HIV/STD
Prevention and Care [Gomprehensive Services] Branch, Texas HIV
Medication Program, Attn: MSJA, Mail Code 1873, P.O. Box 149347
[400 West 49th Street], Austin, Texas 78714-9347 [787563199].
The program's application for assistance is also available online at [the
fl-i g T. ] http:/www.dshs.state.tx.us/hivstd/meds/.
(d) Submit completed application, along with accompanying
documentation and certification forms, to: Department of State Health
Services, HIV/STD Prevention and Care [Cemprehensive Services]
Branch, Texas HIV Medication Program, Attn: MSJA, Mail Code1873, P.O. Box 149347 [400 West 49th Street], Austin, Texas
78714-9347 [78756-3199].
(e) The applicant is expected to give informed consent to the
department so that the program may contact a medical provider, Medi-
care, or Medicare prescription drug plan to verify information con-
tained in the application and/or to request additional supporting doc-
umentation pertaining to the application.
(f) The department may, at any time, verify the eligibility sta-
tus of an enrolled recipient to determine if the recipient is continuing
to meet the eligibility criteria of the program. The recipient must co-
operate with the department, and furnish requested documentation to
the department as directed.
(g) A recipient must renew enrollment in the program every
three years according to the procedures established by the department.
Recipient must demonstrate, at that time, continuing eligibility for the
program to the satisfaction of the department. Recipients must use
the department's renewal application form (which may be obtained
from the department calling toll-free 1-800-255-1090 or writing to:
Department of State Health Services, HIV/STD Prevention and Care
[Comprehensive Services] Branch, Texas HIV Medication Program,
Attn: MSJA, Mail Code 1873, P.O. Box 149347 [4-00 West 49th
Street], Austin, Texas 78714-9347 [78756-3'199]), and comply with all
associated deadlines and requirements for accompanying documents.
98.115. Fiscal Planning.
(a) To ensure the program's expenditures do not exceed the
program's budget, the department will analyze the latest actuarial pro-
jections for the upcoming year, including the average annual cost per
recipient and the projected number of recipients the program will be
able to serve using current budget figures.
(b) The department will perform this analysis of program ex-
penditures every quarter to determine if funds are sufficient to meet
projected expenditures.
(c) To make certain that expenditures do not exceed the pro-
gram's budget, the department may implement the following temporary
cost-containment measures as necessary.
(1) Cost-containment measures [may be implemented in
the following order].
(A) Initiate medical criteria to meet at minimum the
most recent federal Department of Health and Human Services Guide-
lines for the Use of Antiretroviral Agents in HIV-Infected Adults and
Adolescents, which can be found at http://aidsinfo.nih.gov/Guidelines.
(B) Discontinue using the formula for adjusting the ap-
plicant's gross annual income described in 98.109(b) of this title (re-
lating to Financial Eligibility Criteria[.]).
(C) Lower the financial eligibility criteria described in
98.109(a)(4) of this title to a level that is not lower than 125% of
federal poverty level.
(D) Cease enrollment of new applicants.
(2) As funds become available, the department will rescind
the cost-containment measures in a manner which the department
judges most appropriate given the particular circumstances at that time
[in the reverse order of which they were implemented].
(d) Cost-Containment measures, if implemented, will be ap-
plied to recipients enrolling after the cost-containment measure(s) is
implemented.
98.118. Appeal Procedures.38 TexReg 4152 June 28, 2013 Texas Register
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Texas. Secretary of State. Texas Register, Volume 38, Number 26, Pages 4053-4242, June 28, 2013, periodical, June 28, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth313178/m1/100/: accessed May 4, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.