SECTION 364.9. Eligibility Requirements and Provision of Services to Recipients

(a) Individuals covered under the Primary Health Care Services Program are those who are not eligible for other benefits. Individuals eligible for prescription drug benefits under Medicare, Part D, who reside in areas of the state served by program providers that offer prescription drugs as a primary health care service may be eligible for other program services, and for prescription drugs not covered by Medicare, Part D.

(b) Nothing in this section shall preclude a system of integrated eligibility with the commission.

(c) In accordance with program policy, providers shall assure that each individual is:

(1) in financial need based on a family income that does not exceed 200% of the current Federal Poverty Level guidelines; and

(2) a Texas resident.

(d) In accordance with program policy, providers:

(1) shall assist applicants in completing the eligibility screening process and shall provide coverage if the applicant is potentially eligible for program services;

(2) may collect co-payments from eligible individuals who receive primary health care services; and

(3) shall provide services to potentially eligible individuals who require immediate medical attention on a presumptive eligibility basis.

(e) Subsection (d)(4) of this section notwithstanding, no otherwise eligible individual unable to pay a co-payment may be denied services.

(f) If funds are available, the program may pay co-payments required under federal regulations for eligible individuals receiving prescription drug benefits under Medicare, Part D, if the eligible individual resides in an area of the state served by a program provider that offers prescription drugs as a benefit under the primary health care service program.

(g) No eligible individual or person legally responsible for an eligible individual shall be required to make a pre-treatment payment.

(h) An individual found ineligible for program services may reapply at any time.

Source Note: The provisions of this §364.9 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674