SECTION 365.3. Client Eligibility Requirements

(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.

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