SECTION 365.5. Benefits and Limitations

(a) Benefits.

(1) Outpatient drugs and supplies listed on the current KHC formulary.

(2) Transportation reimbursement for ESRD-related medical services.

(3) Medical benefits, including:

(A) access surgery-related services; and

(B) chronic maintenance dialysis.

(4) Medicare Part A and B premium payment. To qualify for this benefit, clients must:

(A) be 65 years of age or older;

(B) be accepted for Medicare hospital and medical insurance;

(C) be obligated to pay the Part A premium;

(D) not be eligible for the following types of Medicare savings programs:

(i) QMB;

(ii) SLMB; or

(iii) QI; and

(E) promptly submit all Medicare premium due notice statements to the program for payment.

(5) Medicare Part B immunosuppressive drug co-insurance amounts. To qualify for this benefit, clients must:

(A) be eligible for program drug benefits;

(B) be accepted for Medicare hospital and medical insurance;

(C) enroll in a Texas Medicare Part D Stand-Alone Plan;

(D) not be enrolled in a Medigap plan;

(E) not be enrolled in a Medicare Advantage Plan with drug coverage; and

(F) not be eligible for the QMB Medicare Savings Program.

(6) Limited Medicare Part D out-of-pocket expenses. To qualify for this benefit, clients must:

(A) be eligible for program drug benefits;

(B) be accepted for Medicare Part D benefits;

(C) enroll in a Texas Medicare Part D stand-alone plan;

(D) not be eligible for LIS from Medicare that covers full premium and deductible amounts; and

(E) not be enrolled in a Medicare Advantage Plan with drug coverage.

(7) Benefits are payable beyond the Medicare three-month qualifying period for eligible clients who have applied for and have been denied Medicare coverage based on ESRD. Clients must submit a copy of the official Social Security Administration Medicare denial notification (based on chronic renal disease) to the department.

(b) Limitations.

(1) Only enrolled providers may be reimbursed for covered services and allowable drugs.

(2) Covered services are limited to a maximum allowable amount based upon:

(A) available funds;

(B) established limits for covered services by type or category;

(C) an agreement between the department and the enrolled provider;

(D) the reimbursement rates established by the department;

(E) any co-payment or co-insurance applied to client service benefits; and

(F) any third-party liability.

(3) Clients eligible for drug coverage under Medicaid, Medicare Advantage Plan, individual or group insurance, Veterans programs, or any other health benefits coverage are not eligible to receive program drug benefits. A client that has exhausted drug coverage under Medicaid, Medicare Advantage Plan, individual or group insurance, Veterans programs, or any other health benefits coverage may be eligible to receive drug benefits from the program.

(4) Access surgery benefits are payable only if the services are performed on or after the date Texas residency is established and not more than 180 days prior to the client's program effective date.

(5) Program medical benefits are payable during the Medicare three-month qualifying period. Benefits are payable for services received on or after the client's program effective date. The three-month qualifying period is calculated from the first day of the month the client begins chronic maintenance dialysis. When a client becomes eligible for Medicare during the three-month period, program medical benefits are not payable from the date of Medicare eligibility.

(6) Transportation reimbursement is available from the first day of the month following the program effective date for in-center dialysis clients or from the program effective date for transplant and home peritoneal dialysis clients.

(7) Clients eligible for coverage under Medicaid, Medicare, individual or group insurance, Veterans programs, or any other health benefits coverage which cover the treatment of ESRD are not eligible to receive program medical benefits.

(8) Clients receiving services, including access surgery, dialysis, or drug benefits through the Veterans Administration (VA) or the military may not be eligible to receive these services through the program, depending on the client's access to VA or military services.

(9) The program is the payor of last resort. All third parties must be billed prior to the program. The Commissioner may waive this requirement in individually considered cases where its enforcement will deny services to a class of ESRD patients because of conflicting state or federal laws or regulations, under the Texas Health and Safety Code, §42.009.

(10) If budgetary limitations exist, the department may:

(A) restrict or categorize covered services. Categories will be prioritized based upon medical necessity, other third party eligibility and projected third party payments for the different treatment modalities, caseloads, and demands for services. Caseloads and demands for services may be based on current or projected data. In the event covered services must be reduced, they will be reduced in a manner that takes into consideration medical necessity and other third party coverage. The department may change covered services by adding or deleting specific services, entire categories or by making changes proportionally across a category or categories, or by a combination of these methods; or

(B) establish a waiting list of eligible applicants. Information will be collected from each applicant who is placed on a waiting list to facilitate contacting the applicant when benefits become available and to allow efficient enrollment of the applicant for benefits.

Source Note: The provisions of this §365.5 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