(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:
(4) Medicare Part A and B premium payment. To qualify for this benefit, clients must:
(5) Medicare Part B immunosuppressive drug co-insurance amounts. To qualify for this benefit, clients must:
(6) Limited Medicare Part D out-of-pocket expenses. To qualify for this benefit, clients must:
(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:
(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:
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