TITLE 25. HEALTH SERVICES

PART 1. DEPARTMENT OF STATE HEALTH SERVICES

CHAPTER 37. MATERNAL AND INFANT HEALTH SERVICES

SUBCHAPTER F. HEMOPHILIA ASSISTANCE PROGRAM

25 TAC §§37.112 - 37.114, 37.116 - 37.118

The Executive Commissioner of the Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), adopts amendments to §§37.112 - 37.114 and 37.116 - 37.118, concerning the Hemophilia Assistance Program (program). The amendments to §§37.112 - 37.114 and 37.116 - 37.118 are adopted without changes to the proposed text as published in the September 2, 2016, issue of the Texas Register (41 TexReg 6624) and, therefore, the sections will not be republished.

BACKGROUND AND PURPOSE

During the 84th Legislative Session, 2015, Senate Bill 200 provided the authority that as of September 1, 2016, the Hemophilia Assistance Program under DSHS was transferred to HHSC's Medical and Social Services Division.

As authorized by Texas Health and Safety Code, Chapter 41, the program contracts with pharmacies, hospitals, and blood banks throughout the state to provide blood factor replacement products that have been approved for payment by the program and are indicated for the treatment of hemophilia. House Bill 1038, 84th Legislature, Regular Session, 2015, amended Texas Health and Safety Code, §41.002, allowing the program to provide insurance premium payment assistance to Texas residents with hemophilia. All program clients are adults who have been diagnosed with hemophilia and have met all program eligibility requirements.

The amendments establish guidelines by which the program may reimburse eligible clients for insurance premium payments.

The amendments to §§37.112 - 37.114 and 37.116 - 37.118 are necessary to establish guidelines by which the program may reimburse eligible clients for insurance premium payments. Historically, program funds have paid for costly blood factor replacement products only. The amendments allow the program to help individuals pay for insurance premiums with existing funds. By providing assistance in obtaining comprehensive insurance coverage, clients will have access to primary and specialty care in health benefit plans. By having access to routine health care services, there is less likelihood of poor health outcomes and permanent disabilities.

Under the amended rules, eligible clients may receive either covered blood factor replacement products or approved insurance premium payment assistance, up to the maximum allowed in the same fiscal year, but not at the same time.

SECTION-BY-SECTION SUMMARY

The amendments to §37.112 revise existing definitions and add new definitions. New terms used in this subchapter include "approved health plan" and "insurance premium payment."

An amendment to §37.113 updates eligibility requirements to allow program clients to be dually eligible for Medicare and the program.

The amendments to §37.114 revise benefits and limitations by adding language regarding the payment of insurance premiums.

The amendments to §37.116 add new language for the payment of insurance premiums and establish filing deadlines for premium reimbursements.

An amendment to §37.117 updates clients' rights to include choosing a health plan, subject to program limitations.

An amendment to §37.118 adds new language allowing the department to modify, suspend, deny, or terminate a client's eligibility for failure to reimburse the department for overpayments.

COMMENTS

Comments received during the public comment period did not result in changes to the proposed rule text as published on September 2, 2016, in the Texas Register (41 TexReg 6624).

DSHS, on behalf of HHSC, has reviewed and prepared responses to the comments received regarding the proposed rules during the comment period, which HHSC has reviewed and accepts. The commenters included the Lone Star Chapter of the National Hemophilia Foundation, the Texas Central Hemophilia Association, and the Coalition for Nurses in Advanced Practice (CNAP). The commenters were not against the rules in their entirety; however, the commenters suggested recommendations for change as discussed in the summary of comments.

COMMENT: Two commenters requested that the state provide clear, streamlined procedures to timely determine eligibility and provide reimbursement to the clients that utilize the program.

RESPONSE: HHSC declines to revise the rules based on these comments, as they do not relate to the targeted implementation of House Bill 1038, allowing the program to provide insurance premium payment assistance to Texas residents with hemophilia. Details surrounding eligibility and benefits are addressed in program policies, which are reviewed and updated routinely.

COMMENT: The commenters suggested the need to provide information and guidance to clients to allow them to make good decisions on the purchase of healthcare insurance.

RESPONSE: HHSC declines to revise the rules based on these comments, as the program does not have the authority to provide information and guidance to clients regarding the purchase of health care insurance. The program is authorized, however, to verify that an eligible client has insurance that meets the program's definition of an "approved health plan" in order to qualify for insurance reimbursement assistance. Section 37.112(4) defines an approved health plan as "an insurance plan that provides coverage for hemophilia medical treatment."

COMMENT: The commenters suggested that the program rules, procedures, and processes be adopted prior to November 1st to enable funds to be utilized in the upcoming open enrollment period.

RESPONSE: HHSC declines to revise the rules based on these comments, as the state must follow rulemaking policy for the adoption of rules, which did not meet the suggested timeframe.

COMMENT: One commenter suggested §37.112 be modified to add definitions for Advanced Practice Registered Nurse (APRN) and Physician Assistant (PA); that §37.113(a)(1) be modified to allow an APRN or PA to certify that an applicant has a diagnosis of hemophilia; and that §37.114(b) be modified to allow an APRN or PA to prescribe allowable blood factor products.

RESPONSE: HHSC declines to revise the rules based on this comment, as it does not relate to the targeted implementation of House Bill 1038, allowing the program to provide insurance premium payment assistance to Texas residents with hemophilia. Unrelated additions to the rules would require that the rules be re-published as proposed, thus delaying the adoption of the rule amendments already proposed.

LEGAL CERTIFICATION

DSHS General Counsel, Lisa Hernandez, certifies that the rules, as adopted, have been reviewed by legal counsel and found to be a valid exercise of the agencies' legal authority.

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code, §531.0055, and Texas Health and Safety Code, §1001.075, which authorize the Executive Commissioner of the Health and Human Services Commission to adopt rules and policies necessary for the operation and provision of health and human services by DSHS and for the administration of Texas Health and Safety Code, Chapter 1001.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on February 9, 2017.

TRD-201700571

Lisa Hernandez

General Counsel

Department of State Health Services

Effective date: March 1, 2017

Proposal publication date: September 2, 2016

For further information, please call: (512) 776-6972