• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: 737-255-4300

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220.100

Purchasing Emergency Medications for Clients Awaiting an Eligibility Decision from the Texas HIV Medication Program

Policy
Policy Number 220.100
Effective Date May 22, 1996
Revision Date November 18, 2002
Approval Authority TB/HIV/STD Section Director

1.0 Purpose

To provide guidance on the appropriate use of grant funds to purchase emergency medications for clients awaiting an eligibility decision from the Texas HIV Medication Program. This policy is directed to contracting agencies providing HIV-related public health services whose activities allow for medication purchases (i.e., Ryan White Title II, state services, and Early Intervention programs). Implementation of this policy will assure that grant funds reimburse for medication only if no other parties will pay and is not intended to supplant the use of the Texas HIV Medication Program.

 

2.0 Authority

Health and Safety Code §85 Subchapter C, HIV Medication Program; Insurance Code, Article 51-6D Cancellation Prohibited for HIV and AIDS

 

3.0 Where to Go for Assistance

Clients needing medications to manage an HIV-related condition and seeking assistance to purchase prescribed medication must seek assistance from their private insurance company if appropriate. Case managers should assist clients who do not have private insurance coverage to apply for health care benefits with Medicaid and with their local or county indigent health care program if they may be eligible.

The Texas HIV Medication Program is another resource; however, the program does not aid clients whose insurance covers medications. Clients enrolled in Medicaid or local or county indigent health care programs may simultaneously qualify for assistance from the Texas HIV Medication Program.

 

4.0 Private Insurance

Clients whose private insurance covers the prescribed medications must use the insurance company's coverage to purchase HIV medications. Case managers should direct clients who are having trouble paying insurance premiums to the insurance assistance program in their HIV service delivery area for eligibility determination. The cost to the state of helping pay premiums is much less than the cost of the client's care should that person lose insurance coverage.

By law (Insurance Code, Article 3.51-6D) an insurance company cannot drop clients because they are HIV positive or have AIDS. If a client refuses to submit claims to the insurance company for medication reimbursement, contractors may not use grant funds to purchase medications that are on the Texas HIV Medication Program formulary for that client.

 

5.0 Indigent Non-Insured

Clients who lack insurance or whose insurance does not cover the prescribed medications and who need help paying for medications should immediately apply to the following programs with the case manager's assistance:

  • Medicaid,
  • the local or county indigent health care program, and
  • the Texas HIV Medication Program.

Local indigent programs may help eligible clients purchase medications that are over the Medicaid monthly allotment or that the Texas HIV Medication Program does not cover. The Texas HIV Medication Program will only provide medications that are on the formulary for eligible clients.

Clients may need to have prescriptions filled before they receive eligibility certification for the Texas HIV Medication Program. In these cases, contractors may purchase medications for clients who are awaiting an eligibility decision only if the client's physician determines that taking the medications is an emergency and if no more than a 30-day supply is purchased.

Contractors cannot buy more than a 30-day supply of medications that are on the Texas HIV Medication Program formulary for each client. If the Texas HIV Medication Program denies the client coverage, the client's case manager should work with the client and the client's attending physician to find alternate funding sources. Alternate sources may include manufacturers' compassionate use programs, religious groups, or other community programs.

Address any questions about implementing this policy to the Texas HIV Medication Program at (800) 255-1090 or the HIV/STD Prevention and Care Branch at (737) 255-4300.

 

6.0 Compliance

The HIV/STD Prevention and Care Branch, Texas HIV Medication Program, and Field Operations Branch staff will work together to verify that contractors follow this policy. During site visits, these staff members will look for documentation of applications, referrals, phone calls, etc. Contractors that violate this policy will face administrative sanctions.

 

7.0 Revision History

Date Action Section
Revision History
9/1/2017 Changed "TB/HIV/STD Unit" to "TB/HIV/STD Section" to reflect new program designation -
9/25/2014 Converted format (Word to HTML) -
12/30/2002 Removal of Medication Reimbursement Initiative. Program no longer in existence. All

 


Last updated June 15, 2020