Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule specifies payment standards,
confidentiality provisions, termination of clients from the program,
antidiscrimination policy, distribution of funding, and delivery of
services.
(1) The department
shall not pay for any item or service if payment has been made or is expected
to be made under any state compensation plan, including Medicaid, insurance,
federal, or state health benefits programs or by an entity that provides health
services on a prepaid basis.
(A) The
department shall be billed only after all third party sources have been
eliminated as payors.
(B) The
department shall only reimburse providers for medications that are listed on
the department's current Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome (HIV/AIDS) formulary on the date of the claim.
1. The department shall include medications
on the formulary which it has determined are-
A. FDA approved;
B. Medically effective for HIV infected
person; and
C. Cost effective as
determined by the department.
2. The department shall determine which
medications are medically effective and appropriate for inclusion on the
formulary based upon advice provided by the Missouri HIV/AIDS Medications
Advisory Committee, the department's medical consultants, and department
staff.
(C) Reimbursement
payments will only be made on behalf of enrolled clients as specified in
19 CSR
20-43.030, and will only be made for claims submitted
within contractual time limits.
1. If a
client becomes ineligible for medications assistance and the pharmacy or agent
supplying medications should reasonably have been aware at the time the
services were provided, as specified in the provider's contract, that the
client was ineligible, reimbursement will not be made.
2. The department or its agents may review
client records and program invoices to ensure compliance with the
program.
(2)
Available medications funds will be allocated statewide.
*Original authority: 192.006, RSMo 1993, amended 1995 and
192.020, RSMo 1939, amended 1945, 1951.
