Current through Register No. 40, October 3, 2024
(a)
Tuberculosis (TB) patient care financial assistance shall be provided for
tuberculosis related treatment and services to applicants meeting the
eligibility requirements set forth in this section. Applications for financial
assistance shall be considered in chronological order among all eligible
applicants. However, assistance to which these rules apply shall be subject to
the availability of funds and shall not be financially open-ended.
(b) Qualified applicants shall be eligible to
receive financial assistance for the following patient care:
(1) Medications approved by the Federal Food
and Drug Administration for the treatment of tuberculosis, latent tuberculosis
infection, or any medical condition caused by tuberculosis or tuberculosis
medications;
(2) Licensed
healthcare provider visits for active tuberculosis and high risk latent
tuberculosis diagnosis, treatment and follow-up, when indicated;
(3) Diagnostic procedures to diagnose or
monitor the disease;
(4) Laboratory
tests related to the diagnosis of tuberculosis or its treatment; and
(5) Home health agency visits to provide
directly observed therapy.
(c) Financial assistance for approved TB
patient care shall be provided for applicants who meet the following
eligibility requirements:
(1) Are residents
of the state of New Hampshire;
(2)
Are infected with active tuberculosis or high-risk Latent Tuberculosis
Infection, or those undergoing diagnostic procedures because of suspected
TB;
(3) Are under a physician's
care for TB; and
(4) Have an annual
gross household income which is less than 300% of the Federal poverty income
guidelines.
(d) As the
payor of last resort, nothing contained in these rules shall authorize or
require the program to provide payment for drugs, diagnostics or monitoring
services which would otherwise be paid for by medicaid, medicare or any other
medical insurance program or policy.
(e) Each recipient shall notify the program
in writing within 30 days of any change in the recipient's medical insurance
coverage which results in coverage for patient care costs which are being paid
for by the program.
(f) An
application for financial assistance shall be submitted to the program before
the program provides financial assistance. The application shall include:
(1) The name and address of the
applicant;
(2) Documentation of
active tuberculosis or high-risk latent tuberculosis infection diagnosis, or a
statement that the applicant is undergoing diagnostic procedures because of
suspected TB;
(3) Proof of New
Hampshire residency;
(4) A
statement of financial resources signed by the applicant, including any of the
following:
a. The most recent income tax form
of those persons whose income is considered in determining family
income;
b. A recent pay stub for
each individual in (g) (4) a. above;
c. A letter from the employer(s) of those
individuals in a. above attesting to present wages; and
d. In the case of zero income, a letter from
the healthcare provider or public health nurse case manager attesting to means
of financial support.
(g) An application for financial assistance
shall be submitted to the program before the program provides financial
assistance.
(h) The application
referred to in (g) above shall include:
(1)
The name and address of the applicant; and additional information about the
applicant including:
a. Place of birth,
social security number, race, sexual orientation, and ethnicity;
b. The first three letters of the applicant's
mother's first name;
c. The status
of the applicant's housing and the applicant's contact information and mailing
address; and
d. Information
relating to contacting the applicant by answering machine, email or
mail;
(2) Proof of NH
residency;
(3) Documentation of
active tuberculosis or high-risk latent tuberculosis infection;
(4) The name and contact information for the
applicant's primary and specialty care physician and pharmacy contact
information;
(5) A statement of
financial resources, including any of the following:
a. The current income tax form of those
persons whose income is considered in determining family income;
b. Recent pay stubs for the individuals
referred to in (4) a. above;
c. A
letter from the employer(s) of those individuals referred to in a. above
attesting to present wages; and
d.
In the case of zero income, a letter from the case manager attesting to means
of financial support; and
e. Copy
of insurance card or proof of insurance, if applicable;
(i) A signed authorization that:
(1) The applicant understands that DHHS:
a. Shall not discriminate against people
because of their age, sex race, creed, color, marital or familial status,
physical or mental disability, national origin, sexual orientation or political
affiliation or belief;
b. Shall
follow all federal and state laws and rules prohibiting such discrimination;
and
c. Shall provide the applicant
with access to information about filing a report of any perceived such
discrimination;
(2) That
financial statements made as part of the application and eligibility
determination are true and correct to the best of the applicant's
knowledge,
(3) The applicant
understands that:
a. Intentional
misrepresentations may result in legal action on the basis of state or federal
laws; and
b. That participation and
eligibility shall be denied if information is intentionally withheld,
misrepresented or omitted;
(5) The applicant shall notify NH TB
Financial Assistance Program within 30 days of any change in name, address,
eligibility, financial, insurance status or household size, income or medical
expenses and to provide evidence thereof;
(6) The applicant authorizes his or
physician, or physician's representative to release information relative to the
content of the applicant's medical record to NH TB Financial Assistance Program
and the department for the purpose of determining eligibility as described in
He-P 301.17(c);
(7) The information
from the medical record including the applicant's identity shall be maintained
in strict confidence and not revealed to any person outside of the
department;
(8) The applicant
authorizes the staff at NH TB Financial Assistance Program to communicate with
and release information including the applicant's diagnosis to physicians and
other health care professionals including the applicant's pharmacist, case
manager and other treatment providers to ensure planning and delivery of
services to the applicant; and
(9)
The releases in (6) and (8) above are valid for one year from the date of
signature unless revoked by the applicant in writing.
(j) The commissioner shall determine whether
the applicant meets the eligibility requirements pursuant to paragraph (g)
above.
(k) The commissioner shall
authorize the commencement, duration, redetermination of eligibility and
reapplication according to the following:
(1)
When the commissioner determines that an applicant is eligible for financial
assistance in accordance with He-P 301.17(c), the applicant shall remain
eligible for 12 months commencing with the date of eligibility;
(2) The commissioner shall not reimburse the
applicant or any other person for any payment that was made before the
eligibility commencement;
(3) The
commissioner shall evaluate eligibility for financial assistance prior to the
expiration of the 12 month period described in (1) above; and
(4) A household or individual who has applied
for financial assistance and has been determined to be ineligible can reapply
when and if the financial or medical status changes.
(l) Notice of determination and notice of
other action shall be as follows:
(1) The
commissioner shall notify the applicant within 10 days from the date of receipt
of application that the commissioner has determined that the applicant is
eligible or ineligible for assistance; and
(2) The commissioner shall notify a recipient
in writing at least 30 days in advance of any other action which the
commissioner has decided to take which affects the recipient's eligibility
including termination of eligibility.
(m) An applicant may appeal an adverse
eligibility determination as follows:
(1) If
an applicant is dissatisfied with any determination, the applicant may request,
within 30 days of the date of the commissioner's notification letter, an
informal case review conference;
(2) The commissioner shall notify the
applicant in writing after the case review conference whether he or she
concurs, modifies or revokes the determination; and
(3) If the applicant is dissatisfied with the
result of the case review conference, he or she may request, within 30 days of
notification of the results of the case review conference, an adjudicative
proceeding held in accordance with RSA 541-A.
(n) The applicant may contact the office of
the ombudsman at any point in the process for a neutral resolution of the
applicant's complaint.
(p) The
applicant shall contact the NH CARE program manager if eligibility is denied;
and may contact the NH section director if dissatisfied with the response from
the NH CARE program manager.
(o)
The applicant shall contact the ID Care Services manager if eligibility is
denied, and may contact the NH section director if dissatisfied with the
response from the ID Care Services manager.
(p) Reimbursement shall be made directly to
the provider of the service or to the pharmacy and not directly to the
applicant.
#6634, eff 11-25-97; ss by #8242, eff 12-30-04; ss by
#9172, eff 6-6-08; ss by #12033, eff 11-3-16; amd by #12586, eff
7-24-18
