PURPOSE: This rule specifies payment standards, confidentiality provisions, termination of clients from the program, antidiscrimination policy, distribution of funding, and delivery of services.

1. (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.

   1. (A) The department shall be billed only after all third party sources have been eliminated as payors.
   2. (B) The department will only reimburse providers for medications that are listed on the department’s current human immunodeficiency/Acquired Immune Deficiency Syndrome (HIV/AIDS) formulary as maintained by the custodian in the bureau.
   3. (C) If a client becomes ineligible for services and the provider should reasonably have been aware that the client was ineligible, reimbursement will not be made. 19 CSR 40-13

2. (2) Confidentiality of a client’s HIV or AIDS infection status, the results of HIV testing, and all information in the client’s record shall be maintained as specified in section 191.656, RSMo (1994).

   1. (A) The department or its agents may review client records and program invoices to ensure compliance with the program.

3. (3) A client who knowingly provides false information or fails to meet applicable statutes and regulations may be terminated from the program.

   1. (A) Clients shall be notified in writing prior to termination and may appeal the termination within thirty (30) days of the effective date. Appeals must be in writing and submitted to the director.
   2. (B) Clients may be readmitted to the program if they previously refused services; if they move back within Missouri; or if they have been terminated for noncompliance and have signed an agreement to ensure that they will comply with the statutes and rules governing the program. Clients are responsible for making the contact for readmission and must again satisfy all eligibility criteria specified in 19 CSR 40-13.030.
4. (4) No person shall be discriminated against for services as defined by section 191.665, RSMo (1994), and Chapter 213, RSMo (1994). This includes discrimination based on race, color, religion, national origin, sex, disability, veteran status, or age.
5. (5) Available medications funds, with the exception of the specialty programs, will be distributed regionally on a formula based on morbidity. Total allocations each year will depend on funding received by the department, and total regional allocations will also depend on the funding for each year.
6. (6) The allocations for specialty programs will be distributed regionally pursuant to a formula containing a base allocation plus a morbidity factor. The base allocation is defined as fifteen percent (15%) of the funds allocated to the specialty program divided equally among the regions. Allocations each year will depend on applicable funding received by the department.
7. (7) For each separate region, the department may extend available specialty program coverage to qualifying clients on a random basis as determined by computer, if demand in that region for specialty medications coverage exceeds available specialty medications funding. Qualifying clients for this random selection method must meet the eligibility criteria specified in 19 CSR 40-13.030 and must establish that they reside within the region for which they have applied to participate in the random selection method. Individuals who met the automatic eligibility requirements as specified in 19 CSR 40-13.030(4) will not be required to participate in the random selection method.
8. (8) The department may reallocate any medications program funding if the utilization of medications is different than anticipated after ninety (90) days or more of operating the program.

AUTHORITY: sections 191.650–191.698, 192.006, 192.020, 192.025, and Chapter 213, RSMo (1994) and (Cum. Supp. 1996).* Emergency rule filed Nov. 21, 1996, effective Dec. 1, 1996, expired May 29, 1997. Original rule filed Dec. 10, 1996, effective May 30, 1997. *Original authority: 1911.650–161.698 see Missouri Revised Statutes 1994 and Cum. Supp. 1996; 192.006, RSMo (1993), amended 1995; 192.020, RSMo (1939), amended 1945, 1951; 192.025, RSMo (1951); and Chapter 213, see Missouri Revised Statutes 1984 and Cum. Supp. 1996.