Administration of the HIV/AIDS Medications Program

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. AUTHORITY: sections 192.006, RSMo Supp. 1998 and 192.020, RSMo 1994 .* Previously filed as 19 CSR 40-13.020. Emergency rule filed Nov. 21, 1996, effective Dec. 1, 1996, expired May 29, 1997. Original rule filed Dec. 10, 1996, effective May 30, 1997. Moved to 19 CSR 20-43.020 and amended: Filed Jan. 14, 1999, effective Aug. 30, 1999. *Original authority: 192.006, RSMo 1993, amended 1995 and 192.020, RSMo 1939, amended 1945, 1951.