Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter J - MEDICAID THIRD PARTY RECOVERY
Division 2 - APPLICANT AND RECIPIENT REQUIREMENTS
Section 354.2313 - Duty of Applicant or Recipient to Inform and Cooperate

Universal Citation: 1 TX Admin Code § 354.2313

Current through Reg. 49, No. 38; September 20, 2024

(a) An applicant or recipient of Medicaid benefits has a duty and responsibility to inform HHSC or other State agency, at the time of application, during the period of eligibility, or at any time after receiving services from the Medicaid program, of the following:

(1) any pending or unsettled claim for injuries for which a claim for health care items or services has or will be submitted to the Medicaid program for payment;

(2) the name and address of any attorney the applicant or recipient hires to represent the applicant or recipient in any claim for injuries for which a claim for health care items or services has or will be submitted to the Medicaid program for payment;

(3) any court or administrative order requiring any person to make medical support payments to the recipient or the Title IV-D agency; this duty and responsibility does not apply to any woman defined in the §1905(n)(1) (poverty level pregnant women) (codified at 42 U.S.C. § 1396d(n)(1));

(4) the identity of the father of any child who is an applicant or recipient of Medicaid benefits, and to cooperate with the Title IV-D Agency in establishing paternity and medical support payments for the child;

(5) any third party resource who is or may be responsible for paying for or providing health coverage to the applicant or recipient, including the name and relationship of the insured, the name of the policyholder, the policy number, the dates coverage is in effect, the date of occurrence of any accident or injury and any other information required by HHSC or the third party resource to file a claim or identify the recipient as an insured or covered person; and

(6) any other resource that is or becomes available to provide or pay for health care items or services covered by the Medicaid program.

(b) An applicant or recipient, or an attorney or other person who represents or acts on behalf of an applicant or recipient, must notify and provide information regarding the existence or potential existence of any of the resources listed in subsection (a) of this section. The applicant must provide the information at the time of application, and the recipient must provide notice and information within 60 days of learning of or discovering the existence of the resource, or at the time of re-certification, whichever is sooner. Notice may be provided to HHSC either by telephone or by mail according to the provisions of § 354.2334 of this subchapter (relating to Notices and Payments).

(c) An applicant or recipient will have his or her application for benefits denied, and a recipient will have his or her benefits terminated if the applicant or recipient fails or refuses to assign his or her own rights and those of any other individual for whom they can legally make an assignment, or fails or refuses to cooperate with HHSC as required by subsection (a) of this section, unless cooperation is waived under the procedures specified at 45 Code of Federal Regulations, Chapter III for child support enforcement, or HHSC's procedures for waiving cooperation for any other individual.

(d) The existence of an unsettled claim for damages for personal injuries will not be used by HHSC to deny or discontinue health care items or services under the Medicaid program.

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