Current through Reg. 49, No. 38; September 20, 2024
(a) Any applicant or client shall be notified
in writing of the action, the reason(s) for the action, and the right of appeal
in accordance with § 354.17 of this title (relating to Right of Appeal),
if the program proposes to modify, suspend, deny, or terminate program
eligibility or benefits for reasons, which include but are not limited to the
following:
(1) the application or other
requested information is erroneous or falsified;
(2) financial eligibility requirements are
not met;
(3) failure to establish
or maintain Texas residency;
(4)
financial or residency documentation is not provided as required or
requested;
(5) failure to provide
information when requested;
(6) the
client is or becomes incarcerated in a city, county, state, or federal jail, or
prison;
(7) the client is or
becomes a ward of the state;
(8)
failure to receive allowable products through a program provider;
(9) failure to reimburse the department, as
requested, for overpayments made to the client; or
(10) failure to continue insurance premium
payments on individual or group insurance or prepaid medical plans, where such
plans provide benefits for the care and treatment of persons who have
hemophilia and eligibility for benefits under the plan(s) was effective prior
to eligibility for the program, and failure to provide a statement on the
application form outlining the reason(s) why such insurance cannot be
maintained.
(b) Any
provider shall be notified in writing of the action, if the program modifies,
suspends, denies, or terminates a client's benefits or provider's enrollment.
The written notification shall include the reason(s) for the action. The
reasons for modifying, suspending, denying, or terminating a provider's
enrollment include, but are not limited to:
(1) failure to maintain required current
licensures or certifications in the state;
(2) failure to maintain status as a Texas
Medicaid Program provider;
(3)
failure to have a current program provider agreement on file;
(4) failure to submit a completed department
Child Support Certification form;
(5) failure to notify the program of change
of ownership;
(6) failure to comply
with all the provisions of the program provider agreement and the Provider
Manual; or
(7) the reduction or
curtailment in funds available for the program.
