Current through Reg. 49, No. 52; December 27, 2024
(a) A person
shall meet all of the following requirements to be eligible for Epilepsy
Services benefits:
(1) have a diagnosis of
epilepsy certified by a licensed physician, or be suspected of having
epilepsy;
(2) if younger than 21
years of age, be determined not eligible for benefits from the Children With
Special Health Care Needs Program (CSHCN) or be currently on the CSHCN waiting
list for services;
(3) be a
resident of Texas as determined in § 355.5 of this title (relating to
Residency and Residency Documentation Requirements); and not be:
(A) incarcerated in city, county, state, or
federal jail, or prison;
(B) a ward
of the state; or
(C) a
Medicaid-eligible nursing home recipient.
(4) submit an application for benefits
through a contracted provider; and
(5) meet, or the person(s) who has a legal
obligation to support the applicant meet, the financial guidelines as outlined
in § 355.9 of this title (relating to Financial Criteria);
(b) If an applicant meets all
eligibility requirements as outlined in subsection (a) of this section except
for the financial guidelines outlined in subsection (a)(5) of this section, the
applicant is eligible only for support services as outlined in § 355.11 of
this title (relating to Limitations and Benefits Provided).
(c) A recipient may have all Epilepsy
Services benefits modified, suspended, or terminated for any of the following
reasons:
(1) failure to maintain Texas
residency or, upon demand, furnish evidence of such using the criteria in
§ 355.5 of this title (relating to Residency and Residency Documentation
Requirements);
(2) failure to
provide income verification as requested by the contracted provider to
determine continued Epilepsy Program eligibility;
(3) recipient is incarcerated in a city,
county, state, or federal jail, or prison;
(4) recipient becomes a ward of the
state;
(5) the contracted provider
determines that the recipient has made a material mis-statement or
misrepresentation on their application or any document required to support
their application;
(6) failure to
continue premium payments on individual or group insurance, prepaid medical
plan, and health insurance plans under the Social Security Act, Title XVIII, as
amended, where such plans provide benefits for the care and treatment of
persons who have epilepsy and the person's eligibility for benefits under the
plans(s) was effective prior to eligibility for the Epilepsy Program, or
provide a statement on the application form outlining the reason(s) why such
insurance cannot be maintained; or
(7) failure to receive services through a
contracted provider.
(d)
In order to requalify for Epilepsy Program benefits, an applicant shall reapply
and requalify for Epilepsy Program benefits when eligibility for program
benefits is terminated.
