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RULE §354.2313Duty of Applicant or Recipient to Inform and Cooperate

(a) An applicant or recipient of Medicaid benefits has a duty and responsibility to inform the Commission 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 medical 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 medical 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 health insurer or third party 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 the Commission or the third party health insurer or third party 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 medical 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 the Commission either by telephone or by mail to the telephone number and mailing address listed in Subchapter J Division 4 §354.2334 of this chapter for notices and Commission contact.

(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/or those of any other individual for whom they can legally make an assignment, or fails or refuses to cooperate with the Commission as required by subsection (a) of this section, unless cooperation is waived under the procedures specified at 45 Code of Federal Regulations, Part 232 for child support enforcement, or the Commission'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 the Commission to deny or discontinue medical services under the Medicaid program.

Source Note: The provisions of this §354.2313 adopted to be effective April 30, 1999, 24 TexReg 3083; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective March 28, 2004, 29 TexReg 2867

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