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RULE §37.63Denial of Application, and Modification, Suspension, or Termination of Newborn Screening Program Benefits

(a) An individual applying for or receiving benefits described in §37.60 of this title (relating to Newborn Screening Program Benefits) may have his/her application denied or his/her benefits modified, suspended, or terminated for any of the following reasons:

  (1) the individual does not have a confirmed diagnosis of a disorder screened by the program for which benefits are available (including confirmatory testing), as referenced in §37.61(a)(1) of this title (relating to Eligibility Requirements for the Newborn Screening Program Benefits);

  (2) the individual is not a bona fide resident of the state;

  (3) the individual fails or refuses to provide the information requested by the program (e.g., regarding residency, financial status, eligibility for other benefits);

  (4) the individual submits an application form, or any document required in support of the application or continued participation in the program, which contains an intentional misstatement of fact which is material to the program's determination that the individual is eligible for program benefits; or

  (5) exhaustion of budgeted program funds, prioritized as required under §37.60 of this title.

(b) An individual applying for or receiving benefits under §37.60 of this title may not appeal or request an administrative hearing concerning adjustments made by the program regarding the type and amount of program benefits available when such adjustments are necessary to conform to budgetary limitations.

(c) An individual applying for benefits will be notified in writing if the individual's application is denied. The notification will state the reasons for denial.

(d) An individual receiving benefits will be notified by certified mail to the most recent address known to the program if the benefits are to be modified, suspended, or terminated. The program will state the reasons for the proposed action.

(e) Prior to making a final decision adverse to an affected individual, the program shall give the affected individual written notice of an opportunity for a hearing on the proposed action. The notice shall contain:

  (1) a statement of the action the department intends to take;

  (2) an explanation of the reasons for the action the department intends to take;

  (3) a reference to the statutory and regulatory authority supporting the intended action;

  (4) an explanation of the affected person's right to request a hearing; and

  (5) the procedure by which an affected person may request a hearing.

(f) The affected individual has 20 days after receiving the notice to request a hearing on the proposed action. It is a rebuttable presumption that a notice is received five days after the date of the notice. Unless the notice letter specifies an alternative method, a request for a hearing shall be made in writing, and mailed or hand-delivered to the program at the following address: Newborn Screening Unit, Mail Code 1918, Department of State Health Services, P.O. Box 149347, Austin, Texas 78714-9347. If an individual who is offered the opportunity for a hearing does not request a hearing within the prescribed time for making such a request, the individual is deemed to have waived the hearing and the action may be taken.

(g) Appeals and administrative hearings will be conducted in accordance with the department's fair hearing rules at §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

Source Note: The provisions of this §37.63 adopted to be effective November 1, 2006, 31 TexReg 8835; amended to be effective December 31, 2013, 38 TexReg 9567

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