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RULE §354.15Modifications, Suspensions, Denials and Terminations

(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 §37.119 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.

Source Note: The provisions of this §354.15 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981

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