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RULE §355.3Recipient Requirements

(a) A person shall meet all of the following requirements to be eligible for Epilepsy Program 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 §37.213 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 §37.215 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 §37.216 of this title (relating to Limitations and Benefits Provided).

(c) A recipient may have all Epilepsy Program 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 §37.213 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.

Source Note: The provisions of this §355.3 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981

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