SECTION 365.10. Modifications, Suspensions, Denials, and Terminations

(a) An applicant's or client's eligibility for benefits may be modified, suspended, or denied for failing to comply with the applicant and client responsibilities listed in §61.3 of this title (relating to Client Eligibility Requirements) and §61.9(c) of this title (relating to Rights and Responsibilities).

(b) A provider's participation may be modified, suspended or denied for failing to comply with the provider responsibilities listed in 1 TAC §392.605 (relating to Kidney Health Care Provider Requirements and Effective Dates) and §61.9(d) of this title.

(c) A client's eligibility may be terminated for any of the following reasons:

(1) failing to maintain Texas residency or to furnish evidence upon demand of residency using the criteria in §61.3 of this title;

(2) failing to continue to meet the income requirements for program eligibility or to provide income data as requested by the department to determine continued program eligibility;

(3) failing to reimburse the department as requested for overpayments made to the client;

(4) failing to apply for medical, drug, and transportation benefits under Title XIX, Social Security Act (Medicaid);

(5) becoming eligible for drug, transportation, and medical benefits under the Medicaid Program;

(6) regaining native kidney function;

(7) voluntarily discontinuing treatment for ESRD;

(8) becoming incarcerated by or in the custody of a city, county, state, or federal entity;

(9) becoming a ward of the state;

(10) determination by the program that the client made a material misstatement or misrepresentation on their application or any document required to support their application;

(11) determination by the program that the client submitted false claim(s); or

(12) lack of a claim for benefits paid by the program on behalf of the client for a minimum period of 12 consecutive months.

(d) Any action taken under subsections (a) or (c) of this section does not relieve the client, or the person(s) with legal obligation to support the client, of any financial obligation owed to the program.

(e) A client must reapply for benefits when eligibility for program benefits is terminated.

(f) A client who loses eligibility will not be reinstated until all outstanding debts owed to the program by the client are paid or arrangements acceptable to the program are made for payment.

(g) A client whose benefits are modified or suspended, or whose eligibility is terminated, may appeal the program's decision under §61.11 of this title (relating to Rights of Appeal).

(h) An enrolled provider's participation may be terminated or suspended for any of the following reasons:

(1) loss of approval or exclusion from participation in the Medicare program;

(2) exclusion from participation in the Medicaid program;

(3) providing false or misleading information regarding any participation criteria;

(4) material breach of any contract or agreement with the program;

(5) filing false or fraudulent information or claims for program benefits;

(6) failure to submit a payable claim to the program during a minimum period of 12 consecutive months; or

(7) failure to maintain the participation criteria contained in 1 TAC §392.605.

(i) Enrolled providers may appeal a termination or suspension under §61.11 of this title.

Source Note: The provisions of this §365.10 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421