25 TAC §§37.211 - 37.218
STATUTORY AUTHORITY
The proposed amendments are authorized by Health and Safety Code, §40.003,
which allows the department to adopt rules necessary to administer epilepsy
services; and Government Code, §531.0055, and Health and Safety Code, §1001.075,
which authorize the Executive Commissioner of the Health and Human Services
Commission to adopt rules and policies necessary for the operation and provision
of health and human services by the department and for the administration
of Health and Safety Code, Chapter 1001.
The proposed amendments affect Health and Safety Code, Chapter 40.
§37.211.General.
(a)
Purpose. The purpose of this chapter is to establish rules
for [
the
] Epilepsy
Services
[
Program
]. The
authority for these rules is granted in the Texas Health and Safety Code,
Chapter 40.
[
(b)
Delegation of Authority. Under the Texas
Health and Safety Code, Chapter 11, §11.013, the Board of Health (board)
delegates to the Commissioner of Health (commissioner), or to the person acting
as commissioner in the commissioner's absence, the authority to administer
the Epilepsy Program, exclusive of rulemaking authority.
]
(b)
[
(c)
] Definitions. The following
words and terms when used in this chapter shall have the following meanings,
unless the context clearly indicates otherwise.
(1)
Action--A denial, termination, suspension or reduction
of Epilepsy
Services benefits
[
Program services
] or
eligibility.
(2)
Applicant--An individual whose application for Epilepsy
Services
[
Program
] benefits has been submitted to a contracted
provider and has not received a final determination of eligibility. This
definition
includes an individual whose application is submitted by
a representative or person with legal authority to act for the individual.
[
(3)
Board--The Texas Board of Health.
]
[
(4)
Commissioner--The commissioner of the
Texas Department of Health.
]
(3)
[
(5)
] Contracted Provider--Any individual
or entity with
department
[
Epilepsy Program
] approval
to furnish covered services to Epilepsy
Services
[
Program
] recipients.
(4)
[
(6)
] Department--The [
Texas
] Department of
State
Health
Services
.
(5)
[
(7)
] Epilepsy--A chronic neurological
condition characterized by abnormal electrical discharges in the brain manifested
by two or more seizures. It is characterized by sudden, brief attacks of altered
consciousness, motor activity, or sensory phenomena. Convulsive seizures are
the most common form of attacks, but any recurrent seizure pattern is considered
epilepsy.
[
(8)
Fair hearing--The informal hearing process
the department follows under §37.219 of this title (relating to Notice
and Fair Hearing).
]
[
(9)
Final decision--A decision that is reached
by a decision maker after conducting a fair hearing under this title.
]
(6)
[
(10)
] Recipient--An individual
who is eligible to receive Epilepsy
Services
[
Program
]
benefits.
[
(11)
Reconsideration--The administrative process
the Epilepsy Program follows under §37.218 of this title (relating to
Notice of Intent to Take Action and Reconsideration).
]
(7)
[
(12)
] Request for Proposal (RFP)--A
document intended to solicit proposals from interested parties
that
[
which
] details qualifications and plans for provision of a specific
service or range of services. Services may be targeted to a selected geographic
area and/or special population group, or statewide coverage.
§37.212.Recipient Requirements.
(a)
A person shall meet all of the following requirements to
be eligible for Epilepsy
Services
[
Program
] benefits:
(1)
(No change.)
(2)
if younger than 21 years of age,
be determined not
eligible
[
not be eligible
] for benefits from the Children
With Special Health Care Needs Program (CSHCN)
or be currently on the
CSHCN waiting list for services
;
(3) - (5)
(No change.)
(b)
(No change.)
(c)
A recipient may have all Epilepsy
Services
[
Program
] benefits modified, suspended, or terminated for any of the
following reasons:
(1)
(No change.)
(2)
failure to provide income data as requested by the contracted
provider to determine continued Epilepsy
Services
[
Program
] eligibility;
(3) - (5)
(No change.)
(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 plan(s) was effective prior to eligibility for [
the
] Epilepsy
Services
[
Program
], or provide a
statement on the application form outlining the reason(s) why such insurance
cannot be maintained; or
(7)
(No change.)
(d)
In order to requalify for [
the
] Epilepsy
Services benefits
[
Program
], an applicant shall reapply and
requalify for Epilepsy
Services
[
Program
] benefits when
eligibility for program benefits is terminated.
[
(e)
A recipient whose benefits are modified,
suspended or terminated may appeal the Epilepsy Program's decision under the
procedure contained in §37.218 of this title (relating to Notice of Intent
to Take Action and Reconsideration) and §37.219 of this title (relating
to Notice and Fair Hearing).
]
[
(f)
The Epilepsy Program may not terminate
program participation until a final decision is rendered under the department's
reconsideration and fair hearings process, if a reconsideration or hearing
is requested by the recipient.
]
§37.213.Residency and Residency Documentation Requirements.
(a) - (c)
(No change.)
[
(d)
All documents submitted to establish the
residency of an applicant shall be in English, or if required by the contracted
provider, accompanied by an accurate English translation.
]
[
(1)
An applicant who is currently a Texas
resident and has been currently approved to receive Texas Medicaid benefits
is not required to provide additional residency verification.
]
[
(2)
An applicant, or person establishing residency
for the applicant under subsections (b) and (c) of this section, may submit
a copy of any one of the following documents as evidence of residency. All
documents shall be in the applicant's name, or in the name of the person establishing
residency for the applicant, and provide some verification of a Texas address
or domicile:
]
[
(A)
a valid Texas driver's license, or an
identification card issued by the Texas Department of Public Safety;
]
[
(B)
a valid Texas voter's registration card,
or a copy of a validated (at the county clerk's office) application for a
voter's registration card;
]
[
(C)
a current Texas motor vehicle registration
or automobile license plate registration renewal form;
]
[
(D)
a mortgage payment receipt from any of
the three months immediately preceding the date of the application;
]
[
(E)
a rent payment receipt from any of the
three months immediately preceding the date of the application;
]
[
(F)
a notarized statement reflecting that
the applicant is currently receiving rent-free housing. The statement must
be signed by the individual providing the rent-free housing and must include
the address and phone number of the individual providing the rent-free housing;
]
[
(G)
a utility payment receipt from any of
the three months immediately preceding the date of the application;
]
[
(H)
a Texas property tax receipt for the most
recently completed tax year;
]
[
(I)
a payroll or retirement check dated within
the three months immediately preceding the date of the application;
]
[
(J)
employment/unemployment records prepared
within the three months immediately preceding the date of the application;
]
[
(K)
a statement from a financial institution
issued within the three months preceding the date of the application; or
]
[
(L)
social security supplemental income or
disability income records or social security retirement benefit records issued
within the three months immediately preceding the date of the application.
]
[
(e)
Applications submitted under subsections
(b) and (c) of this section shall also include evidence of the legal relationship
between the applicant and the resident, such as:
]
[
(1)
a marriage license or declaration of non-ceremonial
marriage to document the marriage of the applicant and spouse;
]
[
(2)
a birth certificate establishing the parent/child
relationship between the applicant and the resident;
]
[
(3)
a final order showing the appointment
of the resident as guardian for the minor;
]
[
(4)
a final order naming the applicant's managing
conservator; or
]
[
(5)
an income tax return showing name and
relationship of the applicant to the resident.
]
[
(f)
Any difference between the name of the
applicant and the name on any document must be explained by additional documentation
(Example: marriage license, divorce decree, or adoption decree).
]
§37.214.Applications and Eligibility Date.
Persons meeting the eligibility requirements set forth in §37.212(a)(1),
(2), (3) and (5) of this title (relating to Recipient Requirements) must make
an application for benefits through an approved Epilepsy
Services
[
Program
] contracted provider.
(1) - (2)
(No change.)
(3)
Eligibility date for Epilepsy
Services
[
Program
] benefits. The date on which a person's eligibility will be
determined will be the date upon which a properly completed application is
received by the contracted provider. The Epilepsy
Services
[
Program
] eligibility date will be the later of:
(A) - (D)
(No change.)
§37.215.Financial Criteria.
Financial need is established annually on the basis of income legally
available to the applicant or the person(s) who have a legal obligation to
support the applicant.
(1) - (2)
(No change.)
(3)
The income level for eligibility is established at 200%
of the Federal Poverty Level Guidelines, currently published by the
United States Department of
[
U.S.
] Health and Human Services
and adopted by the
department
[
Texas Department of Health
(department)
].
§37.216.Limitations and Benefits Provided.
(a)
Benefits provided by [
the
] Epilepsy
Services
[
Program
] are outlined in the contract with each provider
and may include:
(1) - (3)
(No change.)
(b)
All Epilepsy
Services
[
Program
] benefits
are limited to services received in Texas
from
[
at
]
a contracted provider.
(c)
Depending on the recipient's eligibility status, services
will be provided based upon:
(1)
(No change.)
(2)
any contract between the
department
[
Texas
Department of Health (department)
] and the recipient's service provider;
and
(3)
(No change.)
(d)
[
The
] Epilepsy
Services
[
Program
] is
the
payor of last resort. Benefits are payable only
after all third parties or government entities (e.g., private/group insurance
or the Veterans Administration) have met their liability.
§37.217.Participating Providers.
(a)
Selection of Service Providers. Providers are solicited
and selected by a Request for Proposal (RFP) process. An organization may
apply to become a contracted provider by responding to an RFP [
to participate
in the Epilepsy Program
] that has been published in accordance with
department
[
Texas Department of Health (department)
] policy.
[
The RFP must be accompanied by documentation which is acceptable to
the department and which is sufficient to demonstrate that the organization:
]
[
(1)
can provide the range of medical, non-medical
and support activities outlined in the RFP and deemed necessary by the department
to effectively serve eligible persons in the designated geographic area;
]
[
(2)
agrees to comply with the department's
Uniform Grant Management Standards as promulgated by the State of Texas Governor's
Office; and
]
[
(3)
agrees to cooperate with the department
in accordance with Texas Health and Safety Code, Chapter 40; Title 25 Texas
Administrative Code §§37.211 - 37.222; and the Texas Family Code, §231.006.
]
(b)
An applicant and/or a current contractor
that is aggrieved in connection with the award of a department contract to
provide epilepsy services may file a protest in accordance with department
policy.
[
(b)
Provision of Services. Epilepsy Program
services shall be furnished by providers under contract with the department.
]
(c)
The department may deny, modify, suspend,
or terminate the approval of providers for submitting false or fraudulent
claims or failing to provide and maintain quality services according to acceptable
standards. A provider's performance under its contract may subject the provider
to review, fraud referral to the appropriate authority, and/or administrative
sanctions.
[
(c)
Suspension or Termination of Service Providers.
Any contracted provider may be terminated or suspended from participation
in the Epilepsy Program for any of the following reasons:
]
[
(1)
providing false or misleading information
regarding any participation criteria;
]
[
(2)
a material breach of any contract or agreement
with the Epilepsy Program;
]
[
(3)
failure to maintain the participation
criteria contained in subsection (a) of this section.
]
[
(d)
Appeal of Termination or Suspension. A
contracted provider may appeal a termination or a suspension through the department's
reconsideration and fair hearings process, as contained in §37.218 of
this title (relating to Notice of Intent to Take Action and Reconsideration)
and §37.219 of this title (relating to Notice and Fair Hearing).
]
[
(1)
The Epilepsy Program may not terminate
program participation until a final decision is rendered under the department's
reconsideration and fair hearing process.
]
[
(2)
The Epilepsy Program shall not enter into,
extend, or renew a contract or agreement with a contracted provider until
a final decision is rendered under the department's reconsideration and fair
hearings process.
]
[
(3)
A contracted provider may not appeal a
termination of a contract which results from limitations in appropriations
or funding for covered services or benefits or which terminates under its
own terms.
]
§37.218.Notice of Intent to Take Action and Fair Hearing [ Reconsideration ].
(a)
When notice of intent to take action is required. An Epilepsy
Services
[
Program
] applicant
or
[
,
]
recipient [
, or provider
] is entitled to [
a
] notice
anytime Epilepsy Services intends
[
of intent
] to take action
under this section [
anytime the Epilepsy Program intends to take action
].
(b)
Time of notice of intent to take action.
Epilepsy
Services shall provide a written
[
A
] notice of intent to
take action
under this section
[
shall be mailed
] to
the applicant
or
[
,
] recipient [
, or provider
]
not less than 20 days prior to the
effective date of the
[
time the Epilepsy Program intends to take an
] action.
(c)
Content of notice of intent to take action. The notice
shall contain the following information:
(1)
a statement of the action [
the
] Epilepsy
Services
[
Program
] intends to take;
(2)
an explanation of the reasons for the action [
the
] Epilepsy
Services
[
Program
] intends to take;
(3)
an explanation of the applicant's
or
[
,
] recipient's [
, or provider's
] right to request a
fair hearing regarding
[
reconsideration before
] the action
[
is taken
];
[
(4)
the procedure by which the applicant,
recipient, or provider may request a reconsideration from the Epilepsy Program,
including the address where written requests shall be submitted and any phone
number the applicant, recipient, or provider may call to request assistance
or a reconsideration; and
]
[
(5)
a statement that the applicant, recipient,
or provider shall make a request for reconsideration within 20 days of the
date on the notice and that if the applicant, recipient, or provider does
not request a reconsideration, the applicant's, recipient's, or provider's
right to a reconsideration and fair hearing will be waived and the action
will become final.
]
(d)
A recipient or applicant aggrieved by the
intent to take action may appeal the decision according to the procedures
in §§1.51-1.55 of this title (relating to Fair Hearing Procedures).
If an aggrieved recipient requests a hearing, the department shall not terminate
services to the recipient until a final decision has been rendered.
[
(d)
No request. If a request for reconsideration
is not received within the time allowed, the action shall become final 20
days after the date on the notice and the right to reconsideration or a fair
hearing is waived.
]
[
(e)
Reconsideration procedure. If an applicant,
recipient, or provider contacts the Epilepsy Program requesting a reconsideration,
the Epilepsy Program will conduct a review of the request and the action shall
not become final until a decision is made as described in this subsection.
]
[
(1)
The Epilepsy Program will conduct a comprehensive
review of the request within 180 days of the Epilepsy Program's receipt of
the request. The Epilepsy Program will:
]
[
(A)
obtain any additional medical information
or documentation required or available to support the request; and
]
[
(B)
review the request along with all supporting
documentation.
]
[
(2)
If the Epilepsy Program determines that
the request is approved based on the comprehensive review, the Epilepsy Program
will notify the applicant, recipient, or provider that the request is approved.
]
[
(3)
If the Epilepsy Program determines that
the request is not approved and that an action will be taken, the Epilepsy
Program will notify the applicant, recipient, or provider of their right to
a fair hearing as described in §37.219 of this title (relating to Notice
and Fair Hearing).
]
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on June 5, 2006.
TRD-200603039
Cathy Campbell
General Counsel
Department of State Health Services
Earliest possible date of adoption: July 16, 2006
For further information, please call: (512) 458-7111 x6972
Subchapter K. EPILEPSY PROGRAM
25 TAC §§37.219 - 37.222
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Department of State Health Services or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
STATUTORY AUTHORITY
The proposed repeals are authorized by Health and Safety Code, §40.003,
which allows the department to adopt rules necessary to administer epilepsy
services; and Government Code, §531.0055, and Health and Safety Code, §1001.075,
which authorize the Executive Commissioner of the Health and Human Services
Commission to adopt rules and policies necessary for the operation and provision
of health and human services by the department and for the administration
of Health and Safety Code, Chapter 1001.
The proposed repeals affect Health and Safety Code, Chapter 40.
§37.219.Notice and Fair Hearing.
§37.220.Forms.
§37.221.Confidentiality of Information.
§37.222.Nondiscrimination Statement.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on June 5, 2006.
TRD-200603040
Cathy Campbell
General Counsel
Department of State Health Services
Earliest possible date of adoption: July 16, 2006
For further information, please call: (512) 458-7111 x6972