(a) Eligibility for health care benefits. In order to be determined eligible for program health care benefits, applicants must meet the medical, financial, and other criteria in this section.
  (1) Medical or dental criteria. At least annually, a physician or dentist must certify that the person meets the definition of "child with special health care needs" as defined by §38.2(5) of this title (relating to Definitions). The medical or dental criteria certification must be based upon a physical examination conducted within the 12 months immediately preceding the date of certification. The physician or dentist must document the medical or dental diagnosis code and descriptor from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), or its successor, for the person's primary diagnosis that meets the medical or dental criteria certification definition and for each of the person's other medical or dental conditions for statistical and referral purposes. To facilitate application to the program for certain applicants, the program Medical Director or Assistant Medical Director may accept written documentation of medical or dental criteria certification submitted by a physician or dentist who is licensed to practice in a state or jurisdiction of the United States of America other than Texas. The program does not reimburse for written documentation of medical or dental criteria certification. If a physician or dentist requests coverage of diagnosis and evaluation services to determine if the person meets the definition of a "child with special health care needs" and the person meets all other eligibility criteria for health care benefits, then the person may be given up to 60 days of program coverage for diagnosis and evaluation services only. Only program providers as specified in §38.6 of this title (relating to Providers), may be reimbursed for services as defined in §38.2 of this title.
  (2) Financial criteria. Financial criteria are determined at least annually or as directed by statute. Financial criteria are based upon the determinations of income, family size, and disregards. All families must verify their income and disregards.
    (A) The income level for eligibility is 200% of the FPL. If the family income exceeds this level, and the applicant's family can document its responsibility for family medical bills incurred within 12 months prior to the application date or within 6 months after the financial eligibility denial date that are equal to or greater than the amount in excess of the 200% level, the applicant may be determined financially eligible for a period of 6 months, or as directed by statutory requirements, beginning on the eligibility date.
    (B) Applications to Medicaid and the SSI programs.
      (i) If actual or projected program expenditures for an ongoing client currently not eligible for Medicaid exceed $2,000 per year and the client's age and citizenship status meet Medicaid eligibility criteria, the client shall be required to apply for any applicable Medicaid programs and, if eligible, to participate in those programs in order to remain eligible for further program benefits. Within 60 days of the date of the notification letter, the client must submit to the program documentation of an eligibility determination from Medicaid. During this 60-day period, program coverage will continue. If the client does not provide documentation of an eligibility determination from Medicaid within the 60-day time limit, program coverage shall be terminated and may not be reinstated unless an eligibility determination is received. The program may grant the client a 30-day extension to obtain the determination.
      (ii) The program also may require an ongoing client for whom actual or projected expenditures exceed $2,000 per year to apply for the SSI program and, if eligible, to participate in that program in order to remain eligible for further program benefits. Within 60 days of the date of the notification letter, the client must submit to the program verification of a timely and complete application to SSI. During this 60-day period, program coverage will continue. If the client does not provide this verification within the 60-day time limit, program coverage may be terminated. With verification of an application to SSI, the program may continue coverage pending receipt of an SSI eligibility determination.
  (3) Health insurance.
    (A) All health insurance coverage insuring the applicant and family must be listed on the application. If insurance coverage was effective prior to program eligibility, such coverage must be kept in force. Noncompliance with this requirement may result in the termination of program benefits. If insurance cannot be maintained, the applicant or parent, guardian, or managing conservator must, upon request, provide to the program proof of:
      (i) cancellation from the insurer or plan sponsor;
      (ii) discontinuation of the insurance plan by the insurer or plan sponsor;
      (iii) exhaustion of the right to continue group insurance coverage as provided under federal or state law; or
      (iv) financial inability to continue paying the cost of any health insurance except CHIP.
    (B) Applicants or clients who may be eligible for coverage under Medicare, Medicaid, or CHIP by reason of citizenship, residency status, age, or medical condition must apply for coverage. Proof of eligibility determination must be received within 60 days of the date of notification by the program. With verification of an application to Medicare, Medicaid, CHIP, or an available health insurance plan, the program may extend this deadline pending receipt of an insurance eligibility determination. If the applicant or client is eligible for any health insurance or buy-in program, the applicant or client must be enrolled. Such insurance must be kept in force as though it were effective prior to program eligibility.
    (C) The program will assist in determining possible eligibility for insurance and may provide program benefits for ongoing clients during insurance application, enrollment, or limited or excluded coverage periods.
    (D) Before canceling, terminating, or discontinuing existing health insurance or electing not to enroll a client in available health insurance, including canceling, terminating, discontinuing, or not enrolling in CHIP, the parent, guardian, or managing conservator must notify the program 30 days prior to cancellation, termination, discontinuance, or end of the enrollment period. When the program provides assistance in keeping or acquiring health insurance, the parent, guardian, or managing conservator must maintain or enroll in the health insurance.
  (4) Age. The applicant, other than one with cystic fibrosis, must be under the age of 21.
  (5) Residency. The applicant must be a Texas resident.
  (6) Application.
    (A) Applications are available to anyone seeking assistance from the program. To be considered by the program, the application must be made on forms currently in use.
    (B) A person is considered to be an applicant from the time that the program receives an application. The program will respond in writing regarding eligibility status within 30 working days after the completed application is received. Applications will be considered:
      (i) denied if eligibility requirements are not met;
      (ii) incomplete if required information that includes a CHIP, Medicaid, or SSI determination or any other data and document(s) needed to process the application is not provided or if an outdated form is submitted; or
      (iii) approved if all criteria are met.
    (C) The denial of any application submitted to the program shall be in writing and shall include the reason(s) for such denial. The applicant has the right of administrative review and a fair hearing as set out in §38.13 of this title (relating to Right of Appeal).
    (D) Any person has the right to reapply for program coverage at any time or whenever the person's situation or condition changes.
  (7) Verification of information.
    (A) The program shall make the final determination on a person's eligibility using the information provided with the application. The program may request verification of any information provided by the applicant to establish eligibility.
    (B) The program shall verify selected information on the application. Documentation of date of birth, residency, income, and income disregards shall be required. The program shall notify the applicant and family in writing when specific documentation is required. It is the responsibility of the applicant and family to provide the required information.
Cont'd...
(C) Those applicants or clients financially eligible for CHIP, Medicaid, or other programs with eligibility income guidelines that meet the program's eligibility income guidelines, and who also meet the program age and residency requirements, will be considered financially eligible. The applicant, client, or family must notify the program, if the applicant or client is no longer eligible for such programs.
  (8) Determination of continuing eligibility for health care benefits. Financial criteria for eligibility for health care benefits must be re-established at least annually or as directed by statute. Medical or dental criteria must be re-established at least annually (i.e., within 365 days from the first day of the client's initial date of program eligibility or within 366 days during a leap year). Clients for health care benefits will be notified of program deadlines for re-establishment of eligibility. If an ongoing client for health care benefits does not meet program deadlines for submitting information required for the determination of continuing eligibility, the client's eligibility for health care benefits will end. If the then former client re-applies to the program after such lapse in eligibility and is determined eligible for health care benefits, the former client will be considered a new client. If the program has a waiting list for health care benefits, the new client will be placed on the waiting list in order according to the date and time the client is determined eligible for health care benefits.
(b) Eligibility for case management services. The program may provide or reimburse for case management services to persons in need of such services who are Texas residents and who are determined not to have another primary provider or funding source for such services. The program's case management services are focused on individuals (and their families) who are eligible, seeking eligibility, or potentially seeking eligibility for the program's health care benefits (this includes clients who are on the waiting list for health care benefits). However, the program may offer and provide case management services to individuals (and their families) who are not eligible or not seeking eligibility for the program's health care benefits.

Source Note: The provisions of this §351.3 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982