Texas Register, Volume 10, Number 44, Pages 1807-1878, June 7, 1985 Page: 1,850
1807-1878 p. ; 28 cm.View a full description of this periodical.
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(F) the person notifies the pro-
gram in writing that they no longer want to
claim program benefits. Such a statement
does not free the recipient, or persons with
legal obligation to support the recipient, of
any reimbursement obligation owing the
program at the time of withdrawal;
(G) the person dies.
(2) Benefits may be denied, modi-
fied, suspended, or terminated if:
(A) the person submits an appli-
cation form or any document required in
support of the application which contains
a misstatement of fact which is material to
the department's determination that the
person is eligible for program benefits;
(B) the recipient submits false
claims to the program;
(C) the program has not paid a
claim for benefits on behalf of the recipient
during any one-year period;
(D) program funds are curtailed;
(E) funds allocated for pay-
ments on behalf of a recipient are
exhausted.
(3) Procedures for the denial of ap-
plications or modification, suspension, or
termination of benefits: Any applicant for
or recipient of benefits from the program
will be notified if their application may be
denied or their benefits may be modified,
suspended, or terminated. Notification will
be by certified mail to the most recent ad-
dress known to the program.
(A) These procedures do not
apply to adjustments made by the program
in the type of program benefits or the
amount of benefits available when such ad-
justments are necessary to conform to
budgetary limitations as provided in 61.3
of this title (relating to Payment of Program
Benefits).
(B) Within 30 days after receiv-
ing the notice mentioned in this paragraph,
the applicant/recipient notified or that per-
son's authorized representative must re-
spond to the program's notice with a writ-
ten response to the program. The response
must be by certified mail to the following
address: Kidney Health Care Program,
Texas Department of Health, 1100 West
49th Street, Austin, Texas 78756. Failure to
respond will be deemed a waiver of the op-
portunity to respond to the program and a
waiver of the opportunity for a hearing and
the proposed action will become final.
(C) Upon receipt of the appli-
cant's/recipient's response, the program
will affirm or reverse its proposed action in
writing to the applicant/recipient (by cer-
tified mail), giving the reason(s) for the de-
cision.
(D) Any applicant/recipient ag-
grieved by the program's decision is entitl-
ed to appeal the decision to the Texas
Department of Health. The appeal process
will be in accordance with department hear-
ing procedures. To initiate the appeal pro-
cess, the applicant/recipient must notify the
department, in writing, that he or she re-quests a hearing on the decision. The re-
quest must be by certified mail and must be
received by the department within 10 work-
ing days from the receipt of the program's
decision letter. Failure to provide written
notice will be deemed a waiver of the op-
portunity for a hearing and the proposed
action will become final.
61.8. Kidney Health Care Approved
Outpatient Dialysis Facilities and Out-of-
State Facilities.
(a) An approved outpatient dialysis
facility is one that:
(1) has met all Medicare certifica-
tion requirements;
(2) has been assigned a Medicare
ESRD provider number;
(3) has entered into a contract with
the department to participate in the Texas
Kidney Health Care Program and agrees to
cooperate with the program in accordance
with Texas Civil Statutes, Article 4477-20,
and the program rules adopted by the Texas
Board of Health; and
(4) has submitted facility operation
cost reports for the most recent fiscal year
of operation, in a manner prescribed by the
department, no later than 90 days after the
clce of the facility's fiscal year, and an
audited (by an independent certified public
accountant) cost report within 180 days of
fiscal year end;
(5) has authorized the department
to conduct audits of its records, at reason-
able time intervals, to determine the cost of
providing services.
(b) The program approval date may
not be earlier than the approval date
granted by the Health Care Financing Ad-
ministration for Medicare ESRD approval.
(c) Facilities under interim approval
for Medicare participation also will be
classified as interim approval by the pro-
gram. Recipient claims will be held by the
program until the facility is approved by
HCFA; however, applications for program
benefits will be processed for approval.
(d) The department may contract on-
ly with facilities located within the State of
Texas. An exception to this requirement
may be a situation where it is clearly a hard-
ship or great risk for a program recipient
to travel to an adequate medical facility in
Texas when an out-of-state medical facili-
ty within 50 miles of the Texas border is
closer. The out-of-state facility must meet
all the requirements of this section for ap-
proved facilities within the State of Texas.
A contract entered into with an out-of-state
facility will be renewed provided all the re-
quirements of this section are met and the
department has determined that the hard-
ship or great risk situation continues to
exist.
61.9. Denial, Modification, Suspension,
or Termination of Facility Approval; Ven-
dor Hold.
(a) The following are reasons for the
denial, modification, suspension, or ter-mination of program facility approval. A
program-approved outpatient dialysis facili-
ty or out-of-state facility will have its
privilege to participate in the program
denied, modified, suspended, or terminated
if:
(1) the facility loses Medicare ap-
proval;
(2) the facility fails or refuses to
enter into a contract with the department
to participate in the program;
(3) the facility with interim ap-
proval from the program fails to get
Medicare/HCFA approval;
(4) the contract between the facility
and the department is terminated for any
reason, including:
(A) facility fails to comply with
terms of applicable contracts and fails to
cure such failure within 30 days after receipt
of written notice from the department;
(B) federal or state law, or other
requirements, are amended or judicially in-
terpreted so as to render fulfillment of the
contract, on the part of either party, sub-
stantially unreasonable or impossible;
(C) the contracting parties are
unable to agree upon any amendment which
would therefore be needed to enable
substantial continuation of the provision of
recipient services contemplated in the
contract;
(D) facility voluntarily with-
draws from participation in the program by
providing the department with 60 days writ-
ten notice;
(E) by mutual consent of the de-
partment and the facility;
(5) the facility fails or refuses to
submit, in a manner prescribed by the
department, information which is:
(A) requested by the department
for the purpose of determining the facili-
ty's compliance with the provisions of the
Texas Kidney Health Care Act or these pro-
gram rules;
(B) requested by the department
for the purpose of monitoring the facility's
performance under the contract between the
facility and the department;
(C) required to be provided by
the facility to the department under the
terms of the contract between the facility
and the department, as follows:
(i) cost reports: A copy of the
applicable Medicare cost report (HCFA
Form 265 or HCFA Form 2552, Supple-
mental Worksheet I, or their successors) for
the fiscal year ending during the period
covered by the contract. These copies are
due within 90 calendar days after the close
of the facility fiscal year. Audited (by an
independent certified public accountant)
cost reports shall be submitted to the
department within 180 days after the close
of the facility's fiscal year.
(ii) if the facility is a hospital,
to provide the required RCC statement as
outlined in 61.3(d)(3) of this title (relating
to Payment of Program Benefits);10 TexReg 1850 June 7, 1985 Texas Register 4
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Texas. Secretary of State. Texas Register, Volume 10, Number 44, Pages 1807-1878, June 7, 1985, periodical, June 7, 1985; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth243695/m1/46/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.