1. (a) An applicant for oral health treatment benefits must be referred to the Oral Health Program by a third-party nominator who knows the individual's economic condition.

2. (b) Each applicant for oral health treatment benefits must complete or cause to be completed an application form, which shall include the following information for the individual needing treatment:

   1. (1) personal information, including name, address, birthdate, gender, and ethnicity;
   2. (2) a statement from the referring third-party nominator that oral health treatment is necessary to prevent or reduce the probability of pain, infection, or disease of a dental nature; and

   3. (3) a statement by the applicant or the person responsible for the applicant's support that:

      1. (A) treatment benefits are requested;
      2. (B) the applicant is a bona fide resident of Texas and the family income does not exceed the financial guidelines as required in §49.6 of this title (relating to Eligibility Requirements for Referral);
      3. (C) the applicant is not eligible for another program or other benefit providing dental care; and
      4. (D) the applicant or the person responsible for the applicant's support is financially unable to pay for all or part of the cost of the necessary oral health treatment benefits.
3. (c) Each applicant who will be referred for oral health treatment benefits, as described in §49.7 of this title (relating to Eligibility Requirements to Receive FFS Oral Health Treatment Benefits), must have his/her application prior authorized in accordance with policies and procedures, as defined in the manual.
4. (d) The denial of any application must be in writing and must include the reason(s) for such denial. Unless the application is denied because Oral Health Program funds are reduced, curtailed, or unavailable, the individual applying for oral health treatment benefits has the right to an administrative review and a due process hearing in accordance with Subchapter D of this chapter (relating to Appeals Process for FFS Oral Health Treatment Benefits and Services).
5. (e) An individual has the right to reapply for FFS oral health treatment benefits at any time when there is a change of situation or condition.

Source Note:The provisions of this §49.5 adopted to be effective October 16, 2008, 33 TexReg 8522; amended to be effective July 22, 2013, 38 TexReg 4634.