1 Tex. Admin. Code § 353.2 - Definitions
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.
(1) Action--
(A) An action is defined as:
(i) the denial or limited authorization of a
requested Medicaid service, including the type or level of service;
(ii) the reduction, suspension, or
termination of a previously authorized service;
(iii) the failure to provide services in a
timely manner;
(iv) the denial in
whole or in part of payment for a service; or
(v) the failure of a managed care
organization (MCO) to act within the timeframes set forth by the Texas Health
and Human Services Commission (HHSC) and state and federal law.
(B) "Action" does not include
expiration of a time-limited service.
(2) Acute care--Preventive care, primary
care, and other medical or behavioral health care provided by the provider or
under the direction of a provider for a condition having a relatively short
duration.
(3) Acute care
hospital--A hospital that provides acute care services.
(4) Adoption Assistance Program--The program
administered by DFPS in accordance with 40 TAC Chapter 700, Subchapter H
(relating to Adoption Assistance Program).
(5) Agreement or Contract--The formal,
written, and legally enforceable contract and amendments thereto between HHSC
and an MCO.
(6) Allowable
revenue--All managed care revenue received by the MCO pursuant to the contract
during the contract period, including retroactive adjustments made by HHSC.
This would include any revenue earned on Medicaid managed care funds such as
investment income, earned interest, or third party administrator earnings from
services to delegated networks.
(7)
Appeal--The formal process by which a member or his or her representative
requests a review of the MCO's action.
(8) Applicant Provider--A physician or other
health care provider applying for expedited credentialing as defined in Texas
Government Code §
533.0064.
(9) Behavioral health service--A covered
service for the treatment of mental, emotional, or substance use
disorders.
(10) Capitated
service--A benefit available to members under the Texas Medicaid program for
which an MCO is responsible for payment.
(11) Capitation rate--A fixed predetermined
fee paid by HHSC to the MCO each month, in accordance with the contract, for
each enrolled member in exchange for which the MCO arranges for or provides a
defined set of covered services to the member, regardless of the amount of
covered services used by the enrolled member.
(12) CFR--Code of Federal
Regulations.
(13) Children's
Medicaid Dental Services--The dental services provided through a dental MCO to
a client birth through age 20.
(14)
Clean claim--A claim submitted by a physician or provider for health care
services rendered to a member, with the data necessary for the MCO or
subcontracted claims processor to adjudicate and accurately report the claim. A
clean claim must meet all requirements for accurate and complete data as
further defined under the terms of the contract executed between the MCO and
HHSC.
(15) Client--Any
Medicaid-eligible recipient.
(16)
CMS--The Centers for Medicare & Medicaid Services, which is the federal
agency responsible for administering Medicare and overseeing state
administration of Medicaid.
(17)
Complainant--A member, or a treating provider or other individual designated to
act on behalf of the member, who files a complaint.
(18) Complaint--Any dissatisfaction expressed
by a complainant, orally or in writing, to the MCO about any matter related to
the MCO other than an action. Subjects for complaints may include:
(A) the quality of care of services
provided;
(B) aspects of
interpersonal relationships such as rudeness of a provider or employee;
and
(C) failure to respect the
member's rights.
(19)
Consumer Directed Services (CDS) option--A service delivery option (also known
as self-directed model with service budget) in which an individual or legally
authorized representative employs and retains service providers and directs the
delivery of certain program services.
(20) Covered services--Unless a service or
item is specifically excluded under the terms of the state plan, a federal
waiver, a managed care services contract, or an amendment to any of these, the
phrase "covered services" means all health care, long term services and
supports, or dental services or items that the MCO must arrange to provide and
pay for on a member's behalf under the terms of the contract executed between
the MCO and HHSC, including:
(A) all services
or items comprising "medical assistance" as defined in §
32.003 of the
Human Resources Code; and
(B) all
value-added services under such contract.
(21) Credentialing--The process through which
an MCO collects, assesses, and validates qualifications and other relevant
information pertaining to a Medicaid enrolled health care provider to determine
whether the provider may be contracted to deliver covered services as part of
the network of the managed care organization.
(22) Cultural competency--The ability of
individuals and systems to provide services effectively to people of various
disabilities, cultures, races, ethnic backgrounds, and religions in a manner
that recognizes, values, affirms, and respects the worth of the individuals and
protects and preserves their dignity.
(23) Day--A calendar day, unless specified
otherwise.
(24) Default
enrollment--The process established by HHSC to assign a Medicaid managed care
enrollee to an MCO when the enrollee has not selected an MCO.
(25) Dental contractor--A dental MCO that is
under contract with HHSC for the delivery of dental services.
(26) Dental home--A provider who has
contracted with a dental MCO to serve as a dental home to a member and who is
responsible for providing routine preventive, diagnostic, urgent, therapeutic,
initial, and primary care to patients, maintaining the continuity of patient
care, and initiating referral for care. Provider types that can serve as dental
homes are federally qualified health centers and individuals who are general
dentists or pediatric dentists.
(27) Dental managed care organization (dental
MCO)--A dental indemnity insurance provider or dental health maintenance
organization licensed or approved by the Texas Department of
Insurance.
(28) Dental service--The
routine preventive, diagnostic, urgent, therapeutic, initial, and primary care
provided to a member and included within the scope of HHSC's agreement with a
dental contractor. For purposes of this chapter, "dental service" does not
include dental devices for craniofacial anomalies; treatment rendered in a
hospital, urgent care center, or ambulatory surgical center setting for
craniofacial anomalies; or emergency services provided in a hospital, urgent
care center, or ambulatory surgical center setting involving dental trauma.
These types of services are treated as health care services in this
chapter.
(29) DFPS--The Texas
Department of Family and Protective Services.
(30) Disability--A physical or mental
impairment that substantially limits one or more of an individual's major life
activities, such as caring for oneself, performing manual tasks, walking,
seeing, hearing, speaking, breathing, learning, socializing, or
working.
(31) Disproportionate
Share Hospital (DSH)--A hospital that serves a higher than average number of
Medicaid and other low-income patients and receives additional reimbursement
from the State.
(32) Dual
eligible--A Medicaid recipient who is also eligible for Medicare.
(33) Elective enrollment--Selection of a
primary care provider (PCP) and MCO by a client during the enrollment period
established by HHSC.
(34) Emergency
behavioral health condition--Any condition, without regard to the nature or
cause of the condition, that in the opinion of a prudent layperson possessing
an average knowledge of health and medicine:
(A) requires immediate intervention and/or
medical attention without which the client would present an immediate danger to
themselves or others; or
(B)
renders the client incapable of controlling, knowing, or understanding the
consequences of his or her actions.
(35) Emergency medical condition--A medical
condition manifesting itself by acute symptoms of recent onset and sufficient
severity (including severe pain), such that a prudent layperson, who possesses
an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical care to result in:
(A) placing the patient's health in serious
jeopardy;
(B) serious impairment to
bodily functions;
(C) serious
dysfunction of any bodily organ or part;
(D) serious disfigurement; or
(E) serious jeopardy to the health of a
pregnant woman or her unborn child.
(36) Emergency service--A covered inpatient
and outpatient service, furnished by a network provider or out-of-network
provider that is qualified to furnish such service, that is needed to evaluate
or stabilize an emergency medical condition and/or an emergency behavioral
health condition. For health care MCOs, the term "emergency service" includes
post-stabilization care services.
(37) Encounter--A covered service or group of
covered services delivered by a provider to a member during a visit between the
member and provider. This also includes value-added services.
(38) Enrollment--The process by which an
individual determined to be eligible for Medicaid is enrolled in a Medicaid MCO
serving the service area in which the individual resides.
(39) EPSDT--The federally mandated Early and
Periodic Screening, Diagnosis, and Treatment program defined in 25 TAC Chapter
33 (relating to Early and Periodic Screening, Diagnosis, and Treatment). The
State of Texas has adopted the name Texas Health Steps (THSteps) for its EPSDT
program.
(40) EPSDT-CCP--The Early
and Periodic Screening, Diagnosis, and Treatment-Comprehensive Care Program
described in Chapter 363 of this title (relating to Texas Health Steps
Comprehensive Care Program).
(41)
Exclusive provider benefit plan (EPBP)--An MCO that complies with 28 TAC
§§
3.9201-
3.9212, relating to the Texas
Department of Insurance's requirements for EPBPs, and contracts with HHSC to
provide Medicaid coverage.
(42)
Expedited Credentialing--The process under Texas Government Code §
533.0064 in which an
MCO allows an applicant provider to provide Medicaid services to members on a
provisional basis pending completion of the credentialing process.
(43) Experience rebate--The portion of the
MCO's net income before taxes that is returned to the State in accordance with
the MCO's contract with HHSC.
(44)
Fair hearing--The process adopted and implemented by HHSC in Chapter 357,
Subchapter A of this title (relating to Uniform Fair Hearing Rules) in
compliance with federal regulations and state rules relating to Medicaid fair
hearings.
(45) Federal Poverty
Level (FPL)--The household income guidelines issued annually and published in
the Federal Register by the United States Department of Health
and Human Services under the authority of
42 U.S.C. §
9902(2) and as in effect for
the applicable budget period determined in accordance with
42 C.F.R. §
435.603(h). HHSC uses the
FPL to determine an individual's eligibility for Medicaid.
(46) Federal waiver--Any waiver permitted
under federal law and approved by CMS that allows states to implement Medicaid
managed care.
(47) Federally
Qualified Health Center (FQHC)--An entity that is certified by CMS to meet the
requirements of 42 U.S.C.
§
1395x(aa)(3) as a
Federally Qualified Health Center and is enrolled as a provider in the Texas
Medicaid program.
(48) Former
Foster Care Children (FFCC) program--The Medicaid program for young adults who
aged out of the conservatorship of DFPS, administered in accordance with
Chapter 366, Subchapter J of this title (relating to Former Foster Care
Children's Program).
(49)
Functional necessity--A member's need for services and supports with activities
of daily living or instrumental activities of daily living to be healthy and
safe in the most integrated setting possible. This determination is based on
the results of a functional assessment.
(50) Habilitation--Acquisition, maintenance,
and enhancement of skills necessary for the individual to accomplish ADLs,
IADLs, and health-related tasks based on the individual's person-centered
service plan.
(51) Health and Human
Services Commission (HHSC)--The single state agency charged with administration
and oversight of the Texas Medicaid program or its designee.
(52) Health care managed care organization
(health care MCO)--An entity that is licensed or approved by the Texas
Department of Insurance to operate as a health maintenance organization or to
issue an EPBP.
(53) Health care
provider group--A legal entity, such as a partnership, corporation, limited
liability company, or professional association, enrolled in Medicaid, under
which certified or licensed individual health care providers provide health
care items or services.
(54) Health
care services--The acute care, behavioral health care, and health-related
services that an enrolled population might reasonably require in order to be
maintained in good health, including, at a minimum, emergency services and
inpatient and outpatient services.
(55) Health maintenance organization
(HMO)--An organization that holds a certificate of authority from the Texas
Department of Insurance to operate as an HMO under Chapter 843 of the Texas
Insurance Code, or a certified Approved Non-Profit Health Corporation formed in
compliance with Chapter 844 of the Texas Insurance Code.
(56) Hospital--A licensed public or private
institution as defined in the Texas Health and Safety Code at Chapter 241,
relating to hospitals, or Chapter 261, relating to municipal
hospitals.
(57) Intermediate care
facility for individuals with an intellectual disability or related condition
(ICF-IID)--A facility providing care and services to individuals with
intellectual disabilities or related conditions as defined in §1905(d) of
the Social Security Act (42
U.S.C. 1396(d)).
(58) Legally authorized representative
(LAR)--A person authorized by law to act on behalf of an individual with regard
to a matter described in this chapter, and may, depending on the circumstances,
include a parent, guardian, or managing conservator of a minor, or the guardian
of an adult, or a representative designated pursuant to
42 C.F.R.
435.923.
(59) Long term service and support (LTSS)--A
service provided to a qualified member in his or her home or other
community-based setting necessary to allow the member to remain in the most
integrated setting possible. LTSS includes services provided under the Texas
State Plan as well as services available to persons who qualify for STAR+PLUS
Home and Community-Based Program services or Medicaid 1915(c) waiver services.
LTSS available through an MCO in STAR+PLUS, STAR Health, and STAR Kids varies
by program model.
(60) Main
dentist--See definition of "dental home" in this section.
(61) Managed care--A health care delivery
system or dental services delivery system in which the overall care of a
patient is coordinated by or through a single provider or
organization.
(62) Managed care
organization (MCO)--A dental MCO or a health care MCO.
(63) Marketing--Any communication from an MCO
to a client who is not enrolled with the MCO that can reasonably be interpreted
as intended to influence the client's decision to enroll, not to enroll, or to
disenroll from a particular MCO.
(64) Marketing materials--Materials that are
produced in any medium by or on behalf of the MCO that can reasonably be
interpreted as intending to market to potential members. Materials relating to
the prevention, diagnosis, or treatment of a medical or dental condition are
not marketing materials.
(65)
MDCP--Medically Dependent Children Program. A §1915(c) waiver program that
provides community-based services to assist Medicaid beneficiaries under age 21
to live in the community and avoid institutionalization.
(66) Medicaid--The medical assistance program
authorized and funded pursuant to Title XIX of the Social Security Act
(42 U.S.C. §
1396 et seq) and administered by
HHSC.
(67) Medicaid for
transitioning foster care youth (MTFCY) program--The Medicaid program for young
adults who aged out of the conservatorship of DFPS, administered in accordance
with Chapter 366, Subchapter F of this title (relating to Medicaid for
Transitioning Foster Care Youth).
(68) Medical Assistance Only (MAO)--A person
who qualifies financially and functionally for Medicaid assistance but does not
receive Supplemental Security Income (SSI) benefits, as defined in Chapters
358, 360, and 361, of this title (relating to Medicaid Eligibility for the
Elderly and People with Disabilities, Medicaid Buy-In Program, and Medicaid
Buy-In for Children Program).
(69)
Medical home--A PCP or specialty care provider who has accepted the
responsibility for providing accessible, continuous, comprehensive, and
coordinated care to members participating in an MCO contracted with
HHSC.
(70) Medically necessary--
(A) For Medicaid members birth through age
20, the following Texas Health Steps services:
(i) screening, vision, dental, and hearing
services; and
(ii) other health
care services or dental services that are necessary to correct or ameliorate a
defect or physical or mental illness or condition. A determination of whether a
service is necessary to correct or ameliorate a defect or physical or mental
illness or condition:
(I) must comply with the
requirements of a final court order that applies to the Texas Medicaid program
or the Texas Medicaid managed care program as a whole; and
(II) may include consideration of other
relevant factors, such as the criteria described in subparagraphs (B)(ii) -
(vii) and (C)(ii) - (vii) of this paragraph.
(B) For Medicaid members over age 20,
non-behavioral health services that are:
(i)
reasonable and necessary to prevent illnesses or medical conditions, or provide
early screening, interventions, or treatments for conditions that cause
suffering or pain, cause physical deformity or limitations in function,
threaten to cause or worsen a disability, cause illness or infirmity of a
member, or endanger life;
(ii)
provided at appropriate facilities and at the appropriate levels of care for
the treatment of a member's health conditions;
(iii) consistent with health care practice
guidelines and standards that are endorsed by professionally recognized health
care organizations or governmental agencies;
(iv) consistent with the member's medical
need;
(v) no more intrusive or
restrictive than necessary to provide a proper balance of safety,
effectiveness, and efficiency;
(vi)
not experimental or investigative; and
(vii) not primarily for the convenience of
the member or provider.
(C) For Medicaid members over age 20,
behavioral health services that:
(i) are
reasonable and necessary for the diagnosis or treatment of a mental health or
substance use disorder, or to improve, maintain, or prevent deterioration of
functioning resulting from such a disorder;
(ii) are in accordance with professionally
accepted clinical guidelines and standards of practice in behavioral health
care;
(iii) are furnished in the
most appropriate and least restrictive setting in which services can be safely
provided;
(iv) are the most
appropriate level or supply of service that can safely be provided;
(v) could not be omitted without adversely
affecting the member's mental and/or physical health or the quality of care
rendered;
(vi) are not experimental
or investigative; and
(vii) are not
primarily for the convenience of the member or provider.
(71) Member--A person who is
eligible for benefits under Title XIX of the Social Security Act and Medicaid,
is in a Medicaid eligibility category included in the Medicaid managed care
program, and is enrolled in a Medicaid MCO.
(72) Member education program--A planned
program of education:
(A) concerning access to
health care services or dental services through the MCO and about specific
health or dental topics;
(B) that
is approved by HHSC; and
(C) that
is provided to members through a variety of mechanisms that must include, at a
minimum, written materials and face-to-face or audiovisual
communications.
(73)
Member materials--All written materials produced or authorized by the MCO and
distributed to members or potential members containing information concerning
the managed care program. Member materials include member ID cards, member
handbooks, provider directories, and marketing materials.
(74) Non-capitated service--A benefit
available to members under the Texas Medicaid program for which an MCO is not
responsible for payment.
(75)
Nursing facility--As defined in §
358.103 of this title (relating to
Definitions) and 26 TAC §
554.101(relating to Definitions),
an entity or institution, also called nursing home or skilled nursing facility,
that provides organized and structured nursing care and services and is subject
to licensure under Texas Health and Safety Code Chapter 242.
(76) Nursing facility add-on services--The
types of services that are provided in a nursing facility setting by a nursing
facility provider or another provider, but are not included in the nursing
facility unit rate, including emergency dental services, physician-ordered
rehabilitative services, customized power wheel chairs, augmentative
communication devices, tracheostomy care for youth under age 22, and ventilator
care.
(77) Nursing facility
services--The services included in the nursing facility unit rate, nursing
facility Medicare coinsurance, and nursing facility add-on services.
(78) Nursing facility unit rate--The rate for
the type of services included in the Medicaid fee-for-service (FFS) daily rate
for nursing facility providers as defined in 26 TAC §
554.2601(relating to Vendor
Payment (Items and Services Included)), including room and board, medical
supplies and equipment, personal needs items, social services, and
over-the-counter drugs. The nursing facility unit rate also includes applicable
nursing facility staff rate enhancements as described in §
355.308 of this title (relating to
Direct Care Staff Rate Component), and professional and general liability
insurance add-on payments as described in §
355.312 of this title (relating to
Reimbursement Setting Methodology--Liability Insurance Costs). The nursing
facility unit rate excludes nursing facility add-on services.
(79) Outside regular business hours--As
applied to FQHCs and rural health clinics (RHCs), means before 8 a.m. and after
5 p.m. Monday through Friday, weekends, and federal holidays.
(80) Participating MCO--An MCO that has a
contract with HHSC to provide services to members.
(81) Permanency Care Assistance Program--The
program administered by DFPS in accordance with 40 TAC Chapter 700, Subchapter
J, Division 2 (relating to Permanency Care Assistance Program).
(82) Person-centered care--An approach to
care that focuses on members as individuals and supports caregivers working
most closely with them. It involves a continual process of listening, testing
new approaches, and changing routines and organizational approaches in an
effort to individualize and de-institutionalize the care environment.
(83) Person-centered planning--A documented
service planning process that includes people chosen by the individual, is
directed by the individual to the maximum extent possible, enables the
individual to make choices and decisions, is timely and occurs at times and
locations convenient to the individual, reflects cultural considerations of the
individual, includes strategies for solving conflict or disagreement within the
process, offers choices to the individual regarding the services and supports
they receive and from whom, includes a method for the individual to require
updates to the plan, and records alternative settings that were considered by
the individual.
(84)
Post-stabilization care service--A covered service, related to an emergency
medical condition, that is provided after a Medicaid member is stabilized in
order to maintain the stabilized condition, or, under the circumstances
described in 42 C.F.R.
§
438.114(b) and (e)
and 42 C.F.R. §
422.113(c)(iii) to improve
or resolve the Medicaid member's condition.
(85) Primary care provider (PCP)--A physician
or other provider who has agreed with the health care MCO to provide a medical
home to members and who is responsible for providing initial and primary care
to patients, maintaining the continuity of patient care, and initiating
referral for care.
(86) Provider--A
credentialed and licensed individual, facility, agency, institution,
organization, or other entity, and its employees and subcontractors, that has a
contract with the MCO for the delivery of covered services to the MCO's
members.
(87) Provider education
program--Program of education about the Medicaid managed care program and about
specific health or dental care issues presented by the MCO to its providers
through written materials and training events.
(88) Provider network or Network--All
providers that have contracted with the MCO for the applicable managed care
program.
(89) Quality
improvement--A system to continuously examine, monitor, and revise processes
and systems that support and improve administrative and clinical
functions.
(90) Rural Health Clinic
(RHC)--An entity that meets all of the requirements for designation as a rural
health clinic under §1861(aa)(1) of the Social Security Act (42 U.S.C. §
1395x(aa)(1)) and is
approved for participation in the Texas Medicaid program.
(91) Service area--The counties included in
any HHSC-defined service area as applicable to each MCO.
(92) Significant traditional provider
(STP)--A provider identified by HHSC as having provided a significant level of
care to the target population, including a DSH.
(93) STAR--The State of Texas Access Reform
(STAR) managed care program that operates under a federal waiver and primarily
provides, arranges for, and coordinates preventive, primary, acute care, and
pharmacy services for low-income families, children, and pregnant
women.
(94) STAR Health--The
managed care program that operates under the Medicaid state plan and primarily
serves:
(A) children and youth in DFPS
conservatorship;
(B) young adults
who voluntarily agree to continue in a foster care placement (if the state as
conservator elects to place the child in managed care); and
(C) young adults who are eligible for
Medicaid as a result of their former foster care status through the month of
their 21st birthday.
(95)
STAR Kids--The program that operates under a federal waiver and primarily
provides, arranges, and coordinates preventative, primary, acute care, and
long-term services and supports to persons with disabilities under the age of
21 who qualify for Medicaid.
(96)
STAR+PLUS--The managed care program that operates under a federal waiver and
primarily provides, arranges, and coordinates preventive, primary, acute care,
and long-term services and supports to persons with disabilities and elderly
persons age 65 and over who qualify for Medicaid by virtue of their SSI or MAO
status.
(97) STAR+PLUS Home and
Community-Based Services Program--The program that provides person-centered
care services that are delivered in the home or in a community setting, as
authorized through a federal waiver under §1115 of the Social Security
Act, to qualified Medicaid-eligible clients who are age 21 or older, as
cost-effective alternatives to institutional care in nursing
facilities.
(98) State plan--The
agreement between the CMS and HHSC regarding the operation of the Texas
Medicaid program, in accordance with the requirements of Title XIX of the
Social Security Act.
(99)
Supplemental Security Income (SSI)--The federal cash assistance program of
direct financial payments to people who are 65 years of age or older, are
blind, or have a disability administered by the Social Security Administration
(SSA) under Title XVI of the Social Security Act. All persons who are certified
as eligible for SSI in Texas are eligible for Medicaid. Local SSA claims
representatives make SSI eligibility determinations. The transactions are
forwarded to the SSA in Baltimore, which then notifies the states through the
State Data Exchange (SDX).
(100)
Texas Health Steps (THSteps)--The name adopted by the State of Texas for the
federally mandated Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) services, described at
42 U.S.C. §
1396d(r) and
42 CFR §
440.40 and §§
441.40 -
441.62.
(101) Value-added service--A service provided
by an MCO that is not "medical assistance," as defined by §
32.003 of the
Texas Human Resources Code.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.