1 Tex. Admin. Code § 353.409 - Scope of Services
(a) An MCO must
provide covered services to members. The MCO is not responsible for providing
or paying for non-capitated services or members' cost sharing obligations, if
any.
(b) HHSC will establish the
scope and level of benefits, which all MCOs must agree to provide as a
condition for participation. In accordance with
42 C.F.R.
438.210, the scope of benefits must be
provided at least in an amount, duration, and scope available to Medicaid
fee-for-service clients, unless otherwise explicitly authorized by HHSC through
a waiver. The amount, duration, and scope of benefits may exceed the scope of
fee-for-service in accordance with subsection (f) of this section. These
requirements will be contained in all contracts entered into by an MCO and
HHSC.
(c) MCOs are encouraged to
provide any value-added services or benefits beyond the level and scope
required as a condition for participation in the competitive procurement
process. These services and benefits must be approved by HHSC and cannot
increase the cost borne or capitation rates paid by HHSC during any current
contract term or in any subsequent contract term. These services or benefits
cannot violate any other state or federal rule or regulation.
(d) A value-added service may be unique to an
MCO, and limited to a member who meets the MCO's qualification criteria for the
service.
(e) Before approving a
value-added service, HHSC will determine whether it is an actual health care
service, dental service, benefit, or positive incentive designed to promote a
healthy lifestyle and improve a health or dental outcome. HHSC will not approve
best practice approaches to delivering covered services as value-added
services. Examples of potential value-added services include: health or
dental-related programs; programs that encourage health-conscious behaviors;
and for children enrolled in STAR Health, non-health care services and benefits
that support the child's physical, mental, or developmental well
being.
(f) On a case-by-case basis,
an MCO may offer to individual members additional benefits that are outside the
scope of services. Case-by-case services may be based on medical necessity,
cost-effectiveness, the wishes of the member or the member's family, or the
potential for improving the member's health status. For STAR+PLUS members,
these case-by-case services may also be based on functional necessity. These
services and benefits cannot increase the cost borne or capitation rates paid
by HHSC during any current contract term or in any subsequent contract term and
cannot violate any other state or federal rule or regulation.
Notes
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