1 Tex. Admin. Code § 354.4003 - Definitions
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
(1) CDS employer--Consumer
directed services employer. A member or the member's legally authorized
representative who participates in the CDS option and whose financial
management services agency (FMSA) uses an electronic visit verification (EVV)
vendor system or an EVV proprietary system. A CDS employer is responsible for
hiring and retaining a service provider who delivers a service described in
§
354.4005 of this subchapter
(relating to Personal Care Services that Require the Use of EVV) or §
354.4006 of this subchapter
(relating to Home Health Care Services that Require the Use of EVV).
(2) CDS option--Consumer directed services
option. A service delivery option in which a CDS employer employs and retains a
service provider and directs the delivery of a service described in §
354.4005 or §
354.4006 of this
subchapter.
(3) CFC--Community
First Choice. A Medicaid state plan option governed by Code of Federal
Regulations, Title 42, Part 441, Subpart K, Home and Community-Based Attendant
Services and Supports State Plan Option (Community First Choice). CFC services
include the following.
(A) CFC HAB--CFC
habilitation. A Medicaid state plan service that provides habilitation through
CFC as described in §
354.1361 of this chapter (relating
to Definitions).
(B) CFC PAS--CFC
personal assistance services. A Medicaid state plan service that provides
personal assistance services through CFC as described in §
354.1361 of this chapter.
(C) CFC PAS/HAB--CFC personal assistance
services/habilitation. A Medicaid state plan service provided through CFC that
provides both personal assistance services and
habilitation.
(4) CLASS
Program--Community Living Assistance and Support Services Program. A Medicaid
waiver program approved by the Centers for Medicare & Medicaid Services
under Title XIX, Section 1915(c) of the Social Security Act, as described in 26
TAC Chapter 259 (relating to Community Living Assistance and Support Services
(CLASS) Program and Community First Choice (CFC) Services).
(5) CMS--Centers for Medicare & Medicaid
Services. The federal agency within the United States Department of Health and
Human Services that administers the Medicare and Medicaid programs.
(6) Community Attendant Services Program--A
Medicaid state plan program operating under Title XIX of the Social Security
Act, as described in 40 TAC Chapter 47 (relating to Primary Home Care,
Community Attendant Services, and Family Care Programs).
(7) DBMD Program--Deaf Blind with Multiple
Disabilities. The Medicaid waiver program approved by CMS under Title XIX,
Section 1915(c) of the Social Security Act, as described in 26 TAC Chapter 260
(relating to Deaf Blind with Multiple Disabilities (DBMD) Program and Community
First Choice (CFC) Services).
(8)
EVV--Electronic visit verification. The documentation and verification of
service delivery through an EVV system.
(9) EVV aggregator--A centralized database
that collects, validates, and stores statewide EVV visit data transmitted by an
EVV system.
(10) EVV claim--A
request for payment of a service described in §
354.4005 or §
354.4006 of this subchapter
submitted to HHSC, HHSC's designated contractor, or a managed care organization
(MCO) in accordance with the EVV Policy Handbook.
(11) EVV Policy Handbook--A handbook
promulgated by HHSC that contains policies and requirements related to
EVV.
(12) EVV portal--An online
system established by HHSC that allows users to perform searches, view reports
and view EVV claim match results associated with data in the EVV
aggregator.
(13) EVV portal user--A
person who is employed by or contracts with a program provider or FMSA and has
access to the EVV portal.
(14) EVV
proprietary system--An HHSC EVV system purchased or developed by a program
provider or FMSA approved by HHSC in accordance with §
354.4013 of this subchapter
(relating to HHSC and MCO Compliance Reviews and Enforcement Actions) that a
program provider or FMSA uses instead of an EVV vendor system.
(15) EVV system--An EVV vendor system or an
EVV proprietary system used to electronically document and verify the data
elements described in §
354.4009(a) of
this subchapter (relating to EVV Visit Transaction and EVV Claim) for a visit
conducted to provide a service described in §
354.4005 or §
354.4006 of this
subchapter.
(16) EVV system user--A
person who has access to the EVV system, including a person employed by or
contracting with a program provider, FMSA, or CDS employer.
(17) EVV vendor system--An EVV system
developed and operated by a vendor that contracts with HHSC or HHSC's
designated contractor that a program provider or FMSA uses instead of an EVV
proprietary system.
(18) EVV visit
transaction--A record generated by an EVV system that contains the data
elements described in §
354.4009(a) of
this subchapter for a visit conducted to provide a service described in §
354.4005 or §
354.4006 of this
subchapter.
(19) FC Program--Family
Care Program. A program funded under Title XX, Subtitle A of the Social
Security Act, as described in 40 TAC Chapter 47.
(20) FMSA--Financial management services
agency. A program provider that contracts with HHSC or an MCO to provide
financial management services to a CDS employer as described in 40 TAC Chapter
41 (relating to Consumer Directed Services Option).
(21) HCBS-AMH Program--Home and
Community-Based Services Adult Mental Health Program. A Medicaid state plan
option approved by CMS under Title XIX, Section 1915(i) of the Social Security
Act, as described in 26 TAC Chapter 307, Subchapter B (relating to Home and
Community-Based Services--Adult Mental Health Program).
(22) HCS Program--Home and Community-based
Services Program. A Medicaid waiver program approved by CMS under Title XIX,
Section 1915(c) of the Social Security Act, as described in 26 TAC Chapter 263
(relating to Home and Community-based Services (HCS) Program and Community
First Choice (CFC)).
(23)
HHSC--Texas Health and Human Services Commission.
(24) Home health aide--Has the meaning set
forth in 26 TAC §
558.2 (relating to
Definitions).
(25)
ICF/IID--Intermediate care facility for individuals with an intellectual
disability or related conditions. An ICF/IID is a facility that is licensed in
accordance with THSC Chapter 252 or certified by HHSC.
(26) IMD--Institution for mental diseases.
Has the meaning set forth in 25 TAC §
419.373 (relating to
Definitions).
(27) LVN--Licensed
vocational nurse. A person licensed to practice as a vocational nurse as
described in Texas Occupations Code Chapter 301.
(28) MCO--Managed care organization. Has the
meaning set forth in Texas Government Code §
543A.0001.
(29) MDCP--Medically Dependent Children
Program. A Medicaid waiver program approved by CMS under Title XIX, Section
1915(c) of the Social Security Act, as described in Chapter 353, Subchapter M
of this title (relating to Home and Community Based Services in Managed
Care).
(30) MDCP STAR Health
covered service--Medically Dependent Children Program STAR Health covered
service. A service provided to a member eligible to receive MDCP benefits under
the STAR Health Program.
(31) MDCP
STAR Kids covered service--Medically Dependent Children Program STAR Kids
covered service. A service provided to a member eligible to receive MDCP
benefits under the STAR Kids Program.
(32) Member--A person enrolled in one of the
following:
(A) traditional Medicaid service
delivery model also referred to as fee-for-service;
(B) the CLASS Program;
(C) the Community Attendant Services
Program;
(D) the DBMD
Program;
(E) the FC
Program;
(F) the HCBS-AMH
Program;
(G) the HCS
Program;
(H) the Primary Home Care
Program;
(I) the STAR
Program;
(J) the STAR Health
Program;
(K) the STAR Kids
Program;
(L) the STAR+PLUS
Program;
(M) the STAR+PLUS Home and
Community-Based Services Program;
(N) the STAR+PLUS Medicare-Medicaid
Program;
(O) the Texas Home Living
Program;
(P) Texas Health Steps
Comprehensive Care Program (CCP); or
(Q) the Youth Empowerment Services
Program.
(33) Nursing
facility--A facility licensed in accordance with Texas Health and Safety Code
Chapter 242.
(34) Occupational
therapist--A person licensed as an occupational therapist in accordance with
Texas Occupations Code Chapter 454.
(35) PCS--Personal Care Services. Support
services provided to a member enrolled in Texas Health Steps CCP who requires
assistance with activities of daily living or instrumental activities of daily
living as described in §
363.602 of this title (relating to
Definitions).
(36) PDN--Private
duty nursing. Has the same meaning as the term "Private duty nursing (PDN)
Services" in 1 TAC Chapter 363, Subchapter C, §363.303 (relating to
Definitions).
(37) Primary Home
Care Program--A Medicaid state plan program operating under Title XIX of the
Social Security Act, as described in 40 TAC Chapter 47.
(38) Physical therapist--A person licensed as
a physical therapist in accordance with Texas Occupations Code Chapter
453.
(39) Program provider--An
entity that contracts with HHSC or an MCO to provide a service described in
§
354.4005 or §
354.4006 of this subchapter and
that uses an EVV vendor system or an EVV proprietary system. A service provider
described in paragraph (43)(B) of this section is both a program provider and a
service provider.
(40)
PSO--Proprietary system operator. A program provider or FMSA that uses an EVV
proprietary system.
(41) Reason
code--A standardized HHSC-approved code entered in an EVV system to explain the
reason for completing visit maintenance.
(42) RN--Registered nurse. A person licensed
to practice as a registered nurse as described in Texas Occupations Code
Chapter 301.
(43) Service
provider--A person who provides a service described in §
354.4005 or §
354.4006 of this subchapter and
who:
(A) is employed by or contracting with:
(i) a program provider; or
(ii) a CDS employer; or
(B) who is contracting with:
(i) an MCO; or
(ii) HHSC.
(44) SRO--Service responsibility option. A
service delivery option described in 40 TAC Chapter 43 (relating to Service
Responsibility Option) in which a member or legally authorized representative
selects, trains, and provides daily management of a service provider, while the
fiscal, personnel, and service back-up plan responsibilities remain with the
program provider.
(45) STAR--State
of Texas Access Reform.
(46) STAR
Health Program--A Medicaid program operating under Title XIX, Section 1915(a)
of the Social Security Act and Texas Family Code, Chapter 266. The program
provides services through a managed care delivery model to a member enrolled in
STAR Health as described in Chapter 353, Subchapter H of this title (relating
to STAR Health).
(47) STAR Kids
Program--A Medicaid program operating under Title XIX, Section 1115 of the
Social Security Act and Texas Government Code Chapter 540. The program provides
services through a managed care delivery model to a member enrolled in STAR
Kids as described in Chapter 353, Subchapter N of this title (relating to STAR
Kids).
(48) STAR Program--A
Medicaid program operating under Title XIX, Section 1115 of the Social Security
Act. The program provides services through a managed care delivery model to a
member enrolled in STAR as described in Chapter 353, Subchapter I of this title
(relating to STAR).
(49) STAR+PLUS
HCBS Program--STAR+PLUS Home and Community-Based Services Program. A Medicaid
program operating through a federal waiver under Title XIX, Section 1115 of the
Social Security Act. The program provides services to a member eligible to
receive HCBS benefits under the STAR+PLUS Program, as described in Chapter 353,
Subchapter M of this title (relating to Home and Community Based Services in
Managed Care).
(50) STAR+PLUS
MMP--STAR+PLUS Medicare-Medicaid Plan. A managed care program operating under
Title XIX, Section 1115A of the Social Security Act that provides the authority
to test and evaluate a fully integrated care model for clients who are dual
eligible. The STAR+PLUS MMPs contract with CMS and HHSC to participate in the
Dual Demonstration Program described in Chapter 353, Subchapter L of this title
(relating to Texas Dual Eligibles Integrated Care Demonstration
Project).
(51) STAR+PLUS Program--A
Medicaid program operating under Title XIX, Section 1115 of the Social Security
Act, and Texas Government Code Chapter 540. The program provides services
through a managed care delivery model to a member enrolled in STAR+PLUS as
described in Chapter 353, Subchapter G of this title (relating to
STAR+PLUS).
(52) TAC--Texas
Administrative Code.
(53) Texas
Health Steps CCP--Texas Health Steps Comprehensive Care Program. A Medicaid
comprehensive program approved by CMS under Title XIX, Section 1905 of the
Social Security Act, as described in Chapter 363 of this title (relating to
Texas Health Steps Comprehensive Care Program.
(54) TxHmL--Texas Home Living Program. A
Medicaid waiver program approved by CMS under Title XIX, Section 1915(c) of the
Social Security Act, as described in 26 TAC Chapter 262 (relating to Texas Home
Living (TxHmL) Program and Community First Choice (CFC)).
(55) Vendor hold--A temporary suspension of
payments for claims that are due to a program provider or FMSA.
(56) Visit maintenance--As described in the
EVV Policy Handbook, a process to:
(A)
manually enter data elements described in §
354.4009(a) of
this subchapter in an EVV system;
(B) correct the data elements described in
§
354.4009(a) of
this subchapter that are inaccurate in an EVV visit transaction; or
(C) include the data elements described in
§
354.4009(a) of
this subchapter that are missing in an EVV visit
transaction.
(57) YES
Program--Youth Empowerment Services Program. A Medicaid waiver approved by CMS
under Title XIX, Section 1915(c) of the Social Security Act as described in 26
TAC Chapter 307, Subchapter A (relating to Youth Empowerment Services
(YES)).
Notes
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