26 Tex. Admin. Code § 351.2 - Definitions
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.
(1) Act--The Children with
Special Health Care Needs Services Act, Health and Safety Code, Chapter
35.
(2) Advanced practice
registered nurse--A registered nurse approved by the Texas Board of Nursing to
practice as an advanced practice registered nurse.
(3) Applicant--A person making an initial
application or re-application for CSHCN Services Program services.
(4) Case management services--Case management
services include, but are not limited to:
(A)
planning, accessing, and coordinating needed health care and related services
for children with special health care needs and their families. Case management
services are performed in partnership with the child, the child's family,
providers, and others involved in the care of the child and are performed as
needed to help improve the well-being of the child and the child's family;
and
(B) counseling for the child
and the child's family about measures to prevent the transmission of AIDS or
HIV and the availability in the geographic area of any appropriate health care
services, such as mental health care, psychological health care, and social and
support services.
(5)
Child with special health care needs--A person who:
(A) is younger than 21 years of age and who
has a chronic physical or developmental condition; or
(B) has cystic fibrosis, regardless of the
person's age; and
(C) may have a
behavioral or emotional condition that accompanies the person's physical or
developmental condition. The term does not include a person who has behavioral
or emotional condition without having an accompanying physical or developmental
condition.
(6) CHIP--The
Children's Health Insurance Program administered by the Texas Health and Human
Services Commission under Title XXI of the Social Security Act.
(7) Chronic developmental condition--A
disability manifested during the developmental period for a child with special
health care needs which results in impaired intellectual functioning or
deficiencies in essential skills, which is expected to continue for a period
longer than one year, and which causes a person to need assistance in the major
activities of daily living or in meeting personal care needs. For the purpose
of this chapter, a chronic developmental condition must include physical
manifestations and may not be solely a delay in intellectual, mental,
behavioral, or emotional development.
(8) Chronic physical condition--A disease or
disabling condition of the body, of a bodily tissue, or of an organ which will
last or is expected to last for at least 12 months, that results, or without
treatment, may result in limits to one or more major life activities, and that
requires health and related services of a type or amount beyond those required
by children generally. Such a condition may exist with accompanying
developmental, mental, behavioral, or emotional conditions, but is not solely a
delay in intellectual development or solely a mental, behavioral, or emotional
condition.
(9) Claim form--The
document approved by the CSHCN Services Program for submitting a claim for
processing and payment.
(10)
Client--A person who has applied for program services and who meets all CSHCN
Services Program eligibility requirements and is determined to be eligible for
program services.
(A) New client:
(i) a person who has applied to the program
for the first time and who is determined to be eligible for program services;
or
(ii) a person who has re-applied
to the program (after a lapse in eligibility) and who is determined to be
eligible for program services.
(B) Ongoing client--A client who currently is
not on the program's waiting list.
(C) Waiting list client--A client who
currently is on the program's waiting list.
(11) CMS--The Centers for Medicare and
Medicaid Services.
(12)
Commission--The Texas Health and Human Services Commission.
(13) Commissioner--The Commissioner of the
Department of State Health Services.
(14) Co-insurance--A cost-sharing arrangement
in which a covered person pays a specified percentage of the charge for a
covered service. The covered person may be responsible for payment at the time
the health care service is provided.
(15) Co-pay and co-payment--A cost-sharing
arrangement in which a client pays a specified charge for a specified service.
The client is usually responsible for payment at the time the health care
service is provided.
(16) CSHCN
Services Program--The services program for children with special health care
needs described in §38.1 of this title (relating to Purpose and Common
Name).
(17) Date of service
(DOS)--The date a service is provided.
(18) Deductible--A cost-sharing arrangement
in which a client is responsible for paying a specific amount annually for
covered services before an insurance carrier or plan begins to pay for covered
services.
(19) Dentist--An
individual licensed by the State Board of Dental Examiners to practice
dentistry in the State of Texas.
(20) Department--The Department of State
Health Services.
(21) Diagnosis and
evaluation services--The process of performing specialized examinations, tests,
or procedures to determine whether a CSHCN Services Program applicant for
health care benefits has a chronic physical or developmental condition as
determined by a physician or dentist participating in the CSHCN Services
Program or to help determine whether a waiting list client has an "urgent need
for health care benefits" according to the criteria and protocol described in
§38.16(e) of this title (relating to Procedures to Address Program Budget
Alignment).
(22) Disregards--An
amount of money deducted from the family's total income for allowable expenses,
such as child care.
(23)
Eligibility date for the CSHCN Services Program health care benefits--The
effective date of eligibility for the CSHCN Services Program health care
benefits is the date of receipt of a complete, approved application except in
the following circumstances.
(A) The effective
date of eligibility for newborns who are not born prematurely will be the date
of birth. Newborn means a child 28 days old or younger.
(B) The effective date of eligibility for an
applicant who is born prematurely shall be the day after the applicant has been
out of the hospital for 14 consecutive days, but no earlier than the date of
receipt of the application.
(C) The
effective date of eligibility following traumatic injury shall be the day after
the acute phase of treatment ends, but no earlier than the date of receipt of
the application.
(D) The effective
date of eligibility for applicants with spenddown is the date of receipt of the
medical bills which document that spenddown has been met, following the receipt
of a complete application. Only medical bills having a DOS within 12 months
prior to or 6 months after the date of receipt of the application may be
included to satisfy spenddown requirements. Medical bills for any member of the
family for which the applicant, parent(s), guardian or managing conservator of
the CSHCN Services Program applicant is responsible may be included. Medical
bills used to meet spenddown cannot be paid by the CSHCN Services
Program.
(E) Excluding applications
for clients who are known to be ineligible for Medicaid and the CHIP due to
age, citizenship status, or insurance coverage, all applications must include a
determination of eligibility from Medicaid and the CHIP. If the CSHCN Services
Program application is received without a Medicaid determination, a CHIP
determination, or other data or documents needed to process the application, it
will be considered incomplete. The applicant will be notified that the
application is incomplete and given 60 days to submit the Medicaid
determination, CHIP denial or enrollment, or other missing data or documents to
the CSHCN Services Program. If the application is made complete within the
60-day time limit, the client's eligibility effective date will be established
as the date the CSHCN Services Program application was first received. If the
application is made complete more than 60 days after initial receipt, the
eligibility effective date will be established as the date the application was
made complete.
(24)
Emergency--A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent person with
average knowledge of health and medicine could reasonably expect that the
absence of immediate medical care could result in:
(A) placing the person's health in serious
jeopardy;
(B) serious impairment to
bodily functions; or
(C) serious
dysfunction of any bodily organ or part.
(25) Emotional or behavioral
condition--Behavior which varies significantly from normal, that is chronic and
does not quickly disappear, and that is unacceptable because of social or
cultural expectations. Emotional or behavioral responses which are so different
from those of the generally accepted, age-appropriate norms of people with the
same ethnic or cultural background as to result in significant impairment in
social relationships, self-care, educational progress, or classroom behavior.
Examples include but are not limited to the following:
(A) an inability to build or maintain
satisfactory age-appropriate interpersonal relationships with peers or
adults;
(B) dangerously aggressive,
self-destructive, severely withdrawn, or noncommunicative behaviors;
(C) a pervasive mood of unhappiness or
depression; or
(D) evidence of
excessive anxiety or fears.
(26) Facility--A hospital, psychiatric
hospital, rehabilitation hospital or center, ambulatory surgical center, renal
dialysis center, specialty center, or outpatient clinic.
(27) Family--For the purpose of determining
family size for program eligibility, the family includes the following persons
who live in the same residence:
(A) the
applicant;
(B) those related to the
applicant as a parent, stepparent, or spouse who have a legal responsibility to
support the applicant, or guardians or managing conservators who have a duty to
provide food, shelter, education, and medical care for the applicant;
(C) children under age 19 or wards of the
applicant; and
(D) children under
age 19 or wards of a parent, stepparent, or spouse.
(28) Family support
services--Disability-related support, resources, or other assistance provided
to the family of a child with special health care needs. The term may include
services described by Part A of the Individuals with Disabilities Education Act
(20 U.S.C. §
1400
et seq.), as amended,
and permanency planning, as that term is defined by Texas Government Code
§
546.0201.
(29) Federal Poverty Level (FPL)--The minimum
income needed by a family for food, clothing, transportation, shelter, and
other necessities in the United States, according to the United States
Department of Health and Human Services, or its successor agency or agencies.
The FPL varies according to family size and after adjustment for inflation, is
published annually in the Federal Register.
(30) Federally qualified health center--A
federally qualified health center is designated by CMS to provide core medical
services to a Medically Underserved Population.
(31) Financial independence--A state in which
a person currently files his or her own personal U.S. income tax return and is
not claimed as a dependent by any other person on his or her U.S. income tax
return.
(32) Guardian--A statutory
officer appointed under the Texas Probate Code who has a duty to provide food,
shelter, education, and medical care for his or her ward.
(33) Health care benefits--CSHCN Services
Program benefits consisting of diagnosis and evaluation services,
rehabilitation services, medical home care management services, family support
services, transportation related services, and insurance premium payment
services.
(34) Health insurance and
health benefits plan--A policy or plan, individual, group, or
government-sponsored, that an individual purchases or in which an individual
participates that provides benefits when medical or dental costs are or would
be incurred. Sources of health insurance include, but are not limited to,
health insurance policies, buy-in programs, health maintenance organizations,
preferred provider organizations, employee health welfare plans, union health
welfare plans, medical expense reimbursement plans, United States Department of
Defense or Department of Veterans Affairs benefit plans, Medicaid, CHIP, and
Medicare. Benefits may be in any form, including, but not limited to,
reimbursement based upon cost, cash payment based upon a schedule, or access
without charge or at minimal charge to providers of medical or dental care.
Benefits from a municipal or county hospital, joint municipal-county hospital,
county hospital authority, hospital district, county indigent health care
programs, or the facilities of a publicly supported medical school shall not
constitute health insurance for purposes of this chapter.
(35) Income--The gross income, either earned
or unearned, before deductions over a given period of time for each family
member.
(36) Managing
conservator--A person designated by a court to have daily legal responsibility
for a child.
(37) Medicaid--A
program of medical care authorized by Title XIX of the Social Security Act and
the Human Resources Code.
(38)
Medical home--A respectful partnership between a client, the client's family as
appropriate, and the client's primary health care setting. A medical home is
family centered health care that is accessible, continuous, comprehensive,
coordinated, compassionate, and culturally competent. A medical home provides
primary care that includes preventive care, care coordination, and appropriate
referral and collaboration with specialist and other service providers as
required.
(39) Medicare--A federal
program that provides medical care for people age 65 or older and the disabled
as authorized by Title XVIII of the Social Security Act.
(40) Natural home--The home in which a person
lives that is either the residence of his or her parent(s), foster parent(s) or
guardian, or extended family member(s), or the home in the community where the
person has chosen to live, alone or with other persons. A natural home may
utilize natural support systems such as family, friends, co-workers, and
services available to the general population as they are available.
(41) Other benefit--A benefit, other than a
benefit provided under this chapter, to which a person is entitled for payment
of the costs of services included in the scope of coverage of the CSHCN
Services Program including, but not limited to, benefits available from:
(A) an insurance policy, group health plan,
health maintenance organization, or prepaid medical or dental care
plan;
(B) home, auto, or other
liability insurance;
(C) Title
XVIII, Title XIX, or Title XXI of the Social Security Act (42 U.S.C. §§
1395
et seq., 1396
et seq., and 1397aa et seq.), as
amended;
(D) the United States
Department of Veterans Affairs;
(E)
the United States Department of Defense;
(F) workers' compensation or any other
compulsory employers' insurance program;
(G) a public program created by federal or
state law or under the authority of a municipality or other political
subdivision of the state, excluding benefits created by the establishment of a
municipal or county hospital, a joint municipal-county hospital, a county
hospital authority, a hospital district, a county indigent health care program,
or the facilities of a publicly supported medical school; or
(H) a cause of action for the cost of care,
including medical care, dental care, facility care, and medical supplies,
required for a person applying for or receiving services from the department or
a settlement or judgment based on the cause of action if the expenses are
related to the need for services provided under this chapter.
(42) Otologist--A physician whose
specialty is diseases of the ear.
(43) Permanency planning--A planning process
undertaken for children with chronic illness or developmental disabilities who
reside in institutions or are at risk of institutional placement, with the
explicit goal of securing a permanent living arrangement that enhances the
child's growth and development, which is based on the philosophy that all
children belong in families and need permanent family relationships. Permanency
planning is directed toward securing: a consistent, nurturing environment, an
enduring, positive adult relationship(s), and a specific person who will be an
advocate for the child throughout the child's life. Permanency planning
provides supports to enable families to nurture their children, to reunite with
their children when they have been placed outside the home, and to place their
children in family environments.
(44) Person--An individual, corporation,
government or governmental subdivision or agency, business trust, partnership,
association, or any other legal entity.
(45) Physician--A person licensed by the
Texas Medical Board to practice medicine in this state.
(46) Physician assistant--A person licensed
as a physician assistant by the Texas Physician Assistant Board.
(47) Practitioner--A person who is licensed
to practice medicine, dentistry, nursing or an allied health
profession.
(48) Prematurity or
born prematurely--A child born at less than 36 weeks gestational age and
hospitalized since birth.
(49)
Program--The Children with Special Health Care Needs (CSHCN) Services
Program.
(50) Provider--A person or
facility as defined in §38.6 of this title (relating to Providers) that
delivers services purchased by the CSHCN Services Program for the purpose of
implementing the Act.
(51)
Rehabilitation services--The process of the physical restoration, improvement,
or maintenance of a body function destroyed or impaired by congenital defect,
disease, or injury which includes the following acute and chronic or
rehabilitative services:
(A) facility care,
medical and dental care, and occupational, speech, and physical
therapies;
(B) the provision of
medications, braces, orthotic and prosthetic devices, durable medical
equipment, and other medical supplies; and
(C) other services specified in this
chapter.
(52) Respite
care--A service provided on a short-term basis for the purpose of relief to the
primary care giver in providing care to individuals with disabilities. Respite
services can be provided in either in-home or out-of-home settings on a planned
basis or in response to a crisis in the family where a temporary caregiver is
needed.
(53) Rural health clinic--A
rural health clinic is designated by CMS to provide core medical services in a
Medically Underserved Area.
(54)
Routine child care--Child care for a child who needs supervision while the
parent or guardian is at work, in school, or in job training.
(55) Services--The care, activities, and
supplies provided under the Act, including but not limited to, both acute and
chronic or rehabilitative medical care, dental care, facility care,
medications, durable medical equipment, medical supplies, occupational,
physical, and speech therapies, family support services, case management
services, and other care specified by program rules.
(56) Social service organization--For
purposes of this chapter, a for-profit or nonprofit corporation or other
entity, not including individual persons, that provides funds for travel, meal,
lodging, and family supports expenses in advance to enable CSHCN Services
Program clients to obtain program services.
(57) Specialty center--A facility and staff
that meet the CSHCN Services Program minimum standards established in this
chapter and are designated for use by CSHCN Services Program clients as part of
the comprehensive services for a specific medical condition.
(58) Spenddown--A process that allows an
applicant to obtain program financial eligibility when the applicant's family
income exceeds 200% of the FPL. The family must prove cumulative medical
expenses that exceed the difference between the family income and 200% of the
FPL income limit.
(59) State--The
State of Texas.
(60)
Subrogation--Assumption by third party, such as a second creditor or an
insurance company, of another person's legal right to collect a debt or
damages.
(61) Supplemental Security
Income Program (SSI)--Title XVI of the Social Security Act which provides for
payments to individuals (including children under age 18) who are disabled and
have limited income and resources.
(62) Support--The contribution of money or
services necessary for a person's maintenance, including, but not limited to,
food, clothing, shelter, transportation, and health care.
(63) Texas resident--A person who:
(A) is physically present within the
geographic boundaries of the state;
(B) has an intent to remain within the
state;
(C) maintains an abode
within the state (i.e., house or apartment, not merely a post office
box);
(D) has not come to Texas
from another country for the purpose of obtaining medical care with the intent
to return to the person's native country;
(E) does not claim residency in any other
state or country; and
(i) is a minor child
residing in Texas whose parent(s), managing conservator, guardian of the
child's person, or caretaker (with whom the child consistently resides and
plans to continue to reside) is a Texas resident;
(ii) is a person residing in Texas who is the
legally dependent spouse of a Texas resident; or
(iii) is an adult residing in Texas,
including an adult whose parent(s), managing conservator, guardian of the
adult's person, or caretaker (with whom the adult resides and plans to continue
to reside).
(64) Treatment plan--The plan of care for the
client (time and treatment specific) as certified by and implemented under the
supervision of a physician or other practitioner in the program.
(65) United States Public Health Service
price--The average manufacturer price for a drug in the preceding calendar
quarter under Title XIX of the Social Security Act, reduced by the rebate
percentage, as authorized by the Veterans Health Care Act of 1992 (P.L.
102-585 , November 4, 1992).
(66) Urgent need for health care benefits--A
need for health care services when the lack of those services would cause a
permanent increase in disability, intense pain or suffering, or
death.
(67) Ward--An individual
placed under the protection of a guardian, or a person who by reason of
incapacity is under the protection of a court either directly or through a
guardian appointed by the court.
Notes
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