26 Tex. Admin. Code § 365.2 - Definitions
The following words and terms when used in this subchapter have the following meanings, unless the context clearly indicates otherwise.
(1) Access surgery--The
surgical procedure which creates or maintains the access site necessary to
perform dialysis.
(2) Action--A
suspension, modification, denial, or termination of program eligibility,
benefits, or participation.
(3)
Administrative review--A process that allows applicants, clients, or providers
the opportunity to request an informal review of any intended program action
that would suspend, modify, deny, or terminate their eligibility, benefits or
participation in the program.
(4)
Allowable amount--The maximum amount that the program will pay or reimburse for
a covered benefit or service.
(5)
Applicant--A person who has submitted an application for program benefits and
has not received a final determination of eligibility.
(6) Authorized entity--Any individual or
organization approved by the program to submit applications for benefits or
travel verification reports on behalf of an applicant or client.
(7) Claim--A request for payment or
reimbursement of services.
(8)
Client--A person who has applied for program services and who meets all program
eligibility requirements and is determined to be eligible for program
services.
(9) CMS--The Centers for
Medicare and Medicaid Services.
(10) Co-insurance--A cost-sharing arrangement
in which a covered person is responsible for paying a specified percentage of
the charge for a covered service or product.
(11) Commissioner--The commissioner of the
Department of State Health Services.
(12) Co-pay/Co-payment--A cost-sharing
arrangement in which a covered person is responsible for paying a specified or
fixed charge for a covered service or product.
(13) CRNA--Certified registered nurse
anesthetist.
(14) Date of service
(DOS)--The date a service is rendered.
(15) Denial--An action by the program that
disallows program eligibility, benefits, or provider enrollment.
(16) Department--The Department of State
Health Services.
(17) Effective
date--The date a program client or enrolled provider is approved to receive
program benefits or reimbursements.
(18) End-Stage Renal Disease (ESRD)--The
final stage of renal failure that requires dialysis or kidney transplant to
reduce uremic symptoms and prevent the death of the patient.
(19) Enrolled provider--Any individual or
entity who has completed all the requirements located in the Texas Health and
Human Services Commission rule at 1 TAC §
392.605, Kidney Health Care
Provider Requirements and Effective Dates, and is deemed enrolled by the
program to furnish covered services to program clients including:
(A) outpatient dialysis facilities;
(B) out-of-state outpatient dialysis
facilities;
(C) hospitals and
ambulatory surgical centers (ASCs) located in Texas and operating in compliance
with applicable law;
(D)
out-of-state hospitals and ASCs;
(E) military or Veterans Administration
hospitals located in Texas which have a renal unit;
(F) pharmacies approved as Texas Medicaid
providers and licensed to operate within the United States and its territories,
including mail order pharmacies;
(G) physicians and certified registered nurse
anesthetists (CRNAs) licensed in Texas;
(H) out-of-state physicians and CRNAs;
and
(I) Medicare Prescription Drug
Plan (PDP) providers.
(20) Explanation of benefits (EOB) --A form,
in paper or electronic format, which provides an explanation of benefits. It is
used to explain a payment or denial of a claim.
(21) Fair hearing--The informal hearing
process the department follows under §§ 1.51- 1.55 of Title 25
(relating to Fair Hearing Procedures).
(22) Filing deadline--The last date that a
claim may be received by the program and still be considered eligible for
benefit.
(23) Final decision--A
decision that is made by a decision maker after conducting a fair hearing under
§§ 1.51- 1.55 of Title 25.
(24) Incomplete claim--A claim that is
submitted to the program without the required information to enable
determination of program liability or payment.
(25) KHC--Kidney Health Care.
(26) KHC formulary--A list of general
therapeutic categories of drugs, over-the-counter products, and limited
diabetic supplies that are covered for reimbursement by the program.
(27) Low Income Subsidy (LIS)--The subsidy
provided under the Medicare Prescription Drug, Improvement and Modernization
Act (MMA) of 2003 for Medicare Part D plan premiums and related costs, at
varying levels, for some low-income Medicare beneficiaries.
(28) Medical benefit--Any medical treatment
or procedure approved by the program as a covered service.
(29) Medicare Advantage Plan--A Medicare
health plan that is similar to a health maintenance organization, participating
provider organization, or other Medicare health plan, and includes medical,
drug coverage and other benefits.
(30) Medicare Part A--Hospital insurance for
people age 65 or older, or under age 65 with certain disabilities, that helps
cover inpatient hospital stays, care in a skilled nursing facility, hospice
care, and some home health care.
(31) Medicare Part B--Health insurance for
people age 65 or older, or under age 65 with certain disabilities, and any age
with ESRD, that helps cover medically necessary services, such as doctors'
services and outpatient care, and some preventive services.
(32) Medicare Part D--Established by the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA),
it provides members with prescription drug coverage, expanded health plan
options, improved health care access for rural Americans, and preventive care
services.
(33) Medicare Part D
out-of-pocket expenses--Include premiums, deductibles, co-payments, or
co-insurance amounts.
(34) Medicare
Part D Premium--The amount paid monthly under a Medicare Part D contract to
insure coverage.
(35) Medicare
Prescription Drug Plan (PDP)--A stand-alone drug plan offered by insurers and
other private companies to individuals eligible for Medicare Part D.
(36) Medigap plan--A Medicare supplement
insurance policy sold by private insurance companies to fill "gaps" in Medicare
coverage.
(37) Modification--A
change made to a client or provider account that can affect program benefits,
eligibility, or enrollment.
(38)
Program--Kidney Health Care.
(39)
Provider--Any individual or entity who furnishes benefits or services to
program clients.
(40) Qualified
Individual (QI) Program--A Medicaid program for beneficiaries who need help in
paying for Medicare Part B premiums. The beneficiary must be entitled to
Medicare Part A, have limited income and resources as calculated using federal
and state guidelines, and not be otherwise eligible for Medicaid. For those who
qualify, the Medicaid program pays full Medicare Part B premiums
only.
(41) Qualified Medicare
Beneficiary (QMB) Program--A Medicaid program for beneficiaries who need help
in paying for Medicare services. The beneficiary must be entitled to Medicare
Part A, have limited income and resources as calculated using federal and state
guidelines. For those who qualify, the Medicaid program pays Medicare Part A
premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for
Medicare services.
(42)
Reimbursement--Payment of a claim for covered benefits or services.
(43) Reimbursement rate--The program payment
rate for covered benefits or services.
(44) Resubmitted claim--A claim that is
submitted to the program more than once to correct errors.
(45) Specified Low Income Medicare
Beneficiary (SLMB) Program--A Medicaid program that pays for Medicare Part B
premiums for individuals who have Medicare Part A, a low monthly income, and
limited resources as calculated using federal and state guidelines.
(46) Suspension--An action by the program,
which holds client benefits or reimbursement to enrolled providers pending
satisfaction of a program request or requirement.
(47) Termination--A final action by the
program, which ends client or enrolled provider participation in the
program.
(48) Veterans
programs--Health care programs authorized and administered by the United States
Department of Veterans Affairs and the United States Department of
Defense.
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.