The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise.
(1) Assessments--Managed care organization (MCO) evaluation
of a member's medical and functional service needs, including community-based
long-term services and supports, behavioral health services, therapies
(e.g., physical, occupational, speech), and nursing services. This
includes the MCO's completion of program-specific instruments and
forms.
(2) Audio-only--An interactive, two-way audio communication
that uses only sound and that meets the privacy requirements of the
Health Insurance Portability and Accountability Act. Audio-only includes
the use of telephonic communication. Audio-only does not include face-to-face
communication.
(3) Audio-visual--Interactive, two-way audio and video
communication that conforms to privacy requirements under the Health
Insurance Portability and Accountability Act. Audio-visual does not
include audio-only or in-person communication.
(4) C.F.R.--Code of Federal Regulations.
(5) Change in condition--A significant change in a
member's health, caregiver support, or functional status that will
not normally resolve itself without further intervention and requires
review of and revision to the member's current service plan or individual
service plan.
(6) Community-based long-term services and supports
(LTSS)--Services provided to a qualified member in their home or another
community-based setting necessary to allow the member to remain in
the most integrated setting possible. Community-based LTSS includes
Medicaid state plan services available to all members, as well as
services available to members who qualify for the Home and Community
Based Services (HCBS) Program or Medicaid 1915(c) waiver programs,
including the STAR+PLUS Home and Community-Based Services (HCBS) Program
and the Medically Dependent Children Program. Community-based LTSS
is available to both HCBS -eligible and non-HCBS eligible members.
Community-based LTSS in Medicaid managed care varies by program model.
(7) Community First Choice (CFC)--A Medicaid state
plan benefit described in 1 TAC Chapter 354, Subchapter A, Division
27 (relating to Community First Choice).
(8) 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,
nonemergency medical transportation services, 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
the Texas Health and Human Services Commission, including:
(A) all services or items comprising "medical assistance"
as defined in Human Resources Code §32.003; and
(B) all value-added services under such contract.
(9) Declared state of disaster--A State of Disaster
declared by the governor in accordance with Texas Government Code §418.014.
(10) Face-to-face--In-person or audio-visual communication
that meets the requirements of the Health Insurance Portability and
Accountability Act. Face-to-face does not include audio-only communication.
(11) Functionally necessary covered services--Community-based
long-term services and supports provided to assist members with activities
of daily living based on a functional assessment of the member's activities
of daily living and a determination of the amount of supplemental
supports necessary for the member to remain independent or in the
most integrated setting.
(12) Healthcare service plan--An individualized plan
developed with and for a member with special healthcare needs in the
STAR Health program. The healthcare service plan includes the following:
(A) the member's history;
(B) a summary of current medical and social needs and
concerns;
(C) short and long-term needs and goals; and
(D) a treatment plan to address the member's physical,
psychological, and emotional healthcare problems and needs, including:
(i) a list of required services;
(ii) the frequency of each service;
(iii) a description of who will provide each service;
and
(iv) for a member in the Early Childhood Intervention
program, the individual family service plan.
(13) HHSC--The Texas Health and Human Services Commission
or its designee. HHSC is the single state agency charged with administration
and oversight of the Texas Medicaid program, including Medicaid managed
care. HHSC's authority is established in Texas Government Code Chapter
531.
(14) HIPAA--Health Insurance Portability and Accountability
Act. Collectively, the Health Insurance Portability and Accountability
Act of 1996, 42 U.S.C. §§1320d et seq., and regulations
adopted under that act, as modified by the Health Information Technology
for Economic and Clinical Health Act (HITECH) (P.L. 111-105), and
regulations adopted under that act at 45 CFR Parts 160 and 164.
(15) Individual service plan (ISP)--An individualized
and person-centered plan in which a member enrolled in the STAR Kids,
STAR Health or STAR+PLUS HCBS program operated by an MCO, with assistance
as needed, identifies and documents the member's preferences, strengths,
and health and wellness needs in order to develop short term objectives
and action steps to ensure personal outcomes are achieved within the
most integrated setting by using identified supports and services.
The ISP is supported by the results of a member's program-specific
assessment and must meet the requirements of 42 C.F.R. §441.301.
(16) Information technology--Includes text, email,
fax, secure transmission of clinical information, and HIPAA-compliant
telecommunication tools such as health plan websites where a member
or the member's legally authorized representative can access the member's
healthcare information, including service plans.
(17) In-person (or in person)--Within the physical
presence of another person. In-person or in person does not include
audio-visual or audio-only communication.
(18) Legally authorized representative (LAR)--A person
authorized by law to act on behalf of an individual with regard to
a matter described in this subchapter, 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.
(19) Managed care organization (MCO)--An entity licensed
and approved by the Texas Department of Insurance with which HHSC
contracts to provide Medicaid services and that complies with Chapter
353 of this title (relating to Medicaid Managed Care).
(20) Medical consenter--The person who may consent
to medical care for a member under Texas Family Code Chapter 266.
(21) Medically Dependent Children Program (MDCP)--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.
(22) Medically necessary--Has the meaning as defined
in §353.2 of this chapter (relating to Definitions).
(23) Medical Necessity Level of Care (MN/LOC)--An assessment
instrument used to determine medical necessity for a nursing facility
as defined by 26 TAC §554.2601. An MN/LOC is required for STAR+PLUS
HCBS Program and CFC eligibility.
(24) Member--A person who is eligible for benefits
under Medicaid, is in a Medicaid eligibility category included in
the Medicaid managed care program, and is enrolled in a Medicaid MCO.
(25) Minimum data set (MDS)--Has the meaning as defined
in 26 TAC §554.101.
(26) Nursing facility--An entity that provides organized
and structured nursing care and services, and is subject to licensure
under Texas Health and Safety Code, Chapter 242.
(27) Nursing facility level of care--The determination
that the level of care required to adequately serve a member is at
or above the level of care provided by a nursing facility.
(28) 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.
(29) Resident Assessment Instrument (RAI)--Has the
meaning as defined in 26 TAC §554.101.
Cont'd... |
