The following words and terms apply only to this subchapter
and have the following meanings, unless the context clearly indicates
otherwise.
(1) Contractor--The entity with which HHSC contracts,
pursuant to the requirements of the Code of Federal Regulations, Title
42, Part 434.
(2) Correct or ameliorate--To improve, maintain, or
slow the deterioration of the recipient's health status.
(3) Day--A calendar day.
(4) Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT)--The child and adolescent health component of the Medicaid
program for recipients under 21 years of age, defined in the United
States Code, Title 42, §1396d(r), and the Code of Federal Regulations,
Title 42, §440.40(b). EPSDT means screening, vision, dental,
hearing, laboratory, health care, treatment, diagnostic services,
and other measures necessary to correct or ameliorate defects and
physical and mental illnesses and conditions.
(5) Federal financial participation (FFP)--The federal
government's share of a Medicaid expenditure made by a state agency,
as defined in the Code of Federal Regulations, Title 45, §95.4.
(6) HHSC--The Texas Health and Human Services Commission
or its designee, including a contractor or MCO.
(7) Home and Community Support Services Agency (HCSSA)--A
public or private agency or organization licensed by the Texas Department
of Aging and Disability Services under 40 TAC Chapter 97 (relating
to Licensing Standards for Home and Community Support Services Agencies).
(8) Identified contingency plan--A structured process,
developed by the recipient or the responsible adult and the Medicaid-enrolled
provider, by which a recipient will receive care when a scheduled
health care provider is unexpectedly unavailable, as required by 40
TAC §97.290 (relating to Backup Services and After Hours Care).
(9) Licensed Vocational Nurse (LVN)--An individual
who is recognized by the Texas Board of Nursing to practice vocational
nursing in Texas at the time and place the service is provided, pursuant
to Texas Occupations Code §301.002(5) and 22 TAC, Part 11 (relating
to Texas Board of Nursing).
(10) Medicaid--The Texas Medical Assistance Program,
a joint federal and state program provided for in Chapter 32, Texas
Human Resources Code, and subject to Title XIX of the Social Security
Act, 42 U.S.C. §1396 et seq.
(11) Medicaid managed care organization (MCO)--Any
entity with which HHSC contracts to provide Medicaid managed care
services and that complies with Chapter 353 of this title (relating
to Medicaid Managed Care).
(12) Medical Director--HHSC's, its contractor's, or
MCO's medical director or associate medical director.
(13) Notice--A letter provided by HHSC, its contractor,
or MCO to a recipient informing the recipient of any reduction, denial,
or termination of a requested service, as described in the Code of
Federal Regulations, Title 42, §431.206 and §431.210.
(14) Physician--A doctor of medicine (MD) or osteopathy
(DO) who is licensed in the state in which they practice.
(15) Private duty nursing (PDN) Services--Nursing,
described by the Texas Occupations Code Chapter 301, and its implementing
regulations at 22 TAC, Part 11 (relating to Texas Board of Nursing),
when the recipient requires more individual and continuous care than
is available from a visiting nurse or than is routinely provided by
the nursing staff of a hospital or skilled nursing facility. PDN services
include observation, assessment, intervention, evaluation, rehabilitation,
care and counsel, or health teachings of a recipient who has a disability
or chronic health condition or who is experiencing a change in normal
health processes.
(16) Private duty nursing services provider--An independently
practicing registered nurse, a licensed vocational nurse (LVN) under
the supervision of a registered nurse, or a home and community support
services agency (HCSSA) enrolled in the Texas Medicaid Program to
provide private duty nursing services.
(17) Qualified Aide--An aide providing services consistent
with the requirements of:
(A) 40 TAC Chapter 94 (relating to Nurse Aides);
(B) 40 TAC Chapter 95 (relating to Medication Aides--Program
Requirements); or
(C) home health aide outlined in 40 TAC Chapter 97
(relating to Licensing Standards for Home and Community Support Services
Agencies).
(18) Recipient--An individual who is eligible to receive
services through the Texas Medicaid Program.
(19) Registered Nurse (RN)--An individual who is recognized
by the Texas Board of Nursing to practice professional nursing in
Texas at the time and place the service is provided, pursuant to the
Texas Occupations Code §301.002.
(20) Responsible adult--An individual who is an adult,
as defined by the Texas Family Code, who has agreed to accept the
responsibility for providing food, shelter, clothing, education, nurturing,
and supervision for a recipient who is a minor under the age of 18;
or is over 18 years of age and the responsible adult is the managing
conservator or legal guardian. Responsible adults include biological
parents, adoptive parents, foster parents, guardians, court-appointed
managing conservators, and other family members by birth or marriage.
(21) Texas Health Steps - Comprehensive Care Program--Medical,
dental, and treatment services available as a federally mandated service
for eligible EPSDT Medicaid recipients in Texas under the age of 21
years, pursuant to the EPSDT provision of Title XIX of the Social
Security Act, 42 U.S.C. §1396d(r), and the Code of Federal Regulations,
Title 42, §440.40(b).
(22) Treating physician--A physician who provides ongoing
medical care of the recipient and ongoing medical supervision of the
recipient's plan of care.
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