The following words and terms, when used in this chapter, have
the following meanings, unless the context clearly indicates otherwise:
(1) Action--
(A) In the context of an eligibility or disenrollment
determination by HHSC or its designee, action is defined as:
(i) denial of Children's Health Insurance Program (CHIP)
eligibility;
(ii) disenrollment from CHIP; or
(iii) the failure of HHSC or its designee to act within
45 days on an applicant's request for CHIP eligibility determination.
(B) "Action" does not include expiration of a time-limited
service.
(2) Acute care--Preventive care, primary care, and
other medical or behavioral health care provided for a condition having
a relatively short duration.
(3) Acute care hospital--A hospital that provides acute
care services.
(4) Adverse determination--A determination by a managed
care organization (MCO) that the health care services or dental services
furnished, or proposed to be furnished, to a patient are not medically
necessary or appropriate.
(5) Agreement or Contract--The formal, written, and
legally enforceable contract and amendments thereto between HHSC and
an MCO.
(6) Alien--A person who is not a native born or naturalized
citizen of the United States of America.
(7) Allowable revenue--All managed care revenue received
by the MCO pursuant to the contract during the contract period, including
retroactive adjustments made by HHSC. This would include any revenue
earned on CHIP managed care funds such as investment income, earned
interest, or third party administrator earnings from services to delegated
networks.
(8) Appeal--The formal process by which a member or
his or her representative requests a review of the MCO's action.
(9) Applicant--An individual who applies for health
and dental care coverage on behalf of the child. An applicant can
only be:
(A) a child's parent, whether biological or adoptive;
(B) a child's grandparent, relative or other adult
who provides care for the child;
(C) a minor not living with an adult applying for himself/herself;
(D) a child's step-parent; or
(E) a taxpayer who expects to claim the child on a
federal income tax return for the taxable year in which CHIP eligibility
is requested
(10) Application--The standardized, written document
that an applicant must complete to apply for health and dental care
coverage through CHIP.
(11) Behavioral health service--A covered service for
the treatment of mental, emotional, or chemical dependency disorders.
(12) Capitation rate--A fixed, predetermined fee paid
by HHSC to the MCO each month, in accordance with the contract, for
each enrolled member in exchange for which the MCO arranges for or
provides a defined set of covered services to the member, regardless
of the amount of covered services used by the enrolled member.
(13) Child--An adoptive, step, or natural child who
is under the age of 19.
(14) Children's Health Insurance Program or CHIP or
Program--The Texas State Children's Health Insurance Program established
under Title XXI of the federal Social Security Act (42 U.S.C. §§1397aa,
et seq.) the Texas Health and Safety Code, Chapters 62 (relating to
Child Health Plan For Certain Low-Income Children) and 63 (relating
to Health Benefits Plan for Certain Children).
(15) CHIP Dental Services--The dental services provided
through a dental MCO to a CHIP member.
(16) Claims processing entity--The MCO or its subcontractor
that processes claims for CHIP.
(17) CMS--The Centers for Medicare and Medicaid Services,
which is the federal agency responsible for administering Medicare
and overseeing state administration of Medicaid and CHIP.
(18) HHSC--The Texas Health and Human Services Commission.
(19) Complainant--A member, or a treating provider
or other individual designated to act on behalf of the member, who
files a complaint.
(20) Complaint--Any dissatisfaction, expressed by a
complainant, orally or in writing, to the MCO, with any aspect of
the MCO's operation, including dissatisfaction with plan administration;
procedures related to review or appeal of an adverse determination,
as set forth in Texas Insurance Code, Chapter 843, Subchapter G (relating
to Dispute Resolution); the denial, reduction, or termination of a
service for reasons not related to medical necessity; the way a service
is provided; or disenrollment decisions. The term does not include
misinformation that is resolved promptly by supplying the appropriate
information or clearing up the misunderstanding to the satisfaction
of the member.
(21) Cost Sharing--Any enrollment fees or co-payments
the member is responsible for paying.
(22) Covered service--A health care service or a dental
service or item 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 HHSC. This includes all covered services and benefits
identified in the Texas CHIP State Plan, and all value-added services
approved by HHSC.
(23) Cultural competency--The ability of individuals
and systems to provide services effectively to people of various cultures,
races, ethnic backgrounds, and religions in a manner that recognizes,
values, affirms, and respects the worth of the individuals and protects
and preserves their dignity.
(24) Day--Calendar day, unless otherwise specified.
(25) Default enrollment--The process established by
HHSC to assign a CHIP managed care enrollee to an MCO when the enrollee
has not selected an MCO.
(26) Dental contractor--A dental MCO that is under
contract with HHSC for the delivery of dental services.
(27) Dental home--A provider who has contracted with
a dental MCO to serve as a dental home to a member and who is responsible
for providing routine preventive, diagnostic, urgent, therapeutic,
initial, and primary care to patients, maintaining the continuity
of patient care, and initiating referral for care. Provider types
that can serve as dental homes are federally qualified health centers
and individuals who are general dentists or pediatric dentists.
(28) Dental managed care organization (dental MCO)--A
dental indemnity insurance provider or dental health maintenance organization
licensed or approved by the Texas Department of Insurance.
(29) Dental service--The routine preventive, diagnostic,
urgent, therapeutic, initial, and primary care provided to a member
and included within the scope of HHSC's agreement with a dental contractor.
For purposes of this chapter, "dental service" does not include dental
devices for craniofacial anomalies; treatment rendered in a hospital,
urgent care center, or ambulatory surgical center setting for craniofacial
anomalies; or emergency services provided in a hospital, urgent care
center, or ambulatory surgical center setting involving dental trauma.
These types of emergency services are treated as health care services
in this chapter.
(30) Designee--A contractor of HHSC authorized to act
on behalf of HHSC under this chapter.
(31) Disability--A physical or mental impairment that
substantially limits one or more of an individual's major life activities,
such as caring for oneself, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning, socializing, or working.
(32) Eligible provider--A network provider who provides
medical services to a member or a non-network provider who agrees
with an MCO to see a member for an agreed-upon rate on a case-by-case
basis.
(33) Emergency behavioral health condition--Any condition,
without regard to the nature or cause of the condition, that in the
opinion of a prudent layperson possessing an average knowledge of
health and medicine:
(A) requires immediate intervention and/or medical
attention without which the client would present an immediate danger
to themselves or others; or
(B) renders the client incapable of controlling, knowing,
or understanding the consequences of his or her actions.
(34) Emergency Medical Condition--A medical condition
manifesting itself by acute symptoms of recent onset and sufficient
severity (including severe pain), such that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate medical care could result in:
(A) placing the patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) serious disfigurement; or
Cont'd... |
