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RULE §412.103Definitions

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.

  (1) Ability to pay--The person has third-party coverage that will pay for needed services, the person's maximum monthly fee is greater than zero, or the person has identified payment for a needed service or services in an approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense ).

  (2) Community services or services--Except for inpatient services in a state mental health facility and non-crisis residential services, the required and optional mental health services described in the performance contract, including:

    (A) 24-hour emergency screening and rapid crisis stabilization services;

    (B) community-based crisis residential services or inpatient services in a mental health facility that is not a state mental health facility;

    (C) community-based assessments, including the development of interdisciplinary treatment plans, and diagnosis and evaluation services;

    (D) family support services, including respite care;

    (E) case management services;

    (F) medication-related services, including medication clinics, laboratory monitoring, medication education, mental health maintenance education, and the provision of medication; and

    (G) psychosocial rehabilitation programs, including social support activities, independent living skills, and vocational training.

  (3) Department--The Department of State Health Services.

  (4) Extraordinary expenses--Major medical or health related expenses, major casualty losses, and child care expenses for the previous year or projections for the next year.

  (5) Family members--

    (A) For an unmarried person under the age of 18 years--The person, the person's parents, and the dependents of the parents, if residing in the same household;

    (B) For an unmarried person age 18 years or older--The person and his/her dependents;

    (C) For a married person of any age--The person, his/her spouse, and their dependents.

  (6) Full subsidy eligible individual-An individual who has income below 135 percent of the federal poverty level applicable to the individual's family size and has resources that do not exceed the limits specified in 42 CFR §423.773(b). A full subsidy individual is eligible to receive premium and cost-sharing subsidies for Medicare Part D prescription drug plans. All individuals who are dually eligible for Medicaid and Medicare are full subsidy eligible individuals.

  (7) Gross income--Revenue from all sources before taxes and other payroll deductions. The term does not include child support received.

  (8) Inability to pay--The person's maximum monthly fee is zero and the person:

    (A) does not have third-party coverage;

    (B) has third-party coverage, but has exceeded the maximum benefit of the covered service(s) or the third-party coverage will not pay because the services needed by the person are not covered services; or

    (C) has not identified payment for a needed service or services in an approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense ).

  (9) Income-based public insurance--Government funded third-party coverage that bases eligibility on income e.g., CHIP and Medicaid.

  (10) LMHA or local mental health authority--An entity designated as the local mental health authority by the department in accordance with the Texas Health and Safety Code, §533.035(a).

  (11) Performance contract--A written agreement between the department and a LMHA for the provision of one or more functions as described in the Texas Health and Safety Code, §533.035(a).

  (12) Person--A person in the priority population who is seeking or receiving services through a LMHA.

  (13) Priority population--Those groups of persons with mental illness identified in the department's current strategic plan as being most in need of mental health services.

  (14) Significant financial change--Any change in the person's (or parent's) financial documentation, as described in §412.105(d) of this title (relating to Accountability), that affects the person's (or parent's) ability to pay. Examples of a significant financial change are:

    (A) a reduction in income due to the loss of a job or due to a reduction in hours worked on a job;

    (B) an increase in income because of an inheritance or a salary increase;

    (C) an increase or decrease in the number of family members;

    (D) the gain or loss of third-party coverage; and

    (E) an increase or decrease in extraordinary expenses.

  (15) Standard charge--A fixed price for a community service or unit of service.

  (16) State mental health facility--A state hospital or a state center with an inpatient component.

  (17) Team--The interdisciplinary team, multidisciplinary team, or treatment team.

  (18) Third-party coverage--A public or private payer of community services for a specific person that is not the person (e.g., Medicaid, Medicare, private insurance, CHIP, TRICARE).

Source Note: The provisions of this §412.103 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806

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