The following words and terms, when used in this chapter, shall
have the following meanings, unless the context clearly indicates
otherwise.
(1) Act--The Children with Special Health Care Needs
Services Act, Health and Safety Code, Chapter 35.
(2) Advanced practice registered nurse--A registered
nurse approved by the Texas Board of Nursing to practice as an advanced
practice registered nurse.
(3) Applicant--A person making an initial application
or re-application for CSHCN Services Program services.
(4) Case management services--Case management services
include, but are not limited to:
(A) planning, accessing, and coordinating needed health
care and related services for children with special health care needs
and their families. Case management services are performed in partnership
with the child, the child's family, providers, and others involved
in the care of the child and are performed as needed to help improve
the well-being of the child and the child's family; and
(B) counseling for the child and the child's family
about measures to prevent the transmission of AIDS or HIV and the
availability in the geographic area of any appropriate health care
services, such as mental health care, psychological health care, and
social and support services.
(5) Child with special health care needs--A person
who:
(A) is younger than 21 years of age and who has a
chronic physical or developmental condition; or
(B) has cystic fibrosis, regardless of the person's
age; and
(C) may have a behavioral or emotional condition that
accompanies the person's physical or developmental condition. The
term does not include a person who has behavioral or emotional condition
without having an accompanying physical or developmental condition.
(6) CHIP--The Children's Health Insurance Program administered
by the Texas Health and Human Services Commission under Title XXI
of the Social Security Act.
(7) Chronic developmental condition--A disability manifested
during the developmental period for a child with special health care
needs which results in impaired intellectual functioning or deficiencies
in essential skills, which is expected to continue for a period longer
than one year, and which causes a person to need assistance in the
major activities of daily living or in meeting personal care needs.
For the purpose of this chapter, a chronic developmental condition
must include physical manifestations and may not be solely a delay
in intellectual, mental, behavioral, or emotional development.
(8) Chronic physical condition--A disease or disabling
condition of the body, of a bodily tissue, or of an organ which will
last or is expected to last for at least 12 months, that results,
or without treatment, may result in limits to one or more major life
activities, and that requires health and related services of a type
or amount beyond those required by children generally. Such a condition
may exist with accompanying developmental, mental, behavioral, or
emotional conditions, but is not solely a delay in intellectual development
or solely a mental, behavioral, or emotional condition.
(9) Claim form--The document approved by the CSHCN
Services Program for submitting a claim for processing and payment.
(10) Client--A person who has applied for program services
and who meets all CSHCN Services Program eligibility requirements
and is determined to be eligible for program services.
(A) New client:
(i) a person who has applied to the program for the
first time and who is determined to be eligible for program services;
or
(ii) a person who has re-applied to the program (after
a lapse in eligibility) and who is determined to be eligible for program
services.
(B) Ongoing client--A client who currently is not on
the program's waiting list.
(C) Waiting list client--A client who currently is
on the program's waiting list.
(11) CMS--The Centers for Medicare and Medicaid Services.
(12) Commission--The Texas Health and Human Services
Commission.
(13) Commissioner--The Commissioner of the Department
of State Health Services.
(14) Co-insurance--A cost-sharing arrangement in which
a covered person pays a specified percentage of the charge for a covered
service. The covered person may be responsible for payment at the
time the health care service is provided.
(15) Co-pay and co-payment--A cost-sharing arrangement
in which a client pays a specified charge for a specified service.
The client is usually responsible for payment at the time the health
care service is provided.
(16) CSHCN Services Program--The services program for
children with special health care needs described in §38.1 of
this title (relating to Purpose and Common Name).
(17) Date of service (DOS)--The date a service is provided.
(18) Deductible--A cost-sharing arrangement in which
a client is responsible for paying a specific amount annually for
covered services before an insurance carrier or plan begins to pay
for covered services.
(19) Dentist--An individual licensed by the State Board
of Dental Examiners to practice dentistry in the State of Texas.
(20) Department--The Department of State Health Services.
(21) Diagnosis and evaluation services--The process
of performing specialized examinations, tests, or procedures to determine
whether a CSHCN Services Program applicant for health care benefits
has a chronic physical or developmental condition as determined by
a physician or dentist participating in the CSHCN Services Program
or to help determine whether a waiting list client has an "urgent
need for health care benefits" according to the criteria and protocol
described in §38.16(e) of this title (relating to Procedures
to Address Program Budget Alignment).
(22) Disregards--An amount of money deducted from the
family's total income for allowable expenses, such as child care.
(23) Eligibility date for the CSHCN Services Program
health care benefits--The effective date of eligibility for the CSHCN
Services Program health care benefits is the date of receipt of a
complete, approved application except in the following circumstances.
(A) The effective date of eligibility for newborns
who are not born prematurely will be the date of birth. Newborn means
a child 28 days old or younger.
(B) The effective date of eligibility for an applicant
who is born prematurely shall be the day after the applicant has been
out of the hospital for 14 consecutive days, but no earlier than the
date of receipt of the application.
(C) The effective date of eligibility following traumatic
injury shall be the day after the acute phase of treatment ends, but
no earlier than the date of receipt of the application.
(D) The effective date of eligibility for applicants
with spenddown is the date of receipt of the medical bills which document
that spenddown has been met, following the receipt of a complete application.
Only medical bills having a DOS within 12 months prior to or 6 months
after the date of receipt of the application may be included to satisfy
spenddown requirements. Medical bills for any member of the family
for which the applicant, parent(s), guardian or managing conservator
of the CSHCN Services Program applicant is responsible may be included.
Medical bills used to meet spenddown cannot be paid by the CSHCN Services
Program.
(E) Excluding applications for clients who are known
to be ineligible for Medicaid and the CHIP due to age, citizenship
status, or insurance coverage, all applications must include a determination
of eligibility from Medicaid and the CHIP. If the CSHCN Services Program
application is received without a Medicaid determination, a CHIP determination,
or other data or documents needed to process the application, it
will be considered incomplete. The applicant will be notified that
the application is incomplete and given 60 days to submit the Medicaid
determination, CHIP denial or enrollment, or other missing data or
documents to the CSHCN Services Program. If the application is made
complete within the 60-day time limit, the client's eligibility effective
date will be established as the date the CSHCN Services Program application
was first received. If the application is made complete more than
60 days after initial receipt, the eligibility effective date will
be established as the date the application was made complete.
(24) Emergency--A medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain)
such that a prudent person with average knowledge of health and medicine
could reasonably expect that the absence of immediate medical care
could result in:
(A) placing the person's health in serious jeopardy;
(B) serious impairment to bodily functions; or
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