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TITLE 26HEALTH AND HUMAN SERVICES
PART 1HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 351CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM
RULE §351.4Covered Services

(a) Introduction. The program provides no direct medical services, but reimburses for services rendered by program providers or contractors. Clients must receive services as close to their home communities as possible unless program contracts or policies require treatment at specific facilities or specialty centers or the clients' conditions require specific specialty care.

(b) Types of service.

  (1) Early identification. The program may conduct outreach activities to identify children for program enrollment, increase their access to care, and help them use services appropriately. Outreach services may include, but are not limited to:

    (A) promotion of the program to the general public or targeted to potential clients and providers;

    (B) development and distribution of educational materials to assist applicants and clients in the access and use of program services;

    (C) development and distribution of population-based educational materials concerning children with special health care needs;

    (D) integration with programs which screen for or provide treatment of newborn congenital anomalies or other specialty care; and

    (E) links with community, regional, or school-based clinics to identify, assess needs, and provide appropriate resources for children with special health care needs.

  (2) Diagnosis and evaluation services. These services may be covered for the purpose of determining whether an applicant meets the program definition of a child with special health care needs in order to receive health care benefits. Diagnosis and evaluation services must be prior authorized and coverage is limited in duration. If a physician or dentist requests coverage of diagnosis and evaluation services to determine if the applicant meets the definition of a "child with special health care needs" and the applicant meets all other eligibility criteria, then the applicant may be given up to 60 days of program coverage for diagnosis and evaluation services only. The program medical director or other designated medical staff may prior authorize limited coverage of diagnosis and evaluation services for waiting list clients if needed to help determine "urgent need for health care benefits" as described in §38.16(e) of this title (relating to Procedures to Address Program Budget Alignment). Only program providers may be reimbursed for diagnosis and evaluation services.

  (3) Rehabilitation services. Rehabilitation services means a process of physical restoration, improvement, or maintenance of a body function destroyed or impaired by congenital defect, disease, or injury which includes the following acute and chronic or rehabilitative services: facility care, medical and dental care, occupational, speech, and physical therapies, the provision of medications, braces, orthotic and prosthetic devices, durable medical equipment, other medical supplies, and other services specified in this chapter. To be eligible for program reimbursement, treatment must be for a client and must have been prescribed by a practitioner in compliance with all applicable laws and regulations of the State of Texas. Services may be limited and the availability of certain services described in the following subparagraphs is contingent upon implementation of automation procedures and systems.

    (A) Medical or dental assessment and treatment. A physician or dentist must provide medical or dental assessment and treatment services, including necessary laboratory and radiology studies. All practitioners must be licensed by the State of Texas, enrolled as providers in the program, and practicing within the scope of their respective licenses or registrations.

    (B) Outpatient mental health services. Outpatient mental health services are limited to no more than 30 encounters in a calendar year by all professionals licensed to provide mental or behavioral health services including psychiatrists, psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors per eligible client per calendar year. Coverage includes, but is not limited to psychological or neuropsychological testing, psychotherapy, and counseling.

    (C) Preventive and therapeutic dental services (including oral and maxillofacial surgery). Preventive and therapeutic dental services must be provided by licensed dentists enrolled to participate in the program. Coverage for therapeutic dental services, including prosthetics and oral and maxillofacial surgery, follows the Texas Medicaid program guidelines. Orthodontic care must be prior authorized and may be provided only for CSHCN Services Program eligible clients with diagnoses of cleft-craniofacial abnormalities, dentofacial abnormalities, or late effects of fractures of the skull and face bones.

    (D) Podiatric services. Podiatric services must be provided by licensed practitioners enrolled to participate in the program. Podiatrists are limited to services medically necessary to treat conditions of the foot and ankle. Podiatric services follow the Texas Medicaid program guidelines. Supportive devices, such as molds, inlays, shoes, or supports, must comply with coverage limitations for foot orthoses.

    (E) Treatment in program participating facilities. Hospital care must be provided in facilities that are enrolled as program providers. The length of stay is limited according to diagnosis, procedures required, and the client's condition.

      (i) Inpatient hospital care, coverage limitations, and inpatient psychiatric care.

        (I) Inpatient hospital care. Coverage excludes the following:

          (-a-) maternity care, newborn care, infertility treatment, or other reproductive services unless directly related to a covered chronic physical or developmental condition;

          (-b-) personal comfort items, such as television or newspaper delivery; and

          (-c-) private duty nursing or attendant care.

        (II) Coverage limitations. Coverage is limited to 60 days per calendar year. For stem cell transplantation, an additional 60 days coverage may be allowed.

        (III) Inpatient psychiatric care. Coverage is limited to inpatient assessment and crisis stabilization and is to be followed by referral to an appropriate public or private mental health program. Admission must be prior authorized. Services include those medically necessary and furnished by a Medicaid psychiatric hospital or facility under the direction of a psychiatrist.

      (ii) Inpatient rehabilitation care. Medically necessary inpatient rehabilitation care is limited to an initial admission not to exceed 30 days based on the functional status and potential of the client as certified by a physician participating in the program. Services beyond the initial 30 days may be approved by the program based upon the client's medical condition, plan of treatment, and progress. Payment for inpatient rehabilitation care is limited to 90 days during a calendar year.

      (iii) Ambulatory surgical care. Ambulatory surgical care is limited to the medically necessary treatment of a client and may be performed only in program approved ambulatory surgical centers as defined in §38.7 of this title (relating to Ambulatory Surgical Care Facilities).

      (iv) Emergency care. Care including, but not limited to hospital emergency departments, ancillary, and physician services, is limited to medical conditions manifested 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 placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. If a client is admitted to a non-participating program hospital provider following care in that provider's emergency room and the admitting facility declines to enroll or does not qualify as a program provider, the client must be discharged or transferred to a program provider as soon as the client's medical condition permits. All providers must enroll in order to receive reimbursement.

      (v) Care for renal disease. Renal dialysis is limited to the treatment of acute renal disease or chronic (end stage) renal disease. Treatment may be provided through a renal dialysis facility, inpatient or outpatient hospital, or in the client's home. Covered services include, but are not limited to dialysis, laboratory services, drugs and supplies, declotting shunts, on-site physician services, and appropriate access surgery. Renal transplants must be prior authorized, and approval is subject to the availability of funds. If funding is available, renal transplants may be covered in approved renal transplant centers if the projected cost of the transplant and follow-up care is less than that of continuing renal dialysis. Estimated cost of the renal transplant over a one-year period versus the cost of renal dialysis for one year at their facility must be documented. For each client 18 years of age and older, the transplant team must also provide a plan of care to be implemented after the client reaches 21 years of age and is no longer eligible for program services.

    (F) Orthotic and prosthetic devices. Orthotic and prosthetic devices must be prescribed by a practitioner licensed to do so and supplied by an orthotist or prosthetist licensed by the State of Texas.

    (G) Medications. Outpatient medications available through pharmacy providers, including over-the-counter products, must be prescribed by practitioners licensed to do so.

    (H) Nutrition services and nutritional products, excluding hyperalimentation and total parenteral nutrition (TPN).

      (i) Nutrition services. Nutrition services must be prescribed by a practitioner licensed to do so.

      (ii) Nutritional products. Nutritional products, including over-the-counter products, are limited to those covered by the program and prescribed by a practitioner licensed to do so, for the treatment of an identified metabolic disorder or other medical condition and serving as a medically necessary therapeutic agent for life and health or when part or all nutritional intake is through a tube.

    (I) Hyperalimentation and TPN Services. Services include, but are not limited to solutions and additives, supplies and equipment, customary and routine laboratory work, enteral supplies, and nursing visits. These services may be provided on a daily basis when oral intake cannot maintain adequate nutrition. Covered services must be reasonable, medically necessary, appropriate, and prescribed by a practitioner licensed to do so.

    (J) Medical foods. Coverage for medical foods is limited to the treatment of inborn metabolic disorders. Treatment for any other condition with medical foods requires documentation of medical necessity and prior authorization.

    (K) Durable medical equipment. All equipment must be prescribed by a practitioner licensed to do so. Some equipment may be ordered from a specific supplier.

    (L) Medical supplies. Supplies must be medically necessary for the treatment of an eligible client.

    (M) Professional vision services. Vision services medically necessary for the treatment of a client include, but are not limited to:

      (i) medically necessary eye examinations with refraction for diagnoses of refractive error, aphakia, diseases of the eye, or eye surgery;

      (ii) one eye examination with refraction for the purpose of obtaining eyewear during a calendar year; and

      (iii) one pair of non-prosthetic eye wear per calendar year prescribed by a practitioner licensed to do so.

    (N) Speech-language pathology and audiology. Speech-language pathology and audiology services medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a speech-language pathologist or audiologist licensed by the State of Texas. Program coverage of speech-language pathology and audiology services may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.

    (O) Hearing services include, but are not limited to, hearing screening, audiological assessment, otological examination, hearing aid evaluation, hearing aid devices, hearing aid fitting and repair, hearing aid batteries and supplies, and ear molds.

    (P) Occupational and physical therapy. Occupational and physical therapy medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a therapist licensed by the State of Texas. Program coverage of physical and occupational therapy may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.

    (Q) Certified respiratory care practitioner services. Respiratory therapy medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a certified respiratory care practitioner. Program coverage of respiratory therapy may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.

Cont'd...

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