| (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 Cont'd... |
