| (a) Except as specified in the department-established
service exclusions and limitations, counties are required to provide
the following basic health care services to eligible households by
reimbursing providers of services who meet the requirements of this
chapter and the responsible county.
(1) Inpatient hospital services. Services must be medically
necessary and:
(A) provided in an acute care hospital;
(B) provided to hospital inpatients;
(C) provided by or under the direction of a physician;
and
(D) provided for the care and treatment of patients.
(2) Outpatient hospital services. Services must be
medically necessary and:
(A) provided in an acute care hospital or hospital-based
ambulatory surgical center;
(B) provided to hospital outpatients;
(C) provided by or under the direction of a physician;
and
(D) are diagnostic, therapeutic, or rehabilitative.
(3) Physician services. Services must be medically
necessary and provided by a physician in the doctor's office, a hospital,
a skilled nursing facility, or elsewhere.
(4) Up to three prescriptions for drugs per recipient
per month. New and refilled prescriptions count equally toward this
total prescription limit. Drugs must be prescribed by a physician
or other practitioner within the scope of practice under law. The
quantity of drugs prescribed depends on the prescribing practice of
the physician and the needs of the patient.
(5) Skilled nursing facility services (SNF). Services
must be medically necessary, ordered by a physician, and provided
in a skilled nursing facility that provides daily services on an inpatient
basis.
(6) Rural health clinic services. Rural health clinic
services must be provided in a rural health clinic by a physician,
a physician's assistant, a nurse practitioner, a nurse midwife, or
other specialized nurse practitioner.
(7) Family planning services. These are preventive
health and medical services that assist an individual in controlling
fertility and achieving optimal reproductive and general health.
(8) Laboratory and x-ray services. These are technical
laboratory and radiological services ordered and provided by, or under
the direction of, a physician in an office or a similar facility other
than a hospital outpatient department or clinic.
(9) Immunizations. These are given when appropriate.
(10) Medical screening services. These medical services
include blood pressure, blood sugar, and cholesterol screening.
(11) Annual physical examinations. These are examinations
provided once per calendar year by a physician or a physician's assistant
(PA). Associated testing, such as mammograms, can be covered with
a physician's referral. These services may also be provided by an
Advanced Practice Nurse (APN) if they are within the scope of practice
of the APN in accordance with the standards established by the Board
of Nurse Examiners and published in 22 Texas Administrative Code, §221.13.
(b) The following services are optional health care
services.
(1) Ambulatory surgical center (ASC) services. These
services must be provided in a freestanding ASC, and are limited to
items and services provided in reference to an ambulatory surgical
procedure, including those services on the Center for Medicare and
Medicaid Services (CMS)-approved list and selected Medicaid-only procedures.
(2) Federally Qualified Health Center (FQHC) services.
These services must be provided in an FQHC by a physician, a physician's
assistant, a nurse practitioner, a clinical psychologist, or a clinical
social worker.
(3) Physician assistant (PA) services. These services
must be medically necessary and provided by a PA under the direction
of a physician and may be billed by and paid to the supervising physician.
(4) Advanced practice nurse (APN) services. An APN
must be licensed as a registered nurse (RN) within the categories
of practice, specifically, a nurse practitioner, a clinical nurse
specialist, a certified nurse midwife (CNM), and a certified registered
nurse anesthetist (CRNA), as determined by the Board of Nurse Examiners.
APN services must be medically necessary, provided within the scope
of practice of an APN, and covered in the Texas Medicaid Program.
(5) Counseling services. Psychotherapy services must
be medically necessary based on a physician referral, and provided
by a licensed professional counselor (LPC), a licensed master social
worker-advanced clinical practitioner (LMSW-ACP), a licensed marriage
family therapist (LMFT), or a Ph.D. psychologist. These services may
also be provided based on an APN referral if the referral is within
the scope of their practice in accordance with the standards established
by the Board of Nurse Examiners and published in 22 Texas Administrative
Code, §221.13.
(6) Diabetic medical supplies and equipment. These
supplies and equipment must be medically necessary and prescribed
by a physician. The county may require the supplier to receive prior
authorization. Items covered are lancets, alcohol prep pads, syringes,
test strips, humulin pens and glucometers. These supplies and equipment
may also be prescribed by an APN if this is within the scope of their
practice in accordance with the standards established by the Board
of Nurse Examiners and published in 22 Texas Administrative Code, §221.13.
(7) Colostomy medical supplies and equipment. These
supplies and equipment must be medically necessary and prescribed
by a physician. The county may require the supplier to receive prior
authorization. Items covered are colostomy bags/pouches; cleansing
irrigation kits, paste, or powder; and skin barriers with flange
(wafers). These supplies and equipment may also be prescribed by an
APN if this is within the scope of their practice in accordance with
the standards established by the Board of Nurse Examiners and published
in 22 Texas Administrative Code, §221.13.
(8) Durable medical equipment. This equipment must
be medically necessary; meet the Medicare/Medicaid requirements; and
provided under a written, signed, and dated physician's prescription.
The county may require the supplier to receive prior authorization.
Items can be rented or purchased, whichever is the least costly. Items
covered are crutches, canes, walkers, standard wheel chairs, hospital
beds, home oxygen equipment (including masks, oxygen hose, and nebulizers),
and reasonable and appropriate appliances for measuring blood pressure.
These supplies and equipment may also be prescribed by an APN if this
is within the scope of their practice in accordance with the standards
established by the Board of Nurse Examiners and published in 22 Texas
Administrative Code, §221.13.
(9) Home and community health care services. These
services must be medically necessary; meet the Medicare/Medicaid requirements;
and provided by a certified home health agency. A plan of care must
be recommended, signed, and dated by the recipient's attending physician
prior to care being given. The county may require prior authorization.
Items covered are Registered Nurse (RN) visits for skilled nursing
observation, assessment, evaluation, and treatment provided a physician
specifically requests the RN visit for this purpose. A home health
aide to assist with administering medication is also covered. Visits
made for performing housekeeping services are not covered.
(10) Dental care. These services must be medically
necessary and provided by a DDS, a DMD, or a DDM. The county may require
prior authorization. Items covered are an annual routine dental exam
and the least costly service for emergency dental conditions for the
removal or filling of a tooth due to abscess, infection, or extreme
pain.
(11) Vision care, including eyeglasses. The county
may require prior authorization. Items covered are one examination
of the eyes by refraction and one pair of prescribed glasses every
24 months.
(12) Emergency medical services. These services are
ground ambulance transport services. When the client's condition is
life-threatening and requires the use of special equipment, life support
systems, and close monitoring by trained attendants while en route
to the nearest appropriate facility, ground ambulance transport is
an emergency service.
(13) Physical therapy services. These services must
be medically necessary and may be covered if provided in a physician's
office, a therapist's office, in an outpatient rehabilitation or freestanding
rehabilitation facility, or in a licensed hospital. Services must
be within the provider's scope of practice, as defined by Occupations
Code, Chapter 453.
(14) Occupational therapy services. These services
must be medically necessary and may be covered if provided in a physician's
office, a therapist's office, in an outpatient rehabilitation or free-standing
rehabilitation facility, or in a licensed hospital. Services must
be within the provider's scope of practice, as defined by Occupations
Code, Chapter 454.
(15) Other medically necessary services or supplies
that the local governmental municipality/entity determines to be cost
effective.
|
