| (E) serious jeopardy to the health of a pregnant woman
or her unborn child.
(35) Emergency Service--A covered inpatient and outpatient
service, furnished by a network provider or out-of-network provider
that is qualified to furnish such service, that is needed to evaluate
or stabilize an emergency medical condition and/or an emergency behavioral
health condition. For health care MCOs, the term "emergency service"
includes post-stabilization care services.
(36) Enrollment--The process by which a child determined
to be eligible for CHIP is enrolled in a CHIP MCO serving the service
area in which the child resides.
(37) Exclusive provider benefit plan (EPBP)--An MCO
that complies with 28 TAC §§3.9201 - 3.9212 (relating to
the Texas Department of Insurance's requirements for EPBPs), and contracts
with HHSC to provide CHIP coverage.
(38) Experience rebate--The portion of the MCO's net
income before taxes that is returned to the State in accordance with
the MCO's contract with HHSC.
(39) Federal Poverty Level (FPL)--The income guidelines
issued annually and published in the Federal
Register by the United States Department of Health and Human
Services.
(40) Health care managed care organization (health
care MCO)--An entity that is licensed or approved by the Texas Department
of Insurance to operate as a health maintenance organization or to
issue an EPBP.
(41) Health care services--The acute care, behavioral
health care, and health-related services that an enrolled population
might reasonably require in order to be maintained in good health,
including, at a minimum, emergency services and inpatient and outpatient
services.
(42) Health maintenance organization (HMO)--An organization
that holds a certificate of authority from the Texas Department of
Insurance to operate as an HMO under Chapter 843 of the Texas Insurance
Code, or a certified Approved Non-Profit Health Corporation formed
in compliance with Chapter 844 of the Texas Insurance Code (relating
to Certification of Nonprofit Health Corporations).
(43) Hospital--A licensed public or private institution
as defined in the Texas Health and Safety Code at Chapter 241 (relating
to Hospitals), or Chapter 261 (relating to Municipal Hospitals).
(44) Household composition--The group of individuals
who are considered in determining eligibility for an applicant or
recipient for certain medical programs based on tax status, tax relationships,
living arrangements, and family relationships, referenced in 42 CFR §435.603(f)
as "household."
(45) Main dental home provider--See definition of "dental
home" in this section.
(46) Main dentist--See definition of "dental home"
in this section.
(47) Managed care--A health care delivery system or
dental services delivery system in which the overall care of a patient
is coordinated by or through a single provider or organization.
(48) Managed care organization (MCO)--A dental MCO
or a health care MCO.
(49) Marketing--Any communication from an MCO to a
client who is not enrolled with the MCO that can reasonably be interpreted
as intended to influence the client's decision to enroll, not to enroll,
or to disenroll from a particular MCO.
(50) Marketing materials--Materials that are produced
in any medium by or on behalf of the MCO that can reasonably be interpreted
as intending to market to potential members. Materials relating to
the prevention, diagnosis or treatment of a medical or dental condition
are not marketing materials.
(51) Medical home--A primary care provider (PCP) or
specialty care provider who has accepted the responsibility for providing
accessible, continuous, comprehensive, and coordinated care to members
participating in an MCO contracted with HHSC.
(52) Medically necessary health care services--Means:
(A) Dental services and non-behavioral health services
that are:
(i) reasonable and necessary to prevent illnesses or
medical conditions, or provide early screening, interventions, or
treatments for conditions that cause suffering or pain, cause physical
deformity or limitations in function, threaten to cause or worsen
a disability, cause illness or infirmity of a member, or endanger
life;
(ii) provided at appropriate facilities and at the
appropriate levels of care for the treatment of a member's health
conditions;
(iii) consistent with health care practice guidelines
and standards that are endorsed by professionally recognized health
care organizations or governmental agencies;
(iv) consistent with the member's diagnoses;
(v) no more intrusive or restrictive than necessary
to provide a proper balance of safety, effectiveness, and efficiency;
(vi) not experimental or investigative; and
(vii) not primarily for the convenience of the member
or provider.
(B) Behavioral health services that:
(i) are reasonable and necessary for the diagnosis
or treatment of a mental health or chemical dependency disorder, or
to improve, maintain, or prevent deterioration of functioning resulting
from such a disorder;
(ii) are in accordance with professionally accepted
clinical guidelines and standards of practice in behavioral health
care;
(iii) are furnished in the most appropriate and least
restrictive setting in which services can be safely provided;
(iv) are the most appropriate level or supply of service
that can safely be provided;
(v) could not be omitted without adversely affecting
the member's mental and/or physical health or the quality of care
rendered;
(vi) are not experimental or investigative; and
(vii) are not primarily for the convenience of the
member or provider.
(53) Member education program--A planned program of
education:
(A) concerning access to health care services or dental
services through the MCO and about specific health or dental topics;
(B) that is approved by HHSC; and
(C) that is provided to members through a variety of
mechanisms that must include, at a minimum, written materials and
face-to-face or audiovisual communications.
(54) Member materials--All written materials produced
or authorized by the MCO and distributed to members or potential members
containing information concerning the managed care program. Member
materials include member ID cards, member handbooks, provider directories,
and marketing materials.
(55) Member--A child enrolled in a CHIP MCO.
(56) Participating MCO--An MCO that has a contract
with HHSC to provide services to members.
(57) Primary care provider (PCP)--A physician or other
provider who has agreed with the health care MCO to provide a medical
home to members and who is responsible for providing initial and primary
care to patients, maintaining the continuity of patient care, and
initiating referral for care.
(58) Provider--A credentialed and licensed individual,
facility, agency, institution, organization or other entity, and its
employees and subcontractors, that has a contract with the MCO for
the delivery of covered services to the MCO's members.
(59) Provider education program--Program of education
about the CHIP managed care program and about specific health or dental
care issues presented by the MCO to its providers through written
materials and training events.
(60) Provider network or network--All providers that
have contracted with the MCO for the CHIP program.
(61) Quality improvement--A system to continuously
examine, monitor, and revise processes and systems that support and
improve administrative and clinical functions.
(62) Recipient--An individual receiving CHIP services,
including a person who is renewing eligibility for CHIP.
(63) Risk--The potential for loss as a result of expenses
and costs of the MCO exceeding payments made by HHSC under the contract.
(64) Service area--The counties included in any HHSC-defined
service area as applicable to each MCO.
(65) Qualified Alien--An alien who, at the time of
application, satisfies the criteria established under 8 U.S.C. §1641(b).
(66) Significant traditional provider (STP)--A provider
identified by HHSC as having provided a significant level of care
to the target population.
(67) SSI--Supplemental Security Income.
(68) State Fiscal Year--The 12-month period beginning
September 1 of each calendar year and ending August 31 of the following
calendar year.
(69) State Plan--The plan permitted under federal law
and approved by CMS that allows the state to implement the CHIP program.
(70) Value-added service--A service provided by an
MCO that is in addition to the covered services included within the
scope of the CHIP State Plan and the MCO's contract with HHSC.
|
| Source Note: The provisions of this §370.4 adopted to be effective April 4, 2001, 26 TexReg 2519; amended to be effective September 1, 2003, 28 TexReg 7337; amended to be effective August 24, 2004, 29 TexReg 4448; amended to be effective January 1, 2006, 30 TexReg 8666; amended to be effective September 1, 2007, 32 TexReg 5359; amended to be effective March 1, 2012, 37 TexReg 1301; amended to be effective July 8, 2012, 37 TexReg 4854; amended to be effective January 1, 2014, 38 TexReg 9477; amended to be effective June 1, 2014, 39 TexReg 3983; amended to be effective January 22, 2015, 39 TexReg 9889 |
