| (i) screening, vision, dental, and hearing services;
and
(ii) other health care services or dental services
that are necessary to correct or ameliorate a defect or physical or
mental illness or condition. A determination of whether a service
is necessary to correct or ameliorate a defect or physical or mental
illness or condition:
(I) must comply with the requirements of a final court
order that applies to the Texas Medicaid program or the Texas Medicaid
managed care program as a whole; and
(II) may include consideration of other relevant factors,
such as the criteria described in subparagraphs (B)(ii) - (vii) and
(C)(ii) - (vii) of this paragraph.
(B) For Medicaid members over age 20, 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 medical need;
(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.
(C) For Medicaid members over age 20, behavioral health
services that:
(i) are reasonable and necessary for the diagnosis
or treatment of a mental health or substance use 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.
(72) Member--A person who is eligible for benefits
under Title XIX of the Social Security Act and Medicaid, is in a Medicaid
eligibility category included in the Medicaid managed care program,
and is enrolled in a Medicaid MCO.
(73) 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.
(74) 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.
(75) Non-capitated service--A benefit available to
members under the Texas Medicaid program for which an MCO is not responsible
for payment.
(76) Outside regular business hours--As applied to
FQHCs and rural health clinics (RHCs), means before 8 a.m. and after
5 p.m. Monday through Friday, weekends, and federal holidays.
(77) Participating MCO--An MCO that has a contract
with HHSC to provide services to members.
(78) Permanency Care Assistance Program--The program
administered by DFPS in accordance with 40 TAC Chapter 700, Subchapter
J, Division 2 (relating to Permanency Care Assistance Program).
(79) Person-centered care--An approach to care that
focuses on members as individuals and supports caregivers working
most closely with them. It involves a continual process of listening,
testing new approaches, and changing routines and organizational approaches
in an effort to individualize and de-institutionalize the care environment.
(80) Person-centered planning--A documented service
planning process that includes people chosen by the individual, is
directed by the individual to the maximum extent possible, enables
the individual to make choices and decisions, is timely and occurs
at times and locations convenient to the individual, reflects cultural
considerations of the individual, includes strategies for solving
conflict or disagreement within the process, offers choices to the
individual regarding the services and supports they receive and from
whom, includes a method for the individual to require updates to the
plan, and records alternative settings that were considered by the
individual.
(81) Post-stabilization care service--A covered service,
related to an emergency medical condition, that is provided after
a Medicaid member is stabilized in order to maintain the stabilized
condition, or, under the circumstances described in 42 C.F.R. §438.114(b)
and (e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve
the Medicaid member's condition.
(82) 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.
(83) 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.
(84) Provider education program--Program of education
about the Medicaid managed care program and about specific health
or dental care issues presented by the MCO to its providers through
written materials and training events.
(85) Provider network or Network--All providers that
have contracted with the MCO for the applicable managed care program.
(86) Quality improvement--A system to continuously
examine, monitor, and revise processes and systems that support and
improve administrative and clinical functions.
(87) Rural Health Clinic (RHC)--An entity that meets
all of the requirements for designation as a rural health clinic under §1861(aa)(1)
of the Social Security Act (42 U.S.C. §1395x(aa)(1)) and is approved
for participation in the Texas Medicaid program.
(88) Service area--The counties included in any HHSC-defined
service area as applicable to each MCO.
(89) Significant traditional provider (STP)--A provider
identified by HHSC as having provided a significant level of care
to the target population, including a DSH.
(90) STAR--The State of Texas Access Reform (STAR)
managed care program that operates under a federal waiver and primarily
provides, arranges for, and coordinates preventive, primary, acute
care, and pharmacy services for low-income families, children, and
pregnant women.
(91) STAR Health--The managed care program that operates
under the Medicaid state plan and primarily serves:
(A) children and youth in DFPS conservatorship;
(B) young adults who voluntarily agree to continue
in a foster care placement (if the state as conservator elects to
place the child in managed care); and
(C) young adults who are eligible for Medicaid as a
result of their former foster care status through the month of their
21st birthday.
(92) STAR Kids--The program that operates under a federal
waiver and primarily provides, arranges, and coordinates preventative,
primary, acute care, and long-term services and supports to persons
with disabilities under the age of 21 who qualify for Medicaid.
(93) STAR+PLUS--The managed care program that operates
under a federal waiver and primarily provides, arranges, and coordinates
preventive, primary, acute care, and long-term services and supports
to persons with disabilities and elderly persons age 65 and over who
qualify for Medicaid by virtue of their SSI or MAO status.
Cont'd... |
