| (B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) serious disfigurement; or
(E) serious jeopardy to the health of a pregnant woman
or her unborn child.
(36) 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.
(37) Encounter--A covered service or group of covered
services delivered by a provider to a member during a visit between
the member and provider. This also includes value-added services.
(38) Enrollment--The process by which an individual
determined to be eligible for Medicaid is enrolled in a Medicaid MCO
serving the service area in which the individual resides.
(39) EPSDT--The federally mandated Early and Periodic
Screening, Diagnosis, and Treatment program defined in 25 TAC Chapter
33 (relating to Early and Periodic Screening, Diagnosis, and Treatment).
The State of Texas has adopted the name Texas Health Steps (THSteps)
for its EPSDT program.
(40) EPSDT-CCP--The Early and Periodic Screening, Diagnosis,
and Treatment-Comprehensive Care Program described in Chapter 363
of this title (relating to Texas Health Steps Comprehensive Care Program).
(41) 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 Medicaid coverage.
(42) Expedited Credentialing--The process under Texas
Government Code §533.0064 in which an MCO allows an applicant
provider to provide Medicaid services to members on a provisional
basis pending completion of the credentialing process.
(43) 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.
(44) Fair hearing--The process adopted and implemented
by HHSC in Chapter 357, Subchapter A of this title (relating to Uniform
Fair Hearing Rules) in compliance with federal regulations and state
rules relating to Medicaid fair hearings.
(45) Federal Poverty Level (FPL)--The household income
guidelines issued annually and published in the
Federal Register by the United States Department of Health
and Human Services under the authority of 42 U.S.C. §9902(2)
and as in effect for the applicable budget period determined in accordance
with 42 C.F.R. §435.603(h). HHSC uses the FPL to determine an
individual's eligibility for Medicaid.
(46) Federal waiver--Any waiver permitted under federal
law and approved by CMS that allows states to implement Medicaid managed
care.
(47) Federally Qualified Health Center (FQHC)--An entity
that is certified by CMS to meet the requirements of 42 U.S.C. §1395x(aa)(3)
as a Federally Qualified Health Center and is enrolled as a provider
in the Texas Medicaid program.
(48) Former Foster Care Children (FFCC) program--The
Medicaid program for young adults who aged out of the conservatorship
of DFPS, administered in accordance with Chapter 366, Subchapter J
of this title (relating to Former Foster Care Children's Program).
(49) Functional necessity--A member's need for services
and supports with activities of daily living or instrumental activities
of daily living to be healthy and safe in the most integrated setting
possible. This determination is based on the results of a functional
assessment.
(50) Habilitation--Acquisition, maintenance, and enhancement
of skills necessary for the individual to accomplish ADLs, IADLs,
and health-related tasks based on the individual's person-centered
service plan.
(51) Health and Human Services Commission (HHSC)--The
single state agency charged with administration and oversight of the
Texas Medicaid program or its designee.
(52) 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.
(53) Health care provider group--A legal entity, such
as a partnership, corporation, limited liability company, or professional
association, enrolled in Medicaid, under which certified or licensed
individual health care providers provide health care items or services.
(54) 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.
(55) 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.
(56) 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.
(57) Intermediate care facility for individuals with
an intellectual disability or related condition (ICF-IID)--A facility
providing care and services to individuals with intellectual disabilities
or related conditions as defined in §1905(d) of the Social Security
Act (42 U.S.C. 1396(d)).
(58) Legally authorized representative (LAR)--A person
authorized by law to act on behalf of an individual with regard to
a matter described in this chapter, and may, depending on the circumstances,
include a parent, guardian, or managing conservator of a minor, or
the guardian of an adult, or a representative designated pursuant
to 42 C.F.R. 435.923.
(59) Long term service and support (LTSS)--A service
provided to a qualified member in his or her home or other community-based
setting necessary to allow the member to remain in the most integrated
setting possible. LTSS includes services provided under the Texas
State Plan as well as services available to persons who qualify for
STAR+PLUS Home and Community-Based Program services or Medicaid 1915(c)
waiver services. LTSS available through an MCO in STAR+PLUS, STAR
Health, and STAR Kids varies by program model.
(60) Main dental home provider--See definition of "dental
home" in this section.
(61) Main dentist--See definition of "dental home"
in this section.
(62) 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.
(63) Managed care organization (MCO)--A dental MCO
or a health care MCO.
(64) 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.
(65) 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.
(66) MDCP--Medically Dependent Children Program. A §1915(c)
waiver program that provides community-based services to assist Medicaid
beneficiaries under age 21 to live in the community and avoid institutionalization.
(67) Medicaid--The medical assistance program authorized
and funded pursuant to Title XIX of the Social Security Act (42 U.S.C. §1396
et seq) and administered by HHSC.
(68) Medicaid for transitioning foster care youth (MTFCY)
program--The Medicaid program for young adults who aged out of the
conservatorship of DFPS, administered in accordance with Chapter 366,
Subchapter F of this title (relating to Medicaid for Transitioning
Foster Care Youth).
(69) Medical Assistance Only (MAO)--A person who qualifies
financially and functionally for Medicaid assistance but does not
receive Supplemental Security Income (SSI) benefits, as defined in
Chapters 358, 360, and 361, of this title (relating to Medicaid Eligibility
for the Elderly and People with Disabilities, Medicaid Buy-In Program
and Medicaid Buy-In for Children Program).
(70) Medical home--A 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.
(71) Medically necessary--
(A) For Medicaid members birth through age 20, the
following Texas Health Steps services:
Cont'd... |
