| (VI) specialized equipment, including porch or stair
lifts, air purification systems or air conditioners, positioning equipment,
bath aids, supplies prescribed by licensed practitioners that are
not covered through other systems, and other non-medical disability-related
equipment that assists with family activities, promotes the client's
self-reliance, or otherwise supports the family; and
(VII) other disability-related services that support
permanency planning, independence, or participation in family life
and integrated or inclusive community activities.
(E) Unallowable services. Family support funds may
not be used to provide those services that do not relate to the client's
disability and do not directly support the client's living in his
or her natural home and participating in family life and integrated
or inclusive community activities. Examples of unallowable services
include, but are not limited to:
(i) items for which a less expensive alternative of
comparable quality is available;
(ii) purchase or lease of vehicles or vehicle maintenance
and repair;
(iii) home mortgage or rent expenses or basic home
maintenance and repair;
(iv) income taxes;
(v) medical services;
(vi) services in segregated settings other than respite
facilities or camps;
(vii) insurance premiums;
(viii) death benefits, burial policies, and funeral
expenses;
(ix) costs for allowable services incurred before the
requested family support service is prior authorized;
(x) non-medical foods, routine shelter, routine utilities,
routine home repairs, routine home appliances, routine furnishings,
fences, and yard work;
(xi) medical benefit items or services paid for or
reimbursed by private insurance, Medicaid, Medicare, CHIP, the CSHCN
Services Program or other health insurance programs for which the
client is eligible;
(xii) services, equipment, or supplies that have been
denied by Medicaid, CHIP, or the program because a claim was received
after the filing deadline, because insufficient information was submitted,
or because an item was considered inappropriate or experimental;
(xiii) over-the-counter or prescription medications;
(xiv) architectural modifications to a public facility;
(xv) school tuition or fees, or equipment, items, or
services that should be provided through the public school system;
(xvi) items that could endanger the health and safety
of the client;
(xvii) routine child care;
(xviii) computers and software unless for use as an
assistive technology device or necessary to perform a critical or
essential function, such as environmental control or written or oral
communication, which the client is unable to perform without the computer;
(xix) services provided by an individual under the
age of 18 years or by the client's parent(s), guardian, or other
individual(s) residing with the client; and
(xx) services exclusively to support the care of siblings
or other individual(s) residing with the client, but which are not
necessary to meet the medical needs of the client.
(F) Reduction or termination of services. Reasons for
terminating or reducing family support services may include, but are
not limited to:
(i) the client no longer meets the eligibility criteria
for the program;
(ii) services available through the program are discontinued
due to budget restrictions;
(iii) While there is a waiting list for health care
benefits, limitations in reimbursement or prior authorization may
be instituted as provided in §38.16 of this title;
(iv) the client's family indicates that the need for
family support services no longer exists;
(v) the client moves out of Texas;
(vi) the client is placed in a nursing facility or
other institutional setting for an indefinite period of time;
(vii) the client dies;
(viii) the client's designated case manager is unable
to locate the client and family; or
(ix) the family knowingly does not comply with the
family assessment and service plan in which case the family may also
be liable for restitution.
(6) Other types of services. The following services
also are available through the program.
(A) Ambulance services. Emergency ground, non-emergency
ground and air ambulance services are covered for the medically necessary
transportation of a client. Non-emergency ambulance transport is covered
if the client cannot be transported by any other means without endangering
the health or safety of the client and when there is a scheduled medical
appointment for medically necessary care at the nearest appropriate
facility. Transportation by air ambulance is limited to instances
when the client's pickup point is inaccessible by land or when great
distance interferes with immediate admission to the nearest appropriate
medical treatment facility. Transports to out-of-locality providers
are covered if a local facility is not adequately equipped to treat
the client. Out-of-locality refers to one-way transfers 50 miles or
more from point of pickup to point of destination.
(B) Transportation. The program may provide transportation
for a client and, if needed, a responsible adult, to and from the
nearest medically appropriate facility (in Texas or in the United
States 50 or fewer miles from the Texas border) to obtain medically
necessary and appropriate health care services that are within the
scope of coverage of the program and are provided by a program enrolled
provider. The lowest-cost appropriate conveyance should be used. The
program shall not assist if transportation is the responsibility of
the client's school district or can be obtained through Medicaid.
Transportation to out-of-state services located more than 50 miles
from the Texas border will not be approved except as specified in §38.6(e)
of this title (relating to Providers).
(C) Meals and lodging. The program may provide meals
and lodging to enable a client, accompanied by a parent, guardian,
or their designee as needed, to obtain inpatient or outpatient care
at a facility located away from their home. The reason for the inpatient
or outpatient visit must be directly related to medically necessary
treatment for the client that is provided by program enrolled providers
and covered by the program. Meals and lodging associated with travel
to services that are provided more than 50 miles from the Texas border
will not be approved except as specified in §38.6(e) of this
title.
(D) Transportation of deceased. The program may provide
the following services:
(i) transportation cost for the remains of a client
who expires in a program-approved facility while receiving program
health care benefits, if the client was not in the family's city of
residence in Texas, and the transportation cost of a parent or other
person accompanying the remains from the facility to the place of
burial in Texas that is designated by the parent or other person legally
responsible for interment;
(ii) embalming of the deceased if required by law for
transportation;
(iii) a coffin meeting minimum requirements if required
by law for transportation; and
(iv) any other necessary expenses directly related
to the care and return of the client's remains.
(E) Payment of insurance premiums, coinsurance, co-payments,
and deductibles. The program may pay public or private health insurance
premiums to maintain or acquire a health benefit plan or other third
party coverage for the client, and if paying for such health insurance
can reasonably be expected to be cost effective for the program. The
program may pay for coinsurance and deductible amounts when the total
amount paid (including all payers) to the provider does not exceed
the amount allowed by the program for the covered service. The program
may reimburse clients for co-payments paid for covered drugs. The
program will not pay premiums, deductibles, coinsurance, or co-payments
for clients enrolled in CHIP.
(c) Services not covered. Services which are not covered
by the program even though they may be medically necessary for and
provided to a client include, but are not limited to:
(1) treatments which are considered experimental or
investigational;
(2) chiropractic services;
(3) care for premature infants;
(4) care for alcohol or substance abuse;
(5) pregnancy prevention, except when medically necessary
for the specific treatment of a condition meeting the parameters of
the "child with special health care needs" definition;
Cont'd... |
