| (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;
(6) maternity care services specific to routine pregnancy
care, labor and delivery, and maternal post-partum care;
(7) infertility treatment;
(8) services provided by a nursing home or facility;
and
(9) services provided while the client is in the custody
of or incarcerated by any municipal, county, state, or federal governmental
entity. Case management or prior approved family support services
not provided by the governmental entity that are needed during the
time when a client is transitioning from custody or incarceration
into a community living setting may be covered.
(d) Authorization and prior authorization of selected
services.
(1) Provider's responsibility. A program provider must
request services in specific terms on department-prepared forms so
that an authorization may be issued and sufficient monies encumbered
to cover the cost of the service. If a service is authorized, payment
may be made to the provider as long as the service is not covered
by a third party resource and all billing requirements are met. Program
authorization should not be considered an absolute guarantee of payment.
Once a service is delivered and if the service requires authorization
for payment, the authorization request for that service must be submitted
within 95 days of the date of service.
(2) Required prior authorization for selected services.
At the program's option, selected services may require authorization
prior to the delivery of services in order for payment to be made.
Prior authorization requests must be submitted prior to the date of
service.
(3) 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.
(4) Denied authorization requests are authorization
requests which are incomplete, submitted on the wrong form, lack necessary
documentation, contain inaccurate information, fail to meet authorization
request submission deadlines, are for ineligible persons, services,
or providers, or are for clients who do not qualify for the health
care benefit requested. Denied authorization requests may be corrected
and resubmitted for reconsideration. Authorization requests must meet
authorization request submission deadlines. Denied authorization requests
may be appealed according to §38.13 of this title.
(e) Pilot projects. The program may initiate and participate
in pilot projects. New projects are possible only if funds are available
in the current fiscal year. All pilot projects are limited to no more
than 10% of the fiscal year appropriation.
|
| Source Note: The provisions of this §351.4 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982 |
