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(F) Orthotic and prosthetic devices. Orthotic and prosthetic
devices must be prescribed by a practitioner licensed to do so and
supplied by an orthotist or prosthetist licensed by the State of Texas.
(G) Medications. Outpatient medications available through
pharmacy providers, including over-the-counter products, must be prescribed
by practitioners licensed to do so.
(H) Nutrition services and nutritional products, excluding
hyperalimentation and total parenteral nutrition (TPN).
(i) Nutrition services. Nutrition services must be
prescribed by a practitioner licensed to do so.
(ii) Nutritional products. Nutritional products, including
over-the-counter products, are limited to those covered by the program
and prescribed by a practitioner licensed to do so, for the treatment
of an identified metabolic disorder or other medical condition and
serving as a medically necessary therapeutic agent for life and health
or when part or all nutritional intake is through a tube.
(I) Hyperalimentation and TPN Services. Services include,
but are not limited to solutions and additives, supplies and equipment,
customary and routine laboratory work, enteral supplies, and nursing
visits. These services may be provided on a daily basis when oral
intake cannot maintain adequate nutrition. Covered services must be
reasonable, medically necessary, appropriate, and prescribed by a
practitioner licensed to do so.
(J) Medical foods. Coverage for medical foods is limited
to the treatment of inborn metabolic disorders. Treatment for any
other condition with medical foods requires documentation of medical
necessity and prior authorization.
(K) Durable medical equipment. All equipment must be
prescribed by a practitioner licensed to do so. Some equipment may
be ordered from a specific supplier.
(L) Medical supplies. Supplies must be medically necessary
for the treatment of an eligible client.
(M) Professional vision services. Vision services medically
necessary for the treatment of a client include, but are not limited
to:
(i) medically necessary eye examinations with refraction
for diagnoses of refractive error, aphakia, diseases of the eye, or
eye surgery;
(ii) one eye examination with refraction for the purpose
of obtaining eyewear during a calendar year; and
(iii) one pair of non-prosthetic eye wear per calendar
year prescribed by a practitioner licensed to do so.
(N) Speech-language pathology and audiology. Speech-language
pathology and audiology services medically necessary for the treatment
of a client must be prescribed by a practitioner licensed to do so
and provided by a speech-language pathologist or audiologist licensed
by the State of Texas. Program coverage of speech-language pathology
and audiology services may be limited to certain conditions, by type
of service, by age, by the client's medical status, and whether the
client is eligible for services for which a school district is legally
responsible.
(O) Hearing services include, but are not limited to,
hearing screening, audiological assessment, otological examination,
hearing aid evaluation, hearing aid devices, hearing aid fitting and
repair, hearing aid batteries and supplies, and ear molds.
(P) Occupational and physical therapy. Occupational
and physical therapy medically necessary for the treatment of a client
must be prescribed by a practitioner licensed to do so and provided
by a therapist licensed by the State of Texas. Program coverage of
physical and occupational therapy may be limited to certain conditions,
by type of service, by age, by the client's medical status, and whether
the client is eligible for services for which a school district is
legally responsible.
(Q) Certified respiratory care practitioner services.
Respiratory therapy medically necessary for the treatment of a client
must be prescribed by a practitioner licensed to do so and provided
by a certified respiratory care practitioner. Program coverage of
respiratory therapy may be limited to certain conditions, by type
of service, by age, by the client's medical status, and whether the
client is eligible for services for which a school district is legally
responsible.
(R) Home health nursing services. Home health nursing
services must be medically necessary, be prescribed by a physician,
and be provided only by a licensed and certified home and community
support services agency participating in the program. Home health
nursing services are limited to 200 hours per client per calendar
year. Up to 200 additional hours of service per client per calendar
year may be approved with documented justification of need and cost
effectiveness.
(S) Hospice care. Hospice care includes palliative
care for clients with a presumed life expectancy of six months or
less during the last weeks and months before death. Services apply
to care for the hospice terminal diagnosis condition or illnesses.
Treatment for conditions unrelated to the terminal condition or illnesses
is unaffected. Hospice care must be prescribed by a practitioner licensed
to do so who also is enrolled as a program provider.
(4) Care management.
(A) Medical home. Each program client should receive
care in the context of a medical home.
(i) Comprehensive, coordinated health care of infants,
children, and adolescents should encompass the following services:
(I) provision of preventive care, including but not
limited to, immunizations, growth and development assessments, appropriate
screening health care supervision, client and parental counseling
about health care supervision, and client and parental counseling
about health and psychological issues;
(II) assurance of ambulatory and inpatient care for
acute illness, 24 hours a day, seven days a week (including after
hours and weekends);
(III) provision of care over an extended period of
time to enhance continuity;
(IV) identification of the need for sub-specialty consultation
and referrals, provision of medical information about the client to
the consultant, evaluation of the consultant's recommendations, implementation
of recommendations that are indicated and appropriate, and interpretation
of the consultant's recommendations for the family;
(V) interaction with school and community agencies
to assure that the special health needs of the client are addressed;
(VI) guidance and assistance needed to make the transition
to all aspects of adult life, including adult health care, work, and
independence; and
(VII) maintenance of a central record and database
containing all pertinent medical information about the client including
information about hospitalizations.
(ii) The CSHCN Services Program may require periodic
reports from the medical home.
(B) Case management. Case management services may be
made available to program clients through public health regional offices
or other resources to assist clients and their families in obtaining
adequate and appropriate services to meet the client's health and
related services needs. The program will make available case management
as needed or desired to all clients who are eligible for health care
benefits (includes clients who are on the waiting list for health
care benefits). The program also may make available case management
services to clients who are not eligible for the program's health
care benefits.
(5) Family support services. Family support services
include disability-related support, resources, or other assistance
and may be provided to the family of a client with special health
care needs.
(A) Eligibility. A client is eligible to receive family
support services if:
(i) the client is not receiving services from a Medicaid
waiver program, and the family support needs cannot be met by services
from other family support programs, such as the Department of Aging
and Disability Services or the In-Home and Family Support Program;
and
(ii) the client's family collaborates with the assigned
case manager to identify and pursue other sources of support and to
develop a family assessment and service plan.
(B) Processing and evaluation of requests.
(i) Families of clients indicate their need for family
support services by completing and signing an approved request form.
(ii) Requests for family support services are processed
in chronological order by the date of the request.
(iii) All requests for family support services must
be prior authorized (approved by the program prior to delivery).
(iv) 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.
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