| (i) clients who are less than 21 years old who do not
have an urgent need for health care benefits and who are clients who
were placed on the waiting list when they were ongoing clients and
who have had no lapse in eligibility while on the waiting list;
(ii) clients who are 21 years of age or older who do
not have an urgent need for health care benefits and who are clients
who were placed on the waiting list when they were ongoing clients
and who have had no lapse in eligibility while on the waiting list;
(B) provide health care benefits (which may or may
not include coverage of outstanding bills for health care benefits)
as stipulated in paragraph (1)(B) of this subsection for these clients
taken off the waiting list;
(C) provide limited health care benefits for clients
identified in subparagraph (A)(i) and (ii) of this paragraph who are
on the waiting list and remain on the waiting list, payment of outstanding
bills for health care benefits for clients identified in subparagraph
(A)(i) and (ii) of this paragraph who are on the waiting list and
remain on the waiting list, or payment of outstanding bills for health
care benefits for clients who have been taken off the waiting list.
The program's coverage of such health care benefits may be limited
in scope, amount, and duration and is not intended to be sustained
over time. If limited health care benefits coverage includes coverage
of family support services, the coverage of family support services
must be limited according to the parameters set forth in subsection
(b)(2)(C)(i) of this section. This coverage may be provided at any
point during activities described by subparagraphs (A) and (B) of
this paragraph and only as stipulated in paragraph (1)(C)(i) - (iii)
of this subsection;
(D) remove any of the additional measures taken to
generate cost savings by rule according to subsection (c)(1)(C) of
this section; and
(E) remove any reductions or limitations to contractor
reimbursements that have been implemented.
(e) The program shall establish a protocol to be used
by the medical director or other designated medical staff to determine
whether a client has an "urgent need for health care benefits" by
considering criteria including, but not limited to, the following:
(1) the physician or dentist who signs the client's
application or the treating physician or dentist attests or documents
the physician's or dentist's determination that delay in receiving
health care benefits could result in loss of life, permanent increase
in disability, or intense pain and suffering;
(2) the client or family states that no other source
of health insurance coverage is available to the client;
(3) information on the application for health care
benefits indicates the complexity of the client's condition or need
for care;
(4) information received from program regional case
management staff or contractors supports other information gathered
or indicates that a delay in health care benefits could reasonably
be expected to result in an out-of-home placement or institutionalization
of the client because the family cannot continue to care for the client;
and
(5) information obtained from diagnosis and evaluation
services as prior authorized by the program medical director or other
designated medical staff.
(f) The program central office may establish and administer
the waiting list for health care benefits to address a budget shortfall.
(1) In order to facilitate contacting clients on the
waiting list, the program shall collect information including, but
not limited to the following:
(A) the client's name, address, and telephone number;
(B) the name, address, and telephone number of a contact
person other than the client;
(C) the date of the client's earliest application for
health care benefits;
(D) the date on which the client became eligible for
health care benefits;
(E) the client's functional limitations or needs;
(F) the range of services needed by the client; and
(G) a date on which the client is scheduled for reassessment.
(2) The waiting list is maintained continually from
one fiscal year to the next. Clients must maintain eligibility for
health care benefits to remain on the waiting list. A lapse of eligibility
for health care benefits constitutes loss of position on the waiting
list.
(3) The program shall refer clients on the waiting
list to other possible sources of services and shall contact waiting
list clients periodically to confirm their continuing need for program
services.
(4) The program will offer case management services
as needed or desired to all clients who are eligible for health care
benefits including those on the waiting list for health care benefits.
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| Source Note: The provisions of this §351.16 adopted 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 |
