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TITLE 26HEALTH AND HUMAN SERVICES
PART 1HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 351CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM
RULE §351.16Procedures to Address Program Budget Alignment

(d) When the program projects that the estimated amount of funds to be expended by the program in the fiscal year is less than the program's appropriated funds and other available resources due to the cost reduction, limitation, or deferral procedures implemented according to subsections (b) or (c) of this section, or the program's receipt of additional funding, or funding analysis resulting in a projected amount of unobligated funds, the program shall increase the amount of funds to be expended by the program.

  (1) In an effort to expend unobligated funds (except for unobligated funds resulting from program actions taken according to subsection (c) of this section), the program shall utilize the following steps in the order listed only until the program projects that the estimated amount of unobligated funds will be expended by the program during the fiscal year:

    (A) take clients off the waiting list according to the original date and time that starts the client's latest uninterrupted sequence of eligibility for program health care benefits and in the following group order:

      (i) clients who are less than 21 years old and who have an urgent need for health care benefits as described in subsection (e) of this section;

      (ii) clients who are 21 years of age or older and who have an urgent need for health care benefits as described in subsection (e) of this section;

      (iii) all other clients who are less than 21 years old who do not have an urgent need for health care benefits; and

      (iv) all other clients who are 21 years of age or older who do not have an urgent need for health care benefits;

    (B) provide health care benefits for clients taken off the waiting list as long as program unobligated funds are available;

    (C) provide limited health care benefits for clients who are on the waiting list and remain on the waiting list, payment of outstanding bills for health care benefits for clients 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 only:

      (i) when projected unobligated funds are projected to be insufficient to take clients (or additional clients) off the waiting list and maintain continuous program health care benefits coverage for those clients or when projected unobligated funds may lapse if not expended in this manner;

      (ii) as long as program unobligated funds are available; and

      (iii) if the outstanding bills for health care benefits are for dates of service that are within the time period that program unobligated funds are available and provided the client was eligible for program health care benefits at the time of the dates of service;

    (D) if the program projects that the amount of funds to be expended by the program in the fiscal year will be less than the program's appropriated funds and other available resources after no clients eligible for program health care benefits remain on the waiting list, the program may take the following actions in the following order:

      (i) eliminate limitations on prior authorization for family support services;

      (ii) provide prior authorized coverage of diagnosis and evaluation services for applicants who qualify for up to 60 days of program coverage for diagnosis and evaluation services only;

      (iii) remove any of the additional measures taken to reduce or limit the amount of funds to be expended by the program as directed by rule;

      (iv) remove any reductions or limitations to contractor reimbursements that have been implemented; and

      (v) expand program services.

  (2) In an effort to expend unobligated funds resulting from program actions taken according to subsection (c) of this section (unobligated cost savings funds that remain after all clients with urgent need for health care benefits have been removed from the waiting list and provided health care benefits), the program shall utilize the following steps in the order listed only until the program projects that the estimated amount of unobligated funds will be expended by the program during the fiscal year:

    (A) take additional clients off the waiting list according to the original date and time that starts the client's latest uninterrupted sequence of eligibility for program health care benefits and in the following group order:

      (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.


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

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