The following terms are specific to the Texas Medicaid Wellness
Program, when used in this division, have the following meanings,
unless the context clearly indicates otherwise.
(1) Care management--An approach or process for persons
with complex needs and/or chronic illness that is focused on preventing
acute or urgent care utilization through the use of accepted clinical
and non-clinical interventions. These interventions include services
such as care coordination; telephone access to nurses skilled in monitoring
and providing consultation on how to address disease symptoms and
complications, including answering medication questions; providing
patient education; self-management care skills; and providing physician-coordinated
(2) Case management--A process whereby covered persons
with specific healthcare needs are identified and a care plan is developed
and implemented that efficiently utilizes health care resources to
achieve the optimum outcome in the most cost-effective manner.
(3) Claim--A request for payment for authorized benefits
submitted on the applicable approved form that meets the established
(4) Texas Medicaid Wellness Program--A holistic approach
to health care delivery designed to identify and provide services
to Medicaid fee-for-service clients with, or who are at risk for,
incurring high-cost medical services due to chronic illness or complex
(5) Eligible client--An individual who has been designated
by the State as eligible for medical care and services under the Medicaid
program and meets the requirements for the Texas Medicaid Wellness
(6) Fee-for-Service Reimbursement--The traditional
health care payment system under which physicians and other providers
receive a payment for each unit of service they provide or an insurance
product in which clients are allowed total freedom to choose their
health care providers.
(7) Health severity level assessment--An assessment
by the Texas Medicaid Wellness Program vendor that determines the
(8) Medical assistance program--The program implemented
by the State of Texas under the provisions of Title XIX of the Social
Security Act, as amended.
(9) Medical home--A community-based system of health
care delivery that provides individual patients a known resource (primary
care provider or clinic) for all primary and preventive care services.
It also provides continuity of care for acute care needs 24 hours
a day, including consultative, specialty, and health-related services.
(10) Physician--A doctor of medicine or doctor of osteopathy
(MD or DO) legally authorized to practice medicine or osteopathy at
the time and place the service is provided.
(11) Preventive care--Comprehensive care emphasizing
prevention, early detection, and early treatment of conditions, generally
including routine physical examination, immunization, well-person
care, and age-appropriate screening exams.
(12) Primary care provider (PCP)--A physician or provider
who has agreed to provide a medical home to Medicaid clients and who
is responsible for providing care to patients, maintaining the continuity
of patient care and initiating referral for care.
(13) Stratify--A method used by the Texas Medicaid
Wellness Program vendor to organize interventions based on the client's
specific needs at a given time.
|Source Note: The provisions of this §354.1417 adopted to be effective February 20, 2005, 30 TexReg 666; amended to be effective September 1, 2007, 32 TexReg 1904; amended to be effective July 19, 2011, 36 TexReg 4555; amended to be effective March 1, 2012, 37 TexReg 1300