The following words and terms when used in this subchapter
have the following meanings, unless the context clearly indicates
otherwise.
(1) Access surgery--The surgical procedure which creates
or maintains the access site necessary to perform dialysis.
(2) Action--A suspension, modification, denial, or
termination of program eligibility, benefits, or participation.
(3) Administrative review--A process that allows applicants,
clients, or providers the opportunity to request an informal review
of any intended program action that would suspend, modify, deny, or
terminate their eligibility, benefits or participation in the program.
(4) Allowable amount--The maximum amount that the
program will pay or reimburse for a covered benefit or service.
(5) Applicant--A person who has submitted an application
for program benefits and has not received a final determination of
eligibility.
(6) Authorized entity--Any individual or organization
approved by the program to submit applications for benefits or travel
verification reports on behalf of an applicant or client.
(7) Claim--A request for payment or reimbursement of
services.
(8) Client--A person who has applied for program services
and who meets all program eligibility requirements and is determined
to be eligible for program services.
(9) CMS--The Centers for Medicare and Medicaid Services.
(10) Co-insurance--A cost-sharing arrangement in which
a covered person is responsible for paying a specified percentage
of the charge for a covered service or product.
(11) Commissioner--The commissioner of the Department
of State Health Services.
(12) Co-pay/Co-payment--A cost-sharing arrangement
in which a covered person is responsible for paying a specified or
fixed charge for a covered service or product.
(13) CRNA--Certified registered nurse anesthetist.
(14) Date of service (DOS)--The date a service is rendered.
(15) Denial--An action by the program that disallows
program eligibility, benefits, or provider enrollment.
(16) Department--The Department of State Health Services.
(17) Effective date--The date a program client or enrolled
provider is approved to receive program benefits or reimbursements.
(18) End-Stage Renal Disease (ESRD)--The final stage
of renal failure that requires dialysis or kidney transplant to reduce
uremic symptoms and prevent the death of the patient.
(19) Enrolled provider--Any individual or entity who
has completed all the requirements located in the Texas Health and
Human Services Commission rule at 1 TAC §392.605, Kidney Health
Care Provider Requirements and Effective Dates, and is deemed enrolled
by the program to furnish covered services to program clients including:
(A) outpatient dialysis facilities;
(B) out-of-state outpatient dialysis facilities;
(C) hospitals and ambulatory surgical centers (ASCs)
located in Texas and operating in compliance with applicable law;
(D) out-of-state hospitals and ASCs;
(E) military or Veterans Administration hospitals located
in Texas which have a renal unit;
(F) pharmacies approved as Texas Medicaid providers
and licensed to operate within the United States and its territories,
including mail order pharmacies;
(G) physicians and certified registered nurse anesthetists
(CRNAs) licensed in Texas;
(H) out-of-state physicians and CRNAs; and
(I) Medicare Prescription Drug Plan (PDP) providers.
(20) Explanation of benefits (EOB)--A form, in paper
or electronic format, which provides an explanation of benefits. It
is used to explain a payment or denial of a claim.
(21) Fair hearing--The informal hearing process the
department follows under §§1.51 - 1.55 of this title (relating
to Fair Hearing Procedures).
(22) Filing deadline--The last date that a claim may
be received by the program and still be considered eligible for benefit.
(23) Final decision--A decision that is made by a decision
maker after conducting a fair hearing under §§1.51 - 1.55
of this title.
(24) Incomplete claim--A claim that is submitted to
the program without the required information to enable determination
of program liability or payment.
(25) KHC--Kidney Health Care.
(26) KHC formulary--A list of general therapeutic categories
of drugs, over-the-counter products, and limited diabetic supplies
that are covered for reimbursement by the program.
(27) Low Income Subsidy (LIS)--The subsidy provided
under the Medicare Prescription Drug, Improvement and Modernization
Act (MMA) of 2003 for Medicare Part D plan premiums and related costs,
at varying levels, for some low-income Medicare beneficiaries.
(28) Medical benefit--Any medical treatment or procedure
approved by the program as a covered service.
(29) Medicare Advantage Plan--A Medicare health plan
that is similar to a health maintenance organization, participating
provider organization, or other Medicare health plan, and includes
medical, drug coverage and other benefits.
(30) Medicare Part A--Hospital insurance for people
age 65 or older, or under age 65 with certain disabilities, that helps
cover inpatient hospital stays, care in a skilled nursing facility,
hospice care, and some home health care.
(31) Medicare Part B--Health insurance for people age
65 or older, or under age 65 with certain disabilities, and any age
with ESRD, that helps cover medically necessary services, such as
doctors' services and outpatient care, and some preventive services.
(32) Medicare Part D--Established by the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (MMA), it provides
members with prescription drug coverage, expanded health plan options,
improved health care access for rural Americans, and preventive care
services.
(33) Medicare Part D out-of-pocket expenses--Include
premiums, deductibles, co-payments, or co-insurance amounts.
(34) Medicare Part D Premium--The amount paid monthly
under a Medicare Part D contract to insure coverage.
(35) Medicare Prescription Drug Plan (PDP)--A stand-alone
drug plan offered by insurers and other private companies to individuals
eligible for Medicare Part D.
(36) Medigap plan--A Medicare supplement insurance
policy sold by private insurance companies to fill "gaps" in Medicare
coverage.
(37) Modification--A change made to a client or provider
account that can affect program benefits, eligibility, or enrollment.
(38) Program--Kidney Health Care.
(39) Provider--Any individual or entity who furnishes
benefits or services to program clients.
(40) Qualified Individual (QI) Program--A Medicaid
program for beneficiaries who need help in paying for Medicare Part
B premiums. The beneficiary must be entitled to Medicare Part A,
have limited income and resources as calculated using federal and
state guidelines, and not be otherwise eligible for Medicaid. For
those who qualify, the Medicaid program pays full Medicare Part B
premiums only.
(41) Qualified Medicare Beneficiary (QMB) Program--A
Medicaid program for beneficiaries who need help in paying for Medicare
services. The beneficiary must be entitled to Medicare Part A, have
limited income and resources as calculated using federal and state
guidelines. For those who qualify, the Medicaid program pays Medicare
Part A premiums, Part B premiums, and Medicare deductibles and coinsurance
amounts for Medicare services.
(42) Reimbursement--Payment of a claim for covered
benefits or services.
(43) Reimbursement rate--The program payment rate for
covered benefits or services.
(44) Resubmitted claim--A claim that is submitted to
the program more than once to correct errors.
(45) Specified Low Income Medicare Beneficiary (SLMB)
Program--A Medicaid program that pays for Medicare Part B premiums
for individuals who have Medicare Part A, a low monthly income, and
limited resources as calculated using federal and state guidelines.
(46) Suspension--An action by the program, which holds
client benefits or reimbursement to enrolled providers pending satisfaction
of a program request or requirement.
(47) Termination--A final action by the program, which
ends client or enrolled provider participation in the program.
(48) Veterans programs--Health care programs authorized
and administered by the United States Department of Veterans Affairs
and the United States Department of Defense.
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