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
treatment plans.
(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
itemization requirements.
(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
conditions.
(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
Program.
(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
appropriate interventions.
(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.
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| 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 |
