Part 1.
TEXAS DEPARTMENT OF HEALTH
Chapter 14.
COUNTY INDIGENT HEALTH CARE PROGRAM
The Texas Department of Health (department) adopts the repeal of §§14.2,
14.401-14.406, amendments to §§14.1, 14.101-14.102, 14.104-14.105,
14.201-14.205 and new §14.2 concerning the County Indigent Health Care
Program (CIHCP). Sections 14.1, 14.101, 14.201, and 14.204 are adopted with
changes to the proposed text as published in the October 29, 1999 issue of
the
Texas Register
(24 TexReg 9516). Sections §14.2,
14.102, 14.104, 14.105, 14.202-14.203, 14.205 and the repeal of §§14.2
and 14.401-14.406 are adopted without change and therefore the sections will
not be republished.
The repeal, amendments, and new section comply with House Bill 1398 and
Chapter 61, Health and Safety Code, which requires that the standards and
procedures used to determine eligibility must be consistent with the Temporary
Assistance to Needy Families (TANF) and Medicaid standards and procedures.
Pursuant to Government Code §2001.039, each state agency is required
to review and consider for readoption each rule adopted by that agency. The
sections have been reviewed and the department has determined that reasons
for adopting the sections continue to exist. Sections 14.103, 14.106-14.108,
14.301, and 14.302 are being readopted without any changes.
The department published a Notice of Intention to Review for §§14.1;
14.2; 14.101-14.108; 14.201-14.205; 14.301; 14.302; and 14.401-14.406 as required
by Rider 167 in the
Texas Register
(23 TexReg
9077) on September 4, 1998. No comments were received by the department due
to publication of this notice.
The following written comments were received. A public hearing was held
on January 13, 2000, but no persons who wished to comment were present.
Comment: Concerning §14.201(a)(11), a comment was received that the
term Nurse Practitioner (NP) replace Advanced Practice Nurse (APN), and a
category of Clinical Nurse Specialist (CNS) be added that could provide psychotherapy.
Response: The department diasagrees because Medicaid does not have a provider
category of NP or CNS services. No change was made as a result of this comment.
Comment: Concerning §14.201(a)(11), a comment was received that APN
services include performing annual physicals and ordering associated testing,
diabetic supplies, colostomy supplies, psychotherapy, and durable medical
equipment.
Response: The department agrees and language was added to §14.201(7)-(10)
to indicate that an APN can provide services within the scope of their practice
in accordance with the standards established by the Board of Nurse Examiners.
Comment: Concerning §14.201(b)(6) two comments were received that
suggested the language concerning Certified Registered Nurse Anesthestist
(CRNA) services delete all language regarding physician supervision.
Response: The department disagrees, but did change the wording to correspond
to the supervision language for Medicaid as defined in 25 TAC §29.502(a)
and 25 TAC §29.2101 that states that CRNA services must be prescribed
and supervised by a physician (MD or DO), dentist, or podiatrist, who must
be licensed in the state in which he or she practices.
Comment: Concerning §14.201(b)(8), a comment was received requesting
humulin pens be included in the diabetic supplies as an optional service.
Response: The department agrees and a change was made to include humulin
pens in the diabetic supplies as an optional service because they are covered
in the Medicaid Vendor Drug Program.
The department is making the following changes due to staff comments.
Change: Concerning §14.1(e)(3), language was added relating to a county
that provides indigent health care services to its eligible residents through
a hospital established by a board of managers jointly appointed by a county
and a municipality was added as a result of House Bill 1398.
Change: Concerning §14.101(h)(2), a semicolon was inserted to correct
punctuation.
Change: Concerning §14.204(h)(4)(C)(iii), mandatory services was changed
to basic and department approved optional services.
Subchapter A. COUNTY PROGRAM ADMINISTRATION
25 TAC §14.1
The amendment is adopted under Health and Safety Code Chapter
61 and Human Resources Code Chapters 22 and 32. The department has rule making
authority for the County Indigent Health Care Program under Health and Safety
Code Chapter 61. Government Code §2001.039 passed by the 76th Legislature,
1999 is implemented by this proposal.
§14.1.County Program Administration.
(a)
Definitions. The following words and terms, when used in
this section, shall have the following meanings, unless the context clearly
indicates otherwise:
(1)
A county refers to:
(A)
a county not fully served by a public hospital or a hospital
district; or
(B)
a county that provides indigent health care services to
its eligible residents through a hospital established by a board of managers
jointly appointed by a county and a municipality.
(2)
Day on which county expends funds--The county
expends funds on the day the county writes a check paying for a bill.
(3)
Days--Calendar days.
(4)
Eligibility staff--Individuals who determine program
eligibility. These individuals may be county officials, county personnel,
or persons determining program eligibility under contract with the county.
If the term "staff" is used alone, it has the same meaning.
(5)
General revenue tax levy (GRTL) - The county's annual
general revenue tax levy. The GRTL includes all county property taxes and
sales and use tax revenue that the county expects to receive in the calendar
year in which the state fiscal year begins. Sales and use tax revenue is collected
under the County Sales and Use Tax Act in compliance with the Tax Code, §26.042(c).
The GRTL excludes the $.30 county tax for farm-to-market roads or flood control
(lateral road fund) and the $.15 county tax for maintenance of public roads
(special road and bridge fund). The GRTL used to establish the county's 8.0%
limit for the County Indigent Health Care Program in the coming state fiscal
year is the county's adjusted GRTL as of July 31 of the current year minus
the amount of revenue dedicated for program services in the previous year.
In counties partially served by a hospital district, the counties' 8.0% limit
is based on the GRTL for the property outside the area served by the hospital
district.
(6)
Public facility--A public hospital or a hospital district
owned, operated, or leased by a hospital district.
(7)
Public hospital--A hospital owned, operated, or leased
by a county, city, town, hospital authority, or other political subdivision
of the state, excluding a hospital district and hospital authority. A hospital
is not considered to be a public hospital for the purposes of providing indigent
care if the hospital:
(A)
is owned, operated, or leased by a city with a population
of less than 5,500, according to the most recent federal decennial census;
(B)
was leased before January 1, 1981, by a city that at the
time of the lease did not have a legal obligation to provide indigent care;
(C)
was established under Texas Civil Statutes, Article 4494i-1;
or
(D)
was leased to a nongovernmental person or entity at the
time of sale and was sold on or after January 1, 1988, to a nongovernmental
purchaser.
(8)
State fiscal year--The 12-month period beginning
September 1 of each calendar year and ending August 31 of the following calendar
year.
(b)
County responsibility for an indigent health care program.
Each county without a public facility legally obligated to serve the entire
county must administer a county indigent health care program that serves all
or that portion of the county not served by a public facility. The county's
program must provide basic health care services to eligible county residents
who do not live in a county area served by a public facility. A county that
adopts a property tax rate exceeding 8.0% (as calculated under the Tax Code, §26.04)
and designates a portion of that tax rate for basic health care services must
spend the revenues produced by that portion of the designated rate for basic
health care services only. If a county owns a public hospital, and the county
sells or leases the hospital to another party, the terms of the sale or lease
agreement determine the type and level of county responsibility. If the sale
or lease represents the county's attempt to totally divest itself of the public
hospital or reduce the level of services provided by the hospital, the Indigent
Health Care and Treatment Act, Subtitles D and E, apply.
(c)
General administrative requirements. Each county required
to administer a program must:
(1)
provide public notice and make a reasonable effort to notify
the public, at the beginning of the state's fiscal year, of the county's eligibility
standards, and the county's application, documentation, and verification procedures
and the verification and documentation procedures that applicants must comply
with to establish eligibility;
(2)
establish an application procedure;
(3)
furnish each applicant with a written application
form;
(4)
assist applicants in completing the application form
and the application process, and inform applicants that this assistance is
available;
(5)
require applicants to sign a written statement swearing
to the truth of the information they supply;
(6)
determine eligibility within 14 days after the date
a completed application is received;
(7)
provide applicants with a written notice of the eligibility
decision. Each county must include on its notice to denied applicants the
reason for denial and an explanation of the county's appeal process;
(8)
inform approved households that they must report any
changes in income and resources within 14 days after the date the change occurs;
(9)
review the eligibility of each household at least
once every six months;
(10)
develop a process for reviewing denied cases and
for hearing appeals requested by households that are denied assistance;
(11)
maintain a case record for each eligible and denied
applicant. Case records for denied applicants must be maintained for a minimum
of three state fiscal years after the relevant state fiscal year;
(12)
allow denied applicants to resubmit an application
whenever circumstances justify an eligibility redetermination.
(13)
All counties required to provide indigent health
care shall submit annual financial reports to the department. A county satisfies
the annual reporting requirements if the county submits information to the
department as required by law to obtain an annual distribution under the Agreement
Regarding Disposition of Settlement Proceeds filed on July 24, 1998, in the
United States District Court, Eastern District of Texas, in the case styled
The State of Texas v. The American Tobacco Co., et al., No. 5-96CV-91.
(d)
County administrative option.
(1)
Counties may administer or may contract with others to
administer a program that uses:
(A)
the eligibility policies; the application, documentation,
and verification procedures; and the service definitions contained in this
chapter; or
(B)
county-developed standards and procedures that are less
restrictive than those contained in this chapter.
(2)
Counties may change eligibility standards to
make them more or less restrictive than their preceding standards. However,
the new standards can be no more restrictive than those contained in Subchapter
B of this chapter (relating to Determining Eligibility).
(3)
If a city in the county with a population below 15,000
according to the last federal census owns, operates, or leases a public hospital,
the city and county may enter into an agreement transferring part of the public
hospital's indigent health care responsibility to the county. The transfer
agreement is irrevocable and cannot be amended unless a hospital district
is created after the effective date of the agreement and the boundaries of
the district cover all or part of the county. It must:
(A)
specify that the county is assuming the hospital's responsibility
for paying other providers for services delivered to eligible city residents
on an emergency basis or because the service is unavailable at the hospital;
(B)
require that the city public hospital continues to otherwise
provide health care services to eligible city residents as required by law;
(C)
occur by August 31, 1989, by adoption of an ordinance,
resolution, or order by the commissioners' court and city governing body;
and
(D)
take effect on a September 1, within two years after the
date of the agreement.
(4)
The county and city must establish coordinated
application and eligibility verification procedures that comply with subsection
(c) of this section and the Indigent Health Care and Treatment Act, §10.03.
These procedures must ensure the efficient and timely referral of the eligible
city residents to the proper city or county entity. County expenditures for
services made under the terms of the agreement are creditable towards the
county's 8.0% limit if the city resident otherwise meets the eligibility standards
contained in Chapter 4 of this title (relating to Determining Eligibility).
County expenditures for coordinating application and verification procedures
cannot be credited towards the county's 8.0% limit. Within 30 days after the
agreement is made, the city and county must notify the department of the agreement
and its effective date and send the department a copy of all ordinances, resolutions,
or other orders pertaining to the County Indigent Health Care Program agreement.
(5)
Upon county request, the Texas Medicaid or Vendor
Drug Program will reimburse the counties for basic services provided to otherwise
eligible county residents appealing a social security disability determination
denial and who are later determined to be retroactively SSI/Medicaid-eligible.
County eligibility for reimbursement is subject to §14.204(h) and (i)
of this title (relating to Services and Payment Liability, Limitations, and
Options). Reimbursement is available only for services covered by the Texas
Medicaid or Vendor Drug Program.
(e)
State assistance fund.
(1)
The Texas Department of Health (department) is responsible
for distributing state assistance to eligible counties to the extent appropriated
state funds are available.
(2)
A county is eligible for the state assistance fund
only if the county:
(A)
complied with the eligibility policies and the application,
documentation, and verification procedures contained in this chapter; and
(B)
expended 8.0% of the applicable GRTL in the state fiscal
year for the provision of basic and department approved optional health care
services to eligible county residents;
(C)
the department may waive the requirement that the county
meet the minimum expenditure level and provide state assistance at a lower
level determined by the department. The county must submit the waiver request
to the department prior to the beginning of the state fiscal year for which
the waiver is being requested. The department must make a determination on
the request not later than 90 days after the department's receipt of the request
and shall notify the county of their determination. The county must demonstrate
on their waiver request, through an appropriate actuarial analysis, that the
county is unable to satisfy the 8.0% GRTL level based on the following:
(i)
although the county's GRTL has increased significantly,
expenditures for health care services have not increased by the same percentage;
or
(ii)
the county is at the maximum allowable ad valorem tax
rate, has a small population, or has insufficient taxable property.
(3)
Counties may not credit expenditures towards
eligibility for state assistance if the expenditures are for a resident eligible
under less restrictive eligibility standards but ineligible under the department
eligibility standards, except for net income standards up to 50% of the Federal
Poverty Income Limits (FPIL). A county that provides indigent health care
services to its eligible residents through a hospital established by a board
of managers jointly appointed by a county and a municipality may use less
restrictive eligibility and resource standards and may credit expenditures
towards eligibility for state assistance. If a county has a contract with
a state agency to provide basic services to eligible county residents in a
hospital maintained or operated by the state agency, the county may credit
all expenditures for a county resident eligible under the department or less
restrictive county standards.
(4)
The department distributes funds to eligible counties
based on a maximum annual allocation for each county potentially eligible
for state assistance, subject to funding. The maximum annual allocation for
each county will be based on such factors as spending history, population,
and the number of residents living below the Federal Poverty Income Limit.
The maximum annual allocation will be recomputed at least every six months.
The minimum annual allocation, subject to funding, will be no less than the
average of what a county would have received in state fiscal years 1997, 1998,
and 1999 at the 8.0% GRTL threshold with a 90% state match. At the end of
the state fiscal year the department may reallocate the distribution of money
to eligible counties.
(f)
Eligibility requirements for counties applying for state
assistance.
(1)
Each county that plans to credit expenditures towards eligibility
for the state assistance fund must:
(A)
comply with the eligibility standards and the application,
documentation, and verification procedures contained in this chapter. County
use of the department application for assistance form, the eligibility worksheet,
and the monthly financial/activity report is also required. County use of
other department forms is not required if the county substitutes a similar
form with the same content as the department form;
(B)
notify the department by telephone as soon as possible
before the dates on which the county anticipates it will expend both 6.0%
and 8.0% of its GRTL. The telephone calls reporting these expenditure levels
must occur no later than the date on which the county reaches these expenditure
levels;
(C)
notify the department in writing within seven days after
the county telephones the department to report that the county has reached
the 6.0% expenditure level. The county must also notify the department and
the county's mandated providers in writing within seven days after the county
telephones the department to report that the county has reached the 8.0% expenditure
level;
(D)
use adequate, auditable accounting records and procedures
that establish a clear, accurate audit trail for each expenditure;
(E)
complete and submit reports prescribed by the department
to the department within 10 days after the end of each month. All counties
that are eligible to receive state assistance must submit monthly financial
reports covering the 12-month period preceding the date on which state assistance
is sought.
(F)
complete and submit a State of Texas purchase voucher to
the department to claim state matching funds;
(G)
maintain a case record for each eligible and denied resident;
(H)
cooperate fully with the department by providing any and
all information requested by the department in an audit of county records
or a review of county eligibility for state assistance;
(I)
maintain all records and vouchers for three state fiscal
years after the relevant state fiscal year; and
(J)
report the county's GRTL, as shown in county records on
July 31 of each year, to the State Property Tax Board no later than October
1 of the same year. If part of the county is served by a hospital district,
request the county appraisal district to determine the GRTL of county propertylocated
outside the area served by a hospital district.
(2)
Counties may not credit payments for the following
towards eligibility for state assistance:
(A)
ineligible individuals;
(B)
non-basic or department non-approved optional services;
(C)
amounts for basic or department approved optional services
that exceed the payment rates established by the department;
(D)
basic or department approved optional services if:
(i)
a physician provides the service and does not certify in
writing that the service was medically necessary; or
(ii)
a nonphysician provides the service and does not certify
in writing that the service was ordered by a physician;
(E)
county program administrative expenses.
(3)
Counties may also credit toward eligibility for
state assistance the value of health care services credited or paid in a state
fiscal year and provided to county residents eligible under the eligibility
and payment standards established by the department in Subchapters B, C, and
D of this chapter (relating to Determining Eligibility, Providing Services,
and Care Management) under the following types of contracts:
(A)
a health care provider and a county entered into a contract,
on or before January 1, 1985, require that the provider furnish a certain
level of mandatory health care services to eligible county residents; or
(B)
the terms of a sales contract between a county and a purchaser
of the county's hospital require the purchaser to provide inpatient and outpatient
hospital services. The sale must have occurred on or after January 1, 1988,
and the hospital must have been:
(i)
leased to a nongovernmental person or entity at the time
of sale; and
(ii)
purchased by a nongovernmental person or entity.
(g)
Determining county eligibility for state assistance.
(1)
Within 30 days from the date the department receives written
notification that the county expended 6.0% of its GRTL for basic and department
approved optional services for eligible residents, the department must:
(A)
complete a review of the county's eligibility system;
(B)
provide the county with a report of the findings of the
review; and
(C)
provide information relevant to a department audit of the
country's financial accounting system.
(2)
If the eligibility systems review does not identify
any serious deficiencies in the county's eligibility system, the county is
eligible for state assistance when it reaches the 8.0% expenditure level.
If deficiencies are identified, the county must correct the deficiencies before
claiming state assistance funds.
(h)
The department state-assistance-fund audits.
(1)
The department may routinely audit a county that receives
state assistance funds. The audit may occur after the state assistance fund
is depleted or at the end of the state fiscal year.
(2)
A county may request an administrative review of the
department audit report if the county disagrees with the report findings.
The county requests an administrative review by sending written notice, an
explanation of the county's reason for disagreement, and all relevant information
to the department Indigent Health Care Policy Section. The county's written
request must be postmarked within 30 days from the date of the county's audit
exit conference.
(3)
If the policy section does not receive a written request
for administrative review as stipulated in paragraph (2) of this subsection,
the findings of the department audit report are final.
(4)
The policy section must determine the accuracy of
the department audit report and notify the county of its decision by letter
postmarked within 30 days from the date the department received the county's
audit.
(5)
If the county disagrees with the policy section's
decision on the audit report, the county may file a request to appeal the
policy section's decision with the department's office of the general counsel.
The county must send its written request appealing the policy section's decision,
and all other relevant information, within 14 days from the date the county
received the policy section's decision.
(6)
The office of the general counsel conducts the appeal
hearing according to the department's contract appeal rules.
(i)
The department administration of state assistance funds.
The following procedures are established to assist the department in its administration
of state assistance funds and to assist counties in the management of their
programs.
(1)
After a county reaches the 6.0% GRTL expenditure level,
the county must contact the department by telephone immediately before any
commissioners court meets to authorize program expenditures; the county must
report the amount of expenditures the court will be asked to authorize and
the amount of any other unpaid bills for services.
(2)
After a county reaches the 8.0% expenditure level,
the county must contact the department by telephone to encumber available
state assistance funds to match expenditures that the commissioners court
will be asked to authorize.
(A)
The department provides the county with an approval code
number for the state-assistance-encumbered funds.
(B)
The county must complete the State of Texas purchase voucher
form, enter the approval code number for the encumbered funds on the voucher,
and submit the voucher to the department within 30 days after the commissioners
court authorizes the expenditures. If the county does not submit the purchase
voucher within the 30-day period, the encumbered state assistance funds become
unencumbered.
(3)
The department prepares a weekly report on the
status of the state assistance fund after 50% of the fund is expended, and
the department sends the report to counties that reported reaching the 6.0%
expenditure level.
(4)
The department cannot ensure that a county will expend
only the amount it is legally obligated to spend on its program unless the
county complies with the requirements contained in this section.
(5)
If a county underclaims state assistance funds for
a state fiscal year, and state assistance funds for that fiscal year are expended,
the department cannot match the underclaimed county expenditures.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on March 10, 2000.
TRD-200001863
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: October 29, 1999
For further information, please call: (512) 458-7236
25 TAC §14.2
The repeal is adopted under Health and Safety Code Chapter
61 and Human Resources Code Chapters 22 and 32. The department has rule making
authority for the County Indigent Health Care Program under Health and Safety
Code Chapter 61. Government Code §2001.039 passed by the 76th Legislature,
1999 is implemented by this proposal.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on March 10, 2000.
TRD-200001864
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: October 29, 1999
For further information, please call: (512) 458-7236
The new section is adopted under Health
and Safety Code Chapter 61 and Human Resources Code Chapters 22 and 32. The
department has rule making authority for the County Indigent Health Care Program
under Health and Safety Code Chapter 61. Government Code §2001.039 passed
by the 76th Legislature, 1999 is implemented by this proposal.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on March 10, 2000.
TRD-200001865
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: October 29, 1999
For further information, please call: (512) 458-7236
25 TAC §§14.101, 14.102, 14.104, 14.105
The amendments are adopted under Health and Safety Code Chapter
61 and Human Resources Code Chapters 22 and 32. The department has rule making
authority for the County Indigent Health Care Program under Health and Safety
Code Chapter 61. Government Code §2001.039 passed by the 76th Legislature,
1999 is implemented by this proposal.
§14.101.Application Processing.
(a)
The following words and terms, when used in Subchapters
(B)-(E) of this chapter (relating to Determining Eligibility, Providing Services,
and Case Management, shall have the following meanings, unless the context
clearly indicates otherwise:
(1)
Application completion date--The date the county receives
a complete Application for Assistance Form.
(2)
Application file date--The date the county first received
an identifiable application.
(3)
Complete application--An application with:
(A)
the applicant's full name and address;
(B)
the applicant's social security number, if available;
(C)
the names of all other household members (excluding AFDC,
Medicaid, or SSI recipients) and their relationship to the applicant;
(D)
the applicant's county of residence;
(E)
information about any medical insurance and hospital or
health care benefits the household members receive;
(F)
the gross monthly income of each household member;
(G)
information about the assets and property that the household
members own and the equity value of any vehicles or property;
(H)
the applicant's signature and the date the form is filled
out; and
(I)
all needed verifications.
(4)
Identifiable application--An application that
minimally contains the applicant's name, address, signature, and the date
signed.
(5)
SSI--Supplemental security income.
(6)
SSDI--Social security disability income.
(7)
Social security disability denial--A Social Security
Administration denial of either SSI and/or SSDI when disability is the basis
for application.
(8)
SSI/SSDI appellant--A person appealing a supplemental
security income and/or social security disability income denial.
(9)
Temporary Assistance to Needy Families (TANF)--Name
change for the Aid to Families with Dependent Children (AFDC) program.
(b)
The applicant for indigent health care or his representative
may request an application form by contacting the office designated by the
county or a provider participating in the program. If the applicant wants
help in completing the form, he may request that eligibility staff assist
him.
(c)
Eligibility staff must mail or give the Texas Department
of Health (department) Application for Assistance Form to the applicant or
his representative on the same day the request is received. Eligibility staff
must briefly explain the application process and applicant's responsibilities
to the requestor.
(d)
The applicant is responsible for correctly filling out
the form; providing all needed verification for all eligible household members;
and reporting any individual, entity, or other third party legally liable
for all or any part of the cost of health care services received by the household
during the period of county program eligibility. The applicant must provide
the county with necessary information about the third party. If the applicant
is married and his spouse is a household member, the spouse must also sign
the form. By signing the form, the applicant, spouse, or authorized representative
assign, to the county, the household's rights to recovery of health care costs
from any individual, entity, or other third party legally liable for any health
care services paid by the county, and swear to the truth of the information
supplied. Persons that intentionally misrepresent information to receive benefits
they are not entitled to receive:
(1)
are responsible for reimbursing the county for the cost
of benefits they were ineligible to receive; and
(2)
may be subject to prosecution under the Texas Penal
Code.
(e)
If the applicant requests help in completing the application
process, eligibility staff must assist the applicant in correctly filling
out the form and completing the process. Anyone who helped fill out the application
form must sign it.
(f)
If the applicant is not physically or mentally able to
complete the application form, his spouse, relative, or other representative
may complete and sign the form for him.
(g)
Eligibility staff may determine eligibility without interviewing
the applicant. Interviews may be face-to-face or by telephone.
(h)
Eligibility staff must not accept an application for processing
unless it is identifiable.
(i)
Eligibility staff must enter on the identifiable Application
for Assistance Form the date they accept the form. This date is the application
file date.
(j)
Eligibility staff must screen the application to determine
any missing components. Eligibility staff must determine if the application
is complete or incomplete.
(k)
If the application is complete, eligibility staff must
determine if the applicant is eligible or ineligible within 14 days after
the complete application is received. A provider may consider a patient automatically
eligible if the 14-day processing limit is not met. By the 14th day, eligibility
staff must give or send a notice of his eligibility or denial. The grounds
for denial include but are not limited to income over the income limits; resources
over the resource limits; failure to provide verification or information;
failure to keep appointment; failure to return review application; failure
to comply with requirements to obtain other assistance; not being a resident
of the county; being a recipient of Medicaid; or voluntary withdrawal.
(1)
Eligibility staff must enter the application completion
date on the eligibility worksheet.
(2)
Eligibility staff must consider each eligibility factor
and document the basis for the eligibility decision on the department eligibility
worksheet.
(3)
Notice of approval to the applicant must include information
about the services he is entitled to receive and his rights and responsibilities.
(l)
If eligibility staff determine an identifiable application
is incomplete because it is missing some components of a complete application,
other than verification of ineligibility for AFDC, SSI, or Medicaid:
(1)
eligibility staff must give or mail the applicant the Eligibility
Verification Form, identify the needed information, and request that the applicant
provide the information within 14 days;
(2)
by the end of 14 days, eligibility staff must:
(A)
process the complete application if the applicant has provided
the requested information in accordance with subsection (k) of this section;
or
(B)
give or send the Notice of Ineligibility Form to the applicant
and any provider who assisted in the application process if the applicant
did not provide the requested information.
(m)
If eligibility staff determine an identifiable application
is incomplete only because verification of ineligibility for TANF, Medicaid,
or SSI is needed, eligibility staff must give or mail the applicant the Eligibility
Verification Form and the Case Information Release Form. Eligibility staff
must:
(1)
use the Eligibility Verification Form to:
(A)
inform the applicant that:
(i)
his eligibility cannot be determined until his ineligibility
for TANF, Medicaid, or SSI is verified by the appropriate program; and
(ii)
he has 14 days to provide proof of application or appointment
for application to the appropriate program; and
(B)
refer the applicant to:
(i)
the Department of Human Services for a TANF or Medicaid
application, if eligibility for these programs is likely; or
(ii)
the Social Security Administration for an SSI application
if the applicant is seriously disabled, terminally ill, or age 65 or over;
(2)
deny the incomplete application if the applicant
does not provide proof of application or appointment for application to the
appropriate program by the 14th day, and give or send the applicant (and provider,
if appropriate) the Notice of Ineligibility Form for failure to cooperate
with the county application process. If the applicant provides the required
proof, periodically check with the appropriate program to determine the status
of the eligibility decision;
(3)
request the applicant to provide notice of eligibility
or ineligibility when he receives it. If the applicant is:
(A)
ineligible for TANF, Medicaid, or SSI, eligibility staff
process the complete application for current and retroactive eligibility in
accordance with subsection (k) of this section;
(B)
eligible for TANF, Medicaid, or SSI, eligibility staff
give or send a notice of denial to the applicant and any provider who assisted
in the application process.
(n)
An approved household is retroactively eligible for services
beginning with the first calendar day in any one or all of the three months
before the identifiable application was received if:
(1)
the household met all eligibility requirements;
(2)
the household received basic or department approved
optional services; and
(3)
the bills for these services are unpaid.
(o)
Current eligibility begins on the first calendar day in
the:
(1)
month an identifiable application was filed, if the applicant
was otherwise eligible for that month; or
(2)
earliest month after the month the identifiable application
was filed in which all eligibility requirements were met, if not eligible
in the month the application was filed.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed
with the Office of the Secretary of State on March 10, 2000.
TRD-200001866
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: October 29, 1999
For further information, please call: (512) 458-7236
25 TAC §§14.201 - 14.205
The amendments are adopted under Health and Safety Code Chapter
61 and Human Resources Code Chapters 22 and 32. The department has rule making
authority for the County Indigent Health Care Program under Health and Safety
Code Chapter 61. Government Code §2001.039 passed by the 76th Legislature,
1999 is implemented by this proposal.
§14.201.Required and Optional Services, and Their Definitions.
(a)
Except as specified in §14.202 of this title (relating
to Exclusions and Limitations), counties are required to provide the following
services to eligible households by reimbursing providers of services who meet
the requirements of the Indigent Health Care and Treatment Act, this chapter,
and the responsible county.
(1)
Inpatient hospital services. Services must be medically
necessary and:
(A)
provided in a licensed hospital;
(B)
provided to hospital inpatients;
(C)
provided under the direction of a physician (MD or DO);
and
(D)
provided for diagnosis or treatment.
(2)
Outpatient hospital services. Services must be
medically necessary and:
(A)
must be diagnostic, therapeutic, rehabilitative, or palliative;
(B)
furnished to hospital outpatients;
(C)
furnished by or under the direction of a physician (MD
or DO); and
(D)
furnished by a licensed hospital facility.
(3)
Physician services. Services must be medically
necessary and provided by a medical or an osteopathic doctor in the doctor's
office, a hospital, a skilled nursing facility, or elsewhere.
(4)
Up to three prescriptions for drugs per recipient
per month. New and refilled prescriptions count equally towards this total
prescription limit. Drugs must be prescribed by a physician or other licensed
practitioner within the scope of practice under law.
(5)
Skilled nursing facility services. Services must be
medically necessary, ordered by a physician, and provided in a licensed, skilled
nursing facility that provides daily services on an inpatient basis.
(6)
Rural health care clinic services. Primary health
care services must be provided in a licensed or an approved rural health clinic
by a physician, a physician's assistant, a nurse practitioner, a nurse midwife,
or other specialized nurse practitioner.
(7)
Family planning services. These are services that
enable individuals to limit family size or space their children and to prevent
or reduce births out of wedlock.
(8)
Laboratory and x-ray services. These are technical
laboratory and radiological services ordered and provided by or under the
direction of a physician (MD or DO) in an office or a similar facility other
than a hospital outpatient department or clinic. An independent laboratory
must be certified.
(9)
Immunizations.
(10)
Medical screening services, including blood pressure,
blood sugar, and cholesterol.
(11)
Annual physical examinations, once per calendar year,
can be provided by a M.D., a D.O, or a P.A. Associated testing such as mammograms
can be covered with a physician's referral. These services may also be provided
by an Advanced Practice Nurse (APN) if they are within the scope of their
practice in accordance with the standards established by the Board of Nurse
Examiners and published in 22 Texas Administrative Code §221.13.
(b)
The following services are optional services. A county
must notify the department of the county's intent to provide any of the following
services prior to the beginning of a state fiscal year. If the services are
approved by the department or if the department fails to notify the county
of the department's disapproval before the 31st day after the date the department
receives the county's request, the county may credit the services toward eligibility
for state assistance for the state fiscal year following the date of the request.
A county must notify the department in writing if they decide to discontinue
providing any of the optional services that were department approved. (For
state fiscal year 2000 only, a county must notify the department of the county's
intent to provide any of the following services within 45 days of the final
adoption of these rules. If approved by the department, the county may credit
these services toward eligibility for state assistance the month following
the date of the approval.)
(1)
Ambulatory surgical center (ASC) services. These services
must be provided in a Title XIX Medicaid enrolled ASC, and are limited to
items and services furnished in reference to an ambulatory surgical procedure,
including those services on the HCFA approved list and selected Medicaid-only
procedures.
(2)
Federally Qualified Health Center (FQHC) services.
These services must be provided in an approved FQHC by a physician, a physician's
assistant, a nurse practitioner, a clinical psychologist, or a clinical social
worker.
(3)
Physician assistant (PA) services. These services
must be medically necessary and provided by a PA under the direction of a
M.D. or a D.O. and must be billed by and paid to the supervising physician.
(4)
Advanced practice nurse (APN) services. These services
must be medically necessary and provided within the scope of practice of an
APN and covered in the Texas Medicaid Program when provided by a licensed
physician.
(5)
Certified nurse midwife (CNM) services. These services
must be medically necessary and provided within the scope of practice of the
CNM, and covered by the Texas Medicaid Program when provided by a licensed
physician.
(6)
Certified registered nurse anesthetist (CRNA) services.
These services must be medically necessary; provided within the scope of practice
of a CRNA; and prescribed and supervised by a physician, dentist, or podiatrist
who must be licensed in the state in which they practice.
(7)
Counseling services. Psychotherapy services must be
medically necessary based on a physician referral and provided by a licensed
professional counselor (LPC), a licensed master social worker-advanced clinical
practitioner (LMSW-ACP), a licensed marriage family therapist (LMFT), or a
PhD psychologist. These services may also be provided based on an APN referral
if the referral is within the scope of their practice in accordance with the
standards established by the Board of Nurse Examiners and published in 22
Texas Administrative Code §221.13.
(8)
Diabetic medical supplies and equipment. These supplies
and equipment must be medically necessary and prescribed by a physician. The
county may require the supplier to receive prior authorization. Items covered
are lancets, alcohol prep pads, syringes, test strips, humulin pens and glucometers.
These supplies and equipment may also be prescribed by an APN if this is within
the scope of their practice in accordance with the standards established by
the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13.
(9)
Colostomy medical supplies and equipment. These supplies
and equipment must be medically necessary and prescribed by a physician. The
county may require the supplier to receive prior authorization. Items covered
are colostomy bags/pouches; cleansing irrigation kits, paste or powder; and
wafers. These supplies and equipment may also be prescribed by an APN if this
is within the scope of their practice in accordance with the standards established
by the Board of Nurse Examiners and published in 22 Texas Administrative Code §221.13.
(10)
Durable medical equipment. This equipment must be
medically necessary; meet the Medicare/Medicaid requirements; and provided
under a written, signed and dated physician's prescription. The county may
require the supplier to receive prior authorization. Items can be rented or
purchased whichever is the least costly. Items covered are crutches, canes,
walkers, standard wheel chairs, hospital beds, TENS units, home oxygen equipment
(including masks, oxygen hose, and nebulizers) and reasonable and appropriate
appliances for measuring blood pressure. These supplies and equipment may
also be prescribed by an APN if this is within the scope of their practice
in accordance with the standards established by the Board of Nurse Examiners
and published in 22 Texas Administrative Code §221.13.
(11)
Home and community health care services. These services
must be medically necessary; meet the Medicare/Medicaid requirements; and
provided by a certified home health agency. A plan of care must be recommended,
signed, and dated by the recipient's attending physician prior to care being
given. The county may require prior authorization. Items covered are R.N.
visits for skilled nursing observation, assessment, evaluation, and treatment
provided a physician specifically requests the R.N. visit for this purpose.
A home health aide to assist with administering medication is also covered.
Visits made for performing housekeeping services are not covered.
(12)
Dental care. These services must be medically necessary
and provided by a DDS, a DMD, or a DDM. The county may require prior authorization.
Items covered are an annual routine dental exam and the least costly service
for emergency dental conditions for the removal or filling of a tooth due
to abscess, infection or extreme pain.
(13)
Vision care, including eyeglasses. The county may
require prior authorization. Items covered are one examination of the eyes
by refraction and one pair of prescribed glasses meeting the Medicaid requirements
every 24 months.
§14.204.Services and Payment Liability, Limitations, and Options.
(a)
This section defines county liability. Counties are liable
for payment for basic and department approved optional services unless an
eligible county resident:
(1)
is adequately covered for the services through another
public or private health care source. A service is adequately covered if the
health care source pays an amount equal to the appropriate payment standard
specified in §14.203 of this title (relating to Payments for Basic and
Department Approved Optional Services). If the health care source pays less
than the appropriate payment standard, the county is responsible for the amount
remaining up to the payment standard amount;
(2)
receives services in a hospital that is out of compliance
with a Hill-Burton obligation to provide free services to indigent persons.
The county may require the hospital to verify that it is in compliance with
its Hill-Burton obligation;
(3)
is eligible for Medicaid benefits or would be eligible
if he/she applied.
(b)
The county is the payor of last resort; however, a state
hospital or clinic (excluding those listed in §14.102(d)(2)) of this
title (relating to Residency) shall be entitled to payment for services rendered
to an eligible resident under the provisions of this chapter applicable to
other providers.
(c)
County liability for services and payments is limited to:
(1)
payment of no more than $30,000 in the state fiscal year
for basic and department approved optional services for an eligible county
resident delivered by all providers, including hospitals and skilled nursing
facilities;
(2)
payment for a total of 30 days (cumulative) in the
state fiscal year for hospital and/or skilled nursing facility care, or a
combination of both, or a maximum payment of $30,000 for all basic and department
approved optional services provided to an eligible county resident, whichever
comes first;
(3)
8.0% of the county's general revenue tax levy, if
state assistance funds are not available;
(4)
8.0% of the county's general revenue tax levy and,
if state assistance funds are available, 10% of the expenditures above the
8.0% GRTL;
(5)
payments for basic and department approved optional
services equivalent to the established payment standard for the service;
(6)
payments to providers who certify in writing that:
(A)
the service was medically necessary. This applies only
to physicians, and dentists and podiatrists providing physician services;
(B)
the service was ordered by a physician. This applies only
to nonphysician providers.
(d)
Counties have the option to:
(1)
make payments above those payment standards specified in §14.203
of this title (relating to Payments for Basic and Department Approved Optional
Services);
(2)
provide additional services not specified in §14.201
of this title (relating to Required and Optional Services, and Their Definitions).
(e)
If the county chooses the options contained in subsection
(d) of this section, expenditures above the established payment standards
or for additional services cannot be credited towards the county's eligibility
for the state assistance fund.
(f)
Counties have the option to request that an eligible county
resident, except an SSI/SSDI appellant, contribute a nominal amount toward
the cost of basic and department approved optional services. If, however,
the resident is unable or unwilling to make the nominal contribution, the
county cannot deny eligibility or limit services. Counties that select this
option must define the nominal amount.
(g)
The county may recover the cost of health care services
provided to a recipient if any individual, entity, or other third party is
legally liable for the cost of the health care services. Third parties include,
but are not limited to, worker's compensation, automobile, medical or other
insurance, and individuals determined liable through litigation. Applicants
assign their rights to third party recovery to the county upon their signature
of the Application for Assistance Form.
(h)
Only counties not fully served by a public hospital or
hospital district may submit claims for Texas Medicaid or Vendor Drug Program
reimbursement to the department for basic and department approved optional
services provided to an otherwise eligible SSI/SSDI appellant if the services
are furnished by a Title XIX-enrolled provider; if the SSI/SSDI appellant
is later determined to be retroactively eligible for SSI/Medicaid; and the
appellant and the provider assign reimbursement rights by completing the appellant/provider
assignment form.
(1)
An SSI/SSDI appellant assigns his third-party recovery
rights to the county and the Texas Department of Health (department) by completing
and signing the appellant/provider assignment form. The SSI/SSDI appellant's
Medicaid ineligibility is verified by a social security denial.
(2)
By assigning his Medicaid reimbursement rights to
the county and the department, the provider agrees that payment by the county
of the lesser of the billed amount or the CIHCP payment standard constitutes
payment in full; and the provider is prohibited from billing the eligible
county resident for any services reimbursed by the county.
(3)
The county determines the Medicaid eligibility status
of all eligible residents who are also SSI/SSDI appellants by using the National
Heritage Insurance Company (NHIC) automated inquiry system (NAIS) at least
once a month.
(A)
To use NAIS, the county requests a telephone access code
number from the department in writing. Upon receipt of the county's written
request, the department sends the county the access code number and instructions
for using the NAIS toll-free number from a touch-tone telephone.
(B)
NAIS provides the county with information about the SSI/SSDI
appellant's current Medicaid eligibility.
(C)
The county must follow all procedures established by the
department for CIHCP counties accessing NAIS.
(4)
Within 10 workdays of determining the SSI/SSDI
appellant's current Medicaid eligibility, in accordance with paragraph (4)
of this subsection, the county must:
(A)
complete and send the notice of ineligibility form to the
Medicaid-eligible person; and
(B)
notify all providers who assigned their Medicaid reimbursement
rights:
(i)
of the person's Medicaid eligibility;
(ii)
that the Medicaid-eligible person is ineligible for the
County Indigent Health Care Program;
(iii)
that all unpaid bills for services should be filed directly
with the Texas Medicaid or Vendor Drug Program; and
(C)
separately claim reimbursement for prescription drugs and
non-prescription services provided during the period of retroactive Medicaid
eligibility by:
(i)
fully completing the SSI/SSDI Appellant Notification Claim
Form;
(ii)
attaching one copy of the Appellant/Provider Assignment
Form for the county resident and each provider who received county reimbursement;
and
(iii)
enclosing the original bills for all paid basic or department
approved optional services.
(5)
The department will process the claim, complete
a State of Texas purchase voucher, and send it to the county for signature
and submittal to the department to receive reimbursement.
(A)
Upon receipt of reimbursement, the county subtracts the
amount of reimbursement from expenditures creditable toward eligibility for
state assistance funds in the state fiscal year in which reimbursement is
received.
(B)
County expenditures for basic and department approved optional
services provided to an SSI/SSDI appellant are creditable toward the county's
8.0% GRTL liability and eligibility for state assistance funds whether or
not the county claims Texas Medicaid or Vendor Drug Program reimbursement.
Not creditable are county expenditures for bills received by the county on
or after the date the county is notified of the appellant's Medicaid/SSI eligibility.
This agency hereby certifies that the adoption
has been reviewed by legal counsel and found to be a valid exercise of the
agency's legal authority.
Filed
with the Office of the Secretary of State on March 10, 2000.
TRD-200001867
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: October 29, 1999
For further information, please call: (512) 458-7236
25 TAC §§14.401 - 14.406
The repeals are adopted under Health and Safety Code Chapter
61 and Human Resources Code Chapters 22 and 32. The department has rule making
authority for the County Indigent Health Care Program under Health and Safety
Code Chapter 61. Government Code §2001.039 passed by the 76th Legislature,
1999 is implemented by this proposal.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on March 10, 2000.
TRD-200001862
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: October 29, 1999
For further information, please call: (512) 458-7236
Subchapter F. PHYSICIAN SERVICES
25 TAC §29.502
On behalf of the State Medicaid Director, the Texas Department
of Health (department) adopts an amendment to §29.502 concerning the
addition of anesthesiologist assistants (AAs) services to be covered under
authorized physician services without changes to the proposed text as published
in the December 24, 1999, issue of the
Texas Register
(24 TexReg 11690). Therefore, the section will not be republished.
Adoption of this amendment will allow AAs to provide services under the
supervision of an anesthesiologist in the Texas Medical Assistance Program.
This adopted rule will allow for Medicaid reimbursement to the anesthesiologist
when AAs perform services pursuant to protocols jointly developed with the
anesthesiologist, and in accordance with their scope of practice and state
law.
No comments were received concerning the amendment during the comment period.
The amendment is adopted under the Human Resources Code, §32.021
and the Texas Government Code, §531.021, which provide the Health and
Human Services Commission with the authority to administer the state's medical
assistance program. Rules are submitted by the Texas Department of Health
under its agreement with the Health and Human Services Commission to operate
the purchased health services program as authorized by Acts of the 72nd Legislature,
First Called Session, Chapter 15, §1.07, (1991).
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on March 10, 2000.
TRD-200001845
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: December 24, 1999
For further information, please call: (512) 458-7236
25 TAC §29.3001, §29.3002
On behalf of the State Medicaid Director, the Texas Department
of Health (department) adopts amendments to §§29.3001 and 29.3002,
concerning the addition of licensed marriage and family therapists to provide
counseling services in the Texas Medical Assistance Program without changes
to the proposed text as published in the December 24, 1999 issue of the
Adoption of these amendments will allow licensed marriage and family therapists
to enroll in the Texas Medical Assistance Program to provide counseling services
for emotional disorders or conditions as allowed by their licensing law. The
department has determined the need to amend its rules to comply with the terms
of House Bill 2304, 76th Legislative Session, 1999, which allows licensed
marriage and family therapists to participate in the Medicaid program.
No comments were received concerning the proposal during the comment period.
The amendments are adopted under the Human Resources Code, §32.021
and the Texas Government Code, §531.021, which provide the Health and
Human Services Commission with the authority to adopt rules to administer
the state's medical assistance program. Rules are submitted by the Texas Department
of Health under its agreement with the Health and Human Services Commission
to operate the purchased health services program as authorized by Acts of
the 72nd Legislature, First Called Session, Chapter 15, §1.07, (1991).
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on March 10, 2000.
TRD-200001836
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: April 1, 2000
Proposal publication date: December 24, 1999
For further information, please call: (512) 458-7236
Subchapter F. LICENSE REGULATIONS
Subchapter B. DETERMINING ELIGIBILITY
Subchapter C. PROVIDING SERVICES
Subchapter E. SLIAG REIMBURSEMENT FOR COUNTY INDIGENT HEALTH CARE PROGRAM SERVICES PROVIDED TO ELIGIBLE LEGALIZED ALIENS
Chapter 29.
PURCHASED HEALTH SERVICES
Subchapter EE. LICENSED PROFESSIONAL COUNSELORS, LICENSED MASTER SOCIAL WORKER ADVANCED CLINICAL PRACTITIONERS, AND LICENSED MARRIAGE AND FAMILY THERAPISTS
Chapter 289.
RADIATION CONTROL