40 TAC §§4.1002, 4.1012, 4.1016
The Texas Department of Human Services (DHS) adopts amendments
to §§4.1002, 4.1012, and 4.1016 in its Medicaid Programs--Children
and Pregnant Women chapter to the proposed text published in the November
23, 2001, issue of the
Texas Register
(26
TexReg 9467). Section 4.1012 is adopted with changes, and §4.1002 and §4.1016
are adopted without changes to the proposed text, and will not be republished.
DHS received 30 written comments from Advocacy Inc., the Center for Public
Policy Priorities, the Children's Defense Fund Texas, the Children's Hospital
Association of Texas, the Consumers Union, the Dallas Region Texcare Partnership
Outreach Coalition, the Gulf Coast Children's Health Insurance Program, Seton
Healthcare Network, the Texas Association of Health Plans, the Texas Department
of Health, the Texas State Employees Union, the Texas Hospital Association,
the Texas Medical Association, the Texas Welfare Reform Organization, Texas
Rural Legal Aid, Inc., and two individuals. An additional nine oral comments
were received at a public hearing on December 14, 2001. Almost all commentors
indicated the rules should be simple, client-friendly, and result in improved
access for children to health care coverage. A summary of the comments and
the department's responses follows.
Comment: Commentors said the proposed rules are too restrictive concerning
the health care orientation and Texas Health Steps requirements; could result
in parents being wrongly penalized due to the limitations of Texas' Medicaid
data system; and should refer to an operations manual cited in the rule language.
Response: We have attempted to address these concerns by allowing the parent
to self-declare compliance with the health care orientation and Texas Health
Steps requirements. We also have allowed these requirements to be met if the
parent has not yet had the orientation or Texas Health Steps checkup but self-declares
they are scheduled for one. Additionally, we have included the ability for
the parent to claim good cause for not having complied with these requirements.
Good cause may include reasons such as lack of transportation, lack of available
providers, illness, or other medical conditions that conflict with work hours
and other similar reasons.
Comment: Commentors said Senate Bill (SB) 43 does not mandate a penalty
for parents who fail to comply with the health care orientation and Texas
Health Steps requirements. They said the law simply requires parents to receive
an orientation and ensure their children are up-to-date with checkups. They
also advocated eliminating the specified time frames for compliance with the
health care orientation and Texas Health Steps requirements and provisions
related to face-to-face interviews when these requirements are not met. Instead,
the timeframe and face-to-face interview provisions should be contained in
an operating guide. This operating guide should be referenced in the rule
language.
Alternatively, commentors recommended phasing in the face-to-face interview
requirement after efforts have been made to expand the number of providers,
improve data/reporting systems, and encourage families to obtain health care
orientations and Texas Health Steps checkups.
Response: Staff agree with eliminating the specified time frames for compliance
with the health care orientations and Texas Health Steps requirements and
recommends the rules be clarified to delete references to specific time frames
and to reference DHS Medicaid simplification operating guidelines.
Based on the transcript of the House floor debate regarding SB 43, we do
not believe we can recommend eliminating the face-to-face interview if these
requirements are not met.
Comment: Commentors said parents should not be penalized for situations
outside of their control, such as: 1) they cannot get the required health
care orientation because the state has not made it easily accessible; 2) Texas
Medicaid data systems cannot provide accurate information about checkups;
3) they lack transportation; 4) they cannot find a doctor or clinic to deliver
a checkup; or 5) they cannot obtain an appointment during the times when they
are off work.
Response: We have attempted to address these concerns by allowing the parent
or guardian to self-declare they have complied with the health care orientation
or Texas Health Steps requirements. We also have allowed these requirements
to be met if the parent has not yet had the orientation or Texas Health Steps
checkup but self-declares they are scheduled for one. Additionally, we have
included the ability for the parent to claim good cause for not having complied
with these requirements. Good cause may include reasons such as lack of transportation,
lack of available providers, illness, or other medical conditions that conflict
with work hours and other similar reasons.
Comment: Commentors recommended an SB 43 operations manual, which would
describe all processes related to Medicaid simplification, including the roles
of HHSC, the Texas Department of Health, DHS, and any other party involved.
They said the manual should encompass all topics included in the Proposed
Implementation Outline, including topics added as a result of the comment
process on the proposed rules. They also said the manual should be available
free of charge on the HHSC web page and updated regularly as it would not
be subject to the notice and comment requirements that apply to rules under
the Texas Administrative Code.
Response: We recommend the rule language be clarified to cite DHS operating
guidelines and specify that these guidelines will be published and available
to the public free of charge and updated regularly to reflect procedural changes.
Because DHS cannot establish rules for other agencies, we are unable to include
references to a guide that sets requirements for other agencies in our rule
base as suggested. The Texas Health and Human Services Commission has, however,
published an SB 43 implementation plan on its web site that details the policies
and procedures across agencies.
In addition to specific comments concerning rule language, some commentors
also mentioned: 1) advocacy for the creation of a task force to implement
and monitor the operating guidelines; 2) concern that the number of state
employees should not be reduced as a result of Medicaid simplification; 3)
concern that DHS can adequately train all staff who will implement the policy;
4) concern that the Texas Department of Health will have enough staff to conduct
the health care orientations; 5) the need to expand the Medicaid provider
base; 6) the need to invest in medical transportation options for Medicaid
recipients; 7) stronger linkage of Texas Health Steps exam to a medical home;
8) elimination of the separate enrollment process for Medicaid and Texas Health
Steps for providers; 9) increase funding for outreach materials, as well as
a consumer-friendly Medicaid information booklet to be given to recipients
at the health care orientation; 10) implementation of this policy on a statewide
basis versus allowing regional flexibility; 11) that policies and operating
guidelines should not be revised absent of a fair opportunity for advocates
to review and provide input; and 12) concern that the state of Texas lacks
legal recourse/protection for Medicaid recipients, as recipients do not have
ability to have a state judicial court review of their case.
The amendments are adopted under the Human Resources Code, Title
2, Chapter 32, which authorizes DHS to administer public and medical assistance
programs and under Texas Government Code §531.021, which provides the
Health and Human Services Commission with the authority to administer federal
medical assistance funds.
The amendments implement the Human Resources Code, §§32.001 -
32.042.
§4.1012.Medicaid Eligibility.
(a)
CPW applicants must meet the requirement stipulated in
the AFDC rules for three months prior coverage.
(b)
Regular Medicaid eligibility for all applicants except
pregnant women begins the earliest day in the application month on which the
client meets all eligibility criteria.
(c)
Medicaid eligibility for pregnant women begins as early
as the first day of the third month before the month of application, but no
earlier than the month their pregnancies began.
(d)
Medicaid eligibility for children certified under the newborn
children provision must begin on the child's date of birth.
(e)
CPW clients are not eligible for four months post Medicaid
coverage.
(f)
Medicaid eligibility for pregnant women ends the second
month following the month the pregnancy terminates.
(g)
Medicaid eligibility for children certified under the newborn
children provision ends the earliest of the following:
(1)
the month the mother's Medicaid ends;
(2)
the month the child is no longer a member of his mother's
household; or
(3)
the month the child becomes one year old.
(h)
Medicaid eligibility for children under age 19 determined
to be eligible for medical assistance on or after January 1, 2002, continues
for a six-month period without additional review and regardless of changes
in resources or income, until the earlier of:
(1)
the 180th day after the date on which the child's eligibility
was determined; or
(2)
the child's 19th birthday.
(i)
A parent or guardian of a child under 19 receiving Medicaid
must
(1)
receive a health care orientation from a department representative;
or
(2)
accompany the child to an appointment with a health care
provider; or
(3)
have a face-to-face interview to renew the child's eligibility
for Medicaid and to receive appropriate counseling on the need for comprehensive
health care.
(j)
Children under 19 who are receiving Medicaid and are eligible
for the Texas Health Steps program must be in compliance with the regimen
of care prescribed by the Texas Health Steps program or have a face-to-face
interview to renew the child's eligibility for Medicaid and to receive appropriate
counseling on the need for comprehensive health care.
(k)
Services and policies under subsections (h), (i), and (j)
of this section will be administered following the procedures specified in
DHS Medicaid simplification operating guidelines that are published and available
to the public, and updated regularly to reflect procedural changes.
(l)
Subsections (h)(1), (h)(2), (i) and (j) of this section
are effective with eligibility determinations made on or after January 1,
2002.
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 December 31, 2001.
TRD-200108312
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Effective date: January 20, 2002
Proposal publication date: November 23, 2001
For further information, please call: (512) 438-3734