Part 12.
COMMISSION ON STATE EMERGENCY COMMUNICATIONS
Chapter 251.
REGIONAL PLANS--STANDARDS
1 TAC §251.1
The Commission on State Emergency Communications (CSEC) proposes
amendments to §251.1, concerning regional plans for 9-1-1 service to
include new criteria to accommodate Voice over the Internet Protocol (VoIP)
telephone service, to streamline the rule in conjunction with development
of related Program Policy Statement, and to delete references to Mobile PSAPs
that are no longer applicable.
Paul Mallett, executive director, has determined that for the first five-year
period the rule is in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the rule.
Mr. Mallett has determined that for each year of the first five years the
section is to be in effect, the public benefit anticipated as a result of
enforcing the section will be improved effectiveness and reliability of 9-1-1
call delivery systems in the state program regions throughout the state. No
historical data is available, however, there appears to be no direct impact
on small or large businesses. There is no anticipated economic cost to persons
who are required to comply with the section as proposed. There is no anticipated
local employment impact as a result of enforcing the section.
Comments on the proposed rule may be submitted in writing within 30 days
after publication of the proposal in the
Texas Register
to Paul Mallett, Executive Director, Commission on State Emergency
Communications, 333 Guadalupe Street, Suite 2-212, Austin, Texas 78701-3942.
The amendments are proposed under Health and Safety Code, Chapter
771, §§771.051, 771.055, 771.056, 771.057, and 771.075; and Title
1 Texas Administrative Code, Part 12, Chapter 251, Regional Plan Standards,
which provide the Commission on State Emergency Communications with the authority
to plan, develop, provide provisions for and enhance the effectiveness and
efficiency of 9-1-1 service.
No other statutes, articles or codes are affected by the proposed amendment.
§251.1.Regional Strategic Plans for 9-1-1 Service.
(a) - (e)
(No change.)
(f)
All regional plans for 9-1-1 service must include
one Primary PSAP and
the following equipment and service
at all
PSAPs
:
(1) - (3)
(No change.)
[
(4)
[
(5)
[
(6)
[
(7)
[
(A)
Network connections between each telephone central office
or mobile switch and the SR;
(B)
Network connections from the SR to the PSAP;
(C)
Network connections from the ALI database to the PSAP;
(D)
Database routers;
(E)
Telephone sets and/or integrated ANI and ALI display call
taking positions;
(F)
Stand-alone TDD units [
(G)
Any other equipment essential to the 9-1-1 call-taking
function.
(8)
[
(9)
[
(10)
[
(A)
Contingency routing plan;
(B)
Network testing plan;
(C)
Local monitoring plan;
(D)
Capital asset plan;
(E)
Network diagrams;
(F)
Database maintenance plan; and
(G)
Equipment maintenance plan.
(g)
(No change.)
(h)
Call Taking Positions. Requests for an increase in the
number of positions within a PSAP should be submitted for approval
with
submission of
[
[
[
[
[
(i)
Adding a PSAP. Should there be a need to add a new PSAP
within the region, the RPC shall follow the requirements for amendments in
accordance with Commission Rule 251.6, Guidelines for Strategic Plans, Amendments,
and Revenue Allocation. The amendment
request
shall
comply
with Commission rules, policies and procedures.
[
[
[
[
[
[
[
[
[
[
(j)
[
(k)
[
(l)
[
(m)
[
(n)
[
(o)
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on July 25, 2005.
TRD-200503016
Paul Mallett
Executive Director
Commission on State Emergency Communications
Earliest possible date of adoption: September 4, 2005
For further information, please call: (512) 305-6933
1 TAC §254.1
The Commission on State Emergency Communications (CSEC) proposes
new Chapter 254, §254.1, concerning operations and funding of Poison
Control Centers.
Health and Safety Code, Chapter 777, §777.001(b) and §777.009(b)
require that CSEC jointly adopt rules regarding Poison Control Centers with
the Department of State Health Services (DSHS). DSHS has repealed and replaced
its rules regarding the poison control center network (25 Texas Administrative
Code §5.51 and §5.52). As required by statute, CSEC must post and
adopt its own rule to mirror the intent and language of the DSHS rules.
Paul Mallett, executive director, has determined that for the first five-year
period the rule is in effect there will be no fiscal implications for state
or local government as a result of enforcing or administering the rule.
Mr. Mallett has determined that for each year of the first five years the
section is to be in effect, the public benefit anticipated as a result of
this section will be increased clarity and ease of understanding the rules.
No historical data is available, however, there appears to be no direct impact
on small or large businesses. There is no anticipated economic cost to persons
who are required to comply with the section as proposed. There is no anticipated
local employment impact as a result of enforcing the section.
Comments on the proposed rule may be submitted in writing within 30 days
after publication of the proposal in the
Texas Register
to Paul Mallett, Executive Director, Commission on State Emergency
Communications, 333 Guadalupe Street, Suite 2-212, Austin, Texas 78701-3942.
The new section is proposed under Health and Safety Code, Chapter
777, §777.001(b) and §777.009(b), which require that CSEC jointly
adopt rules regarding Poison Control Centers with DSHS.
No other statutes, articles or codes are affected by the proposed new section.
§254.1.Operations and Funding of Poison Control Centers.
(a)
Purpose. Health and Safety Code, Chapter 777, and 25 TAC §5.51,
provide the Department of State Health Services (Department) and the Commission
on State Emergency Communications (Commission) with the authority to establish
a program to award grants to fund a network of regional poison control centers.
(b)
Background. The Commission and the Department shall adopt
a statewide telecommunications network plan. The plan may establish phased
implementation of the network. The plan shall consider the following:
(1)
uniform statewide 800-service availability for community
and professional access for poison information and referral;
(2)
direct access from Public Safety Answering Points to Poison
Control Answering Points for emergency calls; and
(3)
other features as appropriate and identified by this section.
(c)
As required by Health and Safety Code, §777.001, the
Texas Health and Human Services (HHS) regions shall define the service areas
for the Poison Control Answering Points, except where telecommunications network
design would greatly increase the cost of routing the system. The regions
are as follows:
(1)
The University of Texas Medical Branch at Galveston--HHS
Regions 5 and 6;
(2)
The Dallas County Hospital District/North Texas Poison
Center--HHS Regions 3 and 4;
(3)
The University of Texas Health Science Center at San Antonio--HHS
Regions 8 and 11;
(4)
R.E. Thomason General Hospital, El Paso County Hospital
District--HHS Regions 9 and 10;
(5)
Northwest Texas Hospital, Amarillo Hospital District--HHS
Regions 1 and 2; and
(6)
Scott and White Memorial Hospital, Temple--HHS Region 7.
(d)
Eligibility for funding.
(1)
The entities eligible to request funding are the regional
poison control centers for the state, designated under the Health and Safety
Code, Chapter 777, as follows:
(A)
University of Texas Medical Branch at Galveston;
(B)
Dallas County Hospital District/North Texas Poison Center;
(C)
University of Texas Health Science Center at San Antonio;
(D)
R.E. Thomason General Hospital, El Paso County Hospital
District;
(E)
Northwest Texas Hospital, Amarillo Hospital District; and
(F)
Scott and White Memorial Hospital, Temple.
(2)
In accordance with Health and Safety Code, §777.009,
and 25 TAC §5.52, each poison control center must be certified by the
American Association of Poison Control Centers (AAPCC) until a statewide system
certification is achieved. The Commission and Department shall work together
with the AAPCC to certify the statewide poison control network and/or individual
centers as required.
(e)
Funding criteria. As required by 25 TAC §5.52, applicants
must meet all of the goals and objectives outlined in the annual Request for
Proposals, including:
(1)
the need of the region based on population served for poison
control services, and the extent to which the grant would meet the identified
need;
(2)
a four-year strategic plan assuring provision of quality
service;
(3)
a demonstration that the Poison Control Answering Point
is working toward achieving and/or maintaining certification as a poison control
center with the AAPCC; and
(4)
the availability of other funding sources; the maintenance
of effort; and the development or existence of telecommunications systems.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on July 25, 2005.
TRD-200503015
Paul Mallett
Executive Director
Commission on State Emergency Communications
Earliest possible date of adoption: September 4, 2005
For further information, please call: (512) 305-6933
Chapter 353.
MEDICAID MANAGED CARE
Subchapter A. GENERAL PROVISIONS
1 TAC §353.4
The Texas Health and Human Services Commission (HHSC) proposes
new §353.4, detailing Medicaid managed care organizations requirements
related to out-of-network providers.
Background and Justification
House Bill 2292, 78th Legislature, Regular Session, 2003, mandates that
a managed care organization (MCO) that contracts with HHSC in the STAR or
STAR+PLUS programs is subject to certain requirements involving out-of-network
providers. Those requirements include network adequacy, appropriate payment
rates for out-of-network services received by a Medicaid managed care member,
and appropriate limits on the MCO's usage of out-of-network providers. The
bill addresses provider complaints to HHSC regarding reimbursement for, or
overuse of, out-of-network services and the time frame for HHSC to respond
to those complaints. House Bill 2292 also requires HHSC to initiate a corrective
action plan if an MCO does not meet the requirements related to reimbursement
or network adequacy. The MCO is required to submit a report to HHSC with information
regarding number, type, and scope of services provided by out-of-network providers.
To facilitate a better understanding of the practices and concerns associated
with the issues addressed by House Bill 2292, HHSC commissioned The Lewin
Group to conduct a study of out-of-network reimbursement and related policies.
In its study, The Lewin Group conducted interviews with HHSC staff, provider
associations, hospital providers, and Medicaid managed care contracted health
plans. It also researched the experience of other states. From its findings,
The Lewin Group made a number of policy recommendations to HHSC regarding
out-of-network services.
HHSC also solicited stakeholder input concerning The Lewin Group's recommendations
and how best to implement the mandates of House Bill 2292. Stakeholders from
both the provider community and the managed care industry reviewed drafts
of the proposed rule and provided comments and recommendations.
Using the mandates of House Bill 2292, findings and recommendations from
The Lewin Group report, as well as input from stakeholders, HHSC developed
the proposed rule concerning the responsibilities of Medicaid MCOs in the
STAR and STAR+PLUS programs when one of their members receives services from
an out-of-network provider as well as HHSC's oversight of those MCO responsibilities.
The rule mandates that Medicaid MCOs have an adequate network to meet the
needs of their members and that they allow referrals to out-of-network providers
under certain circumstances. The rule requires an MCO to reimburse out-of-area
out-of-network and in-area out-of-network provider at a reasonable rate, which
is established by the rule. Each MCO must provide information quarterly to
HHSC related to services delivered by out-of-network providers. Using these
reports and standards established in the proposed rule HHSC will determine
if MCO member utilization of out-of-network providers is appropriate. If HHSC
determines the MCO member utilization to be excessive, the rule describes
the consequences for the MCO, including an increase in the reimbursement payable
to out-of-network providers for specified timeframes. HHSC will accept and
investigate complaints by providers related to out-of-network reimbursement
or usage. If HHSC finds a complaint to be valid, HHSC must implement a corrective
action plan and seek appropriate reimbursement from the MCO. The rule describes
the circumstances and the contents of a corrective action plan.
Section-by-Section Summary
Subsection (a) of the rule identifies HHSC as the state agency with oversight
for the Medicaid managed care program and confirms the responsibility of the
participating managed care organizations (MCOs) to offer a provider network
that meets the needs of their members. Subsection (b) outlines the steps for
an appropriate referral to an out-of-network provider, use of out-of-network
emergency services, and member access to other out-of-network services that
may be necessary in other circumstances.
Subsection (c) describes the methodology used to determine the amount of
reimbursement paid by an MCO for out-of-network services. Subsection (d) describes
the timing and content of quarterly financial statistical reports to HHSC
from MCOs. Subsection (e) concerns MCO member utilization of out-of-network
services, including the standards by which excessive utilization will be determined
and the special circumstances taken into consideration by HHSC in calculating
an MCO's out-of-network utilization.
The provider complaint process is covered in subsection (f), including
the timeframes for HHSC's response and for any action required from the MCO
if HHSC determines that the complaint is valid. Subsection (g) describes when
a corrective action plan will be required for an MCO, what the plan will require,
and what actions are taken either by HHSC or the MCO as a result of the need
for a corrective action plan.
Fiscal Note
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
during the first five-year period the proposed rule is in effect there will
be a fiscal impact of $3.2 million in additional costs to state government.
The proposed rule will not result in any fiscal implications for local health
and human services agencies. Local governments will not incur additional costs.
Small and Micro-business Impact Analysis
Mr. Suehs has also determined that there will be no effect on small businesses
or micro businesses to comply with the proposal, as they will not be required
to alter their business practices as a result of the rule. There are no anticipated
economic costs to persons who are required to comply with the proposed rule.
There is no anticipated negative impact on local employment.
Public Benefit
Billy Millwee, Deputy Director of Health Plan Operations, has determined
that for each year of the first five years the section is in effect, the public
will benefit from the adoption and enforcement of the section. The anticipated
public benefit will be improved health plan networks for Medicaid MCO members
as well as increased provider access and choice for those members.
Regulatory Analysis
HHSC has determined that this proposal is not a "major environmental rule"
as defined by §2001.0225 of the Texas Government Code. "Major environmental
rule" is defined to mean a rule the specific intent of which is to protect
the environment or reduce risk to human health from environment exposure and
that may adversely affect, in a material way, the economy, a sector of the
economy, productivity, competition, jobs, the environment or the public health
and safety of a state or a sector of the state. This proposal is not specifically
intended to protect the environment or reduce risks to human health from environment
exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit an owner's
right to his or her property that would otherwise exist in the absence of
government action and, therefore, does not constitute a taking under §2007.043
of the Government Code. No takings impact assessment is required.
Public Comment
Written comments on the proposal may be submitted to Lesa Ledbetter, at
Health and Human Services, P.O. Box 85200, Austin, Texas 78708-5200, by fax
to (512) 491-1953, or by e-mail to lesa.ledbetter@hhsc.state.tx.us within
30 days of publication of this proposal in the
Texas
Register
.
Public Hearing
A public hearing is scheduled for August 17, 2005 from 3:00 PM to 4:00
PM (central time) in the public hearing room of the Texas Health and Human
Services Commission, 11209 Metric Boulevard, Building H, Austin, Texas 78758.
Persons requiring further information, special assistance, or accommodations
should contact Carmen Capetillo at (512) 491-1104.
Statutory Authority
The new rule is proposed under the Texas Government Code, §531.033,
which provides the Commissioner of HHSC with broad rulemaking authority; the
Human Resources Code, §32.021 and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas; and the Texas Government Code, §531.021(b),
which provides HHSC with the authority to propose and adopt rules governing
the determination of Medicaid reimbursements.
The proposed rule affects the Human Resources Code, Chapter 32, and the
Texas Government Code, Chapters 531 and 533. No other statutes, articles,
or codes are affected by this proposal.
§353.4.Requirements of STAR and STAR+PLUS Programs Concerning Out-of-Network Providers.
(a)
Network adequacy. The Health and Human Services Commission
(HHSC) is the state agency responsible for overseeing and monitoring the Medicaid
managed care program. The managed care organizations (MCOs) participating
in the Medicaid managed care program must offer a network of providers that
is sufficient to meet the needs of the Medicaid population who are MCO members.
HHSC will monitor MCO members' access to an adequate provider network through
reports from the MCOs and complaints received from providers and members.
The reporting requirements are discussed in subsection (d) of this section.
(b)
MCO requirements concerning treatment of members by out-of-network
providers.
(1)
The MCO shall allow referral of its member(s) to an out-of-network
provider, shall timely issue the proper authorization for such referral, and
shall timely reimburse the out-of-network provider for authorized services
provided when:
(A)
Medicaid covered services are medically necessary and these
services are not available through an in-network provider;
(B)
A provider currently providing authorized services to the
member requests authorization for such services to be provided to the member
by an out-of-network provider; and
(C)
The authorized services are provided within the time period
specified in the MCO's authorization. If the services are not provided within
the required time period, a new request for referral from the requesting provider
must be submitted to the MCO prior to the provision of services.
(2)
An MCO may not refuse to reimburse an out-of-network provider
for emergency or post-stabilization services provided as a result of the MCO's
failure to arrange for and authorize a timely transfer of a member.
(3)
MCO requirements concerning emergency services.
(A)
The MCO shall allow its members to be treated by any emergency
services provider for emergency services and/or for services to determine
if an emergency condition exists.
(B)
The MCO is prohibited from requiring an authorization for
emergency services or for services to determine if an emergency condition
exists.
(4)
MCOs may be required by contract with HHSC to allow members
to obtain services from out-of-network providers in circumstances other than
those described in paragraphs (1) - (3) of this subsection.
(c)
Reasonable Reimbursement Methodology
(1)
The MCO shall reimburse an out-of-network, in area service
provider no less than the prevailing Medicaid Fee-For-Service (FFS) rate less
3 percent. The Medicaid Fee-For-Service rates are defined as those rates for
providers of services in the Texas Medicaid Program for which reimbursement
methodologies are specified in Chapter 355 of this title, exclusive of the
rates and payment structures in Medicaid Managed Care.
(2)
The MCO shall reimburse an out-of-network, out-of-area
service provider at no less than 100 percent of the Medicaid Fee-For-Service
rate.
(3)
In accordance with §533.005(a)(12) and (b) of the
Government Code, all post stabilization services provided to a member by an
out-of-network provider must be reimbursed by the MCO at the rates for providers
of services in the Texas Medicaid Program for which reimbursement methodologies
are specified in Chapter 355 of this title, until the MCO arranges for the
timely transfer of the member, as determined by the member's attending physician,
to a provider in the MCO's network.
(d)
Reporting requirements
(1)
Each MCO that contracts with HHSC to provide health care
services to members in a health care service region must submit quarterly
information in its financial statistical report to HHSC. Each MCO must provide
its financial statistical report to HHSC by the 30th calendar day of the month
following the end of each quarter.
(2)
Each financial statistical report submitted by an MCO must
contain information about members enrolled in each HHSC Medicaid managed care
program provided by the MCO. The report shall include the following information:
(A)
The types of services provided by out-of-network providers
for members of the MCO's Medicaid managed care plan.
(B)
The scope of services provided by out-of-network providers
to members of the MCO's Medicaid managed care plan.
(C)
Total number of hospital admissions, as well as number
of admissions that occur at each out-of-network hospital. Each out-of-network
hospital must be identified.
(D)
Total number of emergency room visits, as well as total
number of emergency room visits that occur at each out-of-network hospital.
Each out-of-network hospital must be identified.
(E)
Total dollars billed for other outpatient services, as
well as total dollars billed by out-of-network providers for other outpatient
services.
(F)
Any additional information required by HHSC.
(3)
HHSC will determine the specific form of the report described
above and will include the report form as part of the Medicaid managed care
contract between HHSC and the MCOs.
(e)
Utilization
(1)
Upon review of the reports described in subsection (d)
of this section that are submitted to HHSC by the MCOs, HHSC may determine
that an MCO exceeded maximum Out-of-Network usage standards set by HHSC for
out-of-network access to health care services during the reporting period.
(2)
Out-of-Network Usage Standards
(A)
Inpatient Admissions: No more than 25 percent of an MCO's
total hospital admissions, by service delivery area, may occur in out-of-network
facilities.
(B)
Emergency Room Visits: No more than 30 percent of an MCO's
total emergency room visits, by service delivery area, may occur in out-of-network
facilities.
(C)
Other Outpatient Services: No more than 30 percent of total
dollars billed to an MCO for "other outpatient services" may be billed by
out-of-network providers.
(3)
Special Considerations in Calculating MCO Out-of-Network
Usage of Inpatient Admissions and Emergency Room Visits.
(A)
In the event that an MCO exceeds the maximum Out-of-Network
usage standard set by HHSC for Inpatient Admissions or Emergency Room Visits,
HHSC may modify the calculation of that MCO's Out-of-Network usage for that
standard if:
(i)
The admissions or visits to a single out-of-network facility
account for 25% or more of the MCO's admissions or visits in a reporting period;
and
(ii)
HHSC determines that the MCO has made all reasonable efforts
to contract with that out-of-network facility as a network provider without
success.
(B)
In determining whether the MCO has made all reasonable
efforts to contract with the single out-of-network facility described above
in subparagraph (A) of this paragraph, HHSC will consider at least the following
information:
(i)
How long the MCO has been trying to negotiate a contract
with the out-of-network facility;
(ii)
The in-network payment rates the MCO has offered to the
out-of-network facility;
(iii)
The other, non-financial contractual terms the MCO has
offered to the out-of-network facility, particularly those relating to prior
authorization and other utilization management policies and procedures;
(iv)
The MCO's history with respect to claims payment timeliness,
overturned claims denials, and provider complaints;
(v)
The MCO's solvency status; and
(vi)
The out-of-network facility's reasons for not contracting
with the MCO.
(C)
If the conditions described in subparagraph (A) of this
paragraph are met, HHSC may modify the calculation of the MCO's Out-of-Network
usage for the relevant reporting period and standard by excluding from the
calculation the Inpatient Admissions or Emergency Room Visits to that single
out-of-network facility.
(f)
Provider Complaints.
(1)
HHSC will accept provider complaints regarding reimbursement
for or overuse of out-of-network providers and will conduct investigations
into any such complaints.
(2)
When a provider files a complaint regarding out-of-network
payment, HHSC will require the relevant MCO to submit data to support its
position on the adequacy of the payment to the provider. The data will include
at a minimum a copy of the claim for services rendered and an explanation
of the amount paid and of any amounts denied.
(3)
Not later than the 60th day after HHSC receives a provider
complaint, HHSC shall notify the provider who initiated the complaint of the
conclusions of HHSC's investigation regarding the complaint. The notification
to the complaining provider will include:
(A)
A description of the corrective actions, if any, required
of the MCO in order to resolve the complaint; and
(B)
If applicable, a conclusion regarding the amount of reimbursement
owed to an out-of-network provider.
(4)
If HHSC determines through investigation that an MCO did
not reimburse an out-of-network provider based on a reasonable reimbursement
methodology as described within subsection (c) of this section, HHSC shall
initiate a corrective action plan. Refer to subsection (g) of this section
for information about the contents of the corrective action plan.
(5)
If, after an investigation, HHSC determines that additional
reimbursement is owed to an out-of-network provider, the MCO must:
(A)
Pay the additional reimbursement owed to the out-of-network
provider within 90 days from the date the complaint was received by HHSC or
30 days from the date the clean claim, or information required that makes
the claim clean, is received by the MCO, whichever comes first; or,
(B)
Submit a reimbursement payment plan to the out-of-network
provider within 90 days from the date the complaint was received by HHSC.
The reimbursement payment plan provided by the MCO must provide for the entire
amount of the additional reimbursement to be paid within 120 days from the
date the complaint was received by HHSC.
(6)
If the MCO does not pay the entire amount of the additional
reimbursement within 90 days from the date the complaint was received by HHSC,
HHSC may require the MCO to pay interest on the unpaid amount. If required
by HHSC, interest accrues at a rate of 18 percent simple interest per year
on the unpaid amount from the 90th day after the date the complaint was received
by HHSC, until the date the entire amount of the additional reimbursement
is paid.
(7)
HHSC will pursue any appropriate remedy authorized in the
contract between the MCO and HHSC if the MCO fails to comply with a corrective
action plan under subsection (g) of this section.
(g)
Corrective Action Plan.
(1)
A corrective action plan is required by HHSC in the following
situations:
(A)
The MCO exceeds a maximum standard established by HHSC
for out-of-network access to health care services described in subsection
(e) of this section; or
(B)
The MCO does not reimburse an out-of-network provider based
on a reasonable reimbursement methodology as described within subsection (c)
of this section.
(2)
A corrective action plan imposed by HHSC will require one
of the following:
(A)
Reimbursements by the MCO to out-of-network providers at
rates that equal the allowable rates for the health care services as determined
under §32.028 and §32.0281, Human Resources Code, for all health
care services provided during the period:
(i)
the MCO is not in compliance with a utilization standard
established by HHSC; or
(ii)
the MCO is not reimbursing out-of-network providers based
on a reasonable reimbursement methodology, as described in subsection (c)
of this section.
(B)
Initiation of an immediate freeze by HHSC on the enrollment
of additional recipients in the MCO's managed care plan until HHSC determines
that the provider network under the managed care plan can adequately meet
the needs of the additional recipients;
(C)
Education by the MCO of recipients enrolled in the managed
care plan regarding the proper use of the provider network under the health
care plan; or
(D)
Any other actions HHSC determines are necessary to ensure
that Medicaid recipients enrolled in managed care plans provided by the MCO
have access to appropriate health care services and that providers are properly
reimbursed by the MCO for providing medically necessary health care services
to those recipients.
This agency hereby certifies that the proposal
has been reviewed by legal counsel and found to be within the agency's legal
authority to adopt.
Filed with the Office of
the Secretary of State on July 21, 2005.
TRD-200502978
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: September 4, 2005
For further information, please call: (512) 424-6900
Subchapter J. PURCHASED HEALTH SERVICES
4.
MEDICAID HOSPITAL SERVICES
(4)
One Primary PSAP per RPC.
If there is more than one PSAP, the system may be arranged for two or more
PSAPs to share the 24-hour duty requirement;]
(5)
] TDD/TTY or TDD/TTY compatible
equipment in compliance with the Americans with Disabilities Act (ADA) and
in compliance with Commission Rule 251.4, Guidelines Accessibility Equipment;
(6)
] A standby power supply for
the 9-1-1 equipment;
(7)
] Forced disconnect feature to
allow the PSAP to clear incoming circuits when necessary;
(8)
] The following redundant crucial
service items [
at each PSAP
]:
as applicable
]; and
(9)
] A published ten-digit emergency
telephone number that can accept emergency calls
24 hours a day, 7 days
a week, 365 days a year and which is answered by a qualified 9-1-1 call taker
;
(10)
] A positive response to each
9-1-1 call to include an audible ringing tone connecting to a PSAP where either
the call is answered by personnel at the PSAP or a recorded announcement provides
further information; and
(11)
] The following required elements
to ensure the reliability of the 9-1-1 equipment and service:
in
] the regional strategic plan [
along
with justification for the increase
]. If an increase in the number of
positions is required after the regional plan has been approved [
and
the addition of the position(s) will require no additional funding
],
the RPC shall
comply with Commission rules, policies and procedures.
[
follow the requirements for amendment in accordance with Commission
Rule 251.6, Guidelines for Strategic Plans, Amendments, and Revenue Allocation.
If additional funding is required for the additional position(s), the request
shall be submitted to the Commission for consideration and approval in accordance
with Commission Rule 251.6, Guidelines for Strategic Plans, Amendments, and
Revenue Allocation. No amendment request is necessary when increased call
taking positions to a PSAP or PSAPs do not increase the total number of call
taking positions within the region. Each PSAP shall be equipped with adequate
call taking positions to meet anticipated call volume. Factors that may be
considered in determining the proper number of positions include:
]
(1)
Historical 9-1-1 call volume
and growth;]
(2)
Call duration information;]
(3)
Anticipated area population
growth; and]
(4)
Peak 9-1-1 call volume patterns.]
provide the Commission
written justification supporting the request. Appropriate justification shall
include statistical information such as call volume and growth rates, or jurisdictional
changes within the region. All requests for a new PSAP must include specific
costs for equipment and services, as well as a complete written description
and schematic illustrating the relationship of the proposed PSAP to the balance
of the region’s network. These requirements apply to the addition of
a remote or mobile PSAP, as well as, Primary and Secondary PSAPs.
]
(j)
Mobile PSAP Procedures. When
a RPC is approved to add a mobile PSAP, they must submit a Standard Operating
Procedure (SOP) for that PSAP that includes, at a minimum:]
(1)
Designation of responsible local agency;]
(2)
Proposed hours of operation;]
(3)
Primary location of operation;]
(4)
Procedure for notification of relocation of
PSAP;]
(5)
Asset management plan or insurance coverage
to safeguard the equipment;]
(6)
Security plan for control of the equipment
and data;]
(7)
Revised Interlocal Agreement to include the
mobile PSAP; and]
(8)
Plan for equipment disposal upon termination
of the use of the mobile PSAP.]
(k)
] Contracts. The RPC shall execute
interlocal agreements between itself and its local governments responsible
for PSAPs relating to the planning, development, operation and provision of
9-1-1 service, the use of 9-1-1 funds and adherence to applicable law in accordance
with Commission Rule 251.12, Contracts for 9-1-1 Services.
(l)
] Procurement. The RPC shall
use competitive procurement practices and procedures similar to those required
by state law for cities or counties, as well as any additional Commission
policies, in conjunction with the procurement of 9-1-1 Customer Premises Equipment,
9-1-1 Network, and 9-1-1 Database Services, and any other items to be obtained
with 9-1-1 funds in accordance with Commission Rule 251.8, Guidelines for
the Procurement of Equipment and Services with 9-1-1 funds.
(m)
] Equipment Management. The RPC
is responsible for the 9-1-1 equipment in accordance with Commission Rule
251.5, Guidelines for 9-1-1 Equipment Management and Disposition. Any integration
of expanded third-party applications onto a call taking position must be in
accordance with Commission Rule 251.7, Guidelines for Implementing Integrated
Service. If changes or extensions of 9-1-1 service occur, the RPC is to administer
and report them in accordance with Commission Rule 251.2, Guidelines for Changing
or Extending 9-1-1 Service Arrangements.
(n)
] Testing. The RPC shall test
all 9-1-1 Customer Premises Equipment (including TDD/TTY), 9-1-1 Network,
and 9-1-1 Database services. Testing shall occur when new service or equipment
is installed, service or equipment is modified, and on a regular basis to
ensure system reliability and compliance with ADA. A schedule for ongoing
testing shall be developed by the RPC and shall be available to the Commission
for monitoring.
(o)
] Monitoring. The Commission
reserves the right to perform on-site monitoring of the RPC and/or its performing
local governments or PSAPs, including mobile PSAPs, for compliance with applicable
law in accordance with Commission Rule 251.11, Monitoring Policies and Procedures.
(p)
] Performance Reporting. A RPC
shall submit financial and performance reports to the Commission at least
quarterly on a schedule to be established by the Commission. The financial
report shall identify actual implementation costs by county, strategic plan
priority level, and component. The performance report shall reflect the progress
of implementing the region’s strategic plan including, but not limited
to, the status of equipment, services, and program deliverables in a format
to be determined by the Commission.
Chapter 254
POISON CONTROL CENTERS
Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355.
REIMBURSEMENT RATES