The new section is adopted under Human Resources Code, Chapter 22 and Chapter 32, the Health and Safety Code, §12.001 and the Government Code §531.021, which provides the Health and Human Services Commission with the authority to administer the state's medical assistance program and are submitted by the department under its agreement with the Health and Human Services Commission to operate the purchased health services program as authorized under Acts 1991, 72nd Legislature, First Called Session, Chapter 15, §1.07.

§40.1.Definitions of Terms.

The following words and terms, when used in the Medical Transportation Program (MTP) rules, shall have the following meanings, unless the content clearly indicates otherwise.

(1)

Abuse--The willful infliction of intimidation or injury resulting in physical harm, pain, or mental anguish.

(2)

Adjacent county(ies)--The county or counties next to the client's county of residence.

(3)

Advance funds--Funds authorized by Regional MTP staff in advance of travel and provided to a client or attendant for a medically-necessary health care service.

(4)

Attendant--An individual, translator, other assistant or service animal that accompanies an eligible client.

(5)

Batch--A group of mass-transit tickets or tokens with one unique confirmation number.

(6)

Cancellation--Verbal or written notification from a client, a client advocate, or contractor prior to the scheduled medical transportation service which indicates that the particular service is not needed.

(7)

Certification Period--A period of time for which service is certified.

(8)

Children with Special Health Care Needs-Chronically Ill and Disabled Children (CSHCN-CIDC)--A department program funded with general revenue and federal funds. Services for eligible children include early identification, diagnosis and evaluation, resulting in early health care intervention.

(9)

Contractor--An individual, a for-profit business, a non-profit organization, or a governmental unit that has entered into a legally binding contract with the department to provide authorized MTP transportation services, advance funds, meals and/or lodging to eligible clients.

(10)

Curb-to-curb service--Transportation from curb at origin to curb at destination. This service includes providing assistance, as required, to passengers entering and exiting the vehicle.

(11)

Department--Texas Department of Health. The State agency that operates the Medical Transportation Program under Title XIX of the Social Security Act.

(12)

Dependent care--Necessary care for a child or disabled adult.

(13)

Destination--The place or point to which a client has been authorized by MTP to travel.

(14)

Door-to-door service--Transportation from the door of the trip origin to the door of the trip destination as authorized by Regional MTP staff. This service includes providing assistance, as required, to passengers entering and exiting the vehicle.

(15)

Eligible MTP client--A person enrolled in Medicaid, Children with Special Health Needs (CSHCN-CIDC), or the Transportation for Indigent Cancer Patients (TICP) programs.

(16)

Fraud--Deliberate misrepresentation or intentional concealment of information in order to obtain services or payment for services to which a person or contractor is not entitled.

(17)

Health-Care Provider's Statement of Need--A written statement or MTP form submitted by a health care provider which documents the client's need for health services.

(18)

Hotel--An establishment that provides overnight lodging.

(19)

Individual contractor (IC)--A person who contracts with the department for mileage reimbursement at a prescribed rate to provide transportation for an eligible client to a covered health care service.

(20)

Lock-in--An action taken by the department to restrict the individual's choice of providers.

(21)

Mass transit--Transportation that is subsidized by sales taxes or Federal Transit Administration funds and provided to the general public within a predetermined local area.

(22)

Medicaid--A health care program provided to eligible individuals under Title XIX of the federal Social Security Act and the Texas Human Resources Code, Chapter 32.

(23)

Medicaid-allowable service--A service covered under the State's Medicaid Plan for which a client is eligible. This includes health care services that are provided to the client by a charitable organization but not billed to Medicaid as well as value-added services provided by a Medicaid managed care plan to a Medicaid-enrolled member.

(24)

Medically necessary--services that are:

(A)

reasonably necessary to: prevent illness(es) or medical condition(s); maintain function or to slow further functional deterioration; provide early screening, intervention, care, and/or provide care or treatment for eligible recipients who have medical condition(s) that cause suffering or pain, physical deformity or limitations in function, or that threaten to cause or worsen a disability, illness or infirmity, or endanger life;

(B)

provided at appropriate locations and at the appropriate levels of care for the treatment of the medical condition(s);

(C)

consistent with health care practice guidelines and standards endorsed by professionally recognized health care organizations or governmental agencies;

(D)

consistent with the diagnosis(es) of the condition(s); and

(E)

no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency.

(25)

Medical Transportation Program (MTP)--A program which provides non-emergency transportation services to and from health care services for persons enrolled in Medicaid, CSHCN-CIDC, or TICP who have no other means of transportation to the health service.

(26)

Minor--An individual under 18 years of age who has never been married or emancipated by court ruling.

(27)

No show--

(A)

a client who does not respond within ten minutes of the time the contractor arrives at the designated pick-up point and scheduled time and announces its presence; or

(B)

a contractor who fails to arrive at the designated pick-up point and time.

(28)

One-way trip--Transportation of a passenger from point-of-origin to destination.

(29)

On-time--Contractor arrives at the health care facility no more than one hour prior to the MTP client's scheduled medical appointment time and returns for pick up no later than one hour after the scheduled return trip time.

(30)

Origin--The location at which the contractor is authorized to pick up the client.

(31)

Overnight stay--A service enabling a client to remain beyond the date of MTP transportation at a health care facility located outside the client's city of residence.

(32)

Passenger assistance--Assistance which enables a client to walk, enter or exit a vehicle, or transfer from a wheelchair. This does not include lifting or carrying a person.

(33)

Prior authorization--Authorization or approval for the delivery of certain services obtained from the department or its designee before the services are rendered. Prior authorized services may be limited in duration, scope, and amount. Services provided beyond those authorized are not reimbursable by MTP. If a prior authorization is limited in duration, scope or amount, a separate request must be submitted and approved for any additional services.

(34)

Reasonable transportation--Transportation within a client?s county of residence, or to an adjacent county, using the most cost-effective transportation that meets the client's medical needs.

(35)

Rescheduled authorized trips--Authorized trips postponed by a contractor because of scheduling conflicts and/or seating capacity limitations.

(36)

Retroactive payments--Payments made to a contractor for eligible services which would have been authorized had they been requested prior to the service.

(37)

Routine medical transportation--Authorized medical transportation of eligible clients to and/or from the nearest facility where health care needs will be met.

(38)

Same-day service--An urgent request authorized by MTP staff.

(39)

Sanctions--Disciplinary action against an MTP contractor for validated infractions of program rules, policies, or contract terms.

(40)

Scheduling--Authorized medical transportation arranged for clients by contractors to ensure the client's timely arrival at health care services on or before the scheduled medical appointment.

(41)

Service animal--A guide dog or a signal dog trained to provide assistance to an individual with a disability.

(42)

Sexual harassment--Unwelcome sexual advances, requests for sexual favors, or other unwanted verbal or physical conduct of a sexual nature directed toward a person by another individual during the provision of MTP services.

(43)

Special medical transportation--Medical transportation to and/or from a health care facility beyond the county adjacent to the client's county of residence.

(44)

Subcontractor--An individual, for-profit business, non-profit organization, or governmental unit that has entered into a legal contract with the department's MTP contractor to provide transportation services, advance funds, meals, and/or lodging to eligible clients authorized by Regional MTP staff.

(45)

Transportation for Indigent Cancer Patients (TICP) Program--A state-funded program that provides medical transportation services to clients diagnosed with cancer or a cancer-related illness and who meet certain residency and financial criteria.

(46)

Urgent--A request for same-day transportation service.

(47)

Usual and customary charge--The fee a contractor customarily charges the general public for a service.

(48)

Workday--Normal department operating hours from 8:00 a.m. - 5:00 p.m. Monday through Friday with the exception of state and federal holidays.

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 21, 2001.

TRD-200101630

Susan K. Steeg

General Counsel

Texas Department of Health