Part 1.
TEXAS DEPARTMENT OF HEALTH
Chapter 27.
CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN
25 TAC §§27.1, 27.3, 27.5, 27.7, 27.9, 27.11, 27.13, 27.15
The Texas Department of Health (department) proposes new §§27.1,
27.3, 27.5, 27.7, 27.9, 27.11, 27.13 and 27.15, concerning case management
for children and pregnant women. Specifically, these new sections cover definitions;
eligible recipients; case management service provisions; service limitations;
applicant and provider qualifications; application; case management provider
review and monitoring processes.
The proposed new rules for Case Management for Children and Pregnant Women
will provide case management services to Medicaid eligible women of all ages
who have a high risk pregnancy and to children from birth to 21 years of age
with a health condition/health risk. The programs, Medicaid Case Management
for High Risk Pregnant Women and High Risk Infants and the Texas Health Steps
Medical Case Management will become one program due to the proposed repeal
of §§32.301 - 32.305, 32.307, 33.501 - 33.506, and 37.81 - 37.86
of this title and will become proposed new sections of Chapter 27. The new
program will provide a greater continuity of services for all eligible recipients.
New §27.1 covers definitions and includes language from proposed repealed §33.501
and proposed repealed §37.82. New §27.3 covers eligible recipients
and includes language from proposed repealed §33.502 and proposed repealed §37.82.
New §27.5 covers Case Management for Children and Pregnant Women's services
and includes language from proposed repealed §33.503 and proposed repealed §37.83.
New §27.7 covers service limitations and includes language from proposed
repealed §33.504. New §27.9 covers applicant qualifications and
includes language from proposed repealed §33.505 and proposed repealed §37.84.
New §27.11 covers provider requirements and includes language from proposed
repealed §33.505 and proposed repealed §37.84. New §27.13 covers
application processes and includes language from proposed repealed §33.506
and proposed repealed §37.85. New §27.15 covers case management
provider review and monitoring process and includes language from proposed
repealed §33.506 and proposed repealed §37.85.
The department also proposes the repeal of §§32.301 - 32.305
and §32.307, concerning case management for high risk pregnant women
and high risk infants. Specifically these sections cover definitions; eligible
individuals; case management services; service limitations; provider qualifications
and the right to appeal. These sections are being proposed for repeal as they
are repeated in §§37.81 - 37.86. Sections 32.301 - 32.305 and 32.307
were not repealed when §§37.81 - 37.86 were adopted.
The department further proposes repeal of Early and Periodic Screening,
Diagnosis, and Treatment, Subchapter J, Texas Health Steps Medical Case Management §§33.501
- 33.506. Specifically, these sections cover definitions; eligible recipients;
THSteps Medical Case Management Services; service limitations; applicant and
provider qualifications; application, review and monitoring process. These
sections are being proposed for repeal in an effort to integrate services
to the eligible population for case management services: children with a health
condition/health risk birth to 21 years and/or high risk pregnant women of
all ages.
The department at the same time is proposing the repeal of §§37.81
- 37.86, concerning Medicaid case management for high risk pregnant women
and high risk infants. Specifically, these sections cover introduction; definitions;
case management services; provider qualifications; application and review
process; and documents adopted by reference. Pertinent portions of the proposed
repealed sections will be integrated in proposed new Chapter 27 of this title.
The department provides health services to women and children in Texas
under the authority of the Health and Safety Code, Chapter 32; the State Appropriations
Act; and the Social Security Act, Title V. The Targeted Case Management Program
for High Risk Pregnant Women and High Risk Infants was established under the
authority of the Social Security Act, Title XIX, §1915(g). Section 1915(g)
authorized states to provide case management as a distinct service to targeted
populations, through a waiver from the Health Care Financing Administration
(HCFA), now the Centers for Medicare and Medicaid Services or CMS. The Health
and Human Services Commission (HHSC) provides authority to the department
to propose rules to administer certain Medicaid program services in Texas.
Human Resources Code, §22.0031, mandates case management for high-risk
pregnant women and high-risk children to age one as provided under §1915(g)
of the federal Social Security Act (42 U.S.C. §1396n). Case management
for children up to age 21 is authorized under 42 U.S.C. §1396d.
The Government Code, §531.021, provides HHSC with the authority to
propose rules to administer the state's medical assistance program. The Texas
Department of Health submitted the current rules under its agreement with
HHSC to operate the Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) program, and as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapter 15, §1.07. In Texas, the EPSDT program is known
as Texas Health Steps (THSteps). The purpose of these sections is to make
available medically necessary THSteps medical case management services mandated
by the federal EPSDT program.
Ravi Rupsingh, M.P.A., Actuary, Actuary Analysis, HHSC, has determined
for the first five years the sections are in effect, there will be cost savings
to the state through the combination of the two programs as described in this
preamble. Total cost savings per year are $1,724,820, $6,153,493, $6,348,526,
$6,549,411 and $6,745,893 in state fiscal years 2003, 2004, 2005, 2006 and
2007, respectively, for a total of $27,522,143 over these five state fiscal
years. There will be no impact on local government.
Duane Thomas, Ph.D., Texas Department of Health, Director of Regional Case
Management has also determined that for each of the first five years the sections
are in effect, anticipated public benefits include better access to primary
care providers, preventative health services, other health services and community
resources for children and pregnant women accessing the services. There will
be costs to small businesses and micro-businesses. This was determined after
concluding that the elimination of the Intake as a billable contact for Targeted
Case Management for Pregnant Women and Infants providers will decrease the
amount of reimbursement that these providers currently receive. The cost to
small and micro-businesses for the first year of implementation is estimated
to be $7,327 while the cost to large businesses for the first year of implementation
is estimated to be $7,281. The estimated costs are based on the assumption
that 70% of Targeted Case Management for Pregnant Women and Infants providers
are large businesses and 30% of providers are small or micro-businesses. There
will be no anticipated economic costs to persons who receive the services.
The department has determined that the proposed rules do not restrict or limit
an owner's right to their property that would otherwise exist in the absence
of governmental action and therefore does not constitute a taking under Government
Code, §2007.043.
Comments on the proposal may be submitted to Cossy Hough, LMSW-ACP, Texas
Department of Health, 1100 West 49th Street, Austin, Texas 78756, (512) 458-7111,
extension 6664. Comments will be accepted for 30 days following publication
of the proposal in the
Texas Register
.
A public hearing regarding these proposed rules will be held on April 8,
2003, from 1:00 p.m. to 4:00 p.m. at the Texas Department of Health, Moreton
Building, Room M-739, 1100 West 49th Street, Austin, Texas 78756.
The new sections are proposed under the Health and Safety Code, §12.001,
which provides the Board of Health (board) with the authority to adopt rules
to implement every duty imposed by law on the board, the department and the
commissioner of health; and under the Health and Safety Code, Chapter 32,
which provides the board with the authority to establish maternal and infant
health improvement services programs in the department to serve eligible recipients;
the Human Resources Code, §22.0031, which mandates case management for
high risk pregnant women and high risk infants under §1915(g) of the
federal Social Security Act (42 U.S.C. §1396n); the Human Resources Code,
Chapter 32, which enables the state to provide medical assistance; the Government
Code, §531.021, which provides HHSC with the authority to propose rules
to administer the state's medical assistance program and are submitted by
the Texas Department of Health under its agreement with HHSC to operate the
EPSDT program, and as authorized under §1.07 of the Acts of the 72nd
Legislature, First Called Session (1991), Chapter 15, as amended by the Acts
of the 73rd Legislature, Chapter 747, §2.
The proposed new sections affect the Health and Safety Code, Chapter 32,
the Human Resources Code, §22.0031 and Chapter 32.
§27.1.Definition of Terms.
The following words and terms when used in this chapter shall have
the following meanings unless the context clearly indicates otherwise.
(1)
Access--The ability of an eligible recipient to obtain
health and health-related services, as determined by factors such as: the
availability of THSteps services; service acceptability to the eligible child,
family, and/or pregnant woman; the location of health care facilities and
other resources; transportation; hours of facility operation and length of
time available to see the healthcare provider.
(2)
Applicant--An agency, organization, or individual who submits
an application to the department to provide Case Management for Children and
Pregnant Women under this subchapter and who meets the applicant qualifications
and requirements as stated in §27.9 and §27.11 of this title (relating
to Applicant Qualifications and Case Management Provider Requirements).
(3)
Application process--Submission of an application to provide
Case Management for Children and Pregnant Women and the department's ensuing
review and disposition of the application.
(4)
Billable contact--A documented Comprehensive Visit or Follow-up
contact with an eligible recipient, by an approved case manager who provides
an eligible case management service, as defined in §27.5 of this title
(relating to Case Management and Pregnant Women).
(5)
Board--The Texas Board of Health.
(6)
Case manager--An individual who provides Case Management
for Children and Pregnant Women services either independently or as an employee
of a Case Management Provider.
(7)
Case management provider--An agency or individual approved
by the department to provide Case Management for Children and Pregnant Women
Services and enrolled as a Medicaid provider.
(8)
Case Management for Children and Pregnant Women--The federal
enhancement service which assists eligible recipients in gaining access to
medically necessary medical, social, educational, and other services.
(9)
Children with a health condition/health risk--Children
who have or are at risk for a medical condition, illness, injury, or disability
that results in limitation of function, activities or social roles in comparison
with healthy age peers in the general areas of physical, cognitive, emotional,
or social growth and development.
(10)
Continuity of care--The degree to which: the care of a
child is provided by the same medical home or primary care provider; the system
of care remains stable and services are consistent, unduplicated and uninterrupted.
(11)
Department--The Texas Department of Health.
(12)
EPSDT--Early and Periodic Screening, Diagnosis and Treatment
program. All states participating in the Medicaid program must offer EPSDT
to children under age 21 who qualify for Medicaid. EPSDT provides medical
and dental services to Medicaid and Texas Health Steps clients under age 21
years. In Texas, EPSDT is known as Texas Health Steps (THSteps).
(13)
Family--A basic unit in society having at its nucleus:
one or more adults living together and cooperating in the care and rearing
of their own or adopted children; a person or persons acting as the family
of an individual; a foster family or identifiable support person or persons.
(14)
Health and health-related services--Services which are
provided to meet the comprehensive (preventive, primary, tertiary and specialty)
health needs of the eligible recipient, including but not limited to, well
care and dental check ups, immunizations, acute care visits, pediatric specialty
consultations, physical therapy, occupational therapy, audiology, speech language
services, mental health professional services, pharmaceuticals, medical supplies,
prenatal care, family planning, adolescent preventive health, durable medical
equipment, nutritional supplements, prosthetics, eye glasses, and hearing
aids.
(15)
High risk pregnant women--Women who are pregnant and have
one or more high-risk medical and/or personal/psychosocial condition(s) during
pregnancy.
(16)
Preventive services--Services that include health counseling
and education, immunizations, wellness care, nutritional supplementation,
family planning and screening aimed at avoiding illness and/or disability.
(17)
Primary services--Services that include care for minor
illnesses, injuries and abnormalities discovered through screenings.
(18)
State--The State of Texas.
(19)
Tertiary services--Services that include care for major
illnesses and injuries, and chronic or disabling conditions.
(20)
Texas Health Steps Program (THSteps)--In Texas, the federal
program known as EPSDT, which is required of states participating in the Medicaid
program, is called Texas Health Steps.
§27.3.Eligible Recipients.
Clients eligible for case management services under this subchapter
must be either children with a health condition/health risk or high-risk pregnant
women who are:
(1)
Medicaid eligible in Texas;
(2)
in need of services to prevent illness(es) or medical condition(s),
to maintain function or slow further deterioration; and
(3)
desire case management.
§27.5.Case Management for Children and Pregnant Women.
Case Management for Children and Pregnant Women's services, as defined
in §27.1 of this title (relating to Definitions), are provided to assist
eligible recipients in gaining access to medically necessary medical, social,
educational and other services for which federal financial participation is
available in order to: encourage the use of cost-effective health and health-related
care; make referrals to appropriate community resources; discourage over utilization
or duplication of services; and reduce morbidity and mortality. Case Management
for Children and Pregnant Women is not a "gatekeeper" function.
(1)
The following contacts are billable:
(A)
Comprehensive Visit--a face-to-face visit that includes
the development of:
(i)
Family Needs Assessment--a written evaluation of all issues
that impact the short and long term health and well being of the eligible
recipient and his/her family. Together, the case manager and family shall
assess the medical, social, educational and other medically necessary service
needs of the eligible recipient. Documentation of the Family Needs Assessment
should include, at a minimum:
(I)
the assessment of the medical, social/family, nutritional,
educational, vocational, developmental and health care transportation needs;
(II)
individualized assessment of the client; and
(III)
the case manager's dated signature.
(ii)
Service Plan--the written summary which:
(I)
documents the services to be accessed;
(II)
identifies the individual responsible for contacting the
appropriate health and human service providers;
(III)
designates the time frame within which the eligible recipient
should access services;
(IV)
may be sent to the medical provider or others as appropriate
in accordance with the limits of confidentiality;
(V)
includes, at a minimum: the interventions and referrals
for addressing needs identified in the Family Needs Assessment; the time frame
for the client to access services; the client/parent/guardian's and case manager's
dated signatures.
(B)
Follow-up contact--a face-to-face or telephone contact
with the eligible recipient and his/her family. The case manager and the client/family
review and reassess the client/family's needs, determine what referrals and
services specified in the Service Plan have been received by the client/family,
and develop appropriate modifications to the Service Plan. The Follow-up contact
includes the review of the referrals that have occurred or are still needed
to complete the Service Plan and meet the client/family's needs. Follow-up
contacts for children should occur as needed. Follow-up contacts for pregnant
women should occur as needed through the 59th day post partum. Documentation
of the Follow-up contacts should include, at a minimum:
(i)
a review of complete Service Plan;
(ii)
efforts to ascertain on an ongoing basis which needs specified
in the Service Plan have been addressed with appropriate referrals provided
and services accessed; and
(iii)
evidence of problem solving with client/parent/guardian
when needs are not addressed or referrals not accessed.
(2)
Case Management for Children and Pregnant Women services
will include a non-billable intake with each client/family. The intake will
include the collection of demographic information and determination of the
client's eligibility.
(3)
Only one billable contact per client shall be billed per
day.
§27.7.Service Limitations.
(a)
Case Management for Children and Pregnant Women services
are not reimbursable if they are duplicative of other billed, comprehensive
Medicaid case management services.
(b)
Following intake completion, the initial prior authorization
request for billable Case Management for Children and Pregnant Women services
must be supported by required documentation and submitted to the department
for review and disposition. The amount of Comprehensive Visits and Follow-up
contacts that are prior authorized will be based on the client's level of
need, level of medical involvement and complicating psychosocial factors.
(c)
Any additional requests for Case Management for Children
and Pregnant Women services must also be prior authorized. Required documentation
must be submitted to the department for review and disposition before any
additional services may be prior authorized.
§27.9.Applicant Qualifications.
(a)
The minimum qualifications for a Case Management for Children
and Pregnant Women applicant are:
(1)
completion and approval of an application for Case Management
for Children and Pregnant Women as defined in §27.1 of this title (relating
to Definitions);
(2)
agreeing to comply with the department rules, policies
and procedures on Case Management for Children and Pregnant Women and the
applicable statutory provisions;
(3)
agreeing to comply with applicable state and federal laws
governing participation of providers in the Medicaid program; and
(4)
employment of case managers with the following qualifications:
(A)
Registered nurse (with a diploma, an associate's, bachelor's
or advanced degree) or Social Worker (with bachelor's or advanced degree),
currently licensed by the respective Texas licensure board and whose license
is not temporary or provisional in nature; and
(B)
possessing two years of cumulative paid full-time work
experience or two years of supervised, full-time educational internship/practicum
experience in the past ten years with children, up to age 21, and/or pregnant
women. Experience must include assessing the psychosocial and health needs
of and making community referrals for these populations.
(5)
agreeing to comply with all licensure requirements of the
case manager(s) respective state licensure/examining boards including the
obligation to report all suspected child abuse/neglect; and
(6)
knowledge of and coordination with providers of health
and health-related services and other active community resources.
(b)
A case manager employed in an approved Targeted Case Management
for Pregnant Women and Infants or Texas Health Steps Medical Case Management
agency at the time of implementation of these rules but who does not meet
the licensure, educational and/or experience requirements outlined in subsection
(a)(4)(A) and (B) of this section, is eligible to continue to provide case
management services until the case manager leaves the employ of that agency
unless state licensure law does not allow the case manager to provide the
services.
(c)
An applicant under investigation or being sanctioned by
the department or any other State of Texas or Federal Governmental agency
will not be approved as a case management provider.
§27.11.Case Management Provider Requirements.
In order to remain a Case Management Provider, an individual or agency
must:
(1)
comply with applicable state and federal laws and regulations
governing participation of providers in the Medicaid program;
(2)
maintain provider status with the department;
(3)
develop and maintain a system for Case Management for Children
and Pregnant Women services incorporating the following elements:
(A)
Case Management for Children and Pregnant Women services
in locations convenient for the eligible recipient to facilitate face-to-face
contact;
(B)
Provision of Case Management for Children and Pregnant
Women services in order to assist eligible recipients in accessing necessary
medical, social, educational, and other services;
(C)
a comprehensive resource directory, updated at least annually,
which contains the names, addresses, and telephone numbers of providers of
health and health-related services including, but not limited to: physicians;
other primary care providers; Early Childhood Intervention (ECI); Children
with Special Health Care Needs (CSHCN); Special Supplemental Nutrition Program
for Women, Infants and Children (WIC); rehabilitation services; the Medicaid
Medical Transportation Program (MTP); the Texas Information and Referral Network,
and locally active community services;
(D)
an internal quality assurance plan that includes, but is
not limited to, chart reviews and staff observation;
(E)
a current list of opened and closed client records;
(F)
an accounts receivable system through which billed claims
will be tracked and matched with paid claims and client records to assure
claims are billed and paid for correct dates of service, were billed with
appropriate procedure codes and are not duplicative of other claims for the
same client;
(G)
outreach activities that assure individualized referrals.
The following activities may impede client choice and therefore are prohibited:
(i)
door to door, telephone or other cold-call marketing or
solicitation of clients by providers;
(ii)
the distribution of materials to Case Management for Children
and Pregnant Women recipients that can reasonably be interpreted as intended
to market the provider's services;
(iii)
the distribution of any false or materially misleading
materials to Case Management for Children and Pregnant Women recipients;
(iv)
obtaining lists of Medicaid clients without a specific
referral;
(v)
offering incentives for enrollment into case management
services; and/or
(vi)
entering into exclusive referral relationships with referral
sources.
(4)
assure Case Management for Children and Pregnant Women
services will be provided by approved case managers who meet the qualifications
defined in §27.9 and §27.11 of this title (relating to Applicant
Qualifications and Case Management Provider Requirements);
(5)
assure that approved case managers:
(A)
have received department-approved education and training
regarding Case Management for Children and Pregnant Women;
(B)
have the opportunity to participate in appropriate Medicaid,
case management and THSteps workshops, seminars, and training;
(C)
assume responsibility for all Case Management for Children
and Pregnant Women services they provide to eligible recipients, including
services by their designated support staff;
(D)
participate in relevant motion or cost studies;
(E)
agree to permit the department or its designee access to
the Case Management for Children and Pregnant Women provider's records, and
permit direct observation of case management activities for the purpose of
determining the provider's suitability to continue participation as a Case
Management for Children and Pregnant Women provider; and
(F)
participate in local and/or regional case management systems/coalitions
in accordance with program policies to assure cooperation and coordination
with local health departments, the department's public health region(s), school
districts and other Medicaid-approved case management providers as evidenced
by:
(i)
participation in community coalition meetings in accordance
with program policy;
(ii)
collaboration in planning case management delivery systems;
and involvement in resolving case management problems.
(6)
share information, within the limits of confidentiality,
with the department and collaborating agencies to facilitate referral and
monitoring of eligible recipients; and
(7)
comply in a timely manner with all department data collection
and reporting requirements.
§27.13.Application Process.
(a)
Applications to become a Case Management for Children and
Pregnant Women provider may be obtained by contacting the department or by
accessing the department website.
(b)
Applicants must include copies of documentation of all
agency licenses, contracts and/or written agreements with their application.
(c)
Applications must be typed and accompanied by all required
supporting documentation set out in this subchapter. An original must be sent
to the appropriate department regional office and one copy of the application
must be submitted to the department central office.
(d)
All applications shall be reviewed by the department staff.
The review process shall be completed within 20 working days following receipt
of an application.
(e)
Incomplete applications shall not be approved and shall
be returned to the applicant for completion.
(f)
Applicants will be notified in writing of approval or non-approval
by the department. Applicants must still enroll as Medicaid providers through
Medicaid provider enrollment.
(g)
Applicants who have submitted complete applications and
who are not approved by the department to provide case management services
must wait, at a minimum, 6 months before resubmission of a new application.
§27.15.Case Management Provider Review and Monitoring Process.
(a)
Approved providers will be monitored on an as-needed basis
for compliance with rules and policies.
(b)
Case managers or Case Management Providers who do not comply
with program requirements may be terminated, placed on probationary status,
referred to appropriate professional licensure entities for review, and/or
referred for fraud and abuse investigation as described in department policies
and procedures.
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 March 21, 2003.
TRD-200301861
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
Subchapter C. CASE MANAGEMENT FOR HIGH-RISK PREGNANT WOMEN AND HIGH-RISK INFANTS
25 TAC §§32.301 - 32.305, 32.307
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Health or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Health (department) proposes
the repeal of §§32.301 - 32.305 and §32.307, concerning case
management for high-risk pregnant women and high-risk infants. Specifically,
these sections cover definitions; eligible individuals; case management services;
service limitations; provider qualifications and right to appeal.
Government Code, §2001.039, requires that each agency review and consider
for readoption each rule adopted by that agency pursuant to the Government
Code, Chapter 2001 (Administrative Procedure Act). The department has reviewed §§32.301
- 32.305 and §32.307 and determined that the proposed repeals are necessary
because the subject of these rules will be incorporated into a new chapter
proposed for adoption as described in this preamble.
The department published a Notice of Intention to Review §§32.301
- 32.305 and §32.307 in the
Texas Register
on
November 19, 1999 (24 TexReg 10378). No comments have been received.
The proposed repeal of §§32.301 - 32.305 and §32.307 is
necessary in order to combine services in new rules in Chapter 27, entitled
Case Management for Children and Pregnant Women, of this title. Combining
these sections in this new chapter will ensure integration of services to
the eligible population for case management services, children with a health
condition/health risk birth to 21 years and/or high-risk pregnant women of
all ages. Specifically, the repealed sections cover definitions; eligible
individuals; case management services; service limitations; provider qualifications,
and the right to appeal. These rules are repeated in §§37.81 - 37.86
and were not repealed when §§32.301 - 32.305 and §32.307 were
adopted.
The department also proposes the repeal of Early and Periodic Screening,
Diagnosis, and Treatment, Subchapter J, Texas Health Steps Medical Case Management, §§33.501
- 33.506. Specifically, these repealed sections cover definitions, eligible
recipients; THSteps Medical Case Management Services; service limitations;
applicant and provider qualifications, and application, review and monitoring
process.
The department at the same time is proposing the repeal of §§37.81
- 37.86 of this title concerning Medicaid case management for high risk pregnant
women and high risk infants. Specifically, these sections cover introduction;
definitions; case management services; provider qualifications; application
and review process, and documents adopted by reference and will be integrated
in the new Chapter 27 of this title.
The department also proposes new Chapter 27, Case Management for Children
and Pregnant Women, §§27.1, 27.3, 27.5, 27.7, 27.9, 27.11, 27.13
and 27.15. The new sections are proposed as an effort to combine case management
programs to meet the needs of pregnant women of all ages and children with
a health condition/health risk birth to 21 years. Specifically, these new
sections cover definitions; eligible recipients; case management service provision;
service limitations; applicant and provider qualifications; and application,
review and monitoring processes.
The department provides health services to women and children in Texas
under authority of the Health and Safety Code, Chapter 32; the State Appropriations
Act and the Social Security Act, Title V. The Targeted Case Management Program
for High Risk Pregnant Women and High Risk Infants was established under the
authority of federal law, Social Security Act, Title XIX, §1915(g). This
authorizes states to provide case management as a distinct service to target
populations, through a waiver from Health Care Financing Administration (HCFA),
now the Centers for Medicare and Medicaid Services or CMS. The Health and
Human Services Commission (HHSC) provides authority to the department to propose
rules to administer certain Medicaid program services in Texas. Human Resources
Code, §22.0031, requires the establishment of a program for the case
management of high-risk pregnant women of all ages and high-risk children
to age one.
The Government Code, §531.021, provides HHSC with the authority to
propose rules to administer the state's medical assistance program. The current
rules were submitted by the department under its agreement with HHSC to operate
the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program,
and as authorized under §1.07, Acts of the 72nd Legislature, First Called
Session (1991), Chapter 15, as amended by the Acts of the 73rd Legislature,
Chapter 747, §2. The purpose of these sections is to make available medically
necessary medical case management services mandated by EPSDT program. In Texas,
the EPSDT program is known as Texas Health Steps (THSteps).
The proposed new rules for Case Management for Children and Pregnant Women
will provide case management services to Medicaid eligible women of all ages
who have a high risk pregnancy and to children with a health condition/health
risk from birth to 21 years of age. The Medicaid Case Management for High
Risk Pregnant Women and High Risk Infants Program, and the Texas Health Steps
Medical Case Management Program, will become one program in the proposed new
sections of Chapter 27 with the repeal of §§32.301 - 32.305, 32.307,
33.501 - 33.506, and 37.81 - 37.86. The new program will provide a greater
continuity of services for all eligible recipients.
Ravi Rupsingh, M.P.A., Actuary, Actuary Analysis, HHSC, has determined
for the first five years the repeals are in effect, there will be cost savings
to the state through the combination of the two programs as described in this
preamble. Total cost savings per year are $1,724,820, $6,153,493, $6,348,526,
$6,549,411 and $6,745,893 in state fiscal years 2003, 2004, 2005, 2006 and
2007, respectively, for a total of $27,522,143 over these five state fiscal
years. There will be no impact on local government.
Duane Thomas, Ph.D., Texas Department of Health, Director of Regional Case
Management has also determined that for each of the first five years the repeals
are in effect, anticipated public benefits include better access to primary
care providers, preventative health services, other health services and community
resources for children and pregnant women accessing the services. There will
be costs to small businesses and micro-businesses. This was determined after
concluding that the elimination of the Intake as a billable contact for Targeted
Case Management for Pregnant Women and Infants providers will decrease the
amount of reimbursement that these providers currently receive. The cost to
small and micro-businesses for the first year of implementation is estimated
to be $7,327 while the cost to large businesses for the first year of implementation
is estimated to be $7,281. The estimated costs are based on the assumption
that 70% of Targeted Case Management for Pregnant Women and Infants providers
are large businesses and 30% of providers are small or micro-businesses. There
will be no anticipated economic costs to persons who receive the services.
The department has determined that the proposed repeals do not restrict or
limit an owner's right to their property that would otherwise exist in the
absence of governmental action and therefore does not constitute a taking
under Government Code, §2007.043.
Comments on the proposal may be submitted to Cossy Hough, LMSW-ACP, Texas
Department of Health, 1100 West 49th Street, Austin, Texas 78756, (512) 458-7111,
extension 6664. Comments will be accepted for 30 days following publication
of the proposal in the
Texas Register
.
A public hearing regarding this repeal will be held on April 8, 2003, from
1:00 p.m. to 4:00 p.m. at the Texas Department of Health, Board of Health
Room, Room M739, 1100 West 49th Street, Austin, Texas 78756.
The repeals are proposed under the Health and Safety Code, §12.001,
which provides the Board of Health (board) with the authority to adopt rules
to implement every duty imposed by law on the board, the department and the
commissioner of health; and under the Health and Safety Code, Chapter 32,
which provides the board with the authority to establish maternal and infant
health improvement services programs in the department to serve eligible recipients;
the Human Resources Code, §22.0031, which mandates case management for
high risk pregnant women and high risk infants; the Human Resources Code,
Chapter 32, which enables the state to provide medical assistance; the Government
Code, §531.021, which provides HHSC with the authority to propose rules
to administer the state's medical assistance program and are submitted by
the Texas Department of Health under its agreement with HHSC to operate the
EPSDT program, and as authorized under §1.07 of the Acts of the 72nd
Legislature, First Called Session (1991), Chapter 15, as amended by the Acts
of the 73rd Legislature, Chapter 747, §2.
The proposed repeals affect the Health and Safety Code, Chapter 32, the
Human Resources Code, §22.0031 and Chapter 32.
§32.301.Definitions.
§32.302.Eligible Individuals.
§32.303.Case Management Services.
§32.304.Service Limitations.
§32.305.Provider Qualifications.
§32.307.Right To Appeal.
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 March 21, 2003.
TRD-200301862
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
The Texas Department of Health (department) proposes amendments to §§33.13-33.14,
33.61-33.63, 33.66, 33.112, 33.122-33.123, 33.125, 33.131-33.135 the repeal
of §33.139, and new §33.15 and §33.140 concerning the administration
of Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
services.
Specifically, the proposed amendments cover program purpose; outreach,
informing and support services; recipient rights; confidentiality of records;
consent; freedom of choice; eligibility for services; periodicity; periodic
check-up due date; exceptions to timely delivery of Texas Health Steps (THSteps)
services; medical check-up services; medical diagnosis and treatment services;
approved medical check-up providers; primary responsibilities of medical check-up
providers; and claims. The proposed new sections concern definitions and management
of complaints. The proposed repeal covers replacement of hearing aids.
The proposed amendments will clarify program specifications, specify the
components of the program that are administered by the department and delete
obsolete terms. These amendments will also replace the terms "early and periodic
screening, diagnosis and treatment (EPSDT)" with "Texas Health Steps (THSteps)"
and replace the term "screening" with the word "check-up" throughout the chapter.
Texas Health Steps is the name of the EPSDT program in Texas.
In addition, the amendments to §33.122 reflect that a THSteps medical
check-up is recommended annually for adolescents, rather than biennially,
beginning at age eleven. THSteps continues to emphasize the importance of
separate counseling and anticipatory guidance for the child and the accompanying
parent/guardian during the adolescent years. Currently THSteps adolescent-aged
recipients are eligible to receive a medical check-up annually. In accordance
with federal EPSDT regulations, proposed amendments to §33.131 add, "lead
toxicity screening" as a component of a THSteps medical check-up. Currently
THSteps includes lead toxicity screening as a component of a THSteps medical
check-up. Proposed amendments to §33.133 expand the type of providers
who can provide THSteps medical check-ups and proposed amendments to §33.135
reflect the responsibilities of the Health and Human Services Commission (HHSC)
in relation to the claims administration portion of the THSteps program.
New §33.15 adds a definition section applicable throughout subchapters
A, B, C, D, and E; and new §33.140 addresses complaints concerning unlawful
activities and quality of care issues.
Section §33.139 is being proposed for repeal because the department
no longer maintains the authority to implement this section. Authority to
implement this section was moved to the HHSC on September 1, 2001. Also, the
rule should be repealed rather than transferred to HHSC because the language
in this section is obsolete and does not reflect requirements of the EPSDT
program under current law. Under current EPSDT law, there is no limit on the
number of replacement hearing aids for EPSDT recipients as long as they are
medically necessary. At this time, HHSC does not limit the number of replacement
hearing aids.
In addition, the title of Subchapter A has been changed from Penalties
to General Provisions in order to more accurately reflect the subchapter's
content.
Government Code, §2001.039, requires that each state agency review
and consider for re-adoption each rule adopted by that agency pursuant to
the Government Code, Chapter 2001 (Administrative Procedure Act). The department
has reviewed the sections and has determined that reasons for adopting the
sections continue to exist; however, the revisions are needed in order to
reflect the changes to program administration and the laws that pertain to
them.
The department published a Notice of Intention to Review for §§33.13-33.14,
33.61-33.63, 33.66, 33.112, 33.122-33.123, 33.125, 33.131-33.135, and 33.139,
in the
Texas Register
on May 12, 2000 (25
TexReg 4358). No comments were received.
Linda M. Altenhoff, D.D.S., Director, Texas Health Steps and Medical Transportation
Division, has determined that for each year of the first five years the sections
are in effect, there will be no fiscal implications to state or local governments
as a result of enforcing or administering the rules as proposed.
Dr. Altenhoff has also determined that for each year of the first five
years the amended sections are in effect, the anticipated benefits include
program clarification and more accurate reflection of the program's operations
to Texas Health Steps recipients, families and providers. There will be no
costs to micro-businesses or small businesses to comply with the sections
as proposed. This was determined after concluding that there will be no new
requirements or responsibilities imposed upon micro-businesses and small businesses.
There are no anticipated economic costs to persons who are required to comply
with the sections as proposed. There is no anticipated impact on local employment.
Comments on the proposal may be submitted to Linda Altenhoff, D.D.S., Director,
Texas Health Steps and Medical Transportation Division, Texas Department of
Health, 1100 West 49th Street, Austin, Texas 78756-3189, (512) 458-7745. Comments
will be accepted for 30 days following publication of the proposal in the
A public hearing on the proposed sections will be held on Thursday, April
10, 2003, at 4:00 p.m., in the Texas Department of Health Auditorium (K-100),
1100 West 49th Street, Austin, Texas.
Subchapter A. GENERAL PROVISIONS
25 TAC §§33.13 - 33.15
The amendments and new section are proposed under the Human
Resources Code, §32.021(c), which allows the department to establish
rules governing the Medicaid program; the Health and Safety Code, §12.001,
which provides the Texas Board of Health (board) with the authority to adopt
rules for its procedures and the performance of each duty imposed by law on
the board, the department and the Commissioner of Health; 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 Early and Periodic Screening, Diagnosis,
and Treatment program as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapter 15, §1.07.
The proposed amendments and new section affect the Human Resources Code,
Chapter 32.
§33.13. Purpose [
(a)
The Texas Medicaid Early and
Periodic, Screening, Diagnosis, and Treatment (EPSDT) program is a Title XIX
federally-mandated program of prevention, diagnosis, and treatment for Medicaid
recipients under age 21 years. In Texas, EPSDT is known as the Texas Health
Steps (THSteps) program. The Texas Department of Health administers the medical
and dental check-ups and treatment components of this program.
(b)
[
(c)
The rules in this subchapter
implement the medical and dental check-up, dental treatment, and outreach
and informing components of THSteps.
§33.14. Outreach, Informing , and Support Services .
(a)
THSteps or its designee informs
[
(b)
THSteps recipients
[
§33.15.Definitions.
The following words or terms, when used in Subchapters A, B, C, D,
and E, shall have the following meanings unless the context clearly indicates
otherwise:
(1)
Accompanied--A parent, guardian or authorized adult who
presents a recipient under age 15 at a THSteps medical or dental check-up,
or treatment visit and continues to wait for the child while the check-up
or treatment takes place. It is a requirement of §33.134(e) of this title
(relating to Primary Responsibilities of Medical Check-up Providers) of Subchapter
E that a recipient under the age of 15 be accompanied as a condition for reimbursement,
unless services are provided by an exempt entity.
(2)
Authorized adult--A person, including an adult related
to the child, who is authorized by a child's parent or guardian to accompany
that child to a THSteps medical or dental check-up or treatment visit.
(3)
Board--The Texas Board of Health.
(4)
EOB--Explanation of Benefits.
(5)
EPSDT--Early and Periodic Screening, Diagnosis, and Treatment
is a service of the Medicaid program. EPSDT provides medical and dental check-ups,
diagnosis, and treatment to Medicaid eligible recipients younger than 21 years
of age. EPSDT is known in Texas as Texas Health Steps, (THSteps).
(6)
Exempt entity--A child-care facility (as defined in the
Human Resources Code §42.002(3)), school health clinic, and Head Start
programs that are exempt from the parental accompaniment requirement under §33.134(e)
of this title of Subchapter E.
(7)
FFP--Federal financial participation is the federal government's
share of a state's expenditures under the Medicaid program.
(8)
HHSC--The Health and Human Services Commission.
(9)
Medicaid--The medical assistance program implemented by
the State of Texas under the provisions of Title XIX of the Social Security
Act, as amended, (42.U.S.C. §§1396-1396v).
(10)
Parental Involvement--The encouragement and involvement
in and management of the health care of children receiving services from an
exempt entity as defined in paragraph (6) of this section. Parental involvement
includes the exempt entity notifying the child's parent, guardian, or other
authorized adult before each visit for a THSteps medical or dental check-up
or treatment visit of the time and place of the child's appointment and encouraging
the parent, guardian, or other authorized adult to attend. Notification shall
be done by the means of communication determined by the exempt entity to be
the most effective. Such communication must be documented and may include,
but is not limited to, one or more of the following options: a home visit
from an outreach worker, written or printed correspondence, or telephone contact.
(11)
Recipient--An individual who has been determined eligible
for Medicaid.
(12)
R&S--A Remittance and Status report that provides
information on pending, paid, denied, and adjusted claims.
(13)
TDH--Texas Department of Health.
(14)
THSteps--Texas Health Steps (THSteps) is the Texas name
for the federally-mandated Medicaid service known as EPSDT.
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 March 21, 2003.
TRD-200301855
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.61 - 33.63, 33.66
The amendments are proposed under the Human Resources Code, §32.021(c),
which allows the department to establish rules governing the Medicaid program;
the Health and Safety Code, §12.001, which provides the Texas Board of
Health (board) with the authority to adopt rules for its procedures and the
performance of each duty imposed by law on the board, the department and the
Commissioner of Health; 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 Early and Periodic Screening, Diagnosis, and Treatment program as authorized
under Acts 1991, 72nd Legislature, First Called Session, Chapter 15, §1.07.
The proposed amendments affect the Human Resources Code, Chapter 32.
§33.61.Recipient Rights.
(a)
Acceptance of
THSteps
[
(b)
A recipient who refuses
THSteps
[
(c)
All
THSteps
[
§33.62.Confidentiality of Records.
(a)
Public
laws
[
(b)
Contracted agencies performing certain administrative functions
are considered an extension of
TDH
[
§33.63.Consent.
Consent by a person who may legally give consent is necessary for participation
in
THSteps
[
(1) - (4)
(No change.)
(5)
a statement that the person is free to
deny
[
§33.66.Freedom of Choice.
(a)
All
THSteps
[
(b)
(No change.)
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 March 21, 2003.
TRD-200301856
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §33.112
The amendment is proposed under the Human Resources Code, §32.021(c),
which allows the department to establish rules governing the Medicaid program;
the Health and Safety Code, §12.001, which provides the Texas Board of
Health (board) with the authority to adopt rules for its procedures and the
performance of each duty imposed by law on the board, the department and the
Commissioner of Health; 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 Early and Periodic Screening, Diagnosis, and Treatment program as authorized
under Acts 1991, 72nd Legislature, First Called Session, Chapter 15, §1.07.
The proposed amendment affects the Human Resources Code, Chapter 32.
§33.112.Eligibility for Services.
[
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 March 21, 2003.
TRD-200301857
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.122, 33.123, 33.125
The amendments are proposed under the Human Resources Code, §32.021(c),
which allows the department to establish rules governing the Medicaid program;
the Health and Safety Code, §12.001, which provides the Texas Board of
Health (board) with the authority to adopt rules for its procedures and the
performance of each duty imposed by law on the board, the department and the
Commissioner of Health; 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 Early and Periodic Screening, Diagnosis, and Treatment program as authorized
under Acts 1991, 72nd Legislature, First Called Session, Chapter 15, §1.07.
The proposed amendments affect the Human Resources Code, Chapter 32.
§33.122.Periodicity.
[
(a)
[
(1) - (15)
(No change.)
(16)
10 years [
(17)
11 years;
(18)
[
(19)
13 years;
(20)
[
(21)
15 years;
(22)
[
(23)
17 years;
(24)
[
(25)
19 years;
(26)
[
[
[
[
[
[
[
(b)
[
§33.123.Periodic Check-up [
The due date for
medical check-ups
[
§33.125.Exceptions to Timely Delivery of THSteps Services .
Exceptions to standards for the timely delivery of
THSteps
services
can be made if:
(1)
the recipient or family loses eligibility. This means that
the recipient or family does not have a valid
Medicaid
[
(2)
the recipient or family could not be located despite a
good faith effort to do so. This means that no personal contact
could
[
(3)
the recipient's failure to receive necessary services in
a timely manner was due to an action or decision of the family or recipient
rather than a failure of
THSteps or its designee
[
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 March 21, 2003.
TRD-200301858
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.131 - 33.135, 33.140
The amendments and new section are proposed under the Human
Resources Code, §32.021(c), which allows the department to establish
rules governing the Medicaid program; the Health and Safety Code, §12.001,
which provides the Texas Board of Health (board) with the authority to adopt
rules for its procedures and the performance of each duty imposed by law on
the board, the department and the Commissioner of Health; 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 Early and Periodic Screening, Diagnosis,
and Treatment program as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapter 15, §1.07.
The proposed amendments and new sections affect the Human Resources Code,
Chapter 32.
§33.131.Medical Check-up [
(a)
Medical
check-up
[
(b)
[
(1)
[
(2)
[
(3)
[
(4)
[
(5)
[
(6)
[
(7)
[
(8)
[
(9)
[
(10)
[
[
§33.132.Medical Diagnosis and Treatment Services.
[
(1)
Service coverage is determined on an individual basis,
requires prior approval for payment by
HHSC
[
[
(2)
[
(3)
[
[
§33.133.Approved Medical Check-up [
(a)
Medical
check-up
[
(1)
[
(2)
public or private health care providers or facilities
that can perform the required medical
check-up
[
(3)
advanced practice nurses whose
educational curriculum includedcourses of study in advanced pediatric physical
assessment of infants, children and adolescents.
(b)
Providers as defined in subsection
(a) of this section must be enrolled as Medicaid and THSteps providers in
order to submit claims to receive reimbursement for medical check-ups.
[
§33.134.Primary Responsibilities of Medical Check-up [
[
(1)
to conduct medical
check-ups
[
(2)
to provide clinic surroundings which will establish a good
relationship between clinic personnel, the recipient, and the recipient's
family;
(3)
to interpret medical
check-up
[
(4)
to make referrals for needed follow-up diagnosis and treatment
services; and
(5)
to ensure
a recipient under age 15 is accompanied
by
a parent, guardian or authorized adult [
(A)
obtains written consent to the services, which has not
been revoked, from the child's parent or guardian within the one-year period
prior to the date the services are provided; and
(B)
encourages parental involvement in and management of the
health care of the children receiving services from the clinic, program, or
facility.
[
[
§33.135.Claims - Time Limits, Return, and Denial.
(a)
The
THSteps
[
(1)
THSteps
[
[
(2)
[
(3)
[
(b)
All appeals of
denied
claims and requests for
claims
adjustments must be received by
HHSC or its designee
[
(c)
Claims received by
HHSC or its designee
[
§33.140.Management of Complaints.
TDH will report all allegations of Medicaid fraud and other unlawful
activities to the appropriate authority for review of the allegations and
determination of the appropriate action as defined in TDH policy. TDH will
refer all complaints alleging quality of care issues to the appropriate licensing
or regulatory authority.
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 March 21, 2003.
TRD-200301859
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §33.139
(Editor's note: The text of the following section proposed
for repeal will not be published. The section may be examined in the offices
of the Texas Department of Health or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeal is proposed under the Human Resources Code, §32.021(c),
which allows the department to establish rules governing the Medicaid program;
the Health and Safety Code, §12.001, which provides the Texas Board of
Health (board) with the authority to adopt rules for its procedures and the
performance of each duty imposed by law on the board, the department and the
Commissioner of Health; 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 Early and Periodic Screening, Diagnosis, and Treatment program as authorized
under Acts 1991, 72nd Legislature, First Called Session, Chapter 15, §1.07.
The proposed repeal affects the Human Resources Code, Chapter 32.
§33.139.Replacement of Hearing Aids.
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 March 21, 2003.
TRD-200301860
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
The Texas Department of Health (department) proposes amendments to §§33.301-33.304,
33.334, 33.351-33.358, new §§33.305-33.311, 33.314-33.315, 33.317-33.320,
33.331, and the repeal of §§33.305-33.309, 33.312-33.318, and 33.331-33.333
concerning the Texas Health Steps dental services.
Specifically, the proposed amendments to §§33.301-33.304 cover
definitions; oral evaluations and dental services; preventive dental services,
and therapeutic dental services. Proposed new §§33.305-33.311 covers
orthodontic services limitations, eligibility for orthodontic services, payment
limitations for orthodontic services, emergency dental services; allowable
services and limitations; eligibility for Texas Health Steps dental services,
and requirements for provider enrollment and continuing participation. Proposed
new §§33.314-33.315 cover charges to recipients and payment of claims.
Proposed new §§33.317-33.320 cover change to another provider; and
standards of care. Proposed new §33.331 covers the purpose of the dental
utilization review process; the proposed amendment to §33.334 covers
post-payment orthodontic review; the proposed amendments to §§33.351-33.352
cover types of department utilization reviews and selection of dentists for
department utilization review. The proposed amendment to §§33.353
adds a requirement that the notice to providers of a utilization review be
in writing. The proposed amendments to §§33.354-33.358 cover provider
cooperation, disposition of department utilization review results, recoupment
of overpayments as a result of department utilization review, administrative
actions and/or sanctions and referral for investigation of fraud or program
abuse.
Specifically, the proposed repeals of §§33.331-33.333 cover orthodontic
service limitations, eligibility for orthodontic services and payment limitations
for orthodontic services.
The department also proposes new §§33.319-33.320 that covers
management of complaints and performance of dental services.
The proposed amendments to §33.301 add new definitions; the proposed
amendments to §33.302 exclude non-applicable language to the section
while clarifying service limitations; the proposed amendments to §§33.303-33.304
ensure consistency in service standards; new §33.305 is renamed Orthodontic
Services Limitations and incorporates language from proposed repealed §33.333
while excluding language concerning emergency dental services. Proposed new §33.306
is retitled Eligibility for Orthodontic Services, excludes language concerning
allowable services and limitations and includes language from the proposed
repeal of §33.332. Proposed new §33.307 is renamed Payment Limitations
for Orthodontic Services, excludes language concerning eligibility and adds
language regarding payment limitations for orthodontic services. Proposed
new §33.308, renamed Emergency Dental Services, excludes language regarding
provider enrollment and continuing participation requirements while adding
language concerning emergency dental services. Proposed repeal of §33.309
excludes language concerning termination of a provider agreement, as the department
no longer maintains the authority to enforce those provisions. Proposed new §33.309
adds language relating to allowable services and limitations.
Proposed new §33.310, renamed as Eligibility for THSteps Dental Services,
excludes language pertaining to maximum payment and adds language concerning
eligibility for THSteps dental services. Proposed new §33.311 is renamed
as Requirements for Provider Enrollment and Continuing Participation, and
appropriate language pertinent to the new title is added. The proposed repeal
of §33.312 excludes language that covered charges to recipients.
Language relating to payment of claims is excluded from the repeal of §33.313.
Proposed new §33.314 adds a new title, Charges to Recipients, as well
as language appropriate to the new title. The previous title, Claims - Time
Limits, Submission and Denial is deleted in the repeal of §33.316; the
repeal also excludes language pertaining to this title as the department is
not authorized to set time limits on claim submission and denial.
Proposed new §33.315 renames this section as Payment of Claims and
adds appropriate language to this section. The prior title of this section,
Changes to Another Provider, is deleted and moved to proposed new §33.317.
Pertinent language relating to change to another provider is also moved to
proposed new §33.317.
Language relating to Standards of Care is excluded in the repeal of §33.316
and moved to proposed new §33.318.
Proposed new §33.317 is renamed as Change to Another Provider and
adds language pertinent to the new title. The former title of this section,
Management of Complaints and accompanying language is moved to proposed new §33.319.
Proposed new §33.318 is renamed as Standards of Care and incorporates
language pertinent to the new title. The prior name of this section, Performance
of Dental Services and relevant language, is moved to proposed new §33.320.
Proposed new §33.331 is renamed as Purpose and explains the purpose
of the dental utilization review process. The prior name of this section,
Orthodontic Services Limitation, and accompanying language is moved to proposed
amended §33.305.
Proposed amended §33.334 restructures pertinent portions for clarity.
Proposed amended §33.351 clarifies the responsibility of the department
and HHSC related to utilization reviews. Proposed amended §33.352 adds
stricter standards and designates the proper entity to which complaints should
be made.
Proposed amended §33.353 requires that providers be notified in writing
of a utilization review.
Proposed amended §33.354 restructures the section for clarity; proposed
amended §33.355 adds a new standard concerning review results and also
reflects changes in the entity that may forward utilization results to the
Office of Investigations and Enforcement at the Health and Human Services
Commission.
Government Code, §2001.039, requires that each state agency review
and consider for readoption each rule adopted by that agency pursuant to the
Government Code, Chapter 2001 (Administrative Procedure Act). The department
has reviewed §§33.301-33.309, 33.312-33.318 and §§33.331-33.334,
and §33.351-33.358 and has determined that reasons for adopting these
sections continue to exist. However, the rules need revision as described
in this preamble.
The department published a Notice of Intention to Review §§33.301-33.318
in the May 12, 2000 issue of the
Texas Register
(25
TexReg 4358). No comments were received. The department published a Notice
of Intention to Review §§33.331-33.334, and 33.351-33.358 in the
November 22, 2002 issue of the
Texas Register
(27
TexReg 10957). No comments were received.
Lee Johnson, Financial Management Division Director, has determined that
for each year of the first five-year period the revised sections are in effect,
there will be no fiscal implications to state or local government as a result
of enforcing or administering the sections as proposed.
Jerry W. Felkner, State Dental Director, Division of Oral Health, has determined
that for each year of the first five years these sections are in effect, the
public benefit anticipated as a result of enforcing the sections will be a
more effective and efficient provision of Texas Health Steps dental services
to eligible recipients. Additionally, the proposed sections will provide more
specific guidance to providers and recipients. The rules will have no adverse
economic effect on micro-businesses and/or small businesses because the sections
do not add any new or additional requirements on either eligible providers
or recipients. There are no anticipated economic costs to persons who are
required to comply with the sections as proposed. There is no anticipated
impact on local employment.
Comments on the proposal may be submitted to Mike McAnally, Program Policy
Analyst, Division of Oral Health, Texas Department of Health, 1100 West 49th
Street, Austin, Texas 78756, (512) 458-7323. Comments will be accepted for
30 days following publication of this proposal in the
Texas Register
.
The department's Board of Health (board) voted on the proposed repeal of §§33.310
- 33.311 concerning reimbursement rates. Subsequent to the board's approval
on February 28, 2003, and prior to this publication, the Health and Human
Services Commission transferred 25 TAC §§33.310 - 33.311 to 1 TAC §§355.8443
and 355.8445. The transfer was filed by the Health and Human Services Commission
with the Office of the Secretary of State on March 4, 2003, and was published
in the March 21, 2003, issue of the
Texas Register
(28 TexReg 2523). Therefore, the repeal of §§33.310 - 33.311
is not included in this proposal.
Subchapter G. DENTAL SERVICES
25 TAC §§33.301 - 33.311, 33.314, 33.315, 33.317 - 33.320
The amendments and new sections are proposed under the Health
and Safety Code, §32.021, which allows the Texas Department of Health
to establish rules governing the Medicaid program; the Health and Safety Code, §12.001,
which provides the Texas Board of Health (board) with authority to adopt rules
for its procedures and the performance of each duty imposed by law on the
board, the department and the commissioner of health; 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 Early and Periodic Screening, Diagnosis, and Treatment program,
also known as THSteps, as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapters 15, §1.07.
The proposed amendments and new sections affect the Human Resources Code,
Chapter 32.
§33.301.Definitions.
The following words and terms
,
when used in Subchapters
G and H of this chapter, shall have the following meanings, unless the context
clearly indicates otherwise.
(1)
Accompanied--A parent, guardian or authorized adult
who
presents a recipient under age 15 at
a Texas Health Steps (THSteps)
[
(2)
Authorized adult--A person, including an adult related
to the child, who is authorized by a child's parent or guardian to accompany
a child to a
THSteps
[
(3)
Adjusted Fee--The fee which
results from action taken by the HHSC or its designee in some instances in
order to reduce the fee billed by the provider to below the maximum amount
which can be billed.
(4)
[
(A)
of the professional dental community;
(B)
within the American Dental Association's Dental Practice
Parameters, published by the American Dental Association, Revised 1997; and/or
(C)
within the Quality Assurance Criteria of the American Academy
of Pediatric Dentistry, as applicable, published in Pediatric Dentistry, Journal
of the American Academy of Pediatric Dentistry, Reference Manual, 2000-2001,
Volume 22, Number 7.
[
(5)
Division--The Division of Oral
Health of the Texas Department of Health.
(6)
EOB--Explanation of Benefits.
(7)
[
(8)
Exempt entity--A child-care
facility (as defined in Human Resources Code §42.002(3)), school health
clinic, and Head Start programs which are exempt from the parental accompaniment
requirement under §33.318 of this title (relating to Standards of Care).
(9)
FFP--Federal financial participation
is the federal government's share of a State's expenditures under the Medicaid
program.
(10)
[
(11)
[
(12)
[
(13)
OHSAC--The Oral Health Services
Advisory Committee is the official body which assists the TDH Division of
Oral Health by providing review, advice, and recommendations regarding a variety
of subjects related to the operations and policy of the Division.
(14)
[
(15)
[
(16)
[
(17)
R & S--A Remittance and
Status report which provides information on pending, paid, denied, and adjusted
claims.
(18)
[
(19)
TDH--Texas Department of Health.
(20)
THSteps--Texas Health Steps
is the Texas name for the federally-mandated Medicaid service known as EPSDT.
§33.302.Oral Evaluations and Dental Services.
[
(a)
[
(b)
Periodicity - Routine dental
check-up services are available for eligible recipients one year of age and
older once every six months, based on the date of the recipient's last dental
check-up.
§33.303.Preventive Dental Services.
Preventive dental services include only
the following
:
(1)-(6)
(No change.)
§33.304.Therapeutic Dental Services.
Therapeutic services include
only the following
:
(1)-(8)
(No change.)
(9)
orthodontics, as defined in
§§33.305-33.307
[
§33.305.Orthodontic Services Limitations.
(a)
Orthodontic services are limited to treatment of severe
handicapping malocclusion and other related conditions as described and measured
by the procedures and standards published in the manual.
(b)
Orthodontics for cosmetic reasons only is not an allowable
service.
§33.306.Eligibility for Orthodontic Services.
(a)
Recipients must be younger than 21 years of age and eligible
for Medicaid and THSteps on the date that the prior authorization request
for orthodontic services is approved in order to be eligible for orthodontic
services.
(b)
If a recipient reaches 21 years of age or becomes ineligible
for Medicaid before orthodontic treatment is completed, payment may be provided
to complete the single course of orthodontic treatment that was prior-authorized
and initiated while the recipient was younger than 21 years of age and Medicaid-eligible.
§33.307.Payment Limitations for Orthodontic Services.
(a)
Except for the initial orthodontic visit, all orthodontic
services must be prior-authorized by HHSC or its designee according to the
procedures described in the manual.
(b)
A prior authorization is issued for a complete plan of
orthodontic treatment and includes all procedures for completion of the single
course of treatment to be accomplished over a specified period of time.
(c)
A prior authorization for orthodontic services is not transferable
to another provider.
(d)
If a request for prior authorization of a plan of orthodontic
services for a recipient is not approved, the provider may file a claim and
receive payment to defray the costs of the diagnostic materials required for
submitting the request. TDH policy in effect at the time of service delivery
shall determine the number of denials for which reimbursement of costs shall
be available.
§33.308.Emergency Dental Services.
(a)
Emergency dental services are limited to the following:
(1)
procedures necessary to control bleeding, relieve pain,
and eliminate acute infection;
(2)
operative procedures required to prevent imminent loss
of teeth; and
(3)
treatment of injuries to the teeth and supporting structures.
(b)
Routine restorative procedures and root canal therapy are
not emergency services.
(c)
Prior authorization is not required for emergency dental
services.
§33.309.Allowable Services and Limitations.
(a)
For the most effective use of available funds and to offer
services to as many recipients as possible, the TDH may impose certain limitations,
such as those regarding allowable services and age, and others as described
in the Medicaid dental fee schedule published in the manual.
(b)
Payment shall be made only for services for which dental
necessity has been established and for which FFP is available and that are
delivered in accordance with the Medicaid program requirements in effect on
the date of service.
(c)
A prior authorization is not transferable to another provider.
§33.310.Eligibility for THSteps Dental Services.
(a)
Persons are eligible for dental services if they have a
current Texas Medicaid identification or Medicaid verification letter that
indicates Medicaid and THSteps eligibility for the time period during which
services are delivered, and they are under age 21. Providers may also verify
eligibility for clients who do not have a Medicaid identification or Medicaid
verification letter by contacting HHSC or its designee.
(b)
Medicaid recipients under age 21 are eligible for THSteps
medical and dental check-ups, diagnosis and treatment services through the
month of the recipient's 21st birthday, except for recipients who already
have an approved treatment plan for orthodontic services. If a recipient reaches
age 21 or loses Medicaid eligibility before the authorized orthodontic treatment
is completed, reimbursement is provided to complete the orthodontic treatment
that was authorized and initiated while the recipient was younger than age
21, eligible for Medicaid and THSteps, and if such treatment is completed
within 36 months.
(c)
Recipients one year of age and older who are eligible for
THSteps services may receive periodic, preventive dental services as defined
in §33.303 of this title (relating to Preventive Dental Services) every
six months.
(d)
Recipients may receive THSteps dental check-ups beginning
at 12 months of age and every six months thereafter through age 21. Recipients
younger than 12 months of age are not eligible for routine dental examinations;
however, they may be referred when a medical check-up identifies the necessity
for dental services. Recipients younger than 12 months also can be seen for
emergency dental services by the dentist for trauma or baby bottle tooth decay.
Recipients up to age 21 may also self-refer for dental services.
§33.311.Requirements for Provider Enrollment and Continuing Participation.
(a)
Dentists providing THSteps dental services must:
(1)
be licensed by the SBDE;
(2)
operate in accordance with the laws relating to the practice
of dentistry and the rules and regulations of the SBDE;
(3)
document the dental necessity of a stainless steel crown
before the crown is applied by radiographs or other documentation methods
established by the SBDE;
(4)
comply with a minimum standard of documentation and record
keeping for each of the dentist's patients, pursuant to 22 T.A.C. §§108.7-108.8,
concerning SBDE minimum standards of care and documentation requirements,
whether the patient's costs are paid privately or through the Texas Medicaid
program;
(5)
practice in the United States of America; and
(6)
be enrolled as THSteps dental provider.
(b)
Dentists who deliver emergency dental services as defined
in §33.308 of this title (relating to Emergency Dental Services) to Medicaid
and THSteps-eligible Texas recipients while the recipients are out of state
are not required to be licensed by the SBDE, but must be authorized to provide
Title XIX services in the state in which the services are delivered.
(c)
Enrollment and continuing participation as a THSteps dental
provider are voluntary. An application for enrollment may be denied and/or
continuing participation may be terminated for any of the following reasons:
(1)
disciplinary action(s) taken against the provider by the
SBDE or the licensing entity of any other state;
(2)
previous or current Medicaid or other federally funded
health care program violation(s);
(3)
prior imposition of sanctions by a regulatory entity of
the State of Texas or any other state;
(4)
failure of the provider to comply with THSteps program
rules;
(5)
a judgment in civil litigation or a criminal conviction
based on fraud or abuse in Medicaid or any other federally funded health care
program in any state. This includes a plea into a first offender program,
misdemeanor, or felony;
(6)
failure to comply with Family Code, §231.006, regarding
payment of child support;
(7)
notification from the HHSC OIE of adverse action taken
against the provider; or
(8)
any other reason authorized by rules, regulations, statute,
or contract.
(d)
A provider shall cease providing THSteps services and notify
TDH, HHSC or its designee if the SBDE suspends or revokes the provider's license,
unless the suspension or revocation is probated in its entirety and without
conditions or limitations.
§33.314.Charges to Recipients.
(a)
A provider shall not require a down payment before providing
Medicaid-allowable services to eligible recipients.
(b)
A provider shall not charge recipients for missed appointments.
(c)
If the denial or reduction of a dental claim is the result
of any of the following errors that are attributed to the provider, a provider
shall neither bill, nor take recourse against an eligible recipient for services
that are within the amount, duration, and scope of benefits of THSteps:
(1)
failure to submit a claim, including claims not received
by the HHSC or its designee;
(2)
failure to submit a claim within the filing deadlines;
(3)
filing of an incorrect paper or electronic claim;
(4)
failure to resubmit a corrected paper or electronic claim
within the appropriate time period;
(5)
failure to appeal a claim denial within the appropriate
time period; or
(6)
errors made in claims preparation, appeal submission, or
the appeal process.
(d)
A provider may bill a recipient for a dental service or
item only if:
(1)
a request for prior authorization or a claim for payment
for the service or item did not establish dental necessity, the service or
item is not a benefit of the Medicaid program, or the service or item is not
allowable according to program rules and policy requirements; and
(2)
the service or item was provided at the request of the
recipient and the provider obtained a written client acknowledgment statement,
as described in the manual, which was signed and dated by the recipient or
the recipient's parent/guardian prior to the initiation of the specified dental
service, and is retained in the recipient's dental record.
§33.315.Payment of Claims.
(a)
The provider must accept payment by HHSC or its designee
as payment in full for services.
(b)
Providers will be reimbursed for allowable services delivered
in accordance with applicable laws, regulations, operational instructions,
and the provider agreement. Payment may be withheld or suspended for services
not delivered in accordance with applicable rules and regulations. Medicaid
payments will not be made for services that are allowable and payable by any
other third-party insurer or assistance program.
(c)
In the event of the provider's death, a completed claim
will be considered for payment only if the executor of the estate signs the
claim and the services were performed by the provider in accordance with the
THSteps program requirements.
§33.317.Change to Another Provider.
(a)
A provider may refer a recipient to another provider or
discontinue treatment for any of the following reasons:
(1)
treatment by a dental specialist, such as a pediatric dentist,
periodontist, endodontist, orthodontist, or oral surgeon, is indicated;
(2)
services needed are outside the skills or scope of practice
of the initial provider; or
(3)
documented failure by the recipient or the recipient's
caretaker or guardian to keep appointments, documented noncompliance with
the treatment plan, or documented conflicts with the recipient or recipient's
family member(s).
(b)
A recipient may select another provider if he or she so
desires.
(c)
The TDH may refer a recipient to another provider as a
result of information obtained during a utilization review or resolution of
a complaint from either the recipient or the provider or upon the provider's
or recipient's documented request.
§33.318.Standards of Care.
(a)
THSteps recipients or their parents or guardians who can
give informed consent shall:
(1)
receive information following an oral evaluation regarding:
(A)
the dental diagnosis;
(B)
scope of proposed treatment, including alternatives and
risks;
(C)
anticipated results; and
(D)
need for administration of sedation or anesthesia, including
risks.
(2)
receive a full explanation of the treatment plan and give
informed consent prior to its implementation.
(b)
THSteps recipients shall:
(1)
receive dental services specified in the treatment plan
which meet the standards of care established by the laws relating to the practice
of dentistry and the rules and regulations of the SBDE;
(2)
receive dental services free from abuse or harm from the
provider or the provider's staff; and
(3)
receive only that treatment required to address documented
dental necessity and which meets professionally recognized standards of health
care as recognized by the SBDE.
(c)
If the recipient is younger than 15 years of age and services
are not provided by an exempt entity, the THSteps dental provider shall require
that the recipient be accompanied by a parent, guardian, or another adult
authorized by the parent or guardian to a THSteps dental appointment. If services
are provided by an exempt entity, the exempt entity must, as a condition for
reimbursement:
(1)
obtain written consent to the services, which has not been
revoked, from the child's parent or guardian, within the one-year period prior
to the date services are provided; and
(2)
encourage parental involvement in the management of the
oral health care of the children receiving services from the clinic, program,
or facility.
§33.319.Management of Complaints.
(a)
The division administration has responsibility for the
management of complaints and payments regarding dental providers and recipients.
Complaints may be received in either written or verbal form and may originate
from any source. In accordance with each agency's guidelines for referrals
of complaints, the TDH shall refer a provider or recipient to the OIE, the
SBDE, the TDH Office of Criminal Investigation, or the Texas Department of
Human Services. The referral shall be in writing. If discrepancies or irregularities
are reported to the TDH or found during a utilization review, the appropriate
agency may take one or more administrative actions. The provider will be notified
in writing of the review findings and of any proposed administrative action.
This notification may occur before or after other action is taken by professional
dental or governmental organizations.
(b)
Referrals to other state agencies.
(1)
The TDH shall refer to OIE based on OIE criteria. OIE criteria
for referrals by the TDH include, but are not limited to, complaints or allegations
of provider fraud or abuse, including program abuse; abuse or harm to a recipient;
lack of medical or dental necessity; overbilling; soliciting or collecting
unauthorized payments from recipients; or failure to refund payments to recipients.
Such complaints or allegations shall be made in writing and forwarded to the
OIE. The OIE may utilize staff from the TDH to assist in determining the validity
of any complaints or allegations received. A TDH employee acting as an agent
of OIE is governed by the parameters of authority and investigation for OIE.
(2)
Complaints about the practice of dentistry as described
in the Texas Dental Practice Act or the rules and regulations of the SBDE
shall be made in writing to the SBDE.
(3)
Allegations of fraud or program abuse committed by a THSteps
recipient shall be reported to the appropriate authority for review of the
allegations and determination of the appropriate action as defined in TDH
policy.
§33.320.Performance of Dental Services.
All THSteps dental services shall be performed by the enrolled provider
except for that work authorized to be done by a licensed dental hygienist,
dental assistant, or dental technician in a dental laboratory on the premises
where the dentist practices or in a commercial laboratory registered with
the SBDE. The Texas Dental Practice Act and the rules and regulations of the
SBDE define the scope of work that dental auxiliary personnel may perform.
Any deviations from these practice limitations shall be reported to the SBDE
and could result in sanctions or other actions being taken against the provider.
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 March 24, 2003.
TRD-200301891
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.305 - 33.309, 33.312 - 33.318
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Health or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Health and Safety
Code, §32.021, which allows the Texas Department of Health to establish
rules governing the Medicaid program; the Health and Safety Code, §12.001,
which provides the Texas Board of Health (board) with authority to adopt rules
for its procedures and the performance of each duty imposed by law on the
board, the department and the commissioner of health; 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 Early and Periodic Screening, Diagnosis, and Treatment program,
also known as THSteps, as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapters 15, §1.07.
The proposed repeals affect the Human Resources Code, Chapter 32.
§33.305.Emergency Dental Services.
§33.306.Allowable Services and Limitations.
§33.307.Eligibility for Texas Health Steps Dental Services.
§33.308.Requirements for Provider Enrollment and Continuing Participation.
§33.309.Termination of a Provider Agreement.
§33.312.Charges to Recipients.
§33.313.Payment of Claims.
§33.314.Claims--Time Limits, Submission, and Denial.
§33.315.Change to Another Provider.
§33.316.Standards of Care.
§33.317.Management of Complaints.
§33.318.Performance of Dental Services.
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 March 24, 2003.
TRD-200301892
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.331 - 33.333
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Health or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Health and Safety
Code, §32.021, which allows the Texas Department of Health to establish
rules governing the Medicaid program; the Health and Safety Code, §12.001,
which provides the Texas Board of Health (board) with authority to adopt rules
for its procedures and the performance of each duty imposed by law on the
board, the department and the commissioner of health; 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 Early and Periodic Screening, Diagnosis, and Treatment program,
also known as THSteps, as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapters 15, §1.07.
The proposed repeals affect the Human Resources Code, Chapter 32.
§33.331.Orthodontic Services Limitations.
§33.332.Eligibility for Orthodontic Services.
§33.333.Payment Limitations for Orthodontic Services.
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 March 24, 2003.
TRD-200301893
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.331, 33.334, 33.351 - 33.358
The new section and amendments are proposed under the Health
and Safety Code, §32.021, which allows the Texas Department of Health
to establish rules governing the Medicaid program; the Health and Safety Code, §12.001,
which provides the Texas Board of Health (board) with authority to adopt rules
for its procedures and the performance of each duty imposed by law on the
board, the department and the commissioner of health; 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 Early and Periodic Screening, Diagnosis, and Treatment program,
also known as THSteps, as authorized under Acts 1991, 72nd Legislature, First
Called Session, Chapters 15, §1.07.
The proposed new section and amendments affect the Human Resources Code,
Chapter 32.
§33.331.Purpose.
The purpose of the Dental Utilization Review process is to ensure program
fiscal integrity and to respond to the federal mandate requiring that program
dollars be spent only on services as allowed under THSteps and that the services
be appropriately provided to eligible recipients.
§33.334.Post-payment Orthodontic Utilization Review.
(a)
(No change.)
(b)
As part of an orthodontic utilization review, a provider
may be required to submit study models
,
[
§33.351.Types of TDH [
(a)
TDH, HHSC or its designee
[
(b)
The
TDH
[
(1)-(2)
(No change.)
(c)
Dental utilization reviews shall be based on written procedures
and screening criteria which are evaluated and updated periodically with input
from practicing dentists
, the OHSAC, and/or the SBDE
. Criteria
shall be objective, clinically valid, and compatible with established principles
of dental care. The
TDH
[
§33.352.Selection of Dentists for TDH [
(a)
An individual or group dental provider may be selected
by the
TDH
[
(1)-(2)
(No change.)
(3)
information or complaints received by the
TDH
[
(b)
Providers suspected of program fraud or abuse
shall
[
(c)
The division shall refer complaints
[
§33.353.Notification to Provider of TDH [
(a)
The
TDH
[
(b)-(c)
(No change.)
§33.354.Provider Cooperation.
(a)
The provider, the provider's associate(s) in a group practice,
or the provider's office staff shall not contact, examine, or treat recipients
identified as part of the utilization review [
(1)
for emergency services as defined
in §33.308 of this title (relating to Emergency Dental Services); or
(2)
upon approval of the provider's
request by the TDH.
(b)-(c)
(No change.)
§33.355.Disposition of TDH [
The results of utilization reviews, either automated or on-site, shall
be forwarded by the
TDH or HHSC's designee
[
§33.356.Recoupment of Overpayments as a Result of TDH [
If the results of a
TDH
[
[
[
§33.357.Administrative Actions and/or Sanctions.
Evaluation of a utilization review may result in one or more of the
following administrative actions or sanctions by the appropriate agency or
the agency's designee:
(1)-(2)
(No change.)
(3)
recoupment of any overpayment identified according to §33.356
of this title (relating to Recoupment of Overpayments as a Result of
TDH
[
(4)-(8)
(No change.)
§33.358.Referral for Investigation of Fraud or Program Abuse.
All allegation of Medicaid fraud and other unlawful activities
will be reported to the appropriate authority for review of the allegations
and determination of the appropriate action as defined in TDH policy. All
complaints alleging quality of care issues will be referred to the appropriate
licensing or regulatory authority.
[
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 March 24, 2003.
TRD-200301894
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
25 TAC §§33.501 - 33.506
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Health or in the Texas Register office, Room 245,
James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Health (department) proposes
the repeal of §§33.501 - 33.506, concerning the Texas Health Steps
Medical Case Management.
The proposed new rules for Case Management for Children and Pregnant Women
will provide case management services to Medicaid eligible women of all ages
who have a high risk pregnancy and to children from birth to 21 years of age
with a health condition/health risk. The programs, Medicaid Case Management
for High Risk Pregnant Women and High Risk Infants and the Texas Health Steps
Medical Case Management will become one program due to the proposed repeal
of §§32.301 - 32.305, §32.307, 33.501 - 33.506, and 37.81 -
37.86 of this title and will become proposed new sections of Chapter 27. The
new program will provide a greater continuity of services for all eligible
recipients.
Government Code, §2001.039, requires that each agency review and consider
for readoption each rule adopted by that agency pursuant to the Government
Code, Chapter 2001 (Administrative Procedure Act). The department has reviewed §§33.501
- 33.506 and determined that the proposed repeals are necessary because the
subject of these rules will be incorporated into a new chapter proposed for
adoption as described in this preamble.
The department published a Notice of Intention to Review §§33.501
- 33.506 in the
Texas Register
on December
10, 1999 (24 TexReg 11129). No comments have been received.
The proposed repeal of §§33.501 - 33.506 is necessary in order
to combine services in new rules in Chapter 27, entitled Case Management for
Children and Pregnant Women, of this title. Combining these sections in a
new chapter will ensure integration of services to the eligible population
for case management services, children with a health condition/health risk
birth to 21 years and/or high-risk pregnant women of all ages. Specifically,
the repealed sections cover definitions; eligible recipients; THSteps Medical
Case Management services, services limitations, applicant and provider qualifications;
and application, review and monitoring processes.
The department also proposes the repeal of §§32.301 - 32.305
and §32.307, of this title concerning case management for high-risk pregnant
women and high-risk infants. Specifically these sections cover definitions;
eligible individuals; case management services; service limitations; provider
qualifications and the right to appeal. These sections are being proposed
for repeal as they are repeated in §§37.81 - 37.86. Sections 32.301
- 32.305 and §32.307 were not repealed when §§37.81 - 37.86
were adopted.
The department at the same time is proposing the repeal of §§37.81
- 37.86 of this title concerning Medicaid case management for high-risk pregnant
women and high-risk infants. Specifically, these sections cover introduction;
definitions; case management services; provider qualifications; application
and review process, and documents adopted by reference and will be integrated
in the new Chapter 27 of this title.
The department also proposes new Chapter 27, Case Management for Children
and Pregnant Women, §§27.1, 27.3, 27.5, 27.7, 27.9, 27.11, 27.13
and 27.15. The new sections are proposed as an effort to combine case management
programs to meet the needs of pregnant women of all ages and children with
a health condition/health risk birth to 21 years. Specifically, these new
sections cover definitions; eligible recipients; case management service provisions;
service limitations; applicant and provider qualifications; and application,
review and monitoring processes.
The department provides health services to women and children in Texas
under the authority of the Health and Safety Code, Chapter 32; the State Appropriations
Act; and the Social Security Act, Title V. The Targeted Case Management Program
for High Risk Pregnant Women and High Risk Infants was established under the
authority of the Social Security Act, Title XIX, §1915(g). Section 1915(g)
authorized states to provide case management as a distinct service to targeted
populations, through a waiver from the Health Care Financing Administration
(HCFA), now the Centers for Medicare and Medicaid Services or CMS. The Health
and Human Services Commission (HHSC) provides authority to the department
to propose rules to administer certain Medicaid program services in Texas.
Human Resources Code, §22.0031, mandates case management for high-risk
pregnant women and high-risk children to age one as provided under §1915(g)
of the federal Social Security Act (42 U.S.C. §1396n). Case management
for children up to age 21 is authorized under 42 U.S.C. §1396d.
The Government Code, §531.021, provides HHSC with the authority to
propose rules to administer the state's medical assistance program. The current
rules were submitted by the department under its agreement with HHSC to operate
the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program,
and as authorized under §1.07, Acts of the 72nd Legislature, First Called
Session (1991), Chapter 15, as amended by the Acts of the 73rd Legislature,
Chapter 747, §2. The purpose of these sections is to make available medically
necessary medical case management services mandated by EPSDT program. In Texas,
the EPSDT program is known as Texas Health Steps (THSteps).
The proposed new rules for Case Management for Children and Pregnant Women
will provide case management services to Medicaid eligible women of all ages
who have a high risk pregnancy and to children from birth to 21 years of age
who have a health condition/health risk. The programs, Medicaid Case Management
for High Risk Pregnant Women and High Risk Infants and The Texas Health Steps
Medical Case Management, will become one program in the proposed new sections
of Chapter 27 with the proposed repeal of §§32.301 - 32.305, 32.307,
33.501 - 33.506, and 37.81 - 37.86. The new program will provide, through
a larger provider base, more continuity of services for all consumers who
are eligible for these services. The new program will provide a greater continuity
of services for all eligible recipients.
Ravi Rupsingh, M.P.A., Actuary, Actuary Analysis, HHSC, has determined
for the first five years the repeals are in effect, there will be cost savings
to the state through the combination of the two programs as described in this
preamble. Total cost savings per year are $1,724,820, $6,153,493, $6,348,526,
$6,549,411 and $6,745,893 in state fiscal years 2003, 2004, 2005, 2006 and
2007, respectively, for a total of $27,522,143 over these five state fiscal
years. There will be no impact on local government.
Duane Thomas, Ph.D., Texas Department of Health, Director of Regional Case
Management has also determined that for each of the first five years the repeals
are in effect, anticipated public benefits include better access to primary
care providers, preventative health services, other health services and community
resources for children and pregnant women accessing the services. There will
be costs to small businesses and micro-businesses. This was determined after
concluding that the elimination of the Intake as a billable contact for Targeted
Case Management for Pregnant Women and Infants providers will decrease the
amount of reimbursement that these providers currently receive. The cost to
small and micro-businesses for the first year of implementation is estimated
to be $7,327 while the cost to large businesses for the first year of implementation
is estimated to be $7,281. The estimated costs are based on the assumption
that 70% of Targeted Case Management for Pregnant Women and Infants providers
are large businesses and 30% of providers are small or micro-businesses. There
will be no anticipated economic costs to persons who receive the services.
The department has determined that the proposed repeals do not restrict or
limit an owner's right to their property that would otherwise exist in the
absence of governmental action and therefore does not constitute a taking
under Government Code, §2007.043.
Comments on the proposal may be submitted to Cossy Hough, LMSW-ACP, Texas
Department of Health, 1100 West 49th Street, Austin, Texas 78756, (512) 458-7111,
extension 6664. Comments will be accepted for 30 days following publication
of the proposal in the
Texas Register
.
A public hearing regarding this repeal will be held on April 8, 2003, from
1:00 p.m. to 4:00 p.m. at the Texas Department of Health, Board of Health
Room, Room M739, 1100 West 49th Street, Austin, Texas 78756.
The repeals are proposed under the Health and Safety Code, §12.001
which provides the Board of Health (board) with the authority to adopt rules
to implement every duty imposed by law on the board, the department and the
commissioner of health; and under the Health and Safety Code, Chapter 32,
which provides the board with the authority to establish maternal and infant
health improvement services programs in the department to serve eligible recipients;
the Human Resources Code, §22.0031, which mandates case management for
high risk pregnant women and high risk infants; the Human Resources Code,
Chapter 32, which enables the state to provide medical assistance; the Government
Code, §531.021, which provides HHSC with the authority to propose rules
to administer the state's medical assistance program and are submitted by
the Texas Department of Health under its agreement with HHSC to operate the
EPSDT program, and as authorized under §1.07 of the Acts of the 72nd
Legislature, First Called Session (1991), Chapter 15, as amended by the Acts
of the 73rd Legislature, Chapter 747, §2.
The repeals affect the Health and Safety Code, Chapter 32, the Human Resources
Code, §22.0031 and Chapter 32.
§33.501.Definitions.
§33.502.Eligible Recipients.
§33.503.THSteps Medical Case Management Services.
§33.504.Service Limitations.
§33.505.Applicant and Provider Qualifications.
§33.506.Application, Review and Monitoring Processes.
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 March 21, 2003.
TRD-200301863
Susan K. Steeg
General Counsel
Texas Department of Health
Earliest possible date of adoption: May 4, 2003
For further information, please call: (512) 458-7236
Subchapter E. MEDICAID CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN AND HIGH RISK INFANTS
Chapter 32.
CASE MANAGEMENT
Chapter 33.
EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT Legal Base ].
The Texas Department of Health must provide
required early and periodic screening, diagnosis, and treatment (EPSDT) screening
and treatment services to eligible families or recipients who request these
services. The periodicity schedule determines when specified screening services
are delivered. The department must provide any
]
THSteps check-up
[
EPSDT
] services
will be provided when
requested
by the recipient according to periodic eligibility for service
.
[
and when medically necessary.
]
Other THSteps services will be provided
when medical or dental necessity is established and federal financial participation
is available.
The Texas
Department of Health must inform each family of the availability of
]
THSteps
[
EPSDT
]
recipients and their families about
THSteps
services no later than 60 days after the Medicaid certification
date
and on a periodic basis thereafter using a combination of methods
including written, oral, and in-person contact
. This notification must
be done in writing and
/or in-person
using [
face-to-face contact
in
] clear,
non-technical
[
nontechnical
] language.
THSteps uses
[
The department must use
] procedures suitable
for informing persons who are illiterate, blind, deaf, or who cannot understand
the English language.
All new eligibles
]
and families who become eligible after a period of
Medicaid
ineligibility
are also informed about THSteps services upon recertification and on a periodic
basis thereafter.
[
must be properly informed. However, a family
need not be informed more than twice in a 12-month period. Families with no
member receiving any EPSDT services must be informed in writing of EPSDT at
least once each year.
]
Subchapter B. RECIPIENT RIGHTS
all early and periodic
screening, diagnosis, and treatment (EPSDT)
] services
is
[
must be
] voluntary. Acceptance or refusal of
THSteps
[
EPSDT
] services does not affect eligibility for or benefits of any other
Medicaid
[
department
] service.
EPSDT
] services may,
still subsequently
[
at a later time,
] request and be provided such services if still eligible for Medicaid
and THSteps
.
EPSDT
] records about
recipients are considered confidential information.
law
] and Medicaid regulations
prohibit the disclosure of information about Medicaid recipients without
the recipient's
consent, except for purposes directly connected
with
[
to
] the administration of the program
(see 42
U.S.C. §1396a(a)(7); 42 C.F.R. §§431.301-431.306; Human Resources
Code §§12.003 and 21.012; Government Code §552.101)
.
Eligibility
and other
information
for which the recipient
gives consent may
[
information will
] be provided to
THSteps
[
screening, diagnosis and treatment
] providers [
and other information for which the recipient gives consent
]. Medicaid
providers of
THSteps services
[
screening, diagnosis, and treatment
] are not considered directly connected with the administration of the
program. Consequently,
THSteps
[
screening, diagnosis and treatment
] providers are not entitled to confidential information, including
lists of names and addresses of recipients, without the consent of the recipient.
the department
]
in exercising its
responsibility
[
responsibilities
]
to ensure effective
THSteps
program operations. Such agencies,
including [
TDH and
] contractors for outreach,
informing
[
follow-up
], and transportation
services
, may receive confidential
information without an individual recipient's consent to the extent that it
is necessary in the administration of the contract.
Pursuant to 42 U.S.C
.§1396a(a)(7), 42 C.F.R. §§431.301-431.306 and Human Resources
Code §12.003
[
However
], these agencies are bound by
the same standards of confidentiality as
TDH
[
the department
]. They must provide effective safeguards to ensure confidentiality.
EPSDT
]. Consent requires the free exercise
of choice without any force, fraud, deceit, constraint, or coercion by an
individual or his legally authorized representative. The basic elements necessary
to consent include:
not consent
] or withdraw consent and discontinue participation at any
time without any loss of other
Medicaid
[
department
]
benefits and services.
EPSDT
] recipients have
the right to choose participating providers of
THSteps
medical
and
[
screening,
] dental
check-up
[
,and
]
diagnosis
,
and treatment services.
Subchapter C. ELIGIBILITY
All
] Medicaid recipients under age 21 are eligible for
THSteps medical and dental check-ups, diagnosis, and treatment
[
EPSDT
] services[
. Services can be continued
] through the
month
of
the
recipient's 21st birthday
[
eligible
recipient becomes 21
].
Subchapter D. PERIODICITY
(a)
The Texas Department of Health
provides early and periodic screening, diagnosis, and treatment (EPSDT) services
requested by recipients according to the recipient's periodic eligibility
for service.]
(b)
]
THSteps comprehensive
[
Comprehensive
] medical
check-up
[
screening
] services are available [
once
] at each of the following
time periods:
through 11 years
];
(17)
] 12 years [
through 13
years
];
(18)
] 14 years [
through 15
years
];
(19)
] 16 years [
through 17
years
];
(20)
] 18 years [
through 19
years
];
(21)
] 20 years.
(c)
Adolescent preventive service
visits are available once at each of the following time periods:]
(1)
11 years;]
(2)
13 years;]
(3)
15 years;]
(4)
17 years; and]
(5)
19 years.]
(d)
] Periodic routine dental
check-up
services are available
for
[
to
] eligible
recipients one year of age and older once every six months
,
based
on the [
last
] date of
the recipient's last
dental
check-up
[
services
].
Screening ] Due Date.
periodic screening
] is [
defined as
] the starting date of a new period of eligibility
for medical
check-ups
[
screening or for dental services
].
medical
care
] identification
form
[
card
] or Medicaid verification
letter for the date that a medical
check-up
[
screening
]
or the first
appointment
[
encounter
] for diagnosis and
treatment is scheduled;
can
] be made with an adult member of the recipient's family;
the department
] to offer and provide support services.
Subchapter E. MEDICAL PHASE Screening ] Services.
screening
] services are provided under the
THSteps
[
Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT)
] Program to ensure
that Medicaid recipients under 21 years of age have continuous
access
to
preventive health care. The objectives of
a medical check-up
[
screening
] are the early detection of [
suspected
]
health problems and the referral for definitive diagnosis and treatment
when
[
if
] indicated by the
medical check-up
[
screening
].
(1)
] The
following are
components
of
a THSteps
comprehensive medical
check-up
[
screening
services are
]:
(A)
] comprehensive health and developmental
history (including physical and mental);
(B)
] comprehensive unclothed physical
examination;
(C)
] developmental assessment;
(D)
] immunizations appropriate for
age and health history;
(E)
] assessment of nutritional status;
(F)
] vision testing;
(G)
] hearing testing;
(H)
] laboratory tests appropriate
to age and risk
, including lead toxicity screening
;
(I)
] health education (includes
anticipatory guidance); and
(J)
] referral to a dentist for
periodic, routine
diagnosis,
[
diagnostic
] and treatment
services for recipients one year of age and older.
(2)
The components of adolescent
preventive service visits are health guidance to promote the health and well-being
of adolescents/parents and screening for biomedical, behavioral, and emotional
conditions relatively common to adolescents.]
(a)
]
Payment will be considered
[
The Texas Department of Health (department) or its designee will consider
payment on an exception basis
] for any service
considered medically
necessary and for which federal financial participation is available,
[
the department is allowed to provide with Medicaid/Title XIX federal matching
funds when required to diagnose or treat a condition identified during an
EPSDT medical screening performed on or after April 1, 1990, whether or not
the service is currently included in the Title XIX state plan. Services exceeding
the Title XIX state plan coverage are
] subject to the following limitations:
the department
] or its designee, and is subject to periodic reassessment.
(2)
Services must be medically
necessary.]
(3)
] Clients must be under age 21
and eligible for Medicaid on the date of service.
(4)
] Payment for services will be
made only to approved providers enrolled in the Texas Medicaid Program.
(b)
Reimbursement for EPSDT medical
diagnosis and treatment services will be based on existing Medicare and Medicaid
fee schedules/profiles.]
Screening ] Providers.
screening
] providers
include
currently licensed:
licensed
] physicians (MD or DO)
;
[
and
]
screening
] procedures under a physician's direction
;and
[
.
]
(b)
To be eligible for reimbursement,
screening providers must be enrolled as screening providers by the department
or its designee.]
Screening ] Providers.
(a)
]
The primary responsibilities of medical
check-up
[
screening
] providers are:
screening
] according to policies and procedures established by
TDH
[
the Texas Department of Health
];
screening
] results to the recipient or the recipient's parent, conservator, or
responsible adult, [
and/or recipient
] during the
course of
the medical check-up
[
exit interview
];
presents a recipient
under age 15
] at
a THSteps
[
an EPSDT
] medical
check-up
[
checkup and continues to wait for the child while the
checkup takes place
] unless the services are provided by
an exempt
entity and if the exempt entity
[
a school health clinic, Head Start
program, or child-care facility (as defined in the Human Resources Code, §42.002(3))
if the clinic, program or facility
] :
(b)
The term "authorized adult"
means a person, including an adult related to the child, who is authorized
by a child's parent or guardian to accompany a child to a Texas Health Steps
medical checkup.]
(c)
The term "parental involvement"
applies only to school health clinics, Head Start programs, and child-care
facilities which are exempt from the parental accompaniment requirement under
subsection (a)(5) of this section. The term means exempt entities shall encourage
parental involvement in and management of the health care of children receiving
services from the clinic, program, or facility by notifying the child's parent,
guardian, or other authorized adult before each visit for an EPSDT medical
checkup of the time and place of the child's appointment and encouraging the
parent, guardian, or other authorized adult to attend. The parent, guardian,
or other authorized adult shall be notified in a timely manner by the means
of communication determined by the clinic, program, or facility to be most
effective. Such communication must be documented and may include, but is not
limited to, one or more of the following options: a home visit from an outreach
worker, written or printed correspondence, or telephone contact.]
Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT)
] Program has time limits for submitting
claims. Payment is denied if
these
[
the
] time
limits
[
frames
] are not met. Time limits are as follows:
EPSDT
] medical
check-up
provider
[
screening
] claims must be received by
HHSC
or its designee
[
the health insuring agent
] within 95 days
from each date of service on the claim.
(2)
Claims for diagnostic and
treatment services must be received by the health insuring agent within 95
days from each date of service on the claims.]
(3)
] If a service is billed to another
insurance resource, the claim must be received
by HHSC or its designee
within 95 days of the
claim
disposition by the other resource.
(4)
] If a service is billed to a
third-party resource that has not responded, the claim must be received by
HHSC or its designee
[
the health insuring agent
] within
365 days
[
12 months
] of the service date; however, the claim
must not be submitted
to HHSC or its designee
[
the health
insuring agent
] before 110 days after the third party has been billed.
the health insuring agent
] within 180 days from the date of the last
denial of and/or adjustment to the original claim.
the health insuring agent
] which are lacking the information necessary
for processing are
listed on the R&S report with an EOB code requesting
the missing information
[
denied as incomplete claims
]. The
resubmission of the claim containing the necessary information must be received
by
HHSC or its designee
[
the health insuring agent
]
within 180 days from the
date on the R&S to be considered for payment
[
last denial date
].
Chapter 33.
EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT
an EPSDT
]
medical or
dental
check-up,
[
checkup
]
or treatment visit
and continues to wait for the
child while the
check-up
[
checkup
]
or treatment
takes place.
It is a requirement of §33.318 of this title
(relating to Standards of Care) that a recipient under the age of 15 be accompanied
as a condition of reimbursement, unless services are provided by an exempt
entity.
Texas Health Steps
]
medical
or
dental
check-up or treatment visit
[
checkup
].
(3)
] Dental necessity--
For
[
for
] dental services or products provided, whether a prudent
dentist would provide the service or product to a patient to diagnose, prevent,
or treat orofacial pain, infection, disease, dysfunction, or disfiguration
in accordance with generally accepted practices:
(4)
Department--The Texas Department
of Health.]
(5)
]
EPSDT--
Early and
Periodic Screening, Diagnosis, and Treatment [
(EPSDT)--
]
is a service of the Medicaid program. EPSDT provides medical and dental check-ups,
diagnosis and treatment to Medicaid eligible recipients younger than 21 years
of age. EPSDT is known in Texas as Texas Health Steps.
[
A component
of the Medicaid program, also known as Texas Health Steps (THSteps), which
provides medical check-up and dental services to Medicaid and Texas Health
Steps clients under age 21 years.
]
(6)
] HHSC--
The
Health
and Human Services Commission.
(7)
] Manual--The Texas Medicaid
Provider Procedures Manual, including all updates published in the Texas Medicaid
Bulletin.
(8)
] Medicaid--
The medical
assistance program implemented by the State of Texas under the provisions
of Title XIX of the Social Security Act, as amended (42 U.S.C.
§§1396-1396v).
[
A medical and dental program provided under Title XIX of the federal
Social Security Act and the Human Resources Code, Chapter 32
].
(9)
] OIE--The Office of Investigations
and Enforcement at the Health and Human Services Commission.
(10)
] Parental involvement--
The encouragement and involvement in and management of the health care of
children receiving services from an exempt entity as defined in paragraph
(8) of this section. Parental involvement includes the exempt entity
[
this term applies only to school health clinics, Head Start programs, and
child-care facilities which are exempt from the parental accompaniment requirement
under §33.316(c) of this title (relating to Standards of Care). The term
means exempt entities shall encourage parental involvement in and management
of the health care of children receiving services from the clinic, program,
or facility by
] notifying the child's parent, guardian, or other authorized
adult before each visit for
a THSteps
[
an EPSDT
]
medical or
dental
check-up
[
checkup
] of the time
and place of the child's appointment and encouraging the parent, guardian,
or other authorized adult to attend.
Notification shall be done by
[
The parent, guardian, or other authorized adult shall be notified in a timely
manner by
] the means of communication determined by the
exempt
entity
[
clinic, program, or facility
] to be the most effective.
Such communication must be documented and may include, but is not limited
to, one or more of the following options: a home visit from an outreach worker,
written or printed correspondence or telephone contact.
(11)
] Recipient--
An individual
who has been determined eligible for Medicaid
[
A Medicaid-enrolled
client
].
(12)
] SBDE--The State Board of
Dental Examiners.
(a)
The name of the Early and
Periodic Screening, Diagnosis, and Treatment program has been changed to Texas
Health Steps.]
(b)
] In addition to initial and
periodic diagnostic oral evaluations, which may include radiographs and other
diagnostic tests, three categories of dental services are available--preventive,
therapeutic, and emergency--as defined in the following sections. These services
are described in the Medicaid dental fee schedule published annually by the
TDH
[
department
] in the manual. [
These services are
subject to the limitations listed in the dental fee schedule and in the description
of Texas Health Steps dental services in the manual.
] Prior authorization
may be required for certain services. Services delivered
must
[
should
] conform to professionally recognized standards of care as recognized
by the SBDE, and are subject to utilization review.
§§33.331-33.334
] of this title (relating to Orthodontic
Services).
Subchapter H. DENTAL UTILIZATION REVIEW
and
] diagnostic
work-up information and records at the provider's expense.
Department ] Utilization Reviews.
The department
or its claims processing contractor
] may conduct utilization reviews
through automated analysis of a provider's pattern(s) of practice, including
peer group analysis. Such analysis may result in the subsequent conduct of
an on-site utilization review.
Utilization reviews may also be conducted
[
The department or its claims processing contractor may conduct
utilization reviews
] at the direction of OIE, according to HHSC rules.
department
] may conduct
dental utilization reviews which:
department
] shall apply review
and screening criteria with flexibility appropriate to the circumstances of
each case.
Department ] Utilization Review.
department
] for a utilization review as
a result of:
department
], except those alleging fraud or abuse or concerning the
practice of dentistry as described in
§33.319
[
§33.317
] of this title (relating to Management of Complaints).
will
] not be subject to a utilization review by the
TDH
[
department, but will instead be referred to
]
.
The TDH shall refer such providers to the
OIE for disposition.
Complaints
] regarding the practice of dentistry [
will be referred
]
to
the
SBDE.
Department ] On-Site Utilization Review.
department
] shall give the
provider at least 30 days
written
notice of the time and place
of a utilization review, unless such notice would jeopardize an active investigation.
(with the exception of
emergency services as defined in §33.305 of this title (relating to Emergency
Dental Services), or upon approval of the provider's request by the department)
] from the time the provider receives
written
notification
identifying the recipients to be reviewed until notified in writing by the
TDH
[
department
] that normal contacts may be resumed.
There are two exceptions to this exclusion:
Department ] Utilization Review Results.
department or
by its claims processing contractor
] to the OIE for evaluation and final
disposition. Results of a review which reflects no deviation from review standards
shall
[
will
] be
forwarded
[
mailed
]
to the provider
within 30 days of
[
in a timely manner upon
] completion of the review.
Department ] Utilization Review.
department
] utilization
review indicate overpayment for services delivered or that payment was made
for services not delivered, recoupment is required. The appropriate agency
or agency designee
shall
[
will
] notify the provider
in writing
of any overpayment identified and the method of recoupment
to be used
. [
A provider's recoupment obligation may involve either
or both of the following:
]
(1)
the dollar amount of the discrepancies
in the claims reviewed; or]
(2)
a dollar amount calculated
by applying the monetary discrepancy rate found in the claims reviewed to
all remaining claims for the types of services sampled with dates of service
during the period under review.]
Department
] Utilization Review);
Suspected cases of fraud or
abuse will be immediately referred to the OIE. Department utilization reviews
will not be initiated on any provider suspected of fraud or abuse.
]
Subchapter J. TEXAS HEALTH STEPS MEDICAL CASE MANAGEMENT
Chapter 37.
MATERNAL AND INFANT HEALTH SERVICES