Part 1.
DEPARTMENT OF STATE HEALTH SERVICES
Chapter 37.
MATERNAL AND INFANT HEALTH SERVICES
Subchapter R. SCHOOL HEALTH ADVISORY COMMITTEE
25 TAC §37.350
The Executive Commissioner of the Health and Human Services
Commission, on behalf of the Department of State Health Services (department),
proposes new §37.350, concerning the School Health Advisory Committee
(committee).
BACKGROUND AND PURPOSE
The new section complies with Senate Bill 42, 79th Legislature, 2005, (now
codified in part as Health and Safety Code, §1001.0711), which requires
the department to provide assistance to the State Health Services Council
(council) in establishing a leadership role for the department in the support
and delivery of coordinated school health programs and school health services.
Government Code, §2110.008, which allows state agencies to designate
a date on which the committee will automatically be abolished, and does not
apply to a committee created under this section.
Senate Bill 42, 79th Legislature, 2005, establishes, a comprehensive school
health education package for public primary and secondary schools. The legislation
focuses on health education, physical activity, and food products. It: (1)
cites proper nutrition and exercise as the focus of health for the required
enrichment curriculum in kindergarten through grade 12; (2) authorizes the
State Board of Education (SBOE) to adopt rules for expansion of the requirement
for daily physical activity into middle school and junior high school; (3)
provides for coordinated school health programs to be made available for middle
schools and junior high schools; (4) holds districts accountable for the bill's
requirements by requesting information on student health and physical activity
information; and (5) establishes a state-level school health advisory committee.
The 76th, 77th and 78th Legislative Sessions created and modified School
Health Advisory Councils (SHAC) at the school district level for the purpose
of advising local school boards on coordinated school health programs, based
on the needs of the individual district. Research has shown that having an
active SHAC promotes district-wide coordinated school health.
The establishment of a state-level committee with a membership that reflects
the broad diversity of our challenging school health issues, will add another
dimension to the systematic dissemination of coordinated school health programming
and school health services in Texas. The law mandates that a representative
from the Texas Education Agency and the Texas Department of Agriculture serve
as members of the committee. Additional appointments by the Executive Commissioner
of the Health and Human Services Commission of members with a broad range
of school health experience will strengthen the knowledge base of the committee.
The membership nomination process will combine the Health and Human Services
Commission guidelines, research-based criteria, stakeholder input, and department
staff guidance.
SECTION-BY-SECTION SUMMARY
New §37.350 establishes the committee and provides procedures for
its operation. Specifically, the section includes language describing how
the committee shall be appointed and governed; states the applicable laws
to which the committee is subject; explains the purpose of the committee;
details the composition of its membership; and, outlines procedures relating
to terms of membership, terms of office, attendance, staff support, parliamentary
procedures, establishment of subcommittees, statements by members, reporting
processes to the council and expenses reimbursement policies.
FISCAL NOTE
Casey Blass, Section Director, Disease Prevention and Intervention, has
determined that for each year of the first five-year period that the section
will be in effect, there will be fiscal implications to the state as a result
of enforcing and administering the sections as proposed. The effect on state
government will be in the form of an allocation of costs resulting from a
shift of time and salaries to provide appropriate staff support for the committee.
These costs are estimated to be $20,528 the first calendar year and an estimated
$20,528 each year for calendar years two through five, contingent upon continuation
of the committee, for three staff with the department. These figures also
include estimated percentage allocations of time and salary for the Texas
Department of Agriculture and Texas Department of Education representatives
serving as members of the committee mandated by Health and Safety Code, §1001.0711.
There is no anticipated fiscal implication for local governments.
SMALL AND MICRO-BUSINESS IMPACT ANALYSIS
Mr. Blass has also determined that there will be no effect on small businesses
or micro-businesses. This was determined by interpretation of the rule that
small businesses and micro-businesses will not be required to alter their
business practices in order to comply with the section as proposed. There
are no anticipated economic costs to persons who are required to comply with
the section as proposed. There is no anticipated negative impact on local
employment.
PUBLIC BENEFIT
In addition, Mr. Blass has determined that for each year of the first five
years the section is in effect, the public will benefit from adoption of the
section. The public benefit anticipated as a result of establishing the committee
will be more than likely anecdotal during the first one to three years with
statistical results emerging towards the end of the five-year period. The
most significant outcomes, however, will be the long term effect from the
results of the efforts of the committee. By that time, the original intent
of the law will have become a reality and the department will be recognized
as a credible, informed leader for providing support and delivery of coordinated
school health programs and school health services for Texas schools. The committee
will be able to study and recommend solutions to complex school health issues
based on successful coordination of multi-level systems. The short and long
term effect of the efforts of the state committee and the dynamic and supportive
leadership of the department will have an effect on our future workforce.
Recommendations by the committee will provide support for school systems,
organizations, communities and consumers that have the potential to reduce
childhood obesity in Texas.
REGULATORY ANALYSIS
The department has determined that this proposal is not a "major environmental
rule" as defined by Government Code, §2001.0225. "Major environmental
rule" is defined to mean a rule the specific intent of which is to protect
the environment or reduce risk to human health from environmental exposure
and that may adversely affect, in a material way, the economy, a sector of
the economy, productivity, competition, jobs, the environment or the public
health and safety of a state or a sector of the state. This proposal is not
specifically intended to protect the environment or reduce risks to human
health from environmental exposure.
TAKINGS IMPACT ASSESSMENT
The department has determined that the proposed new rule does not restrict
or limit an owner's right to his or her property that would otherwise exist
in the absence of government action and, therefore, do not constitute a taking
under Government Code, §2007.043.
PUBLIC COMMENT
Comments on the proposal may be submitted to Ellen Kelsey, Information
Specialist, Youth-Focused Group, Department of State Health Services, 1100
West 49th Street, Austin, Texas 78756, (512) 458-7111, extension 2140 or by
email to ellen.kelsey@dshs.state.tx.us. Comments will be accepted for 30 days
following publication of the proposal in the
Texas
Register
.
LEGAL CERTIFICATION
The Department of State Health Services General Counsel, Cathy Campbell,
certifies that the proposed rule has been reviewed by legal counsel and found
to be within the state agencies' authority to adopt.
STATUTORY AUTHORITY
The new section is authorized by Health and Safety Code, §1001.0711,
which requires the Health and Human Services Commission to establish this
advisory committee; and Government Code, §531.0055, and Health and Safety
Code, §1001.075, which authorize the Executive Commissioner of the Health
and Human Services Commission to adopt rules and policies necessary for the
operation and provision of health and human services by the department and
for the administration of Chapter 1001, Health and Safety Code.
The new section affects the Health and Safety Code, Chapter 1001; and Government
Code, Chapter 531.
§37.350.School Health Advisory Committee.
(a)
The committee. The School Health Advisory Committee (committee)
shall be appointed under and governed by this section. The committee is established
under the Health and Safety Code, §11.016, which allows the Health and
Human Services Commission (commission) to establish advisory committees.
(b)
Applicable law. Government Code, §2110.008, does not
apply to a committee created under this section. The committee is subject
to the Health and Safety Code, §1001.0711, concerning the School Health
Advisory Committee.
(c)
Purpose. The purpose of the committee is to provide assistance
to the State Health Services Council (council) in establishing a leadership
role for the Department of State Health Services (department) in support for
and delivery of coordinated school health programs and school health services.
(d)
Composition.
(1)
The committee shall be composed of 20 members appointed
by the Executive Commissioner of the Health and Human Services Commission.
The members shall consist of:
(A)
one representative from the Department of Agriculture appointed
by the Commissioner of Agriculture;
(B)
one representative from the Texas Education Agency, appointed
by the Commissioner of Education;
(C)
the School Health Coordinator from the department;
(D)
two individuals representing school superintendents or
other school administrators; and/or school district board members;
(E)
one registered nurse with school district or school health
administrative nursing experience;
(F)
five consumer members who are parents of school-age children
with at least one parent of a child with special needs;
(G)
one physician, or physician's assistant, or nurse practitioner
providing health services to school aged children;
(H)
one representative working in the school setting with certification
in student counseling and guidance and/or safety;
(I)
four members representing organizations and/or agencies
involved with the health of school children;
(J)
one representative working in the school setting with certification
as a physical educator;
(K)
one representative working in the school setting with certification
as a health educator; and
(L)
one representative working in the school setting as part
of the district's school nutrition services.
(2)
During all phases of the membership selection process,
the following information will be regarded with special consideration in an
effort to build a committee reflective of the current Texas population: race,
gender, age and ethnic diversity; urban, rural and suburban diversity; and,
a broad statewide geographic representation whenever possible.
(e)
Terms of office: The term of office of each member shall
be six years. Members shall serve after expiration of their term until a replacement
is appointed.
(1)
Members shall be appointed for staggered terms so that
the terms of a substantially equivalent number of members will expire on June
1 of each odd-numbered year beginning in 2007.
(2)
If a vacancy occurs, an individual shall be appointed to
serve the unexpired portion of that term.
(f)
Officers. The Executive Commissioner of the Health and
Human Services Commission shall appoint a presiding officer and an assistant
presiding officer to begin serving on June 1 of each odd-numbered year.
(1)
Each officer shall serve until May 31 of each odd-numbered
year. Each officer may hold over until the Executive Commissioner of the Health
and Human Services Commission appoints his or her replacement.
(2)
The presiding officer shall preside at all committee meetings
at which he or she is in attendance, call meetings in accordance with this
section, appoint subcommittees of the committee as necessary, and cause proper
reports to be made to the Executive Commissioner of the Health and Human Services
Commission. The presiding officer may serve as an ex-officio member of any
subcommittee of the committee.
(3)
The assistant presiding officer shall perform the duties
of the presiding officer in case of the absence or disability of the presiding
officer. If the office of the presiding officer becomes vacant, the assistant
presiding officer will serve until a successor is appointed to complete the
unexpired portion of the term of the office of presiding officer.
(4)
If the office of assistant presiding officer becomes vacant,
it may be filled temporarily by vote of the committee until the Executive
Commissioner of the Health and Human Services Commission appoints a successor.
(5)
A member shall serve no more than two consecutive terms
as presiding officer and/or assistant presiding officer.
(6)
The committee may reference its officers by other terms,
such as chairperson and vice-chairperson.
(g)
Meetings. The committee shall meet at least twice each
year.
(1)
A meeting may be called by agreement of the department
staff and either the presiding officer or at least three members of the committee.
(2)
The department shall make meeting arrangements and shall
contact committee members to determine availability for a meeting date and
place.
(3)
The committee is not a "governmental body" as defined in
the Open Meetings Act, Government Code, Chapter 551. However, in order to
promote public participation, each meeting of the committee shall be announced
and conducted in accordance with the Open Meetings Act, Government Code, Chapter
551, with the exception that the provisions allowing executive sessions shall
not apply.
(4)
Each member of the committee shall be informed of a committee
meeting at least five working days before the meeting.
(5)
Ten members of the committee shall constitute a quorum
for the purpose of transacting official business.
(6)
The committee is authorized to transact official business
only when in a legally constituted meeting with a quorum present.
(7)
The agenda for each committee meeting shall include an
item entitled public comment under which any person will be allowed to address
the committee on matters relating to committee business. The presiding officer
may establish procedures for public comment, including a time limit on each
comment.
(h)
Attendance. Members shall attend committee meetings as
scheduled. Members shall attend meetings of subcommittees to which the member
is assigned.
(1)
A member shall notify the presiding officer or appropriate
department staff if he or she is unable to attend a scheduled meeting.
(2)
It is grounds for removal from the committee if a member
cannot discharge the member's duties for a substantial part of the term for
which the member is appointed because of illness or disability, is absent
for more than half of the committee and subcommittee meetings during a calendar
year, or is absent from at least three consecutive committee meetings.
(3)
The validity of an action of the committee is not affected
by the fact that it is taken when a ground for removal of a member exists.
(i)
Staff. The department shall provide administrative support
for the committee.
(j)
Procedures. Roberts Rules of Order, Newly Revised, shall
be the basis of parliamentary decisions except where otherwise provided by
law or rule.
(1)
Any committee action must be approved with a quorum present
and by a majority vote of the members present.
(2)
Each member shall have one vote.
(3)
A member may not authorize another individual to represent
the member by proxy.
(4)
The committee shall make decisions in the discharge of
its duties without discrimination based on any person's race, creed, gender,
religion, national origin, age, physical condition, or economic status.
(5)
Minutes of each committee meeting shall be taken by the
department staff.
(A)
A draft of the minutes approved by the presiding officer
shall be provided to the council and each member of the committee within 30
days of each meeting.
(B)
After approval by the committee, the minutes shall be signed
by the presiding officer.
(k)
Subcommittees. The committee may establish subcommittees
as necessary to assist the committee in carrying out its duties.
(1)
The presiding officer shall appoint members of the committee
to serve on subcommittees and to act as subcommittee chairpersons. The presiding
officer may also appoint nonmembers of the committee to serve on subcommittees.
(2)
Subcommittees shall meet when called by the subcommittee
chairperson or when so directed by the committee.
(3)
A subcommittee chairperson shall make regular reports to
the committee at each of its meetings or in interim written reports as needed.
The reports shall include an executive summary or minutes of each subcommittee
meeting.
(l)
Statement by members.
(1)
The commission, the council, the department, and the committee
shall not be bound in any way by any statement or action on the part of any
committee member except when a statement or action is in pursuit of specific
instructions from the commission, council, department, or committee.
(2)
The committee and its members may not participate in legislative
activity in the name of the commission, the council, the department, or the
committee except with approval through the department's legislative process.
Committee members are not prohibited from representing themselves or other
entities in the legislative process.
(m)
Reports to council. The committee shall file an annual
written report to the council.
(1)
The report shall list the meeting dates of the committee
and any subcommittees, the attendance records of its members, a brief description
of actions taken by the committee, a description of how the committee has
accomplished the tasks given to the committee by the council, the status of
any rules which were recommended by the committee to the council and anticipated
activities of the committee for the next year.
(2)
The report shall identify the costs related to the committee's
existence, including the cost of agency staff time spent in support of the
committee's activities.
(3)
The report shall cover the meetings and activities in the
immediate preceding 12 months and shall be filed with the council each June.
The presiding officer and appropriate department staff shall sign it.
(n)
Reimbursement for expenses. In accordance with the requirements
set forth in the Government Code, Chapter 2110, a committee member may receive
reimbursement for the member's expenses incurred for each day the member engages
in official committee business if authorized by the General Appropriations
Act or budget execution process.
(1)
No compensatory per diem shall be paid to members unless
required by law.
(2)
A committee member who is an employee of a state agency,
other than the department, may not receive reimbursement for expenses from
the department.
(3)
A nonmember of the committee who is appointed to serve
on a subcommittee may not receive reimbursement for expenses from the department.
(4)
Each member who is to be reimbursed for expenses shall
submit to staff the member's receipts for expenses and any required official
forms not later than 14 days after each committee meeting.
(5)
Requests for reimbursement of expenses shall be made on
official state vouchers prepared by department staff.
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 December 23, 2005.
TRD-200506099
Cathy Campbell
General Counsel
Department of State Health Services
Earliest possible date of adoption: February 5, 2006
For further information, please call: (512) 458-7236
25 TAC §§38.1 - 38.14, 38.16
The Executive Commissioner of the Health and Human Services
Commission, on behalf of the Department of State Health Services (department),
proposes amendments to §§38.1 - 38.14 and 38.16, concerning the
Children with Special Health Care Needs Services Program (CSHCN Services Program).
BACKGROUND AND PURPOSE
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). Sections
38.1 - 38.14 and 38.16 have been reviewed, and the department has determined
that reasons for adopting the sections continue to exist because rules on
this subject are needed.
The amendments are made in compliance with the Government Code, §2001.039,
and they clarify language, make corrections of fact, make changes to grammar
or syntax, and improve consistency in the rules.
SECTION-BY-SECTION SUMMARY
The following changes to names and addresses have been made throughout §§38.1
- 38.14 and 38.16. For simplicity and uniformity, the common name of the Children
with Special Health Care Needs Services Program has been changed to "CSHCN
Services Program." References to legacy agencies now part of the Health and
Human Services Commission have been amended to reflect the department's name
change from "Texas Department of Health" to "Department of State Health Services,"
and references to the Board of Health have been deleted. Since the Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS) and the Civilian
Health and Medical Program of the Veterans Administration (CHAMPVA) are no
longer identified by these acronyms, these programs will be identified only
as "United States Department of Defense or Department of Veterans Affairs
benefit plans."
The identification of the CSHCN Services Program Division Director has
been changed to "the manager of the department unit having responsibility
for oversight of the CSHCN Services Program." The professional designation
for "master social worker-advanced clinical practitioner" has been corrected
to "licensed clinical social worker (LCSW)," the current professional nomenclature.
The CSHCN Services Program mailing address has been corrected. Minor textual
changes to punctuation, grammar, syntax, and/or spelling have also been made.
In addition to the name and other changes identified above, amendments
to §38.2 include deletion of the definitions for "advisory committee"
and "board," because those entities no longer exist. The definition for "newborn
screening" has been deleted, because the term is no longer used in the chapter.
A definition for "commission" has been added to identify the Texas Health
and Human Services Commission. The definitions have been renumbered to reflect
these additions and deletions.
The definition for "applicant" has been amended to be more comprehensive
by including individuals who are seeking to establish initial or continuing
eligibility as well as to re-establish lapsed eligibility.
The definition for "effective date of eligibility for applicants with spenddown"
at §38.2(23)(D) has been amended to clarify that medical bills qualifying
to meet "spenddown" requirements must have dates of service 12 months prior
to the date of receipt of the application or within 6 months after the date
eligibility was previously denied. This change is consistent with a statutory
requirement that changed the eligibility period from 12 to 6 months.
The definition of "medical home" has been amended to update the definition
and incorporate elements recommended by the American Academy of Pediatrics
and the Medical Home Work Group of the CSHCN Services Program. In the definition
of "natural home" at §38.2(34), "the eligible person" has been changed
to "a person." Eligibility for the CSHCN Services Program has no bearing on
this definition.
In addition to name changes identified above, the definition of "other
benefit" at §38.2(36) has been amended to clarify that the intended costs
of services are those "included in the scope of coverage of" the CSHCN Services
Program. The phrase "but not limited to" has been incorporated in the introductory
sentence before the listing of some types of "other benefits." At new §38.2(34)(B),
home, auto, and other liability insurance have been added as "other benefits,"
and subsequent subparagraphs have been renumbered.
The definition for "specialty center" has been amended to clarify that
the centers are designated for use "by CSHCN Services Program clients" as
part of comprehensive services for a specific medical condition.
In addition to name and other changes identified previously, amendments
to §38.3 of this title (relating to Eligibility for CSHCN Program Services)
include the following. The title of the section has been changed from "Eligibility
for CSHCN Program Services" to "Eligibility for Services." Section 38.3(a)(1)
has been amended to clarify the requirements for a dentist or physician who
certifies that a person meets the medical criteria for certification as a
"child with special health care needs." The medical criteria certification
must be made at least annually and must be based upon a physical examination
conducted within the 12 months immediately preceding the date of certification.
The certifying physician or dentist must provide not only the diagnosis code,
but also the descriptor, and the section has been amended to clarify that
the requirement applies to each of the person's medical conditions. These
changes are consistent with current CSHCN Services Program instructions for
completion of the form that supplies this documentation.
Section 38.3(a)(1) also has been amended to authorize the CSHCN Services
Program Medical Director to accept written documentation of medical certification
criteria from a physician or dentist licensed to practice in a state or jurisdiction
of the United States other than Texas. The individual for whom the subparagraph
describes medical criteria eligibility has been changed from "child/applicant"
or "applicant" to "person" throughout. Section 38.3(a)(1) also has been amended
to clarify that the CSHCN Services Program may not reimburse physicians or
dentists for providing written documentation of medical criteria certification,
and to reaffirm that only a physician or dentist who is a CSHCN Services Program
participating provider may be reimbursed for services.
At §38.3(a)(2), in accordance with requirements of the 79th Texas
Legislature in Regular Session (2005), Appropriations Act, DSHS Rider 63,
paragraph d, compliance with financial eligibility criteria must be determined
"every six months, or as directed by statutory requirements" rather than "annually."
Section 38.3(2) also has been amended to delete explanations concerning net
income and insurance premium payments in connection with the Children's Health
Insurance Program, as they are now both inaccurate and superfluous.
Section 38.3(a)(2)(A) has been amended to make provisions concerning documentation
of a family's income and relating to the length of time that financial criteria
must be determined consistent with the amendments to §38.3(a)(2).
Section 38.3(a)(2)(B)(i) has been amended to clarify that the subparagraph
applies to "an ongoing" client "currently not eligible for Medicaid;" to delete
"medical condition" as a factor relevant to whether a client must apply to
Medicaid; and to replace the reference to "Medicaid, specifically including
the Medically Needy program" with "any applicable Medicaid programs."
Section 38.3(a)(2)(B)(ii) has been amended to clarify that its provisions
apply to "an ongoing" client.
At §38.3(a)(3)(B), concerning health insurance coverage, the subparagraph
has been amended to clarify that both Medicaid and the Children's Health Insurance
Program (CHIP) are among the types of health insurance coverage for which
an applicant/client must apply and remain eligible, if not exempt from such
coverage. Concerning when the program may extend the deadline, the phrase
"and/or continue CSHCN program coverage" has been deleted, because it is not
relevant to this deadline extension. The subparagraph also has been amended
to state that, if the applicant/client is eligible for "any other health insurance,"
the applicant/client must be enrolled. The subparagraph formerly specified
only that the eligible applicant/client must be enrolled in the CHIP.
At §38.3(a)(3)(C), the paragraph has been amended to clarify that
its provisions apply to "ongoing clients," and to delete the statement that
a family support services plan may not be implemented until the determination
of program eligibility is complete. The statement is not relevant to the determination
of program eligibility requirements.
Section 38.3(a)(7)(C) has been amended to state more clearly that applicants
or clients who are financially eligible for Medicaid, CHIP, or other programs
with eligibility income guidelines that meet the CSHCN Services Program's
income eligibility guidelines, and who also meet the CSHCN Services Program's
age and residency requirements, will be considered financially eligible for
the CSHCN Services Program.
Section 38.3(a)(8) has been amended to distinguish between the lengths
of time for which financial and medical eligibility may be reestablished.
As required by the 79th Texas Legislature in Regular Session (2005), Appropriations
Act, SB1, DSHS Rider 63, paragraph (d), financial eligibility must be reestablished
"every six months, or as directed by statutory requirements," rather than
"at least annually." The determination of medical criteria for eligibility
continues to be at least annually. Requirements concerning notification and
deadlines for determination of continuing eligibility have been amended by
deleting "annual," so that they are applicable to both financial or medical
criteria.
In addition to name and other general changes identified previously, amendments
to §38.4 of this title (relating to Covered Services) include the following.
At §38.4(b)(3), the phrase "with a chronic physical or developmental
condition as specified in §38.3(a)(1) of this title (relating to Eligibility
for CSHCN Program Services)" has been deleted, because the term "client" is
defined in §38.2 of this title (relating to Definitions).
At §38.4(b)(3)(B), the phrase "in a calendar year" has been added
to specify the time period within which no more than 30 outpatient mental
health service encounters may be provided.
At §38.4(b)(3)(E)(i)(II), regarding inpatient psychiatric care, the
phrase "Texas Department of Mental Health and Mental Retardation programs
or other" has been deleted and replaced with "public or private mental health
program" as a referral resource. In addition, the specificity of the five-day
limitation on care has been deleted; however, the requirement that all admissions
be prior authorized remains.
Although coverage of medical foods is not a new benefit, a description
of the coverage for medical foods previously stated only in program policy
has been added at new §38.4(b)(3)(J). Subsequent subparagraphs have been
re-alphabetized.
At §38.4(b)(3)(L)(ii), the benefit limitation of one eye examination
with refraction has been clarified by stating that the benefit shall be available
during "a calendar" year, rather than during "the state fiscal" year. The
same limitation for one pair of non-prosthetic eyewear per year has been applied
per "calendar" year at §38.4(b)(3)(L)(iii).
Also, for consistency and clarification, the home health services benefit
limitations have been changed from hours per year to hours per "calendar"
year at §38.4(b)(3)(Q).
Section 38.4(b)(5)(A)(i), concerning eligibility for family support services,
has been deleted as redundant, and subsequent subparagraphs have been renumbered.
At §38.4(b)(5)(A)(ii), a reference to family support programs received
through the Texas Department of Human Services or the Texas Department of
Mental Health and Mental Retardation has been deleted and replaced with references
to the Primary Home Care Program and the Medically Dependent Children's Program,
as examples of other family support services programs.
At §38.4(b)(5)(A)(iii), the reference to family "support services
plan" has been replaced by a family "assessment and service" plan to describe
more accurately the plan that is actually developed.
Also relating to family support services, §38.4(b)(5)(B)(i) concerning
the processing and evaluation of requests for family support services has
been amended by adding "of clients" to describe the families for whom the
subparagraph applies, and by deleting the time limit within which a family
must indicate in writing the need for family support services. Families of
clients may request family support services at any time.
At §38.4(b)(5)(B)(iv), the descriptor for §38.16 of this title,
"(relating to Procedures to Address CSHCN Services Program Budget Alignment),"
has been added.
Sections 38.4(b)(5)(C)(i) and 38.4(b)(5)(C)(vi) also have been amended
to replace "written family support services" plan is with "family assessment
and service" plan.
Sections 38.4(b)(5)(C)(ii)(II) and 38.4(b)(5)(C)(iii) have been amended
by adding "calendar" to describe the year in which the service plan and cost
allowance limitations apply.
Section 38.4(b)(5)(C)(iv)(II) has been amended to further define the term
"vendor" by adding the descriptor, "enrolled as a CSHCN Services Program provider."
Section 38.4(b)(5)(D)(iii)(V) has been amended by replacing "the Texas
Rehabilitation Commission" with "the Department of Assistive and Rehabilitation
Services (DARS)."
Section 38.4(b)(5)(E)(ix), concerning unallowable services, has been amended
to clarify that costs for allowable services must be incurred before the "requested
family support service is prior authorized," rather than before the "written
service plan is approved."
At §38.4(b)(5)(F)(iii), the descriptor for §38.16 of this title,
"(relating to Procedures to Address CSHCN Services Program Budget Alignment),"
has been added, and at §38.4(b)(5)(F)(ix), the "written family support
services" plan has been changed to the "family assessment and service" plan.
Section 38.4(b)(6)(B), concerning the CSHCN Services Program transportation
benefit, has been amended to clarify that the benefit may include transportation
"to" as well as "from" the nearest medically appropriate facility. Further
description of the facility and benefit has been added by the phrase, "(in
Texas or in the United States 50 or fewer miles from the Texas border) to
obtain medically necessary and appropriate health care services that are within
the scope of the coverage of the CSHCN Services Program and are provided by
a CSHCN Services Program enrolled provider." The section also has been clarified
by adding that transportation to services available more than 50 miles from
the Texas border will not be approved, except as specified in §38.6(e)
of this title (relating to Providers).
At §38.4(b)(6)(C), new language clarifies that the benefit for meals
and lodging must be directly related to medically necessary treatment for
the client "that is provided by program enrolled providers and covered by
the program." New language also provides that coverage for meals and lodging
associated with travel more than 50 miles from the Texas border will not be
approved, except as specified in §38.6(e) of this title (relating to
Providers).
Regarding transportation of the remains of a deceased client, §38.4(b)(6)(D)(i)
has been amended by replacing "while receiving CSHCN program services" with
"while receiving CSHCN Services Program health care benefits," to more correctly
indicate the applicable circumstances. The scope of this benefit also has
been clarified by adding that such transportation is, "from the facility to
the place of burial in Texas that is designated by the parent or other person
legally responsible for interment."
Section 38.4(b)(6)(E), concerning payment of insurance premiums, coinsurance,
co-payments, and/or deductibles, has been amended by inserting phrases to
improve the specifications for payment of coinsurance and deductible amounts
when the total amount paid "(including all payers)" to the provider does not
exceed the maximum allowed "by the CSHCN Services Program" for the covered
service.
Section 38.4(c)(5) has been amended to clarify that, although pregnancy
prevention in general is not a covered service, an exception exists for the
specific treatment of "a condition meeting the parameters of the 'child with
special health care needs' definition."
Section 38.4(c)(6) has been amended to further define the scope of the
exclusion of "maternity care" as a covered service by addition of the description,
"services specific to routine pregnancy care, labor and delivery, and maternal
post-partum care."
Section 38.4(c)(7) has been amended to clarify that infertility treatment
or other reproductive services are covered if directly related to "a condition
meeting the parameters of the 'child with special health care needs' definition."
Section 38.4(d)(2) has been amended to clarify that requests for authorization
of certain services must be submitted prior to the date of service.
Section 38.4(d)(4) has been deleted as repetitive, and the subsequent subparagraph
has been renumbered.
At §38.4(d)(5), the reference to "ineligible "recipients" has been
changed to "ineligible persons," and application of the term "denied authorization
requests" to those "clients who do not qualify for the health care benefit
requested" has been clarified.
In addition to the CSHCN Services Program name change identified previously, §38.5,
relating to Rights and Responsibilities of Parents/Foster Parents/Guardian/Managing
Conservator or the Adult Client, §38.5(a)(4) has been amended to include
representatives of "the commission or" the department among those whom a parent/foster
parent/guardian/managing conservator or the adult client may refuse entry
into the home.
Section 38.6(a)(3) has been amended to clarify that providers must agree
to accept the CSHCN Services Program "allowed amount of" payment "(regardless
of payer)" as payment in full for services "provided to CSHCN Services Program
clients." The following sentence also has been added concerning payment for
services: "Providers may not request or accept payment from the client or
client's family for completing any CSHCN Services Program forms."
Section 38.6(a)(4) has been amended to identify more specifically all other
"public or private" benefits available to the client, including "but not limited
to" Medicaid or Medicaid waiver programs, CHIP, or Medicare, "and casualty
or liability coverage" prior to requesting payment from the CSHCN Services
Program, which is the payer of last resort.
Section 38.6(e)(1) has been amended by adding the following phrases to
clarify the scope of out-of-state coverage: 50 "or fewer" miles "from the
Texas state border" and "the CSHCN Services Program may cover services that
are within the scope of the program and provided by health care providers"
in New Mexico, Oklahoma, Arkansas, or Louisiana located "50 or fewer miles
from" the Texas state border. The last sentence of the current section has
been moved and redesignated as new subparagraph 38.6(e)(4).
At §38.6(e)(2), pertaining to travel "more than" 50 miles from the
Texas border, the manager of the department unit having responsibility for
oversight of the CSHCN Services Program, instead of the commissioner of health,
has been authorized to approve payment to out-of-state providers, and coverage
has been limited to "services that are within the scope of the CSHCN Services
Program and provided by health care providers located within the United States
and more than 50 miles from the Texas border." The current §38.6(e)(3)
has deleted and redesignated as new §38.6(e)(2)(B) stating, "the medical
literature indicates that the out-of-state treatment is accepted medical practice
and is anticipated to improve the client's quality of life," and subsequent
subparagraphs have been renumbered.
New §38.6(e)(3) states that the out-of-state limitations do not apply
to coverage or payment for selected products or devices including, but not
limited to, medical foods or hearing amplification devices, which either are
less costly and/or may only be available, from out-of-state sources.
Section 38.6(e)(5) has been restated to more clearly and comprehensively
describe the coverage for costs of transportation and associated meals and
lodging for a client and, if necessary, a responsible adult for travel to
and from the location of out-of-state services that meet program approval
parameters.
Changes to §38.7, relating to Ambulatory Surgical Care Facilities,
include only changes to the CSHCN Services Program previously identified.
Section 38.8, relating to Inpatient Rehabilitation Centers, includes only
name and minor grammatical changes identified previously, except for the amendment
to §38.8(b)(8) stating that a center serving pediatric clients shall
have at least one recreational area or playroom "that is bed and wheelchair
accessible."
Changes to §38.9 of this title (relating to Cleft/Craniofacial Center
Teams) include only changes to the name of the CSHCN Services Program and
minor grammatical changes.
In addition to name and other changes identified previously, §38.10
(relating to Payment of Services) has been amended by adding the following
sentence to the introductory paragraph of §38.10: "Providers may not
request or accept payment from the client or the client's family for completing
any CSHCN Services Program forms."
At §38.10(1)(B), the reference to ineligible "recipients" has been
changed to ineligible "persons," and the definition of "denied claims" has
been expanded by adding those "for clients who do not qualify for the health
care benefit claimed."
Section 38.10(2), concerning claims involving health insurance coverage,
CHIP or Medicaid, has been amended by stating that the CSHCN Services Program
may pay covered health care benefits during a CHIP or other health insurance
enrollment waiting period, and that during such periods, providers may file
claims directly with the CSHCN Services Program without evidence of denial
by the other insurer.
At §38.10(3)(C), "recipient" has been changed to "client."
Section 38.10(6) concerning CSHCN Services Program fee schedules, has been
amended by adding, simplifying, or correcting reimbursement or pricing methodologies
to reflect current practice. The amendments do not represent increases or
decreases in reimbursement to individual provider types. In many instances,
the phrase, "the lower of the billed amount or the maximum amount allowed
by the Texas Medicaid Program," replaces more detailed language that describes
the way(s) in which the Medicaid maximum reimbursement amounts were derived.
At new §38.10(6)(G), a pricing methodology has been added for medical
foods, which is the lower of the billed amount, the manufacturer's suggested
retail price, or the maximum charge allowed by the Texas Medicaid program
up to a maximum of $200 per client per month. Subsequent subparagraphs have
been re-alphabetized throughout the section.
At §38.10(6)(H), the methodology for expendable medical supplies has
been changed to the lower of the billed amount or the maximum amount allowed
by the Texas Medicaid program.
At §38.10(6)(I), current language has been deleted and new language
concerning the reimbursement methodology for durable medical equipment has
been added to improve accuracy and to reflect current program practice. The
penalty for delayed delivery has been deleted.
The reimbursement methodology for orthotics and prosthetics, formerly §38.10(6)(I)(iii),
has been redesignated as §38.10(6)(K), and subsequent subparagraphs have
been re-alphabetized.
At new §38.10(6)(M), the limitation for home health nursing services
has been clarified by adding "calendar" to describe the maximum allowable
number of hours per year.
At new §38.10(6)(O), the state reimbursement methodology for audiological
testing and amplification devices has been changed to the lower of the billed
amount or the amount allowed by the Program for Amplification for Children
of Texas (PACT).
At new §38.10(6)(U), "Centers for Medicare and Medicaid Services"
has been substituted for the abbreviation "CMS."
At new §38.10(6)(X), the reimbursement methodology for independent
laboratory services has been changed to the lower of the billed amount or
the maximum allowed by the Texas Medicaid program.
At new §38.10(6)(AA), the reimbursement methodology for vision services
has been amended to add an exception for high-powered lenses.
Section 38.11 of this title (relating to Contracts, Written Agreements,
and Donations) includes no amendments other than name and general grammatical
changes described previously.
Section 38.12 of this title (relating to Denial/Modification/Suspension/Termination
of Eligibility for Health Care Benefits and/or Health Care Benefits) includes
no amendments other than name or general grammatical changes described previously.
In addition to name and other general changes described previously, §38.13
of this title (relating to Right of Appeal) includes the following amendments.
At §38.13(a)(1)(A), citations to other sections have been corrected.
At §38.13(a)(1)(D), the reference to "the department" as the entity that
establishes by rule provider reimbursement and the program's budget alignment
methodologies has been updated to refer to "the commission." The terms "reimbursement"
or "reimbursement methodologies" have been included, replacing "fee schedules"
at §38.13(a)(1)(D) because "fee schedules" are more detailed, frequently
changing lists that evolve from stated reimbursement methodologies.
There are no additional amendments to §38.14 of this title (relating
to Development and Improvement of Standards and Services) includes no amendments
other than name or general grammatical changes described previously.
Section 38.16(c)(3) has been clarified to state that provision of "health
care benefits" may "or may not" include "coverage," rather than "payment,"
of outstanding bills in all cases.
At §38.16(c)(4), the process for providing limited health care benefits
and/or payment of outstanding bills for health care benefits to as many clients
with urgent need for health care benefits as possible who are on the waiting
list and remain on the waiting list has been amended by adding the requirement
that if family support services are included among limited health care benefits
provided for clients with urgent need for health care benefits who are on
the waiting list and remain on the waiting list, the coverage of family support
services must be limited according to the parameters set forth in §38.16(b)(2)(C)(i).
Those parameters require that family support services be provided to ongoing
clients only to continue services already being provided, and/or when the
specific services are required to prevent out-of-home placement of the client,
and/or when the provision of such services is cost effective for the program.
At §38.16(d), the phrase "as described in subsection (a)(2) of this
section" concerning funding analysis" has been deleted.
Section 38.16(d)(1)(A)(iii) and 38.16(d)(1)(A)(iv), concerning the order
in which groups of clients shall be taken off the waiting list, have been
deleted because they present administrative obstacles to implementation of §38.16(d)
as a whole, and deletion causes neither favorable or adverse consequences
for clients to whom the sections were applicable. Section 38.16(d)(1)(A)(v)
and 38.16(d)(1)(A)(vi) have been renumbered as §38.16(d)(1)(A)(iii) and §38.16(d)(1)(A)(iv).
Section 38.16(d)(1)(B)(i) and 38.16(d)(1)(B)(ii), concerning providing
health care benefits for clients taken off the waiting list, have been deleted
as superfluous because §38.16(d)(1)(B) also has been amended by addition
of the phrase, "as long as program unobligated funds are available," and the
rule addressed at §38.16(d)(1)(B)(ii) repeats §38.16(c)(3)(B).
Section 38.16(d)(1)(C) has been amended to authorize payment of limited
health care benefits for "clients who are on the waiting list and remain on
the waiting list;" payment of outstanding bills for health care benefits for
clients who are on the waiting list and remain on the waiting list; and/or
"payment of outstanding bills for health care benefits for clients who have
been taken off the waiting list." Consistent with changes to §38.16(c)(4),
coverage of family support services must be limited according to the parameters
set forth in §38.16(b)(2)(C)(i), if family support services are included
among limited health care benefits. The requirement that clients on the waiting
list be served in the same order as in paragraph (1) of the subsection and
the limitation that only clients on the waiting list may be served by this
provision have been deleted, and the reference to paragraphs (1) - (2) has
been corrected.
Section 38.16(d)(1) has been amended to enable the program to expend unobligated
funds after or while removing clients from the waiting list and providing
them with health care benefits; only when projected unobligated funds are
insufficient to take clients off the waiting list and also maintain continuous
program health care benefits or when projected unobligated funds may lapse
if not expended by the end of the fiscal year; only as long as program unobligated
funds are available; and only if the outstanding bills for health care benefits
are for dates of service that are within the time period that program unobligated
funds are available and provided that the client is eligible for health care
benefits at the time of the dates of service. The new language improves administrative
efficiency and permits needed flexibility to expend unobligated funds near
the end of a budget term.
At §38.16(d)(2)(B), the parenthetical phrase describing health care
benefits has been amended by clarifying that "coverage," rather than "payment,"
of outstanding bills for health care benefits may "or may not" be included.
"Or" at the end of §38.16(d)(2)(B) has been deleted as grammatically
unnecessary.
Section 38.16(d)(2)(C) has been amended to be consistent with §38.16(d)(1)(C),
as amended, and to provide limited health care benefits to clients "identified
in subsection (d)(2)(A)(i) and (ii) who are on the waiting list and remain
on the waiting list;" and/or "payment of outstanding bills for health care
benefits for clients who have been taken off the waiting list." Section 38.16(d)(2)(C)
has also been amended by the addition of a sentence providing that the coverage
of family support services must be limited according to the parameters set
forth in §38.16(b)(2)(C)(i) if family support services are included among
limited health care benefits.
Consistent with the requirements of §38.16(d)(1)(C), as amended, §38.16(d)(2)(C)
has been amended by deletion of the requirement that clients on the waiting
list be served in the same order as in paragraph (2)(A) of the subsection
and the limitation that only clients on the waiting list may be served. These
amendments make §38.16(d)(2) consistent with other sections, as amended,
and increase the efficiency and flexibility with which the program may expend
unobligated funds resulting from program cost savings near the end of a budget
term.
FISCAL NOTE
Sam B. Cooper, III, MSW, LMSW, Unit Manager, Purchased Health Services
Unit, Specialized Health Services Section, has determined that for each year
of the first five-year period that the sections will be in effect, there will
be no fiscal implications to state or local governments as a result of enforcing
and administering the sections as proposed.
The department allocates legislative appropriations for the CSHCN program
according to the following general budgetary categories: (1) health care benefits
services for CSHCN who are uninsured or underinsured; (2) essential public
health services including, but not limited to, case management, quality assurance,
needs assessment, education/training, and information and referral for children
with special health care needs and their families; and (3) program administration.
CSHCN budgeting decisions are guided by the following principles: the CSHCN
Program is not an entitlement program; the cost of services required to serve
the needs of all the clients eligible to receive them is expected to exceed
anticipated funding; and the program establishes and manages waiting lists
according to the procedures to address CSHCN Services Program budget alignment
as specified in rule.
SMALL BUSINESS AND MICRO-BUSINESS IMPACT ANALYSIS
Mr. Cooper has also determined that there will be no effect on small businesses
or micro-businesses required to comply with the sections as proposed, because
neither small businesses nor micro-businesses that are providers of CSHCN
services will be required to alter their business practices in order to comply
with the sections. There are no anticipated economic costs to persons who
are required to comply with the sections as proposed. There is no anticipated
negative impact on local employment.
PUBLIC BENEFIT
Mr. Cooper has determined that for each year of the first five years the
sections are in effect, the public will benefit from adoption of the sections.
The public benefit anticipated as a result of enforcing or administering the
sections is improved accuracy and consistency in the rules, and more accurate
interpretation of their intent. In addition, amendments to the rules will
allow the program to function more efficiently and effectively.
REGULATORY ANALYSIS
The department has determined that this proposal is not a "major environmental
rule" as defined by Government Code, §2001.0225. "Major environmental
rule" is defined to mean a rule the specific intent of which is to protect
the environment or reduce risk to human health from environmental exposure
and that may adversely affect, in a material way, the economy, a sector of
the economy, productivity, competition, jobs, the environment or the public
health and safety of a state or a sector of the state. This proposal is not
specifically intended to protect the environment or reduce risks to human
health from environmental exposure.
TAKINGS IMPACT ASSESSMENT
The department has determined that the proposed amendments do not restrict
or limit an owner's right to his or her property that would otherwise exist
in the absence of government action and, therefore, do not constitute a taking
under Government Code, §2007.043.
PUBLIC COMMENT
Comments on the proposal may be submitted by mail to Kathy Griffis-Bailey,
MS, Purchased Health Services Unit MC1938, Department of State Health Services
G31000, 1100 West 49th Street, Austin, Texas 78756, by telephone at (512)
458-7111, extension 3069, or by email to kathy.griffisbailey@dshs.state.tx.us.
Comments will be accepted for 30 days following publication of the proposal
in the
Texas Register
.
PUBLIC HEARING
A public hearing to receive comments on the proposal is scheduled for January
17, 2006, at 9:00 a.m., at the Department of State Health Services, Room G-107,
1100 West 49th Street, Austin, Texas 78756. Persons who require disability-related
accommodations or a language interpreter should contact Kathy Griffis-Bailey
at 512/458-7111 at least three working days prior to the scheduled hearing
time.
LEGAL CERTIFICATION
The Department of State Health Services General Counsel, Cathy Campbell,
certifies that the proposal has been reviewed by legal counsel and found to
be within the state agencies' authority to adopt.
STATUTORY AUTHORITY
The Health and Safety Code, §§35.003, 35.004, 35.0041, 35.005,
35.006, 35.007, 35.009, and 12.001, authorize the executive commissioner of
the Health and Human Services Commission to adopt rules for the performance
of every duty imposed by law on the department and the commissioner of health.
The Government Code, §531.0055(e), and the Health and Safety Code, §1001.075,
also authorize the executive commissioner of the Health and Human Services
Commission to adopt rules and policies necessary for the operation and provision
of health and human services by the department and for the administration
of Chapter 1001, Health and Safety Code.
The proposed amendments affect Health and Safety Code, Chapter 35.
§38.1.Purpose and Common Name.
(a)
Purpose. The purpose of this chapter is to implement the
Services Program for Children with Special Health Care Needs (CSHCN)
that
[
(1) - (7)
(No change.)
(b)
(No change.)
§38.2.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
(1) - (2)
(No change.)
[
(3)
[
[
(4)
[
(A)
is physically present within the geographic boundaries
of the state;
(B)
has an intent to remain within the state;
(C)
maintains an abode within the state (i.e., house or apartment,
not merely a post office box);
(D)
has not come to Texas from another country for the purpose
of obtaining medical care, with the intent to return to the person's native
country;
(E)
does not claim residency in any other state or country;
and
(i)
is a minor child residing in Texas whose parent(s), managing
conservator, guardian of the child's person, or caretaker (with whom the child
consistently resides and plans to continue to reside) is a bona fide resident;
(ii)
is a person residing in Texas who is the legally dependent
spouse of a bona fide resident; or
(iii)
is an adult residing in Texas, including an adult whose
parent(s), managing conservator, guardian of the adult's person, or caretaker
(with whom the adult consistently resides and plans to continue to reside)
is a bona fide resident or who is his/her own guardian.
(5)
[
(A)
planning, accessing, and coordinating needed health care
and related services for children with special health care needs and their
families. Case management services are performed in partnership with the child,
the child's family, providers, and others involved in the care of the child
and are performed as needed to help improve the well-being of the child and
the child's family; and
(B)
counseling for the child and the child's family about measures
to prevent the transmission of AIDS or HIV and the availability in the geographic
area of any appropriate health care services, such as mental health care,
psychological health care, and social and support services.
(6)
[
(A)
is younger than 21 years of age and who has a chronic physical
or developmental condition; or
(B)
has cystic fibrosis, regardless of the person's age; and
(C)
may have a behavioral or emotional condition that accompanies
the person's physical or developmental condition. The term does not include
a person who has behavioral or emotional condition without having an accompanying
physical or developmental condition.
(7)
[
(8)
[
(9)
[
(10)
[
(11)
[
(A)
New client:
(i)
a person who has applied to the program for the first time
and who is determined to be eligible for program services; or
(ii)
a person who has re-applied to the program (after a lapse
in eligibility) and who is determined to be eligible for program services.
(B)
Ongoing client--A client who currently is not on the program's
waiting list.
(C)
Waiting list client--A client who currently is on the program's
waiting list.
(12)
Commission--The Texas Health
and Human Services Commission.
(13)
[
(14)
[
(15)
[
(16)
[
(17)
[
(18)
[
(19)
[
(20)
[
(21)
[
(22)
[
(A)
The effective date of eligibility for newborns who are
not born prematurely will be the date of birth. Newborn means a child 30 days
old or younger.
(B)
The effective date of eligibility following traumatic injury
will be the day after the acute phase of treatment ends, but no earlier than
15 days prior to the date of receipt of the application.
(C)
The effective date of eligibility for an applicant that
is born prematurely will be the day after the applicant has been out of the
hospital for 14 consecutive days, but no earlier than 15 days prior to the
date of receipt of the application.
(D)
The effective date of eligibility for applicants with spenddown
is the day after the earliest DOS on which the cumulative bills are sufficient
to meet the spenddown amount, but no earlier than 15 days prior to the date
of receipt of the application. Only medical bills having a DOS within 12 months
prior to
[
(E)
Excluding applications for clients who are known to be
ineligible for Medicaid and/or the CHIP due to age, citizenship status or
insurance coverage, all applications must include a determination of eligibility
from Medicaid and/or the CHIP. If the CSHCN
Services Program
application
is received without a Medicaid determination, a CHIP determination, or other
data/documents needed to process the application, it will be considered incomplete.
The applicant will be notified that the application is incomplete and given
60 days to submit the Medicaid determination, CHIP denial or enrollment, or
other missing data/documents to
the
CSHCN
Services Program
. If the application is made complete within the 60-day time limit,
the client's eligibility effective date will be established as 15 days prior
to the date the CSHCN
Services Program
application was first received.
If the application is made complete more than 60 days after initial receipt,
the eligibility effective date will be established as 15 days prior to the
date the application was made complete.
(23)
[
(A)
placing the person's health in serious jeopardy;
(B)
serious impairment to bodily functions; or
(C)
serious dysfunction of any bodily organ or part.
(24)
[
(A)
an inability to build or maintain satisfactory age-appropriate
interpersonal relationships with peers or adults;
(B)
dangerously aggressive, self-destructive, severely withdrawn,
or noncommunicative behaviors;
(C)
a pervasive mood of unhappiness or depression; or
(D)
evidence of excessive anxiety or fears.
(25)
[
(26)
[
(A)
the applicant;
(B)
those related to the applicant as a parent, step-parent
or spouse who have a legal responsibility to support the applicant or guardians/managing
conservators who have a duty to provide food, shelter, education, and medical
care for the applicant;
(C)
children of the applicant; and
(D)
children of a parent, step-parent or spouse.
(27)
[
(28)
[
(29)
[
(30)
[
(31)
[
(A)
mother;
(B)
father;
(C)
stepparent;
(D)
spouse;
(E)
foster parent(s), managing conservator, or guardian;
(F)
grandparent(s);
(G)
sibling(s);
(H)
stepbrother(s); or
(I)
stepsister(s).
(32)
[
(33)
[
[
(34)
[
(A)
an insurance policy, group health plan, health maintenance
organization, or prepaid medical or dental care plan;
(B)
home, auto, or other liability
insurance;
(C)
[
(D)
[
(E)
[
(F)
[
(G)
[
(H)
[
(35)
[
(36)
[
(37)
[
(38)
[
(39)
[
(40)
[
(41)
[
(A)
facility care, medical and dental care, and occupational,
speech, and physical therapies;
(B)
the provision of medications, braces, orthotic and prosthetic
devices, durable medical equipment, and other medical supplies; and
(C)
other services specified in this chapter.
(42)
[
(43)
[
(44)
[
(45)
[
(46)
[
(47)
[
(48)
[
(49)
[
(50)
[
(51)
[
(52)
[
(53)
[
§38.3.Eligibility for [
(a)
Eligibility for health care benefits. In order to be determined
eligible for CSHCN
Services Program
[
(1)
Medical criteria.
At least annually, a
[
(2)
Financial criteria. Financial criteria are determined
every six months, or as directed by statutory requirements. Financial criteria
[
(A)
The income level for eligibility is 200% of the federal
poverty level. If the family income exceeds this level, and the applicant's
family can document its responsibility for household medical bills incurred
within 12 months
prior to
[
(B)
Applications to Medicaid and the Supplemental Security
Income (SSI) programs.
(i)
If actual or projected CSHCN
Services Program
[
(ii)
The CSHCN
Services Program
[
(3)
Health insurance.
(A)
All health insurance coverage insuring the applicant and/or
family must be listed on the application. If insurance coverage was effective
prior to CSHCN
Services Program
[
(i) - (iv)
(No change.)
(B)
If the applicant/client does not have health insurance
at the time of application or eligibility renewal, but coverage may be available,
including coverage under
Medicaid or
CHIP, the applicant/client
that is not ineligible for such coverage by reason of age, citizenship, or
residency status must apply for coverage and receive an eligibility determination
within 60 days of the date of notification. With verification of an application
to
Medicaid, CHIP, or
an available health insurance plan, the program
may extend this deadline [
(C)
The CSHCN
Services Program
[
(D)
Before canceling, terminating, or discontinuing existing
health insurance, or electing not to enroll a client in available health insurance,
including canceling, terminating, discontinuing, or not enrolling in CHIP,
the parent/guardian/managing conservator must notify the CSHCN
Services
Program
[
(4) - (5)
(No change.)
(6)
Application.
(A)
Applications are available to anyone seeking assistance
from the CSHCN
Services Program
[
(B)
A person is considered to be an applicant from the time
that the CSHCN
Services Program
[
(i) - (iii)
(No change.)
(C)
The denial of any application submitted to the CSHCN
Services Program
[
(D)
Any person has the right to reapply for CSHCN
Services
Program
[
(7)
Verification of information.
(A)
The CSHCN
Services Program
[
(B)
The CSHCN
Services Program
[
(C)
Those applicants/clients financially eligible for CHIP,
Medicaid, or other programs with
eligibility
[
(8)
Determination of continuing eligibility for health care
benefits.
Financial
[
(b)
Eligibility for case management services. The CSHCN
Services Program
[
§38.4.Covered Services.
(a)
Introduction. The CSHCN
Services Program
[
(b)
Types of service.
(1)
Early identification. The CSHCN
Services Program
[
(A)
CSHCN
Services Program
[
(B) - (E)
(No change.)
(2)
Diagnosis and evaluation services. May be covered for the
purpose of determining whether a CSHCN
Services Program
[
(3)
Rehabilitation services. Rehabilitation services means
a process of physical restoration, improvement, or maintenance of a body function
destroyed or impaired by congenital defect, disease, or injury which includes
the following acute and chronic/rehabilitative services: facility care, medical
and dental care, occupational, speech, and physical therapies, the provision
of medications, braces, orthotic and prosthetic devices, durable medical equipment,
other medical supplies, and other services specified in this chapter. To be
eligible for CSHCN
Services Program
[
(A)
Medical assessment and treatment. Medical assessment and
treatment services, including medically necessary laboratory and radiology
studies, must be provided by physicians and other practitioners licensed by
the State of Texas, enrolled as participating providers in the CSHCN
Services Program
[
(B)
Outpatient mental health services. Outpatient mental health
services are limited to no more than 30 encounters
in a calendar year
by all professionals licensed to provide mental/behavioral health services,
including psychiatrists, psychologists, licensed
clinical social workers
(LCSW)
[
(C)
Preventive and therapeutic dental services (including oral/maxillofacial
surgery). Preventive and therapeutic dental services must be provided by licensed
dentists enrolled to participate in the CSHCN
Services Program
[
(D)
Podiatric services. Podiatric services must be provided
by licensed podiatrists enrolled to participate in the CSHCN
Services
Program
[
(E)
Treatment in CSHCN
Services Program
[
(i)
Inpatient hospital care and inpatient psychiatric care.
(I)
(No change.)
(II)
Inpatient psychiatric care. Coverage is limited to inpatient
assessment and crisis stabilization and is to be followed by referral to
an
[
(ii)
Inpatient rehabilitation care. Medically necessary inpatient
rehabilitation care is limited to an initial admission not to exceed 30 days,
based on the functional status and potential of the client as certified by
a physician participating in the CSHCN
Services Program
[
(iii)
Ambulatory surgical care. Ambulatory surgical care is
limited to the medically necessary treatment of a client and may be performed
only in CSHCN
Services Program
[
(iv)
Emergency care. Care including, but not limited to hospital
emergency departments, ancillary, and physician services, is limited to medical
conditions manifested by acute symptoms of sufficient severity (including
severe pain) such that a prudent person with average knowledge of health and
medicine could reasonably expect that the absence of immediate medical care
could result in placing the client's health in serious jeopardy, serious impairment
to bodily functions, or serious dysfunction of any bodily organ or part. If
a client is admitted to a non-participating CSHCN
Services Program
[
(v)
Care for renal disease. Renal dialysis is limited to the
treatment of acute renal disease or chronic (end stage) renal disease through
a renal dialysis facility and includes, but is not limited to dialysis, laboratory
services, drugs and supplies, declotting shunts, on-site physician services,
and appropriate access surgery. Renal transplants may be covered in approved
renal transplant centers if the projected cost of the transplant and follow-up
care is less than that of continuing renal dialysis. Renal transplants must
be prior authorized.
(F) - (G)
(No change.)
(H)
Nutrition services and nutritional products, excluding
hyperalimentation/total parenteral nutrition (TPN).
(i)
(No change.)
(ii)
Nutritional products. Nutritional products, including
over-the-counter products, are limited to those covered by the CSHCN
Services Program
[
(I)
(No change.)
(J)
Medical foods. Coverage for
medical foods is limited to the treatment of inborn metabolic disorders. Treatment
for any other condition with medical foods requires documentation of medical
necessity and prior authorization. Medical foods are approved products listed
in enrolled providers' catalogs and are lacking in the compounds that cause
complications of a covered metabolic disorder.
(K)
[
(L)
[
(M)
[
(i)
medically necessary eye examinations with refraction for
diagnoses of refractive error, aphakia, diseases of the eye, or eye surgery;
(ii)
one eye examination with refraction for the purpose of
obtaining eyewear during
a calendar
[
(iii)
one pair of non-prosthetic eye wear per
calendar
year prescribed by a practitioner licensed to do so.
(N)
[
(O)
[
(P)
[
(Q)
[
(R)
[
(S)
[
(4)
Care management.
(A)
Medical home. Each CSHCN
Services Program
[
(i)
Comprehensive coordinated health care of infants, children,
and adolescents should encompass the following services:
(I) - (V)
(No change.)
(VI)
maintenance of a central record and
database
[
(ii)
The CSHCN
Services Program
[
(B)
(No change.)
(5)
Family support services. Family support services include
disability-related support, resources, or other assistance and may be provided
to the family of a client with special health care needs.
(A)
Eligibility. A client is eligible to receive family support
services if:
[
(i)
[
(ii)
[
(B)
Processing and evaluation of requests.
(i)
Families
of clients
indicate their need for
family support services [
(ii)
(No change.)
(iii)
All requests for family support services must be prior
authorized (approved by the CSHCN
Services Program
[
(iv)
While there is a waiting list for health care benefits,
limitations in reimbursement and/or prior authorization may be instituted
as provided in §38.16 of this title.
(v) - (ix)
(No change.)
(C)
Service plan and cost allowances.
(i)
In order to obtain prior authorization for family support
services, the case manager and the client/family must develop a
family
assessment and service
[
(ii)
The CSHCN
Services Program
[
(I)
(No change.)
(II)
assistance of up to $3,600 per
calendar
year
per eligible client to purchase other allowable services. This limit may increase
to no more than $7,200 for the purchase of vehicle lifts and modifications;
(iii)
Service plan cost allowances may be prorated for plans
that cover less than one
calendar
year.
(iv)
Disbursement of assistance:
(I)
(No change.)
(II)
may be made to the family or to the vendor
enrolled
as a CSHCN Services Program provider
; and
(III)
(No change.)
(v)
(No change.)
(vi)
The annual
family assessment and
service plan
may be amended at any time, but will be reevaluated by the client/family and
case manager at least annually to coincide with the client's reapplication
for the CSHCN
Services Program
[
(D)
Allowable services.
(i)
Family support services for CSHCN
Services Program
clients and their families include those allowable services and items
that:
(I) - (III)
(No change.)
(ii)
(No change.)
(iii)
Allowable services include:
(I) - (IV)
(No change.)
(V)
vehicle lifts and modifications consistent with those available
through the
Department of Assistive and Rehabilitative Services (DARS)
[
(VI) - (VII)
(No change.)
(E)
Unallowable services. Family support funds may not be used
to provide those services that do not relate to the client's disability and
do not directly support the client's living in his/her natural home and participating
in family life and integrated/inclusive community activities. Examples of
unallowable services include, but are not limited to:
(i) - (viii)
(No change.)
(ix)
costs for allowable services incurred before the
requested family support service is prior authorized
[
(x)
(No charge.)
(xi)
medical benefit items or services paid for or reimbursed
by private insurance, Medicaid, Medicare, CHIP, the CSHCN
Services Program
[
(xii)
services, equipment, or supplies that have been denied
by Medicaid, CHIP, or the CSHCN
Services Program
[
(xiii) - (xx)
(No change.)
(F)
Reduction/termination of services. Reasons for terminating
or reducing family support services may include, but are not limited to:
(i)
the client no longer meets the eligibility criteria for
the CSHCN
Services Program
[
(ii)
(No change.)
(iii)
While there is a waiting list for health care benefits,
limitations in reimbursement and/or prior authorization may be instituted
as provided in §38.16 of this title;
(iv) - (viii)
(No change.)
(ix)
the family knowingly does not comply with the
family
assessment and service
[
(6)
Other types of services. The following services also are
available through the CSHCN
Services Program
[
(A)
(No change.)
(B)
Transportation. The CSHCN
Services Program
[
(C)
Meals and lodging. The CSHCN
Services Program
[
(D)
Transportation of deceased. The CSHCN
Services Program
[
(i)
transportation cost for the remains of a client who expires
in a CSHCN
Services Program
participating facility while receiving
CSHCN
Services Program health care benefits
[
(ii) - (iv)
(No change.)
(E)
Payment of insurance premiums, coinsurance, co-payments,
and/or deductibles. The CSHCN
Services Program
[
(c)
Services not covered. Services which are not covered by
the CSHCN
Services Program
[
(1) - (4)
(No change.)
(5)
pregnancy prevention, except when medically necessary for
the specific treatment of a [
(6)
maternity care
services specific to routine pregnancy
care, labor and delivery, and maternal post-partum care
; and
(7)
infertility treatment or other reproductive services, unless
directly related to a [
(d)
Service authorization. The CSHCN
Services Program
[
(1)
Provider's responsibility. A CSHCN
Services Program
provider must request services in specific terms on department-prepared
forms so that an authorization may be issued and sufficient monies encumbered
to cover the cost of the service. If a service is authorized, payment may
be made to the provider as long as the service is not covered by a third party
resource, and all billing requirements are met. Program authorization should
not be considered an absolute guarantee of payment. Once a service is delivered
and if the service requires authorization for payment, the authorization request
for that service must be submitted within 90 days of the date of service.
(2)
Required prior authorization for selected services. At
the CSHCN
Services Program's
[
(3)
(No change.)
[
(4)
[
(e)
Pilot projects. The CSHCN
Services Program
[
§38.5.Rights and Responsibilities of Parents/Foster Parents/Guardian/Managing Conservator or the Adult Client.
(a)
Rights. The parent/foster parent/guardian/managing conservator
or the adult client shall have the right to:
(1)
(No change.)
(2)
choose providers subject to CSHCN
Services Program
[
(3)
(No change.)
(4)
refuse entry into the home to any employee, agent, or representative
of
the commission or
the department;
(5)
appeal CSHCN
Services Program
[
(6)
(No change.)
(b)
Responsibilities. The parent/foster parent/guardian/managing
conservator or adult client shall have the responsibility to:
(1)
provide accurate medical information to providers and notify
all providers of CSHCN
Services Program
[
(2)
provide the CSHCN
Services Program
[
(3)
receive and utilize services as close to the client's home
community as possible, unless CSHCN
Services Program
[
(4)
reimburse the CSHCN
Services Program
[
(5)
consult with the provider regarding authorization of service
from the CSHCN
Services Program
[
(6)
utilize services provided by the CSHCN
Services Program
[
(7)
(No change.)
(8)
notify the CSHCN
Services Program
[
(9)
bear a portion of the expense of medical or dental care,
if deemed financially able by the CSHCN
Services Program
[
(c)
(No change.)
§38.6.Providers.
(a)
General requirements for participation. The Children with
Special Health Care Needs Services (CSHCN) Act, Health and Safety Code, §35.004,
authorizes the
approval of
[
(1)
Providers seeking approval for CSHCN
Services Program
[
(2)
All approved CSHCN
Services Program
[
(3)
All CSHCN
Service Program
[
(4)
The CSHCN
Services Program
[
(5)
Overpayments made on behalf of clients to CSHCN
Services
Program
[
(6)
All
CSHCN Services Program
providers of [
(7)
(No change.)
(8)
All providers shall be responsible for the actions of members
of their staffs who provide CSHCN
Services Program
[
(9)
Any provider may withdraw from CSHCN
Services Program
[
(b)
Denial, modification, suspension, and termination of provider
approval.
(1)
The CSHCN
Services Program
[
(A) - (B)
(No change.)
(C)
not adhering to the provider agreement signed at the time
of application or renewal for CSHCN
Services Program
[
(D) - (E)
(No change.)
(2)
The CSHCN
Services Program
[
(3)
Prior to taking an action to deny, modify, suspend, or
terminate the approval of a provider, the CSHCN
Services Program
[
(c)
Provider types. Approved providers include, but are not
limited to:
(1) - (3)
(No change.)
(4)
mental/behavioral health professionals, including psychiatrists,
licensed psychologists, licensed
clinical social workers
[
(5) - (24)
(No change.)
(d)
Requirements for specialty centers.
(1)
The CSHCN
Services Program
[
(2)
Other specialty center standards. The CSHCN
Services
Program
[
(e)
Out-of-state coverage.
(1)
Fifty or fewer
[
(2)
More than
[
(A)
(No change.)
(B)
the medical literature indicates
that the out-of-state treatment is accepted medical practice and is anticipated
to improve the client's quality of life;
(C)
[
(D)
[
(3)
The limitations of this paragraph
do not apply to coverage for or payment to CSHCN Services Program providers
of selected products or devices including, but not limited to, medical foods
or hearing amplification devices, which either are always less costly and/or
are only available, from out-of-state sources.
(4)
For CSHCN Services Program
reimbursement, all program policies and procedures will apply, including the
requirement that all providers be CSHCN Services Program participating providers,
as defined by this section.
[
(5)
[
§38.7.Ambulatory Surgical Care Facilities.
(a)
Ambulatory surgery services may be utilized by the CSHCN
Services Program
[
(1) - (3)
(No change.)
(4)
Staff requirements.
(A)
Surgical staff participating in the CSHCN
Services
Program
[
(B)
An anesthesiologist or certified registered nurse anesthetist
participating in the CSHCN
Services Program
[
(C)
(No change.)
(5)
(No change.)
(6)
Client transfer. The facility must have client transfer
agreements with CSHCN
Services Program
[
(b)
ASC facilities seeking approval for CSHCN
Services
Program
[
(c)
CSHCN
Services Program
reimbursement for care
at freestanding ASC facilities shall be limited to:
(1) - (2)
(No change.)
(d)
Applications for approval for CSHCN
Services Program
[
(1)
Applications will be reviewed by the CSHCN
Services
Program
[
(A) - (B)
(No change.)
(C)
copies of documents have been provided verifying the facility's
state licensure, Medicare certification, and client transfer agreements with
CSHCN
Services Program
[
(2)
The CSHCN
Services Program
[
(3)
(No change.)
(e)
Those providers that have not received any CSHCN
Services Program
[
(1)
Updated information may include, but is not limited to,
the following:
(A)
(No change.)
(B)
current listing of CSHCN
Services Program
[
(C) - (D)
(No change.)
(2)
The provider will be given a current copy of CSHCN
Services Program
[
§38.8.Inpatient Rehabilitation Centers.
(a)
Introduction. The CSHCN
Services Program
[
(b)
Criteria. The criteria for inpatient rehabilitation center
approval include the following.
(1) - (2)
(No change.)
(3)
The center shall agree to allow on-site visits and/or audit
privileges to the CSHCN
Services Program
[
(4)
A physician who is a CSHCN
Services Program
[
(5)
A center which serves pediatric clients (clients less than
14 years old), shall have a designated CSHCN
Services Program
[
(6) - (7)
(No change.)
(8)
A center
that
[
(9)
A center
that
[
(10)
(No change.)
§38.9.Cleft/Craniofacial Center Teams.
To assure that clients with craniofacial anomalies, including cleft
lip and/or cleft palate, receive quality, comprehensive services, cleft/craniofacial
(C/C) teams requesting approval from the CSHCN
Services Program
[
(1)
Approval process. All C/C teams and affiliated providers
must submit a completed CSHCN
Services Program
C/C provider application
packet as specified by the CSHCN
Services Program
[
(2)
C/C team administrator responsibility.
(A)
The C/C team shall clearly identify an administrator who
is responsible for coordinating and maintaining all records associated with
C/C team activities and assuring that the C/C team abides by the CSHCN
Services Program
[
(B)
(No change.)
(3) - (4)
(No change.)
(5)
Affiliated providers.
(A)
To facilitate statewide coverage, providers may be approved
as C/C team members when affiliated with an approved C/C team. Affiliated
providers must meet the CSHCN
Services Program
[
(B)
(No change.)
(C)
As part of its application, an affiliated provider must
specify the comprehensive C/C team(s) with which it is linked. A letter of
agreement between the affiliated provider and the C/C team
that
[
§38.10.Payment of Services.
The CSHCN
Services Program
[
(1)
Payment or denial of claims. All payments made on behalf
of a client will be for claims received by the CSHCN
Services Program
[
(A)
Claims will be paid, if submitted on
claim forms approved
by the CSHCN Services Program
[
(B)
Denied claims are claims which are incomplete, submitted
on the wrong form, lack necessary documentation, contain inaccurate information,
fail to meet the filing deadline, [
(i)
Corrected claims must be submitted on
claim forms
approved by the CSHCN Services Program,
[
(ii)
(No change.)
(2)
Claims involving health insurance coverage, CHIP or Medicaid.
Any health insurance that provides coverage to the client must be utilized
before the CSHCN
Services Program
[
(A)
Health insurance denial or nonresponse. If a claim is denied
by health insurance, the provider may bill the CSHCN
Services Program
[
(B)
Explanation of benefits (EOB). The health insurance EOB
must accompany any claim sent to the CSHCN
Services Program
[
(C)
Late filing. Claims denied by health insurance on the basis
of late filing will not be considered for payment by the CSHCN
Services
Program
[
(D)
Deductibles and coinsurance. If the client has other third
party coverage, the CSHCN
Services Program
[
(3)
Exceptions to the claim receipt or correction and resubmission
deadlines. The
manager of the department unit having responsibility for
oversight of the CSHCN Services Program
[
(A) - (B)
(No change.)
(C)
delay or error or constraint imposed by the program in
the eligibility determination of a
client
[
(D)
(No change.)
(4)
(No change.)
(5)
Other exceptions to claims receipt or correction and resubmission
deadlines. The
manager of the department unit having responsibility for
oversight of the CSHCN Services Program
[
(A) - (D)
(No change.)
(6)
CSHCN
Services Program
[
(A) - (D)
(No change.)
(E)
nutritional products--the lower of the billed amount or
the Average Wholesale Price (AWP) per unit according to the prices in the
current edition of the Drug Topics Red Book, published by Medical Economics
Company, Inc., Montvale, New Jersey 07645-1742, on file with the CSHCN
Services Program
[
(F)
(No change.)
(G)
medical foods--the lower of
the billed amount, the manufacturer's suggested retail price (MSRP), or the
maximum charge allowed by the Texas Medicaid Program up to a maximum of $200
per client per month;
(H)
[
(i)
medications covered by Medicaid when billed by pharmacies--the
same drug costs and dispensing fees allowed by the Texas Medicaid Vendor Drug
Program;
(ii)
medications not covered by Medicaid when billed by pharmacies--the
lower of the billed amount or the drug cost available through the database
used by the Texas Medicaid Vendor Drug Program plus the same dispensing fees
allowed by the Texas Medicaid Vendor Drug Program;
(iii)
medications covered by Medicaid when billed by hospitals--(the
lower of the billed amount or the drug cost available through the database
used by the Texas Medicaid Vendor Drug Program plus $2.28)/0.970; and
(iv)
hemophilia blood factor products--the lower of the billed
price or the United States Public Health Service (USPHS) price in effect on
the date of service plus a dispensing fee of $.04 per unit of factor;
(I)
[
(J)
durable medical equipment--provided
by enrolled home health agencies and durable medical equipment providers,
the lower of the billed amount or the maximum allowable fee for durable medical
equipment established by the Texas Medicaid Program. If the Texas Medicaid
program has not established a maximum fee, then reimbursement will be the
least of the following:
(i)
the billed amount; or
(ii)
the Medicare fee schedule as defined in 25
Texas Administrative Code, §29.301; or
(iii)
the Manufacturer's Suggested Retail Price
(MSRP) minus a discount as established by the Texas Medicaid Program; or if
no MSRP exists, the incurred cost to the dealer plus a percentage as determined
by the Texas Medicaid Program;
[
[
[
[
[
[
[
[
(K)
orthotics and prosthetics--the
lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(L)
[
(M)
[
(i)
services provided by a registered nurse--the lower of the
billed amount or $36 per hour;
(ii)
services provided by a licensed vocational nurse--the
lower of the billed amount or $28 per hour; and
(iii)
services provided by a home health aide or home health
medication aide (including those legally delegated by a supervising registered
nurse)--the lower of the billed amount or $12 per hour;
(N)
[
(i)
services provided by therapists other than physicians--the
lower of the billed amount or the amount allowed by the Texas Medicaid Program;
and
(ii)
services provided by physicians--the lower of the billed
amount or the amount allowed by the Texas Medicaid Program;
(O)
audiological testing and amplification
devices--the lower of the billed amount or the amount allowed by the Program
for Amplification for Children of Texas (PACT);
[
[
[
(P)
[
(Q)
[
(R)
[
(S)
[
(T)
[
(i)
renal dialysis services--the lower of the billed amount
or the amount allowed by the Texas Medicaid Program; and/or
(ii)
renal transplant services--renal transplants may be covered
if the projected cost for the transplant and follow-up care is less than that
of continuing renal dialysis. Negotiated coverage and cost are based on prior
authorization documentation of cost effectiveness;
(U)
[
(V)
[
(W)
[
(X)
[
[
[
[
(Y)
[
(Z)
[
(AA)
[
(7)
Required documentation. The CSHCN
Services Program
[
(8)
Overpayments.
(A)
Overpayments are payments made by the CSHCN
Services
Program
[
(i) - (iii)
(No change.)
(iv)
services disallowed by the CSHCN
Services Program
[
(v)
(No change.)
(B)
(No change.)
§38.11.Contracts, Written Agreements, and Donations.
The CSHCN
Services Program
[
(1)
The CSHCN
Services Program
[
(2)
The CSHCN
Services Program
[
(3)
With [
§38.12.Denial/Modification/Suspension/Termination of Eligibility for Health Care Benefits and/or Health Care Benefits.
(a)
Any person applying for or receiving health care benefits
from the CSHCN
Services Program
[
(1) - (7)
(No change.)
(8)
utilization review indicates inappropriate use of CSHCN
Services Program
[
(9)
CSHCN
Services Program
[
(10)
the client is placed on a waiting list for
CSHCN
Services Program
[
(b)
The CSHCN
Services Program
[
§38.13.Right of Appeal.
(a)
Appeal procedures for families who request authorization
of family support services and/or providers.
(1)
Administrative review.
(A)
If the CSHCN
Services Program
[
(B)
If the CSHCN
Services Program
[
(C)
If the family or provider does not respond in writing within
the 30-day period, the family or provider is presumed to have waived the administrative
review as well as access to a fair hearing, and the CSHCN
Services Program's
[
(D)
The
commission
[
(2)
Fair hearing. If the family and/or provider is dissatisfied
with the CSHCN
Services Program's
[
(b)
Appeal procedures for applicants/clients.
(1)
Administrative review.
(A)
If the CSHCN
Services Program
[
(B)
If the CSHCN
Services Program
[
(C)
If the applicant/client does not respond in writing within
the 30-day period, the applicant/client is presumed to have waived the administrative
review as well as access to a fair hearing, and the CSHCN
Services Program's
[
(2)
Fair hearing. If the applicant/client is dissatisfied with
the CSHCN
Services Program's
[
§38.14.Development and Improvement of Standards and Services.
To ensure that cost-effective, quality, appropriate medical and related
services are available and delivered to clients, the CSHCN
Services Program
[
(1)
Quality assurance. The CSHCN
Services Program
[
(A)
Standards and guidelines. The CSHCN
Services Program
[
(B)
Review of services. The CSHCN
Services Program
[
(C)
Provider review. The CSHCN
Services Program
[
(D)
Survey of clients and families. The CSHCN
Services
Program
[
(2)
Utilization review. Utilization review will assess the
appropriateness of services provided to CSHCN
Services Program
[
(3)
Task forces. The CSHCN
Services Program
[
(4)
Cooperation with other agencies. The department cooperates
with public and private agencies and with persons interested in the welfare
of children with special health care needs. The CSHCN
Services Program
[
(5)
Collaboration with stakeholders. The CSHCN
Services
Program
[
(6)
Systems development activities. The CSHCN
Services
Program
[
(A)
(No change.)
(B)
The CSHCN
Services Program
[
(i)
Community-based service organizations that serve as wellness
centers may include, but are not limited to: hospitals, churches, boys/girls
organizations, health centers, or school-based centers. Existing community-based
service organizations that provide services to children with special health
care needs and their families within a community shall receive preference
in funding by the CSHCN
Services Program
[
(ii) - (iii)
(No change.)
§38.16.Procedures to Address CSHCN Services Program [
(a)
The department shall analyze actuarial cost projections
concerning CSHCN
Services Program
administrative and client services
to estimate the amount of funds needed in the fiscal year by the program to
serve CSHCN
Services Program
clients and shall monitor such program
cost projections and funding analyses at least monthly to determine whether
the estimated amount of funds needed by the program will:
(1) - (2)
(No change.)
(b)
When the CSHCN
Services Program
[
(1)
(No change.)
(2)
take the following actions in the order listed only until
the projected amount of funds to be expended by the program approximately
equals, but does not exceed, the program's appropriated funds and other available
resources:
(A)
implement administrative efficiencies, while avoiding changes
which may jeopardize the quality and integrity of CSHCN
Services Program
[
(B)
(No change.)
(C)
at the same time the waiting list is established:
(i)
provide only limited prior authorization for family support
services for ongoing clients, as determined by the medical director or other
designated medical staff, only in order to continue services already being
provided at the time the waiting list is established, and/or when the specific
services are required to prevent out-of-home placement of the client (as documented
by the CSHCN
Services Program
[
(ii) - (iii)
(No change.)
(D) - (E)
(No change.)
(F)
place clients who are eligible to receive CSHCN
Services
Program
[
(i)
ongoing clients for health care benefits who have one or
more sources of substantial health insurance coverage (such as Medicaid/CHIP/
or other private health insurance similar in scope) in addition to the CSHCN
Services Program
[
(ii) - (iii)
(No change.)
(G)
employ additional measures to reduce/limit the amount of
funds to be expended by the program as
directed
[
(c)
If the procedures described in subsection (b)(2)(A) - (F)
of this section enable the program to project that the estimated amount of
funds to be expended by the program in the fiscal year approximately equals,
but does not exceed, the program's appropriated funds and other available
resources, the program shall take the following additional steps in order
to provide health care benefits to as many clients with urgent need for health
care benefits as possible who are currently on the waiting list.
(1)
generate cost savings by taking the following steps in
the order listed:
(A) - (B)
(No change.)
(C)
employ additional measures to generate cost savings as
directed
[
(2)
(No change.)
(3)
provide health care benefits (which may
or may not
include
coverage
[
(A) - (B)
(No change.)
(4)
provide limited health care benefits and/or payment of
outstanding bills for health care benefits for clients with urgent need for
health care benefits who are on the waiting list and remain on the waiting
list. The program's coverage of such health care benefits may be limited in
scope, amount, and duration and is not intended to be sustained over time.
If limited health care benefits coverage includes coverage of family support
services, the coverage of family support services must be limited according
to the parameters set forth in subsection (b)(2)(C)(i) of this section.
Clients
with urgent need for health care benefits who are on the waiting list will
be served in the same order used in paragraph (2) of this subsection to remove
clients with urgent need for health care benefits from the waiting list. This
coverage may be provided to clients with urgent need on the waiting list prior
to or at any point during activities described by paragraphs (2) - (3) of
this subsection only:
(A) - (C)
(No change.)
(d)
When the CSHCN
Services Program
[
(1)
In an effort to expend unobligated funds (except for unobligated
funds resulting from program actions taken according to subsection (c) of
this section) the program shall utilize the following steps in the order listed
only until the program projects that the estimated amount of unobligated funds
will be expended by the program during the fiscal year:
(A)
take clients off the waiting list according to the original
date/time that starts the client's latest uninterrupted sequence of eligibility
for program health care benefits and in the following group order:
(i) - (ii)
(No change.)
[
[
(iii)
[
(iv)
[
(B)
provide health care benefits [
[
[
(C)
provide limited health care benefits
for clients who
are on the waiting list and remain on the waiting list;
and/or payment
of outstanding bills for health care benefits for clients who are on the waiting
list and remain on the waiting list
; and/or payment of outstanding bills
for health care benefits for clients who have been taken off the waiting list
. The program's coverage of such health care benefits may be limited
in scope, amount, and duration and is not intended to be sustained over time.
If limited health care benefits coverage includes coverage of family support
services, the coverage of family support services must be limited according
to the parameters set forth in paragraph (b)(2)(C)(i) of this section.
[
(i) - (iii)
(No change.)
(D)
if the CSHCN
Services Program
[
(i) - (ii)
(No change.)
(iii)
remove any of the additional measures taken to reduce/limit
the amount of funds to be expended by the program as directed [
(iv) - (v)
(No change.)
(2)
In an effort to expend unobligated funds resulting from
program actions taken according to subsection (c) of this section (unobligated
cost savings funds that remain after all clients with urgent need for health
care benefits have been removed from the waiting list and provided health
care benefits) the program shall utilize the following steps in the order
listed only until the program projects that the estimated amount of unobligated
funds will be expended by the program during the fiscal year:
(A)
(No change.)
(B)
provide health care benefits (which may
or may not
include
coverage
[
(C)
provide limited health care benefits
for clients identified
in subparagraph (A)(i) and (ii) of this paragraph who are on the waiting list
and remain on the waiting list;
and/or payment of outstanding bills
for health care benefits for clients identified in
subparagraph (A)(i)
and (ii) of this paragraph
[
(D)
remove any of the additional measures taken to generate
cost savings [
(E)
(No change.)
(e)
The program shall establish a protocol to be used by the
medical director or other designated medical staff to determine whether a
client has an "urgent need for health care benefits" by considering criteria
including, but not limited to, the following:
(1) - (3)
(No change.)
(4)
information received from CSHCN
Services Program
regional
case management staff/contractors supports other information gathered and/or
indicates that a delay in health care benefits could reasonably be expected
to result in an out-of-home placement/institutionalization of the client because
the family cannot continue to care for the client; and
(5)
(No change.)
(f)
The CSHCN
Services Program
[
(1)
In order to facilitate contacting clients on the waiting
list, the CSHCN
Services Program
[
(A) - (G)
(No change.)
(2)
(No change.)
(3)
The program shall refer clients on the waiting list to
other possible sources of services, and shall contact waiting list clients
periodically to confirm their continuing need for CSHCN
Services Program
[
(4)
(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 December 23, 2005.
TRD-200506108
Cathy Campbell
General Counsel
Department of State Health Services
Earliest possible date of adoption: February 5, 2006
For further information, please call: (512) 458-7236
The Executive Commissioner of the Health and Human Services Commission,
on behalf of the Department of State Health Services (department), proposes
amendments to §§96.101, 96.201 - 96.203, 96.301 - 96.304, 96.401,
96.402, 96.501, and the repeal of §96.601, concerning the applicability,
minimum standards, safety recommendations, device registration procedures
and fees, and sharps injury logs of bloodborne pathogen exposure control plans.
BACKGROUND AND PURPOSE
The amendments and repeal are necessary to comply with Health and Safety
Code, §§81.301 - 81.307, which requires the department to establish
an exposure control plan designed to minimize exposure of employees to bloodborne
pathogens and to implement a registration program for needleless systems and
sharps with engineered sharp injury protections; and House Bill 2292, 78th
Legislature, Regular Session, 2003, §2.42, added Health and Safety Code, §12.0112,
which requires that the term for licenses issued or renewed after January
1, 2005, will be two years.
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). Sections 96.101,
96.201 - 96.203, 96.301 - 96.304, 96.401, 96.402, 96.501, and 96.601 have
been reviewed, and the department has determined that reasons for adopting
the sections continue to exist because rules on this subject are needed and
required by law; except that §96.601 will be repealed because the rule
is no longer necessary.
SECTION-BY-SECTION SUMMARY
Amendments to §96.101 add more components to the definitions of "Governmental
unit" and also provide additional information concerning the contracting of
the Hepatitis B, C, and Human immunodeficiency viruses; §§96.201
- 96.203, 96.301 - 96.304, 96.401, 96.402, and 96.501 update and correct the
department's reference from the "Texas Department of Health" to the "Department
of State Health Services;" §§96.202, 96.303, and 96.401 provide
a new website for information on bloodborne pathogen control; amendments to §96.301
and §96.501 reflect changes in the Department of State Health Services'
organizational unit names and commissioner titles; amendments to §96.302
and §96.304 add a two-year period for registration and renewal fees; §96.501
is amended to change the date of expiration of a waiver from a stipulated
date of December 31, 2001, to December 31 annually; to revise the authorization
of the 1990 federal census and identify the 2000 federal census as the reference
in determining county populations; and to change the request for a waiver
date from January 1, 2001, to January 1 annually.
Section 96.601 is being repealed because the reference to the effective
date of the rules is no longer relevant.
FISCAL NOTE
Jon Huss, Acting Section Director, Community Preparedness Section, has
determined that for each year of the first five years that the sections are
in effect, there will be fiscal implications to the state as a result of enforcing
or administering the sections as proposed. The effect on state government
will be an increase in revenue for the first year of $2,000 due to the two-year
device registration fee. For years two through five, there will be no fiscal
impact and no change in revenue. There will be no effect on local government.
SMALL AND MICRO-BUSINESS IMPACT ANALYSIS
Mr. Huss has also determined that there will be no effect on small businesses
or micro-businesses required to comply with the sections as proposed. This
was determined by interpretation of the rules that small businesses and micro-businesses
will not be required to alter their business practices in order to comply
with the sections. There are no anticipated economic costs to persons who
are required to comply with the sections as proposed. There is no anticipated
negative impact on local employment.
PUBLIC BENEFIT
In addition, Mr. Huss has also determined that for each year of the first
five years the sections are in effect, the public will benefit from adoption
of the sections. The public benefit anticipated as a result of administering
the sections is reducing incidence to sharps injuries and the prevention of
communicable disease in government employees and their contacts.
REGULATORY ANALYSIS
The department has determined that this proposal is not a "major environmental
rule" as defined by Government Code, §2001.0225. "Major environmental
rule" is defined to mean a rule the specific intent of which is to protect
the environment or reduce risk to human health from environmental exposure
and that may adversely affect, in a material way, the economy, a sector of
the economy, productivity, competition, jobs, the environment, or the public
health and safety of the state or a sector of the state. This proposal is
not specifically intended to protect the environment or reduce risks to human
health from environmental exposure.
TAKINGS IMPACT ASSESSMENT
The department has determined that the proposed rules do not restrict or
limit an owner's right to his or her property that would otherwise exist in
the absence of government action and, therefore, do not constitute a taking
under Government Code, §2007.043.
PUBLIC COMMENT
Comments on the proposal may be submitted to Kathryn Gardner, DrPH, RNC,
Infectious Disease Surveillance and Epidemiology Branch, Infectious Disease
Control Unit, Department of State Health Services, 1100 West 49th Street,
Austin, Texas 78756, (512) 458-7676 or by e-mail to Kathryn.Gardner@dshs.state.tx.us.
Comments will be accepted for 30 days following publication of the proposal
in the
Texas Register
.
LEGAL CERTIFICATION
The Department of State Health Services' General Counsel, Cathy Campbell,
certifies that the proposed rules have been reviewed by legal counsel and
found to be within the state agencies' authority to adopt.
Chapter 38.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM
which
] is authorized by Health and Safety Code, Chapter
35 to provide the following services to eligible children:
(3)
Advisory committee--Those
persons appointed by the Texas Board of Health to serve in an advisory capacity
to the Children with Special Health Care Needs (CSHCN) Program staff.]
(4)
] Applicant--A person making
an initial
application
or re-application
for CSHCN
Services Program
[
program
] services[
, but who has not
been determined eligible
].
(5)
Board--The Texas Board of
Health.]
(6)
] Bona fide resident--A person
who:
(7)
] Case management services--Case
management services include, but are not limited to:
(8)
] Child with special health care
needs--A person who:
(9)
] CHIP--The Children's Health
Insurance Program administered by the Texas Health and Human Services Commission
under Title XXI of the Social Security Act.
(10)
] Chronic developmental condition--A
disability manifested during the developmental period for a child with special
health care needs which results in impaired intellectual functioning or deficiencies
in essential skills, which is expected to continue for a period longer than
one year, and which causes a person to need assistance in the major activities
of daily living and/or in meeting personal care needs. For the purpose of
this chapter, a chronic developmental condition must include physical manifestations
and may not be solely a delay in intellectual, mental, behavioral and/or emotional
development.
(11)
] Chronic physical condition--A
disease or disabling condition of the body, of a bodily tissue or of an organ
which will last or is expected to last for at least 12 months; that results,
or without treatment, may result in limits to one or more major life activities;
and that requires health and related services of a type or amount beyond those
required by children generally. Such a condition may exist with accompanying
developmental, mental, behavioral, or emotional conditions, but is not solely
a delay in intellectual development or solely a mental, behavioral and/or
emotional condition.
(12)
] Claim form--The
document
approved by the CSHCN Services Program
[
CSHCN program-approved
document
] for submitting the unpaid claim for processing and payment.
(13)
] Client--A person who has
applied for program services and who meets all CSHCN
Services Program
[
program
] eligibility requirements and is determined to
be eligible for program services.
(14)
] Commissioner--The Commissioner
of Health.
(15)
] Co-insurance--A cost-sharing
arrangement in which a covered person pays a specified percentage of the charge
for a covered service. The covered person may be responsible for payment at
the time the health care service is provided.
(16)
] Co-pay/Co-payment--A cost-sharing
arrangement in which a client pays a specified charge for a specified service.
The client is usually responsible for payment at the time the health care
service is provided.
(17)
] CSHCN
Services Program
[
program
]--The services program for children with special
health care needs described in §38.1 of this title (relating to Purpose
and Common Name).
(18)
] Date of service (DOS)--The
date a service is provided.
(19)
] Deductible--A cost-sharing
arrangement in which a client is responsible for paying a specific amount
annually for covered services before an insurance carrier or plan begins to
pay for covered services.
(20)
] Dentist--An individual licensed
by the State Board of Dental Examiners to practice dentistry in the State
of Texas.
(21)
] Department--The
Department
of State Health Services
[
Texas Department of Health
].
(22)
] Diagnosis and evaluation
services--The process of performing specialized examinations, tests, and/or
procedures to determine whether a CSHCN
Services Program
[
program
] applicant for health care benefits has a chronic physical or
developmental condition as determined by a physician or dentist participating
in the CSHCN
Services Program
[
program
] and/or to help
determine whether a waiting list client has an "urgent need for health care
benefits", according to the criteria and protocol described in §38.16(e)
of this title (relating to Procedures to Address CSHCN
Services
Program
Budget Alignment).
(23)
] Eligibility date for the
CSHCN
Services Program
[
program
] health care benefits--The
effective date of eligibility for the CSHCN
Services Program
[
program
] health care benefits is 15 days prior to the date of receipt
of the application, except in the following circumstances.
from
] the date of receipt of the application, or
a DOS within
6
[
12
] months after the financial eligibility
denial date may be included to satisfy spenddown requirements. Medical bills
for any member of the household for which the applicant, parent(s), guardian
or managing conservator of the CSHCN
Services Program
applicant
is responsible may be included. Medical bills used to meet spenddown cannot
be paid by the CSHCN
Services Program
[
program
].
(24)
] Emergency--A medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent person with average knowledge of health and medicine
could reasonably expect that the absence of immediate medical care could result
in:
(25)
] Emotional or behavioral condition--Behavior
which varies significantly from normal, that is chronic and does not quickly
disappear, and that is unacceptable because of social or cultural expectations.
Emotional or behavioral responses which are so different from those of the
generally accepted, age-appropriate norms of people with the same ethnic or
cultural background as to result in significant impairment in social relationships,
self-care, educational progress, or classroom behavior. Examples include but
are not limited to the following:
(26)
] Facility--A hospital, psychiatric
hospital, rehabilitation hospital or center, ambulatory surgical center, renal
dialysis center, specialty center and/or outpatient clinic.
(27)
] Family--For the purpose of
this chapter, the family includes the following persons who live in the same
residence:
(28)
] Family support services--Disability-related
support, resources, or other assistance provided to the family of a child
with special health care needs. The term may include services described by
Part A of the Individuals with Disabilities Education Act (20 U.S.C.
§
[
Section
] 1400
et seq.
),
as amended, and permanency planning, as that term is defined by Government
Code, §531.151.
(29)
] Financial independence--A
person who currently files his or her own personal U.S. income tax return
and is not claimed as a dependent by any other person on his or her U.S. income
tax return.
(30)
] Health care benefits--
CSHCN Services
Program benefits consisting of diagnosis and evaluation
services, rehabilitation services, medical home care management services,
family support services, transportation related services, and insurance premium
payment services.
(31)
] Health insurance/health benefits
plan--A policy or plan, either individual, group, or government-sponsored,
that an individual purchases or in which an individual participates that provides
benefits when medical and/or dental costs are or would be incurred. Sources
of health insurance include, but are not limited to, health insurance policies,
health maintenance organizations, preferred provider organizations, employee
health welfare plans, union health welfare plans, medical expense reimbursement
plans,
United States Department of Defense or Department of Veterans
Affairs benefit plans
[
the Civilian Health and Medical Program
of the Uniformed Services/Veterans Administration (CHAMPUS, CHAMPVA) or their
successor plans
], Medicaid, the Children's Health Insurance Program
(CHIP), and Medicare. Benefits may be in any form, including, but not limited
to, reimbursement based upon cost, cash payment based upon a schedule, or
access without charge or at minimal charge to providers of medical and/or
dental care. Benefits from a municipal or county hospital, joint municipal-county
hospital, county hospital authority, hospital district, county indigent health
care programs, or the facilities of a medical school shall not constitute
health insurance for purposes of this chapter.
(32)
] Household--The living unit
in which the applicant resides and which also may include one or more of the
following:
(33)
] Medical home--
A respectful
partnership between a client, the client's family as appropriate, and the
client's primary health care setting. A medical home is family centered health
care that is accessible, continuous, comprehensive, coordinated, compassionate,
and culturally competent. A medical home includes a licensed medical professional
who accepts responsibility for the provision and/or coordination of primary,
preventive, and/or specialty care for a client, and coordination of care with
other community services providers.
[
A source of ongoing routine
health care in the community in which providers and families work as partners
to meet the needs of children and families. The medical home assists in early
identification of special health care needs; provides ongoing primary care;
and coordinates with a broad range of other specialty, ancillary, and related
services.
]
(34)
] Natural home--The home in
which
a
[
the eligible
] person lives that is either the
residence of his/her parent(s), foster parent(s) or guardian(s), or extended
family member(s), or the home in the community where the person has chosen
to live, alone or with other persons. A natural home may utilize natural support
systems such as family, friends, co-workers, and services available to the
general population as they are available.
(35)
Newborn screening--The process
required by law through which newborn children are screened for congenital
anomalies, including but not limited to hearing impairment, congenital adrenal
hyperplasia, congenital hypothyroidism, galactosemia, phenylketonuria, and
hemoglobinopathies, such as sickle cell disease.]
(36)
] Other benefit--A benefit,
other than a benefit provided under this chapter, to which a person is entitled
for payment of the costs of services
included in the scope of coverage
of
[
provided under
] the CSHCN
Services Program
[
program
] including
, but not limited to,
benefits available
from:
(B)
] Title XVIII, Title XIX, or
Title XXI of the Social Security Act (42 U.S.C.
§§
[
Sections
] 1395
et seq.
, 1396
et seq.
, and 1397aa
et seq.
), as amended;
(C)
] the
United States
Department
of Veterans Affairs;
(D)
]
the United States Department
of Defense
[
the Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS)
];
(E)
] workers' compensation or any
other compulsory employers' insurance program;
(F)
] a public program created by
federal or state law or under the authority of a municipality or other political
subdivision of the state, excluding benefits created by the establishment
of a municipal or county hospital, a joint municipal-county hospital, a county
hospital authority, a hospital district, or the facilities of a publicly supported
medical school; or
(G)
] a cause of action for the cost
of care, including medical care, dental care, facility care, and medical supplies,
required for a person applying for or receiving services from the department,
or a settlement or judgment based on the cause of action, if the expenses
are related to the need for services provided under this chapter.
(37)
] Permanency planning--A planning
process undertaken for children with chronic illness or developmental disabilities
who reside in institutions or are at risk of institutional placement, with
the explicit goal of securing a permanent living arrangement that enhances
the child's growth and development, which is based on the philosophy that
all children belong in families and need permanent family relationships. Permanency
planning is directed toward securing: a consistent, nurturing environment;
an enduring, positive adult relationship(s); and a specific person who will
be an advocate for the child throughout the child's life. Permanency planning
provides supports to enable families to nurture their children; to reunite
with their children when they have been placed outside the home; and to place
their children in family environments.
(38)
] Person--An individual, corporation,
government or governmental subdivision or agency, business trust, partnership,
association, or any other legal entity.
(39)
] Physician--A person licensed
by the Texas State Board of Medical Examiners to practice medicine in this
state.
(40)
] Prematurity/born prematurely--A
child born at less than 36 weeks gestational age and hospitalized since birth.
(41)
] Program--The services program
for Children with Special Health Care Needs (CSHCN).
(42)
] Provider--A person and/or
facility as defined in §38.6 of this title (relating to Providers) that
delivers services purchased by the CSHCN
Services Program
[
program
] for the purpose of implementing the Act.
(43)
] Rehabilitation services--The
process of the physical restoration, improvement, or maintenance of a body
function destroyed or impaired by congenital defect, disease, or injury which
includes the following acute and chronic/rehabilitative services:
(44)
] Respite care--A service provided
on a short-term basis for the purpose of relief to the primary care giver
in providing care to individuals with disabilities. Respite services can be
provided in either in-home or out-of-home settings on a planned basis or in
response to a crisis in the family where a temporary caregiver is needed.
(45)
] Routine child care--Child
care for a child who needs supervision while the parent/guardian is at work,
in school, or in job training.
(46)
] Services--The care, activities,
and supplies provided under the Act, including but not limited to both acute
and chronic/rehabilitative medical care, dental care, facility care, medications,
durable medical equipment, medical supplies, occupational, physical, and speech
therapies, family support services, case management services, and other care
specified by program rules.
(47)
] Social service organization--For
purposes of this chapter, a for-profit or nonprofit corporation or other entity,
not including individual persons, that provides funds for travel, meal, lodging,
and family supports expenses in advance to enable CSHCN
Services Program
clients to obtain program services.
(48)
] Specialty center--A facility
and staff that meets the CSHCN
Services Program
[
program
]
minimum standards established in this chapter and are designated for [
CSHCN program
] use
by CSHCN Services Program clients
as part
of the comprehensive services for a specific medical condition.
(49)
] Spenddown--Financial eligibility
achieved when household income exceeds 200% of the federal poverty level,
if the applicant's family can document its responsibility for household medical
bills that are equal to or greater than the amount in excess of the 200% level.
(50)
] State--The State of Texas.
(51)
] Supplemental Security Income
Program (SSI)--Title XVI of the Social Security Act which provides for payments
to individuals (including children under age 18) who are disabled and have
limited income and resources.
(52)
] Support--The contribution
of money or services necessary for a person's maintenance, including, but
not limited to, food, clothing, shelter, transportation, and health care.
(53)
] Treatment plan--The plan
of care for the client (time and treatment specific) as certified by and implemented
under the supervision of a physician or other practitioner participating in
the CSHCN
Services Program
[
program
].
(54)
] United States Public Health
Service (USPHS) price--The average manufacturer price for a drug in the preceding
calendar quarter under Title XIX of the Social Security Act, reduced by the
rebate percentage, as authorized by the Veterans Health Care Act of 1992 (P.L.
102-585, November 4, 1992).
(55)
] Urgent need for health care
benefits--A client need that fits the criteria and protocol described in §38.16(e)
of this title.
CSHCN Program ] Services.
program
] health
care benefits, applicants must meet the medical, financial, and other criteria
in this section.
A
] physician or dentist must certify [
annually
] that the
person meets the definition of "child with special health care needs" as defined
by
§38.2(6)
[
§38.2(8)
] of this title (relating
to Definitions).
The medical criteria certification must be based upon
a physical examination conducted within the 12 months immediately preceding
the date of certification. The physician or dentist must document the
[
The CSHCN program must receive a
] medical diagnosis code
and descriptor
from the International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM), or its successor,
for the person's
primary diagnosis that meets the medical criteria certification definition
and for each of the person's other medical conditions
[
on each
condition
] for statistical and referral purposes.
To facilitate
application to the CSHCN Services Program for certain applicants, the CSHCN
Services Program Medical Director may accept written documentation of medical
criteria certification submitted by a physician or dentist who is licensed
to practice in a state or jurisdiction of the United States of America other
than Texas. The CSHCN Services Program does not reimburse for written documentation
of medical criteria certification.
If a physician or dentist requests
coverage of diagnosis and evaluation services to determine if the
person
[
child/applicant
] meets the definition of a "child with
special health care needs", and the
person
[
applicant
]
meets all other eligibility criteria for health care benefits, then the
person
[
applicant
] may be given up to 60 days of program
coverage for diagnosis and evaluation services only.
Only CSHCN Services
Program participating providers as specified in §38.6 of this title (relating
to Providers), may be reimbursed for services as defined in §38.2 of
this title (relating to Definitions).
annually and
] are based upon the same determinations of
income, family size, and disregards as the CHIP.
Premiums
[
The CHIP net income is the family's gross income minus disregards. For applicants
who are not eligible for CHIP, premiums
] paid for health insurance may
be included as
a
[
an additional
] disregard. All families
must verify their income and disregards
, if applicable
.
of
] the application date
or within
6
[
12
] months after the financial eligibility
denial date that are equal to or greater than the amount in excess of the
200% level, the applicant may be determined financially eligible for a period
of
6
[
12
] months
, or as directed by statutory requirements,
beginning on the eligibility date.
program
] expenditures for
an ongoing
[
a
] client
currently not eligible for Medicaid
exceed $2,000 per year,
and
the client's age and
[
the client whose age, medical condition,
or
] citizenship status
meet
[
do not exceed
] Medicaid
eligibility criteria
, the client
shall be required to apply for
any applicable Medicaid programs
[
Medicaid, specifically including
the Medically Needy program
] and, if eligible, to participate in those
programs in order to remain eligible for further CSHCN
Services Program
[
program
] benefits. Within 60 days of the date of the notification
letter, the client must submit to the CSHCN
Services Program
[
program
] documentation of an eligibility determination from Medicaid.
During this 60-day period, CSHCN
Services Program
[
program
] coverage will continue. If the client does not provide documentation
of an eligibility determination from Medicaid within the 60-day time limit,
CSHCN
Services Program
[
program
] coverage shall be terminated
and may not be reinstated unless an eligibility determination is received.
The program may grant the client a 30-day extension to obtain the determination.
program
]
also may require
an ongoing
[
a
] client for whom actual
or projected expenditures exceed $2,000 per year to apply for the SSI program,
and, if eligible, to participate in that program in order to remain eligible
for further CSHCN
Services Program
[
program
] benefits.
Within 60 days of the date of the notification letter, the client must submit
to the CSHCN
Services Program
[
program
] verification
of a timely and complete application to SSI. During this 60-day period, CSHCN
Services Program
[
program
] coverage will continue. If the
client does not provide this verification within the 60-day time limit, CSHCN
Services Program
[
program
] coverage may be terminated. With
verification of an application to SSI, the program may continue coverage,
pending receipt of an SSI eligibility determination.
program
] eligibility,
such coverage must be kept in force. Noncompliance with this requirement may
result in the termination of CSHCN
Services Program
[
program
] benefits. If insurance cannot be maintained, the applicant or parent/guardian/managing
conservator must, upon request, provide to the CSHCN
Services Program
[
program
] proof of:
and/or continue CSHCN program coverage
],
pending receipt of an insurance eligibility determination. If the applicant/client
is eligible for
any other health insurance
[
CHIP
], the
applicant/client must be enrolled [
in CHIP
]. Such insurance must
be kept in force as though it were effective prior to CSHCN
Services
Program
[
program
] eligibility.
program
]
will assist in determining possible eligibility for insurance and may provide
CSHCN
Services Program
[
program
] benefits
for ongoing
clients
during insurance application, enrollment, and/or limited or
excluded coverage periods. [
A family support services plan for an applicant
may not be implemented until the determination of program eligibility, including
eligibility for available insurance plans is complete.
]
program
] 30 days prior to cancellation, termination,
discontinuance, or end of the enrollment period. When the CSHCN
Services
Program
[
program
] provides assistance in keeping or acquiring
health insurance, the parent/guardian/managing conservator must maintain or
enroll in the health insurance.
program
]. To be considered
by the CSHCN
Services Program
[
program
], the application
must be made on forms currently in use.
program
] receives an
application. The CSHCN
Services Program
[
program
] will
respond in writing regarding eligibility status within 30 working days after
the completed application is received. Applications will be considered:
program
] shall be in writing and shall
include the reason(s) for such denial. The applicant has the right of administrative
review and a fair hearing as set out in §38.13 of this title (relating
to Right of Appeal).
program
] coverage at any time or whenever the person's
situation or condition changes.
program
]
shall make the final determination on a person's eligibility using the information
provided with the application. The CSHCN
Services Program
[
program
] may request verification of any information provided by the
applicant to establish eligibility.
program
]
shall verify selected information on the application. Documentation of date
of birth, residency, income, and income disregards shall be required. The
CSHCN
Services Program
[
program
] shall notify the applicant/family
in writing when specific documentation is required. It is the applicant's/family's
responsibility to provide the required information.
similar
]
income guidelines
that
[
who also
] meet the
CSHCN
Services Program's eligibility income guidelines, who also meet the CSHCN
Services Program's
age and residency requirements
,
[
of the CSHCN program
] will be considered financially eligible. The applicant/client/family
must notify the CSHCN
Services Program
[
program
], if
the applicant/client is no longer eligible for such programs.
Medical and financial
] criteria
for eligibility for health care benefits must be re-established
every
six months, or as directed by statutory requirements. Medical criteria must
be re-established
at least annually (i.e., within 365 days from the
first day of the client's current eligibility period, or within 366 days during
a leap year). Ongoing clients for health care benefits will be notified of
CSHCN Services Program
[
program
] deadlines for [
annual
] re-establishment of eligibility. If an ongoing client for health care
benefits does not meet
CSHCN Services Program
[
program
]
deadlines for submitting information required for the [
annual
]
determination of continuing eligibility, the client's eligibility for health
care benefits will end. If the then former client re-applies to the
CSHCN Services Program
[
program
] after such lapse in eligibility
and is determined eligible for health care benefits, the former client will
be considered a new client. If the
CSHCN Services Program
[
program
] has a waiting list for health care benefits, the new client
will be placed on the waiting list in order according to the date/time the
client is determined eligible for [
the program
] health care benefits.
program
] may provide and/or reimburse for
case management services to persons in need of such services who are bona
fide residents and who are determined not to have another primary provider
and/or funding source for such services. The program's case management services
are focused on individuals (and their families) who are eligible, seeking
eligibility, or potentially seeking eligibility for the program's health care
benefits (includes clients who are on the waiting list for health care benefits).
However, the program may offer and provide case management services to individuals
(and their families) who are neither eligible nor seeking eligibility for
the program's health care benefits.
program
] provides no direct medical services, but reimburses for services
rendered by CSHCN
Services Program
[
program
] participating
providers and/or contractors. Clients must receive services as close to their
home communities as possible
,
unless CSHCN
Services Program
[
program
] contracts or policies require treatment at specific
facilities or specialty centers and/or the clients' conditions require specific
specialty care.
program
] may conduct outreach activities to identify children for program
enrollment, increase their access to care, and help them use services appropriately.
Outreach services may include, but are not limited to:
program
]
promotion to the general public, or targeted to potential clients and providers;
program
] applicant for health care benefits meets the CSHCN
Services
Program
[
program
] definition of a child with special health
care needs. Diagnosis and evaluation services must be prior authorized and
coverage is limited in duration. If a physician or dentist requests coverage
of diagnosis and evaluation services to determine if the child/applicant meets
the definition of a "child with special health care needs
,
"[
,
] and the applicant meets all other eligibility criteria, then the
applicant may be given up to 60 days of program coverage for diagnosis and
evaluation services only. The program medical director or other designated
medical staff may prior authorize limited coverage of diagnosis and evaluation
services for waiting list clients if needed to help determine "urgent need
for health care benefits" as described in §38.16(e) of this title (relating
to Procedures to Address CSHCN
Services
Program Budget Alignment).
Only CSHCN
Services Program
[
program
] participating
providers may be reimbursed for diagnosis and evaluation services.
program
] reimbursement,
treatment must be for a client [
with a chronic physical or developmental
condition as specified in §38.3(a)(1) of this title (relating to Eligibility
for CSHCN Program Services),
] and must have been prescribed by a provider
in compliance with all applicable laws and regulations of the State of Texas.
Services may be limited, and the availability of certain services described
in the following subparagraphs is contingent upon implementation of automation
procedures and systems.
program
], and within the scope of their
respective licenses or registrations.
master social worker-advanced clinical practitioners
],
licensed marriage and family therapists, and licensed professional counselors,
per eligible client per calendar year. Coverage includes, but is not limited
to psychological or neuropsychological testing, psychotherapy, psychoanalysis,
counseling, and narcosynthesis.
program
]. Coverage for therapeutic dental services, including prosthetics
and oral/maxillofacial surgery, follows the Texas Medicaid program guidelines.
Orthodontic care may be provided only for CSHCN eligible clients with diagnoses
of cleft/craniofacial abnormalities and/or late effects of fractures of the
skull and face bones.
program
]. Coverage is limited to the medically necessary
treatment of foot and ankle conditions and follows the Texas Medicaid program
guidelines. Supportive devices, such as molds, inlays, shoes, or supports,
must comply with coverage limitations for foot orthoses.
program
] participating facilities. Non-emergency hospital care must be provided
in facilities
that
[
which
] are enrolled as CSHCN
Services Program
[
program
] participating providers. The length
of stay is limited according to diagnosis, procedures required, and the client's
condition.
the Texas Department of Mental Health and Mental Retardation
programs or other
] appropriate
public or private
mental health
program. Admission must be prior authorized [
and is limited to five days
]. Services include those medically necessary and furnished by a Medicaid
psychiatric hospital/facility under the direction of a psychiatrist.
program
]. Services beyond the initial 30 days may be approved by the
CSHCN
Services Program
[
program
] based upon the client's
medical condition, plan of treatment, and progress. Payment for inpatient
rehabilitation care is limited to 90 days during a calendar year.
program
] approved ambulatory
surgical centers as defined in §38.7 of this title (relating to Ambulatory
Surgical Care Facilities).
program
] hospital provider following care in that provider's emergency
room, and the admitting facility declines to enroll or does not qualify as
a CSHCN
Services Program
[
program
] provider, the client
must be discharged or transferred to a participating CSHCN
Services Program
[
program
] provider as soon as the client's medical condition
permits. All providers must enroll in order to receive reimbursement.
program
] and prescribed by a practitioner
licensed to do so, for the treatment of an identified metabolic disorder or
other medical condition and serving as a medically necessary therapeutic agent
for life and health, or when part or all nutritional intake is through a tube.
(J)
] Durable medical equipment.
All equipment must be prescribed by a practitioner licensed to do so. Some
equipment may be supplied on a contract basis, and therefore, shall be ordered
from a specific supplier.
(K)
] Medical supplies. Supplies
must be medically necessary for the treatment of an eligible client.
(L)
] Professional vision services.
Vision services medically necessary for the treatment of a client include,
but are not limited to:
the state fiscal
]
year; and
(M)
] Speech-language pathology/audiology.
Speech-language pathology and audiology services medically necessary for the
treatment of a client must be prescribed by a practitioner licensed to do
so and provided by a speech-language pathologist or audiologist licensed by
the State of Texas. CSHCN
Services Program
[
program
]
coverage of speech-language pathology and audiology services may be limited
to certain conditions, by type of service, by age, by the client's medical
status, and whether the client is eligible for services for which a school
district is legally responsible.
(N)
] Audiological testing, hearing
exams, and amplification devices. Services for clients under 21 years of age
are coordinated through the Program for Amplification for Children of Texas
(PACT). For clients 21 years of age and older and those ineligible for the
PACT, covered services are the same as those available through the PACT.
(O)
] Occupational and physical therapy.
Occupational and physical therapy medically necessary for the treatment of
a client must be prescribed by a practitioner licensed to do so and provided
by a therapist licensed by the State of Texas. CSHCN
Services Program
[
program
] coverage of physical and occupational therapy
may be limited to certain conditions, by type of service, by age, by the client's
medical status, and whether the child is eligible for services for which a
school district is legally responsible.
(P)
] Certified respiratory care
practitioner services. Respiratory therapy medically necessary for the treatment
of a client must be prescribed by a practitioner licensed to do so and provided
by a certified respiratory care practitioner. CSHCN
Services Program
[
program
] coverage of respiratory therapy may be limited
to certain conditions, by type of service, by age, by the client's medical
status, and whether the child is eligible for services for which a school
district is legally responsible.
(Q)
] Home health nursing services.
Home health nursing services must be medically necessary, be prescribed by
a physician, and be provided only by a licensed and certified home and community
support services agency participating in the CSHCN
Services Program
[
program
]. Home health nursing services are limited to 200 hours per
client per
calendar
year. Up to 200 additional hours of service
per client per
calendar
year may be approved with documented justification
of need and cost effectiveness.
(R)
] Hospice care. Hospice care
includes palliative care for clients with a presumed life expectancy of six
months or less during the last weeks and months before death. Services apply
to care for the hospice terminal diagnosis condition or illnesses. Treatment
for conditions unrelated to the terminal condition or illnesses is unaffected.
Hospice care must be prescribed by a practitioner licensed to do so who also
is enrolled as a CSHCN
Services Program
provider.
program
] client should receive care in the context of a medical home.
data base
] containing all pertinent medical information about the client,
including information about hospitalizations.
program
]
may require periodic reports from the medical home.
(i)
the client is fully eligible
for the CSHCN program health care benefits;]
(ii)
] the client is not receiving
services from a Medicaid home and community-based waiver program, and the
requested service does not duplicate services received from other family support
programs, such as the In-Home and Family Support program
, the Primary
Home Care Program, or the Medically Dependent Children's Program
[
at the Texas Department of Human Services or the Texas Department of Mental
Health and Mental Retardation
]; and
(iii)
]the client's family collaborates
with the assigned case manager to identify and pursue other sources of support
and to develop a family
assessment and service
[
support services
] plan.
in writing at the time of their application
or renewal for the CSHCN program, or at any time during their eligibility
period for the CSHCN program
].
program
] prior to delivery).
written family support services
]
plan.
program
]
may establish annual cost allowances based upon the client's/family's level
of assessed need for family support services, not to exceed:
program
].
Texas Rehabilitation Commission
], limited to lifts, wheelchair
tie-downs, occupant restraints, accessories/modifications such as raising
roofs or doors if necessary for lift installation or usage, hand controls,
and repairs of covered modifications not related to inappropriate handling
or misuse of equipment and not covered by other resources;
written service
plan is approved
];
program
] or other health insurance programs for which the
client is eligible;
program
] because a claim was received after the filing deadline, insufficient
information was submitted, or because an item was considered inappropriate
or experimental;
program
];
written family support services
]
plan, in which case the family may also be liable for restitution.
program
].
program
] may provide transportation for a client and, if needed, a responsible
adult, to
and from
the nearest medically appropriate facility
(in Texas or in the United States 50 or fewer miles from the Texas border)
to obtain medically necessary and appropriate health care services that are
within the scope of coverage of the CSHCN Services Program and are provided
by a CSHCN Services Program enrolled provider
. The lowest-cost appropriate
conveyance should be used. The CSHCN
Services Program
[
program
] shall not assist if transportation is the responsibility of the client's
school district or can be obtained through Medicaid.
Transportation to
out-of-state services located more than 50 miles from the Texas border will
not be approved, except as specified in §38.6(e) of this title (relating
to Providers).
program
] may provide meals and lodging to enable a parent, guardian,
or their designee to obtain inpatient or outpatient care for a client at a
facility located away from their home. The reason for the inpatient or outpatient
visit must be directly related to medically necessary treatment for the client
that is provided by program enrolled providers and covered by the program.
Meals and lodging associated with travel to services that are provided more
than 50 miles from the Texas border will not be approved, except as specified
in §38.6(e) of this title
.
program
] may provide the following services:
program services
], if the client was not in the family's city of residence in Texas,
and the transportation cost of a parent or other person accompanying the remains
, from the facility to the place of burial in Texas that is designated by
the parent or other person legally responsible for interment
;
program
]
may pay public or private health insurance premiums to maintain or acquire
a health benefit plan or other third party coverage for the client, if the
parent/foster parent/guardian/managing conservator is financially unable to
do so, and if paying for such health insurance can reasonably be expected
to be cost effective for the CSHCN
Services Program
[
program
]. The CSHCN
Services Program
[
program
] may pay
for coinsurance and deductible amounts when the total amount paid
(including
all payers)
to the provider does not exceed the maximum allowed
by the CSHCN Services Program
for the covered service. The CSHCN
Services Program
[
program
] may reimburse clients for co-payments
paid for covered services. The CSHCN
Services Program
[
program
] may not pay premiums, deductibles, coinsurance or co-payments for
clients enrolled in CHIP.
program
] even though they
may be medically necessary for and provided to a client include, but are not
limited to:
covered
] condition
meeting the
parameters of the "child with special health care needs" definition
;
covered chronic physical or developmental
]
condition
meeting the parameters of the "child with special health care
needs" definition
.
program
] may require authorization (including prior authorization)
of reimbursement for selected services for clients.
program's
] option, selected
services may require authorization prior to the delivery of services in order
for payment to be made.
Prior authorization
[
Authorization
] requests must be submitted prior to the date of service.
(4)
Use of other benefits. The
CSHCN program is the payer of last resort. The Children with Special Health
Care Needs Services Act provides that any health insurance or other benefits
including, but not limited to commercial health insurance, health maintenance
organizations, preferred provider organizations, CHAMPUS/CHAMPVA, Medicaid
or Medicaid waiver programs, CHIP, liability insurance, or worker's compensation
insurance available to the client must be used prior to payment by the CSHCN
program.]
(5)
] Denied authorization requests
are authorization requests which are incomplete, submitted on the wrong form,
lack necessary documentation, contain inaccurate information, fail to meet
authorization request submission deadlines, and/or are for ineligible
persons
[
recipients
], services, or providers
, and/or
are for clients who do not qualify for the health care benefit requested
.
Denied authorization requests may be corrected and resubmitted for reconsideration.
However, authorization requests must meet authorization request submission
deadlines. If the results of the reconsideration process are unsatisfactory,
denied authorization requests may be appealed according to §38.13 of
this title (relating to Right of Appeal).
program
] may initiate and participate in pilot projects to determine
the fiscal impact of changes in eligibility criteria and the types of services
provided. New projects are possible only if funds are available in the current
fiscal year. All pilot projects are limited to no more than 10% of the fiscal
year appropriation.
program
] limitations;
program
] decisions and receive a response within the [
CSHCN program-specified
] deadline as described in §38.13 of this title (relating to Right
of Appeal); and
program
] coverage
prior to delivery of services;
program
] with accurate information regarding any change of circumstance which
might affect eligibility, within 30 days of such change;
program
] contracts, policies, or a referral by a CSHCN
Services Program
provider requires the use of specific facilities or specialty centers;
program
], if payments from health insurance or other benefits are made
directly to the client or parent/guardian/managing conservator for services
or equipment purchased by the CSHCN
Services Program
[
program
];
program
] prior to service
delivery;
program
] appropriately, including keeping appointments
and using supplies and equipment judiciously;
program
] of any other benefits, as defined in §38.2 of this title (relating
to Definitions), available to the client at the time of application or thereafter,
and any lawsuit(s) contemplated or filed concerning the cause of the medical
condition for which the CSHCN
Services Program
[
program
]
has paid for services; and
program
]. Items of routine daily living are not covered by the CSHCN
Services Program
[
program
].
Texas Board of Health to approve
] physicians, dentists, podiatrists, dietitians, facilities, specialty
centers, and other providers to participate in the CSHCN
Services Program
[
program
] according to its criteria and procedures.
program
] participation must submit a completed application
to the CSHCN
Services Program
[
program
] or its designee,
including a signed provider agreement and all documents requested on the application.
program
] providers must agree to abide by CSHCN
Services Program
[
program
] rules and regulations, and not to discriminate against clients
based on source of payment.
program
]
providers must agree to accept
the
CSHCN
Services Program
[
program
]
allowed amount of
payment
(regardless
of payer)
as payment in full for services
provided to CSHCN Services
Program clients
. Providers may collect allowable insurance or health
maintenance organization co-payments in accordance with those plan provisions.
Providers may not request or accept payment from the client or client's family
for completing any CSHCN Services Program forms.
program
]
is the payer of last resort, and CSHCN
Services Program
[
program
] providers must agree to utilize all other
public or private
benefits available to the client, including
but not limited to
Medicaid or Medicaid waiver programs, CHIP, or Medicare,
and casualty
or liability coverage
prior to requesting payment from the CSHCN
Services Program
[
program
].
Providers
[
Program
providers
] must agree to attempt to collect payment from the payer of
other benefits. The CSHCN
Services Program
[
program
]
may pay for certain [
CSHCN program
] services for which other benefits
may be available but have not been definitively determined. If other benefits
become available after the CSHCN
Services Program
[
program
] has paid for
the
[
program
] services, the CSHCN
Services Program
[
program
] shall recover its costs directly
from the payer of other benefits or shall request the provider of [
CSHCN
program
] services to collect payment and reimburse the CSHCN
Services
Program
[
program
].
program
] participating providers must be reimbursed
to the CSHCN
Services Program
[
program
] refund account
by lump sum payment or, at the discretion of the department, in monthly installments
or out of current claims due to be paid the provider. All providers must consent
to on-site visits and/or audits by CSHCN
Services Program
[
program
] staff or its designees.
CSHCN program
] services also covered by Medicaid must enroll and remain
enrolled as Title XIX Medicaid providers. In order to be reimbursed by Medicaid
as the primary payer, a provider must be enrolled on the date of service.
The CSHCN
Services Program
[
program
] will not reimburse
an enrolled provider for any service covered under Medicaid
that
[
which
] was provided to a CSHCN
Services Program
client eligible
for Medicaid at the time of service. If a [
CSHCN program
] service
covered by the CSHCN Services Program
is not covered by Medicaid, the
provider of that service is not required to enroll as a Medicaid provider.
Any provider excluded by Medicaid for any reason shall be excluded by the
CSHCN
Services Program
[
program
].
program
] services.
program
] participation at any time by so notifying the
CSHCN
Services Program
[
program
] in writing.
program
]
may deny, modify, suspend, or terminate a provider's approval to participate
for the following reasons:
program
] participation;
program
]
may deny or suspend approved provider status based on the CSHCN
Services
Program's
[
program's
] knowledge of disciplinary action taken
against the provider by the licensing authority under which the provider practices
in the State of Texas or by the Texas Medicaid Program.
program
] shall give the provider written notice of an opportunity of
appeal in accordance with §38.13 of this title (relating to Right of
Appeal). In addition, a fair hearing is available to any provider for the
resolution of conflict between the CSHCN
Services Program
[
program
] and the provider.
master level social worker-advanced clinical practitioners
], licensed
marriage and family therapists, and licensed professional counselors;
program
]
may accept as participating providers diagnostically specific specialty centers,
such as bone marrow or other transplant centers, approved under the credentialing
and/or approval standards and processes of the Texas Medicaid Program, if
such specialty centers also submit a CSHCN
Services Program
provider
enrollment application.
program
] may establish standards to insure quality
of care for children with special health care needs in the comprehensive diagnosis
and treatment of specific medical conditions for specialty centers with Texas
Medicaid Program separate credentialing standards as well as other specialty
centers for which the Texas Medicaid Program has not established separate
credentialing or approval standards for providers.
Within 50
] miles
from the Texas state border. For clients
[
Clients
] who would
otherwise experience financial hardship or be subject to clear medical risk
, the CSHCN Services Program may cover services that are within the scope
of the program and provided by health care providers
[
may be transported
to medical facilities
] in New Mexico, Oklahoma, Arkansas, or Louisiana
located [
within
] 50
or fewer
miles
from
[
of
] the Texas state border. [
All CSHCN program policies and procedures
will apply, including the requirement that all providers be Medicaid and CSHCN
program participating providers.
]
Outside
] 50 miles
from
[
of
] the Texas state border. The
manager of the
department unit having responsibility for oversight of the CSHCN Services
Program
[
commissioner of health
] may approve
coverage
of services that are within the scope of the CSHCN Services Program and provided
by health care providers located within the United States and more than 50
miles from the Texas border
[
CSHCN program payment to out-of-state
providers
] in unique circumstances in which the CSHCN
Services
Program
[
program
] participating physician(s), the client,
parent or guardian, and the CSHCN
Services Program
medical director
agree that:
(B)
] the same treatment or another
treatment of equal benefit or cost is not available from Texas CSHCN
Services Program
providers; and
(C)
] the out-of-state treatment
should result in a decrease in the total projected CSHCN
Services Program
[
program
] cost of the client's treatment.
(3)
The medical literature must
indicate that the out-of-state treatment is accepted medical practice and
is anticipated to improve the patient's quality of life.]
(4)
]
The CSHCN Services Program
may cover costs of transportation and associated meals and lodging for a client
and, if necessary, a responsible adult for travel to and from the location
of out-of-state services that meet the program approval parameters above.
[
The cost of transportation, meals, and lodging may be reimbursed
for the CSHCN approved out-of-state treatment.
] Travel costs will be
negotiated, with approval of specific travel options based on overall cost
effectiveness.
program
] as a cost-efficient means of providing
surgical care, as long as quality of care is assured. Any hospital participating
in the CSHCN
Services Program
[
program
] whose accreditation
by the Joint Commission on Accreditation of Health Care Organizations includes
hospital-sponsored ambulatory care services may provide ambulatory surgery
services for CSHCN
Services Program
clients. Freestanding ambulatory
surgical care (ASC) facilities, even if governed by or affiliated with a hospital
participating in the CSHCN
Services Program
[
program
],
must apply for CSHCN
Services Program
[
program
] approval.
The CSHCN
Services Program
[
program
] may contract with
a limited number of facilities to contain [
program
] costs. For
approval to participate in the CSHCN
Services Program
[
program
], a freestanding ASC facility must meet the following criteria:
program
] must perform all surgical procedures.
program
]
must be present in the operating room for the induction and completion of
anesthesia and must remain on the premises (immediately available) during
the surgical procedure until the client leaves the facility.
program
] participating
hospitals in the area.
program
] participation must submit documentation
concerning their compliance with the criteria stated in subsection (a)(1)
- (6) of this section to the CSHCN
Services Program
[
program
] or its designee as required by the application process described in
subsection (d) of this section.
program
] participation shall be processed according to
the following procedures:
program
] to assure that:
program
] participating hospitals.
program
]
shall review all complete applications and shall approve or deny each application
in writing within 15 working days of receipt. An incomplete application will
be returned to the applicant with an explanation of the information required.
The application may be resubmitted with the required documentation for reconsideration.
program
] payment for services rendered
during the prior year will be given the option of withdrawing from CSHCN
Services Program
[
program
] approved status, becoming inactive,
or providing updated information to remain active. If updated information
is not received within 60 days of the date of notification, the provider will
be considered inactive. This action will not terminate a provider's approval,
but the provider may be reinstated to active status only by providing current
information to the CSHCN
Services Program
[
program
].
program
] participating medical staff;
program
] rules to review at the time reinstatement
is requested.
program
] shall reimburse only an approved inpatient rehabilitation center
for services provided to clients.
program
] staff.
program
] participating provider, board certified or eligible in his/her
specialty, and able to demonstrate experience in rehabilitation shall be available
as medical director.
program
] participating pediatrician available to participate in direct
client care and consultation. The physician shall be either certified or eligible
for certification by the American Board of Pediatrics.
which
] serves pediatric
clients shall have at least one recreational area or playroom
that is
bed and wheelchair accessible,
with age-appropriate and safe materials
for clients who are at different stages in rehabilitation [
which is bed
and wheelchair accessible
].
which
] serves pediatric
clients shall have specialized age-appropriate equipment necessary for provision
of care.
program
] shall comply with the following standards:
program
]. Applications shall include an application form, CSHCN
Services
Program
provider agreements, documentation of licensure, board certifications
for physicians, documentation of dental specialty for dentists, and a description
of the C/C team composition.
program
] rules and regulations.
program
]
provider enrollment requirements found in §38.6 of this title (relating
to Providers).
which
] verifies the linkage and specifies the method of communication
and consultation must accompany the application.
program
] reimburses
participating providers for covered services for [
CSHCN
] clients.
Payment may be made only after the delivery of the service, with the exception
of meals, transportation, and lodging and insurance premium payments. Excluding
allowable insurance or health maintenance organization co-payments, the client
or client's family must not be billed for the service or be required to make
a preadmission or pretreatment payment or deposit.
Providers may not
request or accept payment from the client or the client's family for completing
any CSHCN Services Program forms.
Providers must agree to accept established
fees as payment in full. The program may negotiate reimbursement alternatives
to reduce costs through requests for proposals, contract purchases, and/or
incentive programs.
program
] or its payment contractor within 95 days of the
date of service, within 95 days from the date of discharge from inpatient
hospital and inpatient rehabilitation facilities, within 95 days from the
date the client's eligibility is added to program automation systems, or within
the submission deadlines listed in paragraphs (1)(B)(ii) and (2) of this section,
whichever is later. If the 95th day for receipt of a claim falls on a weekend
or holiday, the deadline shall be extended to the next business day following
the weekend or holiday. Claims will either be paid or denied within 30 days.
The
manager of the department unit having responsibility for oversight
of the CSHCN Services Program
[
CSHCN Division Director
] or
his/her designee(s) may waive the filing deadlines according to the conditions
and circumstances specified in paragraphs (3) - (5) of this section. A claim
must be processed and paid within 24 months of the date of service. Claims
received by the CSHCN
Services Program
[
program
] or
its payment contractor after this time frame will not be considered for payment
by the CSHCN
Services Program
[
program
].
the CSHCN program-approved claim
form
] (including electronic claims submission systems), and if the required
documentation is received with the claim.
and/or
] are for ineligible
persons
[
recipients
], services, or providers
, and/or
are for clients who do not qualify for the health care benefit claimed
.
the CSHCN program-approved
claim form
] along with required documentation
,
within the
filing deadline established in clause (ii) of this subparagraph.
program
] can pay
for services. Providers must file a claim with health insurance, CHIP, or
Medicaid prior to submitting any claim to the CSHCN
Services Program
[
program
] for payment. Claims with health insurance must
be received by the CSHCN
Services Program
[
program
]
within 95 days of the date of disposition by the other third party resource,
and no later than 365 days from the date of service. The CSHCN
Services
Program
[
program
] will consider claims received for the first
time after the 365-day deadline, if a third party resource recoups a payment
made in error; however, the claim must be received by the CSHCN
Services
Program
[
program
] within 95 days from the third party's disposition.
The CSHCN Services Program may pay for covered health care benefits during
CHIP or other health insurance enrollment waiting periods. During these periods,
providers may file claims directly with the CSHCN Services Program without
evidence of denial by the other insurer.
program
], if the letter of denial also is submitted with
the claim form. If the denial letter is not available, the provider must include
on the claim form the date the claim was filed with the insurance company,
the reason for the denial, name and telephone number of the insurance company,
the policy number, the name of the policy holder and identification numbers
for each policy covering the client, the name of the insurance company employee
who provided the information on the denial of benefits, and the date of the
contact. If more than 110 days have elapsed from the date a claim was filed
with the third party resource and no response has been received, the claim
may be submitted to the CSHCN
Services Program
[
program
]
for consideration of payment. Claims must be submitted with documentation
indicating the third party resource has not responded.
program
] for payment, if available. If the EOB is unavailable, the provider
must include on the claim form the name and telephone number of the insurance
company, the amount paid, the policy number, and name of the insured for each
policy covering the client.
program
].
program
]
may pay a deductible or coinsurance for the client as long as the total amount
paid to the provider does not exceed the maximum allowed for the covered service,
and conforms with current CSHCN
Services Program
[
program
] policies regarding third party resources, deductible, and coinsurance.
CSHCN Division Director
] or his/her designee(s) will consider a provider's request for an exception
to the claim receipt or correction and resubmission deadlines provided in
paragraphs (1) and (2) of this section, if the delay in claim receipt or correction
and resubmission is due to one of the following reasons:
recipient
]
and/or in claims processing, or delay due to erroneous written information
from the program or its designee, or another state agency; or
CSHCN Division Director
] or his/her designee(s) will consider a provider's request for an exception
to claims receipt or correction and resubmission deadlines due to delays caused
by entities other than the provider and the program under the following circumstances:
program
]
fee schedules. The CSHCN
Services Program
[
program
]
or its designee shall reimburse claims for covered medical, dental, and other
services according to the following fee schedules:
program
]. For products not listed in the
current edition of the Drug Topics Red Book, reimbursement shall be based
on the same methodology using the AWP supplied by the manufacturer of the
product;
(G)
] out-patient medications:
(H)
] expendable medical supplies--the
lower of the billed amount or the
maximum
amount
allowed
[
allowable by the United States Department of Health and Human Services, Centers
for Medicare and Medicaid Services (CMS), if available, or
] by the Texas
Medicaid Program;
(I)
durable medical equipment:]
(i)
non-customized--the lower
of the billed amount or the amount allowable by the CMS, if available, or
the Texas Medicaid Program;]
(ii)
customized:]
(I)
customized, non-powered equipment--the lower
of the billed amount or the manufacturer's suggested retail price (MSRP) less
18%;]
(II)
power wheelchairs--the lower of the billed
amount or the MSRP less 15%; and]
(III)
other--when no MSRP has been published, the
lower of the billed amount or the dealer's cost plus 25%; and]
(IV)
delayed delivery penalty--a claim submitted
for customized durable medical equipment that was delivered to the client
more than 75 days after the authorization date shall be reduced by 10%;]
(iii)
orthotics and prosthetics--the
lower of the billed amount or the amount allowed by the CMS, if available,
or the Texas Medicaid Program;]
(J)
] total parenteral nutrition/hyperalimentation
(including equipment, supplies and related services)--the lower of the billed
amount or the maximum amount allowed by the Texas Medicaid Program;
(K)
] home health nursing services
(provided only through CSHCN
Services Program
[
program
]
participating home and community support service agencies)--reimbursement
for a maximum of 200 hours per client per
calendar
year, with an
additional 200 hours per client per
calendar
year available, if
justification of need and cost effectiveness are documented;
(L)
] outpatient physical therapy,
occupational therapy, speech-language pathology, and respiratory therapy:
(M)
audiological testing and amplification
devices:]
(i)
for clients under age 21--payment is made through
the Program for Amplification for Children of Texas (PACT); and]
(ii)
for clients ineligible for PACT and those
age 21 and over--the lower of the billed amount or the amount allowed by PACT;]
(N)
] insurance premium payment assistance
program--the lowest available premium for a plan which covers the client,
if cost-effective;
(O)
] hospital (inpatient and outpatient
care) and inpatient psychiatric care--reimbursed at 80% of the rate authorized
by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), which is
equivalent to the hospital's Medicaid interim rate;
(P)
] inpatient rehabilitation care--reimbursed
at 80% of TEFRA rates, for a maximum of 90 inpatient days per calendar year;
(Q)
] hospice services--the lower
of the billed amount or the amount allowed by the Texas Medicaid Program;
(R)
] care for renal disease--
(S)
] freestanding ambulatory surgical
centers--the lower of the billed amount or the amount allowed by the Texas
Medicaid Program based upon Ambulatory Surgical Code Groupings approved by
the
Centers for Medicare and Medicaid Services (CMS)
[
CMS
] and the
Department of State Health Services
[
Texas
Department of Health
];
(T)
] hospital ambulatory surgical
centers--the lower of the amount billed or the amount allowed by the Texas
Medicaid Program based upon Ambulatory Surgical Code Groupings approved by
the CMS and the
Department of State Health Services
[
Texas
Department of Health
];
(U)
] covered professional services
by physicians, podiatrists, advanced practice nurses, psychologists, licensed
professional counselors, or other providers that are not otherwise specified--the
lower of the billed amount or the amount allowed by the Texas Medicaid Program;
(V)
] independent laboratory--
the lower of the billed amount or the maximum amount allowed by the Texas
Medicaid Program;
[
the lowest of the following:
]
(i)
the amount allowed by the
Texas Medicaid Program state fee schedule;]
(ii)
the amount allowed by the
CMS national fee schedule; or]
(iii)
the billed amount;]
(W)
] radiology services--the lower
of the billed amount or the amount allowed by the Texas Medicaid
Program
[
program
];
(X)
] dental services--the lower
of the billed amount or the amount allowed by the Texas Medicaid
Program
[
program
]; and
(Y)
] vision services--the lower
of the billed amount or the amount allowed by the Texas Medicaid Program
, except high-powered lenses, which are reimbursed at the manufacturer's suggested
retail price less 18%
;
program
] may require documentation of the delivery of goods
and services from the provider.
program
] due to the following:
program
]; and
program
] may contract
on a bid basis for treatment, equipment, medications, supplies, program operations
and other services in order to conserve funds and administer the program effectively.
program
]
may enter into contracts or written agreements with persons or entities for
the development and improvement of program standards and services.
program
]
may use consultants from any medical or dental specialty or other discipline
to address specific issues and problems in relation to the identification,
diagnosis and evaluation, rehabilitation, case management, other family support
services, and health benefits coverage for clients.
the
] approval [
of the board
]
as required by law, the CSHCN
Services Program
[
program
]
may accept gifts and donations.
program
] shall be notified
in writing if the CSHCN
Services Program
[
program
] proposes
to deny, modify, suspend, or terminate such health care benefits because:
program
] services and the client/family
fails to adhere to a plan established to direct and/or supervise the use of
CSHCN
Services Program
[
program
] services;
program
]
funds are reduced or curtailed; or
program
] health care benefits.
program
]
will notify the parent/foster parent/guardian/managing conservator or the
adult applicant/client in writing of the action, the reasons for the action,
and the right of appeal in accordance with §38.13 of this title (relating
to Right of Appeal).
program
] intends to deny a family's authorization request for family support
services according to
§38.4(b)(5)
[
§38.4(b)(5)(B)(viii)
] of this title (relating to Covered Services) and/or a provider's authorization
request according to
§38.4(d)
[
§38.4(d)(5)
]
of this title [
(relating to Covered Services)
] and/or a provider's
claim that has been corrected and resubmitted for reconsideration according
to
§38.10(1)(B)
[
§38.10(1)(B)(ii)
] of this
title (relating to Payment of Services), the program shall give the family
or provider written notice of the denial and the right of the family or provider
to request an administrative review of the denial within 30 days.
program
] intends to deny, modify, suspend, or terminate an individual provider's
participation in the CSHCN
Services Program
[
program
],
the CSHCN
Services Program
[
program
] shall give the
provider written notice of the proposed action and the provider's right to
request an administrative review of the proposed action within 30 days.
program's
] action is final. If the family or provider so
requests, the CSHCN
Services Program
[
program
] will
conduct an administrative review of the circumstances on which the proposed
denial of the authorization request/claim and/or the proposed denial, modification,
suspension, or termination of provider program participation is based and
give the family or provider written notice of the program decision and the
supporting reasons within ten days of receipt of the request for administrative
review.
department
] establishes
provider
reimbursement
[
fee schedules
] and the program's
budget alignment
methodologies
[
methodology
] by rule.
Families and/or providers may not request administrative review and may not
appeal service authorization decisions and/or provider reimbursement amounts
that are in accordance with the
reimbursement
[
fee schedules
] and budget alignment
methodologies
[
methodology
]
as stated in
CSHCN Services Program
[
program
] rules.
program's
] decision
and supporting reasons following the administrative review, the family and/or
provider may request a fair hearing in writing addressed to the Children with
Special Health Care Needs Program,
Purchased Health Services Unit, Department
of State Health Services
[
Bureau of Children's Health, Texas Department
of Health
], 1100
West
[
W.
] 49th Street, Austin,
Texas 78756 within 20 days of receipt of the administrative review decision
notice. If the family and/or provider fails to request a fair hearing within
the 20-day period, the family and/or provider is presumed to have waived the
request for a fair hearing, and the CSHCN
Services Program
[
program
] may take final action. A fair hearing requested by a family
and/or provider shall be conducted in accordance with §§1.51 - 1.55
of this title (relating to Fair Hearing Procedures).
program
] intends to deny eligibility to a program applicant, the program shall
give the applicant written notice of the denial and the applicant's right
to request an administrative review of the denial within 30 days.
program
] intends to deny, modify, suspend, or terminate an individual client's
eligibility for health care benefits and/or health care benefits (unless such
program actions are authorized by §38.16 of this title (relating to Procedures
to Address CSHCN
Services Program
[
program
] Budget Alignment)),
the CSHCN
Services Program
[
program
] shall give the
client written notice of the proposed action and the client's right to request
an administrative review of the proposed action within 30 days.
program's
] action is final. If the applicant/client so
requests in writing, the CSHCN
Services Program
[
program
]
shall conduct an administrative review concerning the circumstances on which
the denial of the applicant's eligibility or the proposed denial, modification,
suspension, or termination of the client's eligibility and/or health care
benefits is based within ten days after receiving the request and shall give
the client written notice of the decision and the supporting reasons.
program's
] decision and
supporting reasons following the administrative review, the applicant/client
may request a fair hearing in writing addressed to the Children with Special
Health Care Needs Program,
Purchased Health Services Unit, Department
of State Health Services
[
Bureau of Children's Health, Texas Department
of Health
], 1100 West 49th Street, Austin, Texas 78756 within 20 days
of receipt of the administrative review decision notice. If the applicant/client
fails to request a fair hearing within the 20-day period, the applicant/client
is presumed to have waived the request for a fair hearing, and the CSHCN
Services Program
[
program
] may take final action. A fair
hearing requested by the applicant/client shall be conducted in accordance
with §§1.51 - 1.55 of this title [
(relating to Fair Hearing
Procedures)
].
program
] may establish a system of program evaluation to
obtain management information about the CSHCN
Services Program's
[
program's
] operation and effectiveness; to establish guidelines and
standards for CSHCN
Services Program
[
program
] health
care services; to monitor compliance with these established standards and
guidelines; to identify and analyze patterns and trends in provider billing
and service delivery; and to develop systems which promote family-centered,
community-based alternatives that nurture and support children with special
health care needs.
program
] may establish a system of monitoring the quality, medical necessity,
and effectiveness of services.
program
] may develop standards and guidelines for services
and providers reimbursed by the CSHCN
Services Program
[
program
] to ensure that quality services are available.
program
] may conduct or contract for concurrent and/or retrospective
review of client care services reimbursed by the CSHCN
Services Program
[
program
].
program
] may conduct periodic quality assurance reviews for provider
services.
program
] shall survey clients periodically to assess
the availability, appropriateness, effectiveness, accessibility, and cultural
sensitivity of provided services.
program
] clients by monitoring systems developed or contracted by the
CSHCN
Services Program
[
program
]. Suspected fraud and
abuse cases will be evaluated by the Office of the General Counsel for possible
prosecution.
program
] may establish task forces to advise the CSHCN
Services
Program
[
program
].
program
] will make every effort to establish cooperative
agreements with other state agencies to define the responsibilities of each
agency in relation to specific programs to avoid duplication of services.
program
] values the participation of all stakeholders
who have an interest in children with special health care needs and will make
every effort to work collaboratively with stakeholders in the design, development,
and implementation of program rules and policies.
program
] may conduct population-based systems development
activities to improve and support the state's infrastructure for serving all
children with special health care needs and their families by program staff
or through contractors.
program
]
may establish wellness centers, which are programs and/or physical locations
of community-based service organizations which provide specific support services
for children with special health care needs and their families.
program
].
Program ] Budget Alignment.
program
] projects that the estimated amount of funds needed in the fiscal year
by the program to serve CSHCN
Services Program
clients will exceed
the program's appropriated funds and other available resources for the fiscal
year, the program shall use the following methodology to reduce/limit the
amount of funds to be expended by the program:
program
] service delivery;
program
] regional case
management staff/contractors), and/or when the provision of such services
is cost effective for the program;
program
] health care benefits and who currently
are not on the waiting list (ongoing clients for health care benefits) on
the waiting list. These clients will be ordered on the waiting list according
to the original date/time that starts the client's latest uninterrupted sequence
of eligibility for program health care benefits, and in the following order
of movement to the waiting list:
program
] (not including those ongoing clients
for whom the CSHCN
Services Program
[
program
] pays the
insurance premiums);
the board
shall direct
] by rule.
the board shall direct
] by rule.
payment
] of outstanding bills
for health care benefits) for clients with urgent need for health care benefits
who are removed from the waiting list;
program
] projects that the estimated amount of funds to be expended by the
program in the fiscal year is less than the program's appropriated funds and
other available resources due to the cost reduction, limitation, or deferral
procedures implemented according to subsections (b) or (c) of this section,
or the program's receipt of additional funding, or funding analysis [
as described in subsection (a)(2) of this section,
] resulting in a projected
amount of unobligated funds, the program shall increase the amount of funds
to be expended by the program.
(iii)
clients who are less than
21 years old who do not have an urgent need for health care benefits and who
are clients who were placed on the waiting list when they were ongoing clients
and who have had no lapse in eligibility while on the waiting list or who
are new clients who are re-applicants for health care benefits and who have
had a lapse in eligibility for no longer than the 12 months prior to the date/time
that starts their latest uninterrupted sequence of eligibility;]
(iv)
clients who are 21 years
of age or older who do not have an urgent need for health care benefits and
who are clients who were placed on the waiting list when they were ongoing
clients and who have had no lapse in eligibility while on the waiting list
or who are new clients who are re-applicants for health care benefits and
who have had a lapse in eligibility for no longer than the 12 months prior
to the date/time that starts their latest uninterrupted sequence of eligibility;]
(v)
] all other clients who are
less than 21 years old who do not have an urgent need for health care benefits;
and
(vi)
] all other clients who are
21 years of age or older who do not have an urgent need for health care benefits
;
[
.
]
(which may include payment
of outstanding bills for health care benefits)
] for clients taken off
the waiting list
as long as program unobligated funds are available;
[
:
]
(i)
as long as program unobligated
funds are available; and]
(ii)
if the outstanding bills
for health care benefits are for dates of service that are within the time
period that program unobligated funds are available and provided the client
was eligible for program health care benefits at the time of the dates of
service;]
Clients on the waiting list will be served in the same order used in paragraph
(1) of this subsection to take clients off the waiting list.
] This coverage
may be provided [
to clients on the waiting list prior to or
] at
any point during activities described by
subparagraphs (A) and (B) of
this paragraph
[
paragraphs (1) - (2) of this subsection
]
only:
program
] projects that the amount of funds to be expended by the program in
the fiscal year will be less than the program's appropriated funds and other
available resources after no clients eligible for
CSHCN Services Program
[
program
] health care benefits remain on the waiting list,
the program may take the following actions in the following order:
by the
board
] by rule;
payment
] of outstanding bills
for health care benefits) as stipulated in
paragraph (1)(B) of this subsection
[
subsection (d)(1)(B) of this section
] for these clients
taken off the waiting list;
subsections (d)(2)(A)(i) and (ii) of
this section
] who are on the waiting list and remain on the waiting
list
; and/or payment of outstanding bills for health care benefits for
clients who have been taken off the waiting list
. The program's coverage
of such health care benefits may be limited in scope, amount, and duration
and is not intended to be sustained over time.
If limited health care
benefits coverage includes coverage of family support services, the coverage
of family support services must be limited according to the parameters set
forth in subsection (b)(2)(C)(i) of this section.
[
These clients
on the waiting list will be served in the same order used in paragraph (2)(A)
of this subsection to take these clients off the waiting list.
] This
coverage may be provided [
to these clients on the waiting list prior
to or
] at any point during activities described by
subparagraphs
(A) and (B) of this paragraph
[
paragraphs (2)(A) and (2)(B) of
this subsection
] and only as stipulated in
paragraph (1)(C)(i)
- (iii) of this subsection;
[
subsections (d)(1)(C)(i) - (iii) of
this section;
]
by the board
] by rule according to subsection (c)(1)(C)
of this section
; and
program
]
central office may establish and administer the waiting list for health care
benefits to address a budget shortfall.
program
] shall collect
information including, but not limited to the following:
program
] services.
Chapter 96.
BLOODBORNE PATHOGEN CONTROL