Source: http://www.sos.state.tx.us/texreg/archive/May122017/Proposed%20Rules/1.ADMINISTRATION.html
Timestamp: 2018-01-16 13:31:59
Document Index: 490154993

Matched Legal Cases: ['art 15', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§2007', '§353', '§531', '§32', '§531', '§353', '§1396', '§438', '§422', '§1861', '§1395', '§1115', '§1396', '§440', '§441', '§32', '§353', '§353', '§531', '§32', '§531', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353', '§353']

The Texas Health and Human Services Commission (HHSC) proposes amendments to Title 1 of the Texas Administrative Code, Part 15, Chapter 353, Subchapter A (regarding General Provisions), §353.2, concerning Definitions; Subchapter G (regarding STAR+PLUS), §353.603, concerning Member Participation; Subchapter H (regarding STAR Health), §353.702, concerning Member Participation; Subchapter I (regarding STAR), §353.802, concerning Member Participation; and Subchapter N (regarding STAR Kids), §353.1203, concerning Member Participation. HHSC also proposes new Subchapter G (regarding STAR+PLUS), §353.609, concerning Service Coordination.
Under the 2014-15 General Appropriations Act (Senate Bill 1, 83rd Legislature, Regular Session, 2013, Article II, Health and Human Services Commission, Rider 51(b)(15)), HHSC was directed to improve care coordination through a capitated managed care program for remaining Medicaid fee-for-service populations. As a result, HHSC will transfer the Adoption Assistance (AA), Permanency Care Assistance (PCA), and Medicaid Breast and Cervical Cancer (MBCC) populations from traditional fee-for-service Medicaid (FFS) to Medicaid managed care on September 1, 2017. The proposed amendments to §§353.603, 353.802, and 353.1203 add the AA, PCA, and MBCC populations as mandatory groups for the appropriate managed care programs.
Proposed amendments to §§353.603, 353.702, and 353.1203 also impact Former Foster Care Children (FFCC) in a 1915(c) waiver.
Adoption Assistance (AA)
The DFPS AA program facilitates the adoption of children with special needs by providing certain adoption assistance benefits to families. One of the benefits provided is Medicaid health coverage for the child being adopted. The Medicaid AA population consists of approximately 44,500 children who were adopted from DFPS conservatorship. This population currently receives Medicaid services through the FFS delivery model, and will start to receive Medicaid services through the managed care delivery model on September 1, 2017. Specifically, the child to be adopted will receive Medicaid services either through the STAR or STAR Kids program, as appropriate.
The DFPS PCA program provides benefits to certain individuals who assume managing conservatorship of a child who was previously in the temporary or permanent managing conservatorship of DFPS. One of the benefits provided is Medicaid health coverage for the child under conservatorship. The PCA program consists of approximately 1,935 children who were previously under the temporary or permanent managing conservatorship of DFPS. This population currently receives Medicaid services through the FFS delivery model and will start to receive Medicaid services through the managed care delivery model on September 1, 2017. Specifically, the child under conservatorship will receive Medicaid services either through the STAR or STAR Kids program, as appropriate.
The HHSC MBCC program provides full Medicaid coverage to women who are screened and found to need treatment for breast or cervical cancer. Services are not limited to the treatment of breast and cervical cancer, and continue as long as the Medicaid provider certifies that active treatment is required for breast or cervical cancer. As of June 2015, there were approximately 4,785 MBCC recipients. This population currently receives Medicaid services through the FFS delivery model and will start to receive Medicaid services through the managed care delivery model on September 1, 2017. Specifically, the MBCC recipients will receive Medicaid services through the STAR+PLUS program.
Former Foster Care Children (FFCC)
The FFCC is a Medicaid eligibility type for young adults who aged out of the conservatorship of Texas Department of Family and Protective Services (DFPS). FFCC individuals ages 18-20 in a 1915(c) waiver are in STAR Health today. The proposed rule amendments allow this population to choose to remain in STAR Health or opt into STAR Kids. FFCC individuals ages 21-26 in a 1915(c) waiver are currently in fee-for-service Medicaid. The proposed rule amendments make this population mandatory for STAR+PLUS.
In addition to amending rules for the transition to managed care, HHSC is proposing new §353.609 regarding service coordination for the STAR+PLUS program.
Proposed amended §353.2 adds definitions for person-centered care and person-centered planning.
Proposed amended §353.603 adds Medicaid Breast and Cervical Cancer program participants as a mandatory population in STAR+PLUS. FFCC members age 21 to 26 who are in a 1915(c) waiver or who are dual eligible (for Medicare and Medicaid) are also added as mandatory participants in STAR+PLUS.
Proposed new §353.609 describes the service coordination benefit available to all STAR+PLUS members, including the MBCC population as of September 1, 2017.
Proposed amended §353.702 adds that FFCC individuals have the option to transition from STAR Health to STAR Kids, if they meet STAR Kids participation criteria. This rule currently only lists STAR as an option for transitioning from STAR Health.
Proposed amended §353.802 adds Adoption Assistance and Permanency Care Assistance program participants as mandatory populations in STAR and makes other nonsubstantive changes.
Proposed amended §353.1203 adds Adoption Assistance and Permanency Care Assistance program participants as mandatory populations in STAR Kids. FFCC individuals are also added to the rule as optional STAR Kids members, if they meet criteria listed in the rule, such as participation in a 1915(c) waiver or being dual eligible.
Greta Rymal, Deputy Executive Commissioner for Financial Services, has determined that for each year of the first five years the proposed and amended rules are in effect, there is an anticipated fiscal impact to costs and revenues of state government.
The transitions of the Adoption Assistance (AA) and Permanency Care Assistance (PCA) programs, as well as the Medicaid Breast and Cervical Cancer (MBCC) program, are anticipated to result in a cost to state government of $4,892,764 General Revenue (GR) ($13,627,316 All Funds (AF)) for State Fiscal Year (SFY) 2018, $6,985,683 GR ($19,070,354 AF) for SFY 2019, $11,060,281 GR ($29,553,023 AF) for SFY 2020, $11,952,742 GR ($31,923,547 AF) for SFY 2021, and $12,928,361 GR ($34,511,786 AF) for SFY 2022.
In addition, for the same programs, there is an anticipated increase of revenue to the state for adopting and implementing this proposal. The increase results from premium tax paid by managed care organizations when the managed care policies are issued. There is no federal component of the anticipated revenues and all collections are deposited in the state general revenue fund. The expected collections are $4,611,730 GR for SFY 2018, $11,962,053 GR for SFY 2019, $8,590,626 GR for SFY 2020, $9,581,257 GR for SFY 2021, and $10,387,184 GR for SFY 2022. There are offsetting costs, such as those related to prior authorization and claims processing, that would be paid by HHSC or the Texas Medicaid & Healthcare Partnership were these clients not carved in to managed care. These costs are already included in the current capitation rate, so there is not an incremental per-client cost for these activities.
There is no anticipated impact to costs and revenues of state government related to the proposed transition of the FFCC individuals to managed care.
There is no anticipated impact to costs and revenues of local governments.
HHSC has determined that there will be no adverse economic effect on small businesses or micro-businesses to comply with proposed and amended rules, as they will not be required to alter their business practices because of the proposed and amended rules.
Jami Snyder, State Medicaid Director, has determined that for each year of the first five years the rules are in effect, the public will benefit from the adoption of rules. The anticipated public benefit will be that individuals enrolled in the programs being carved in will be better served by the managed care model and by having a medical home, which will ensure enhanced quality of care.
Ms. Rymal has also determined that there are no probable economic costs to persons required to comply with the proposed and amended rules.
HHSC has determined that the proposed and amended rules will not affect a local economy. There is no anticipated negative impact on local employment.
HHSC has determined that this proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under §2007.043 of the Texas Government Code.
Written comments on the proposal may be submitted to Jasmin Patel, Senior Policy Analyst, 4900 North Lamar Boulevard, Mail Code H130, Austin TX, 78751; or by e-mail to jasmin.patel@hhsc.state.tx.us within 30 days of publication of this proposal in the Texas Register.
1 TAC §353.2
The amendment is proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.
The proposed amendment implements Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.
§353.2.Definitions.
(61) Medicaid--The medical assistance program authorized and funded pursuant to Title XIX of the Social Security Act (42 U.S.C. §1396 et seq.) and administered by HHSC.
(74) [(72)] Post-stabilization care service--A covered service, related to an emergency medical condition, that is provided after a Medicaid member is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 C.F.R. §438.114(b) and (e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve the Medicaid member's condition.
(75) [(73)] Primary care provider (PCP)--A physician or other provider who has agreed with the health care MCO to provide a medical home to members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.
(76) [(74)] Provider--A credentialed and licensed individual, facility, agency, institution, organization, or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO's members.
(77) [(75)] Provider education program--Program of education about the Medicaid managed care program and about specific health or dental care issues presented by the MCO to its providers through written materials and training events.
(78) [(76)] Provider network or Network--All providers that have contracted with the MCO for the applicable managed care program.
(79) [(77)] Quality improvement--A system to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.
(80) [(78)] Rural Health Clinic (RHC)--An entity that meets all of the requirements for designation as a rural health clinic under §1861(aa)(1) of the Social Security Act (42 U.S.C. §1395x(aa)(1)) and is approved for participation in the Texas Medicaid program.
(81) [(79)] Service area--The counties included in any HHSC-defined service area as applicable to each MCO.
(82) [(80)] Significant traditional provider (STP)--A provider identified by HHSC as having provided a significant level of care to the target population, including a DSH.
(83) [(81)] STAR--The State of Texas Access Reform (STAR) managed care program that operates under a federal waiver and primarily provides, arranges for, and coordinates preventive, primary, acute care, and pharmacy services for low-income families, children, and pregnant women.
(84) [(82)] STAR Health--The managed care program that operates under the Medicaid state plan and primarily serves:
(85) [(83)] STAR Kids--The program that operates under a federal waiver and primarily provides, arranges, and coordinates preventative, primary, acute care, and long-term services and supports to persons with disabilities under the age of 21 who qualify for Medicaid.
(86) [(84)] STAR+PLUS--The managed care program that operates under a federal waiver and primarily provides, arranges, and coordinates preventive, primary, acute care, and long-term services and supports to persons with disabilities and elderly persons age 65 and over who qualify for Medicaid by virtue of their SSI or MAO status.
(87) [(85)] STAR+PLUS Home and Community-Based Services Program--The program that provides person-centered care and services that are delivered in the home or in a community setting, as authorized through a federal waiver under §1115 of the Social Security Act, to qualified Medicaid-eligible clients who are age 21 or older, as cost-effective alternatives to institutional care in nursing facilities.
(88) [(86)] State plan--The agreement between the CMS and HHSC regarding the operation of the Texas Medicaid program, in accordance with the requirements of Title XIX of the Social Security Act.
(89) [(87)] Supplemental Security Income (SSI)--The federal cash assistance program of direct financial payments to people who are 65 years of age or older, are blind, or have a disability administered by the Social Security Administration (SSA) under Title XVI of the Social Security Act. All persons who are certified as eligible for SSI in Texas are eligible for Medicaid. Local SSA claims representatives make SSI eligibility determinations. The transactions are forwarded to the SSA in Baltimore, which then notifies the states through the State Data Exchange (SDX).
(90) [(88)] Texas Health Steps (THSteps)--The name adopted by the State of Texas for the federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, described at 42 U.S.C. §1396d(r) and 42 CFR §440.40 and §§441.40 - 441.62.
(91) [(89)] Value-added service--A service provided by an MCO that is not "medical assistance," as defined by §32.003 of the Texas Human Resources Code.
TRD-201701722
For further information, please call: (512) 424-6902
1 TAC §353.603, §353.609
The amendment and new rule are proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.
The proposed amendment and new rule implement Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.
§353.603.Member Participation.
(a) Enrollment [Except as provided in subsections (b) and (d) of this section, enrollment] in the STAR+PLUS program is mandatory for Medicaid recipients who meet one or more of the following criteria:
(1) have a physical or mental disability [, are age 21 or older,] and qualify for [receive] Supplemental Security Income (SSI) benefits or for Medicaid due to low income;
(2) qualify for [the] STAR+PLUS Home and Community-Based Waiver Services [Program, as described in §353.1153 of this title (relating to STAR+PLUS Home and Community Based Services (HCBS) Program)];
(3) are age 21 or older and receive Medicaid because they are in a Social Security Exclusion program and meet financial criteria for STAR+PLUS Home and Community-Based Services Program; [or]
(4) are age 21 or older and reside in a nursing facility; [.]
(5) are over 18 and under 65 and qualify for Medicaid for Breast and Cervical Cancer as described in Chapter 366, Subchapter D, of this title (relating to Medicaid for Breast and Cervical Cancer); or
(6) FFCC members age 21 through the month of his or her 26th birthday who meet the criteria in subsections (b) or (e) of this section.
(b) In addition to the Medicaid recipients who must enroll in the STAR+PLUS program under subsection (a) of this section, recipients age 21 or older residing in a community-based ICF-IID or receiving services under the following Medicaid 1915(c) waivers and not enrolled in Medicare must enroll in STAR+PLUS to receive acute care services:
(1) Home and Community-based Services (HCS);
(2) Community Living Assistance and Support Services (CLASS);
(3) Texas Home Living (TxHmL); and
(4) Deaf Blind with Multiple Disabilities (DBMD).
(c) Medicaid recipients will have a choice among at least two MCOs.
(d) The following Medicaid recipients cannot participate in the STAR+PLUS program:
(1) persons under age 21;
(2) residents of state supported living centers;
(3) persons not eligible for full Medicaid benefits; and
(4) persons enrolled in Programs of All-Inclusive Care for Elderly (PACE).
(e) Dual eligible individuals.
(1) Enrollment in Medicare does not affect eligibility for the STAR+PLUS program, except as specified in subsection (b) of this section.
(2) Dual eligible individuals who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, and STAR+PLUS Home and Community-Based Services Program through the STAR+PLUS MCO. Dual eligible individuals who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, but may receive additional services through their STAR+PLUS MCO. The STAR+PLUS program does not change the way dual eligibles receive Medicare services.
§353.609.Service Coordination.
(a) All STAR+PLUS members have access to service coordination. Service coordination includes:
(1) face-to-face and telephonic contacts between the member and the service coordinator;
(2) development and maintenance of a comprehensive, person-centered individual service plan (ISP);
(3) coordination, including with providers, to assist the member in accessing services provided by the STAR+PLUS MCO; and
(4) coordination, including with providers as appropriate, to assist the member in accessing services provided by other community entities or service providers.
(b) STAR+PLUS members with a demonstrated need for more intensive service coordination are assigned a single, named service coordinator by the STAR+PLUS MCO. All STAR+PLUS members have access to a single, named service coordinator upon request.
TRD-201701723
SUBCHAPTER H. STAR HEALTH
1 TAC §353.702
§353.702.Member Participation.
(a) Children and young adults in the following categories are eligible to participate in the STAR Health program:
(1) a child in the conservatorship of the Texas Department of Family and Protective Services (DFPS), if the state as conservator elects to place the child in the STAR Health program;
(2) a young adult from age 18 through the month of his or her 22nd birthday who voluntarily agrees to continue in foster care placement, if the state as conservator elects to place the child in the STAR Health program; and
(3) a young adult from age 18 through the month of his or her 21st birthday who is an FFCC member or participating in the MTFCY Program.
(b) A young adult described in subsection (a)(2) and (3) of this section may choose to transfer from the STAR Health program to the STAR program or STAR Kids program, if they meet the member participation requirements in §353.802 of this chapter (relating to Member Participation) or §353.1203 of this chapter (relating to Member Participation).
(c) The following Medicaid recipients cannot participate in the STAR Health program:
(1) Children and youth who have been adjudicated and placed with the Texas Juvenile Justice Department (TJJD);
(2) Children and youth from other states who are placed in Texas through the Interstate Compact Placement Commission (ICPC) as defined by DFPS in 40 TAC Chapter 700, Subchapter S (relating to Interstate Placement of Children);
(3) Children and youth in Medicaid-paid facilities such as nursing facilities or state supported living centers;
(4) Children and youth who are in the conservatorship of DFPS who are placed outside of Texas;
(5) Children and youth who are receiving adoption assistance Medicaid as defined by DFPS in 40 TAC Chapter 700, Subchapter H (relating to Adoption Assistance Program); and
(6) Children who are declared manifestly dangerous as defined by the Texas Department of Health Services in accordance with 25 TAC Chapter 415, Subchapter G (relating to Determination of Manifest Dangerousness).
TRD-201701724
SUBCHAPTER I. STAR
1 TAC §353.802
§353.802.Member Participation.
(a) Enrollment in the State of Texas Access Reform (STAR) program is mandatory for Medicaid recipients who meet the criteria in one or more of the following categories:
(1) individuals [Individuals] age 21 and over who are eligible for the Parents and Other Caretaker Relatives program outlined in Subchapter G of Chapter 366 of this title (relating to Medicaid for Parents and Caretaker Relatives Program);[.]
(2) pregnant [Pregnant] women receiving medical assistance with household income that meets the applicable income limits specified in Subchapter C of Chapter 366 of this title (relating to Pregnant Women's Medicaid);[.]
(3) newborns [Newborns] receiving medical assistance--Children through 12 months of age with household income equal to or less than the FPL level specified in Subchapter E of Chapter 366 of this title (relating to Children's Medicaid) or born to Medicaid-eligible mothers;[.]
(4) children [Children] receiving medical assistance age 13 months through the month of his or her 18th birthday with household income equal to or less than the FPL specified in Subchapter E of Chapter 366 of this title;[.]
(5) FFCC members age 21 through the month of his or her 26th birthday; and[.]
(6) children who meet both of the following criteria:
(A) are receiving medical assistance through the Texas Department of Family and Protective Services Adoption Assistance Program, as described in Title 40 of the Texas Administrative Code, Chapter 700, Subchapter H (relating to Adoption Assistance Program); or Permanency Care Assistance Program, as described in Title 40 of the Texas Administrative Code, Chapter 700, Subchapter J, Division 2 (relating to Permanency Care Assistance Program); and
(B) are not eligible for STAR Kids, as described in Subchapter N of this chapter (relating to STAR Kids).
(b) FFCC STAR Health members ages 18 through 20 may choose to transfer to the STAR program and remain enrolled through the month of his or her 26th birthday.
(c) MTFCY STAR Health members may transfer to the STAR program.
TRD-201701725
SUBCHAPTER N. STAR KIDS
1 TAC §353.1203
§353.1203.Member Participation.
(a) Except as provided in subsection (b) of this section, enrollment in the STAR Kids program is mandatory for a Medicaid client who is under the age of 21 and meets one or both of the following criteria:
(1) has a physical or mental disability and qualifies for Supplemental Security Income (SSI) or SSI-related Medicaid; or
(2) is enrolled in the Medically Dependent Children Program (MDCP) waiver.
(b) Clients birth through age 20 residing in a community-based ICF-IID or nursing facility or receiving services under the following Medicaid 1915(c) waivers must enroll in STAR Kids to receive acute care services and non-facility based state plan services:
(3) Texas Home Living (TxHmL); or
(c) Clients birth through age 20 receiving services under the Youth Empowerment Services (YES) Medicaid 1915(c) waiver must enroll in STAR Kids to receive acute care services and non-facility based state plan services other than Community First Choice state plan services.
(d) The following Medicaid clients cannot participate in the STAR Kids program:
(1) clients residing in the Truman W. Smith Children's Care Center;
(3) residents of state veterans' homes;
(4) persons not eligible for full Medicaid benefits; and
(5) children in the conservatorship of the Texas Department of Family and Protective Services.
(e) Dual eligible clients.
(1) Enrollment in Medicare does not affect eligibility for the STAR Kids program.
(2) Dual eligible clients who participate in the STAR Kids program receive most acute care services through their Medicare provider, and long term services and supports through the STAR Kids MCO. Participation in the STAR Kids program does not change the way dual eligible clients receive Medicare services.
(f) Individuals birth through 20 who participate in the Medicaid Buy-In for Children Program or the Medicaid Buy-In Program must enroll in STAR Kids.
(g) FFCC members ages 18 through 20 may choose to transfer from STAR Health to STAR Kids if they meet the criteria in subsections (b), (c), (e), or (f) of this section.
(h) Except as provided in subsection (d) of this section, children receiving medical assistance through the Texas Department of Family and Protective Services Adoption Assistance Program, as described under Title 40 of the Texas Administrative Code, Chapter 700, Subchapter H (relating to Adoption Assistance Program); or Permanency Care Assistance Program, as described under Title 40 of the Texas Administrative Code, Chapter 700, Subchapter J, Division 2 (relating to Permanency Care Assistance Program) must enroll in STAR Kids if they meet one or more of the criteria in subsections (a), (b), (c), or (e) of this section.
(i) [(g)] STAR Kids Medicaid clients have a choice among at least two MCOs.
TRD-201701726