reglab/statecodes huggingface dataset:
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.050. Dual Medicaid and Medicare Coverage

Sec. 32.050.  DUAL MEDICAID AND MEDICARE COVERAGE.  (a)  At least annually the commission shall identify each individual receiving medical assistance under the medical assistance program who is eligible to receive similar assistance under the Medicare program.
(b)  The commission shall analyze claims submitted for payment for a service provided under the medical assistance program to an individual identified under Subsection (a) to ensure that payment is sought first under the Medicare program to the extent allowed by law.
(c)  For an ambulance service provided to an individual who is eligible under the medical assistance program and Medicare, the medical assistance program shall pay the Medicare deductibles and coinsurance.
(d)  Except as provided by Subsection (e), a nursing facility, a home health services provider, or any other similar long-term care services provider that is Medicare-certified and provides care to individuals who are eligible for Medicare must:
(1)  seek reimbursement from Medicare before billing the medical assistance program for services provided to an individual identified under Subsection (a); and
(2)  as directed by the commission, appeal Medicare claim denials for payment services provided to an individual identified under Subsection (a).
(e)  A home health services provider is not required to seek reimbursement from Medicare before billing the medical assistance program for services provided to a person who is eligible for Medicare and who:
(1)  has been determined as not being homebound; or
(2)  meets other criteria determined by the executive commissioner.
(f)  Repealed by Acts 2005, 79th Leg., Ch. 1067, Sec. 1, eff. June 18, 2005.
Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.03(a), eff. June 20, 1997.  Amended by Acts 1999, 76th Leg., ch. 710, Sec. 1.  Renumbered from Sec. 32.043 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(76), eff. Sept. 1, 1999;  Acts 2003, 78th Leg., ch. 198, Sec. 2.108, eff. Sept. 1, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 1067 (H.B. 1502), Sec. 1, eff. June 18, 2005.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.125, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.051. Misdirected Billing

Sec. 32.051.  MISDIRECTED BILLING.  To the extent authorized by federal law, the commission shall develop a procedure for the state to:
(1)  match claims for payment for medical assistance provided under the medical assistance program against data available from other entities, including the United States Department of Veterans Affairs and nursing facilities, to determine alternative responsibility for payment of the claims; and
(2)  ensure that the appropriate entity bears the cost of a claim.
Added by Acts 1997, 75th Leg., ch. 1153, Sec. 1.03(a), eff. June 20, 1997.  Renumbered from Sec. 32.044 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(77), eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.126, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0531. Pace Program Team

Sec. 32.0531.  PACE PROGRAM TEAM.  (a)  The Department of Aging and Disability Services shall establish a PACE program team composed of experienced personnel.  The team is responsible for:
(1)  increasing public attention and awareness of the availability of PACE program sites;
(2)  increasing the number of PACE program sites operating in this state; and
(3)  serving as a liaison with the state and federal agencies responsible for administering the PACE program, participants in the program, and PACE program sites.
(b)  Expired.
Added by Acts 2011, 82nd Leg., R.S., Ch. 1168 (H.B. 2903), Sec. 2, eff. September 1, 2011.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0532. Pace Program Reimbursement Methodology

Sec. 32.0532.  PACE PROGRAM REIMBURSEMENT METHODOLOGY.  (a)  In this section and Sections 32.0533 and 32.0534, "PACE program" means the program of all-inclusive care for the elderly (PACE) established under Section 32.053.
(b)  In setting the reimbursement rates under the PACE program, the executive commissioner shall ensure that:
(1)  reimbursement rates for providers under the program are adequate to sustain the program; and
(2)  the program is cost-neutral or costs less when compared to the cost to serve a population in the STAR + PLUS Medicaid managed care program that is comparable in:
(A)  age;
(B)  eligibility factors, including:
(i)  income level;
(ii)  health status; and
(iii)  impairment level;
(C)  geographic location;
(D)  living environment; and
(E)  other factors determined to be necessary.
(c)  For purposes of Subsection (b)(2), the commission shall consider data on the cost of services provided to comparable recipients enrolled in the STAR + PLUS Medicaid managed care program to calculate the upper payment limit component of the PACE program reimbursement rates.  The cost of those services includes the Medicaid capitation payment per recipient and Medicaid payments made on a fee-for-service basis for services not covered by the capitation payment.
Added by Acts 2015, 84th Leg., R.S., Ch. 823 (H.B. 3823), Sec. 1, eff. June 17, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0533. Data Collection: Pace and Star + Plus Medicaid Managed Care Programs

Sec. 32.0533.  DATA COLLECTION: PACE AND STAR + PLUS MEDICAID MANAGED CARE PROGRAMS.  The commission, in collaboration with the Department of Aging and Disability Services and appropriate stakeholder groups, shall modify the methods by which the commission and the department collect data for evaluation of the PACE and STAR + PLUS Medicaid managed care programs to allow comparison of recipient outcomes between the programs.  The modification to data collection methods must include changes to:
(1)  survey instruments that measure recipient experience;
(2)  compilation of the same or similar complaint, disenrollment, and appeals data; and
(3)  compilation of the same or similar hospital admissions and readmissions data.
Added by Acts 2015, 84th Leg., R.S., Ch. 823 (H.B. 3823), Sec. 1, eff. June 17, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.055. Catastrophic Case Management

Sec. 32.055.  CATASTROPHIC CASE MANAGEMENT.  (a)  The commission shall develop and implement a catastrophic case management system to be used in providing medical assistance to persons with catastrophic health problems.
(b)  The system must provide for the assignment of a case manager to a recipient of medical assistance with catastrophic health problems that are likely to:
(1)  require the services of multiple, specialized health care providers;  and
(2)  result in major medical costs.
(c)  The commission shall identify the services to be provided by a case manager assigned under the system.  The services must include assessment of the recipient's needs and coordination of all available medical services and payment options.  The services may include other support services such as:
(1)  assistance with making arrangements to receive care from medical facilities;
(2)  assistance with travel and lodging in connection with receipt of medical care;
(3)  education of the recipient and the recipient's family members regarding the nature of the recipient's health problems;
(4)  referral to appropriate support groups; and
(5)  any other service likely to result in better care provided in a cost-effective manner.
(d)  Repealed by Acts 2011, 82nd Leg., R.S., Ch. 1083, Sec. 25(109), eff. June 17, 2011.
Added by Acts 2001, 77th Leg., ch. 408, Sec. 1, eff. Sept. 1, 2001.  Renumbered from Human Resources Code Sec. 32.053 by Acts 2003, 78th Leg., ch. 1275, Sec. 2(99), eff. Sept. 1, 2003.
Amended by:
Acts 2011, 82nd Leg., R.S., Ch. 1050 (S.B. 71), Sec. 23(7), eff. September 1, 2011.
Acts 2011, 82nd Leg., R.S., Ch. 1083 (S.B. 1179), Sec. 25(109), eff. June 17, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.130, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0551. Optimization of Case Management Systems

Sec. 32.0551.  OPTIMIZATION OF CASE MANAGEMENT SYSTEMS.  The commission shall:
(1)  create and coordinate staffing and other administrative efficiencies for case management initiatives across the commission and health and human services agencies; and
(2)  optimize federal funding revenue sources and maximize the use of state funding resources for case management initiatives across the commission and health and human services agencies.
Added by Acts 2005, 79th Leg., Ch. 349 (S.B. 1188), Sec. 8(a), eff. September 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.131, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.056. Compliance With Texas Health Steps Comprehensive Care Program

Sec. 32.056.  COMPLIANCE WITH TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM.  The executive commissioner by rule shall develop procedures to ensure that recipients of medical assistance who are eligible for Texas Health Steps Comprehensive Care Program comply with the regimen of care prescribed by the program.
Added by Acts 2001, 77th Leg., ch. 584, Sec. 5, eff. Jan. 1, 2002.  Renumbered from Human Resources Code Sec. 32.053 by Acts 2003, 78th Leg., ch. 1275, Sec. 2(100), eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.131, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0561. Maternal Depression Screening

Sec. 32.0561.  MATERNAL DEPRESSION SCREENING.  (a)  In this section, "maternal depression" means depression of any severity with postpartum onset.
(b)  The commission shall provide medical assistance reimbursement for a maternal depression screening for a recipient's mother, regardless of whether the mother is also a recipient, that is performed during a covered examination for the recipient under the Texas Health Steps Comprehensive Care Program that occurs before the recipient's first birthday.
(c)  The executive commissioner shall adopt rules necessary to implement this section.  The rules must be based on:
(1)  clinical and empirical evidence concerning maternal depression; and
(2)  information provided by relevant physicians and behavioral health organizations.
(d)  The commission shall seek, accept, and spend any federal funds that are available for the purposes of this section, including priority funding authorized by Section 317L-1 of the Public Health Service Act (42 U.S.C. Section 201 et seq.), as added by the 21st Century Cures Act (Pub. L. No. 114-255).
Added by Acts 2017, 85th Leg., R.S., Ch. 852 (H.B. 2466), Sec. 3, eff. September 1, 2017.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.059. Use of Respiratory Therapists for Respiratory Therapy Services

Sec. 32.059.  USE OF RESPIRATORY THERAPISTS FOR RESPIRATORY THERAPY SERVICES.  The executive commissioner by rule shall require that respiratory therapy services for ventilator-dependent persons furnished as part of a plan of care under this chapter be provided by a respiratory care practitioner authorized to practice respiratory care under Chapter 604, Occupations Code, when:
(1)  respiratory therapy is determined by the recipient's treating physician to be the most effective method of treatment; and
(2)  the use of a respiratory care practitioner is practicable and cost-neutral or cost-effective.
Acts 2003, 78th Leg., ch. 1167, Sec. 1, eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.134, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.061. Community Attendant Services Program

Sec. 32.061.  COMMUNITY ATTENDANT SERVICES PROGRAM.  (a)  Any home and community-based services that the commission provides under Section 1929, Social Security Act (42 U.S.C. Section 1396t) and its subsequent amendments to functionally disabled individuals who have income that exceeds the limit established by federal law for Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.) and its subsequent amendments shall be provided through the community attendant services program.
(b)  In determining an applicant's eligibility for home and community-based services described by Subsection (a), the commission shall exclude $20 of unearned or earned income from the applicant's monthly income.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.110, eff. Sept. 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 795 (S.B. 22), Sec. 1(a), eff. September 1, 2007.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.135, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.062. Admissibility of Certain Evidence Relating to Nursing Institutions

Sec. 32.062.  ADMISSIBILITY OF CERTAIN EVIDENCE RELATING TO NURSING INSTITUTIONS.
(a)  The following are not admissible as evidence in a civil action:
(1)  any finding by the Department of Aging and Disability Services that an institution licensed under Chapter 242, Health and Safety Code, has violated a standard for participation in the medical assistance program under this chapter; or
(2)  the fact of the assessment of a monetary penalty against an institution under Section 32.021 or the payment of the penalty by an institution.
(b)  This section does not apply in an enforcement action in which the state or an agency or political subdivision of the state is a party.
(c)  Notwithstanding any other provision of this section, evidence described by Subsection (a) is admissible as evidence in a civil action only if:
(1)  the evidence relates to a material violation of this chapter or a rule adopted under this chapter or assessment of a monetary penalty with respect to:
(A)  the particular incident and the particular individual whose personal injury is the basis of the claim being brought in the civil action; or
(B)  a finding by the Department of Aging and Disability Services that directly involves substantially similar conduct that occurred at the institution within a period of one year before the particular incident that is the basis of the claim being brought in the civil action;
(2)  the evidence of a material violation has been affirmed by the entry of a final adjudicated and unappealable order of the Department of Aging and Disability Services after formal appeal; and
(3)  the record is otherwise admissible under the Texas Rules of Evidence.
Added by Acts 2003, 78th Leg., ch. 204, Sec. 16.01, eff. Sept. 1, 2003.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 1120 (H.B. 1218), Sec. 3, eff. September 1, 2009.
Redesignated from Human Resources Code, Section 32.060 by Acts 2011, 82nd Leg., R.S., Ch. 91 (S.B. 1303), Sec. 27.001(33), eff. September 1, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.136, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.063. Third-Party Billing Vendors

Sec. 32.063.  THIRD-PARTY BILLING VENDORS.  (a)  A third-party billing vendor may not submit a claim with the commission for reimbursement on behalf of a provider of medical services under the medical assistance program unless the vendor has entered into a contract with the commission authorizing that activity.
(b)  To the extent practical, the contract shall contain provisions comparable to the provisions contained in contracts between the commission and providers of medical services, with an emphasis on provisions designed to prevent fraud or abuse under the medical assistance program.  At a minimum, the contract must require the third-party billing vendor to:
(1)  provide documentation of the vendor's authority to bill on behalf of each provider for whom the vendor submits claims;
(2)  submit a claim in a manner that permits the commission to identify and verify the vendor, any computer or telephone line used in submitting the claim, any relevant user password used in submitting the claim, and any provider number referenced in the claim; and
(3)  subject to any confidentiality requirements imposed by federal law, provide the commission, the office of the attorney general, or authorized representatives with:
(A)  access to any records maintained by the vendor, including original records and records maintained by the vendor on behalf of a provider, relevant to an audit or investigation of the vendor's services or another function of the commission or office of the attorney general relating to the vendor; and
(B)  if requested, copies of any records described by Paragraph (A) at no charge to the commission, the office of the attorney general, or authorized representatives.
(c)  On receipt of a claim submitted by a third-party billing vendor, the commission shall send a remittance notice directly to the provider referenced in the claim.  The notice must:
(1)  include detailed information regarding the claim submitted on behalf of the provider; and
(2)  require the provider to review the claim for accuracy and notify the commission promptly regarding any errors.
(d)  The commission shall take all action necessary, including any modifications of the commission's claims processing system, to enable the commission to identify and verify a third-party billing vendor submitting a claim for reimbursement under the medical assistance program, including identification and verification of any computer or telephone line used in submitting the claim, any relevant user password used in submitting the claim, and any provider number referenced in the claim.
(e)  The commission shall audit each third-party billing vendor subject to this section at least annually to prevent fraud and abuse under the medical assistance program.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.111(a), eff. Jan. 1, 2004.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.137, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.064. Cost Sharing

Sec. 32.064.  COST SHARING.
Text of subsection effective until April 01, 2025
(a)  To the extent permitted under Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), as amended, and any other applicable law or regulations, the executive commissioner shall adopt provisions requiring recipients of medical assistance to share the cost of medical assistance, including provisions requiring recipients to pay:
(1)  an enrollment fee;
(2)  a deductible; or
(3)  coinsurance or a portion of the plan premium, if the recipients receive medical assistance under the Medicaid managed care program under Chapter 533, Government Code.
Text of subsection effective on April 01, 2025
(a)  To the extent permitted under Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), as amended, and any other applicable law or regulations, the executive commissioner shall adopt provisions requiring recipients of medical assistance to share the cost of medical assistance, including provisions requiring recipients to pay:
(1)  an enrollment fee;
(2)  a deductible; or
(3)  coinsurance or a portion of the plan premium, if the recipients receive medical assistance under the Medicaid managed care program under Chapter 540 or 540A, Government Code, as applicable.
(b)  Subject to Subsection (d), cost-sharing provisions adopted under this section shall ensure that families with higher levels of income are required to pay progressively higher percentages of the cost of the medical assistance.
(c)  If cost-sharing provisions imposed under Subsection (a) include requirements that recipients pay a portion of the plan premium, the commission shall specify the manner in which the premium is paid.  The commission may require that the premium be paid to the commission, an agency operating part of the medical assistance program, or the Medicaid managed care plan.
(d)  Cost-sharing provisions adopted under this section may be determined based on the maximum level authorized under federal law and applied to income levels in a manner that minimizes administrative costs.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.112(a), eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.138, eff. April 2, 2015.
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.87, eff. April 1, 2025.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0641. Recipient Accountability Provisions; Cost-Sharing Requirement to Improve Appropriate Utilization of Services

Sec. 32.0641.  RECIPIENT ACCOUNTABILITY PROVISIONS; COST-SHARING REQUIREMENT TO IMPROVE APPROPRIATE UTILIZATION OF SERVICES.  (a)  To the extent permitted under and in a manner that is consistent with Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.) and any other applicable law or regulation or under a federal waiver or other authorization, the executive commissioner shall adopt cost-sharing provisions that encourage personal accountability and appropriate utilization of health care services, including a cost-sharing provision applicable to a recipient who chooses to receive a nonemergency medical service through a hospital emergency room.
(b)  The commission may not seek a federal waiver or other authorization under this section that would:
(1)  prevent a Medicaid recipient who has a condition requiring emergency medical services from receiving care through a hospital emergency room; or
(2)  waive any provision under Section 1867, Social Security Act (42 U.S.C. Section 1395dd).
Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 20, eff. September 1, 2007.
Amended by:
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.09(b), eff. September 28, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.139, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.37, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.34, eff. January 1, 2016.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.067. Delivery of Comprehensive Care Services to Certain Recipients of Medical Assistance

Sec. 32.067.  DELIVERY OF COMPREHENSIVE CARE SERVICES TO CERTAIN RECIPIENTS OF MEDICAL ASSISTANCE.  (a)  In this section, "certified agency" and "home health service" have the meanings assigned by Section 142.001, Health and Safety Code.
(b)  The commission shall assure that any agency licensed to provide home health services under Chapter 142, Health and Safety Code, and not only a certified agency licensed under that chapter, may provide home health services to individuals enrolled in the Texas Health Steps Comprehensive Care Program.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.204, eff. Sept. 1, 2003.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.140, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.068. In-Person Evaluation Required for Certain Services

Sec. 32.068.  IN-PERSON EVALUATION REQUIRED FOR CERTAIN SERVICES.  (a)  A medical assistance provider may order or otherwise authorize the provision of home health services for a recipient only if the provider has conducted an in-person evaluation of the recipient within the 12-month period preceding the date the order or other authorization was issued.
(b)  A physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife that orders or otherwise authorizes the provision of durable medical equipment for a recipient in accordance with Chapter 157, Occupations Code, and other applicable law, including rules, must certify on the order or other authorization that the person conducted an in-person evaluation of the recipient within the 12-month period preceding the date the order or other authorization was issued.
(c)  The executive commissioner shall adopt rules necessary to implement this section.  The executive commissioner may by rule adopt limited exceptions to the requirements of this section.
Added by Acts 2011, 82nd Leg., R.S., Ch. 980 (H.B. 1720), Sec. 31, eff. September 1, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.141, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.069. Chronic Kidney Disease Management Initiative

Sec. 32.069.  CHRONIC KIDNEY DISEASE MANAGEMENT INITIATIVE.  A provider of disease management programs under Section 32.057 shall develop a program to provide screening for and diagnosis and treatment of chronic kidney disease and its medical complications under the medical assistance program.  The program must use generally recognized clinical practice guidelines and laboratory assessments that identify chronic kidney disease on the basis of impaired kidney function or the presence of kidney damage.
Added by Acts 2005, 79th Leg., Ch. 1047 (H.B. 1252), Sec. 3, eff. September 1, 2005.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.142, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0705. External Audits of Certain Medicaid Contractors Based on Risk

Sec. 32.0705.  EXTERNAL AUDITS OF CERTAIN MEDICAID CONTRACTORS BASED ON RISK.
Text of subsection effective until April 01, 2025
(a)  In this section, "Medicaid contractor" means an entity that:
(1)  is not a health and human services agency as defined by Section 531.001, Government Code; and
(2)  under a contract with the commission or otherwise on behalf of the commission, performs one or more administrative services in relation to the commission's operation of Medicaid, such as claims processing, utilization review, client enrollment, provider enrollment, quality monitoring, or payment of claims.
Text of subsection effective on April 01, 2025
(a)  In this section, "Medicaid contractor" means an entity that:
(1)  is not a health and human services agency as defined by Section 521.0001, Government Code; and
(2)  under a contract with the commission or otherwise on behalf of the commission, performs one or more administrative services in relation to the commission's operation of Medicaid, such as claims processing, utilization review, client enrollment, provider enrollment, quality monitoring, or payment of claims.
(b)  The commission shall contract with an independent auditor to perform annual independent external financial and performance audits of any Medicaid contractor used in the commission's operation of Medicaid.  The commission regularly shall review the Medicaid contracts and ensure that:
(1)  the frequency and extent of audits of a Medicaid contractor under this section are based on the amount of risk to the state involved in the administrative services being performed by the contractor;
(2)  audit procedures related to financial audits and performance audits are used consistently in audits under this section; and
(3)  to the extent possible, audits under this section are completed in a timely manner.
(c)  If another state agency succeeds to the commission's operation of a part of Medicaid for which the commission used a Medicaid contractor, the successor agency shall comply with this section with regard to the Medicaid contractor, including the requirement to contract with an independent auditor to perform the external financial and performance audits required by this section.
(d)  An audit required by this section must be completed before the end of the fiscal year immediately following the fiscal year for which the audit is performed.
Added by Acts 1999, 76th Leg., ch. 1411, Sec. 1.10, eff. Sept. 1, 1999.
Transferred, redesignated and amended from Health and Safety Code, Section 12.0123 by Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 3.0016, eff. April 2, 2015.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.88, eff. April 1, 2025.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.072. Direct Access to Eye Health Care Services

Sec. 32.072.  DIRECT ACCESS TO EYE HEALTH CARE SERVICES.  (a)  Notwithstanding any other law, a recipient of medical assistance is entitled to:
(1)  select an ophthalmologist or therapeutic optometrist who is a medical assistance provider to provide eye health care services, other than surgery, that are within the scope of:
(A)  services provided under the medical assistance program; and
(B)  the professional specialty practice for which the ophthalmologist or therapeutic optometrist is licensed; and
(2)  have direct access to the selected ophthalmologist or therapeutic optometrist for the provision of the nonsurgical services without any requirement that the patient or ophthalmologist or therapeutic optometrist obtain:
(A)  a referral from a primary care physician or other gatekeeper or health care coordinator; or
(B)  any other prior authorization or precertification.
(b)  The commission may require an ophthalmologist or therapeutic optometrist selected as provided by this section by a recipient of medical assistance who is otherwise required to have a primary care physician or other gatekeeper or health care coordinator to forward to the recipient's physician, gatekeeper, or health care coordinator information concerning the eye health care services provided to the recipient.
(c)  This section may not be construed to expand the scope of eye health care services provided under the medical assistance program.
Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 21(a), eff. September 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.145, eff. April 2, 2015.
Acts 2017, 85th Leg., R.S., Ch. 901 (H.B. 3675), Sec. 1, eff. September 1, 2017.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.073. Health Information Technology Standards

Sec. 32.073.  HEALTH INFORMATION TECHNOLOGY STANDARDS.  (a)  In this section, "health information technology" means information technology used to improve the quality, safety, or efficiency of clinical practice, including the core functionalities of an electronic health record, an electronic medical record, a computerized health care provider order entry, electronic prescribing, and clinical decision support technology.
(b)  The commission shall ensure that any health information technology used by the commission or any entity acting on behalf of the commission in the medical assistance program conforms to standards required under federal law.
(c)  Not later than the second anniversary of the date national standards for electronic prior authorization of benefits are adopted, the commission shall require a health benefit plan issuer participating in the medical assistance program or the agent of the health benefit plan issuer that manages or administers prescription drug benefits to exchange prior authorization requests electronically with a prescribing provider participating in the medical assistance program who has electronic prescribing capability and who initiates a request electronically.
Added by Acts 2009, 81st Leg., R.S., Ch. 1120 (H.B. 1218), Sec. 4, eff. September 1, 2009.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 1311 (S.B. 8), Sec. 11, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.146, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.074. Access to Personal Emergency Response System

Sec. 32.074.  ACCESS TO PERSONAL EMERGENCY RESPONSE SYSTEM.  (a)  In this section, "personal emergency response system" has the meaning assigned by Section 1702.331, Occupations Code.
(b)  The commission shall ensure that each Medicaid recipient enrolled in a home and community-based services waiver program that includes a personal emergency response system as a service has access to a personal emergency response system, if necessary, without regard to the recipient's access to a landline telephone.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.20, eff. September 28, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.147, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 3.021, eff. September 1, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.075. Employment Assistance and Supported Employment

Sec. 32.075.  EMPLOYMENT ASSISTANCE AND SUPPORTED EMPLOYMENT.  (a)  In this section:
(1)  "Employment assistance" means assistance provided to an individual to help the individual locate paid employment in the community.  Employment assistance includes:
(A)  identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;
(B)  locating prospective employers offering employment compatible with an individual's identified preferences, skills, and requirements; and
(C)  contacting a prospective employer on behalf of an individual and negotiating the individual's employment.
(2)  "Supported employment" means assistance provided, in order to sustain paid employment, to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.  Supported employment includes adaptations, supervision, and training related to an individual's diagnosis.
(b)  This section applies only to the following medical assistance waiver programs:
(1)  the community based alternatives program;
(2)  the community living assistance and support services program;
(3)  the deaf-blind with multiple disabilities program;
(4)  the home and community-based services program;
(5)  the medically dependent children program;
(6)  the STAR + PLUS Medicaid managed care program;
(7)  the Texas home living program; and
(8)  the youth empowerment services program.
(c)  The commission shall provide employment assistance and supported employment to participants in the waiver programs identified in Subsection (b).
Added by Acts 2013, 83rd Leg., R.S., Ch. 506 (S.B. 45), Sec. 1, eff. June 14, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.148, eff. April 2, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.0755. Prevocational Services Under Certain Waiver Programs

Sec. 32.0755.  PREVOCATIONAL SERVICES UNDER CERTAIN WAIVER PROGRAMS.  (a)  In this section, "prevocational services" means services that are designed to prepare an individual for paid or unpaid work and achieve a generalized result rather than being job-task oriented.
(b)  Prevocational services provided under the community living assistance and support services (CLASS) waiver program or another medical assistance waiver program providing long-term services or supports to a medical assistance recipient should be designed to assist the recipient in achieving competitive integrated employment in the community receiving compensation at or above the minimum wage in the recipient's community and in accordance with state and federal law.
(c)  The commission shall seek a waiver or other necessary authorization from the appropriate federal agency to include prevocational services as part of the individualized skills and socialization services delivered under a medical assistance waiver program providing long-term services and supports.
(d)  If the commission's request for a waiver or other authorization under Subsection (c) is not granted, the commission shall collaborate with relevant stakeholders and applicable federal agencies to establish a service similar to prevocational services in a manner that is authorized by federal law.
(e)  If the commission is granted a waiver or other authorization under Subsection (d):
(1)  the reimbursement rate for the service the commission establishes under that subsection may not exceed the reimbursement rate for individualized skills and socialization services; and
(2)  if the service is combined with individualized skills and socialization services, the commission shall ensure the service may not exceed the total allowable hours or the total costs for individualized skills and socialization services provided under a service plan.
(f)  The executive commissioner by rule shall establish clearly stated, service-related performance standards applicable to providers providing prevocational or similar services to recipients under a medical assistance waiver program in accordance with this section.  The commission shall monitor the performance of each provider of prevocational or similar services under a medical assistance waiver program to ensure compliance with those standards.
Added by Acts 2023, 88th Leg., R.S., Ch. 872 (H.B. 4169), Sec. 1, eff. June 13, 2023.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter B. Administrative Provisions › Section 32.076. Substitute Dentists

Sec. 32.076.  SUBSTITUTE DENTISTS.  To the extent allowed by federal law, the executive commissioner of the Health and Human Services Commission shall adopt rules ensuring that the same standards applying to a physician who bills the medical assistance program for services provided by a substitute physician apply also to a dentist who bills the medical assistance program for services provided by a substitute dentist.
Added by Acts 2015, 84th Leg., R.S., Ch. 739 (H.B. 1661), Sec. 1, eff. June 17, 2015.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter C. Medical Assistance Program Provider Database › Section 32.101. Definitions

Sec. 32.101.  DEFINITIONS.  In this subchapter:
(1)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 1 , Sec. 4.465(a)(43), eff. April 2, 2015.
(2)  "Health care provider" means a person, other than a physician, who:
(A)  is licensed or otherwise authorized to provide a health care service in this state, including:
(i)  a pharmacist, dentist, optometrist, mental health counselor, social worker, advanced practice nurse, physician assistant, or durable medical equipment supplier;
(ii)  a pharmacy, hospital, or other institution or organization; or
(iii)  a local public health entity;
(B)  is wholly owned or controlled by:
(i)  a health care provider or a group of health care providers described by Paragraph (A); or
(ii)  one or more hospitals and physicians, including a physician-hospital organization;
(C)  is a professional association of physicians organized under the Texas Professional Association Law, as described by Section 1.008, Business Organizations Code;
(D)  is an approved nonprofit health corporation certified under Chapter 162, Occupations Code;
(E)  is a medical and dental unit, as defined by Section 61.003, Education Code, a medical school, as defined by Section 61.501, Education Code, or a health science center described by Subchapter K, Chapter 74, Education Code, that employs or contracts with physicians to teach or provide medical services, or employs physicians and contracts with physicians in a practice plan; or
(F)  is another person wholly owned by physicians.
Text of subdivision effective until April 01, 2025
(3)  "Managed care organization" has the meaning assigned by Section 533.001, Government Code.
Text of subdivision effective on April 01, 2025
(3)  "Managed care organization" has the meaning assigned by Section 540.0001, Government Code.
Text of subdivision effective until April 01, 2025
(4)  "Managed care plan" has the meaning assigned by Section 533.001, Government Code.
Text of subdivision effective on April 01, 2025
(4)  "Managed care plan" has the meaning assigned by Section 540.0001, Government Code.
(5)  "Participating provider" means a physician or health care provider who is a provider of medical assistance, including a physician or health care provider who contracts or otherwise agrees with a managed care organization to provide medical assistance under this chapter.
(6)  "Physician" means an individual licensed to practice medicine in this state.
(7)  "Recipient" means a recipient of medical assistance.
Added by Acts 2007, 80th Leg., R.S., Ch. 883 (H.B. 2042), Sec. 1, eff. June 15, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.465(a)(43), eff. April 2, 2015.
Acts 2021, 87th Leg., R.S., Ch. 535 (S.B. 73), Sec. 3, eff. September 1, 2021.
Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 2.89, eff. April 1, 2025.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter C. Medical Assistance Program Provider Database › Section 32.102. Database of Medical Assistance Program Providers

Sec. 32.102.  DATABASE OF MEDICAL ASSISTANCE PROGRAM PROVIDERS.  (a)  The executive commissioner shall establish and administer an electronic, searchable, Internet-based database of all participating providers in the medical assistance program.
(b)  The database must include, as applicable, at least the following information regarding each participating provider:
(1)  the provider's:
(A)  name;
(B)  specialty;
(C)  location;
(D)  office hours, including any office hours outside of regular business hours; and
(E)  telephone number;
(2)  whether the provider:
(A)  is accepting new recipients, and if the provider is accepting new recipients and if applicable, the managed care organization or managed care plan under which new recipients are being accepted;
(B)  has any practice limitations, including specific age range limitations; and
(C)  speaks any languages other than English;
(3)  a list of the medical assistance program services offered by the provider; and
(4)  any waiver program or other program within the medical assistance program in which the provider is a participant, including the Texas Health Steps program.
(c)  In establishing the database, the executive commissioner shall ensure that the database:
(1)  allows a person to search a managed care organization by name and by participating provider within each of the managed care plans offered by that managed care organization;
(2)  allows a participating provider to electronically access and change or update the information required by Subsection (b)(1), (2), or (3); and
(3)  is available and accessible to each participating provider and each recipient.
(d)  The executive commissioner shall ensure that the database is updated continually and at least once a month.
Added by Acts 2007, 80th Leg., R.S., Ch. 883 (H.B. 2042), Sec. 1, eff. June 15, 2007.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter C. Medical Assistance Program Provider Database › Section 32.103. Certain Fees Prohibited

Sec. 32.103.  CERTAIN FEES PROHIBITED.  A person, including the executive commissioner, a person acting under a contract under Section 32.104, or a managed care organization, may not charge a participating provider or a recipient a fee, directly or indirectly, for making information available or for accessing information in the database established under this subchapter.
Added by Acts 2007, 80th Leg., R.S., Ch. 883 (H.B. 2042), Sec. 1, eff. June 15, 2007.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter C. Medical Assistance Program Provider Database › Section 32.104. Authority to Contract

Sec. 32.104.  AUTHORITY TO CONTRACT.  (a)  The executive commissioner may contract with a state agency or a private entity for the creation, operation, and maintenance of the database required by this subchapter.
(b)  A contract entered into under this section must allow the executive commissioner to oversee and supervise the contractor and the database.
Added by Acts 2007, 80th Leg., R.S., Ch. 883 (H.B. 2042), Sec. 1, eff. June 15, 2007.
2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 32 - Medical Assistance Program › Subchapter C. Medical Assistance Program Provider Database › Section 32.105. Rules

Sec. 32.105.  RULES.  The executive commissioner shall adopt rules to implement and administer this subchapter.
Added by Acts 2007, 80th Leg., R.S., Ch. 883 (H.B. 2042), Sec. 1, eff. June 15, 2007.