reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter E - STANDARDS FOR MEDICAID MANAGED CARE › Section 353.419 - Financial Standards

Current through Reg. 49, No. 28; July 12, 2024
(a) A managed care
				  organization (MCO) must maintain compliance with the MCO contract requirements,
				  and the Texas Insurance Code and rules promulgated and administered by the
				  Texas Department of Insurance, requiring a fiscally sound operation.
(b) The Health and Human Services Commission
				  (HHSC) may share in the experience rebates in accordance with §
										RSA
				  353.3 of this chapter (relating to Experience
				  Rebate in the Managed Care Program).
(c) HHSC may establish incentive payment
				  programs to encourage MCOs to meet or exceed the goals and objectives of the
				  Medicaid managed care program established by HHSC through its
				  contract.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter E - STANDARDS FOR MEDICAID MANAGED CARE › Section 353.421 - Special Disease Management for Health Care MCOs

Current through Reg. 49, No. 28; July 12, 2024
(a) For purposes of this rule, "Special
				  Disease Management" means a program of coordinated healthcare interventions and
				  communications for populations with conditions in which patient self-care
				  efforts are significant.
(b) In
				  order for a health care MCO to receive a contract from HHSC to provide special
				  disease management services, the health care MCO must:
(1) Implement policies and procedures to
				  ensure that members requiring special disease management services are
				  identified and enrolled into a disease management program;
(2) Develop and maintain screening and
				  evaluation procedures for the early detection, prevention, treatment, or
				  referral of participants at risk for or diagnosed with chronic conditions such
				  as heart disease, chronic kidney disease and its medical complications,
				  respiratory illness including asthma, diabetes, and HIV infection or
				  AIDS;
(3) Ensure that all members
				  identified for special disease management are enrolled in and have the
				  opportunity to opt out of special disease management services within 30 days
				  while still maintaining access to all other covered services; and
(4) Show evidence of the ability to manage
				  complex diseases in the Medicaid population. Such evidence shall be
				  demonstrated by the health care MCO's compliance with this
				  subchapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter E - STANDARDS FOR MEDICAID MANAGED CARE › Section 353.423 - Expedited Credentialing

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  identifies applicant provider types for which an expedited credentialing
				  process must be established and implemented.
(b) An MCO must comply with the requirements
				  of Texas Insurance Code Chapter 1452, Subchapters C, D, and E, regarding
				  expedited credentialing and payment of physicians, podiatrists, and therapeutic
				  optometrists. Additionally, each MCO must establish and implement an expedited
				  credentialing process that allows applicant providers to provide services to
				  members for the following provider types:
(1)
				  dentists;
(2) dental specialists
				  (endodontist, oral/maxillofacial surgeon, orthodontist, pediatric dentist,
				  periodontist, prosthodontist, and physicians providing dental specialty
				  care);
(3) licensed clinical social
				  workers;
(4) licensed professional
				  counselors;
(5) licensed marriage
				  and family therapists; and
(6)
				  psychologists.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter E - STANDARDS FOR MEDICAID MANAGED CARE › Section 353.425 - MCO Processing of Prior Authorization Requests Received with Incomplete or Insufficient Documentation

Current through Reg. 49, No. 28; July 12, 2024
(a) The rules
				  in this section apply when a prior authorization (PA) request is submitted with
				  incomplete or insufficient information or documentation on behalf of a member
				  who is not hospitalized at the time of the request.
(b) In this section, "incomplete PA request"
				  means a request for service that is missing information or documentation
				  necessary to establish medical necessity as listed in the PA requirements on
				  the managed care organization's (MCO's) website.
(c) An MCO must comply with Title 42 Code of
				  Federal Regulations §438.210, applicable provisions of Texas Government
				  Code Chapter 533, and the PA process and timeline requirements included in an
				  MCO's contract with the Texas Health and Human Services Commission
				  (HHSC).
(d) If an MCO or an entity
				  reviewing a request on behalf of an MCO receives a PA request with incomplete
				  or insufficient information or documentation, the MCO or reviewing entity must
				  comply with the following HHSC requirements.
(1) An MCO reviewing the request must notify
				  the requesting provider and the member, in writing, of the missing information
				  no later than three business days after the MCO receives an incomplete PA
				  request.
(2) If an MCO does not
				  receive the information requested within three business days after the MCO
				  notifies the requesting provider and the PA request will result in an adverse
				  benefit determination, the MCO must refer the PA request to the MCO medical
				  director for review.
(3) The MCO
				  must offer to the requesting physician an opportunity for a peer-to-peer
				  consultation with a physician no less than one business day before the MCO
				  issues an adverse benefit determination.
(4) The MCO must make a final determination
				  as expeditiously as the member's condition requires but no later than three
				  business days after the date the missing information is provided to an
				  MCO.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter E - STANDARDS FOR MEDICAID MANAGED CARE › Section 353.427 - Accessibility of Information Regarding Medicaid Prior Authorization Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) In this section, "accessible" means
				  publicly available and capable of being found and read without impediment.
				  Usernames and passwords cannot be required to view the information.
(b) A managed care organization (MCO) must
				  maintain on its public-facing website the MCO's criteria and policy for prior
				  authorizations and website links to any prior authorization request forms the
				  provider uses.
(c) The MCO must
				  maintain the following items on its website in an easily searchable and
				  accessible format.
(1) Applicable timelines
				  for prior authorization requirements, including:
(A) the timeframe in which the MCO must make
				  a determination on a prior authorization request;
(B) a description of the notice the MCO
				  provides to a provider or member regarding the documentation required to
				  complete a prior authorization determination; and
(C) the deadline by which the MCO must submit
				  the notice described in subparagraph (B) of this paragraph.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 353.501 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter implements the Health and
				  Human Services Commission's (HHSC), Office of Inspector General (OIG) authority
				  to approve annually, each managed care organization (MCO) plan to prevent and
				  reduce waste, abuse, and fraud. This authority is granted by Chapter 531,
				  Subchapter C, Government Code, §
										RSA
				  531.113.
(b) An MCO that provides or arranges for the
				  provision of health care services or dental services to an individual under the
				  Medical Assistance Program (Medicaid), must arrange for a special investigative
				  unit to investigate fraudulent claims and other types of program abuse by
				  recipients and providers. An MCO may choose to:
(1) establish and maintain the special
				  investigative unit within the MCO; or
(2) contract with another entity for the
				  investigation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 353.502 - Managed Care Organization's Plans and Responsibilities in Preventing and Reducing Waste, Abuse, and Fraud

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Each managed care organization (MCO) subject to this section must develop a
				  plan to prevent and reduce waste, abuse, and fraud and submit that plan
				  annually to the Health and Human Services Commission (HHSC), Office of
				  Inspector General (OIG) for approval.
(b) The MCO is responsible for investigating
				  possible acts of waste, abuse, or fraud for all services, including those that
				  the MCO subcontracts to outside entities.
(c) The plan submitted to the HHSC-OIG must
				  include the following information to be considered for approval.
(1) A description of the MCO's procedures for
				  detecting possible acts of waste, abuse, and fraud by providers. The
				  description must address each of the following requirements:
(A) use of audits to monitor compliance and
				  assist in detecting and identifying Medicaid program violations and possible
				  waste, abuse, and fraud overpayments through data matching, analysis, trending,
				  and statistical activities;
(B)
				  monitoring of service patterns for providers, subcontractors, and
				  recipients;
(C) use of a hotline or
				  another mechanism to report potential or suspected violations;
(D) use of random payment review of claims
				  submitted by providers for reimbursement to detect potential waste, abuse, or
				  fraud;
(E) use of edits or other
				  evaluation techniques to prevent payment for fraudulent or abusive
				  claims;
(F) use of routine
				  validation of MCO data; and
(G)
				  verification that MCO members actually received services that were
				  billed.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 353.503 - Managed Care Organization's Contracts

Current through Reg. 49, No. 28; July 12, 2024
If a managed care organization (MCO) contracts for the
					 investigation of fraudulent claims and other types of programs abuse by
					 recipients and providers under §
										RSA
					 353.501(e) of this chapter
					 (relating to Purpose), within 10 working days of executing the contract the MCO
					 must file with the Health and Human Services Commission, Office of Inspector
					 General (HHSC-OIG):
(1) a copy of the
				  written contract including any and all attachments.
(2) the names, titles, addresses, telephone
				  numbers, and fax numbers of the principals of the entity with which the MCO has
				  contracted; and
(3) a description
				  of the qualifications of the principals of the entity with which the MCO has
				  contracted to perform the contracted responsibilities.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 353.504 - Review of Managed Care Organization's Records

Current through Reg. 49, No. 28; July 12, 2024
(a) Immediately upon request, the Health and
				  Human Services Commission, Office of Inspector General (HHSC-OIG), Office of
				  the Attorney General-Medicaid Fraud Control Unit (OAG-MFCU) and OAG, Office of
				  the Attorney General-Civil Medicaid Fraud Division (OAG-CMFD), and the United
				  States Health and Human Services, Office of Inspector General (HHS-OIG) may
				  review the records of a managed care organization (MCO) to determine compliance
				  with this subchapter.
(b) Upon
				  receipt of a record review request from any state or federal agency authorized
				  to conduct compliance, regulatory, or program integrity functions, an MCO must:
(1) At no charge to the entities identified
				  in subsection (a) of this section, provide the records requested by a properly
				  identified agent of any state or federal agency authorized to conduct
				  compliance, regulatory, or program integrity functions on the provider, person,
				  MCO, or the services rendered by the provider or person within 24 hours of the
				  request.
(2) An exception to the 24
				  hours stated in paragraph (1) of this subsection may be made when the OIG or
				  another state or federal agency representative reasonably believes that the
				  requested records are about to be altered or destroyed or that the request may
				  be completed at the time of the request and/or in less than 24 hours.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 353.505 - Recovery of Funds

Current through Reg. 49, No. 28; July 12, 2024
(a) If a managed
				  care organization (MCO) discovers fraud or abuse has occurred in the Medicaid
				  or CHIP program, based on information, data, or facts obtained by the MCO, it
				  must:
(1) notify the Health and Human
				  Services Commission-Office of Inspector General (HHSC-OIG) and the Office of
				  the Attorney General (OAG) through a referral as described in §
											RSA
				  353.502 of this subchapter (relating to
				  Managed Care Organization's Plans and Responsibilities in Preventing and
				  Reducing Waste, Abuse, and Fraud) that includes a detailed description of the
				  fraud or abuse and each payment made to a provider as a result of the fraud or
				  abuse;
(2) subject to subsection
				  (b) of this section, begin payment recovery efforts; and
(3) ensure that any payment recovery efforts
				  in which the MCO engages are in accordance with this subchapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.601 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  administers the STAR+PLUS program.
(b) The following subchapters of this chapter
				  apply to the STAR+PLUS program:
(1)
				  Subchapter A (relating to General Provisions);
(2) Subchapter B (relating to Provider and
				  Member Education Programs);
(3)
				  Subchapter C (relating to Member Bill of Rights and
				  Responsibilities);
(4) Subchapter E
				  (relating to Standards for Medicaid Managed Care);
(5) Subchapter F (relating to Special
				  Investigative Units); and
(6)
				  Subchapter J (relating to Outpatient Pharmacy Services).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.603 - Member Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) 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 and
				  qualify for Supplemental Security Income (SSI) benefits or for Medicaid due to
				  low income;
(2) qualify for
				  STAR+PLUS Home and Community-Based Waiver Services;
(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;
(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.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.605 - Participating Providers

Current through Reg. 49, No. 28; July 12, 2024
Acute and long-term services and supports providers who
					 traditionally have served Medicaid clients are given the opportunity to
					 participate in STAR+PLUS managed care organizations (MCOs), provided they meet
					 licensing standards, the MCO's credentialing standards, agree to the MCO's
					 contract provisions, and agree to the MCO's payment
					 arrangements.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.607 - STAR+PLUS Handbook

Current through Reg. 49, No. 28; July 12, 2024
The
STAR+PLUS Handbook
includes policies
					 and procedures to be used by all health and human services agencies and their
					 contractors and providers in the delivery of STAR+PLUS Program services to
					 eligible members. The
STAR+PLUS Handbook
can be found on the
					 Texas Health and Human Services Commission website.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.609 - Service Coordination

Current through Reg. 49, No. 28; July 12, 2024
(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.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.610 - Minimum Performance Standards for Nursing Facilities that Participate in the STAR+PLUS Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. The
				  purpose of this section is to establish minimum performance standards
				  applicable to nursing facility providers that participate in the STAR+PLUS
				  program.
(b) Definitions. The
				  following words and terms, when used in this section, have the following
				  meanings, unless the context clearly indicates otherwise:
(1) CMS--Centers for Medicare & Medicaid
				  Services. The federal agency responsible for administering Medicare and
				  overseeing state administration of Medicaid.
(2) Corrective actions--Actions taken for the
				  purpose of correcting undesirable clinical performance; may also be called a
				  corrective action plan or a performance improvement plan (PIP).
(3) HHSC--The Texas Health and Human Services
				  Commission or its designee.
(4)
				  Long stay quality measure--The CMS long stay quality measure specifications are
				  based on nursing home (NH) residents whose episode is greater than or equal to
				  101 cumulative days in the NH at the end of the target period.
(5) MDS--Minimum data set. A federally
				  mandated standardized clinical assessment of all residents in certified nursing
				  facilities.
(6) Minimum performance
				  standards--Standards applicable to a nursing facility that participates in the
				  STAR+PLUS program that represent the minimal clinical performance expected,
				  based on evidence-based guidelines and analysis.
(7) Nursing facility--A convalescent or
				  nursing home or related institution licensed under Health and Safety Code
				  Chapter 242, that provides long-term services and supports to recipients and
				  that participates in the STAR+PLUS program.
(8) STAR+PLUS Managed Care Organization--An
				  organization under contract with HHSC to manage delivery of Medicaid services
				  to members in the STAR+PLUS program.
(9) STAR+PLUS Program--This term has the
				  meaning set forth in §354.4003 of the title (relating to
				  Definitions).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter H - STAR HEALTH › Section 353.701 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  administers the STAR Health program.
(b) The following subchapters of this chapter
				  apply to the STAR Health program:
(1)
				  Subchapter A (relating to General Provisions);
(2) Subchapter B (relating to Provider and
				  Member Education Programs);
(3)
				  Subchapter C (relating to Member Bill of Rights and
				  Responsibilities);
(4) Subchapter E
				  (relating to Standards for Medicaid Managed Care);
(5) Subchapter F (relating to Special
				  Investigative Units); and
(6)
				  Subchapter J (relating to Outpatient Pharmacy Services).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter H - STAR HEALTH › Section 353.702 - Member Participation

Current through Reg. 49, No. 28; July 12, 2024
(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 DFPS, if the state as conservator elects to place the child
				  in the STAR Health program;
(2) a
				  young adult, from 18 years of age 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;
(3) a young adult, from 18
				  years of age through the month of his or her 21st birthday, who is an FFCC
				  member or participating in the MTFCY Program; and
(4) a child or young adult, from birth
				  through the month of his or her 21st birthday, who is enrolled in the Adoption
				  Assistance Program or the Permanency Care Assistance Program and who:
(A) receives Supplemental Security Income
				  (SSI);
(B) received SSI before
				  becoming eligible for the Adoption Assistance Program or the Permanency Care
				  Assistance Program;
(C) is enrolled
				  in a Medicaid 1915(c) waiver; or
(D) is enrolled in Medicare.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter I - STAR › Section 353.801 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				  Health and Human Services Commission (HHSC) administers the State of Texas
				  Access Reform (STAR) program.
(b)
				  Rules governing the operation of the program will be in accordance with
				  Subchapter E of this chapter (relating to Standards for Medicaid Managed
				  Care).
(c) HHSC selects STAR
				  managed care organizations using the purchasing methods described in Chapter
				  391, Subchapter D of this title (relating to Purchases of Goods and
				  Services).
(d) The STAR program
				  serves members in all service areas in the state.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter I - STAR › Section 353.802 - Member Participation

Current through Reg. 49, No. 28; July 12, 2024
(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 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 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 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 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).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.901 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to implement the
					 requirements of Texas Government Code §
										RSA
					 533.005, which establishes requirements for
					 providing outpatient pharmacy benefits through Medicaid managed care. This
					 subchapter applies to health care managed care organizations.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.903 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meaning unless the context clearly indicates
					 otherwise.
(1) Clinical prior
				  authorization (clinical PA)--A review process authorized by HHSC that is
				  conducted by a healthcare managed care organization (health care MCO) prior to
				  dispensing a drug. All clinical PAs must be identified on the Medicaid Vendor
				  Drug Program website at http://www.txvendordrug.com.
(2) Covered outpatient drug--A drug or
				  biological product included on the formulary and provided in an outpatient
				  setting.
(3) Formulary--The list of
				  covered outpatient drugs for the Texas Medicaid program.
(4) Maximum allowable cost--The highest unit
				  price set by a health care MCO, or its subcontractor, for reimbursement of
				  therapeutically equivalent multi-source drugs.
(5) Network provider--A pharmacy provider who
				  has entered into a contract with the health care MCO to provide outpatient drug
				  benefits to Medicaid enrollees.
(6)
				  Non-preferred drug--A covered outpatient drug on the preferred drug list (PDL)
				  that has been designated as non-preferred.
(7) Pharmacy benefits manager (PBM)--An
				  entity that administers the Medicaid outpatient drug benefit on behalf of a
				  health care MCO.
(8) Preferred
				  drug--A covered outpatient drug on the PDL that has been designated as
				  preferred because it has been evaluated to be safe, clinically effective, and
				  cost-effective compared to other drugs in the same therapeutic drug class on
				  the market.
(9) Preferred drug list
				  (PDL)--The list of covered outpatient drugs reviewed by the Drug Utilization
				  Review Board (DUR Board) . Reviewed drugs are recommended by the DUR Board as
				  either preferred or non-preferred and HHSC establishes the final
				  designation.
(10) Preferred drug
				  list prior authorization (PDL PA)--A review conducted by a health care MCO
				  prior to dispensing a non-preferred drug.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.905 - Managed Care Organization Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A health care managed care organization
				  (health care MCO) must adopt and exclusively use the Health and Human Services
				  Commission's (HHSC's) Medicaid formulary and preferred drug list.
(b) A health care MCO is not authorized to
				  negotiate rebates for covered outpatient drugs with drug manufacturers, or to
				  receive confidential drug pricing regarding covered outpatient drugs from drug
				  manufacturers.
(c) A health care
				  MCO cannot pay claims submitted by a pharmacy provider who is under sanction or
				  exclusion from the Medicaid or CHIP Programs.
(d) Except as provided in subsection (e) of
				  this section, a health care MCO must enter into a network provider agreement
				  with any pharmacy provider that meets the health care MCO's credentialing
				  requirements, and agrees to the health care MCO's financial terms and other
				  reasonable administrative and professional terms.
(e) A health care MCO can enter into
				  selective pharmacy provider agreements for specialty drugs, as defined in
				  §
										RSA 354.1853 of
				  this title (relating to Specialty Drugs), subject to the following limitations:
(1) A health care MCO is prohibited from
				  entering into an exclusive contract for specialty drugs with a pharmacy owned
				  in full or part by a pharmacy benefits manager contracted with the health care
				  MCO.
(2) The selective contracting
				  agreement cannot require the pharmacy provider to contract exclusively with the
				  health care MCO.
(3) A health care
				  MCO cannot require a member to obtain a specialty drug from a mail-order
				  pharmacy.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.907 - Prior Authorization Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A health care managed care organization
				  (health care MCO) may not impose a preferred drug list prior authorization (PDL
				  PA) on a covered outpatient drug before the drug has been considered at a
				  meeting of the Health and Human Services Commission's (HHSC's) Drug Utilization
				  Review Board.
(b) A health care MCO
				  may not impose a PDL PA on a covered outpatient drug that was prescribed before
				  HHSC's designation of the drug as non-preferred, unless the member has
				  exhausted all of the prescription, including any authorized refills.
(c) A health care MCO must allow a provider
				  to submit a request for prior authorization of a covered outpatient drug by
				  telephone, fax, or electronic communications through the Internet.
(d) A health care MCO must respond to a
				  request for prior authorization by telephone, fax, or electronic communications
				  through the Internet no later than 24 hours after receiving the request. If the
				  health care MCO cannot respond to the prior authorization request within this
				  time, then the health care MCO must allow a pharmacy to dispense a 72-hour
				  supply of the prescribed drug.
(e)
				  A health care MCO cannot require a PDL PA for a preferred drug.
(f) A health care MCO must require a PDL PA
				  for a non-preferred drug.
(g) If a
				  member's medical condition does not match the health care MCO's clinical
				  criteria for dispensing a covered outpatient drug, the health care MCO may
				  require a clinical PA for a preferred or non-preferred drug.
(h) HHSC will post on its website clinical
				  PAs that are used in HHSC's fee-for-service Vendor Drug Program. A health care
				  MCO must implement all clinical PAs that HHSC has designated as "mandatory" for
				  the Medicaid managed care programs.
(i) A health care MCO must accept a standard
				  prior authorization form for a covered outpatient drug in accordance with Texas
				  Insurance Code Chapter 1369, Subchapter F.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.909 - Participating Pharmacy Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) To
				  participate in a health care MCO's network, a pharmacy provider must be
				  licensed with the Texas State Board of Pharmacy or, with respect to a patient
				  located in another state, with the pharmacy licensing entity in that state,
				  have a national provider identifier, and be enrolled as a Medicaid provider
				  with HHSC.
(b) A pharmacy provider
				  is subject to the Vendor Drug Program rules in Chapter 354, Subchapter F,
				  Division 1 and Division 5 of this title (relating to Participation; and
				  Audits).
(c) The prescription
				  requirements in § 354.1863(a), (b), and (d) of this title (relating to
				  Prescription Requirements) apply to all pharmacy providers.
(d) Except as prohibited by the health care
				  MCO, a pharmacy provider may substitute one covered outpatient drug for another
				  covered outpatient drug in a prescription only if authorized by the prescribing
				  physician in accordance with 22 TAC §
										RSA
				  309.3(relating to Generic
				  Substitution).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.911 - Members

Current through Reg. 49, No. 28; July 12, 2024
(a) A member must obtain a covered outpatient
				  drug from a network pharmacy provider contracted with the member's health care
				  MCO, except at provided in §
										RSA
				  353.913 of this subchapter (relating to
				  Managed Care Organization Requirements Concerning Out-of-network Outpatient
				  Pharmacy Services).
(b) A member
				  may receive up to a 90-day supply of a covered outpatient drug.
(c) A health care MCO cannot require a member
				  to obtain a specialty drug or other covered outpatient drug from a mail-order
				  pharmacy unless a mail-order pharmacy is the only available dispensing source
				  for the drug. A health care MCO cannot charge the member for mail-order
				  services, including the cost of the drug, fees, or other related
				  services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.913 - Managed Care Organization Requirements Concerning Out-of-Network Outpatient Pharmacy Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Network
				  adequacy.
(1) The Health and Human Services
				  Commission (HHSC) is the state agency responsible for overseeing and monitoring
				  the Medicaid managed care program. A health care managed care organization
				  (health care MCO) participating in the Medicaid managed care program must offer
				  a network of pharmacy providers that is sufficient to meet the needs of the
				  health care MCO's members. HHSC will monitor health care MCO members' access to
				  an adequate provider network through reports from the health care MCOs and
				  complaints received from providers and members. The reporting requirements are
				  discussed in subsection (c) of this section.
(2) A health care MCO may not refuse to
				  reimburse an out-of-network pharmacy provider for emergency covered outpatient
				  pharmacy services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter J - OUTPATIENT PHARMACY SERVICES › Section 353.915 - Access to Network Pharmacies

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  health care managed care organization (MCO) must ensure that a member has
				  access to at least one network pharmacy within 15 miles from his or her
				  residence.
(b) A health care MCO
				  must ensure that a member has access to at least one network pharmacy with
				  24-hour coverage within 75 miles of his or her residence.
(c) If a network pharmacy provider is not
				  available to a member within the mileage radius specified in subsection (a) or
				  (b) of this section, the health care MCO must submit to the Health and Human
				  Services Commission for approval data that indicates covered outpatient
				  pharmacy services are not available to the member within the required
				  distance.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter K - CHILDREN'S MEDICAID DENTAL SERVICES › Section 353.1001 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				  Health and Human Services Commission (HHSC) administers Children's Medicaid
				  Dental Services.
(b) Rules
				  governing the operation of Children's Medicaid Dental Services will be in
				  accordance with Subchapter E of this chapter (relating to Standards for
				  Medicaid Managed Care).
(c) HHSC
				  selects dental managed care organizations using the purchasing methods
				  described in Chapter 391, Subchapter D of this title (relating to Purchase of
				  Goods and Services).
(d) Children's
				  Medicaid Dental Services are provided in all areas of the state.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter K - CHILDREN'S MEDICAID DENTAL SERVICES › Section 353.1003 - Member Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
				  provided in subsection (b) of this section, enrollment in Children's Medicaid
				  Dental Services is
mandatory
for clients from birth through
				  age 20.
(b) The following clients
				  are not eligible for Children's Medicaid Dental Services provided through
				  managed care:
(1) clients age 21 and
				  over;
(2) clients, regardless of
				  age, residing in Medicaid-paid facilities such as nursing facilities, state
				  supported living centers, or intermediate care facilities for people with
				  intellectual and developmental disabilities; and
(3) STAR Health program recipients.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1101 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to implement the Texas
					 Dual Eligibles Integrated Care Demonstration Project (Dual Demonstration) which
					 is a federal-state partnership between the Centers for Medicare & Medicaid
					 Services (CMS) and the Texas Health and Human Services Commission (HHSC) that
					 provides integrated Medicare and Medicaid services through a managed care
					 model. The rules in this subchapter address eligibility for, and enrollment in,
					 the Dual Demonstration and the responsibilities of HHSC as the Medicaid
					 agency.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1103 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC, in
				  conjunction with CMS, administers the Dual Demonstration. The Medicare and
				  Medicaid services are provided through STAR+PLUS Medicare-Medicaid Plans
				  (MMPs).
(b) A STAR+PLUS MMP is a
				  managed care plan contracted with CMS and HHSC to participate in the Dual
				  Demonstration.
(c) Medicare
				  Advantage and Medicare Part D provided through this demonstration are the
				  responsibility of CMS.
(d) All
				  other rules in this chapter governing Medicaid managed care apply to the Dual
				  Demonstration, as applicable, unless specific deviations are noted in this
				  subchapter.
(e) The Dual
				  Demonstration serves members whose primary residence is in one of the following
				  counties:
(1) Bexar;
(2) Dallas;
(3) El Paso;
(4) Harris;
(5) Hidalgo;
(6) Tarrant; and
(7) other counties as authorized by a federal
				  waiver approved by CMS. The dual demonstration will not be implemented in other
				  counties without prior public notice.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1105 - Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) Enrollment in the Dual Demonstration is
				  optional for dual eligible individuals who live in the designated counties and
				  meet the following criteria:
(1) eligible for
				  STAR+PLUS, including those eligible for STAR+PLUS home and community-based
				  waiver services;
(2) enrolled in
				  Medicare Parts A, B, and D; and
(3)
				  age 21 or older.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1107 - Member Enrollment and Disenrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC and CMS, or their designee(s),
				  conduct enrollment and disenrollment activities.
(b) HHSC and CMS establish procedures for
				  enrolling new members into participating MMPs, including enrollment periods and
				  time limits within which enrollment must occur.
(c) HHSC assigns eligible individuals to an
				  MMP based on current Medicare or Medicaid enrollment.
(d) Beginning 60 days prior to the enrollment
				  of an eligible individual in the Dual Demonstration, HHSC sends initial and
				  reminder notifications of the proposed assigned MMP to the eligible individual,
				  informing the individual of their right to either opt out of the Dual
				  Demonstration or to select another MMP.
(e) At any time prior to enrollment,
				  individuals may choose not to participate in the Dual Demonstration, or to
				  select another MMP in their county by notifying HHSC or CMS.
(f) Once enrolled, individuals may notify
				  HHSC or CMS of the choices referenced in subsection (e) of this section at any
				  time. An individual's choice to not participate in the Dual Demonstration or to
				  select another MMP is effective the first day of the month following the date
				  the individual notified HHSC or CMS.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1109 - Participating Providers

Current through Reg. 49, No. 28; July 12, 2024
Acute care and long-term services and supports providers
					 who serve Medicare and Medicaid members are eligible to participate in the Dual
					 Demonstration if they:
(1) meet
				  licensing standards, as applicable;
(2) meet the STAR+PLUS MMP's credentialing
				  standards; and
(3) have a contract
				  with an MMP.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1111 - Benefits

Current through Reg. 49, No. 28; July 12, 2024
Members enrolled in the Dual Demonstration have access to
					 acute care and long-term covered services and supports under Medicare and
					 Medicaid which are coordinated through a single, integrated managed care plan,
					 the MMP.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1113 - Appeals and Fair Hearings

Current through Reg. 49, No. 28; July 12, 2024
For Medicaid covered services, members enrolled in the Dual
					 Demonstration have 60 days from a notice of action to file an appeal with the
					 STAR+PLUS MMP. Members may also file a request for an HHSC fair hearing instead
					 of, or in addition to, a health plan appeal. Rules governing fair hearings for
					 Medicaid covered services are in Chapter 357, Subchapter A, of this title
					 (relating to Uniform Fair Hearing Rules).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter L - TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT › Section 353.1115 - Network Adequacy for Certain Service Providers

Current through Reg. 49, No. 28; July 12, 2024
STAR+PLUS MMPs will adhere to Medicare network adequacy
					 standards set forth by CMS for the following types of Medicaid benefits:
(1) nursing facility;
(2) speech therapy;
(3) occupational therapy; and
(4) physical therapy.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter M - HOME AND COMMUNITY BASED SERVICES IN MANAGED CARE › Section 353.1151 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Home and
				  Community Based Services (HCBS) are community-based services and supports to
				  eligible individuals as an alternative to institutional services, such as those
				  described in Section 1915 of the Social Security Act. HCBS are intended to
				  enhance the individual's integration into the community, maintain or improve
				  the individual's independent functioning, and prevent the individual's
				  admission to an institution.
(b)
				  Delivery of HCBS in managed care must comply with
				  RSA
				  441.530, with the exception of the delivery
				  of out of home respite.
(c)
				  Participation in managed care does not affect an individual's ability to
				  receive HCBS operated by HHSC or another agency if the delivery of HCBS is not
				  through an MCO.
(d) Participation
				  in managed care does not impact an individual's ability to access or maintain a
				  slot on the interest list(s) of an HCBS program.
(e) Delivery of Community First Choice
				  Services in managed care must comply with Chapter 354, Subchapter A, Division
				  27 of this title (relating to Community First Choice).
(f) HCBS providers contracted with MCOs are
				  subject to investigation of suspected or alleged abuse, neglect, or
				  exploitation as described in 40 TAC, Chapter 700 (relating to Child Protective
				  Services), Chapter 705 (relating to Adult Protective Services), and Chapter 745
				  (relating to Licensing).