reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES › Subchapter B - ADVISORY COMMITTEES › Division 1 - COMMITTEES › Section 351.849 - Texas Respite Advisory Committee

Current through Reg. 49, No. 28; July 12, 2024
(a) The Lifespan Respite Care Act (United
					 States Code, Title 42, §300ii) authorizes a state agency to collaborate
					 with a public or private statewide coalition to address the respite needs of
					 family caregivers of adults or children with special needs. Texas Human
					 Resources Code §
											161.079
					 directs DADS to coordinate public awareness outreach efforts regarding the role
					 of informal long-term care caregivers. Texas Human Resources Code, Chapter 161,
					 Subchapter F, creates the Lifespan Respite Services Program operated by DADS.
					 The Texas Respite Advisory Committee (TRAC) assists DADS to develop strategies
					 to reduce barriers to accessing respite services; improve the quality of
					 respite services; and provide training, education, and support to family
					 caregivers.
(b) The tasks of the
					 TRAC include:
(1) assisting DADS to identify
					 barriers and best practices for providing and coordinating respite services in
					 Texas;
(2) responding to requests
					 from DADS for information about the respite needs of caregivers;
(3) advising DADS about effective methods for
					 expanding the availability of affordable respite services in Texas through the
					 use of funds available from respite care programs;
(4) cooperating and sharing resources and
					 knowledge among community stakeholders to facilitate barrier free access for
					 primary caregivers; and
(5)
					 educating the public on the need for community-based options for primary
					 caregivers.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES › Subchapter B - ADVISORY COMMITTEES › Division 2 - COMMITTEES › Section 351.1201 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The DARS Board for Evaluation of Interpreters is an
						advisory board appointed by the Executive Commissioner of the Health and Human
						Services Commission or the Executive Commissioner's designee, to assist DARS in
						administering DARS's interpreter certification programs.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES › Subchapter B - ADVISORY COMMITTEES › Division 2 - COMMITTEES › Section 351.1203 - Legal Authority

Current through Reg. 49, No. 28; July 12, 2024
The BEI Advisory Board is created pursuant to Human
						Resources Code Chapter 81, §81.007, Board for Evaluation of
						Interpreters.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES › Subchapter B - ADVISORY COMMITTEES › Division 2 - COMMITTEES › Section 351.1205 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						division, have the following meanings unless the context clearly indicates
						otherwise:
(1) DARS--The Texas
					 Department of Assistive and Rehabilitative Services.
(2) BEI--Board for Evaluation of
					 Interpreters.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES › Subchapter B - ADVISORY COMMITTEES › Division 2 - COMMITTEES › Section 351.1207 - Substantive Rules

Current through Reg. 49, No. 28; July 12, 2024
DARS rules relating to the duties, authority, and
						responsibilities of the BEI Advisory Board are set forth in detail at Chapter
						109, Subchapter B of this title (relating to Board for Evaluation of
						Interpreters (BEI) General Certificate or Certification).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES › Subchapter B - ADVISORY COMMITTEES › Division 2 - COMMITTEES › Section 351.1209 - Duration of BEI Advisory Board

Current through Reg. 49, No. 28; July 12, 2024
The Board for Evaluation of Interpreters (BEI) Advisory
						Board will continue to exist as long as the BEI interpreter certification
						programs for which it serves as an advisory body continue to exist and the
						board is authorized by state law.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.1 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The enrollment of providers in Medicaid
				and the Children's Health Insurance Program (CHIP) is conducted under the
				authority of the Texas Health and Human Services Commission (HHSC), and is
				administered by HHSC or its designee.
(b) The enrollment requirements in this
				chapter are consistent with:
(1) Title 42,
				Part 455, of the Code of Federal Regulations (CFR); and
(2) Chapter 531 of the Government
				Code.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.3 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
				  have the following meanings, unless the context clearly indicates
				  otherwise:
(1) Applicant--An individual
				or an entity that submits an enrollment application to enroll or re-enroll as a
				provider or to enroll a new practice location in Medicaid or CHIP as described
				in paragraph (7) of this section.
(2) CHIP--The Texas State Children's Health
				Insurance Program established under Title XXI of the federal Social Security
				Act (RSA
				1397aa, et seq.) and Chapter 62 of the Health
				and Safety Code.
(3) Change of
				ownership--A change of ownership related to a partnership, sole proprietorship,
				corporation, or leasing arrangement as defined in
				RSA
				489.18.
(4) Designee--An entity to which HHSC has
				delegated certain functions for provider enrollment purposes. A designee may
				include:
(A) an HHSC contractor;
(B) a health and human services agency;
				or
(C) a managed care organization
				(MCO) that contracts with HHSC under Medicaid or CHIP.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.5 - Provider Enrollment Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Enrollment in Medicaid or CHIP is required for:
(1) a person or an entity seeking to provide
				health care services or benefits in Medicaid or CHIP; and
(2) a health care practitioner who:
(A) refers, orders, prescribes, certifies, or
				renders health care services or benefits for eligible recipients; or
(B) supervises or is supervised by another
				health care practitioner who performs the functions described in subparagraph
				(A) of this paragraph.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.7 - Applying for Enrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) To apply
				for enrollment or re-enrollment, an applicant or re-enrolling provider must:
(1) meet the requirements outlined in §
										RSA
				352.5 of this chapter (relating to Provider
				Enrollment Requirements) and Chapter 371 of this title (relating to Medicaid
				and Other Health and Human Services Fraud and Abuse Program
				Integrity);
(2) complete an
				enrollment application in accordance with the criteria specified by HHSC or its
				designee and the instructions contained in the application;
(3) submit a supplemental application form or
				forms for any new practice location in accordance with the criteria specified
				by HHSC and the instructions contained in the form;
(4) submit an application fee for each
				practice location, as described in subsection (b) of this section;
(5) submit documentation to show proof of
				registration and good standing with the Texas Comptroller of Public Accounts,
				the Texas Secretary of State, or any other documentation requested by HHSC or
				its designee, as applicable;
(6)
				provide a copy of a surety bond obtained pursuant to §
										RSA
				352.5 of this chapter;
(7) certify that the information contained in
				the application is true and accurate to the best of the applicant's or
				re-enrolling provider's knowledge; and
(8) submit a signed provider agreement with
				each enrollment application. By signing the provider agreement, the applicant
				or re-enrolling provider acknowledges that the applicant or re-enrolling
				provider will comply with all terms and conditions of the provider
				agreement.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.9 - Screening Levels

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC assigns an
				applicant or re-enrolling provider a screening level of "Limited," "Moderate,"
				or "High" based on:
(1) the federal screening
				level for the type of provider as provided by
				RSA
				424.518, if applicable;
(2) the federal screening level for the type
				of provider as provided by
				RSA
				455.450; or
(3) HHSC's assessment of:
(A) the risk level for potential fraud,
				waste, or abuse associated with the type of provider or the geographical area;
				or
(B) other factors as determined
				by HHSC, including:
(i) a change in business
				structure or organization;
(ii)
				past practices and circumstances; and
(iii) access to care in a geographical
				area.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.11 - Provider Enrollment Determinations

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC or its designee, in its sole
				discretion, approves, conditionally approves, or denies each enrollment
				application submitted in accordance with the requirements of this chapter. HHSC
				or its designee provides notice of the enrollment determination to the
				applicant or re-enrolling provider.
(1)
				Approval. If an enrollment application is approved, the approval is for a
				time-limited period of participation as specified in the provider agreement or
				notice of the enrollment determination.
(2) Conditional approval. An enrollment
				application may be approved with conditions as specified in the notice of the
				enrollment determination.
(3)
				Denial. If an enrollment application is denied, HHSC will provide notice of the
				enrollment determination by certified mail to the address of record on the
				enrollment application. The reason or reasons for denial are specified in the
				notice.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.13 - Medicare Certification or Enrollment in Medicare

Current through Reg. 49, No. 28; July 12, 2024
(a) To participate in Medicaid or CHIP, an
				applicant or re-enrolling provider must be actively enrolled in Medicare or
				certified by Medicare (if applicable), or both, unless otherwise specified by
				HHSC or its designee or specifically exempted in subsection (b) of this
				section.
(b) HHSC or its designee,
				in its sole discretion, may exempt an applicant or re-enrolling provider from
				subsection (a) of this section if:
(1) the
				type of practice or service is not covered by Medicare;
(2) an HHSC rule or other state agency's rule
				expressly exempts an applicant or re-enrolling provider from Medicare
				enrollment or Medicare certification; or
(3) the applicant's or re-enrolling
				provider's exclusion from participating in Medicaid or CHIP will prevent
				recipients from having access to needed medical services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.15 - Surety Bond Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A surety
				bond may be required for each enrolled location pursuant to the requirements of
				this section if:
(1) a provider or type of
				provider has been identified by federal or state agencies to have a significant
				history of, or potential for, fraud, waste, or abuse; or
(2) HHSC, in its sole discretion, has
				determined that a provider, based on the provider's conduct, including
				falsifying information or any material misrepresentation, will be subject to
				this requirement.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.17 - Out-of-State Medicaid Provider Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) This section applies only to an
				out-of-state Medicaid applicant or re-enrolling provider. An applicant or
				re-enrolling provider is considered out-of-state if:
(1) the physical address where services are
				or will be rendered is located outside the Texas state border and within the
				United States;
(2) the physical
				address where the services or products originate or will originate is located
				outside the Texas state border and within the United States when providing
				services, products, equipment, or supplies to a Medicaid recipient in the state
				of Texas; or
(3) the physical
				address where services are or will be rendered is located within the Texas
				state border, but:
(A) the applicant or
				re-enrolling provider maintains all patient records, billing records, or both,
				outside the Texas state border; and
(B) the applicant or re-enrolling provider is
				unable to produce the originals or exact copies of the patient records or
				billing records, or both, from the location within the Texas state border where
				services are rendered.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.19 - Temporary Moratoria

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC or its
				designee may enforce temporary moratoria imposed pursuant to the requirements
				of §1867 and §1902 of the Social Security Act (RSA
				455.470 and §
									RSA
				457.990) on enrollment of new providers or
				suppliers or impose numerical caps or other limits.
(b) HHSC may determine to impose a temporary
				moratorium in the Texas Medicaid and CHIP programs based on provider or
				supplier type, geographical area, new practice locations, or a category of
				provider or supplier identified as having an increased risk or a potential risk
				of fraud, waste, or abuse, with the concurrence of the Secretary of Health and
				Human Services.
(c) A temporary
				moratorium that is imposed in accordance with this section will be for an
				initial period of six months, and may be extended in six-month increments at
				the direction of or in concurrence with the Secretary of Health and Human
				Services.
(d) HHSC will not process
				an application if a moratorium or other limit on enrollment is in effect. If an
				enrollment application is denied solely as the result of a temporary
				moratorium, HHSC will refund any application fee submitted with the enrollment
				application.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - MEDICAID AND CHILDREN'S HEALTH INSURANCE PROGRAM PROVIDER ENROLLMENT › Section 352.21 - Duty to Report Changes

Current through Reg. 49, No. 28; July 12, 2024
(a) As a
				condition of continued enrollment, a provider must notify HHSC or its designee
				in writing of any change in its status or condition with respect to the
				information disclosed in an enrollment application or other supplemental form
				to an enrollment application, as determined by HHSC, including:
(1) National Provider Identifier or
				associated taxonomy code;
(2)
				Medicare number;
(3) Medicare
				certification status;
(4) federal
				tax identification number;
(5)
				responsible billing party for the provider;
(6) physical address for the provider or
				responsible billing party;
(7) the
				name, address, date of birth, and Social Security number of any managing
				employee of the provider;
(8)
				enrollment type;
(9) provider
				licensure, certification, accreditation;
(10) any change of ownership as required by
				RSA
				489.18;
(11) a change in the person with an ownership
				or control interest in the provider;
(12) information required to be disclosed
				under Chapter 371 of this title (relating to Other Health and Human Services
				Fraud and Abuse Program Integrity);
(13) third-party billing vendor services;
				or
(14) any other information
				required by HHSC or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.1 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this chapter is to define
				  the requirements for the Medicaid Managed Care program.
(b) The rules in this chapter must be read in
				  conjunction with:
(1) federal and state
				  statutes;
(2) rules relating to
				  Medicaid in Chapter 354 of this title (relating to Medicaid Health Services);
				  and
(3) except where otherwise
				  indicated, Texas Department of Insurance rules regarding:
(A) regulation of health maintenance
				  organizations at 28 TAC Chapter 11; and
(B) exclusive provider benefit plans at 28
				  TAC Chapter 3, Subchapter KK.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Action--
(A) An action is defined as:
(i) the denial or limited authorization of a
				  requested Medicaid service, including the type or level of service;
(ii) the reduction, suspension, or
				  termination of a previously authorized service;
(iii) the failure to provide services in a
				  timely manner;
(iv) the denial in
				  whole or in part of payment for a service; or
(v) the failure of a managed care
				  organization (MCO) to act within the timeframes set forth by the Texas Health
				  and Human Services Commission (HHSC) and state and federal law.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.3 - Experience Rebate in the Managed Care Program

Current through Reg. 49, No. 28; July 12, 2024
Each managed care organization (MCO) participating in
					 Medicaid managed care must pay to the state an experience rebate calculated
					 according to the graduated rebate method described in the MCO's contract with
					 the Health and Human Services Commission.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.5 - Internet Posting of Sanctions Imposed For Contractual Violations

Current through Reg. 49, No. 28; July 12, 2024
(a) This section pertains to a managed care
				  organization (MCO) which the Health and Human Services Commission (HHSC)
				  determines has failed to comply with the terms of a contract to provide health
				  care services or dental services to members enrolled in the MCO.
(b) HHSC is responsible for identifying and
				  investigating contract deficiencies and violations, and taking corrective
				  action to remedy contract deficiencies and violations of an MCO. Corrective
				  actions may include assessment of liquidated damages, contract termination,
				  and/or any other sanction or remedy available under the terms and conditions of
				  the contract or state and federal law and regulations.
(c) If HHSC finds that performance issues,
				  problems, or deficiencies exist with an MCO, as those issues pertain or relate
				  to certain deliverable services, HHSC may investigate a claim of contract
				  violation and determine whether a contract violation has occurred or currently
				  exists.
(d) If HHSC determines that
				  a contract violation has occurred or currently exists, HHSC will decide on the
				  appropriate contract sanction or remedy to be imposed.
(e) If required by contract, HHSC will give
				  written notice to the MCO, describing the contract violation, the contract
				  sanction or remedy to be imposed, the method by which reimbursement (if
				  applicable) to HHSC will be made, and the time frame for resolution of the
				  issue.
(f) When a contract
				  violation has been determined and a sanction or remedy imposed, HHSC will post
				  the following information on HHSC's Internet website:
(1) the name and address of the
				  MCO;
(2) a description of the
				  contractual obligation the MCO failed to meet;
(3) the date of determination of
				  noncompliance;
(4) the date the
				  sanction or remedy was imposed;
(5)
				  the maximum sanction or remedy that may be imposed under the contract for the
				  violation; and
(6) the actual
				  sanction or remedy imposed against the MCO.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.6 - Audit of Managed Care Organizations

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and Human Services Commission
				  (HHSC), through the Medicaid and CHIP Services Division, the Office of
				  Inspector General (OIG), and Health and Human Services (HHS) Internal Audit
				  Division, is responsible for audits of MCOs and any entity with which an MCO
				  contracts.
(b) For purposes of this
				  rule, "MCO" includes any entity with which an MCO contracts.
(c) HHSC conducts audits of MCOs, including
				  financial audits, performance audits, compliance audits, and agreed upon
				  procedures:
(1) with the scope and frequency
				  necessary to provide information to allow for the effective oversight and
				  control of the MCOs; and
(2) as
				  necessary to comply with all federal and state laws.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.7 - Continuity of Care with Out-of-Network Specialty Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) A health care MCO must allow a member age
				  20 or younger, who has complex medical needs, to remain under the care of a
				  Medicaid enrolled specialty provider from whom the member is receiving care at
				  the time of the member's enrollment into the health care MCO, even if the
				  specialty provider is an out-of-network provider.
(b) For the purpose of this section "complex
				  medical needs" means a member receiving:
(1)
				  Level 1 Service Coordination as authorized in the STAR Kids managed care
				  contract; or
(2) Service Management
				  as authorized in the STAR Health managed care contract.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter A - GENERAL PROVISIONS › Section 353.8 - Certification of Managed Care Organizations Prior to Contract Awards

Current through Reg. 49, No. 28; July 12, 2024
(a) As provided by
				  § 533.0035 of the Texas Government Code, the Texas Health and Human
				  Services Commission (HHSC) awards a contract under Chapter 533 of the Texas
				  Government Code to a managed care organization (MCO) only if the MCO has been
				  certified by HHSC as reasonably able to fulfill the terms of the contract,
				  including all requirements of applicable federal and state law.
(b) HHSC determines whether to certify an MCO
				  following the evaluation of the proposals submitted in response to a
				  solicitation. Certification and the certification determination process
				  described in this section do not impact an MCO's final score in the evaluation,
				  but failure to obtain certification results in no further consideration of the
				  MCO for the contract award.
(c) In
				  its certification determination, HHSC may review:
(1) materials submitted by the MCO in
				  response to the solicitation;
(2)
				  materials related to the MCO's past performance in any state, including
				  materials required to be monitored by a state's managed care program under
				  RSA
				  438.66(c); and
(3) any additional information and assurances
				  requested by HHSC from the MCO for purposes of the certification
				  determination.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter B - PROVIDER AND MEMBER EDUCATION PROGRAMS › Section 353.101 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter implements the Health and Human Services
					 Commission's authority to establish provider and member education requirements
					 for managed care organizations participating in the Texas Medicaid program.
					 This authority is granted in Government Code §
										RSA
					 531.0211.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter B - PROVIDER AND MEMBER EDUCATION PROGRAMS › Section 353.102 - Provider and Member Education Programs Generally

Current through Reg. 49, No. 28; July 12, 2024
A managed care organization (MCO) that contracts with the
					 Health and Human Services Commission (HHSC) to provide health care services or
					 dental services through the Medicaid program must provide education programs
					 for providers and members using a variety of techniques and media as described
					 in this chapter and in the contract between HHSC and the MCO.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter B - PROVIDER AND MEMBER EDUCATION PROGRAMS › Section 353.104 - Member Education Program

Current through Reg. 49, No. 28; July 12, 2024
A member education program must present information in a
					 manner that is easy to understand. In addition to any requirements specified in
					 the contract between the managed care organization (MCO) and the Health and
					 Human Services Commission, a program must include, at minimum, information
					 on:
(1) a member's rights and
				  responsibilities under the Bill of Rights and the Bill of Responsibilities
				  prescribed in Subchapter C of this chapter (relating to Member Bill of Rights
				  and Responsibilities);
(2) how to
				  access dental services or health care services;
(3) how to access complaint and appeal
				  procedures, the member's right to request a fair hearing, and the process for
				  requesting a fair hearing;
(4)
				  Medicaid policies, procedures, eligibility standards, and benefits;
(5) the policies and procedures of the MCO;
				  and
(6) the importance of
				  prevention, early intervention, and appropriate use of services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter B - PROVIDER AND MEMBER EDUCATION PROGRAMS › Section 353.105 - Provider Education Program

Current through Reg. 49, No. 28; July 12, 2024
In addition to any requirements specified in the contract
					 between the managed care organization and the Health and Human Services
					 Commission, a provider education program must include, at minimum, information
					 on:
(1) Medicaid policies, procedures,
				  eligibility standards, and benefits;
(2) the specific problems and needs of
				  Medicaid clients;
(3) screening,
				  identification, and referral processes for coordinating dental services or
				  health care services; and
(4)
				  members' rights and responsibilities set out in Subchapter C of this chapter
				  (relating to Member Bill of Rights and Responsibilities).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter C - MEMBER BILL OF RIGHTS AND RESPONSIBILITIES › Section 353.201 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter implements the Health and Human Services
					 Commission's authority to adopt a member bill of rights and responsibilities.
					 This authority is granted in Government Code §
										RSA
					 531.0212.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter C - MEMBER BILL OF RIGHTS AND RESPONSIBILITIES › Section 353.202 - Member Bill of Rights

Current through Reg. 49, No. 28; July 12, 2024
Each managed care organization (MCO) participating in the
					 Texas Medicaid program must provide to each member an easy-to-read, written
					 document describing the member's rights, which must include the
					 following:
(1) Member rights for
				  members of health care MCOs:
(A) You have the
				  right to respect, dignity, privacy, confidentiality and nondiscrimination. That
				  includes the right to:
(i) Be treated fairly
				  and with respect.
(ii) Know that
				  your medical records and discussions with your providers will be kept private
				  and confidential.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter C - MEMBER BILL OF RIGHTS AND RESPONSIBILITIES › Section 353.203 - Member Bill of Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
Each managed care organization (MCO) participating in the
					 Texas Medicaid program must provide to each member an easy-to-read, written
					 document, which must include the following:
(1) Member responsibilities for members of
				  health care MCOs:
(A) You must learn and
				  understand each right you have under the Medicaid program. That includes the
				  responsibility to:
(i) Learn and understand
				  your rights under the Medicaid program.
(ii) Ask questions if you do not understand
				  your rights.
(iii) Learn what
				  choices of managed care organizations (MCOs) are available in your
				  area.
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 353.403 - Enrollment and Disenrollment

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Enrollment by HHSC. HHSC will conduct enrollment and disenrollment activities.
				  Except as provided in subsection (d)(2) and (5) of this section, regarding
				  dental home assignments, HHSC may not contract with a participating MCO to
				  serve as the administrator for enrollment or disenrollment activities in any
				  area of the state.
(b) Procedures
				  for enrollment. HHSC will establish procedures for enrollment into
				  participating MCOs, primary care providers (PCPs), and dental homes, including
				  enrollment periods and time limits within which enrollment must occur.
				  Beneficiaries will have at least 15 calendar days from the date notification is
				  mailed to choose an MCO, PCP, and dental home.
(c) Default assignment. Beneficiaries who
				  fail to select an MCO, PCP, or dental home within the timeframe specified in
				  subsection (b) of this section will have an MCO, PCP, or dental home selected
				  for them by HHSC using the default assignment methodology described in
				  subsection (d) of this section.
(d)
				  Default assignment methodology. HHSC's default assignment methodology will
				  include the following criteria, to the maximum extent possible:
(1) Automated PCP assignment. If a
				  beneficiary has not selected a PCP, HHSC or its administrative services
				  contractor will assign one using an automated algorithm that considers:
(A) the beneficiary's established history
				  with a PCP, as demonstrated by Medicaid claims or encounter history with the
				  provider in the preceding year, if available;
(B) the geographic proximity of the
				  beneficiary's home address to the PCP;
(C) whether the provider serves as a PCP to
				  other members of the beneficiary's household;
(D) limitations on default assignment, such
				  as PCP restrictions on age, gender, and capacity; and
(E) other criteria determined by
				  HHSC.
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 353.405 - Marketing

Current through Reg. 49, No. 28; July 12, 2024
(a) Managed care organizations (MCOs) must
				  submit a marketing plan and all marketing materials to the Health and Human
				  Services Commission (HHSC) for prior written approval.
(b) MCOs may present their marketing
				  materials to eligible Medicaid clients through any method or media determined
				  to be acceptable by HHSC. The media may include: written materials, such as
				  brochures, posters, or fliers, which can be mailed directly to the client or
				  left at HHSC eligibility offices; enrollment events; and public service
				  announcements on radio.
(c) MCO
				  enrollment or marketing representatives are required to complete HHSC's
				  marketing orientation and training program prior to engaging in marketing
				  activities on behalf of the MCO.
(d) Prohibited marketing practices.
(1) MCOs and providers must not conduct any
				  direct contact marketing except through enrollment events or when assisting the
				  MCO's current members with reapplication.
(2) MCOs and providers must not make any
				  written or oral statement containing material misrepresentations of fact or law
				  relating to their plan or the Medicaid managed care program.
(3) MCOs and providers must not make false,
				  misleading or inaccurate statements relating to services or benefits,
				  providers, or potential providers through their plan.
(4) MCOs and providers must not offer
				  Medicaid recipients material or financial gain as an inducement for enrollment,
				  unless an exception is made by HHSC.
(5) Marketing or enrollment practices of MCOs
				  and providers must not discriminate against a client because of a client's
				  race, creed, age, color, religion, national origin, ancestry, marital status,
				  sexual orientation, physical or mental disability, health status, or existing
				  need for medical care.
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 353.407 - Requirements for Managed Care Plans

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Entities or individuals who subcontract with an MCO to provide benefits,
				  perform services, or carry out any essential function of the MCO contract must
				  meet the same qualifications and contract requirements as the MCO for the
				  service, benefit, or function delegated under the subcontract.
(b) An MCO must reimburse a Federally
				  Qualified Health Center (FQHC), a Rural Health Clinic (RHC), or a municipal
				  health department's public clinic for health care services provided to a member
				  outside of regular business hours, as defined at §
										RSA 353.2 of this
				  title (relating to Definitions), at a rate that is equal to the allowable rate
				  for those services as determined under § 32.028(e) and (f), Human
				  Resources Code, if the member does not have a referral from the member's
				  primary care provider.
(c) An MCO
				  must comply with HHSC's policy on contracting and subcontracting with
				  historically underutilized businesses (HUBs). HHSC's policy is to meet the
				  goals and good faith effort requirements as stated in the Comptroller of Public
				  Accounts rules at 34 TAC Chapter 20, Subchapter B (relating to Historically
				  Underutilized Business Program).
(d) An MCO must contract with advance
				  practice registered nurses and physicians as primary care providers in
				  compliance with Texas Government Code §
										RSA
				  533.005(a)(13).
(e) Beginning March 1, 2015, an MCO must
				  provide Medicaid benefits to nursing facility residents and reimburse nursing
				  facility providers in compliance with Texas Government Code §
										RSA
				  533.00251(c).
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 353.409 - Scope of Services

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCO must
				  provide covered services to members. The MCO is not responsible for providing
				  or paying for non-capitated services or members' cost sharing obligations, if
				  any.
(b) HHSC will establish the
				  scope and level of benefits, which all MCOs must agree to provide as a
				  condition for participation. In accordance with
				  RSA
				  438.210, the scope of benefits must be
				  provided at least in an amount, duration, and scope available to Medicaid
				  fee-for-service clients, unless otherwise explicitly authorized by HHSC through
				  a waiver. The amount, duration, and scope of benefits may exceed the scope of
				  fee-for-service in accordance with subsection (f) of this section. These
				  requirements will be contained in all contracts entered into by an MCO and
				  HHSC.
(c) MCOs are encouraged to
				  provide any value-added services or benefits beyond the level and scope
				  required as a condition for participation in the competitive procurement
				  process. These services and benefits must be approved by HHSC and cannot
				  increase the cost borne or capitation rates paid by HHSC during any current
				  contract term or in any subsequent contract term. These services or benefits
				  cannot violate any other state or federal rule or regulation.
(d) A value-added service may be unique to an
				  MCO, and limited to a member who meets the MCO's qualification criteria for the
				  service.
(e) Before approving a
				  value-added service, HHSC will determine whether it is an actual health care
				  service, dental service, benefit, or positive incentive designed to promote a
				  healthy lifestyle and improve a health or dental outcome. HHSC will not approve
				  best practice approaches to delivering covered services as value-added
				  services. Examples of potential value-added services include: health or
				  dental-related programs; programs that encourage health-conscious behaviors;
				  and for children enrolled in STAR Health, non-health care services and benefits
				  that support the child's physical, mental, or developmental well
				  being.
(f) On a case-by-case basis,
				  an MCO may offer to individual members additional benefits that are outside the
				  scope of services. Case-by-case services may be based on medical necessity,
				  cost-effectiveness, the wishes of the member or the member's family, or the
				  potential for improving the member's health status. For STAR+PLUS members,
				  these case-by-case services may also be based on functional necessity. These
				  services and benefits cannot increase the cost borne or capitation rates paid
				  by HHSC during any current contract term or in any subsequent contract term and
				  cannot violate any other state or federal rule or regulation.
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 353.411 - Accessibility of Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Provider
				  accessibility.
(1) A managed care
				  organization (MCO) must provide a broad-based and accessible provider network
				  within the service area to ensure member accessibility to a choice of two or
				  more of each of the managed care program's provider types within the time or
				  distance standards set forth below or as otherwise required by HHSC.
Attached
					 Graphic
(2) For
				  STAR+PLUS, STAR Health, and STAR Kids, a health care MCO must ensure the
				  reasonable availability and accessibility of a choice of two or more of each of
				  the long-term services and supports (LTSS) and home and community-based
				  services providers to the extent required by HHSC. These providers must be
				  reasonably accessible to members, as determined by HHSC.
(3) For providers not specifically listed in
				  paragraphs (1) or (2) of this subsection, an MCO must provide reasonable
				  availability and accessibility of providers within the service area to ensure
				  member accessibility to providers in time or distance, or as otherwise required
				  by HHSC.
(4) An MCO must allow a
				  member to choose his network provider to the extent possible and appropriate,
				  as required by RSA
				  438.3(l).
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 353.413 - Managed Care Benefits and Services for Children Under 21 Years of Age

Current through Reg. 49, No. 28; July 12, 2024
(a) A managed care organization (MCO) must
				  provide comprehensive, timely, and cost-effective diagnostic, screening, and
				  treatment services for the medical, vision, hearing, and dental needs of
				  Medicaid managed care program members under the age of 21, at a level and
				  frequency that meet the requirements of the federal EPSDT program, as
				  determined by the Health and Human Services Commission (HHSC). These
				  requirements will be contained in all contracts, as applicable to each managed
				  care program.
(b) An MCO must make
				  available special training about Texas Health Steps (THSteps) benefits and
				  goals to all providers of health and dental services contracting with the MCO
				  to providers' staffs, and to all employees and contractors of the MCO who will
				  provide oral presentations or marketing to members or prospective members. To
				  fulfill this requirement, the MCO may use the training programs created by HHSC
				  or its contractors, or the MCO may create its own training programs. Any
				  training program created by the MCO under this subsection must meet the
				  requirements of and be approved by HHSC.
(c) An MCO must coordinate and cooperate with
				  HHSC in developing effective outreach, access, and monitoring systems to ensure
				  that all qualified members receive THSteps benefits.
(d) The managed care programs of
				  participating MCOs are intended to complement and enhance the effectiveness and
				  availability of THSteps benefits in the service areas. HHSC will not delegate
				  the responsibility and accountability for monitoring and ensuring that THSteps
				  benefits are available and accessible to all eligible children.
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 353.415 - Member Complaint and Appeal Procedures

Current through Reg. 49, No. 28; July 12, 2024
(a) Managed care organizations (MCOs) must
				  develop and maintain a system and process for taking, tracking, reviewing, and
				  reporting member complaints and appeals.
(b) MCOs must establish and maintain internal
				  procedures for the resolution of member complaints and appeals. The procedures
				  must be in writing. The procedures must be detailed and specific regarding how
				  complaints and appeals are to be taken, to whom complaints are referred, and by
				  when a complaint must be resolved.
(c) MCOs must establish a procedure to assist
				  members in understanding and using the MCO's internal complaint and appeal
				  process. The member's complaint and appeal procedure must be:
(1) in writing and distributed to each member
				  upon enrollment;
(2) provided to
				  the member each time the member's benefits are reduced, denied, or terminated
				  for any reason;
(3) easy for
				  members to understand and follow; and
(4) contain a prominent notice to the member
				  that complies with the fair hearing rules found in Chapter 357, Subchapter A of
				  this title (relating to Uniform Fair Hearing Rules), stating the member retains
				  all rights as a Medicaid client to a fair hearing through the Health and Human
				  Services Commission (HHSC), in addition to the MCO's complaint and appeal
				  process.
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 353.417 - Quality Assessment and Performance Improvement

Current through Reg. 49, No. 28; July 12, 2024
(a) Each MCO must develop and implement an
				  ongoing quality assessment and performance improvement (QAPI) program for
				  services it furnishes to its enrollees. The MCO must maintain and provide
				  documentation of its compliance for HHSC's or its contracted External Quality
				  Review Organization's (EQRO's) review, including performance measurement data.
				  The MCO's quality assessment and performance improvement program must meet the
				  requirements contained in
				  RSA
				  438.240 and, at a minimum, include:
(1) a program of performance improvement
				  projects that focus on clinical and non-clinical areas;
(2) mechanisms to assess the quality and
				  appropriateness of care furnished to enrollees with special health care
				  needs;
(3) mechanisms to detect
				  both under and over-utilization of services;
(4) practice guidelines that meet CMS
				  requirements under
				  RSA
				  438.236.