reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter I - MEDICAID PROGRAM APPEALS PROCEDURES › Division 1 - GENERAL › Section 354.2201 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
						shall have the following meanings unless the context clearly indicates
						otherwise.
(1) Action--A denial,
					 termination, suspension, or reduction of Medicaid-covered services; a denial of
					 a prior authorization request for covered services affecting a recipient; the
					 failure of the department to act upon a recipient request for Medicaid covered
					 services within a reasonable time; or a lock-in. This term does not include
					 reaching the date on which a time limited prior authorized service ends. This
					 term does not include a provider action for which the recipient may be held
					 financially liable by the provider.
(2) Administrative Appeal--A request for
					 review of, not a hearing on, claims denied by the claims administrator or
					 claims processing entity for technical and non-medical reasons.
(3) Day--A calendar day.
(4) Commission--Health and Human Services
					 Commission
(5) Designee--The
					 Commission's contractor who administers the claims processing for the Medicaid
					 program.
(6) Final decision--A
					 decision that is reached by the Health and Human Services Commission staff and
					 associated with an administrative, medical, or utilization review appeal or
					 fair hearing.
(7) Lock-in--An
					 action taken by the Commission to restrict the recipient's choice of
					 providers.
(8) Managed care
					 organization (MCO)--A managed care organization under contract with the
					 Commission to provide services to Medicaid recipients.
(9) Medical Appeal--A request for review of,
					 not a hearing on, claims denied by the claims processing entity for medical
					 necessity.
(10) Prior authorized
					 services--Services that are reimbursable only when authorization or approval is
					 obtained before services are rendered. Prior authorized services may be limited
					 in duration, scope, and amount. Services provided beyond those authorized are
					 not reimbursable. If a prior authorization is limited in duration, scope or
					 amount, a separate request and approval must be obtained for each prior
					 authorized service.
(11) Provider
					 action--A denial or reduction of a provider claim for payment for services
					 rendered to a Medicaid recipient.
(12) Utilization Review Appeal--A request for
					 review of, not a hearing on, a determination made by the HHSC Utilization
					 Review department to the Medical Appeals area within HHSC. The authority
					 related to this type of appeal may be found in 1 TAC §
											RSA
					 371.208.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter I - MEDICAID PROGRAM APPEALS PROCEDURES › Division 1 - GENERAL › Section 354.2203 - Recipients with Special Needs or Disabilities

Current through Reg. 49, No. 28; July 12, 2024
The department will make reasonable accommodations to
						assist recipients in reading and understanding notices and procedures under
						this chapter. The department will also provide assistance to recipients who
						require language translations or have hearing or speech communication
						needs.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter I - MEDICAID PROGRAM APPEALS PROCEDURES › Division 2 - RECIPIENT NOTICE AND FAIR HEARING › Section 354.2211 - Recipient Notice and Fair Hearing Request

Current through Reg. 49, No. 28; July 12, 2024
(a) When notice is required. A
					 Medicaid-eligible recipient is entitled to a notice under this subchapter any
					 time the department, its designee, or a managed care organization (MCO) intends
					 to take an action. An MCO is responsible for sending the notice to recipients
					 enrolled in the MCO. The department is responsible for sending notices to all
					 other recipients.
(b) Time of
					 notice. A notice of intent to take action must be mailed to the recipient by
					 the department, its designee or MCO no less than 30 days before the department,
					 its designee, or MCO intends to take an action.
(c) Content of notice. The notice required by
					 subsection (a) of this section must contain the following information:
(1) a statement of the action the department,
					 its designee, or MCO will take;
(2)
					 an explanation of the reasons the department, its designee, or MCO will take an
					 action;
(3) a reference to the
					 state or federal regulations which support the action the department, its
					 designee, or MCO will take;
(4) an
					 explanation of the recipient's right to request a fair hearing from the
					 department;
(5) the procedure by
					 which the recipient may request a fair hearing from the department or through
					 the MCO, including the address where written requests must be submitted and any
					 toll-free or local phone number the recipient may call to request assistance or
					 a fair hearing;
(6) an explanation
					 that recipients may represent themselves or have legal counsel, a relative, a
					 friend, or another spokesperson represent them;
(7) an explanation of whether and under what
					 circumstances services may be continued if a fair hearing is
					 requested;
(8) a statement that the
					 recipient must make a request for a fair hearing within 30 days from the date
					 on the notice, and that if the recipient does not request a fair hearing within
					 this time period, the recipient's right to a fair hearing will be waived. The
					 notice is presumed to be received by the recipient five days from the date of
					 the notice;
(9) an explanation that
					 the recipient may request the fair hearing be conducted based on written
					 information without the necessity of taking oral testimony. The written
					 information may consist of the department's records, the medical information
					 submitted by the recipient, and any additional written information the
					 recipient may wish to submit; and
(10) a notice from an MCO informing
					 recipients of their right to access the department's fair hearing process under
					 § 36.23 of this title (relating to Fair Hearings).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter I - MEDICAID PROGRAM APPEALS PROCEDURES › Division 2 - RECIPIENT NOTICE AND FAIR HEARING › Section 354.2213 - Maintaining Benefits or Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Except
					 as otherwise specified in subsection (e) of this section, if the recipient is
					 currently receiving a service upon which an action is taken and requests a fair
					 hearing within the time allowed, the service will be continued until a final
					 decision is rendered following a fair hearing.
(b) The department may terminate or reduce
					 services before rendering a decision only if:
(1) the department informs the recipient in
					 writing of its intent to reduce or terminate services at least five days before
					 the termination or reduction would be effective; and
(2) it is determined at the fair hearing that
					 the sole issue is one of state or federal law or policy.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter I - MEDICAID PROGRAM APPEALS PROCEDURES › Division 2 - RECIPIENT NOTICE AND FAIR HEARING › Section 354.2215 - Fair Hearing

Current through Reg. 49, No. 28; July 12, 2024
(a) A fair hearing
					 will be conducted under the department's fair hearing procedures found at
					 §§ 1.51-1.55 of this title (relating to Fair Hearing
					 Procedures).
(b) A final decision
					 must be made by the department within 90 days from the date the recipient makes
					 a request for a fair hearing, unless waived in writing by the
					 recipient.
(c) The department will
					 send a written notice of its decision to the recipient.
(d) If the recipient is enrolled in a managed
					 care organization (MCO), the department shall also notify the MCO of its
					 decision. The decision of the department is binding on the MCO.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 1 - GENERAL PROVISIONS › Section 354.2301 - Basis and Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter
					 implements the requirements of Texas Health & Human Services Commission
					 (HHSC) under federal and state law to:
(1) set
					 forth the requirements of Medicaid applicants and recipients, and
					 representatives of applicants and recipients regarding assignment,
					 identification, and cooperation with HHSC in establishing third party liability
					 and recovery;
(2) set forth the
					 rights, restrictions, and limitations of providers to third party recovery;
					 and
(3) establish the priority of
					 distributions of third party recoveries, including distributions into a trust
					 established under the provisions of the Social Security Act §1917(d)(4)
					 (codified at 42 U.S.C.
					 §
													1396p(d)(4)).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 1 - GENERAL PROVISIONS › Section 354.2302 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, have the following meanings unless the context clearly indicates
						otherwise.
(1) Applicant--An
					 individual, or the parent or legal guardian of an individual, who has applied
					 to HHSC or another agency of the state for medical assistance from the Medicaid
					 program.
(2) Capitation payment--A
					 fixed predetermined fee paid to the MCO each month, in accordance with the
					 contract, for each enrolled member in exchange for which the MCO arranges for
					 or provides a defined set of covered services to the member, regardless of the
					 amount of covered services used by the enrolled member.
(3) Coinsurance--A term used to describe the
					 percentage of money an individual is responsible for paying toward health care
					 items or services covered by a health insurer.
(4) Copayment--A set amount of money an
					 individual is required to pay for health care items or services covered by a
					 health insurer.
(5) Deductible--The
					 amount of money an individual is required to pay for health care items or
					 services before the individual's health insurer begins paying for health care
					 items or services.
(6) Designee--An
					 entity to which HHSC has delegated certain functions. 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 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 2 - APPLICANT AND RECIPIENT REQUIREMENTS › Section 354.2311 - Applicant and Recipient Assignment of Rights

Current through Reg. 49, No. 28; July 12, 2024
(a) As a condition for eligibility, each
					 applicant for or recipient of Medicaid benefits assigns to HHSC his or her
					 rights, or the rights of any other individual eligible for Medicaid benefits
					 under the State Plan for whom he or she can legally make an assignment, to
					 medical support and any payment from a third party resource.
(b) No separate assignment from the applicant
					 or recipient is required by HHSC to enforce HHSC's right to recover amounts
					 paid by HHSC for the recipient's medical care.
(c) HHSC's right of recovery against a third
					 party resource is limited to the amount paid by HHSC on all claims submitted
					 for Medicaid-covered services by Medicaid providers for a recipient's medical
					 care.
(d) HHSC's right of recovery
					 against a third party resource includes the ability to seek reimbursement from
					 settlement amounts representing past or future payments for medical
					 care.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 2 - APPLICANT AND RECIPIENT REQUIREMENTS › Section 354.2313 - Duty of Applicant or Recipient to Inform and Cooperate

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant or recipient of Medicaid
					 benefits has a duty and responsibility to inform HHSC or other State agency, at
					 the time of application, during the period of eligibility, or at any time after
					 receiving services from the Medicaid program, of the following:
(1) any pending or unsettled claim for
					 injuries for which a claim for health care items or services has or will be
					 submitted to the Medicaid program for payment;
(2) the name and address of any attorney the
					 applicant or recipient hires to represent the applicant or recipient in any
					 claim for injuries for which a claim for health care items or services has or
					 will be submitted to the Medicaid program for payment;
(3) any court or administrative order
					 requiring any person to make medical support payments to the recipient or the
					 Title IV-D agency; this duty and responsibility does not apply to any woman
					 defined in the §1905(n)(1) (poverty level pregnant women) (codified at
					 42 U.S.C. §
													1396d(n)(1));
(4) the identity of the father of any child
					 who is an applicant or recipient of Medicaid benefits, and to cooperate with
					 the Title IV-D Agency in establishing paternity and medical support payments
					 for the child;
(5) any third party
					 resource who is or may be responsible for paying for or providing health
					 coverage to the applicant or recipient, including the name and relationship of
					 the insured, the name of the policyholder, the policy number, the dates
					 coverage is in effect, the date of occurrence of any accident or injury and any
					 other information required by HHSC or the third party resource to file a claim
					 or identify the recipient as an insured or covered person; and
(6) any other resource that is or becomes
					 available to provide or pay for health care items or services covered by the
					 Medicaid program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 2 - APPLICANT AND RECIPIENT REQUIREMENTS › Section 354.2315 - Duty of Attorney or Representative of a Recipient

Current through Reg. 49, No. 28; July 12, 2024
(a) An attorney or other person who
					 represents or acts on behalf of a recipient in a third party claim or action
					 for damages for personal injuries, regardless of whether a legal action has
					 been filed, for which health care items or services are provided and paid for
					 by Medicaid must send written notice of representation to HHSC. The written
					 notice must be signed by the attorney or representative of the recipient and
					 sent according to the provisions of §
											354.2334 of this subchapter
					 (relating to Notices and Payments). The written notice must be submitted within
					 45 days from the date the attorney or representative undertakes representation
					 of the recipient, or from the date a potential third party resource is
					 identified. The written notice must include the following information, if known
					 at the time of initial filing:
(1) the name
					 and address and identifying information of the recipient (either the date of
					 birth and the Social Security number, or the date of birth and the Medicaid
					 identification number);
(2) the
					 name and address of any third party resource against whom a third party claim
					 is or may be asserted for injuries to the Medicaid applicant or
					 recipient;
(3) the name and address
					 of any health care provider who has asserted a claim for payment provided to
					 the Medicaid applicant or recipient for health care items or services provided
					 to the Medicaid applicant or recipient for which a third party resource may be
					 liable for payment, whether or not the claim may have been submitted to or paid
					 by HHSC; and
(4) if any of the
					 information described in subsection (a) of this section is unknown at the time
					 the initial notice is filed, this should be indicated on the notice, and
					 revised if and when the information becomes known.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 3 - PROVIDER REQUIREMENTS › Section 354.2321 - Provider Billing and Recovery From Third Party Resources

Current through Reg. 49, No. 28; July 12, 2024
(a) Providers must make a good faith effort
					 to determine whether a recipient is or may be insured by a third party resource
					 at the time services are provided, by making a reasonable attempt to verify
					 with the recipient either orally or in.
(b) If a third party resource is identified,
					 providers are required to bill the third party resource before submitting a
					 claim for payment to HHSC under the provisions of §
											354.1003 of this chapter (relating
					 to Time Limits for Submitted Claims) unless otherwise directed by
					 HHSC.
(c) Providers who identify a
					 third party resource, within 12 months from the date of service, and wish to
					 submit a claim for payment to a third party resource after a claim for payment
					 has been submitted and paid by HHSC, must refund any amounts paid by Medicaid
					 prior to submitting a claim for payment to the third party resource.
(d) Providers are limited to the Medicaid
					 payable amount and the provider is required to accept the amount paid by HHSC
					 as payment in full if:
(1) a claim for payment
					 is submitted to and paid by HHSC; and
(2) the provider failed to inform HHSC at the
					 time the claim was filed, or any time thereafter, that a third party resource
					 was also billed for the same service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 4 - DUTIES OF THE COMMISSION › Section 354.2331 - Requests for Information

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC will
					 provide assistance and cooperation to recipients, attorneys and representatives
					 of recipients who seek recovery on behalf of HHSC for amounts owed to HHSC
					 under this subchapter. HHSC will provide information, evidence and documents
					 required to settle and receive judgment for the amounts owed HHSC and provide
					 appropriate and necessary releases and authorizations to settle and distribute
					 amounts owed to HHSC under this subchapter.
(b) HHSC is required to safeguard the best
					 interests of the recipient under the provisions of Social Security Act
					 §1902(a)(19) (codified at
					 42 U.S.C. §
												1396a(a)(19)).
(c) HHSC is required to provide safeguards
					 which restrict the use and disclosure of information concerning applicants and
					 recipients to purposes directly connected with the administration of the
					 Medicaid program under the provisions of Social Security Act §1902(a)(7)
					 (codified at 42 U.S.C.
					 §
												1396a(a)(7)).
(d) Requests for information relating to
					 third party recoveries under this subchapter must fall within the requirements
					 of subsections (a) and (b) of this section.
(e) A recipient or an attorney or
					 representative of a recipient may request information relating to claims
					 submitted or paid or payable by HHSC, and records within the custody and
					 control of HHSC, as they relate to this subchapter if:
(1) the request is signed by the recipient or
					 a person with legal authority to act on behalf of the recipient; or
(2) the attorney or representative making the
					 request has filed a notice which complies with the requirements of §
												354.2315 of this subchapter
					 (relating to Duty of Attorney or Representative of a Recipient).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 4 - DUTIES OF THE COMMISSION › Section 354.2332 - Distribution of Recoveries

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC will
					 distribute third party recoveries, if cost effective, as follows:
(1) HHSC will receive an amount equal to
					 HHSC's total Medicaid expenditures for the recipient, or another individual
					 eligible for Medicaid benefits under the State Plan for whom he or she can
					 legally make an assignment to medical support and payment;
(2) the federal government will receive the
					 federal share of the Medicaid expenditures, minus any incentive payment
					 authorized by federal law; and
(3)
					 the recipient will receive any remaining amount and any amount distributed to
					 the recipient is income or resources for purposes of establishing eligibility
					 for Medicaid benefits.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 4 - DUTIES OF THE COMMISSION › Section 354.2333 - Waiver Authority of the Executive Commissioner

Current through Reg. 49, No. 28; July 12, 2024
(a) The Executive Commissioner has the
					 authority to waive all or part of the state's right to recover from liable
					 third party resources when the Executive Commissioner finds that enforcement of
					 the state's right of recovery would tend to defeat the purpose of public
					 assistance.
(b) The Executive
					 Commissioner has the authority to waive all or part of the federal matching
					 share of HHSC's right to recovery from liable third party resources only if the
					 cost of recovery exceeds the amount, which could be
					 recovered.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 4 - DUTIES OF THE COMMISSION › Section 354.2334 - Notices and Payments

Current through Reg. 49, No. 28; July 12, 2024
Notices and payments required to be submitted to HHSC
						under this subchapter must be submitted by fax or mail to the Texas Medicaid
						claims administrator, Medicaid Third Party Liability/Tort division. Contact and
						address information for the Texas Medicaid claims administrator, Medicaid Third
						Party Liability/Tort division, can be found online in the Texas Medicaid
						Provider and Procedures Manual (TMPPM).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 5 - HEALTH INSURER REQUIREMENTS › Section 354.2341 - Third Party Health Insurer Payment and Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A third party resource must accept HHSC's
					 right of recovery and the assignment to the State of any right of an individual
					 or other entity to payment from the third party resource for a health care item
					 or service provided by the Medicaid program.
(b) A payment made by a third party resource
					 to HHSC or a provider on a claim for payment of a health care item or service
					 provided to a Medicaid recipient is final on the date that is two years after
					 the third party payment was made. After a claim is final, the claim is subject
					 to adjustment only if an action for recovery of an overpayment was commenced
					 under §
											354.2321(b) of
					 this subchapter (relating to Provider Billing and Recovery From Third Party
					 Resources) before the date the claim became final and the recovery is agreed to
					 by HHSC under §
											354.2321(c) of
					 this subchapter.
(c) Third party
					 health insurers must maintain and provide to HHSC, on request, information HHSC
					 deems necessary to determine:
(1) the period
					 during which an individual entitled to medical assistance, the individual's
					 spouse, or the individual's dependents may be, or may have been, covered by
					 coverage issued by the health insurer;
(2) the nature of the coverage; and
(3) the name, address, and identifying number
					 of the health plan under which the individual may be, or may have been,
					 covered.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 5 - HEALTH INSURER REQUIREMENTS › Section 354.2343 - Administrative Penalties for Failure to Provide Information

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC may impose administrative penalties
					 on an insurer who fails to provide information requested by HHSC as required by
					 §354.2341(c) of this division (relating to Third Party Health Insurer
					 Payment and Information Requirements) within 180 days from the date of the
					 request.
(b) If the insurer does
					 not provide the requested information, the administrative penalty will be
					 assessed on a daily basis for each day of non-compliance beginning on the day
					 following the 180th day HHSC made a request for information and continuing
					 until the information is received by HHSC.
(1)
					 HHSC's request for information may be made by any method that provides
					 verification of receipt.
(2) The
					 180th day will be calculated from the date HHSC obtains written or electronic
					 verification of receipt by the insurer.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 5 - HEALTH INSURER REQUIREMENTS › Section 354.2344 - Notice and Appeal of Administrative Penalty

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC will send the insurer a Notice of
					 Administrative Penalty at least 30 days prior to the date that administrative
					 penalties begin to accrue.
(b) The
					 notice will contain the following information:
(1) the date on which administrative
					 penalties begin to accrue if the information requested by HHSC is not received
					 on or before that date; and
(2) the
					 amount of the administrative penalty which will be assessed for each day of
					 non-compliance after the date indicated on the notice.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 6 - BILLING AND PAYMENT GUIDELINES › Section 354.2354 - Billing Medicare Intermediaries

Current through Reg. 49, No. 28; July 12, 2024
HHSC shall pursue reimbursement of Medicaid expenditures
						from each fiscal intermediary who makes a payment to a service provider on
						behalf of the Medicare program, including a reimbursement for a payment made to
						a home health services provider or nursing facility for services rendered to a
						dually eligible individual.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 6 - BILLING AND PAYMENT GUIDELINES › Section 354.2355 - Long Term Care Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) A nursing
					 facility, home health services provider, or any other similar long-term care
					 services provider that is Medicare certified must:
(1) seek reimbursement from Medicare before
					 billing the Medicaid program for health care items or services provided to an
					 individual who is eligible to receive similar services under the Medicare
					 program; and
(2) as directed by
					 HHSC, appeal Medicare claim denials for payment.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 6 - BILLING AND PAYMENT GUIDELINES › Section 354.2356 - Provider Requirements to Bill Third Party Health Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) To the extent allowed by federal law, a
					 health care service provider must seek reimbursement from any third party
					 resource that the provider knows about or should know about before billing
					 Medicaid, except for Medicaid programs and services that are required to be
					 paid first prior to billing the third party resource.
(b) Providers cannot bill Medicaid recipients
					 for copayments, deductibles, or coinsurance for Medicaid-covered services. If a
					 recipient's third party resource does not cover a copayment, deductible, or
					 coinsurance, the provider must bill Medicaid for reimbursement of the
					 copayment, deductible, or coinsurance, as follows.
(1) Deductible or coinsurance: Include the
					 explanation of benefits from the third party resource with the claim showing
					 the payment amount was applied directly to the recipient's deductible or
					 coinsurance.
(2) Copayment: Include
					 the copayment code on the claim form in order to be eligible for
					 reimbursement.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter J - MEDICAID THIRD PARTY RECOVERY › Division 7 - HEALTH INSURANCE PREMIUM PAYMENT GUIDELINES › Section 354.2361 - Medicaid Health Insurance Premium Payment Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. The Medicaid Health Insurance
					 Premium Payment (HIPP) program is established under §1906 of the Social
					 Security Act (RSA
					 1396e) to reimburse an eligible individual's
					 portion of employer-sponsored health insurance premium payments, when
					 cost-effective.
(b) Definitions.
					 The following words and terms, when used in this section, have the following
					 meanings unless the context clearly indicates otherwise:
(1) Cost-effective--In accordance with
					 §1906 of the Social Security Act (RSA
					 1396e(e)(2)), the amount
					 paid for premiums, coinsurance, deductibles, other cost sharing obligations
					 under a group health plan, and additional administrative costs is less than the
					 amount paid for an equivalent set of Medicaid services.
(2) Employer-sponsored insurance (ESI)--A
					 group health plan offered to an employee through the employer.
(3) Explanation of Benefits (EOB)--A document
					 provided by the insurance company that shows the type of medical service, the
					 date of service, the amount paid by the insurance company, and the amount paid
					 by the individual receiving medical services.
(4) Family member--Any member of a family for
					 which the employer-sponsored insurance plan will allow coverage, such as a
					 spouse or child.
(5) Group health
					 plan--In accordance with Title 26, Internal Revenue Code, §5000(b)(1), a
					 plan (including a self-insured plan) of, or contributed to by, an employer
					 (including a self-employed person) or employee organization to provide health
					 care (directly or otherwise) to the employees, former employees, the employer,
					 others associated or formerly associated with the employer in a business
					 relationship, or their families.
(6) Health and Human Services Commission
					 (HHSC)--The single state agency charged with administration and oversight of
					 the Texas Medicaid program, or its designee.
(7) Open enrollment--The time period
					 established by an employer during which an employee is eligible to sign up for
					 ESI or make changes to an existing ESI benefit plan.
(8) Qualifying event--An event which allows
					 for an individual to enroll in or dis-enroll from a group health plan at any
					 time, within or outside the plan's open enrollment period.
(9) Rate sheet--A document provided by an
					 employer or an insurance company that shows the insurance premium amount the
					 employee is responsible for paying each month.
(10) Summary of benefits--A document provided
					 by an employer or an insurance company that shows the amount the insurance
					 company pays for medical services provided under the benefit plan.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL › Section 354.2401 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in the sections
					 under this subchapter, shall have the following meanings, unless the context
					 clearly indicates otherwise.
(1)
				  Abuse--Practices that are inconsistent with sound fiscal, business, or medical
				  practices and that result in unnecessary program cost or in reimbursement for
				  services that are not medically necessary, do not meet professionally
				  recognized standards for health care, or do not meet standards required by
				  contract, statute, regulation, previously sent interpretations of any of the
				  items listed, or authorized governmental explanations of any of the
				  foregoing.
(2)
				  Conflicting--Incompatible, unsuitable for use together because of undesirable
				  chemical or physiological effects. For example, the recipient may receive drugs
				  and/or health care services which may be inadvisable in the presence of certain
				  medical conditions or which conflict with the care ordered by another
				  provider.
(3)
				  Contraindicated--Condition or factor that indicates the inadvisability of a
				  medical treatment or procedure.
(4)
				  Designated Provider--A provider enrolled in the Texas Medicaid program that is
				  not on payment review status; under administrative action, sanction, or
				  investigation for failure to comply with Medicaid rules or acceptable Medicaid
				  practices; or under sanction or inactive or other limited administrative status
				  by a state licensing board or other regulatory entity. The designated provider
				  oversees the Medicaid benefits or services provided to a recipient in lock-in
				  status. A designated provider includes:
(A) a
				  primary health care provider who provides and/or directs all medically
				  necessary health care benefits or services for which the recipient is eligible.
				  The primary health care provider may include a physician, physician group,
				  dentist, dental home, advanced practice nurse, physician assistant, outpatient
				  clinic, Rural Health Clinic, or Federally Qualified Health Center; or
(B) a pharmacy that monitors medications
				  prescribed to a recipient in lock-in status for contraindicative, conflicting,
				  duplicative, or excessive use and that ensures the recipient's use does not
				  represent abuse, misuse, or fraud.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL › Section 354.2403 - Monitoring and Review

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and
				  Human Services Commission (HHSC), in accordance with the Code of Federal
				  Regulations, Chapter 42, §431.54(e), conducts a review and analysis of
				  data and/or incoming referrals, such as referrals from medical providers,
				  managed care organizations, state agencies, law enforcement officials, or
				  members of the general public, to identify Texas Medicaid eligible recipients
				  for lock-in.
(1) HHSC may impose a lock-in if
				  it finds that:
(A) a recipient received
				  duplicative, excessive, contraindicated, or conflicting health care services,
				  including drugs; or
(B) a review
				  indicates abuse, misuse or fraudulent actions related to Medicaid benefits and
				  services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL › Section 354.2405 - Utilization Control

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and
				  Human Services Commission (HHSC) controls a recipient's inappropriate use of
				  Medicaid benefits or services by restricting the recipient to a designated
				  provider(s).
(b) HHSC will send a
				  recipient written notification of intent to restrict the recipient to a
				  designated provider. The notice will include a form allowing the recipient the
				  opportunity to select a designated provider and will inform the recipient of
				  the length of the lock-in period and the recipient's right to a hearing. HHSC
				  will select a designated provider for the recipient if it does not receive the
				  completed form within ten days from the date of the initial notice.
(c) HHSC assigns a lock-in period to a
				  recipient. A recipient remains in lock-in status regardless of a change in
				  address or eligibility program type. HHSC will review and determine whether to
				  continue a recipient's lock-in status prior to the end of a lock-in period.
(1) A recipient who has never been in lock-in
				  status will be assigned a 36-month lock-in period. If a recipient's Medicaid
				  eligibility ends and reactivates during the 36-month lock-in period, then upon
				  reenrollment in Medicaid, that recipient will be locked in for the remaining
				  number of months in the original lock-in period.
(2) A recipient who has completed the
				  36-month lock-in period and is reinstated to lock-in status will be assigned a
				  60-month lock-in period. If a recipient's Medicaid eligibility ends or
				  reactivates during the 60-month lock-in period, then upon reenrollment in
				  Medicaid, that recipient will be locked in for the remaining number of months
				  in the lock-in period.
(3) A
				  recipient is assigned a lifetime lock-in period if the recipient:
(A) has completed the 60-month lock-in
				  period;
(B) is arrested, indicted,
				  or convicted of a crime relating to Medicaid fraud, or of a felony offense
				  relating to controlled substances; or
(C) admits guilt of Medicaid fraud, or a
				  felony offense related to controlled substances.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter K - MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL › Section 354.2407 - Recipient Rights

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and
				  Human Services Commission (HHSC) gives a recipient timely and adequate notice
				  of an action to assign the recipient to a designated provider and opportunity
				  for a fair hearing. Hearings are conducted under Chapter 357, Subchapter A, of
				  this title (relating to Uniform Fair Hearing Rules).
(1) The written notice to a recipient of the
				  recipient's right to a hearing will be mailed at least ten calendar days before
				  the lock-in period effective date.
(2) HHSC will grant a hearing if it receives
				  a recipient's request for a hearing no later than:
(A) 90 calendar days from the date of the
				  initial notice of intent to assign a designated provider; or
(B) 90 calendar days from the date of the
				  notice of intent to continue a lock-in period.
(3) If a request for a hearing is received by
				  the lock-in effective date, HHSC will not implement the lock-in status until
				  the hearing has been held and a final decision rendered.
(4) If a request for a hearing is received
				  after the lock-in effective date, the lock-in status will remain in effect
				  until the hearing has been held and a final decision rendered that reverses the
				  lock-in action.
(5) The recipient
				  does not have the right to a fair hearing when the lock-in is the result of a
				  misdemeanor or felony offense related to fraud and/or abuse of Medicaid
				  benefits and/or services, or to controlled substances.
(6) During the lock-in period, the recipient
				  is not entitled to a fair hearing for denial of either of the following
				  requests:
(A) change in designated provider;
				  or
(B) termination of the lock-in
				  period.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter L - QUALITY IMPROVEMENT PROCESS FOR CLINICAL INITIATIVES › Section 354.2503 - Clinical Initiative Evaluation Process

Current through Reg. 49, No. 28; July 12, 2024
(a) Clinical initiative evaluation process.
				  This process consists of the submission, preliminary review, analysis, and
				  approval of a clinical initiative.
(1)
				  Authorized submitters may submit suggestions of clinical initiatives in written
				  form sent via postal mail, in electronic form via email, or using the
				  designated online form available via the HHSC Internet website required under
				  this subchapter.
(2) Each
				  suggestion for a clinical initiative will be submitted to the state Medicaid
				  director.
(3) Designated HHSC staff
				  will review each suggestion and determine if it warrants a full analysis.
				  Suggestions selected for full analysis will be posted on HHSC Internet website
				  for public comment within 30 days of receipt by the state Medicaid
				  director.
(4) HHSC will determine
				  the number of selected suggestions to undergo full analysis depending on
				  available staff resources. If sufficient staff resources are available, the
				  full analysis will be completed within 180 days of receipt of the suggestion by
				  the state Medicaid director.
(5)
				  HHSC staff will consult appropriate subject matter experts both internally and
				  externally for determination of whether a clinical initiative suggestion
				  warrants full analysis. Subject matter experts will also be consulted during
				  full analysis and report development of the clinical initiative, if additional
				  input is needed.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter L - QUALITY IMPROVEMENT PROCESS FOR CLINICAL INITIATIVES › Section 354.2505 - Action on Approved Clinical Initiatives

Current through Reg. 49, No. 28; July 12, 2024
After HHSC conducts an analysis of a clinical
					 initiative:
(1) If the commission
				  determines that the initiative is cost-effective and will improve the quality
				  of care under the Medicaid program, HHSC may:
(A) Implement the initiative if
				  implementation of the initiative is not otherwise prohibited by law;
				  or
(B) If implementation requires a
				  change in law, submit a copy of the final report together with recommendations
				  relating to the initiative's implementation to the standing committees of the
				  Senate and House of Representatives having jurisdiction over the Medicaid
				  program; and
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter L - QUALITY IMPROVEMENT PROCESS FOR CLINICAL INITIATIVES › Section 354.2507 - Internet Website

Current through Reg. 49, No. 28; July 12, 2024
The content of this website required under this subchapter
					 will include:
(1) An explanation of
				  the clinical initiative evaluation process;
(2) An explanation of how members of the
				  public may submit comments or research related to an initiative;
(3) A copy of each initiative selected for
				  further analysis;
(4) The status of
				  each initiative in the approval process; and
(5) A copy of the final report for each
				  approved clinical initiative.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter M - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Division 1 - GENERAL PROVISIONS › Section 354.2601 - Purpose and Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 purpose of this subchapter is to establish requirements for providing mental
					 health targeted case management and mental health rehabilitative services
					 throughout Medicaid, including the managed care and the fee-for-service
					 models.
(b) This subchapter applies
					 to public and private comprehensive provider agencies delivering Medicaid
					 mental health targeted case management and mental health rehabilitative
					 services.
(c) Nothing in this
					 subchapter shall be construed to override Medicaid State Plan limitations on
					 permissible providers.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter M - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Division 1 - GENERAL PROVISIONS › Section 354.2603 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, have the following meanings unless the context clearly indicates
						otherwise.
(1) Adult--An individual who
					 is age 21 or older.
(2) Appeal--A
					 mechanism for an independent review of an adverse determination or a request
					 for a review of an action or failure to act that may result in a fair
					 hearing.
(3) Audio-only--Has the
					 meaning assigned by §
											354.1430(1) of
					 this chapter (relating to Definitions).
(4) Behavioral health emergency--A situation
					 involving an individual who is behaving in a violent or self-destructive manner
					 and in which preventive, de-escalation, or verbal techniques have been
					 determined to be ineffective and it is immediately necessary to restrain or
					 seclude the individual to prevent:
(A)
					 imminent probable death or substantial bodily harm to the individual because
					 the individual is attempting to commit suicide or inflict serious bodily harm;
					 or
(B) imminent physical harm to
					 others because of acts the individual commits.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter M - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Division 1 - GENERAL PROVISIONS › Section 354.2605 - Fair Hearings and Appeal Processes

Current through Reg. 49, No. 28; July 12, 2024
(a) A Medicaid eligible individual whose
					 request for services is denied or is not acted upon with reasonable promptness,
					 or whose services are terminated, suspended, or reduced, is entitled to an HHSC
					 fair hearing per Chapter 357, Subchapter A, of this title (relating to Uniform
					 Fair Hearing Rules).
(b) An
					 individual receiving services through enrollment in a managed care organization
					 may also appeal with the managed care organization per §
											RSA
					 353.415 of this title (relating to Member
					 Complaint and Appeal Procedures).