reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 15 - HEARING AID SERVICES › Section 354.1235 - Requirements for Provider Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) Provider enrollment. All authorized
					 hearing aid providers, as described in §354.1233 of this Division
					 (relating to Requirements for Hearing Aid Services), claiming reimbursement for
					 hearing aid services provided as a Title XIX benefit to an eligible Medicaid
					 recipient must be enrolled in the Texas Medicaid Program.
(1) To be eligible for reimbursement of Title
					 XIX benefits for hearing aid services covered by the Texas Medicaid Program,
					 each provider of medical care and services must enter into a written agreement
					 with the Health and Human Services Commission (Commission).
(2) Participating providers must comply with
					 all federal and state laws and regulations governing the Texas Medicaid
					 Program. Providers must also comply with the provisions, conditions,
					 certifications, and limitations as described in this subchapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 16 - MIDWIFE SERVICES › Section 354.1251 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, requirements,
						and limitations established by the Texas Health and Human Services Commission
						(HHSC) or its designee and according to state and federal laws, rules, and
						regulations, and in the case of services furnished in an institution, hospital
						or other facility to the extent permitted by the institution, hospital, or
						facility, nurse-midwife services are limited as follows.
(1) Nurse-midwife services must be provided
					 by a certified nurse-midwife (CNM) who is enrolled and approved for
					 participation in the Texas Medical Assistance (Medicaid) Program.
(2) Nurse-midwife services are covered if the
					 services:
(A) Are within the scope of
					 practice for certified nurse midwives, as defined by state law;
(B) Are consistent with rules and regulations
					 promulgated by the Board of Nurse Examiners for the State of Texas or other
					 appropriate state licensing authority; and
(C) Would be covered by the Texas Medical
					 Assistance Program if provided by a licensed physician (M.D. or
					 D.O.).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 16 - MIDWIFE SERVICES › Section 354.1252 - Certified Nurse Midwife: Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, requirements,
						and limitations established by the Texas Health and Human Services Commission
						or its designee (HHSC), nurse-midwife services that are provided by a certified
						nurse-midwife (CNM) are a covered benefit under the Texas Medicaid Program and
						are subject to the following conditions.
(1) The CNM provides nurse-midwife services
					 according to:
(A) requirements in
					 §354.1251 of this division (relating to Benefits and Limitations);
					 and
(B) provisions of the state
					 plan.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 16 - MIDWIFE SERVICES › Section 354.1253 - Licensed Midwife: Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) Criteria. Subject to the specifications,
					 conditions, requirements, and limitations established by the Texas Health and
					 Human Services Commission (HHSC), the Texas Medicaid Program will reimburse a
					 licensed midwife (LM) for a service in accordance with provisions of the state
					 plan only if:
(1) the LM is licensed and
					 approved by the Texas Midwifery Board under Chapter 203 of the Occupations Code
					 and 22 TAC Chapter 831 (relating to Midwifery);
(2) the LM who performs the service is
					 enrolled in and approved for participation in the Texas Medicaid
					 Program;
(3) the service:
(A) is consistent with rules and protocols
					 promulgated by the Texas Midwifery Board or other appropriate state licensing
					 authority;
(B) is provided in a
					 freestanding birthing center that is licensed under Chapter 244 of the Health
					 and Safety Code and approved by HHSC to participate in the Texas Medicaid
					 Program; and
(C) is within the LM's
					 scope of practice, as defined by state law and permitted by the freestanding
					 birthing center;
(4) the
					 service is one of the following:
(A) prenatal
					 care;
(B) labor and
					 delivery;
(C) postpartum care
					 immediately following delivery and until discharge or transfer from the
					 freestanding birthing center; or
(D) newborn care immediately following
					 delivery and until discharge or transfer from the freestanding birthing center;
					 and
(5) the service is
					 not duplicative of any other service charged to the Texas Medicaid
					 Program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 17 - BIRTHING CENTER SERVICES › Section 354.1261 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the
					 specifications, conditions, limitations, and requirements established by the
					 Health and Human Services Commission or its designee (HHSC), birthing center
					 services are those center services determined by the attending physician (MD or
					 DO), certified nurse-midwife (CNM), or licensed midwife (LM), to be reasonable
					 and necessary for the care of the mother and live newborn child following the
					 mother's normal, uncomplicated pregnancy.
(1)
					 The attending physician, CNM, or LM must be licensed at the time and place the
					 services are provided.
(2)
					 Reimbursable services are limited to services provided by the birthing center
					 during the labor, delivery, and immediate postpartum periods.
(3) Unless otherwise specified by HHSC,
					 covered services begin when the mother is in active labor and is admitted to
					 the birthing center, and end within 24 hours after the birth of the
					 child.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 17 - BIRTHING CENTER SERVICES › Section 354.1262 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, limitations,
						and requirements established by the Health and Human Services Commission or its
						designee (HHSC), a birthing center must:
(1) comply with all applicable federal,
					 state, and local laws and regulations;
(2) be licensed by the appropriate state
					 licensing authority to provide a level of service commensurate with the
					 professional skills of the physician (MD or DO), certified nurse-midwife (CNM),
					 or licensed midwife (LM) who acts as the birth attendant;
(3) meet and continue to meet the standards
					 for birthing centers established by the appropriate state licensing
					 authority;
(4) be enrolled and
					 approved for participation in the Texas Medicaid Program;
(5) sign a written provider agreement with
					 HHSC. By signing the agreement, the birthing center agrees to comply with the
					 terms of the agreement and all requirements of the Texas Medicaid Program,
					 including regulations, rules, handbooks, standards, and guidelines published by
					 HHSC;
(6) submit to HHSC copies of
					 all documents required for licensure by the appropriate state licensing
					 authority;
(7) notify HHSC, in
					 writing, within two weeks of any change in its licensure status or information
					 required for licensure; and
(8)
					 bill for services covered under the Texas Medicaid Program in the manner and
					 format prescribed by HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 18 - MATERNITY CLINIC SERVICES › Section 354.1272 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, limitations,
						and requirements established by the department or its designee, a maternity
						clinic must:
(1) be a facility that is
					 not an administrative, organizational, or financial part of a
					 hospital;
(2) be organized and
					 operated to provide maternity clinic services to outpatients;
(3) comply with all applicable federal,
					 state, and local laws and regulations;
(4) employ or have a contractual
					 agreement/formal arrangement with a licensed physician (MD or DO) who assumes
					 professional responsibility for the services provided to the clinic's
					 patients;
(5) adhere to the Bureau
					 of Maternal and Child Health Maternity Guidelines, dated June 20, 1988, and
					 subsequent revisions issued by the Texas Department of Health, unless otherwise
					 specified by the department or its designee;
(6) ensure that services provided to each
					 patient are commensurate with the patient's risk assessment and documented in
					 the patient's medical record;
(7)
					 be enrolled and approved for participation in the Texas Medical Assistance
					 Program;
(8) sign a written
					 provider agreement with the department or its designee. By signing the
					 agreement, the maternity clinic agrees to comply with the terms of the
					 agreement and all requirements of the Texas Medical Assistance Program,
					 including regulations, rules, handbooks, standards, and guidelines published by
					 the department or its designee; and
(9) bill for services covered by the Texas
					 Medical Assistance Program in the manner and format prescribed by the
					 department or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 18 - MATERNITY CLINIC SERVICES › Section 354.1275 - Monitoring

Current through Reg. 49, No. 28; July 12, 2024
The department or its designee monitors each
						participating maternity clinic to ensure compliance with the conditions for
						participation in § 29.1802 of this title (relating to Conditions for
						Participation).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 19 - PSYCHOLOGISTS' SERVICES › Section 354.1281 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to
					 the specifications, conditions, requirements, and limitations established by
					 the Texas Health and Human Services Commission (HHSC) or its designee,
					 psychological counseling and services are covered.
(b) To qualify for reimbursement the services
					 must be provided by a:
(1) Licensed
					 psychologist who is licensed by the Texas State Board of Examiners of
					 Psychologists (TSBEP), if:
(A) The services
					 are within the psychologist's scope of practice, as defined by state law;
					 and
(B) The services would be
					 covered by the Texas Medicaid program when they are provided by a licensed
					 physician (MD or DO).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 19 - PSYCHOLOGISTS' SERVICES › Section 354.1282 - Conditions of Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, limitations,
						and requirements established by the Texas Health and Human Services Commission
						(Commission) or its designee, a psychologist must:
(1) be licensed by the Texas State Board of
					 Examiners of Psychologists or other appropriate state licensing
					 authority;
(2) comply with all
					 applicable federal and state laws and regulations governing the services
					 provided;
(3) be enrolled and
					 participating in Medicare, unless the provider satisfies the criteria for
					 exception described in §354.1173(b);
(4) be enrolled and approved for
					 participation in the Texas Medical Assistance Program;
(5) sign a written provider agreement with
					 the Commission or its designee;
(6)
					 comply with the terms of the provider agreement and all requirements of the
					 Texas Medical Assistance Program, including regulations, rules, handbooks,
					 standards, and guidelines published by the Commission or its designee;
					 and
(7) bill for services covered
					 by the Texas Medical Assistance Program in the manner and format prescribed by
					 the Commission or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 20 - PHYSICAL THERAPISTS' SERVICES › Section 354.1291 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the
					 specifications, conditions, requirements, and limitations established by the
					 Texas Department of Health (department) or its designee, physical therapy
					 services, which include necessary equipment and supplies provided by a licensed
					 physical therapist, are covered by the Texas Medical Assistance Program.
					 Covered services also include the services of a physical therapist assistant
					 when the services are provided under the direction of and billed by the
					 licensed physical therapist.
(b) To
					 be payable, the services must be:
(1) within
					 the physical therapist's scope of practice, as defined by state law;
(2) reasonable and medically necessary, as
					 determined by the department or its designee;
(3) expected to significantly improve the
					 patient's condition in a reasonable and generally predictable period of time,
					 based on the physician's assessment of the patient's restorative potential
					 after any needed consultation with the therapist (benefits are not provided
					 when the patient has reached the maximum level of improvement); and
(4) prescribed by a physician (MD or DO), who
					 is licensed in the state in which he practices.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 20 - PHYSICAL THERAPISTS' SERVICES › Section 354.1292 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, limitations,
						and requirements established by the Texas Department of Health (department) or
						its designee, a physical therapist must:
(1) be licensed by the Texas State Board of
					 Physical Therapy Examiners or other appropriate state licensing
					 authority;
(2) comply with all
					 applicable federal and state laws and regulations governing the services
					 provided;
(3) be enrolled and
					 participating in Medicare;
(4) be
					 enrolled in and approved for participation in the Texas Medical Assistance
					 Program (TMAP);
(5) sign a written
					 provider agreement with the department or its designee;
(6) comply with the terms of the provider
					 agreement and all requirements of the TMAP, including regulations, rules,
					 handbooks, standards, and guidelines published by the department or its
					 designee; and
(7) bill for services
					 covered by the TMAP in the manner and format prescribed by the department or
					 its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 21 - CERTIFIED REGISTERED NURSE ANESTHETISTS' SERVICES › Section 354.1301 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Anesthesia
					 services provided by a Certified Registered Nurse Anesthetist (CRNA) are
					 covered by the Texas Medical Assistance Program and are subject to the
					 specifications, conditions, requirements, and limitations specified in this
					 section and established by the Texas Health and Human Services Commission
					 (HHSC) or its designee.
(b) To be
					 payable, the services must be:
(1) Provided
					 by a CRNA practicing in accordance with the Nursing Practice Act and the rules
					 and regulations promulgated by the Board of Nurse Examiners;
(2) Reasonable and medically necessary as
					 determined by HHSC or its designee;
(3) Ordered and supervised by a physician (MD
					 or DO), dentist, or podiatrist, to the extent allowed by state law, who must be
					 licensed in the state in which he or she practices; and
(4) Provided under one of the following
					 conditions:
(A) No physician anesthesiologist
					 is on the medical staff of the facility where the services are
					 provided;
(B) As determined in
					 accordance with the policies of the facility in which the services are
					 provided, no physician anesthesiologist is available to provide the
					 services;
(C) The physician,
					 dentist, or podiatrist performing the procedure requiring the services
					 specifically requests the services of a CRNA;
(D) The eligible recipient requiring the
					 services specifically requests the services of a CRNA;
(E) The CRNA is scheduled or assigned to
					 provide the services in accordance with policies of the facility in which the
					 services are provided; or
(F) The
					 services are provided by the CRNA in connection with a medical
					 emergency.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 21 - CERTIFIED REGISTERED NURSE ANESTHETISTS' SERVICES › Section 354.1302 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, limitations,
						and requirements established by the department or its designee, a certified
						registered nurse anesthetist must:
(1)
					 be a registered nurse who is approved as an advanced nurse practitioner by the
					 state in which he or she practices and is currently certified by either the
					 Council on Certification of Nurse Anesthetists or the Council on
					 Recertification of Nurse Anesthetists;
(2) comply with all applicable federal and
					 state laws and regulations governing the services provided;
(3) be enrolled and participating in
					 Medicare;
(4) be enrolled and
					 approved for participation in the Texas Medical Assistance Program;
(5) sign a written provider agreement with
					 the department or its designee;
(6)
					 comply with the terms of the provider agreement and all requirements of the
					 Texas Medical Assistance Program, including regulations, rules, handbooks,
					 standards, and guidelines published by the department or its designee;
					 and
(7) bill for services covered
					 by the Texas Medical Assistance Program in the manner and format prescribed by
					 the department or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 22 - SUBSTANCE ABUSE AND DEPENDENCY TREATMENT SERVICES › Section 354.1311 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to
					 the specifications, conditions, limitations, and requirements established by
					 the Health and Human Services Commission (HHSC) or its designee, substance use
					 disorder treatment services are those services provided by a provider or
					 facility licensed by the HHSC to provide substance use disorder treatment
					 services.
(b) Substance use
					 disorder has the definition assigned in the most current American Psychiatric
					 Association's Diagnostic and Statistical Manual of Mental Disorders.
(c) Covered outpatient substance use disorder
					 treatment services include:
(1)
					 assessment;
(2) outpatient group
					 and individual counseling;
(3)
					 medication assisted treatment; and
(4) outpatient withdrawal
					 management.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 22 - SUBSTANCE ABUSE AND DEPENDENCY TREATMENT SERVICES › Section 354.1312 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
Subject to the specifications, conditions, limitations,
						and requirements established by the Health and Human Services Commission (HHSC)
						or its designee, a substance use disorder treatment provider must meet the
						following requirements:
(1) Except as
					 provided in paragraph (2) of this section, be a facility that is licensed by
					 HHSC, the state licensure authority, as a chemical dependency treatment
					 facility.
(2) For medication
					 assisted treatment, be an HHSC-licensed chemical dependency treatment facility,
					 an HHSC-licensed narcotic treatment program, or an appropriately trained
					 physician or other qualified prescriber acting within the scope of his or her
					 licensure.
(A) Medication assisted treatment
					 using methadone for opioid use disorder may only be provided by an
					 HHSC-licensed narcotic treatment program in compliance with 42 Code of Federal
					 Regulations Part 8 Medication Assisted Treatment for Opioid Use
					 Disorders.
(B) Appropriately
					 trained physicians, and other qualified prescribers, as specified in the Texas
					 Medicaid Provider Procedures Manual, may also provide medication assisted
					 treatment using medications other than methadone. To prescribe buprenorphine
					 for the treatment of opioid use disorder, these prescribers must meet any
					 additional federal prescribing requirements.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 23 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 354.1321 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Effective for
					 services on or after April 1, 1990, and subject to the specifications,
					 conditions, limitations, and requirements established by the Texas Department
					 of Health (department), federally qualified health center (FQHC) services are
					 available to eligible Medicaid recipients.
(b) Covered services are limited to:
(1) services as described in the Social
					 Security Act, §1861(aa)(1)(A)-(C); and
(2) other ambulatory services covered by the
					 Texas Medical Assistance Program when provided by other enrolled
					 providers.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 23 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 354.1322 - Provider Participation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Participation requirements. To
					 participate in the Texas Medicaid Program, a federally qualified health center
					 (FQHC) must:
(1) be receiving a grant under
					 the Public Health Service Act §§329, 330, or 340, or be designated by
					 the secretary of the Department of Health and Human Services as meeting the
					 requirements to be receiving such a grant;
(2) comply with all federal, state, and local
					 laws and regulations applicable to the services provided;
(3) be enrolled and approved for
					 participation in the Texas Medicaid Program;
(4) sign a written provider agreement with
					 the Health and Human Services Commission (HHSC) or its designee;
(5) comply with the terms of the provider
					 agreement and all requirements of the Texas Medicaid Program, including
					 regulations, rules, handbooks, standards, and guidelines published by HHSC;
					 and
(6) bill for covered services
					 in the manner and format prescribed by HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 23 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 354.1323 - Reviews/Appeals

Current through Reg. 49, No. 28; July 12, 2024
If a federally qualified health center (FQHC) is
						dissatisfied with a tentative or final settlement, the FQHC may submit a
						request for review to the Texas Department of Health (department) or its
						designee within 60 days of notification of the tentative or final settlement.
						Unless otherwise specified by the department or its designee, the department or
						its designee follows the procedures in 42 Code of Federal Regulations
						§§405.1801-405.1890. The department or its designee will conduct the
						review as soon as possible and notify the FQHC of the results. If the FQHC is
						dissatisfied with the results of the review, the FQHC may request a formal
						hearing under the procedures contained in Chapter 1 of this title (relating to
						Texas Board of Health), except that, in the event of conflict, the procedures
						in this section apply.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 24 - NURSE PRACTITIONER AND CLINICAL NURSE SPECIALIST SERVICES › Section 354.1331 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the
					 specifications, conditions, requirements, and limitations established by the
					 Texas Health and Human Services Commission (HHSC) or its designee, services
					 performed by advanced practice registered nurses (APRNs) are covered if the
					 services:
(1) are within the scope of
					 practice for APRNs, as defined by state law;
(2) are consistent with rules and regulations
					 promulgated by the Texas Board of Nursing or another state's licensing
					 authority as recognized by the Texas Board of Nursing; and
(3) would be covered by the Medicaid program
					 if provided by a licensed physician (MD or DO).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 24 - NURSE PRACTITIONER AND CLINICAL NURSE SPECIALIST SERVICES › Section 354.1332 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
To be a provider of Medicaid covered services, an
						advanced practice registered nurse (APRN) must:
(1) be licensed by the Texas Board of Nursing
					 or another state's licensing authority as recognized by the Texas Board of
					 Nursing;
(2) be recognized by the
					 licensing authority as an APRN;
(3)
					 comply with all applicable federal and state laws and regulations governing the
					 services provided;
(4) be enrolled
					 and approved for participation in the Medicaid program;
(5) sign a written provider agreement with
					 the Texas Health and Human Services Commission (HHSC) or its
					 designee;
(6) comply with the terms
					 of the provider agreement and all requirements of the Medicaid program,
					 including regulations, rules, handbooks, standards, and guidelines published by
					 HHSC or its designee; and
(7) bill
					 for services covered by the Medicaid program in the manner and format
					 prescribed by HHSC or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 25 - SCHOOL HEALTH AND RELATED SERVICES › Section 354.1341 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the
					 specifications, conditions, limitations, and requirements established by HHSC,
					 school health and related services (SHARS) are those Medicaid services that are
					 determined to be medically necessary and reasonable to ensure a
					 Medicaid-enrolled student, 20 years of age or younger with a disability,
					 receives the benefits accorded to the student by federal and state legislation
					 guaranteeing a free and appropriate public education.
(b) SHARS must be prescribed in the student's
					 approved individualized education program (IEP) as required by the Texas
					 Education Code, §
											29.001(7),
					 and implemented through Commissioner of Education rule at 19 TAC §
											89.1001(relating
					 to the Scope and Availability).
(c)
					 SHARS audiology services must be prescribed in an IEP as described in
					 subsection (b) of this section or in a written Section 504 Plan as required by
					 Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
					 §
												794).
(d) SHARS must be delivered in the least
					 restrictive environment consistent with the nature of the specific service(s)
					 and the physical and mental condition of the student.
(e) SHARS include:
(1) audiology, individual and group delivered
					 by licensed/certified therapist or licensed/certified assistant;
(2) counseling, individual and group
					 delivered by licensed/certified therapist;
(3) physician services;
(4) occupational therapy, individual and
					 group delivered by licensed/certified therapist or licensed/certified
					 assistant;
(5) physical therapy,
					 individual and group delivered by licensed/certified therapist or
					 licensed/certified assistant;
(6)
					 psychological services;
(7) speech
					 therapy, individual and group delivered by licensed/certified therapist or
					 licensed/certified assistant;
(8)
					 nursing services, including medication administration and nursing services
					 delegated by a registered nurse (RN) (in compliance with RN delegated nursing
					 tasks criteria as determined by the Texas Board of Nursing) to an employee or
					 health aide;
(9) special
					 transportation services; and
(10)
					 personal care services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 25 - SCHOOL HEALTH AND RELATED SERVICES › Section 354.1342 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
To claim for school health and related services (SHARS)
						as described in §354.1341 of this division (relating to Benefits and
						Limitations), Local Education Agencies (LEAs) must:
(1) ensure that services are provided in a
					 manner and environment consistent with:
(A)
					 the student's physical and mental condition;
(B) the overall goals and objectives of the
					 student's individualized education program (IEP) or Section 504 Plan;
					 and
(C) other services and
					 schedules prescribed in the student's IEP or Section 504 Plan;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 26 - COORDINATED CARE › Section 354.1351 - Coordinated Care Pilot Project

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 Texas Department of Health is conducting a coordinated care pilot project in
					 response to the Human Resources Code, §
											RSA
					 32.041, which was enacted by the Texas
					 Legislature in 1991. The objectives of the project are to ensure adequate
					 access to primary health care, prevent unnecessary utilization of health care
					 resources, reduce inappropriate utilization of health care resources, and
					 enhance the cost effectiveness of the Medicaid program for aid to families with
					 dependent children (AFDC) and AFDC-related clients.
(b) All eligible AFDC and AFDC-related
					 Medicaid clients in the counties specified in subsection (c) of this section
					 must participate in the project. These clients:
(1) will receive the current services
					 available under the Texas Medicaid program, except that the existing
					 three-prescription drug limit for clients over the age of 21 is removed;
					 and
(2) must select an individual
					 primary care provider (PCP) who will manage their medical care.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1360 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
This division implements the Community First Choice (CFC)
						option governed by 42 CFR, Chapter 441, Subchapter K, regarding Home and
						Community-Based Attendant Services and Supports State Plan Option (Community
						First Choice). CFC is a state plan option to provide certain home and community
						based services and supports.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1362 - Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) To be eligible for a CFC service, an
					 individual must:
(1) be eligible for medical
					 assistance under the state plan;
(2) as determined annually, be in an
					 eligibility group under the state plan that includes an institutional level of
					 care; and
(3) receive a
					 determination, at least annually, that in the absence of the home and
					 community-based personal assistance services and supports, the individual would
					 otherwise require the level of care furnished in a hospital, a nursing
					 facility, an intermediate care facility for individuals with an intellectual
					 disability or related condition, an institution providing psychiatric services
					 for individuals under age 21, or an institution for mental disease for
					 individuals age 65 or over, if the cost could be reimbursed under the state
					 plan.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1363 - Assessment

Current through Reg. 49, No. 28; July 12, 2024
(a) Level of care (LOC) assessment.
(1) To determine nursing facility and
					 hospital LOC, HHSC uses the Medical Necessity/Level of Care (MN/LOC)
					 assessment. MN is the determination that an individual requires the services
					 (supervision, assessment, planning, and intervention) of licensed nurses in an
					 institutional setting to carry out a physician's planned regimen for total
					 care.
(2) To determine ICF/IID LOC,
					 HHSC uses the Intellectual Disability/Related Condition assessment (ID/RC). The
					 ID/RC assessment includes all factors needed to determine an LOC: diagnostic
					 information that includes age of onset of the qualifying conditions, names of
					 qualifying conditions, the appropriate International Classification of Diseases
					 codes, results of standardized intelligence testing, and the adaptive behavior
					 level as determined by an approved adaptive behavior assessment tool.
(3) To determine psychiatric inpatient LOC
					 for individuals under age 21, and institution for mental disease LOC for
					 individuals age 65 and over, the Child and Adolescent Needs and Strengths
					 assessment (CANS) or Adult Needs and Strengths assessment (ANSA) is completed
					 and entered into a State system which has an automated clinical and diagnostic
					 tool that helps determine an individual's LOC. The system uses CANS or ANSA
					 data to determine whether an individual meets Medicaid inpatient psychiatric
					 admission criteria.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1364 - Services and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to
					 the specifications, conditions, requirements, and limitations established by
					 HHSC, Community First Choice (CFC) services are provided subject to provisions
					 in
					 RSA 441.500 -
					 RSA
					 441.590. Services include:
(1) CFC personal assistance services. CFC
					 personal assistance services include:
(A) non
					 skilled assistance with the performance of the ADLs and IADLs through hands-on
					 assistance, supervision, and/or cueing;
(B) household chores necessary to maintain
					 the home in a clean, sanitary, and safe environment;
(C) escort services, which consist of
					 accompanying, but not transporting, and assisting an individual to access
					 personal assistance services or activities in the community; and
(D) assistance with health-related
					 tasks.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1365 - Provider Qualifications

Current through Reg. 49, No. 28; July 12, 2024
(a) Community
					 First Choice (CFC) services are provided by long-term services and supports
					 (LTSS) and state plan service providers determined to be qualified by the State
					 in an existing program.
(b) HHSC
					 ensures that all current qualification standards are maintained.
(c) Providers delivering CFC services include
					 licensed Home and Community Support Services agencies (HCSSAs), certified Home
					 and Community-based Services (HCS) Program and Texas Home Living (TxHmL)
					 providers, personal emergency response services agencies, qualified financial
					 management services agencies, and providers hired by individuals using the
					 Consumer Directed Services (CDS) option who meet qualifications.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1366 - Consumer Directed Services and Service Responsibility Option

Current through Reg. 49, No. 28; July 12, 2024
An individual that is eligible to receive Community First
						Choice services may choose to receive those services through a provider agency
						or:
(1) the Consumer Directed Services
					 (CDS) option in accordance with 40 TAC Chapter 41 (relating to Consumer
					 Directed Services Option); or
(2)
					 the Service Responsibility Option (SRO) in accordance with 40 TAC Chapter 43
					 (relating to the Service Responsibility Option).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1367 - Person-Centered Service Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) Compliance with
					 federal law. A person-centered service planning process is provided in
					 accordance with
					 RSA
					 441.540.
(b) Person-centered service plan
					 facilitators. A person-centered service plan facilitator must complete
					 HHSC-approved training on person-centered service planning by June 1, 2017, or
					 within two years of hire date. Person-centered plan facilitators include:
(1) those that conduct the functional
					 assessment for CFC in the DBMD and CLASS waiver programs;
(2) LIDDAs in the HCS, TxHmL, and STAR+PLUS
					 programs;
(3) MCOs in the STAR+PLUS
					 and STAR Health programs; and
(4)
					 DSHS case workers.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1368 - Fair Hearing

Current through Reg. 49, No. 28; July 12, 2024
An individual whose request for eligibility for the CFC
						option is denied or is not acted upon with reasonable promptness, or an
						individual whose CFC services have been terminated, suspended, denied, or
						reduced by HHSC has the right to request a fair hearing in accordance with
						federal and state law.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 27 - COMMUNITY FIRST CHOICE › Section 354.1369 - Attendant Base Wage

Current through Reg. 49, No. 28; July 12, 2024
A provider, individual, or LAR who employs an attendant
						to provide CFC personal assistance services or CFC habilitation must:
(1) pay each attendant at least the base wage
					 specified in § 355.7051 of this title (relating to Base Wage for a
					 Personal Attendant); and
(2) notify
					 any person employed as an attendant of the requirement that the provider,
					 individual, or LAR who employs an attendant must pay each attendant at least
					 the base wage specified in § 355.7051 of this title.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 28 - TUBERCULOSIS › Section 354.1371 - Tuberculosis Clinic Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Covered tuberculosis (TB)-related clinic
					 benefits shall include:
(1) physician and
					 non-physician examination, consultation and evaluation, including counseling
					 and education services on risks, transmission, prevention, and treatment of
					 TB;
(2) diagnostic and evaluation
					 services and procedures which:
(A) permit the
					 presumptive diagnosis of TB;
(B)
					 confirm the presence of infection; and
(C) monitor and assess recipient compliance
					 and drug toxicity;
(3)
					 prescription drugs; and
(4)
					 monitoring recipient compliance and completion of regimes of prescribed drugs
					 including direct observation of recipient intake of prescribed drugs.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 29 - LICENSED PROFESSIONAL COUNSELORS, LICENSED CLINICAL SOCIAL WORKERS, AND LICENSED MARRIAGE AND FAMILY THERAPISTS › Section 354.1381 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Counseling for
					 emotional disorders or conditions provided by licensed professional counselors
					 (LPCs), licensed clinical social workers (LCSWs), and licensed marriage and
					 family therapists (LMFTs) as allowed by each respective licensing law are
					 covered services.
(b) To be
					 considered payable, the services must be reasonable and medically necessary as
					 determined by the Health and Human Services Commission or its
					 designee.
(c) LPCs, LCSWs, or LMFTs
					 who are employed by or remunerated by another provider may not bill the Texas
					 Medical Assistance Program directly for counseling services if that billing
					 would result in duplicate payment for the same services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 29 - LICENSED PROFESSIONAL COUNSELORS, LICENSED CLINICAL SOCIAL WORKERS, AND LICENSED MARRIAGE AND FAMILY THERAPISTS › Section 354.1382 - Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) To
					 participate in the Texas Medical Assistance Program, licensed professional
					 counselors (LPCs) must be licensed by the Texas State Board of Examiners of
					 Professional Counselors in accordance with Chapter 503 of the Texas Occupations
					 Code.
(b) To participate in the
					 Texas Medical Assistance Program, licensed clinical social workers (LCSWs) must
					 be licensed for the practice of clinical social work by the Texas State Board
					 of Social Worker Examiners in accordance with Chapter 505 of the Texas
					 Occupations Code.
(c) To
					 participate in the Texas Medical Assistance Program, licensed marriage and
					 family therapists (LMFTs) must be licensed by the Texas State Board of
					 Examiners of Marriage and Family Therapists in accordance with Chapter 502 of
					 the Texas Occupations Code.
(d)
					 These providers must:
(1) meet the
					 appropriate licensing requirements as required in subsections (a), (b) or (c)
					 of this section;
(2) comply with
					 all applicable federal and state laws and regulations governing the services
					 provided;
(3) be enrolled and
					 approved for participation in the Texas Medical Assistance Program;
(4) sign a written provider agreement with
					 the Commission or its designee;
(5)
					 comply with the terms of the provider agreement and all requirements of the
					 Texas Medical Assistance Program, including regulations, rules, handbooks,
					 standards, and guidelines published by the Commission or its designee;
					 and
(6) bill for services covered
					 by the Texas Medical Assistance Program in the manner and format prescribed by
					 the Commission or its designee.