reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter B - CLIENT SERVICES › Section 27.7 - Client Rights

Current through Reg. 49, No. 28; July 12, 2024
(a) Use of services
				  is voluntary. Acceptance or refusal of services does not affect eligibility for
				  or receipt of any other Medicaid services, or for future case management
				  services.
(b) All records about
				  clients are considered confidential information, in accordance with the
				  standards and requirements described in §
										27.9 of
				  this title (relating to Client Confidentiality).
(c) Clients have the right to:
(1) actively participate in case management
				  decisions, including the right to refuse services from the provider;
(2) receive prior authorized services when
				  services are requested and informed consent is given;
(3) receive services free from abuse or harm
				  from the case manager and the case management provider;
(4) have freedom of choice to choose any
				  active provider in their residing county;
(5) have freedom of choice to request a
				  transfer to another case manager in the client's service area at any time;
				  and
(6) request a fair hearing,
				  conducted in accordance with the rules in 1 TAC, Chapter 357, Subchapter A
				  (relating to Uniform Fair Hearing Rules), within 90 days after receiving
				  written notification that services have been denied, reduced, suspended, or
				  terminated.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter B - CLIENT SERVICES › Section 27.9 - Client Confidentiality

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Federal and state laws and regulations prohibit the disclosure of information
				  about Medicaid clients without effective consent by the client or on behalf of
				  the client, except for purposes directly connected with the administration of
				  the Medicaid program, as described in
				  42 U.S.C.,
				  §1396a(a)(7);
				  42 C.F.R.
				  §§431.301 -
				  431.306;
				  Human Resources Code, §
										12.003
				  and §
										21.012;
				  and Government Code, §
										552.101.
				  Case management providers are not considered directly connected with the
				  administration of the program. Although case management providers are not
				  entitled to confidential information without prior consent, they are able to
				  verify a client's eligibility status.
(b) Entities with which HHSC or the
				  department contracts to perform certain administrative functions, including
				  contractors for outreach, informing, and transportation services, may receive
				  confidential information without the client's consent, but only to the extent
				  necessary to perform and administer the contract. These contracted entities are
				  bound by the same standards of confidentiality applicable to the Medicaid
				  program, and they must provide effective safeguards to ensure
				  confidentiality.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter B - CLIENT SERVICES › Section 27.11 - Components of Case Management for Children and Pregnant Women Services

Current through Reg. 49, No. 28; July 12, 2024
The following are the essential components of Case
					 Management for Children and Pregnant Women services and explanation of billable
					 components.
(1) Intake--A case
				  manager's contact with the client/family/guardian that includes the collection
				  of demographic, health, and other information relevant to the determination of
				  the client's potential eligibility.
(2) Comprehensive visit--A case manager's
				  face-to-face meeting with the client/family/guardian that includes the
				  development of a:
(A) Family Needs
				  Assessment. A comprehensive face-to-face assessment of client needs to
				  determine the need for any medical, educational, social, or other services
				  required to address short- and long-term health and well-being of the client.
				  These assessment activities must be documented on a Family Needs Assessment
				  form and must include:
(i) taking a client's
				  history;
(ii) identifying the
				  client's needs, assessing and addressing family issues that impact the client's
				  health condition/risk or high-risk condition and completing related
				  documentation; and
(iii) gathering
				  information from other sources, such as family members, medical providers,
				  social workers, and educators (if necessary), to form a complete assessment of
				  the client.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter B - CLIENT SERVICES › Section 27.13 - Prior Authorization

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The department may establish policies and procedures that providers must follow
				  in order to obtain prior authorization for services.
(b) Following intake completion, the initial
				  prior authorization request must be supported by required documentation and
				  submitted to the department for review and disposition. If the documentation
				  supports eligibility, a comprehensive visit and follow-up visit(s) will be
				  prior-authorized. The number of follow-up visit(s) that is prior-authorized
				  will be based on the client's level of need, level of medical involvement, and
				  complicating psychosocial factors documented on the request.
(c) Any additional requests for comprehensive
				  or follow-up visit(s) must be prior-authorized. Required documentation must be
				  submitted to the department for review and disposition before any additional
				  services may be prior-authorized.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.15 - Provider Qualifications

Current through Reg. 49, No. 28; July 12, 2024
A provider shall not be approved as a provider of Case
					 Management for Children and Pregnant Women unless they meet the following
					 qualifications:
(1) completion of
				  application process and approval by the department;
(2) agreeing to comply with the rules,
				  policies, and procedures of the department relating to Case Management for
				  Children and Pregnant Women;
(3)
				  agreeing to comply with applicable state and federal laws governing
				  participation of providers in the Medicaid program and to enroll as a state
				  Medicaid provider;
(4) be a
				  provider who meets, or employs or contracts with, one or more case managers who
				  each meet, the qualifications specified in §
										27.21
				  of this title (relating to Case Manager Qualifications); and
(5) has never been terminated by the
				  department and is not listed on the HHSC Office of Inspector General's Excluded
				  Individual Listing.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.17 - Provider Approval Process

Current through Reg. 49, No. 28; July 12, 2024
(a) To
				  become an approved provider, an applicant must submit a completed application
				  to the department.
(b) The
				  department will review the application and provide a response within timeframes
				  specified in policies and procedures. An application will not be reviewed and
				  considered until all information is provided in a clear and understandable
				  manner.
(c) Providers approved by
				  the department must also enroll with the Medicaid Claims Administrator as a
				  Medicaid provider.
(d) Providers
				  who fail to submit an application to enroll as a state Medicaid provider within
				  twelve months of approval by the department must submit a new application to
				  the department.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.19 - Provider Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
Providers must:
(1) operate in accordance with the laws,
				  rules, regulations, and standards of care relating to the practice of their
				  respective license(s); ensure that their case managers are operating within the
				  laws, rules, regulations, and standards of care relating to the practice of
				  their respective license(s); and ensure that their case managers operate only
				  within the scope of their respective license(s);
(2) provide services according to policies
				  and procedures as published in the TMPPM and Medicaid bulletins, and in
				  accordance with the policies and procedures of the department;
(3) cease providing services and notify the
				  department if the professional license of a provider is suspended or revoked,
				  with such notification to be provided to the department no later than seven
				  calendar days after the date that the suspension or revocation is
				  imposed;
(4) assure that case
				  managers attend required trainings provided by the department;
(5) develop and maintain a quality management
				  system for the provision of services with the primary goal of assisting clients
				  in accessing necessary medical, social, educational, and other services related
				  to their health condition/health risk or high-risk condition;
(6) ensure that outreach activities do not
				  impede freedom of client choice, and that they comply with 1 TAC §
										371.27(relating
				  to Prohibition against Solicitation of Medicaid or CHIP Recipients);
				  and
(7) ensure that clients are
				  given choice of providers for case management.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.21 - Case Manager Qualifications

Current through Reg. 49, No. 28; July 12, 2024
An individual shall not be approved to provide Case
					 Management for Children and Pregnant Women unless they meet the following
					 qualifications:
(1) licensed in the
				  State of Texas as a registered nurse (with a bachelor or advanced degree in
				  nursing), whose license is not temporary or provisional in nature; or
(2) licensed in the State of Texas as a
				  registered nurse (with an associate degree in nursing), whose license is not
				  temporary or provisional in nature. The individual must also possess two years
				  of cumulative paid full-time work experience or two years of supervised,
				  full-time educational internship/practicum experience in the past ten years
				  with children, up to age 21, and/or pregnant women. Experience must include
				  assessing the psychosocial and health needs of and making community referrals
				  for these populations; or
(3)
				  licensed in the State of Texas as a social worker with licensure appropriate
				  for his/her practice, including the practice of Independent Social Work, and
				  whose license is not temporary or provisional in nature; and
(4) has completed the department's
				  standardized case management training.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.23 - Case Manager Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
Case managers must:
(1) comply with all licensure requirements of
				  the appropriate state licensure/examining board, including the obligation to
				  report all suspected child abuse/neglect;
(2) cease providing services and notify the
				  department if the case manager's professional license is suspended or revoked,
				  with such notification to be provided to the department no later than seven
				  calendar days after the date that the suspension or revocation is
				  imposed;
(3) provide services
				  convenient to clients, either in their home, an office setting, or other place
				  of client's preference; and
(4)
				  have knowledge of, and coordinate services with, providers of health and
				  health-related services and other active community resources.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.25 - Utilization and Quality Assurance Reviews and Compliance

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of a utilization or quality
				  assurance review is to ensure program fiscal integrity, to address the federal
				  mandate requiring program funds be spent only as allowed under federal and
				  state laws and regulations, and to ensure that services are appropriately
				  provided to clients.
(b) During
				  each fiscal year, the department will conduct quality assurance and utilization
				  reviews of all active and inactive providers to monitor claims, quality of case
				  management services and compliance with Case Management for Children and
				  Pregnant Women rule and policy.
(c)
				  Providers must cooperate with the quality assurance and utilization reviews.
				  Providers will be given notification of upcoming reviews in accordance with the
				  department's policies and procedures.
(d) If the results of the utilization or
				  quality assurance review indicate overpayment, the department will notify HHSC
				  of the overpayment and the provider will be given information about how to
				  arrange for repayment.
(e)
				  Providers must voluntarily notify the Medicaid claims administrator to arrange
				  for repayment if they become aware that they received an overpayment.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 27 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Subchapter C - PROVIDER QUALIFICATIONS AND RESPONSIBILITIES › Section 27.27 - Termination, Suspension, Probation, and Reprimand of Providers

Current through Reg. 49, No. 28; July 12, 2024
A provider's violation or non-compliance with federal and
					 or state Medicaid laws, rules and regulations, rules under this chapter, or
					 Case Management and Pregnant Women policies and procedures may result in one or
					 more of the following actions taken by the department.
(1) Notification to the Medicaid claims
				  administrator through HHSC that the department has terminated the case
				  management provider. Providers will receive written notice of termination.
				  Providers who are terminated will not be approved if they reapply.
(2) Suspension of a provider in accordance
				  with the department's policies and procedures. Providers will receive written
				  notice of suspension.
(3) Probation
				  of a provider in accordance with the department's policies and procedures.
				  Providers will receive written notice of probation.
(4) Reprimand of a provider in accordance
				  with the department's policies and procedures. Providers will receive written
				  notice of reprimand.
(5) Report and
				  referral to the appropriate professional licensure entity.
(6) Report and referral to HHSC Office of
				  Inspector General.
(7) Report to a
				  law enforcement agency.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter A - REGISTER OF MOTHER-FRIENDLY BUSINESSES › Section 31.1 - Register of Mother-Friendly Businesses

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. The following words and
				  terms, when used in this subchapter, shall have the following meanings, unless
				  the context clearly indicates otherwise.
(1)
				  Mother-friendly business--A worksite that actively promotes and supports
				  breastfeeding by its employees and that maintains a written worksite lactation
				  support policy that is regularly communicated to employees.
(2) Department--Department of State Health
				  Services.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter B - FARMERS' MARKET NUTRITION PROGRAM › Section 31.11 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings, unless the context clearly
					 indicates otherwise.
(1) Coupon--A
				  coupon, voucher or other negotiable financial instrument by which benefits
				  under the Farmers' Market Nutrition Program are transferred to
				  recipients.
(2) Farmer--An
				  individual authorized to sell produce at participating farmers'
				  markets.
(3) Farmers' market
				  association--An association of local farmers who assemble at a defined location
				  for the purpose of selling their produce directly to consumers.
(4) Farmers' market agreement--The formal and
				  legally binding agreement between the Department of State Health Services and a
				  vendor authorized to accept and redeem WIC Farmers' Market Nutrition Program
				  coupons.
(5) Farmers' market
				  nutrition program--Section 17 of the Child Nutrition Act of 1966, as amended,
				  authorizes the Special Supplemental Nutrition Program for Women, Infants, and
				  Children (WIC). Subsection 17(m) of the Child Nutrition Act, as amended,
				  authorizes the Farmers' Market Nutrition Program. Chapter 15, Agriculture Code,
				  authorizes the Department of State Health Services to administer the Farmers'
				  Market Nutrition Program in Texas.
(6) Local agency--An entity under contract to
				  the State agency to provide Farmers' Market Nutrition Program services or a
				  Department of State Health Services health services region that provides
				  Farmers' Market Nutrition Program services.
(7) State agency--The Department of State
				  Health Services in its role as administrator of the WIC and Farmers' Market
				  Nutrition Programs.
(8) WIC
				  Program--The Special Supplemental Nutrition Program for Women, Infants, and
				  Children.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter B - FARMERS' MARKET NUTRITION PROGRAM › Section 31.12 - Program Administration

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The state agency shall determine the design, printing, and denominations of the
				  food coupons used in the Farmers' Market Nutrition Program (FMNP) in accordance
				  with federal regulations at 7 CFR Part 248.
(1) The design of the food coupons shall be
				  uniform across the state and shall include, at a minimum, the following
				  information:
(A) the last date, not later
				  than November 30 of each year, the recipient may use the coupon;
(B) a time frame within which farmers' market
				  associations must submit coupons for payment;
(C) a unique, sequential serial
				  number;
(D) a denomination (dollar
				  amount); and
(E) a place the unique
				  identifier of the farmer who sold the food may be added.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.22 - Recipient Eligibility Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual shall be eligible to
				  receive services when the individual receives local agency approval after
				  meeting all of the following requirements.
(1) Be determined categorically eligible.
(A) If a woman, be pregnant or not more than
				  six months postpartum if not breastfeeding or within one year postpartum if
				  breastfeeding; or
(B) If a child,
				  be under age five.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.23 - Recipients of Supplemental Food Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a) Regardless of their age, pregnant,
				  breastfeeding, and postpartum participants may be designated as recipients of
				  supplemental food benefits for themselves and/or their infants and/or
				  children.
(b) Regardless of their
				  age, parents, guardians, caretakers, or foster parents of infant and/or child
				  participants may be designated as recipients of supplemental food benefits for
				  their infants and/or children.
(c)
				  Caretakers of a participant may be designated as recipients of supplemental
				  food benefits for the participant if the caretakers are at least 18 years of
				  age or older.
(d) A proxy who is 16
				  years of age or older may be designated in writing by a WIC Program
				  participant, or parent, caretaker, guardian of a participant, or a foster
				  parent to act as the supplemental food benefit recipient. Each time a proxy is
				  designated to act as the recipient, such designation shall be provided in
				  writing to the local agency, and the proxy shall provide identification for
				  himself or herself and present the participant's WIC Program family
				  identification card.
(e) Proxies of
				  participants residing in a homeless facility, temporary shelter, or institution
				  may pick up and redeem supplemental food benefits for all WIC Program
				  participants in their respective homeless facilities, temporary shelters, or
				  institutions. The state and local agencies shall ensure that adult participants
				  are allowed to participate in the process of picking up and transacting food
				  instruments to the greatest extent possible, within the institutional
				  framework, so that they are aware of the foods prescribed for them as well as
				  the intended benefits of such foods.
(f) Recipients of supplemental food benefits
				  shall sign the WIC Program Supplemental Information Form prior to receiving
				  such benefits.
(g) Recipients of
				  supplemental food benefits shall provide identification at each issuance of
				  food benefits.
(h) Recipients of
				  supplemental food benefits shall receive their benefits at the same time as
				  they receive notification of eligibility for participation in the
				  program.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.25 - Participant Certification Periods

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  applicant who has been determined eligible shall be enrolled and certified to
				  receive WIC Program benefits as specified in this section. The certification
				  period shall begin on the date the applicant is determined eligible.
(b) A pregnant woman shall be certified to
				  receive one set of food instruments each month for the duration of her
				  pregnancy and is eligible to receive one set of food instruments between
				  delivery of the baby and six weeks postpartum. The certification expiration
				  date shall be set at six weeks after her expected delivery date.
(c) A postpartum woman who is not
				  breastfeeding shall be certified to receive one set of food instruments each
				  month until she is six months postpartum. The certification expiration date
				  shall be set for the day the woman is six months postpartum.
(d) A breastfeeding woman shall be certified
				  to receive one set of food instruments each month for up to one year. The
				  certification expiration date shall be set to the last day of the month in
				  which her infant turns one year old or she ceases breastfeeding, whichever
				  occurs first.
(e) A child one to
				  five years of age shall be certified to receive one set of food instruments
				  each month for a six-month period. The certification expiration date shall be
				  set for the last day of the sixth month. For a child turning age five, the
				  certification expiration date shall be set for the last day of the month the
				  child turns age five.
(f) An infant
				  six months of age or older at the time of initial enrollment shall be certified
				  to receive one set of food instruments each month for a six-month period. The
				  certification expiration date shall be set for the last day of the sixth
				  month.
(g) An infant younger than
				  six months of age at the time of initial enrollment shall be certified to
				  receive one set of food instruments each month until the infant's first
				  birthday. The certification expiration date shall be set for the day of the
				  infant's first birthday.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.26 - Notification to Applicants of Ineligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual found ineligible for the
				  WIC Program shall be notified in writing of the reason or reasons for
				  ineligibility.
(b) The notification
				  shall inform the applicant or parent, caretaker, or guardian of a participant
				  that he or she has a right to a fair hearing.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.27 - Notification to Each Participant of Certification Expiration

Current through Reg. 49, No. 28; July 12, 2024
(a) Each participant shall be notified at
				  least 15 days prior to the expiration of each certification period that
				  eligibility is about to expire.
(b)
				  At the time of the notice, participants who are eligible to apply for
				  subsequent certification shall be notified of their categorical eligibility and
				  that they must apply in order for WIC Program benefits to continue.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.28 - Notification to Each Participant of Termination of Certification

Current through Reg. 49, No. 28; July 12, 2024
(a) Participants
				  whose certification in the WIC Program is terminated for program abuse, funding
				  shortages which require that client caseloads be decreased, or a determination
				  that the participant's income exceeds WIC Program eligibility limits, shall be
				  notified 15 days in advance of the date of disqualification. Such notification
				  shall be in writing and shall include the reason for disqualification and a
				  statement of the participant's right to a fair hearing.
(b) If the disqualification is the result of
				  funding shortages as determined by the state agency, the written
				  disqualification notice shall include the categories and priorities of
				  participants being terminated.
(c)
				  If the participant's income is found to exceed WIC Program eligibility limits
				  due to an assessment of income eligibility during a certification period, the
				  participant shall be issued one month of food instruments at the time it is
				  determined a reassessment is necessary. The participant shall be required to
				  present current documentation of continuing income eligibility at the next
				  visit. If the participant also is determined ineligible at the next visit, the
				  individual shall be terminated for exceeding the income limits.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.30 - Participant Fraud and Abuse

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Participants and parents, guardians, client-designated proxies, state
				  agency-appointed proxies, or caretakers of participants identified and
				  documented as having abused the WIC Program shall be sanctioned.
(b) If the state agency or the Office of
				  Inspector General, Health and Human Services Commission, determines that a
				  participant or parent, guardian, client-designated proxy, state
				  agency-appointed proxy, or caretaker of a participant has received benefits
				  unlawfully due to WIC Program abuse, including but not limited to dual
				  participation, the matter may be referred for criminal prosecution.
(c) Program violations means any intentional
				  act of an applicant, participant, parent, guardian or caretaker of an infant or
				  child applicant or participant, client-designated proxy, or state
				  agency-designated proxy that violates Federal or State statutes, regulations,
				  rules, policies or procedures governing the WIC Program. Violations include,
				  but are not limited to, intentionally making a false or misleading statement;
				  intentionally misrepresenting, concealing, or withholding facts to obtain
				  benefits; exchanging food instruments or food for cash, credit, non-food items,
				  or unauthorized foods, including foods in excess of that authorized;
				  threatening to harm or physically harming local agency, vendor or state agency
				  staff; and simultaneous participation in the Program in one or more than one
				  WIC clinic or participation in the Commodity Supplemental Food Program during
				  the same period of time.
(d) The
				  state agency, or local agency as directed by the state agency, shall initiate
				  sanctions which may include disqualification from the Program for up to one
				  year.
(e) Upon a final
				  determination by the Office of the Inspector General, Health and Human Services
				  Commission, that a program violation has occurred, the following mandatory
				  disqualifications shall apply.
(1) For an
				  offense where a claim of $100 or more is assessed, the participant shall be
				  disqualified for one year.
(2) For
				  an offense where a participant illegally received benefits at more than one WIC
				  office and the state agency or the Office of the Inspector General, Health and
				  Human Services Commission, assesses a claim for such dual participation, the
				  participant shall be disqualified for one year.
(3) When the state agency or the Office of
				  the Inspector General, Health and Human Services Commission, assesses a second
				  or subsequent claim of any amount, the participant shall be disqualified for
				  one year.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 31 - NUTRITION SERVICES › Subchapter C - SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) › Section 31.31 - Selection of a Local Agency as a WIC Provider

Current through Reg. 49, No. 28; July 12, 2024
(a) Selection of a local agency to provide
				  WIC Program services will be based on the local agency priority system as
				  follows:
(1) A public or private nonprofit
				  health agency which can provide ongoing routine pediatric and obstetric care or
				  administrative services shall receive first priority consideration.
(2) A public or private nonprofit health or
				  human service agency which will enter into a written agreement with another
				  agency for either ongoing pediatric and obstetric care or administrative
				  services shall receive second priority consideration.
(3) A public or private nonprofit health
				  agency which will enter into a written agreement with private physicians
				  licensed by the state to provide ongoing pediatric and obstetric care to a
				  specific category of participants (women, infants, or children) shall receive
				  third priority consideration.
(4) A
				  public or private nonprofit human service agency which will enter into a
				  written agreement with private physicians licensed by the state to provide
				  ongoing routine pediatric and obstetric care shall receive fourth priority
				  consideration.
(5) A public or
				  private nonprofit human service agency which will provide ongoing routine
				  pediatric and obstetric care through referral to a health provider shall
				  receive fifth priority consideration.
(6) No WIC Program funds shall be expended to
				  reimburse private physicians for the health services performed.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.1 - Purpose and Application

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				  Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program
				  is a Title XIX federally mandated program of prevention, diagnosis, and
				  treatment for Medicaid clients from birth through age 20. In Texas, EPSDT is
				  known as the Texas Health Steps (THSteps) Program. The Texas Department of
				  State Health Services (department), by authorization of the Health and Human
				  Services Commission (HHSC), operates and administers the outreach and
				  informing, medical and dental check-ups, and the dental treatment utilization
				  components of this program.
(b) The
				  rules in this chapter apply to the medical and dental check-up, dental
				  treatment, dental utilization review, and the outreach and informing components
				  of THSteps.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words or terms, when used in this chapter,
					 have the following meanings unless the context clearly indicates
					 otherwise:
(1) Authorized adult--A
				  person, including an adult related to the child, who is authorized by a child's
				  parent or guardian to accompany that child to a THSteps medical or dental
				  check-up or treatment visit.
(2)
				  Client--Any individual under the age of 21 who has been determined eligible for
				  Medicaid.
(3)
				  Department--Department of State Health Services.
(4) EPSDT--Early and Periodic Screening,
				  Diagnosis, and Treatment (EPSDT) is a mandatory program under Medicaid that
				  provides medical and dental check-ups, diagnosis, and treatment to eligible
				  clients from birth through age 20. EPSDT is known in Texas as Texas Health
				  Steps (THSteps).
(5) Guardian--An
				  individual legally authorized to make decisions, including medical consent, on
				  behalf of a minor.
(6) HHSC--Health
				  and Human Services Commission.
(7)
				  Medicaid--The medical assistance program implemented by the State of Texas
				  under the provisions of Title XIX of the Social Security Act, as amended, at
				  42 USC,
				  §1396, et seq.
(8) Medically necessary--Medical services
				  that are supported by documentation which show the services are:
(A) reasonable and necessary to prevent
				  illness, medical or dental conditions, or provide early screening,
				  interventions, and/or treatments for conditions that cause suffering or pain,
				  cause physical deformity or limitations in function, threaten to cause or
				  worsen a disability, cause illness or infirmity of a client, or endanger
				  life;
(B) consistent with health
				  care practice guidelines and standards that are issued by professionally
				  recognized health care organizations or governmental agencies;
(C) consistent with the diagnoses of the
				  conditions;
(D) no more intrusive
				  or restrictive than necessary to provide a proper balance of safety,
				  effectiveness, and efficiency;
(E)
				  not experimental or investigative; and
(F) not primarily for the convenience of the
				  client or provider.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.3 - Outreach, Informing, and Support Services

Current through Reg. 49, No. 28; July 12, 2024
(a) The department, in collaboration with
				  HHSC or its designee, informs clients and their families about THSteps benefits
				  and services no later than 60 days after the Medicaid certification date and on
				  a periodic basis thereafter using a combination of methods including written,
				  oral, and in-person contact. Methods for informing include, but are not limited
				  to, one or more of the following options: written or printed correspondence,
				  telephone contact, or an in-person interaction with a THSteps outreach worker,
				  which may include contractors designated and authorized to perform this
				  function. THSteps uses procedures and methods suitable for effectively
				  informing clients and their families who are illiterate, visually impaired,
				  hard of hearing, or who cannot understand the English language.
(b) Clients and families who become eligible
				  for Medicaid after a period of ineligibility also are informed about THSteps
				  benefits and services upon recertification and on a periodic basis
				  thereafter.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.4 - Receipt and Referral of Complaints and Allegations

Current through Reg. 49, No. 28; July 12, 2024
The department receives and refers, in accordance with
					 state law and department policy, complaints and allegations of fraud, abuse, or
					 waste regarding THSteps services, providers, and clients. The department
					 accepts complaints and allegations in either written or verbal form and from
					 any source.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.5 - THSteps Provider Participation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A THSteps medical check-up provider must
				  be properly licensed, as required under state law, and must be a:
(1) Doctor of Medicine or Doctor of
				  Osteopathy;
(2) public or private
				  health care provider or facility that can perform the required medical check-up
				  procedures under a physician's direction and responsibility;
(3) advanced practice nurse whose educational
				  curriculum included courses of study in advanced pediatric physical assessment
				  of infants, children and adolescents; or
(4) physician assistant.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.6 - THSteps Provider Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The primary responsibilities of THSteps medical and dental providers are to:
(1) operate in accordance with the laws,
				  rules, regulations, and standards of care relating to the practice of their
				  respective profession;
(2) cease
				  providing THSteps services and notify HHSC or its designee if the provider's
				  professional license is suspended or revoked, unless the suspension or
				  revocation is probated in its entirety and without conditions or
				  limitations;
(3) conduct check-ups
				  and treatment services according to policies and procedures as published in the
				  TMPPM and Medicaid bulletins and in accordance with the policies and procedures
				  of the department;
(4) provide
				  clinic surroundings which will establish a good relationship between clinic
				  personnel, the client and the client's family;
(5) interpret and explain check-up and
				  treatment results to the client or the client's parent, guardian, or authorized
				  adult, during or immediately after the check-up;
(6) make referrals for needed follow-up
				  diagnosis and treatment services as indicated; and
(7) assure that a parent, guardian or
				  authorized adult who accompanies a client under age 15 to a THSteps medical or
				  dental check-up or treatment visit, continues to wait for the client while the
				  check-up or treatment takes place. Entities exempt from this parental
				  accompaniment requirement are a child-care facility (as defined in the Human
				  Resources Code, §
											42.002(3)),
				  school health clinic, or Head Start program if the entity encourages parental
				  involvement in and management of the health care of children receiving
				  services. Parental involvement includes the exempt entity notifying the child's
				  parent, guardian, or authorized adult before a THSteps medical or dental
				  check-up or treatment visit, of the time and place of the child's appointment
				  and encouraging the parent, guardian, or other authorized adult to attend.
				  Notification must be done by the means of communication determined by the
				  exempt entity to be the most effective. Such communication must be documented
				  and may include, but is not limited to, one or more of the following options: a
				  home visit from an outreach worker, written or printed correspondence, or
				  telephone contact.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter A - GENERAL PROVISIONS › Section 33.7 - Exceptions to Timely Delivery of THSteps Services

Current through Reg. 49, No. 28; July 12, 2024
Timely delivery of THSteps services, including outreach,
					 informing and check-up services, may not be made if:
(1) the client or family could not be located
				  despite a good faith effort to do so; or
(2) the client or family chooses not to
				  receive available or recommended services in a timely manner after being
				  informed.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter B - CLIENT RIGHTS › Section 33.20 - Client Rights

Current through Reg. 49, No. 28; July 12, 2024
(a) Utilization of
				  THSteps services is voluntary. Acceptance or refusal of THSteps services does
				  not affect eligibility for or receipt of any other Medicaid service, or for
				  future THSteps services.
(b) All
				  THSteps records about clients are considered confidential information, in
				  accordance with the standards and requirements described in §
										33.30
				  of this title (relating to Confidentiality of Records).
(c) Clients have a right to consent to or
				  refuse treatment and actively participate in treatment decisions, including the
				  right to refuse follow-up care or treatment recommended by the
				  provider.
(d) THSteps clients are
				  entitled to receive:
(1) medical and dental
				  services when informed consent is given, including check-ups that are due as
				  described in §
											33.41
				  of this title (relating to Periodicity of Medical and Dental
				  Check-ups);
(2) services free from
				  abuse or harm from the provider or the provider's staff; and
(3) only medically necessary treatment which
				  meets professionally recognized standards of health care.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter B - CLIENT RIGHTS › Section 33.21 - Freedom of Choice

Current through Reg. 49, No. 28; July 12, 2024
(a) Clients who are
				  not enrolled in a Medicaid managed care plan have the freedom to choose any
				  participating THSteps medical provider for their medical check-ups.
(b) Clients who are enrolled in a Medicaid
				  managed care plan need to check with their plan regarding the amount of freedom
				  they have to choose a THSteps provider.
(c) Clients have the freedom to choose any
				  participating THSteps dental provider for dental check-ups and treatment
				  services, except clients in the conservatorship of the Department of Family and
				  Protective Services who receive all dental services from a managed care
				  plan.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter C - CONFIDENTIALITY › Section 33.30 - Confidentiality of Records

Current through Reg. 49, No. 28; July 12, 2024
(a) Federal and
				  state laws and regulations prohibit the disclosure of information about
				  Medicaid clients without effective consent by the client or on behalf of the
				  client, except for purposes directly connected with the administration of the
				  Medicaid program, as described in
				  42 USC,
				  §1396a(a)(7); 42 CFR.
				  §§431.301 - 431.306; Human Resources Code, §
										12.003
				  and §
										21.012;
				  and Government Code, §
										552.101.
				  Providers of THSteps services are not considered directly connected with the
				  administration of the program. Although THSteps providers are not entitled to
				  confidential information without prior consent, they are able to verify a
				  client's eligibility status.
(b)
				  Entities with which HHSC or the department contracts to perform certain
				  administrative functions, including contractors for outreach, informing, and
				  transportation services, may receive confidential information without the
				  client's consent, but only to the extent necessary to performance and
				  administration of the contract. These contracted entities are bound by the same
				  standards of confidentiality applicable to the Medicaid program, and they must
				  provide effective safeguards to ensure confidentiality.
Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 33 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT › Subchapter D - ELIGIBILITY AND PERIODICITY › Section 33.40 - Eligibility for Medical and Dental Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Medical check-ups eligibility. Clients
				  are eligible to receive THSteps medical check-ups and services from birth
				  through the end of the month of their 21st birthday.
(b) Dental Services Eligibility. Clients are
				  eligible to receive THSteps dental check-ups beginning at six months of age or
				  at the first eruption of primary teeth, whichever occurs first, through the end
				  of the month of their 21st birthday. Clients are eligible for any medically
				  necessary dental services from their date of birth. As described in the TMPPM,
				  eligibility for certain dental services may require prior authorization, and
				  for some services, clients lose eligibility on their 21st birthday. A specific
				  exception applies to orthodontic services, as described in §
										33.71(c)
				  of this title (relating to Orthodontic Services and Prior
				  Authorization).