reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 359 - MEDICARE SAVINGS PROGRAM › Section 359.103 - Qualified Medicare Beneficiary Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Authorized under
				RSA
				1396a(a)(10)(E)(i),
				the Qualified Medicare Beneficiary (QMB) Program pays Medicare premiums,
				deductibles, and coinsurance for a person who meets the requirements of this
				section. A person receiving Medicaid may also receive QMB benefits if the
				person meets the requirements of this section.
(b) To be eligible for QMB coverage, a person
				must:
(1) be entitled to benefits under
				Medicare Part A;
(2) meet income
				requirements in
				RSA
				1396d(p), except
				for:
(A) payments made from or interest
				earned on a tuition savings program under §
											RSA
				358.388 of this title (relating to Tuition
				Savings Programs);
(B) payments
				made from or interest earned on an Achieving a Better Life Experience (ABLE)
				account under § 358.389 of this title (relating to Achieving a Better Life
				Experience Program); and
(C)
				income earned on a school-based savings program under § 358.390 of this
				title (relating to School-Based Savings Program).
(3) meet resource requirements in
				RSA
				1396d(p), except
				for:
(A) funds used to establish a tuition
				savings program under §
											RSA
				358.356 of this title (relating to Tuition
				Savings Programs);
(B) funds used
				to establish an ABLE account and funds held in an ABLE account under §
				358.357 of this title (relating to Achieving a Better Life Experience Program);
				and
(C) funds held in a
				school-based savings program under § 358.358 of this title (relating to
				School-Based Savings Program).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 359 - MEDICARE SAVINGS PROGRAM › Section 359.105 - Specified Low-Income Medicare Beneficiary Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Authorized under
				RSA
				1396a(a)(10)(E)(iii),
				the Specified Low-Income Medicare Beneficiary (SLMB) Program pays only Medicare
				Part B premiums for a person who meets the requirements of this section. A
				person receiving Medicaid may also receive SLMB benefits if the person meets
				the requirements of this section.
(b) To be eligible for SLMB coverage, a
				person must meet the eligibility criteria for QMB coverage in §
									RSA
				359.103(b) of
				this chapter (relating to Qualified Medicare Beneficiary Program), except the
				person must have an income that is greater than 100% but less than 120% of the
				federal poverty level.
(c) A person
				is not eligible for SLMB coverage if the person:
(1) is in the custody of penal authorities as
				defined in
				RSA
				411.4(b);
				or
(2) is over 20 years of age and
				under 65 years of age and resides in an institution for mental
				diseases.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 359 - MEDICARE SAVINGS PROGRAM › Section 359.107 - Qualifying Individual Program

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Authorized under
				RSA
				1396a(a)(10)(E)(iv)
				the Qualifying Individual (QI) Program pays only Medicare Part B premiums to a
				person who meets the requirements of this section. A person cannot be eligible
				for regular Medicaid and QI coverage at the same time.
(b) To be eligible for QI coverage, a person
				must meet the eligibility criteria for Qualified Medicare Beneficiary coverage
				in §
									RSA
				359.103(b) of
				this chapter (relating to Qualified Medicare Beneficiary Program), except the
				person must have income that is at least 120% but less than 135% of the federal
				poverty level.
(c) Eligibility for
				QI coverage is determined for each calendar year.
(d) A person's QI eligibility may begin with
				the month of application.
(e) A
				person with QI coverage is eligible for three months prior medical coverage if
				all criteria are met. The three-month prior period cannot extend back into the
				previous calendar year.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 359 - MEDICARE SAVINGS PROGRAM › Section 359.109 - Qualified Disabled and Working Individual Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Authorized under
				RSA
				1396a(a)(10)(E)(ii),
				the Qualified Disabled and Working Individual (QDWI) Program pays only Medicare
				Part A premiums for a person who meets the requirements of this section. A
				person cannot be eligible for regular Medicaid and QDWI coverage at the same
				time.
(b) To be eligible for QDWI
				coverage, a person must:
(1) be under 65 years
				of age;
(2) be entitled to benefits
				under Medicare Part A;
(3) not
				otherwise be eligible for Medicaid;
(4) have a monthly income equal to or less
				than 200% of the federal poverty level, except for the following exclusions:
(A) payments made from or interest earned on
				a tuition savings program under §
											RSA
				358.388 of this title (relating to Tuition
				Savings Programs);
(B) payments
				made from or interest earned on an Achieving a Better Life Experience (ABLE)
				account under § 358.389 of this title (relating to Achieving a Better Life
				Experience Program); and
(C)
				income earned on a school-based savings program under § 358.390 of this
				title (relating to School-Based Savings Program).
(5) have no more than twice the countable
				resources allowed under the Supplemental Security Income (SSI) program, as
				described in §1611 of the Social Security Act (RSA
				1382), except for:
(A) funds used to establish a tuition savings
				program under §
											RSA
				358.356 of this title (relating to Tuition
				Savings Programs);
(B) funds used
				to establish an ABLE account and funds held in an ABLE account under §
				358.357 of this title (relating to Achieving a Better Life Experience Program);
				and
(C) funds held in a
				school-based savings program under § 358.358 of this title (relating to
				School-Based Savings Program).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.101 - Overview and Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This chapter
				governs the eligibility requirements for the Medicaid Buy-In Program (MBI),
				which is authorized under §
									RSA
				531.02444 of the Texas Government Code, and
				which provides Medicaid benefits under the option explained in
				§1902(a)(10)(A)(ii)(XIII) of the Social Security Act (RSA
				1396a(a)(10)(A)(ii)(XIII)).
				All references in this chapter to MBI mean the Medicaid Buy-In
				Program.
(b) MBI is administered by
				the Texas Health and Human Services Commission (HHSC). All references in this
				chapter to HHSC mean the Texas Health and Human Services Commission.
(c) MBI provides Medicaid benefits to working
				persons with disabilities, regardless of age, who apply for Medicaid and meet
				the requirements explained in this chapter.
(d) Nothing in these rules shall be construed
				to violate the maintenance of eligibility requirements of section 5001 of the
				American Recovery and Reinvestment Act of 2009 (Public Law 111-5)
				and make eligibility standards, methodologies, or procedures under the Texas
				State Plan for Medical Assistance (or any waiver under section 1115 of the
				Social Security Act (RSA 1315))
				more restrictive than the eligibility standards, methodologies, or procedures,
				respectively, under such plan (or waiver) that were in effect on July 1,
				2008.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.103 - Applying and Providing Information

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				person applies for MBI by completing an application for MBI and submitting it
				to HHSC. The date of receipt of the signed application by HHSC is the
				application filing date, and thus establishes the application month explained
				in §
									RSA
				360.119 of this chapter (relating to Medical
				Effective Date).
(b) HHSC notifies
				an MBI recipient in writing when it is time to redetermine the recipient's
				eligibility. This usually occurs once per year, although HHSC may require a
				person to reapply sooner if HHSC determines that a special review of the
				person's eligibility is appropriate. An MBI recipient must reapply when HHSC
				sends written notice of the requirement to the recipient's case address of
				record. The written notice explains the deadline to reapply. If an MBI
				recipient fails to reapply by the deadline stated in the written notice, HHSC
				may terminate the recipient's MBI eligibility.
(c) HHSC sends in writing to the person's
				case address of record the eligibility decision on an application,
				reapplication, or reported change. If the person disagrees, the person has the
				right to request a fair hearing to appeal HHSC's decision, as explained in
				HHSC's fair hearing rules in Chapter 357 of this title (relating to
				Hearings).
(d) An applicant for MBI
				must provide HHSC with all requested documentation and information that HHSC
				advises is necessary to determine the applicant's eligibility. If the applicant
				fails or refuses to provide requested information by the date specified in a
				written request from HHSC, HHSC may deny the application for failure to furnish
				information. When this occurs but the person later provides the requested
				information, the date that the requested information is provided to HHSC
				becomes the application filing date explained in subsection (a) of this
				section.
(e) A person who applies
				for or is receiving MBI must report to HHSC within 10 calendar days any
				information that may impact the person's eligibility. If a person fails to
				comply with the requirements of this subsection, HHSC may redetermine the
				person's eligibility as of the date the information should have been reported
				to HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.105 - Citizenship, Immigration Status, and Residency

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for MBI, a person must meet the citizenship,
				  immigration status, and residency requirements in Chapter 358, Subchapter B, of
				  this title (relating to Nonfinancial Requirements).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.107 - Disability

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for MBI, a person must meet the definition of
				  disabled as defined by the Social Security Administration for purposes of the
				  federal Supplemental Security Income program, as explained in
				  RSA
				  416.905 and §
									RSA
				  416.906, except the requirement that the
				  person be unable to engage in any substantial gainful activity does not
				  apply.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.109 - Work

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for MBI, a person must be working and earning
				  income. The person must provide evidence of earnings that is satisfactory to
				  HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.111 - Income

Current through Reg. 49, No. 28; July 12, 2024
(a) Earned income.
(1) To be eligible for MBI, a person's
				monthly countable earned income must be less than 250% of the federal poverty
				level.
(2) Countable earned income
				means earned income for purposes of the Supplemental Security Income (SSI)
				program minus all applicable exclusions and exemptions, as explained in
				RSA
				416.1110 -
				RSA
				416.1112.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.113 - Resources

Current through Reg. 49, No. 28; July 12, 2024
(a) To establish and maintain eligibility for
				MBI, a person's countable resources must be equal to or less than $3,000 plus
				the amount of the Supplemental Security Income (SSI) resource limit for an
				individual that is explained in
				RSA
				416.1205. Countable resources means resources
				for SSI purposes as defined in
				RSA
				416.1205, minus all applicable exemptions and
				exclusions explained in
				RSA
				416.1207 - 416.1239.
(b) In addition to the exemptions and
				exclusions explained in subsection (a) of this section, the following are not
				countable resources under this section:
(1)
				Independence accounts.
(A) An independence
				account (IA) is a segregated account in a financial institution, the purpose of
				which is to save for future health care and work-related expenses to increase
				an individual's independence and employment potential.
(B) Only a person's own earned income may be
				deposited into an IA, and amounts deposited cannot exceed 50% of the person's
				gross earnings. If for any SSA Qualifying Quarter a person deposits more than
				50% of the person's gross earnings into an account that is designated as an IA,
				the account loses its IA designation and the funds in the account become a
				countable resource for the 12-month period beginning with the first month after
				the SSA Qualifying Quarter. An SSA Qualifying Quarter is a three-month period
				that ends on March 31, June 30, September 30, and December 31 of each calendar
				year and during which a person's reported earnings and FICA contributions are
				enough for SSA to give the person Social Security wage credits.
(C) Only health care or work-related expenses
				may be paid from an IA. For any SSA Qualifying Quarter, if funds in an IA
				account are used for any other purpose, the account loses its IA designation
				and the funds in the account become a countable resource for the 12-month
				period beginning with the first month after the SSA Qualifying
				Quarter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.115 - Deeming of Income and Resources

Current through Reg. 49, No. 28; July 12, 2024
(a) For
				purposes of MBI eligibility, each person is considered a household of
				one.
(b) If a person lives with a
				spouse, the person and spouse are each considered a household of one. The
				assets of each spouse are considered only with respect to that spouse. In the
				case of assets owned jointly by both spouses, one half is considered with
				respect to each spouse.
(c) If a
				person is a minor and lives with his or her parents, the assets of the parents
				are not considered with respect to the eligibility of the minor.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.117 - Cost Sharing

Current through Reg. 49, No. 28; July 12, 2024
(a) Monthly
				premiums. As a condition of establishing initial MBI eligibility and to remain
				eligible, a person must pay monthly premiums, as explained in this section,
				based on the amount of the person's countable earned and countable unearned
				income. A person may be exempt from paying monthly premiums as described in
				subsection (h) of this section.
(b)
				Countable earned income. For purposes of this section, countable earned income
				is as defined in RSA
				16.1110 and §
									RSA
				416.1111, minus:
(1) earned income that is excluded by federal
				law, as explained in
				RSA
				416.1112(b);
				and
(2) mandatory payroll
				deductions for federal income tax, FICA, and retirement withholding.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 360 - MEDICAID BUY-IN PROGRAM › Section 360.119 - Medical Effective Date

Current through Reg. 49, No. 28; July 12, 2024
Beginning with the three months before the application month,
				  the eligibility effective date for MBI coverage is the first day of the first
				  month in which a person meets all eligibility criteria, including the timely
				  payment of monthly premiums as explained in §
									RSA 360.117 of this
				  chapter (relating to Cost Sharing).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.101 - Overview and Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This chapter
				governs the eligibility requirements for Medicaid Buy-In for Children (MBIC),
				which is authorized under §
									RSA
				531.02444 of the Texas Government Code. MBIC
				provides Medicaid benefits under the option explained in §1902(cc) of the
				Social Security Act (RSA
				1396a(cc)).
(b) MBIC is a Medicaid buy-in program for
				children with disabilities administered by the Texas Health and Human Services
				Commission (HHSC). It provides Medicaid benefits to eligible children with
				disabilities who are not eligible for Supplemental Security Income (SSI) for
				reasons other than disability. A child does not have to have applied for SSI in
				order to meet eligibility requirements for MBIC.
(c) Nothing in these rules shall be construed
				to violate the maintenance of eligibility requirements of section 5001 of the
				American Recovery and Reinvestment Act of 2009 (Public Law 111-5)
				and make eligibility standards, methodologies, or procedures under the Texas
				State Plan for Medical Assistance (or any waiver under section 1115 of the
				Social Security Act (RSA 1315))
				more restrictive than the eligibility standards, methodologies, or procedures,
				respectively, under such plan (or waiver) that were in effect on July 1,
				2008.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.103 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
				  have the following meanings, unless the context clearly indicates
				  otherwise:
(1) Applicant--A person
				seeking Medicaid benefits under MBIC who is not currently receiving Medicaid
				services.
(2) Authorized
				representative--An individual:
(A) who
				assists and represents a person in the application or eligibility
				redetermination process, and who is familiar with that person and that person's
				financial affairs; or
(B) who is a
				representative payee for an applicant or recipient for another federal
				benefit.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.105 - Applying and Providing Information

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				person or the person's authorized representative applies for MBIC by completing
				an application prescribed by HHSC and submitting it to HHSC in accordance with
				HHSC instructions. The date of receipt of the completed signed application by
				HHSC is the application filing date, which establishes the application month
				explained in §
									RSA
				361.119 of this chapter (relating to Medical
				Effective Date).
(b) An applicant
				or authorized representative must provide HHSC with all requested documentation
				and information that HHSC determines is necessary to make an eligibility
				determination or calculate a monthly premium. If the applicant or authorized
				representative fails or refuses to provide requested information by the date
				specified in a written request from HHSC, HHSC may deny the application for
				failure to furnish information. When this occurs but the person later provides
				the requested information, the date that the requested information is provided
				to HHSC becomes the application filing date explained in subsection (a) of this
				section.
(c) HHSC notifies a
				recipient in writing when it is time to redetermine the recipient's
				eligibility. This usually occurs once per year, although HHSC may require a
				person to send in documentation and information more often if HHSC determines
				that a special review of the person's eligibility is appropriate. A recipient
				must provide requested documentation and information when HHSC sends written
				notice of the requirement to the recipient's case address of record. The
				written notice explains the deadline to provide the information. If a recipient
				fails to provide the information by the deadline stated in the written notice,
				HHSC may terminate the recipient's MBIC eligibility.
(d) An applicant or recipient must report to
				HHSC within 10 calendar days any information that may impact the person's
				eligibility or monthly premium amount, in accordance with
				RSA
				1383(e)(1)(A).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.107 - Nonfinancial Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Citizenship, immigration status, and residency. To be eligible for MBIC, a
				child must meet the citizenship, immigration status, and residency requirements
				in Chapter 358, Subchapter B of this title (relating to Nonfinancial
				Requirements).
(b) Disability. To
				be eligible for MBIC, a child must meet the Supplemental Security Income
				program's definition of disability for children, as explained in
				RSA
				416.906.
(c) Age. A child is eligible for MBIC through
				the month of his or her 19th birthday, if the child meets all other eligibility
				criteria.
(d) Marital status. To be
				eligible for MBIC, a child must not be married.
(e) Living arrangement.
(1) An applicant or recipient must not reside
				in a public institution, including a jail, prison, reformatory, or other
				correctional or holding facility, as defined in
				RSA
				435.1009 and §
										RSA
				435.1010.
(2) If a recipient enters a nursing facility
				or intermediate care facility for persons with mental retardation, HHSC does
				not process the denial of MBIC Medicaid until eligibility for the appropriate
				institutional Medicaid program is determined.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.109 - Third-Party Resources

Current through Reg. 49, No. 28; July 12, 2024
Medicaid is considered the payor of last resort for a
				  person's medical expenses. As a condition of eligibility, in accordance with
				  RSA
				  433.138 -
				  RSA
				  433.148, an applicant or recipient
				  must:
(1) assign to HHSC the
				applicant's or recipient's right to recover any third-party resources available
				for payment of medical expenses covered under the Texas State Plan for Medical
				Assistance; and
(2) report to HHSC
				any third-party resource within 60 days after learning about the third-party
				resource.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.111 - Income

Current through Reg. 49, No. 28; July 12, 2024
(a) To be eligible for MBIC, a child's family
				must have monthly countable income less than or equal to 150% of the Federal
				Poverty Level (FPL).
(b) Countable
				income means:
(1) earned income for purposes
				of the Supplemental Security Income (SSI) program minus all applicable
				exclusions and exemptions, as explained in
				RSA
				416.1110 - 416.1112; and
(2) unearned income for purposes of the SSI
				program minus all applicable exclusions and exemptions, as explained in
				RSA
				416.1120 - 416.1124, except HHSC does not
				count as income:
(A) in-kind support and
				maintenance;
(B) payments made from
				or interest earned on a tuition savings program under §
											RSA
				358.388 of this title (relating to Tuition
				Savings Programs);
(C) payments
				made from or interest earned on an Achieving a Better Life Experience (ABLE)
				account under § 358.389 of this title (relating to Achieving a Better Life
				Experience Program); and
(D)
				income earned on a school-based savings program under § 358.390 of this
				title (relating to School-Based Savings Program).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.113 - Employer-Sponsored Health Insurance

Current through Reg. 49, No. 28; July 12, 2024
As a condition of a child's eligibility for MBIC, a parent of
				  an applicant or recipient living in the same household as the applicant or
				  recipient must apply for, enroll in, and pay any required premiums for an
				  employer-sponsored health insurance plan, if the parent's employer:
(1) offers family coverage under a group
				health plan that covers the applicant or recipient; and
(2) contributes at least 50 percent of the
				total cost of annual premiums.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.115 - Cost Sharing

Current through Reg. 49, No. 28; July 12, 2024
(a) Monthly premium
				requirements for the months after the eligibility certification month. After
				HHSC establishes MBIC eligibility, HHSC or its designee sends the recipient
				written notice of the monthly premium amount and the due date for the monthly
				premium payment. HHSC provides a grace period of 60 days from the date on which
				the monthly premium is past due for the recipient to pay the monthly premium,
				in accordance with
				RSA
				1396o(i)(3). If
				HHSC does not receive a monthly premium payment within the grace period, then
				HHSC terminates MBIC eligibility, effective the first day of the month after
				the grace period ends.
(b) Monthly
				premium requirements for the three months prior to the application month. As
				described in §
									RSA
				361.119 of this chapter (relating to Medical
				Effective Date), an applicant may receive MBIC coverage for up to three months
				prior to the application month if the applicant meets the MBIC eligibility
				requirements. A month prior to the application month is a retroactive month.
				Prior to certifying MBIC eligibility for a retroactive month, HHSC or its
				designee sends the applicant written notice of the monthly premium amount for
				each eligible retroactive month and the due date for the monthly premium
				payment. HHSC provides the applicant at least 60 days to submit the premium
				payment for eligible retroactive months, in accordance with
				RSA
				1396o(i)(3).
				HHSC or its designee must receive, by the due date, a full premium payment for
				at least one of the eligible retroactive months to certify MBIC eligibility for
				a retroactive month. If HHSC or its designee receives a premium payment that is
				less than the total amount due for all of the eligible retroactive months, then
				HHSC or its designee applies the amount to the eligible retroactive months in
				reverse chronological order.
(c)
				Monthly premium amounts. HHSC determines the monthly premium amounts on a
				sliding scale based on total monthly income as described in §
									RSA
				361.111(c)(3)(A)
				of this chapter (relating to Income).
(1) For
				a recipient who is not enrolled in employer-sponsored health insurance, HHSC
				establishes full monthly premium amounts, up to the maximum amounts allowed by
				federal law.
(2) For a recipient
				who is enrolled in employer-sponsored health insurance and who receives premium
				assistance from HHSC under §1906 of the Social Security Act (RSA
				1396e), HHSC establishes reduced monthly
				premium amounts.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.117 - Notice of Eligibility Determination and Right to Appeal

Current through Reg. 49, No. 28; July 12, 2024
(a) After making an eligibility determination
				on an initial application, HHSC sends the applicant:
(1) a written notice of eligibility,
				including notice of any monthly premium requirements and the medical effective
				date described in §
										RSA
				361.119 of this chapter (relating to Medical
				Effective Date); or
(2) a written
				notice of ineligibility and the reason for the decision.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 361 - MEDICAID BUY-IN FOR CHILDREN PROGRAM › Section 361.119 - Medical Effective Date

Current through Reg. 49, No. 28; July 12, 2024
(a) Beginning
				with the three months before the application month, except as described in
				subsection (b) of this section, the medical effective date for MBIC coverage is
				the first day of the first month in which a person meets all eligibility
				criteria.
(b) The medical effective
				date for MBIC cannot predate January 1, 2011.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.201 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter defines the Prescribed
				  Pediatric Extended Care Center services benefit available through the Early and
				  Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, which
				  in Texas is known as the Texas Health Steps Comprehensive Care
				  Program.
(b) This subchapter
				  applies to Medicaid fee-for-service and Medicaid managed care organizations
				  that contract with the Texas Health and Human Services Commission to provide
				  Medicaid services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.203 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings unless the context clearly indicates
					 otherwise.
(1) Activities of daily
				  living (ADLs)--Activities that include eating, toileting, personal hygiene,
				  dressing, bathing, transferring, positioning, and locomotion or
				  mobility.
(2) Basic services--Basic
				  services include:
(A) the development,
				  implementation, and monitoring of a comprehensive protocol of care that:
(i) is provided to a medically dependent or
				  technologically dependent participant;
(ii) is developed in conjunction with the
				  participant's responsible adult; and
(iii) specifies the medical, nursing,
				  psychosocial, therapeutic, and developmental services required by the
				  participant; and
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.205 - Provider Participation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A PPECC service provider must be
				  independently enrolled in the Texas Medicaid program to be eligible to receive
				  Medicaid reimbursement for providing PPECC services through
				  THSteps-CCP.
(b) To participate in
				  THSteps-CCP, a PPECC service provider must:
(1) be currently licensed under and comply
				  with 40 TAC Chapter 15 (relating to Licensing Standards for Prescribed
				  Pediatric Extended Care Centers);
(2) be enrolled and approved for
				  participation in the Texas Medicaid program;
(3) agree to provide services in compliance
				  with all applicable federal, state, and local laws and regulations, including
				  Texas Occupations Code Chapter 301;
(4) comply with the terms of the Texas
				  Medicaid Provider Agreement;
(5)
				  comply with all state and federal regulations and rules relating to the Texas
				  Medicaid program;
(6) comply with
				  the requirements of the Texas Medicaid Provider Procedures Manual, including
				  all published updates and revisions and all handbooks, standards, and
				  guidelines published by HHSC or an MCO with which they contract;
(7) comply with accepted professional
				  standards and principles of nursing practice;
(8) comply with Texas Family Code Chapter
				  261, and Texas Health and Safety Code Chapter 260A, concerning mandatory
				  reporting of suspected abuse or neglect of children and adults with
				  disabilities; and
(9) maintain
				  written policies and procedures for obtaining consent for medical treatment for
				  participants in the absence of the responsible adult that meet the standards of
				  Texas Family Code §
											RSA
				  32.001.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.207 - Participant Eligibility Criteria

Current through Reg. 49, No. 28; July 12, 2024
(a) All
				  requests for PPECC services must be based on the current medical needs of a
				  participant who meets the following admission criteria for a PPECC:
(1) is eligible for THSteps-CCP;
(2) is age 20 or younger;
(3) requires ongoing skilled nursing care and
				  supervision and skilled observations, judgments, and therapeutic interventions
				  all or part of the day to correct or ameliorate his or her health status, such
				  that delayed skilled intervention is expected to result in:
(A) deterioration of a chronic
				  condition;
(B) loss of
				  function;
(C) imminent risk to
				  health status due to medical fragility; or
(D) risk of death;
(4) is considered to be a medically dependent
				  or technologically dependent participant;
(5) is stable and eligible for outpatient
				  medical services in accordance with 40 TAC §
											RSA
				  15.601(relating to Admission
				  Criteria);
(6) has a prescription
				  for each authorization period for PPECC services signed and dated by the
				  ordering physician who has examined the participant within 30 days prior to
				  admission and reviewed all appropriate medical records;
(7) resides with the responsible adult and
				  does not reside in a 24-hour inpatient facility, including a:
(A) general acute hospital;
(B) skilled nursing facility;
(C) intermediate care facility; or
(D) special care facility, including
				  sub-acute units or facilities for the treatment of acquired immune deficiency
				  syndrome; and
(8) has a
				  consent to the participant's admission to the PPECC signed and dated by the
				  participant or by the participant's responsible adult.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.209 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Comprehensive plan of care; permissible PPECC services.
(1) The PPECC must develop, implement, and
				  monitor a comprehensive plan of care that:
(A) is provided to a medically dependent or
				  technologically dependent participant;
(B) is developed in collaboration with the
				  participant's ordering physician, responsible adult, and interdisciplinary
				  team, as well as the participant's existing service providers as needed to
				  coordinate care;
(C) specifies the
				  following prescribed services needed to address the medical, nursing,
				  psychosocial, therapeutic, dietary, functional, and developmental needs of the
				  participant and the training needs of the participant's responsible adult:
(i) skilled nursing;
(ii) personal care services to assist with
				  activities of daily living while in the PPECC;
(iii) functional developmental
				  services;
(iv) nutritional and
				  dietary services, including nutritional counseling;
(v) occupational, physical and speech
				  therapy;
(vi) respiratory
				  care;
(vii) psychosocial services;
				  and
(viii) training for the
				  participant's responsible adult associated with caring for a medically or
				  technologically dependent participant;
(D) specifies if transportation is
				  needed;
(E) is reviewed and revised
				  for each authorization of services per subsection (d) of this section or more
				  frequently as the ordering physician deems necessary;
(F) is signed and dated by the participant's
				  ordering physician;
(G) is signed
				  and dated by the participant or the participant's responsible adult;
(H) meets additional requirements prescribed
				  in 40 TAC §
												RSA
				  15.607(relating to Initial and Updated Plan
				  of Care); and
(I) meets
				  requirements contained in the Texas Medicaid Provider Procedures
				  Manual.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.211 - Service Authorization

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Authorization is required for payment of services. The provider must submit a
				  complete request for prior authorization in order to be considered by HHSC for
				  reimbursement. Prior authorization is a condition for reimbursement, but not a
				  guarantee of payment.
(b) Only
				  those services that HHSC determines to be medically necessary and appropriate
				  are authorized.
(c) PPECC services
				  are prior authorized with reasonable promptness. Prior authorization
				  determinations are completed by HHSC within three business days of receipt of a
				  complete request.
(d) Initial
				  authorization may not exceed 90 days from the start of care. Following the
				  initial authorization, no authorization for payment of PPECC services may be
				  issued for a single service period exceeding 180 days. In addition, specific
				  authorizations may be limited to a time period less than the established
				  maximum based on factors such as the stability and predictability of the
				  participant's medical condition.
(e) HHSC may deny or reduce the PPECC
				  services when:
(1) the participant does not
				  meet the medical necessity criteria for admission;
(2) the participant does not have an ordering
				  physician;
(3) the participant is
				  not 20 years of age or younger;
(4)
				  the services requested are not covered under this subchapter;
(5) the participant's needs are not beyond
				  the scope of services available through Medicaid Title XIX Home Health Skilled
				  Nursing or Home Health Aide Services, because the needs can be met on a
				  part-time or intermittent basis through a visiting nurse as described by
				  Chapter 354, Subchapter A, Division 3 of this title (relating to Medicaid Home
				  Health Services);
(6) there is a
				  duplication of services;
(7) the
				  services are primarily respite care or child care;
(8) the services are provided for the sole
				  purpose of responsible adult training;
(9) the request is incomplete;
(10) the information in the request is
				  inconsistent; or
(11) the requested
				  services are not nursing services as defined by the Texas Occupations Code
				  Chapter 301 and its implementing regulations.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.213 - Ordering Physician Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a) An ordering physician in an employment or
				  contractual relationship with a PPECC cannot provide the required physician's
				  order unless the physician has a therapeutic relationship with and ongoing
				  clinical knowledge of the participant.
(b) The ordering physician's responsibilities
				  include:
(1) providing an examination or
				  treatment to the participant within 30 days before the start of PPECC
				  services;
(2) providing a signed
				  prescription or written, dated physician's order for PPECC services within 30
				  calendar days before the participant's start of services, which is valid
				  through the initial authorization period and complies with requirements
				  contained in the Texas Medicaid Provider Procedures Manual;
(3) providing a signed prescription or
				  written, dated physician's order for each PPECC authorization period, once the
				  initial prescription or order is no longer valid;
(4) performing a face-to-face evaluation of
				  the participant each year;
(5)
				  reviewing, approving, signing, and dating a plan of care, and any other
				  documentation required for service prior authorization, including any updates
				  or changes;
(6) affirming in
				  writing that PPECC services are medically necessary for the
				  participant;
(7) affirming in
				  writing that the participant's medical condition is sufficiently stable to
				  permit safe delivery of PPECC services as described in the plan of care;
				  and
(8) providing continuing care
				  to and medical supervision of the participant.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter B - PRESCRIBED PEDIATRIC EXTENDED CARE CENTER SERVICES › Section 363.215 - Termination, Reduction, or Denial of Authorization for Prescribed Pediatric Extended Care Center Services

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  terminates authorization for PPECC services when:
(1) the participant is no longer eligible for
				  THSteps-CCP;
(2) the participant no
				  longer meets the medical necessity criteria for PPECC services;
(3) the PPECC cannot ensure the health and
				  safety of the participant;
(4) the
				  participant or the participant's responsible adult refuses to comply with the
				  plan of care, and compliance is necessary to assure the health and safety of
				  the participant;
(5) the
				  participant changes PPECC providers, and the change of notification is
				  submitted to HHSC in writing with a prior authorization request from the new
				  PPECC provider; or
(6) after
				  receiving PPECC services, the participant declines PPECC services and receives
				  services at home. The home health agency or independent provider offering these
				  services must submit and update all required authorization
				  documentation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter C - PRIVATE DUTY NURSING SERVICES › Section 363.301 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this subchapter is to
				  establish rules for private duty nursing services under the federal Early and
				  Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, known in Texas as
				  the Texas Health Steps - Comprehensive Care Program (THSteps-CCP).
(b) EPSDT recipients are entitled to all
				  medically necessary EPSDT services that:
(1)
				  correct or ameliorate defects and physical and mental illnesses and conditions;
				  and
(2) are eligible for federal
				  financial participation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter C - PRIVATE DUTY NURSING SERVICES › Section 363.305 - Provider Participation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) PDN services providers must be
				  independently enrolled in the Texas Medicaid Program to be eligible to receive
				  reimbursement for providing private duty nursing services through the Texas
				  Health Steps Comprehensive Care Program.
(b) A PDN services provider must:
(1) be an RN, an LVN under the supervision of
				  an RN, or a licensed HCSSA;
(2) be
				  enrolled in the Texas Medicaid Program;
(3) comply with the terms of the Texas
				  Medical Assistance Provider Agreement;
(4) agree to provide services in compliance
				  with all applicable federal, state, and local laws and regulations, including
				  the Texas Nursing Practice Act;
(5)
				  comply with all applicable state and federal laws and regulations relating to
				  the Texas Medicaid Program;
(6)
				  comply with the requirements of the
Texas Medicaid Provider Procedures
				  Manual,
including all updates and revisions published bimonthly in the
Texas Medicaid Bulletin,
and all handbooks, standards, and
				  guidelines published by HHSC;
(7)
				  comply with accepted professional standards and principles of nursing
				  practice;
(8) comply with Texas
				  Family Code Chapter 261 and Texas Human Resources Code Chapter 48, concerning
				  mandatory reporting of suspected abuse and neglect of children and adults with
				  disabilities; and
(9) maintain
				  written policies and procedures for obtaining consent for medical treatment for
				  clients in the absence of the responsible adult that meet the standards of
				  Texas Family Code §
											RSA 32.001,
				  relating to Consent by Non-Parent.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter C - PRIVATE DUTY NURSING SERVICES › Section 363.307 - Medical Necessity

Current through Reg. 49, No. 28; July 12, 2024
(a) PDN services
				  are available to EPSDT-eligible recipients when the services are medically
				  necessary to correct or ameliorate the recipient's disability or physical or
				  mental illness or condition. The services correct or ameliorate when they
				  improve, maintain, or slow the deterioration of the recipient's health
				  status.
(b) Medical necessity must
				  be documented in the recipient's prior authorization request.