reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1409 - Parent Rights Related to the Family Cost Share System

Current through Reg. 49, No. 28; July 12, 2024
(a) The parent has the right to:
(1) receive certain early childhood
				  intervention services at no cost in accordance with
				  34 CFR §
												303.521(b);
(2) refuse any early childhood intervention
				  services they do not wish to receive;
(3) receive information about any method the
				  contractor may use to verify the family's allowable deductions;
(4) receive information about the
				  contractor's process for determining their maximum charge before signing the
				  family cost share agreement;
(5)
				  not have their personally identifiable information released for billing
				  purposes without prior written consent; and
(6) not have their private insurance billed
				  without prior written consent.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1411 - Early Childhood Intervention Services Provided with No Out-of-Pocket Payment from the Parent

Current through Reg. 49, No. 28; July 12, 2024
(a) The early
				  childhood intervention services provided with no out-of-pocket payment from the
				  parent are:
(1) child find;
(2) evaluation and assessment;
(3) development of the IFSP;
(4) services to children with auditory or
				  visual impairments that are required by an individualized education program
				  (IEP) pursuant to Texas Education Code, § 29.003(b)(1);
(5) case management;
(6) translation and interpreter services;
				  and
(7) administrative and
				  coordination activities related to the implementation of procedural safeguards
				  and other components of the statewide system of early childhood intervention
				  services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1413 - Individualized Family Service Plan (IFSP) Services Subject to Out-of-Pocket Payment from the Family

Current through Reg. 49, No. 28; July 12, 2024
(a) IFSP services
				  subject to out-of-pocket payment from the family are:
(1) assistive technology;
(2) behavioral intervention;
(3) occupational therapy services;
(4) physical therapy services;
(5) speech-language pathology
				  services;
(6) nutrition
				  services;
(7) counseling
				  services;
(8) nursing
				  services;
(9) psychological
				  services;
(10) health
				  services;
(11) social work
				  services;
(12)
				  transportation;
(13) specialized
				  skills training;
(14) family
				  education and training; and
(15)
				  any IFSP services to children with visual impairments or who are deaf or hard
				  of hearing that are not required by an individualized education program (IEP)
				  pursuant to Texas Education Code §
											29.003(b)(1).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1417 - Family Cost Share Agreement

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  parent must sign a family cost share agreement. The parent's signature
				  acknowledges their assigned maximum charge and provides written attestation
				  that:
(1) information regarding third-party
				  coverage, family size, gross income, and allowable deductions is true and
				  accurate; or
(2) the parent chooses
				  not to provide information regarding:
(A)
				  third-party coverage;
(B) gross
				  income and family size; or
(C)
				  allowable deductions.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1419 - Private Insurance

Current through Reg. 49, No. 28; July 12, 2024
(a) The contractor
				  must obtain written parental consent to bill and to release personally
				  identifiable information to private insurance.
(b) The contractor must obtain written
				  parental consent when initially seeking to use their private insurance and each
				  time there is an increase (in frequency, length, duration, or intensity) in the
				  provision of services in the IFSP that requires the contractor to obtain
				  written parental consent.
(c) If
				  private insurance denies payment of the claim, the contractor must bill the
				  family up to their maximum charge, based on their placement on the sliding fee
				  scale.
(d) The contractor must
				  adjust the amount billed to the family if the contractor or parent successfully
				  disputes a denied claim.
(e) The
				  contractor must not deny or delay a child's services if:
(1) the family does not have private
				  insurance; or
(2) the parent does
				  not give consent to bill or to release personally identifiable information to
				  their private insurance. If the parent does not give consent, the contractor
				  bills the family up to their maximum charge, based on their placement on the
				  sliding fee scale.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1421 - Insurance Premiums

Current through Reg. 49, No. 28; July 12, 2024
The policyholder is responsible for paying health care
					 premiums based on their individual policy. The contractor includes insurance
					 premiums when calculating the family's allowable deductions, but insurance
					 premiums do not count toward meeting the maximum charge. Neither HHSC nor the
					 contractor pays the family's private insurance premium.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1423 - Co-Pays, Co-Insurance, and Deductibles

Current through Reg. 49, No. 28; July 12, 2024
(a) The contractor collects co-pays,
				  co-insurance, and deductibles as set by the family's insurance plan, up to the
				  family's maximum charge. The maximum charge includes and is not in addition to
				  co-pays, co-insurance, and deductibles.
(b) HHSC absorbs any additional costs that
				  exceed the family's maximum charge, including costs for services not covered by
				  insurance, co-pays, co-insurance, and deductibles.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1425 - Public Benefits and Insurance

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Medicaid, Children's Health Insurance Program (CHIP), and TRICARE are public
				  insurance programs.
(b) The
				  contractor must assist the parent to:
(1)
				  identify and access other available funding sources to pay for a child's early
				  childhood intervention services; and
(2) enroll a potentially eligible child in
				  Medicaid or CHIP.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1427 - Maximum Charge

Current through Reg. 49, No. 28; July 12, 2024
(a) Before
				  initiating early childhood intervention services, the contractor determines the
				  family's ability or inability to pay and calculates their out-of-pocket maximum
				  charge.
(b) The family's maximum
				  charge is the total amount of money billed to the family for services delivered
				  in one calendar month. The maximum charge includes payments for services not
				  covered by insurance, co-pays, co-insurance, and deductibles.
(c) The family's assigned maximum charge does
				  not increase if the family has more than one child receiving IFSP
				  services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1429 - Family Size and Adjusted Income

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  family size equals:
(1) the total number of
				  people living in the home, including the child's parent(s) and the child;
				  and
(2) other individuals who are
				  financial dependents of the parent.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1431 - Texas Health and Human Services Commission (HHSC) Early Childhood Intervention (ECI) Sliding Fee Scale

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  contractor must provide the family with a copy of the HHSC ECI sliding fee
				  scale. Based on family size and income, placement on the HHSC ECI sliding fee
				  scale determines the family's maximum charge for services received in one
				  calendar month.
(b) The HHSC ECI
				  sliding fee scale assigns a set dollar amount as the maximum charge for
				  adjusted income ranges less than or equal to 1000 percent of the federal
				  poverty level. HHSC calculates the maximum charge for each income range by
				  applying a fixed percentage (ranging from 0.25 to 5 percent) to the mid-point
				  income within each range based on the U.S. Department of Health and Human
				  Services most recently published Federal Poverty Levels.
(c) For children and families who enroll in
				  ECI services on or after September 1, 2015, the family's maximum charge shall
				  be pursuant to Figure: 26 TAC § 350.1431(c) identified in this subsection.
				  If the parent refuses to attest in writing that information about their
				  third-party coverage, family size, and gross income is true and accurate, then
				  the family monthly maximum payment equals the full cost of services.
Attached Graphic
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1433 - Billing Families for IFSP Services

Current through Reg. 49, No. 28; July 12, 2024
(a) The contractor must bill the family up to
				  the family's maximum charge.
(1) The total
				  collection of payments, including third-party payment and the family's
				  out-of-pocket payment, cannot exceed the actual cost of services.
(2) The family's total out-of-pocket for the
				  month cannot exceed the family's maximum charge.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1435 - Suspension of Services for Nonpayment

Current through Reg. 49, No. 28; July 12, 2024
(a) The contractor must suspend
				  Individualized Family Service Plan (IFSP) services subject to an out-of-pocket
				  payment as identified in § 350.1413 of this subchapter (relating to IFSP
				  Services Subject to Out-of-Pocket Payment from the Family) when the balance
				  remains delinquent for 90 days. If the parent uses their public or private
				  insurance, the 90-day time period begins the date the contractor receives
				  notice that the claims are denied for reimbursement and all appeals are
				  exhausted.
(b) Before suspending
				  IFSP services, the contractor must inform the parent that:
(1) he or she has the option to request a:
(A) review of the family cost share
				  agreement, as described in § 350.1417 of this subchapter (relating to
				  Family Cost Share Agreement); or
(B) reconsideration and adjustment of the
				  family cost share obligation, as described in § 350.1437 of this
				  subchapter (relating to Extraordinary Circumstances);
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1437 - Extraordinary Circumstances

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  contractor must develop a local process to reconsider and adjust the current or
				  overdue family cost share obligation based on extraordinary
				  circumstances.
(b) Only the program
				  director or designated administrator has authority to reconsider and adjust the
				  family cost share obligation. The reconsideration may include an assessment of
				  the parent's ability to pay the family cost share obligation in any particular
				  month(s).
(c) Extraordinary
				  circumstances that require a reconsideration of the family cost share
				  obligation are:
(1) increase or decrease in
				  income;
(2) unexpected short-term
				  medical expenses;
(3) unanticipated
				  childcare or respite expenses;
(4)
				  change in family size;
(5)
				  catastrophic loss such as fire, flood, or tornado;
(6) short-term financial hardship such as
				  major repair to the family home or car; or
(7) other extenuating circumstances for which
				  the family requests reconsideration.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 350 - EARLY CHILDHOOD INTERVENTION SERVICES › Subchapter N - FAMILY COST SHARE SYSTEM › Section 350.1439 - Program Fiscal and Recordkeeping Policies

Current through Reg. 49, No. 28; July 12, 2024
(a) The contractor must:
(1) use revenue received from the family cost
				  share system only for early childhood intervention services within the HHSC ECI
				  system;
(2) not supplant any other
				  local fund sources; and
(3) report
				  fees collected to HHSC ECI as program income.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.1 - Purpose and Common Name

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose.
				The purpose of this chapter is to implement the Children with Special Health
				Care Needs (CSHCN) Services Program as authorized by Health and Safety Code,
				Chapter 35, to provide the following services to eligible children:
(1) early identification of children with
				special health care needs;
(2)
				diagnosis and evaluation of children with special health care needs;
(3) rehabilitation services to children with
				special health care needs;
(4)
				development and improvement of standards and services for children with special
				health care needs;
(5) case
				management services;
(6) other
				family support services; and
(7)
				access to health benefits plan coverage.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.2 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise.
(1) Act--The Children with
				Special Health Care Needs Services Act, Health and Safety Code, Chapter
				35.
(2) Advanced practice
				registered nurse--A registered nurse approved by the Texas Board of Nursing to
				practice as an advanced practice registered nurse.
(3) Applicant--A person making an initial
				application or re-application for CSHCN Services Program services.
(4) Case management services--Case management
				services include, but are not limited to:
(A)
				planning, accessing, and coordinating needed health care and related services
				for children with special health care needs and their families. Case management
				services are performed in partnership with the child, the child's family,
				providers, and others involved in the care of the child and are performed as
				needed to help improve the well-being of the child and the child's family;
				and
(B) counseling for the child
				and the child's family about measures to prevent the transmission of AIDS or
				HIV and the availability in the geographic area of any appropriate health care
				services, such as mental health care, psychological health care, and social and
				support services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.4 - Covered Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				The program provides no direct medical services, but reimburses for services
				rendered by program providers or contractors. Clients must receive services as
				close to their home communities as possible unless program contracts or
				policies require treatment at specific facilities or specialty centers or the
				clients' conditions require specific specialty care.
(b) Types of service.
(1) Early identification. The program may
				conduct outreach activities to identify children for program enrollment,
				increase their access to care, and help them use services appropriately.
				Outreach services may include, but are not limited to:
(A) promotion of the program to the general
				public or targeted to potential clients and providers;
(B) development and distribution of
				educational materials to assist applicants and clients in the access and use of
				program services;
(C) development
				and distribution of population-based educational materials concerning children
				with special health care needs;
(D)
				integration with programs which screen for or provide treatment of newborn
				congenital anomalies or other specialty care; and
(E) links with community, regional, or
				school-based clinics to identify, assess needs, and provide appropriate
				resources for children with special health care needs.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.5 - Rights and Responsibilities of a Client's Parent(s), Foster Parent(s), Guardian, or Managing Conservator, or an Adult Client

Current through Reg. 49, No. 28; July 12, 2024
(a) Rights. A client's parent(s), foster
				parent(s), guardian, or managing conservator, or an adult client has the right
				to:
(1) apply for eligibility
				determination;
(2) choose providers
				subject to program limitations;
(3)
				be notified of modification, suspension, or termination of service;
(4) refuse entry into the home to any
				employee, agent, or representative of the commission or the
				department;
(5) appeal program
				decisions and receive a response within the deadline as described in §
				351.13 of this title (relating to Right of Appeal); and
(6) have all client files and other
				information maintained in a confidential manner to the extent authorized by
				law.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.7 - Ambulatory Surgical Care Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Ambulatory surgery services may be utilized by the program as a cost-efficient
				means of providing surgical care as long as quality of care is assured. Any
				hospital participating in the program whose accreditation by the Joint
				Commission includes hospital-sponsored ambulatory care services may provide
				ambulatory surgery services for program clients. The program will reimburse
				only approved ambulatory surgical care facilities for services to
				clients.
(b) Freestanding
				ambulatory surgical care (ASC) facilities, even if governed by or affiliated
				with a hospital participating in the program, must apply for program approval.
				The program may contract with a limited number of facilities to contain costs.
				For approval to participate in the program, a freestanding ASC facility must
				meet the following criteria:
(1) State
				licensure requirements. Facilities must comply with state licensure
				requirements for ambulatory surgical centers at §§
										135.1-
				135.29
				of this title (relating to Operating Requirements for Ambulatory Surgical
				Centers).
(2) Medicare
				certification. Facilities must comply with Medicare standards concerning
				ambulatory surgical services at 42 Code of Federal Regulations, Parts 405 and
				416.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.8 - Inpatient Rehabilitation Centers

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				program will reimburse only an approved inpatient rehabilitation center for
				services provided to clients.
(b)
				The criteria for inpatient rehabilitation center approval include the
				following.
(1) The center shall have current
				accreditation by either the Joint Commission as a comprehensive physical
				rehabilitation program or the Commission on Accreditation of Rehabilitation
				Facilities as a comprehensive inpatient rehabilitation program.
(2) The center shall be located in
				Texas.
(3) The center shall be
				located outside Texas, in the United States within 50 miles of the Texas
				border.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.9 - Cleft-Craniofacial Services

Current through Reg. 49, No. 28; July 12, 2024
To assure that clients with cleft lip, cleft palate, or other
				  craniofacial anomalies receive quality, comprehensive services,
				  cleft-craniofacial teams requesting approval from the program must comply with
				  the following standards:
(1) All
				cleft-craniofacial surgical procedures are provided within the context and
				consultation of a coordinated, comprehensive, interdisciplinary
				cleft-craniofacial team and must be prior authorized. Team composition is
				consistent with current basic standards of the American Cleft
				Palate-Craniofacial Association.
(2) A comprehensive cleft-craniofacial team
				will include an operating surgeon, orthodontist, speech-language pathologist,
				and at least one additional specialist from otolaryngology, audiology,
				pediatrics, genetics, social work, psychology, and general pediatric or
				prosthetic dentistry. Adjunct participants may be added as determined by the
				cleft-craniofacial team to meet the needs of individual clients.
(3) The cleft-craniofacial surgical
				procedures and related cleft-craniofacial team services are provided in
				accordance with a client and family-oriented comprehensive treatment plan
				jointly developed by the client or family and the cleft-craniofacial team.
(A) A copy of the comprehensive treatment
				plan will be given to the family (prior to the surgical procedures), the local
				or referring primary care physician, and other collaborative providers, e.g.
				local dentist, local speech therapist, case manager, etc. who will be providing
				services to the client.
(B) The
				plan will include specific services to be provided by the members of the
				cleft-craniofacial team, action steps, persons responsible, and
				timeframes.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.11 - Contracts, Written Agreements, and Donations

Current through Reg. 49, No. 28; July 12, 2024
The program may contract on a bid basis for treatment,
				  equipment, medications, supplies, program operations, and other services in
				  order to conserve funds and administer the program effectively.
(1) The program may enter into contracts or
				written agreements with persons or entities for the development and improvement
				of program standards and services.
(2) The program may use consultants from any
				medical or dental specialty or other discipline to address specific issues or
				problems in relation to the identification, diagnosis and evaluation,
				rehabilitation, case management, other family support services, and health
				benefits coverage for clients.
(3)
				With approval as required by law, the program may accept gifts and
				donations.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.12 - Denial, Modification, Suspension, or Termination of Program Eligibility or Eligibility for Health Care Benefits

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Any person applying for or eligible for health care benefits from the program
				shall be notified in writing if the program proposes to deny, modify, suspend,
				or terminate such health care benefits because:
(1) the application or other requested
				information is intentionally erroneous or falsified;
(2) the applicant or family does not meet
				financial eligibility requirements;
(3) the person does not meet Texas residency
				requirements;
(4) information,
				including the receipt for a purchased family support service, was not provided
				when requested;
(5) behavioral or
				emotional condition(s) exist, but no physical or developmental
				condition(s);
(6) the client has
				received third party or liability payments and has failed to reimburse the
				department for services provided to the client;
(7) the client attains the age of 21, except
				for adults with cystic fibrosis;
(8) utilization review indicates
				inappropriate use of program services and the client and family fail to adhere
				to a plan established to direct or supervise the use of program
				services;
(9) program funds are
				reduced or curtailed; or
(10) the
				client is placed on a waiting list for program health care benefits.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.14 - Development and Improvement of Standards and Services

Current through Reg. 49, No. 28; July 12, 2024
To ensure that cost-effective, quality, appropriate medical
				  and related services are available and delivered to clients, the program may
				  establish a system of program evaluation. Program evaluation may include
				  information obtained from management about the program's operation and
				  effectiveness, may establish guidelines and standards for program health care
				  services, may monitor compliance with these established standards and
				  guidelines, may identify and analyze patterns and trends in provider billing
				  and service delivery, and may develop systems which promote family-centered,
				  community-based alternatives that nurture and support children with special
				  health care needs.
(1) Quality
				assurance. The program may establish a system of monitoring the quality,
				medical necessity, and effectiveness of services.
(A) Standards and guidelines. The program may
				develop standards and guidelines for services and providers reimbursed by the
				program to ensure that quality services are available.
(B) Review of services. The program may
				conduct or contract for concurrent and/or retrospective review of client care
				services reimbursed by the program.
(C) Provider review. The program may conduct
				periodic quality assurance reviews for provider services.
(D) Survey of clients and families. The
				program shall survey clients periodically to assess the availability,
				appropriateness, effectiveness, accessibility, and cultural sensitivity of
				provided services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.15 - Third Party Recovery

Current through Reg. 49, No. 28; July 12, 2024
(a) The program or
				the program's designee may recover the cost of services provided to a client
				from any person or entity who does not pay or reimburse the department as
				required by Health and Safety Code, §
									35.007.
(b) The program or the program's designee may
				recover the cost of services provided to a client from any third party who has
				a legal obligation to pay for the services provided.
(c) The program's right of recovery against a
				third party liable for the client's condition or injury is limited to the
				amount paid by the program for all claims submitted by program providers for
				covered services to treat the client's condition or injury.
(d) The program or the program's designee may
				agree to waive all or part of the program's right to recover from a liable
				third party if:
(1) the total of all claims
				from providers for the cost of services provided to the client exceeds the
				amount of the available recovery or settlement;
(2) the program or the program's designee
				finds that enforcement of the program's right of recovery of the cost of
				services provided would adversely affect the client's long-term health and
				welfare; or
(3) the program or the
				program's designee finds that the cost of recovery could exceed the cost of
				services provided by the program.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM › Section 351.16 - Procedures to Address Program Budget Alignment

Current through Reg. 49, No. 28; July 12, 2024
(a) The department must analyze actuarial
				cost projections concerning program administrative and client services to
				estimate the amount of funds needed in the fiscal year by the program to serve
				program clients and shall monitor such program cost projections and funding
				analyses at least monthly to determine whether the estimated amount of funds
				needed by the program will:
(1) exceed the
				program's appropriated funds and other available resources for the fiscal year;
				or
(2) be less than the program's
				appropriated funds and other available resources for the fiscal year.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.1 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of the Comprehensive Rehabilitation Services
				  (CRS) program is to provide services that enhance the quality of life for
				  persons who have a traumatic brain injury (TBI) or traumatic spinal cord injury
				  (SCI), or both, and to enable them to function as independently as possible
				  within the home environment and within the community by improving their
				  mobility, self-care, and communication skills.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.3 - Legal Authority

Current through Reg. 49, No. 28; July 12, 2024
Legal authority for funding this program is provided by the
				  comprehensive rehabilitation fund, as authorized by §
									111.060,
				  Texas Human Resources Code, subrogation recovery pursuant to §
									111.059, Texas Human
				  Resources Code, and by general revenue.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.7 - Basic Requirements for Eligibility

Current through Reg. 49, No. 28; July 12, 2024
(a) To meet the basic eligibility criteria
				for the Comprehensive Rehabilitation Services (CRS) program, there must a
				reasonable expectation that services will benefit the person by improving his
				or her ability to function within the home environment or within the community,
				and the person must:
(1) have a traumatic
				brain injury or traumatic spinal cord injury that constitutes or results in a
				substantial impediment to the person's ability to function within the home
				environment or the community;
(2)
				be at least 15 years of age;
(3) be
				a U.S. citizen or lawful permanent resident, and a Texas resident (as defined
				in §
										107.705(52)
				of this subchapter (relating to Definitions));
(4) not be participating in, or be eligible
				for and able to access, another rehabilitation program offering similar
				rehabilitation treatment or therapy services; however the person may
				participate in rehabilitation programs that offer complementary rehabilitation
				services;
(5) be willing to
				participate in services; and
(6) be
				medically stable, including no progression of deficits, no deterioration of
				physical and cognitive status, or both; not be in imminent need of any acute
				care; and be functioning at a Level IV of the Rancho Los Amigos Levels of
				Cognitive Functioning Scale or equivalent.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.9 - Service Arrays

Current through Reg. 49, No. 28; July 12, 2024
The Comprehensive Rehabilitation Services program service
				  arrays are a set of services that may be provided to eligible persons who have
				  a traumatic brain injury (TBI), traumatic spinal cord injury (SCI), or both;
				  services are based on assessed individualized rehabilitation needs. The service
				  arrays are:
(1) inpatient
				comprehensive medical rehabilitation services, which include:
(A) TBI inpatient comprehensive medical
				rehabilitation services; and
(B)
				SCI inpatient comprehensive medical rehabilitation services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.11 - Service Types

Current through Reg. 49, No. 28; July 12, 2024
The Comprehensive Rehabilitation Services program provides
				  two service types that apply across all service arrays, although not all
				  services may be utilized in all the arrays. The two service types are core
				  services and ancillary services and are listed in paragraphs (1) and (2) of
				  this section.
(1) Core services, are a
				set of fundamental services essential to the rehabilitation of persons who have
				traumatic brain injury, traumatic spinal cord injury, or both. Core services
				may include:
(A) aquatic therapy;
(B) art therapy;
(C) behavior management;
(D) case management;
(E) chemical dependency treatment;
(F) cognitive rehabilitation therapy
				(CRT);
(G) dietary nutritional
				services;
(H) massage
				therapy;
(I) medical
				services;
(J) mental restoration
				services;
(K) music
				therapy;
(L) neuropsychiatric
				services;
(M) neuropsychological
				services;
(N) occupational
				therapy;
(O) personal assistance
				services;
(P) physical
				therapy;
(Q) recreational
				therapy;
(R) room and board;
				and
(S) speech-language
				pathology.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.13 - Limitations of Services

Current through Reg. 49, No. 28; July 12, 2024
The following limitations apply to the Comprehensive
				  Rehabilitation Services (CRS) program service arrays.
(1) Inpatient comprehensive medical
				rehabilitation hospitalization services are subject to the following
				limitations:
(A) No more than one year may
				have elapsed between the onset of injury and the time the person initiates
				contact with the agency in order for a person to receive these
				services.
(B) No acute medical
				procedures are permitted.
(C) Only
				inpatient facilities located within the state of Texas may be used.
(D) Services are limited to a maximum of 90
				days.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.14 - Consumer (Client) Participation

Current through Reg. 49, No. 28; July 12, 2024
(a)
				The consumer (client) participation is a monthly contribution the consumer
				(client) may be required to pay for participation in the Comprehensive
				Rehabilitation Services (CRS) Program. Consumer participation applies to
				consumers in active services, as well as those on the interest list who are
				both eligible and receiving services.
(b) The consumer participation is required
				only for CRS consumers when the consumer's liquid assets exceed the basic
				living requirement (BLR) level calculated by the CRS Program, and consequently
				require the consumer to contribute an amount equal to this excess toward the
				cost of the goods and services provided by the CRS Program. The BLR calculation
				is based on:
(1) 200 percent of current U. S.
				Department of Health and Human Services Poverty Guidelines;
(2) DARS BLR tables for the current fiscal
				year;
(3) DARS policies relating to
				consumer participation and BLR; and
(4) information regarding the consumer's
				income, family status, and economic need.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 352 - COMPREHENSIVE REHABILITATION SERVICES › Section 352.15 - Complaint Resolution Process

Current through Reg. 49, No. 28; July 12, 2024
(a)
				This provision applies to the resolution of a complaint through review of a
				determination made by the Comprehensive Rehabilitation Services (CRS) program,
				when the complaint concerns:
(1)
				ineligibility for services;
(2)
				denial of services; or
(3)
				termination of services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.1 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
These rules implement Texas Health and Safety Code, Chapter
				  41. Specifically, the rules establish eligibility requirements; outline program
				  benefits and the methodology used by the program to remain within budgetary
				  limitations; outline provider requirements and provider reimbursement; outline
				  the rights and responsibilities of clients and providers; and stipulate the
				  circumstances that allow for an administrative review.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.3 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
				  will have the following meanings unless the context clearly indicates
				  otherwise.
(1) Administrative review--A
				process that allows applicants, clients, and providers the opportunity to
				request an informal review of any intended program action that would suspend,
				modify, deny, or terminate their eligibility for enrollment, benefits
				participation in the program, or reimbursement for allowable
				products.
(2) Allowable
				products--Blood factor replacement products indicated for the treatment of
				hemophilia and approved for payment by the program.
(3) Applicant--A person making an initial
				application or re-application for the program.
(4) Approved health plan--An insurance plan
				that provides coverage for hemophilia medical treatment.
(5) Attestation--A statement by a person or
				the person's legally authorized representative attesting that:
(A) the person does not have access to
				private health care insurance that provides coverage for the benefit, service,
				or assistance; or
(B) the person
				has access to private health care insurance that provides coverage for the
				benefit, service, or assistance.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.7 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
An eligible client may receive either blood factor
				  replacement products or insurance premium payment assistance in the same fiscal
				  year, but not at the same time.
(1)
				Blood Factor Replacement Products. The program provides limited reimbursement
				to program providers for blood factor replacement products indicated for the
				treatment of hemophilia and prescribed to eligible clients for use in medical
				or dental facilities, or in the home.
(2) Program benefits for allowable products
				are limited to those prescribed by a physician and dispensed by a program
				provider.
(3) The program will pay
				for allowable products based upon:
(A)
				available funds;
(B) established
				limits for allowable products by type or category; and
(C) the reimbursement rates established by
				the department.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.9 - Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) Applicable provider types for the program
				include, but are not limited to:
(1)
				pharmacies;
(2) hospitals;
				or
(3) blood banks.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.11 - Claims Payment

Current through Reg. 49, No. 28; July 12, 2024
(a) Prior
				authorization is required for all allowable products.
(b) The program reimburses program providers
				for allowable product(s) for eligible clients. Payment may be made only after
				the allowable product(s) has been dispensed and submission of a valid claim.
				Claims must be:
(1) submitted on the claim
				form accepted by the program;
(2)
				submitted by a program provider; and
(3) filed directly with the
				program.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.13 - Rights and Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a)
				Client Rights. The applicant, client, or legally authorized representative have
				the right to:
(1) apply for eligibility
				determination;
(2) choose providers
				subject to program limitations;
(3)
				choose a health plan, if applicable, subject to program limitations;
(4) be notified of program decisions relating
				to modifications, suspensions, denials, or terminations;
(5) have all client files and other
				information maintained in a confidential manner to the extent authorized by
				law;
(6) appeal program decisions
				and receive a response within the deadline as described in § 354.17 of
				this title (relating to Right of Appeal); and
(7) reapply for the program when eligibility
				for the program is denied or terminated.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.15 - Modifications, Suspensions, Denials and Terminations

Current through Reg. 49, No. 28; July 12, 2024
(a) Any applicant or client shall be notified
				in writing of the action, the reason(s) for the action, and the right of appeal
				in accordance with § 354.17 of this title (relating to Right of Appeal),
				if the program proposes to modify, suspend, deny, or terminate program
				eligibility or benefits for reasons, which include but are not limited to the
				following:
(1) the application or other
				requested information is erroneous or falsified;
(2) financial eligibility requirements are
				not met;
(3) failure to establish
				or maintain Texas residency;
(4)
				financial or residency documentation is not provided as required or
				requested;
(5) failure to provide
				information when requested;
(6) the
				client is or becomes incarcerated in a city, county, state, or federal jail, or
				prison;
(7) the client is or
				becomes a ward of the state;
(8)
				failure to receive allowable products through a program provider;
(9) failure to reimburse the department, as
				requested, for overpayments made to the client; or
(10) failure to continue insurance premium
				payments on individual or group insurance or prepaid medical plans, where such
				plans provide benefits for the care and treatment of persons who have
				hemophilia and eligibility for benefits under the plan(s) was effective prior
				to eligibility for the program, and failure to provide a statement on the
				application form outlining the reason(s) why such insurance cannot be
				maintained.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - HEMOPHILIA ASSISTANCE PROGRAM › Section 354.17 - Right of Appeal

Current through Reg. 49, No. 28; July 12, 2024
(a) Administrative
				Review.
(1) When the program modifies,
				suspends, denies, or terminates eligibility or benefits, the program shall give
				written notice of and the reason(s) for the action. Applicants, clients,
				providers, or legally authorized representatives, have the right to request an
				administrative review of the action within 30 days of the notice
				date.
(2) If the program denies a
				prior authorization request for program services, the program will give the
				client, provider, or a legally authorized representative, written notice of the
				denial and the right of the client, provider, or legally authorized
				representative, to request an administrative review of the denial within 30
				days of the notice date.
(3) If the
				program receives a written request for administrative review within 30 days of
				the notice date, the program will conduct an administrative review of the
				circumstances surrounding the proposed action. Within 30 days following receipt
				of a request for administrative review, the program will send the applicant,
				client, provider, or legally authorized representative, written notice of:
(A) the program decision, including the
				supporting reason(s) for the decision; or
(B) the need for extended time to research
				the circumstance(s), including an expected date for response to the
				request.
(4) If the
				program does not receive a written request for administrative review within 30
				days of the date of the notification, the applicant, client, provider, or
				legally authorized representative, is presumed to have waived the
				administrative review as well as access to a fair hearing, and the program's
				action is final.
(5) A client,
				provider, or legally authorized representative, may not request administrative
				review of the program's denial of a prior authorization request for program
				services or reduced provider reimbursement amounts that are authorized by
				§ 354.7(f) of this title (relating to Benefits and Limitations).
(6) A client, provider, or legally authorized
				representative, may not request an administrative review of prior authorization
				decisions and reimbursement amounts for claims that are paid in accordance with
				the reimbursement rate as defined in § 354.3(33) of this title (relating
				to Definitions).