reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter B - APPLICATION SCREENING, REFERRAL, PROCESSING, RENEWAL, AND DISENROLLMENT › Division 6 - RENEWAL PROCESS › Section 370.60 - Renewal

Current through Reg. 49, No. 28; July 12, 2024
(a) Every 12 months, HHSC redetermines if the
					 member is still eligible to receive CHIP services.
(b) If the CHIP member is pregnant and
					 eligible to receive continuous eligibility, a renewal will be conducted at the
					 end of the recipient's 12-month postpartum period.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter B - APPLICATION SCREENING, REFERRAL, PROCESSING, RENEWAL, AND DISENROLLMENT › Division 7 - DISENROLLMENT › Section 370.70 - Income Eligibility Check in 6th Month of Coverage

Current through Reg. 49, No. 28; July 12, 2024
(a) CHIP households enrolled in a 12-month
					 coverage period with income levels above 185% FPL will have the household
					 income reviewed during the sixth month of coverage. The household remains
					 eligible for coverage if the household income remains within income eligibility
					 limits described in §
											RSA 370.44 of
					 this title (relating to Income and Assets).
(b) CHIP households described in subsection
					 (a) will be disenrolled if:
(1) the household
					 income is determined to exceed the income eligibility limits described in
					 §
												RSA 370.44 of
					 this title;
(2) the household fails
					 to provide requested income information within the timeframes set by HHSC;
					 or
(3) the household otherwise
					 fails to cooperate with HHSC in the review process.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter B - APPLICATION SCREENING, REFERRAL, PROCESSING, RENEWAL, AND DISENROLLMENT › Division 7 - DISENROLLMENT › Section 370.71 - Review and Reconsideration of Disenrollment Determination

Current through Reg. 49, No. 28; July 12, 2024
(a) A member may request a review of a
					 suspension or termination of enrollment by contacting HHSC in writing within 30
					 working days from the notice of the action, or within 15 working days from the
					 notice of the action if the member is requesting continuation of enrollment
					 pending the review decision.
(b)
					 Following receipt of the request for review, HHSC will complete its review
					 within the timeframes required by federal regulation.
(c) HHSC will notify the requester in writing
					 of the results of its review. The written notification will:
(1) explain the reason for the
					 action;
(2) inform the requestor
					 whether the action was reversed; and
(3) explain any applicable rights to
					 reconsideration or review of the determination or state that the determination
					 is final.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 1 - ENROLLMENT AND DISENROLLMENT › Section 370.301 - CHIP Enrollment Packet

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
					 or its designee will conduct enrollment and disenrollment activities.
(b) Within 5 business days of determining a
					 child is CHIP eligible, HHSC's designee must send the applicant a CHIP
					 enrollment packet containing:
(1) an
					 explanation of CHIP benefits;
(2)
					 information about the value-added services provided by MCOs;
(3) an enrollment form and instructions for
					 completing the form;
(4)
					 information on how to obtain a provider directory for each MCO available in the
					 applicant's service area;
(5) a
					 CHIP member guide;
(6) cost-sharing
					 information specific to the household's percentage of the Federal Poverty Level
					 (FPL) income, which includes:
(A) the
					 enrollment fee, if any;
(B) a
					 schedule of co-payments, if any; and
(C) information about the cost-sharing
					 cap;
(7) the process for
					 requesting review of an action;
(8)
					 information specifying the earliest date coverage can begin and the latest date
					 the completed enrollment form must be received by HHSC or its designee to
					 ensure enrollment on the first day of the appropriate month; and
(9) information summarizing the importance of
					 appropriate MCO, primary care provider (PCP), and dental home
					 choices.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 1 - ENROLLMENT AND DISENROLLMENT › Section 370.303 - Completion of Enrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) To complete
					 CHIP enrollment, an applicant must:
(1)
					 select and indicate on the enrollment form a health care MCO and a dental MCO
					 for all eligible children;
(2)
					 select a PCP and a dental home, and place the names on the enrollment
					 form;
(3) if applicable, indicate
					 if an eligible child has special health care needs based on criteria in the
					 member guide;
(4) sign and return
					 the enrollment form; and
(5) pay
					 any applicable enrollment fee on or before the due date.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 1 - ENROLLMENT AND DISENROLLMENT › Section 370.305 - Enrollment of Children with Special Health Care Needs (CSHCN)

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC or its designee will notify MCOs of
					 members identified through enrollment as having special health care
					 needs;
(b) Each MCO will contact
					 each member identified on the enrollment form as having special health care
					 needs to confirm his or her health care needs status; and
(c) Each MCO will notify HHSC or its designee
					 of members identified through enrollment as having special health care needs
					 who are not confirmed as having special health care needs.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 1 - ENROLLMENT AND DISENROLLMENT › Section 370.307 - Continuous Enrollment Period

Current through Reg. 49, No. 28; July 12, 2024
(a) CHIP enrollment
					 always begins on the first calendar day of the month and continues for a period
					 up to 12 consecutive months.
(b) A
					 pregnant CHIP member is eligible to receive coverage until the end of the
					 member's 12-month postpartum period even if the member turns nineteen years
					 old.
(c) Exceptions to continuous
					 enrollment include, but are not limited to:
(1) a sibling member in the home has an
					 earlier initial date of coverage, in which case the coverage period for the
					 newly enrolled child will be the remaining period of coverage of the already
					 enrolled sibling;
(2) aging out
					 when the member turns 19;
(3)
					 family moves out of state;
(4)
					 death of the member;
(5) data match
					 reveals member is enrolled in both CHIP and Medicaid;
(6) failure to drop current health insurance
					 if member was determined to be CHIP-eligible due to the 10 percent rule
					 regarding the cost of the current insurance;
(7) direction by HHSC based on evidence that
					 the member's original eligibility determination was incorrect; or
(8) child becomes eligible for
					 Medicaid.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 1 - ENROLLMENT AND DISENROLLMENT › Section 370.309 - Incomplete or Missing Information

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
					 or its designee sends a reminder notice to Applicants who have failed to:
(1) sign the enrollment form;
(2) return the enrollment form; or
(3) complete the enrollment form
					 properly.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 1 - ENROLLMENT AND DISENROLLMENT › Section 370.311 - Disenrollment

Current through Reg. 49, No. 28; July 12, 2024
(a) Disenrollment at a member's request.
(1) Members will be informed of disenrollment
					 opportunities no less than annually.
(2) During the first 90 days of enrollment in
					 a managed care organization (MCO), a member may request to move to another MCO
					 for any reason. After 90 days with an MCO, a member must show good cause to
					 move to another MCO.
(3)
					 Disenrollment will take place no later than the first day of the second month
					 after the month in which the member has requested a change.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 2 - COST-SHARING REQUIREMENTS › Section 370.321 - Requirements and Exemptions

Current through Reg. 49, No. 28; July 12, 2024
Cost-sharing requirements are based on a household's
						percentage of the Federal Poverty Level (FPL). Except for costs associated with
						unauthorized, non-emergency services provided to a member by out-of-network
						providers, the co-payments identified in this section are the only amounts a
						provider may collect from an applicant in regard to services provided to a
						member.
(1) An applicant may be
					 required to pay any of the following costs of CHIP coverage for a member:
(A) an enrollment fee; and
(B) co-payments.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter C - ENROLLMENT, RENEWAL, DISENROLLMENT, AND COST SHARING › Division 2 - COST-SHARING REQUIREMENTS › Section 370.325 - Cost-Sharing Cap

Current through Reg. 49, No. 28; July 12, 2024
(a) The aggregate
					 annual Children's Health Insurance Program (CHIP) cost-sharing cap is based on
					 household income (as defined in §
											RSA 370.803 of this
					 chapter (relating to Definitions)), established at the time of eligibility
					 determination, as a percentage of the Federal Poverty Level (FPL). The
					 aggregate annual CHIP cost-sharing cap is established in the Texas CHIP State
					 Plan and approved by the Centers for Medicare and Medicaid Services (CMS). The
					 aggregate annual CHIP cost-sharing cap will not exceed 5 percent of the annual
					 household income as required under federal law and federal regulations (see
					 Social Security Act §2103(e)(3)(B) and §
											RSA
					 457.560(a)). The
					 applicant is responsible for tracking CHIP cost-sharing expenditures for the
					 household on the form provided by HHSC or its designee and advising HHSC's
					 designee when the CHIP cost-sharing cap is reached. HHSC or its designee is
					 responsible for:
(1) computing the aggregate
					 annual CHIP cost-sharing cap for the household and informing the applicant of
					 the amount at enrollment;
(2)
					 providing the applicant with a form for keeping track of each CHIP member's
					 co-payments and enrollment fee payment;
(3) notifying the affected dental MCO and
					 health care MCO within two business days of receiving notice from the applicant
					 that a household has reached the aggregate annual CHIP cost-sharing cap;
					 and
(4) informing HHSC that an
					 applicant is owed a refund in the form of a warrant issued by the State
					 Comptroller's Office, if the applicant notifies HHSC's designee that the
					 household has exceeded its aggregate annual CHIP cost-sharing cap and an
					 enrollment fee has been received from the household that is in excess of the
					 CHIP cost-sharing cap.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter D - ELIGIBILITY FOR UNBORN CHILDREN › Section 370.401 - Perinates

Current through Reg. 49, No. 28; July 12, 2024
(a) An unborn child, also referred to as a
				  "perinate," is eligible for CHIP if:
(1) the
				  mother of the perinate is not eligible for Medicaid; and
(2) he or she meets CHIP income eligibility
				  requirements in §
											RSA 370.44 of
				  this chapter (relating to Income and Assets) and Subchapter I of this chapter
				  (relating to Modified Adjusted Gross Income Methodology).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter E - PROVIDER REQUIREMENTS › Section 370.452 - Significant Traditional Provider

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  Health and Human Services Commission (HHSC) will determine whether a provider
				  meets the definition of significant traditional provider (STP) at §
										RSA 370.4 of this
				  title (relating to Definitions).
(b) If a provider is not initially determined
				  to be an STP, the provider may appeal that determination by sending a written
				  notice to the HHSC, Children's Health Insurance Program, P.O. Box 13247,
				  Austin, Texas 78711-3247, stating that it wishes to appeal the STP
				  determination. HHSC will then notify the provider of the appeal procedure to
				  follow.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter E - PROVIDER REQUIREMENTS › Section 370.453 - Balance Billing

Current through Reg. 49, No. 28; July 12, 2024
(a) A provider may
				  only seek reimbursement from a CHIP managed care organization for a covered
				  service provided to a CHIP member. A provider may not seek reimbursement or
				  attempt to obtain payment from a CHIP member, the CHIP member's family, or the
				  CHIP member's guardian for a covered service.
(b) The provisions of subsection (a) of this
				  section apply to all covered services provided to a CHIP member, including
				  emergency services provided by an out-of-network provider, in compliance with
				  federal regulations (RSA
				  457.515(f)).
(c) The provisions of subsection (a) of this
				  section do not apply to:
(1) co-payment
				  authorized under Subchapter C, Division 2 of this title (relating to
				  Cost-Sharing Requirements);
(2) a
				  covered service of CHIP with a capped benefit level, once the CHIP member
				  exceeds the benefit cap; or
(3)
				  services that are not covered services under CHIP.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter E - PROVIDER REQUIREMENTS › Section 370.454 - Experience Rebate in the Children's Health Insurance Program

Current through Reg. 49, No. 28; July 12, 2024
Each MCO participating in CHIP must pay to the State an
					 experience rebate calculated according to the graduated rebate method described
					 in the MCO's contract with HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter E - PROVIDER REQUIREMENTS › Section 370.455 - Provider Complaints and Appeals Processes

Current through Reg. 49, No. 28; July 12, 2024
Provider complaints and claims payment appeals are subject
					 to disposition consistent with the Texas Insurance Code and any applicable
					 Texas Department of Insurance (TDI) regulations. Providers may report alleged
					 violations to TDI.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 370.501 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter implements the Health and
				  Human Services Commission's (HHSC), Office of Inspector General (OIG) authority
				  to approve annually, each managed care organization (MCO) plan to prevent and
				  reduce waste, abuse, and fraud. This authority is granted by Chapter 531,
				  Subchapter C, Government Code, §
										RSA
				  531.113.
(b) An MCO that provides or arranges for the
				  provision of health care services or dental services to an individual under the
				  children's health insurance program (CHIP), must arrange for a special
				  investigative unit to investigate fraudulent claims and other types of program
				  abuse by recipients and providers. An MCO may choose to:
(1) establish and maintain the special
				  investigative unit within the MCO; or
(2) contract with another entity for the
				  investigation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 370.502 - Managed Care Organization's Plans and Responsibilities in Preventing and Reducing Waste, Abuse, and Fraud

Current through Reg. 49, No. 28; July 12, 2024
(a) Each
				  managed care organization (MCO) subject to this section must develop a plan to
				  prevent and reduce waste, abuse, and fraud and submit that plan annually to the
				  Health and Human Services Commission (HHSC), Office of Inspector General (OIG)
				  for approval.
(b) The MCO is
				  responsible for investigating possible acts of waste, abuse, or fraud for all
				  services, including those that the MCO subcontracts to outside
				  entities.
(c) The plan submitted to
				  the HHSC-OIG must include the following information to be considered for
				  approval.
(1) A description of the MCO's
				  procedures for detecting possible acts of waste, abuse, and fraud by providers.
				  The description must address each of the following requirements:
(A) use of audits to monitor compliance and
				  assist in detecting and identifying CHIP program violations and possible waste,
				  abuse, and fraud overpayments through data matching, analysis, trending, and
				  statistical activities;
(B)
				  monitoring of service patterns for providers, subcontractors, and
				  recipients;
(C) use of a hotline or
				  another mechanism to report potential or suspected violations;
(D) use of random payment review of claims
				  submitted by providers for reimbursement to detect potential waste, abuse, or
				  fraud;
(E) use of edits or other
				  evaluation techniques to prevent payment for fraudulent or abusive
				  claims;
(F) use of routine
				  validation of MCO data; and
(G)
				  verification that MCO members actually received services that were
				  billed.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 370.503 - Managed Care Organization's Contracts

Current through Reg. 49, No. 28; July 12, 2024
If a Managed Care Organization (MCO) contracts for the
					 investigation of fraudulent claims and other types of programs abuse by
					 recipients and providers under subsection 370.501(e), within 10 working days of
					 executing the contract the MCO shall file with the Health and Human Services
					 Commission, Office of Inspector General (HHSC-OIG):
(1) A copy of the written contract including
				  any and all attachments.
(2) The
				  names, titles, addresses, telephone numbers, and fax numbers of the principals
				  of the entity with which the MCO has contracted; and
(3) A description of the qualifications of
				  the principals of the entity with which the MCO has contracted to perform the
				  contracted responsibilities.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 370.504 - Review of Managed Care Organization's Records

Current through Reg. 49, No. 28; July 12, 2024
(a) Immediately upon request, the Health and
				  Human Services Commission, Office of Inspector General (HHSC-OIG), Office of
				  the Attorney General-Medicaid Fraud Control Unit (OAG-MFCU) and OAG, Office of
				  the Attorney General-Civil Medicaid Fraud Division (OAG-CMFD), and the United
				  States Health and Human Services, Office of Inspector General (HHS-OIG) may
				  review the records of a managed care organization (MCO) to determine compliance
				  with this subchapter.
(b) Upon
				  receipt of a record review request from any state or federal agency authorized
				  to conduct compliance, regulatory, or program integrity functions, an MCO must:
(1) At no charge to the entities identified
				  in subsection (a) of this section, provide the records requested by a properly
				  identified agent of any state or federal agency authorized to conduct
				  compliance, regulatory, or program integrity functions on the provider, person,
				  MCO, or the services rendered by the provider or person within 24 hours of the
				  request.
(2) An exception to the 24
				  hours stated in paragraph (1) of this subsection may be made when the OIG or
				  another state or federal agency representative reasonably believes that the
				  requested records are about to be altered or destroyed or that the request may
				  be completed at the time of the request and/or in less than 24 hours.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter F - SPECIAL INVESTIGATIVE UNITS › Section 370.505 - Recovery of Funds

Current through Reg. 49, No. 28; July 12, 2024
(a) If a managed
				  care organization (MCO) suspects fraud or abuse in the Medicaid or CHIP
				  program, based on information, data, or facts obtained by the MCO, it must:
(1) immediately notify the Health and Human
				  Services Commission-Office of Inspector General (HHSC-OIG) and the Office of
				  the Attorney General (OAG);
(2)
				  following the completion of ordinary due diligence regarding a suspected
				  overpayment, begin payment recovery efforts subject to subsection (b) of this
				  section; and
(3) ensure that any
				  payment recovery efforts in which the MCO engages are in accordance with this
				  subchapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter G - STANDARDS FOR CHIP MANAGED CARE › Section 370.601 - Applicability of Medicaid Managed Care Standards to CHIP

Current through Reg. 49, No. 28; July 12, 2024
The following requirements of Chapter 353, Subchapter E of
					 this title (relating to Standards for Medicaid Managed Care) apply to CHIP
					 managed care, except that references to Medicaid are replaced with CHIP:
(1) Section 353.405 (relating to
				  Marketing);
(2) Section 353.407
				  (relating to Requirements of Managed Care Plans);
(3) Section 353.409 (relating to Scope of
				  Services);
(4) Section 353.411
				  (relating to Accessibility of Services);
(5) Section 353.417 (relating to Quality
				  Assessment and Performance Improvement); and
(6) Section 353.419 (relating to Financial
				  Standards).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter G - STANDARDS FOR CHIP MANAGED CARE › Section 370.602 - Member Complaints and Appeals

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  CHIP member complaints and appeals are subject to disposition consistent with
				  applicable federal and state laws, regulations and rules, including the Texas
				  Insurance Code and Texas Department of Insurance (TDI) regulations.
(b) Any member, or a representative acting on
				  behalf of the member, may file a complaint or appeal with their managed care
				  organization (MCO) through the MCO's internal appeal and complaint
				  system.
(c) Any person, including
				  those dissatisfied with the MCO's resolution of a member complaint or appeal,
				  may submit a complaint to report an alleged violation to TDI.
(d) Any member or a representative acting on
				  behalf of the member may request an external review of the MCO's adverse
				  benefit determination, to be conducted by an independent review organization,
				  when:
(1) the MCO internal appeal and
				  complaint system regarding the adverse benefit determination has been
				  exhausted; and
(2) the member or
				  representative acting on behalf of the member is dissatisfied with the MCO's
				  resolution of the appeal of an adverse benefit determination.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter G - STANDARDS FOR CHIP MANAGED CARE › Section 370.604 - Managed Care Organization Requirements Concerning Out-of-Network Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) Network
				  adequacy. Each MCO participating in CHIP must offer a network of providers that
				  is sufficient to meet the needs of CHIP members enrolled in the MCO. HHSC uses
				  reports from the MCOs and complaints received from providers and members to
				  monitor MCO members' access to an adequate provider network. Subsection (c) of
				  this section describes the reporting requirements with which an MCO must
				  comply.
(b) MCO requirements
				  concerning treatment of members by out-of-network providers.
(1) An MCO must allow a provider to submit a
				  referral of its member(s) to an out-of-network provider, must timely issue the
				  proper authorization for such referral consistent with managed care contract
				  requirements for authorization of medically necessary services, and must
				  reimburse the out-of-network provider for authorized services provided in
				  accordance with statutory and contractual timeframes when:
(A) CHIP covered services are medically
				  necessary, as described in section
				  RSA
				  370.4(49) of
				  this chapter (relating to Definitions), and these services are not available
				  through an in-network provider;
(B)
				  a provider currently providing authorized services to the member requests
				  authorization for such services to be provided to the member by an
				  out-of-network provider; and
(C)
				  the authorized services are provided within the time period specified in the
				  MCO's authorization. If the services are not provided within the required time
				  period, the requesting provider must submit a new referral request to the MCO
				  prior to the provision of services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter H - OUTPATIENT PHARMACY SERVICES › Section 370.701 - Applicability of Medicaid Managed Care Standards for Outpatient Pharmacy Services to CHIP

Current through Reg. 49, No. 28; July 12, 2024
Requirements of Chapter 353, Subchapter J of this title
					 (relating to Outpatient Pharmacy Services) apply to the CHIP program, with the
					 following exceptions:
(1) references
				  to Medicaid are replaced with CHIP;
(2) the CHIP program does not have a
				  preferred drug list; therefore, requirements relating to the preferred drug
				  list do not apply to the CHIP program; and
(3) Section
				  RSA
				  353.913 of this title (relating to Managed
				  Care Organization Requirements Concerning Out-of-network Outpatient Pharmacy
				  Services) does not apply to the CHIP program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.801 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to establish income
					 eligibility requirements for the State Children's Health Insurance Program
					 (CHIP) in accordance with §2102(b) of the Social Security Act
					 (RSA
					 1397bb(b)).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.803 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
In this subchapter, words and terms have the following
					 meanings, unless the context clearly indicates otherwise:
(1) Applicant--An individual who applies for
				  health and dental care coverage on behalf of the child. An applicant can only
				  be:
(A) a child's parent, whether biological
				  or adoptive;
(B) a child's
				  grandparent, relative, or other adult who provides care for the
				  child;
(C) a minor not living with
				  an adult applying for himself/herself;
(D) a child's step-parent; or
(E) a taxpayer who expects to claim the child
				  on a federal income tax return for the taxable year in which CHIP eligibility
				  is requested.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.805 - Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC determines income eligibility for
				  CHIP by:
(1) determining the applicant's or
				  recipient's household composition in accordance with §
											RSA
				  370.807 of this subchapter (relating to
				  Determination of Household Composition);
(2) calculating the individual income of each
				  person in the applicant's or recipient's household composition in accordance
				  with §
											RSA
				  370.809 of this subchapter (relating to
				  Calculation of Individual Income);
(3) determining if the individual income of
				  each individual in the applicant's or recipient's household composition is
				  included in the calculation of household income in accordance with §
											RSA
				  370.811 of this subchapter (relating to
				  Determination Regarding Including an Individual's Income in the Household
				  Income); and
(4) calculating the
				  applicant's or recipient's household income in accordance with §
											RSA
				  370.813 of this subchapter (relating to
				  Calculation of Household Income).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.807 - Determination of Household Composition

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  To determine household composition, an individual is designated as:
(1) a taxpayer;
(2) a tax dependent who does not meet any
				  exceptions;
(3) a tax dependent who
				  meets one or more of the exceptions; or
(4) not a taxpayer or tax
				  dependent.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.809 - Calculation of Individual Income

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  calculates individual income in accordance with Internal Revenue Code
				  §36B(d)(2)(B), with adjustments for lump sum payments, certain income of
				  American Indians/Alaskan Natives, and scholarships, awards, and fellowship
				  grants used for education purposes.
(b) Assets tests do not apply to groups
				  subject to the provisions of this subchapter. HHSC may collect information on
				  assets and resources from Medicaid program applicants and recipients during the
				  eligibility determination process.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.811 - Determination Regarding Inclusion of Individual Income in the Household Income

Current through Reg. 49, No. 28; July 12, 2024
(a) Individual
				  income is counted as part of the household income unless:
(1) the individual is a child who is included
				  in the household composition of a parent and is not required to file a federal
				  income tax return for the taxable year in which CHIP eligibility is requested;
				  or
(2) the individual is a tax
				  dependent and is not required to file a federal income tax return for the
				  taxable year in which CHIP eligibility is requested.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.813 - Calculation of Household Income

Current through Reg. 49, No. 28; July 12, 2024
For each applicant, the household income is:
(1) the sum of the individual income for each
				  individual in the applicant's household composition as defined in §
										RSA
				  370.809 of this subchapter (relating to
				  Calculation of Individual Income) and §
										RSA
				  370.811 of this subchapter (relating to
				  Determination Regarding Inclusion of Individual Income in the Household
				  Income); and
(2) less a standard
				  income disregard equal to five percentage points of the Federal Poverty Level
				  (FPL) for the applicable household size, as permitted by
				  RSA
				  435.603(d)(4).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 370 - STATE CHILDREN'S HEALTH INSURANCE PROGRAM › Subchapter I - MODIFIED ADJUSTED GROSS INCOME METHODOLOGY › Section 370.815 - Modification

Current through Reg. 49, No. 28; July 12, 2024
HHSC may modify or implement additional income eligibility
					 policies developed pursuant to this subchapter consistent with State and
					 Federal laws.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.1 - 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) Abuse--A practice by a
				  provider that is inconsistent with sound fiscal, business, or medical practices
				  and that results in an unnecessary cost to the Medicaid program; the
				  reimbursement for services that are not medically necessary or that fail to
				  meet professionally recognized standards for health care; or a practice by a
				  recipient that results in an unnecessary cost to the Medicaid
				  program.
(2) Address of record--
(A) an HHS provider's current mailing or
				  physical address, including a working fax number, as provided to the
				  appropriate HHS program's claims administrator or as required by contract,
				  statute, or regulation; or
(B) a
				  non-HHS provider's last known address as reflected by the records of the United
				  States Postal Service or the Texas Secretary of State's records for business
				  organizations, if applicable.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.3 - Purpose and Authority

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG is
				  responsible for preventing, detecting, auditing, inspecting, reviewing, and
				  investigating fraud, waste, and abuse in Medicaid and other HHS programs. In
				  addition, the OIG is responsible for enforcing state law relating to the
				  provision of HHS in Medicaid and other HHS programs.
(b) The statutory authority for this chapter
				  is provided by Texas Human Resources Code Chapters 32 and 36; Texas Government
				  Code Chapter 531, and federal law (Social Security Act) and regulations (42
				  C.F.R.).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.11 - Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) The OIG is responsible for preventing,
				  detecting, auditing, inspecting, reviewing, and investigating fraud, waste, and
				  abuse in the provision of HHS in Medicaid and other HHS programs. As part of
				  its authority, the OIG may impose sanctions upon a finding by the OIG of fraud,
				  waste, or abuse in Medicaid. The OIG is also responsible for enforcing state
				  law relating to the provision of HHS in Medicaid and other HHS programs. As a
				  result, the OIG may also investigate a suspected regulatory violation in a
				  non-Medicaid, HHS program and, upon a finding of a violation, may recommend the
				  HHS program take appropriate enforcement action to the extent of the HHS
				  program's regulatory authority. The OIG administers program integrity and
				  enforces program violations to the extent of applicable law governing Medicaid
				  and the provision of other HHS. This includes pursuing Medicaid and other HHS
				  fraud, abuse, overpayment, or waste. To accomplish the objectives of this
				  chapter, the OIG implements review processes to distinguish payment
				  discrepancies that can be corrected through routine payment adjustments from
				  those suspected to result from program violations requiring investigation and
				  possible administrative enforcement or judicial action.
(b) The Inspector General establishes
				  objectives and priorities for the OIG that emphasize:
(1) coordinating investigative efforts to
				  aggressively recover funds;
(2)
				  allocating resources to cases that have the strongest supportive evidence and
				  the greatest potential for recovery of money; and
(3) maximizing opportunities for referral of
				  cases to the OAG.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.17 - Detection

Current through Reg. 49, No. 28; July 12, 2024
The OIG utilizes automation as well as other techniques to
					 detect and identify program violations and possible fraud, waste, abuse, and
					 overpayments. These automated detection systems are mandated by state and
					 federal statutes. One automated system is additionally required to utilize
					 neural network and learning technologies. These systems detect patterns of
					 inappropriate billing from which an overpayment is identified immediately
					 without the need for additional investigation. They also detect anomalous
					 billing and service patterns, which then require investigation for evidence of
					 program violations.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.25 - Injunction to Prevent Disposing of Assets and Application to Debts

Current through Reg. 49, No. 28; July 12, 2024
Based on the results of investigative findings and evidence
					 that potential fraud, waste, or abuse exists and a potential overpayment,
					 penalty, or damage has been identified, a method that may be used by the OIG,
					 as a fiduciary for the state, is injunctive relief. The purpose of the
					 injunctive relief is to ensure assets remain to reimburse the state monies owed
					 such as recoupment of overpayments and assessed damages and penalties. The OIG
					 may request that the Attorney General obtain an injunction to prevent a
					 provider or person from disposing of an asset identified by the OIG as
					 potentially subject to recovery by the OIG due to the provider's or person's
					 fraud, waste, or abuse. Upon final resolution of the case, any funds derived
					 from the forfeited asset(s), after offsetting any expenses attributable to the
					 sale of those assets, are applied to the unpaid debt by the OIG
					 .
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.27 - Prohibition against Solicitation of Medicaid or CHIP Recipients

Current through Reg. 49, No. 28; July 12, 2024
(a) A provider or person who furnishes
				  services, under the Medicaid program or Child Health Insurance Plan program,
				  must comply with Chapter 102, Texas Occupations Code.
(b) A provider or person is prohibited from
				  offering to pay or agreeing to accept, directly or indirectly, overtly or
				  covertly, any remuneration in cash or in kind to or from another for securing
				  or soliciting a patient or patronage for or from a person licensed, certified,
				  or registered or enrolled as a provider or otherwise by a state health care
				  regulatory or HHS agency.
(c) A
				  provider or person is prohibited from engaging in any of the actions or conduct
				  described in the provisions relating to bribe, kickback, rebate, or inducement
				  specified in §
										RSA 371.1669 of this
				  chapter (relating to Self-Dealing) .
(d) Providers or persons in violation of the
				  prohibition against solicitation may be excluded from participation in the
				  Medicaid and CHIP programs and may have their contract to participate
				  cancelled.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.29 - Random Prepayment Review

Current through Reg. 49, No. 28; July 12, 2024
The OIG may perform a random prepayment review of claims
					 submitted by Medicaid providers for reimbursement to determine whether the
					 claim involves fraud, waste, or abuse. Suspect claims identified through this
					 process may result in:
(1) imposition
				  of a recoupment of overpayments and/or other pertinent administrative sanctions
				  or actions;
(2) initiation of a
				  full fraud, waste, or abuse investigation;
(3) referral for criminal or civil
				  investigation and prosecution;
(4)
				  withholding payment of these claims for not more than five working days without
				  notice to the provider for which claims were submitted.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.31 - Federal Felony Match

Current through Reg. 49, No. 28; July 12, 2024
The OIG has a system to cross-reference data collected for
					 the programs identified in §
										RSA
					 531.008(c) of
					 the Texas Government Code with the list of fugitive felons maintained by the
					 federal government. The purpose of the data match is to identify fugitive
					 felons who may be enrolled as recipients in programs that are referenced in
					 §
										RSA
					 531.008(c) of
					 the Texas Government Code.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.33 - On-Site Reviews of Prospective Providers

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The Inspector General may implement procedures targeted at minimizing the
				  potential for fraud, abuse, false statements, misrepresentations, and omissions
				  by prospective Medicaid and other HHS providers. The Inspector General may
				  conduct on-site reviews of providers who have applied to provide services to
				  recipients.
(b) On-Site Review
				  Criteria and Effect.
(1) During its on-site
				  review, the Inspector General will determine whether or not an applicant has
				  the ability to provide the services proposed within its application. To make
				  this determination, personnel will conduct the inspections and interviews set
				  forth in subsection (c) of this section (relating to Scope of Review), and
				  evaluate information gathered thereby within the context of applicable industry
				  standards, including state or federal governmental licensing and/or
				  certification standards that apply to the applicant under review.
(2) In the event an on-site review reveals
				  that a provider is not capable of delivering the services proposed within its
				  application or develops other evidence of fraud, abuse, false statements,
				  misrepresentations, or omissions, the application may be denied. The Inspector
				  General also may forward to the Attorney General or other appropriate law
				  enforcement agency any information discovered during an on-site review that the
				  Inspector General believes warrants further evaluation in a law enforcement
				  context.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY › Subchapter B - OFFICE OF INSPECTOR GENERAL › Section 371.35 - Use of Statistical Sampling and Extrapolation

Current through Reg. 49, No. 28; July 12, 2024
(a) When the OIG is determining the amount of
				  a recoupment due because of an overpayment, and a review of all items in the
				  population where the suspected overpayment has occurred is not practical or
				  reasonable, the OIG uses statistical sampling and extrapolation to estimate the
				  amount of the recoupment.
(b) When
				  using statistical sampling and extrapolation, the OIG:
(1) uses the RAT-STATS software available
				  from the Office of Inspector General for the United States Department of Health
				  and Human Services for purposes of selecting the sample and calculating the
				  overpayment estimate; and
(2)
				  adopts and follows policies and procedures that are consistent with the
				  mathematical processes for sampling and overpayment estimation as described by
				  CMS's Medicare Program Integrity Manual.