reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter M - HOME AND COMMUNITY BASED SERVICES IN MANAGED CARE › Section 353.1153 - STAR+PLUS Home and Community Based Services (HCBS) Program

Current through Reg. 49, No. 28; July 12, 2024
(a) The MCO assesses an individual's
				  eligibility for STAR+PLUS HCBS.
(1) To be
				  eligible for the STAR+PLUS HCBS program, an individual must:
(A) be 21 years of age or older;
(B) reside in Texas;
(C) meet the level-of-care criteria for
				  medical necessity for nursing facility care as determined by HHSC;
(D) have an unmet need for support in the
				  community that can be met through one or more of the STAR+PLUS HCBS program
				  services;
(E) choose the STAR+PLUS
				  HCBS program as an alternative to nursing facility services, as described in
				  RSA
				  441.302(d);
(F) not be enrolled in another Medicaid HCBS
				  waiver program approved by CMS; and
(G) be determined by HHSC to be financially
				  eligible for Medicaid, as described in Chapter 358 of this title (relating to
				  Medicaid Eligibility for the Elderly and People with Disabilities) and Chapter
				  360 of this title (relating to Medicaid Buy-In Program).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter M - HOME AND COMMUNITY BASED SERVICES IN MANAGED CARE › Section 353.1155 - Medically Dependent Children Program

Current through Reg. 49, No. 28; July 12, 2024
(a) An MCO assesses an individual's
				  eligibility for MDCP.
(1) To be eligible for
				  MDCP, an individual must:
(A) be under 21
				  years of age;
(B) reside in
				  Texas;
(C) meet the level of care
				  criteria for medical necessity for nursing facility care as determined by
				  HHSC;
(D) have an unmet need for
				  support in the community that can be met through one or more MDCP
				  services;
(E) choose MDCP as an
				  alternative to nursing facility services, as described in
				  RSA
				  441.302(d);
(F) not be enrolled in one of the following
				  Medicaid HCBS waiver programs approved by CMS:
(i) the Community Living Assistance and
				  Support Services (CLASS) Program;
(ii) the Deaf Blind with Multiple
				  Disabilities (DBMD) Program;
(iii)
				  the Home and Community-based Services (HCS) Program;
(iv) the Texas Home Living (TxHmL) Program;
				  or
(v) the Youth Empowerment
				  Services waiver;
(G)
				  live in:
(i) the individual's home;
				  or
(ii) an agency foster home as
				  defined in Texas Human Resource Code, §42.002, (relating to Definitions);
				  and
(H) be determined by
				  HHSC to be financially eligible for Medicaid under Chapter 358 of this title
				  (relating to Medicaid Eligibility for the Elderly and People with
				  Disabilities), Chapter 360 of this title (relating to Medicaid Buy-In Program),
				  or Chapter 361 of this title (relating to Medicaid Buy-In for Children
				  Program).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter N - STAR KIDS › Section 353.1201 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  administers the STAR Kids program.
(b) The following subchapters of this chapter
				  apply to the STAR Kids program:
(1)
				  Subchapter A (relating to General Provisions);
(2) Subchapter B (relating to Provider and
				  Member Education Programs);
(3)
				  Subchapter C (relating to Member Bill of Rights and
				  Responsibilities);
(4) Subchapter E
				  (relating to Standards for Medicaid Managed Care);
(5) Subchapter F (relating to Special
				  Investigative Units); and
(6)
				  Subchapter J (relating to Outpatient Pharmacy Services).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter N - STAR KIDS › Section 353.1203 - Member Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) Except as
				  provided in subsection (b) of this section, enrollment in the STAR Kids program
				  is
mandatory
for a Medicaid client who is younger than 21
				  years of age and meets one or both of the following criteria:
(1) has a physical or mental disability and
				  qualifies for Supplemental Security Income (SSI) or SSI-related Medicaid;
				  or
(2) is enrolled in the Medically
				  Dependent Children Program (MDCP) waiver.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter N - STAR KIDS › Section 353.1205 - Service Coordination

Current through Reg. 49, No. 28; July 12, 2024
(a) All STAR Kids
				  members have access to service coordination. Service coordination includes:
(1) face-to-face and telephonic contacts
				  between the member or the LAR and the service coordinator;
(2) development and maintenance of a
				  comprehensive, person-centered individual service plan (ISP);
(3) coordination to assist the member in
				  accessing services provided by the STAR Kids MCO;
(4) coordination to assist the member or the
				  LAR in accessing services provided by other community entities or service
				  providers; and
(5) transition
				  planning, beginning no later than age 15, to help the member prepare for
				  changes in life circumstances and changes in available healthcare services to
				  ease the shift to adulthood.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter N - STAR KIDS › Section 353.1207 - Participating Providers

Current through Reg. 49, No. 28; July 12, 2024
Acute and long-term services and supports providers have
					 the opportunity to participate in STAR Kids, provided they:
(1) comply with the applicable provisions of
				  this chapter;
(2) comply with
				  Chapter 352 of this title (relating to Medicaid and Children's Health Insurance
				  Program Provider Enrollment);
(3)
				  meet applicable licensing standards;
(4) meet the MCO's credentialing standards;
				  and
(5) contract with the
				  MCO.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter N - STAR KIDS › Section 353.1209 - STAR Kids Handbook

Current through Reg. 49, No. 28; July 12, 2024
The STAR Kids Handbook includes policies and procedures to
					 be used by all health and human services agencies and their contractors and
					 providers in the delivery of STAR Kids Program services to eligible members.
					 The STAR Kids Handbook can be found on the Texas Health and Human Services
					 Commission website.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1302 - Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  This section establishes the Quality Incentive Payment Program (QIPP) for
				  nursing facilities (NFs) providing services under Medicaid managed care on or
				  after September 1, 2019. QIPP is designed to incentivize NFs to improve quality
				  and innovation in the provision of NF services to Medicaid recipients through
				  the use of metrics that are expected to advance at least one of the goals and
				  objectives of the state's quality strategy.
(b) Definitions. The following definitions
				  apply when the terms are used in this section. Terms that are used in this and
				  other sections of this subchapter may be defined in §353.1301 (relating to
				  General Provisions) or §353.1304 (relating to Quality Metrics for the
				  Quality Incentive Payment Program for Nursing Facilities on or after September
				  1, 2019) of this subchapter.
(1) CHOW
				  application--An application filed with HHSC for a NF change of ownership
				  (CHOW).
(2) Program period--A
				  period of time for which an eligible and enrolled NF may receive the QIPP
				  amounts described in this section. Each QIPP program period is equal to a state
				  fiscal year (FY) beginning September 1 and ending August 31 of the following
				  year.
(3) Network nursing
				  facility--A NF located in the state of Texas that has a contract with a Managed
				  Care Organization (MCO) for the delivery of Medicaid covered benefits to the
				  MCO's enrollees.
(4) Non-state
				  government-owned NF--A network nursing facility where a non-state governmental
				  entity located in the state of Texas holds the license and is a party to the
				  NF's Medicaid provider enrollment agreement with the state.
(5) Private NF--A network nursing facility
				  not owned by a governmental entity located in the state of Texas, and holds a
				  license.
(6) Regional Healthcare
				  Partnership (RHP)--A collaboration of interested participants that work
				  collectively to develop and submit to the state a regional plan for health care
				  delivery system reform as defined and established under Chapter 354, Subchapter
				  D, of this title (relating to Texas Healthcare Transformation and Quality
				  Improvement Program).
(7) Runout
				  period--A period of 23 months following the end of the program period during
				  which the MCO may make adjustments to the MCO member
				  months.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1304 - Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Introduction. This section establishes the quality metrics that may be used in
				  the Quality Incentive Payment Program (QIPP) for nursing facilities (NFs) on or
				  after September 1, 2019.
(b)
				  Definitions. The following definitions apply when the terms are used in this
				  section. Terms that are used in this and other sections of this subchapter may
				  be defined in §353.1301 (relating to General Provisions) or §353.1302
				  (relating to Quality Incentive Payment Program for Nursing Facilities on or
				  after September 1, 2019) of this subchapter.
(1) Baseline--A NF-specific initial standard
				  used as a comparison against NF performance in each metric throughout the
				  program period to determine progress in the QIPP quality metrics.
(2) Benchmark--A metric-specific initial
				  standard set prior to the start of the program period and used as a comparison
				  against a NF's progress throughout the program period.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1307 - Quality Metrics for the Comprehensive Hospital Increase Reimbursement Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  This section establishes the quality metrics for the Comprehensive Hospital
				  Increase Reimbursement Program (CHIRP).
(b) Definitions. Terms that are used in this
				  and other sections of this subchapter may be defined in §
										353.1301 of this subchapter
				  (relating to General Provisions) or §
										353.1306 of this subchapter
				  (relating to the Comprehensive Hospital Increase Reimbursement Program for
				  program periods on or after September 1, 2021).
(c) Quality metrics. For each program period,
				  HHSC will designate one or more quality metrics for each CHIRP capitation rate
				  component as described in §
										353.1306(g) of
				  this subchapter. Any quality metric included in CHIRP will be evidence-based
				  and will be identified as a structure, process, or outcome measure. HHSC may
				  modify quality metrics from one program period to the next. The proposed
				  quality metrics for a program period will be presented to the public for
				  comment in accordance with subsection (g) of this section.
(d) Performance requirements. For each
				  program period, HHSC will specify the performance requirements associated with
				  designated quality metrics. The proposed performance requirements for a program
				  period will be presented to the public for comment in accordance with
				  subsection (g) of this section. Achievement of performance requirements will
				  trigger payments as described in §
										353.1306 of this
				  subchapter.
(e) Quality metrics and
				  program evaluation. HHSC will use reported performance of quality metrics to
				  evaluate the degree to which the arrangement advances at least one of the goals
				  and objectives that are incentivized by the payments described under §
										353.1306(g) of
				  this subchapter.
(1) All quality metrics for
				  which a hospital is eligible based on class must be reported by the
				  participating hospital as a condition of participation.
(2) Participating hospitals must stratify any
				  reported data by payor type and must report data according to requirements
				  published under subsection (h) of this section.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1311 - Quality Metrics for the Texas Incentives for Physicians and Professional Services Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  This section establishes the quality metrics that may be used in the Texas
				  Incentives for Physician and Professional Services (TIPPS) program.
(b) Definitions. Terms that are used in this
				  section may be defined in §
										RSA 353.1301
				  of this subchapter (relating to General Provisions) or § 353.1309 of this
				  subchapter (relating to the Texas Incentives for Physicians and Professional
				  Services).
(c) Quality metrics. For
				  each program period, HHSC will designate one or more metrics for each TIPPS
				  capitation rate component.
(1) Each quality
				  metric will be identified as a structure measure, improvement over self (IOS)
				  measure, or benchmark measure.
(2)
				  Any metric developed for inclusion in TIPPS will be evidence-based.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1315 - Rural Access to Primary and Preventive Services Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. This section establishes
				  the Rural Access to Primary and Preventive Services (RAPPS) program. RAPPS is
				  designed to incentivize rural health clinics (RHCs) to improve quality, access,
				  and innovation in the provision of medical services to Medicaid recipients
				  through the use of metrics that are expected to advance at least one of the
				  goals and objectives of the state's managed care quality strategy.
(b) Definitions. The following definitions
				  apply when the terms are used in this section. Other terms used in this section
				  may be defined in §
										353.1301 of this subchapter
				  (relating to General Provisions) or §
										353.1317 of this subchapter
				  (relating to Quality Metrics for Rural Access to Primary and Preventive
				  Services Program).
(1) Freestanding rural
				  health clinic (RHC)--A network RHC that is not affiliated with a
				  hospital.
(2) Hospital-based RHC--A
				  network RHC that is affiliated with a hospital.
(3) Intergovernmental transfer (IGT)
				  notification--Notice and directions regarding how and when IGTs should be made
				  in support of RAPPS.
(4) Network
				  RHC--An RHC located in the state of Texas that has a contract with a managed
				  care organization (MCO) for the delivery of Medicaid-covered services to the
				  MCO's enrollees.
(5) Program
				  period--A period of time for which the Texas Health and Human Services
				  Commission (HHSC) contracts with MCOs to pay increased capitation rates for the
				  purpose of making RHC payments under this section. Each program period is equal
				  to a state fiscal year beginning September 1 and ending August 31 of the
				  following year.
(6) Rural health
				  clinic (RHC)--Has the meaning assigned by
				  42 U.S.C. §
												1396d(l)(1).
(7) Suggested IGT responsibility--Notice of
				  potential amounts that a sponsoring governmental entity may wish to consider
				  transferring in support of RAPPS.
(8) Total program value--The maximum amount
				  available under the RAPPS program for a program period, as determined by
				  HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1317 - Quality Metrics for Rural Access to Primary and Preventive Services Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  This section establishes the quality metrics that may be used in the Rural
				  Access to Primary and Preventive Services (RAPPS) program.
(b) Definitions. The following definitions
				  apply when the terms are used in this section. Other terms used in this section
				  may be defined in §
										RSA 353.1301
				  of this subchapter (relating to General Provisions) or § 353.1315 of this
				  subchapter (relating to Rural Access to Primary and Preventive Services
				  Program).
(1) Baseline--An initial standard
				  used as a comparison against performance in each metric throughout the program
				  period to determine progress in a RAPPS quality metric.
(2) Benchmark--A metric-specific initial
				  standard set prior to the start of the program period and used as a comparison
				  against a rural health clinic's (RHC's) progress throughout the program
				  period.
(3) Measurement period--The
				  time period used to measure achievement of a quality metric.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1322 - Quality Metrics for the Directed Payment Program for Behavioral Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  This section establishes the quality metrics and required reporting that may be
				  used in the Directed Payment Program for Behavioral Health Services.
(b) Definitions. The following definitions
				  apply when the terms are used in this section. Terms that are used in this
				  section may be defined in §353.1301 (relating to General Provisions) or
				  § 353.1320(relating to Directed Payment Program for Behavioral Health
				  Services) of this subchapter.
(1)
				  Baseline--An initial standard used as a comparison against performance in each
				  metric throughout the program period to determine progress in the program's
				  quality metrics.
(2) Benchmark--A
				  metric-specific initial standard set prior to the start of the program period
				  and used as a comparison against a provider's progress throughout the program
				  period.
(3) Measurement period--The
				  time period used to measure achievement of a quality metric.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1401 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this subchapter is to
				  establish requirements for providing mental health targeted case management and
				  mental health rehabilitative services through Medicaid managed care. This
				  subchapter applies to managed care organizations and public and private
				  comprehensive provider agencies of mental health targeted case management and
				  mental health rehabilitative services.
(b) Managed care organizations and public and
				  private comprehensive provider agencies providing mental health targeted case
				  management and mental health rehabilitative services under this subchapter must
				  meet the applicable requirements outlined in Chapter 354, Subchapter M, of this
				  title (relating to Mental Health Targeted Case Management and Mental Health
				  Rehabilitation).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1405 - Managed Care Organization Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a) A managed care organization (MCO) must
				  ensure that each contracted comprehensive provider agency meets the
				  requirements established in this subchapter.
(b) An MCO must develop policies, procedures,
				  and contract requirements to ensure that contracted comprehensive provider
				  agencies adhere to the requirements in this subchapter.
(c) An MCO must not approve or contract with
				  a comprehensive provider agency as a provider of mental health targeted case
				  management and mental health rehabilitative services unless the comprehensive
				  provider agency:
(1) is enrolled as a Texas
				  Medicaid provider in accordance with §
											RSA 352.7
				  of this title (related to Applying for Enrollment);
(2) attests in the credentialing application
				  to the MCO and agrees in the contract to comply with applicable state and
				  federal regulations, rules, policies, and procedures relating to mental health
				  targeted case management and mental health rehabilitative services;
(3) agrees to comply with applicable state
				  and federal laws governing participation of providers in the Medicaid
				  program;
(4) agrees to submit
				  accurate and complete cost reports in accordance with applicable HHSC
				  requirements;
(5) is not listed on
				  the HHSC Inspector General's Excluded Individuals/Entities Listing;
(6) provides or subcontracts for the full
				  array of mental health targeted case management and mental health
				  rehabilitative services listed in Chapter 354, Subchapter M, of this title
				  (relating to Mental Health Targeted Case Management and Mental Health
				  Rehabilitation), with the exception of § 354.2715 of this title (relating
				  to Day Programs for Acute Needs (DPAN)); and
(7) has staff that are credentialed in
				  accordance with § 353.1415 of this subchapter (relating to Staff Member
				  Credentialing).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1407 - Information Systems and Medical Records Systems

Current through Reg. 49, No. 28; July 12, 2024
(a) Management information system. Managed
				  care organizations (MCOs) and comprehensive provider agencies must ensure their
				  management information systems provide timely, accurate, and accessible
				  information that supports clinical, administrative, and fiscal
				  decision-making.
(b) Maintenance of
				  medical records. MCOs and comprehensive provider agencies must ensure:
(1) protection against unauthorized access,
				  disclosure, modification, or destruction of medical records, whether accidental
				  or deliberate;
(2) the
				  availability, integrity, utility, authenticity, and confidentiality of
				  information within the medical record;
(3) a current, organized, legible, and
				  comprehensive records system that:
(A)
				  conforms to good professional practice;
(B) permits effective clinical review and
				  audit; and
(C) facilitates prompt
				  and systematic retrieval of information;
(4) a medical records system with sufficient
				  redundancy to ensure access to individual records; and
(5) a medical records system that ensures
				  compliance with applicable federal and state laws, rules, and regulations,
				  including the Health Insurance Portability and Accountability Act and 42 CFR
				  Part 2.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1409 - Patient Safety, Rights, and Protections

Current through Reg. 49, No. 28; July 12, 2024
(a) Each comprehensive provider agency and
				  staff member must adhere to the following rules regarding patient safety,
				  rights, and protections even if the comprehensive provider agency is not a type
				  of entity specified in the rule:
(1) 25 TAC
				  §
											RSA
				  404.154(relating to Rights of All Persons
				  Receiving Mental Health Services);
(2) 25 TAC §
											RSA
				  404.165(relating to Staff Member Training in
				  Rights of All Persons Receiving Mental Health Services);
(3) 25 TAC §
											RSA
				  412.312(relating to Environment of Care and
				  Safety);
(4) 25 TAC §
											RSA
				  412.313(relating to Rights and
				  Protection);
(5) 25 TAC §
											RSA
				  412.315(relating to Medical Records
				  System);
(6) 25 TAC Chapter 415
				  (relating to Provider Clinical Responsibilities--Mental Health Services),
				  Subchapter F (relating to Interventions in Mental Health Services);
				  and
(7) 40 TAC §
											RSA
				  711.201(relating to What is Your Duty to
				  Report If You Are a Direct Provider or Service Provider?).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1411 - Access to Mental Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Telephone system access. A comprehensive
				  provider agency must ensure the availability of a telephone system that allows
				  individuals to contact the comprehensive provider agency through a toll-free
				  number that must:
(1) be answered by a person
				  without being answered by telephone answering equipment at least on business
				  days during normal business hours, except:
(A) on national holidays;
(B) due to uncontrollable interruption of
				  service; or
(C) with prior approval
				  of HHSC;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1413 - Staff Member Competency

Current through Reg. 49, No. 28; July 12, 2024
(a) Prior
				  to providing services or accessing an individual's confidential information,
				  the comprehensive provider agency must ensure that each staff member:
(1) can provide services within the scope of
				  the staff member's license, job description, or contract
				  specification;
(2) has completed
				  required training modules as identified by HHSC; and
(3) has the following minimum competencies:
(A) an understanding of the nature of severe
				  mental illness and serious emotional disturbances;
(B) an understanding of the developmental
				  needs of an adult, child, or youth;
(C) the ability to interact appropriately
				  with an individual who has a physical disability;
(D) the ability to respond to an individual's
				  linguistic and cultural needs through knowledge of customs, beliefs, and values
				  of various, racial, ethnic, religious, and social groups;
(E) identification of an individual
				  experiencing a crisis and the process for accessing crisis services;
(F) knowledge of appropriate actions to take
				  in managing a crisis;
(G) knowledge
				  of available resources within the local community;
(H) an understanding of the dignity and
				  rights of an individual, as described in 25 TAC §
												RSA
				  404.154(relating to Rights of All Persons
				  Receiving Mental Health Services) and 25 TAC §
												RSA
				  404.163(relating to Communication of Rights
				  to Individuals Receiving Mental Health Services);
(I) the ability to identify, prevent, and
				  report abuse, neglect, and exploitation, in accordance with 40 TAC Chapter 705
				  (relating to Adult Protective Services) and Chapter 711 (relating to
				  Investigations of Individuals Receiving Services from Certain
				  Providers);
(J) knowledge of
				  individual confidentiality and relevant state and federal laws affecting
				  confidentiality of medical records, including Title 42 CFR Part 2;
(K) knowledge of professional ethics and
				  standards of conduct;
(L) knowledge
				  of proper documentation of services provided;
(M) understanding exposure control of blood
				  borne pathogens; and
(N) the
				  ability to respond to severe weather, disasters, and bioterrorism.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1415 - Staff Member Credentialing

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Qualified Mental Health Professional-Community Services (QMHP-CS). A staff
				  member must meet at least one of three minimum requirements to be credentialed
				  as a QMHP-CS:
(1) The staff member has at
				  least a bachelor's degree from an accredited college or university and a
				  minimum number of hours that is equivalent to a major in psychology, social
				  work, medicine, nursing, rehabilitation, counseling, sociology, human growth
				  and development, physician assistant, gerontology, special education,
				  educational psychology, early childhood education, or early childhood
				  intervention.
(2) The staff member
				  is a registered nurse.
(3) The
				  staff member is a Licensed Practitioner of the Healing Arts
				  (LPHA).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1417 - Comprehensive Provider Agency Requirements for Staff Member Credentialing and Appeals

Current through Reg. 49, No. 28; July 12, 2024
(a) A comprehensive
				  provider agency must:
(1) justify in writing
				  and document in a staff member's personnel file support of the staff member's
				  qualifications to provide mental health targeted case management and mental
				  health rehabilitative services based on credentialing requirements listed in
				  §353.1415 of this division (relating to Staff Member Credentialing);
				  and
(2) regularly monitor each
				  staff member's demonstrated competency throughout the staff member's
				  tenure.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter P - MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION › Section 353.1419 - Supervision Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Policies
				  and procedures. The comprehensive provider agency must develop and implement
				  written policies and procedures for supervision of all applicable levels of
				  staff members providing services to individuals.
(b) Licensed staff member supervision. All
				  licensed staff members must be supervised in accordance with applicable law and
				  rules.
(c) Clinical supervision.
(1) Clinical supervision must be provided by
				  an LPHA or a QMHP-CS.
(2) The
				  supervising LPHA or QMHP-CS must conduct at least monthly documented meetings
				  with each staff member being supervised.
(3) For staff members providing mental health
				  rehabilitative services, the supervising LPHA or QMHP-CS must be an employee of
				  the comprehensive provider agency and conduct a documented observation of the
				  staff member providing mental health rehabilitative services at a frequency
				  determined by the supervisor based on the staff member's skill level.
(4) For staff members providing mental health
				  targeted case management, the supervising QMHP-CS must:
(A) be an employee of the comprehensive
				  provider agency;
(B) demonstrate
				  competency in mental health targeted case management evidenced-based practices;
				  and
(C) demonstrate competencies
				  outlined in § 353.1413 of this subchapter (relating to Staff Member
				  Competency).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter Q - PROCESS TO RECOUP CERTAIN OVERPAYMENTS › Section 353.1451 - Purpose and Authority

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to describe the due
					 process a managed care organization (MCO) must give to recoup an overpayment
					 related to an electronic visit verification visit transaction in accordance
					 with Texas Government Code, §
										RSA
					 531.1135 and the due process an MCO must give
					 to recoup an overpayment related to a determination of fraud or abuse in
					 accordance with Texas Government Code, §
										RSA
					 531.1131.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter Q - PROCESS TO RECOUP CERTAIN OVERPAYMENTS › Section 353.1452 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
(1) Abuse--This term has
				  the meaning set forth in §
										RSA 371.1 of this
				  title (relating to Definitions).
(2) EVV visit transaction--Electronic visit
				  verification visit transaction. This term has the meaning set forth in §
				  354.4003 of this title (relating to Definitions).
(3) FMSA--Financial management services
				  agency. An entity that contracts with a managed care organization to provide
				  financial management services to a consumer directed services employer as
				  described in Title 40, Texas Administrative Code, Chapter 41 (relating to
				  Consumer Directed Services Option).
(4) Fraud--This term has the meaning set
				  forth in §
										RSA 371.1 of this
				  title.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter Q - PROCESS TO RECOUP CERTAIN OVERPAYMENTS › Section 353.1453 - Due Process Procedures to Recoup an Overpayment Related to an EVV Visit Transaction that Is Not Fraud or Abuse and Limitation on Audit Period

Current through Reg. 49, No. 28; July 12, 2024
(a) In an audit of a provider or FMSA
				  conducted by a managed care organization (MCO), the MCO must limit the review
				  of EVV visit transactions to those that occurred during the 24 months prior to
				  the audit.
(b) If, based on an
				  audit or investigation of a provider or FMSA, an MCO identifies a deficiency
				  related to an EVV visit transaction that is not fraud or abuse and the MCO
				  decides to recoup an overpayment because of the deficiency, the MCO must give
				  the provider or FMSA written notice of the MCO's intent to recoup overpayments
				  not later than the 30th day after the date the audit or investigation is
				  completed.
(c) An MCO must include
				  the following in the written notice required by subsection (b) of this section:
(1) a description of the basis for the
				  intended recoupment;
(2) if the
				  basis of the intended recoupment is an EVV visit transaction, the specific EVV
				  visit transaction and associated claim that are the basis of the intended
				  recoupment;
(3) if the basis of the
				  intended recoupment is a missing EVV visit transaction, the claim for which
				  there is no associated EVV visit transaction;
(4) that the MCO must receive a response to
				  the notice from the provider or FMSA no later than the 30th day after the date
				  the provider or FMSA receives the written notice, if the provider or FMSA
				  intends to respond;
(5) the
				  specific number of days allowed to correct and explain the deficiency before
				  the MCO begins any efforts to collect overpayments, which must be no fewer than
				  60 days from the notice date;
(6)
				  the process by which the provider or FMSA should communicate with and send
				  information to the MCO about the EVV visit transactions that are the basis of
				  the intended recoupment;
(7) the
				  provider's or FMSA's option to seek an informal resolution with the MCO of the
				  intended recoupment; and
(8) the
				  MCO's process for the provider or FMSA to appeal the intended
				  recoupment.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter Q - PROCESS TO RECOUP CERTAIN OVERPAYMENTS › Section 353.1454 - Due Process Procedures to Recoup an Overpayment Because of a Discovery of Fraud or Abuse

Current through Reg. 49, No. 28; July 12, 2024
(a) If a managed
				  care organization (MCO) decides to recoup an overpayment from a provider or
				  FMSA because of a discovery of fraud or abuse as permitted by §
										RSA 353.505 of
				  this chapter (relating to Recovery of Funds), the MCO must have due process
				  procedures that include the following:
(1)
				  written notice to the provider or FMSA of the MCO's intent to recoup
				  overpayments that includes the following:
(A)
				  a description of the basis for the intended recoupment;
(B) the specific claims that are the basis of
				  the intendedrecoupment;
(C) the
				  process by which the provider or FMSA should send information to the MCO about
				  claims that are the basis of the intended recoupment;
(D) the provider's or FMSA's option to seek
				  an informal resolution with the MCO of the intended recoupment; and
(E) the MCO's process for the provider or
				  FMSA to appeal the intended recoupment;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter R - TELECOMMUNICATIONS IN MANAGED CARE SERVICE COORDINATION AND ASSESSMENTS › Section 353.1501 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter establishes requirements for the use of
					 telecommunications in Medicaid managed care for service coordination and
					 assessments conducted by managed care organizations (MCOs) contracted with the
					 Texas Health and Human Services Commission. Medicaid MCOs must be fully
					 compliant with the rules contained in this subchapter no later than July 1,
					 2023.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter R - TELECOMMUNICATIONS IN MANAGED CARE SERVICE COORDINATION AND ASSESSMENTS › Section 353.1505 - Additional Requirements for Assessments and Service Coordination in STAR+PLUS and STAR Kids

Current through Reg. 49, No. 28; July 12, 2024
(a) Information
				  technology, including HIPAA-compliant text or email, may supplement
				  audio-visual communication or in-person assessments, but may not be used as the
				  sole means of conducting an assessment or service coordination visit.
(b) When a managed care organization (MCO)
				  conducts an assessment or service coordination visit using telecommunications,
				  the MCO must:
(1) monitor the health care
				  services provided to the recipient for evidence of fraud, waste, and
				  abuse;
(2) determine whether
				  additional social services or supports are needed;
(3) document verbal consent to use
				  telecommunications; and
(4) adhere
				  to HIPAA, including the use of a HIPAA-compliant audio-visual communication
				  product.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter R - TELECOMMUNICATIONS IN MANAGED CARE SERVICE COORDINATION AND ASSESSMENTS › Section 353.1506 - Additional Requirements for Assessments and Service Management in STAR Health

Current through Reg. 49, No. 28; July 12, 2024
(a) Information
				  technology, including HIPAA-compliant text or email, may supplement
				  audio-visual or in-person assessments, but may not be used as the sole means of
				  conducting an assessment or service management visit.
(b) When a managed care organization (MCO)
				  conducts an assessment or service management visit using telecommunications,
				  the MCO must:
(1) monitor the health care
				  services provided to the recipient for evidence of fraud, waste, and
				  abuse;
(2) determine whether
				  additional social services or supports are needed;
(3) document verbal consent to use
				  telecommunications; and
(4) adhere
				  to HIPAA, including the use of a HIPAA-compliant audio-visual communication
				  product.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 1 - MEDICAID PROCEDURES FOR PROVIDERS › Section 354.1001 - Claim Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Eligible providers are required to provide separate claim information for each
					 eligible recipient. Claims must be complete, accurate, and as specified by the
					 Texas Health and Human Services Commission (HHSC) or its designee.
(b) Required information includes the
					 following:
(1) name, address, and appropriate
					 Texas provider identification number of the provider of services or supplies or
					 both;
(2) the date of the
					 claim;
(3) the name, address,
					 identification number, and date of birth of the individual who received
					 services or supplies or both;
(4)
					 the type of such services or supplies or both provided;
(5) the date(s) each service or supplies or
					 both were provided;
(6) the amounts
					 of each charge for the various types of services or supplies or both;
(7) the total charge for services or supplies
					 or both;
(8) credits for any
					 payments made at the time of submission of the claim, including payments made
					 by private health insurance and under Medicare;
(9) indication that the eligible recipient
					 has health, accident, or other insurance policies, or is covered by private or
					 governmental benefit systems, or other third party liability, when reported,
					 known, or suspected;
(10) the date
					 of the eligible recipient's death, if applicable; and
(11) the name and associated national
					 provider identifier of:
(A) the eligible
					 billing provider;
(B) the ordering
					 or referring provider or other professional, if services or supplies, or both,
					 are ordered or referred; and
(C)
					 the supervising and supervised provider, except for pharmacy claims, if:
(i) the services or supplies, or both, were
					 provided due to a referral or ordered by a provider;
(ii) the referring or ordering provider is
					 acting at the direction or under the supervision of another provider;
					 and
(iii) the referral or order is
					 based on the supervised provider's evaluation of the recipient or
					 enrollee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 1 - MEDICAID PROCEDURES FOR PROVIDERS › Section 354.1002 - Compliance with Civil Rights Act

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 The Texas Department of Health (department) has ensured compliance with the
					 Department of Health, Education, and Welfare regulations promulgated under
					 Title VI of the Civil Rights Act of 1964 which states: "No person in the United
					 States shall, on the ground or race, color, or national origin, be excluded
					 from participation in, be denied the benefits of, or be subjected to
					 discrimination under any program or activity receiving federal financial
					 assistance."
(b) Under this policy,
					 payment to eligible providers cannot be made for care and services under
					 federally assisted programs conducted by the department unless such care and
					 service is provided without discrimination on the ground of race, color, or
					 national origin. Written complaints of noncompliance should be made to the
					 Commissioner of Health, 1100 West 49th Street, Austin, Texas 78756-3199, or the
					 secretary of HEW, Washington, D.C., or both.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 1 - MEDICAID PROCEDURES FOR PROVIDERS › Section 354.1003 - Time Limits for Submitted Claims

Current through Reg. 49, No. 28; July 12, 2024
(a) Claims filing deadlines. Claims must be
					 received by the Health and Human Services Commission (HHSC) or its designee in
					 accordance with the following time limits to be considered for payment. Due to
					 the volume of claims processed, claims that do not comply with the following
					 deadlines will be denied payment.
(1)
					 Inpatient hospital claims. Final inpatient hospital claims must be received by
					 HHSC or its designee within 95 days from the date of discharge or 95 days from
					 the date the Texas Provider Identifier (TPI) Number is issued, whichever occurs
					 later. In the following situations, hospitals may, and in one instance, must
					 file interim claims:
(A) Hospitals reimbursed
					 according to prospective payment may submit an interim claim after the patient
					 has been in the facility 30 consecutive days or longer.
(B) Children's hospitals reimbursed according
					 to Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) methodology may
					 submit interim claims prior to discharge and must submit an interim claim if
					 the patient remains in the hospital past the hospital's fiscal year
					 end.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 1 - MEDICAID PROCEDURES FOR PROVIDERS › Section 354.1004 - Retention of Records

Current through Reg. 49, No. 28; July 12, 2024
The provider must maintain all records necessary to fully
						disclose the services provided. These records must be retained for a period of
						five years from the date of the service, or until all audit questions are
						resolved, whichever is longer. Records and supporting information must be made
						available upon request, regarding any payment of claims for services or
						supplies by the provider, to the Texas Department of Health or its designated
						agent.