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 32 - TEXAS MEDICAID WELLNESS PROGRAM › Section 354.1417 - Definitions for Wellness Services

Current through Reg. 49, No. 28; July 12, 2024
The following terms are specific to the Texas Medicaid
						Wellness Program, when used in this division, have the following meanings,
						unless the context clearly indicates otherwise.
(1) Care management--An approach or process
					 for persons with complex needs and/or chronic illness that is focused on
					 preventing acute or urgent care utilization through the use of accepted
					 clinical and non-clinical interventions. These interventions include services
					 such as care coordination; telephone access to nurses skilled in monitoring and
					 providing consultation on how to address disease symptoms and complications,
					 including answering medication questions; providing patient education;
					 self-management care skills; and providing physician-coordinated treatment
					 plans.
(2) Case management--A
					 process whereby covered persons with specific healthcare needs are identified
					 and a care plan is developed and implemented that efficiently utilizes health
					 care resources to achieve the optimum outcome in the most cost-effective
					 manner.
(3) Claim--A request for
					 payment for authorized benefits submitted on the applicable approved form that
					 meets the established itemization requirements.
(4) Texas Medicaid Wellness Program--A
					 holistic approach to health care delivery designed to identify and provide
					 services to Medicaid fee-for-service clients with, or who are at risk for,
					 incurring high-cost medical services due to chronic illness or complex
					 conditions.
(5) Eligible client--An
					 individual who has been designated by the State as eligible for medical care
					 and services under the Medicaid program and meets the requirements for the
					 Texas Medicaid Wellness Program.
(6) Fee-for-Service Reimbursement--The
					 traditional health care payment system under which physicians and other
					 providers receive a payment for each unit of service they provide or an
					 insurance product in which clients are allowed total freedom to choose their
					 health care providers.
(7) Health
					 severity level assessment--An assessment by the Texas Medicaid Wellness Program
					 vendor that determines the appropriate interventions.
(8) Medical assistance program--The program
					 implemented by the State of Texas under the provisions of Title XIX of the
					 Social Security Act, as amended.
(9) Medical home--A community-based system of
					 health care delivery that provides individual patients a known resource
					 (primary care provider or clinic) for all primary and preventive care services.
					 It also provides continuity of care for acute care needs 24 hours a day,
					 including consultative, specialty, and health-related services.
(10) Physician--A doctor of medicine or
					 doctor of osteopathy (MD or DO) legally authorized to practice medicine or
					 osteopathy at the time and place the service is provided.
(11) Preventive care--Comprehensive care
					 emphasizing prevention, early detection, and early treatment of conditions,
					 generally including routine physical examination, immunization, well-person
					 care, and age-appropriate screening exams.
(12) Primary care provider (PCP)--A physician
					 or provider who has agreed to provide a medical home to Medicaid clients and
					 who is responsible for providing care to patients, maintaining the continuity
					 of patient care and initiating referral for care.
(13) Stratify--A method used by the Texas
					 Medicaid Wellness Program vendor to organize interventions based on the
					 client's specific needs at a given time.