The following words and terms, when used in this chapter, have the following meanings, unless the content clearly indicates otherwise.

1. (1) Action--

   1. (A) An action is defined as:

      1. (i) the denial or limited authorization of a requested Medicaid service, including the type or level of service;
      2. (ii) the reduction, suspension, or termination of a previously authorized service;
      3. (iii) the failure to provide services in a timely manner;
      4. (iv) the denial in whole or in part of payment for a service;
      5. (v) the failure of a managed care organization (MCO) to act within the timeframes set forth by the Health and Human Services Commission (HHSC) and state and federal law; or
      6. (vi) for a resident of a rural area with only one MCO, the denial of a member's request to obtain services outside the network.
   2. (B) "Action" does not include expiration of a time-limited service.
2. (2) Acute care--Preventive care, primary care, and other medical or behavioral health care provided for a condition having a relatively short duration.
3. (3) Acute care hospital--A hospital that provides acute care services.
4. (4) Adverse determination--A determination by an MCO that the health care services or dental services furnished, or proposed to be furnished, to a patient are not medically necessary or appropriate.
5. (5) Agreement or Contract--The formal, written, and legally enforceable contract and amendments thereto between HHSC and an MCO.
6. (6) Allowable revenue--All managed care revenue received by the MCO pursuant to the contract during the contract period, including retroactive adjustments made by HHSC. This would include any revenue earned on Medicaid managed care funds such as investment income, earned interest, or third party administrator earnings from services to delegated networks.
7. (7) Appeal--The formal process by which a member or his or her representative requests a review of the MCO's action.
8. (8) Behavioral health service--A covered service for the treatment of mental, emotional, or chemical dependency disorders.
9. (9) Capitated service--A benefit available to members under the Texas Medicaid program for which an MCO is responsible for payment.
10. (10) Capitation rate--A fixed predetermined fee paid by HHSC to the MCO each month, in accordance with the contract, for each enrolled member in exchange for which the MCO arranges for or provides a defined set of covered services to the member, regardless of the amount of covered services used by the enrolled member.
11. (11) Children's Medicaid Dental Services--The dental services provided through a dental MCO to a client birth through age 20.
12. (12) Client--Any Medicaid-eligible recipient.
13. (13) CMS--The Centers for Medicare and Medicaid Services, which is the federal agency responsible for administering Medicare and overseeing state administration of Medicaid.
14. (14) Complainant--A member, or a treating provider or other individual designated to act on behalf of the member, who files a complaint.

15. (15) Complaint--Any dissatisfaction expressed by a complainant, orally or in writing, to the MCO about any matter related to the MCO other than an action. Subjects for complaints may include:

    1. (A) the quality of care of services provided;
    2. (B) aspects of interpersonal relationships such as rudeness of a provider or employee; and
    3. (C) failure to respect the member's rights.

16. (16) Covered services--Unless a service or item is specifically excluded under the terms of the state plan, a federal waiver, a managed care services contract, or an amendment to any of these, the phrase "covered services" means all health care or dental services or items that the MCO must arrange to provide and pay for on a member's behalf under the terms of the contract executed between the MCO and HHSC, including:

    1. (A) all services or items comprising "medical assistance" as defined in §32.003 of the Human Resources Code; and
    2. (B) all value-added services under such contract.
17. (17) Cultural competency--The ability of individuals and systems to provide services effectively to people of various cultures, races, ethnic backgrounds, and religions in a manner that recognizes, values, affirms, and respects the worth of the individuals and protects and preserves their dignity.
18. (18) Day--A calendar day, unless specified otherwise.
19. (19) Default enrollment--The process established by HHSC to assign a Medicaid managed care enrollee to an MCO when the enrollee has not selected an MCO.
20. (20) Dental managed care organization (dental MCO)--A dental indemnity insurance provider or dental health maintenance organization licensed or approved by the Texas Department of Insurance.
21. (21) Dental contractor--A dental MCO that is under contract with HHSC for the delivery of dental services.
22. (22) Dental home--A provider who has contracted with a dental MCO to serve as a dental home to a member and who is responsible for providing routine preventive, diagnostic, urgent, therapeutic, initial, and primary care to patients, maintaining the continuity of patient care, and initiating referral for care. Provider types that can serve as dental homes are federally qualified health centers and individuals who are general dentists or pediatric dentists.
23. (23) Dental service--The routine preventive, diagnostic, urgent, therapeutic, initial, and primary care provided to a member and included within the scope of HHSC's agreement with a dental contractor. For purposes of this chapter, "dental service" does not include dental devices for craniofacial anomalies; treatment rendered in a hospital, urgent care center, or ambulatory surgical center setting for craniofacial anomalies; or emergency services provided in a hospital, urgent care center, or ambulatory surgical center setting involving dental trauma. These types of services are treated as health care services in this chapter.
24. (24) Disproportionate Share Hospital (DSH)--A hospital that serves a higher than average number of Medicaid and other low-income patients and receives additional reimbursement from the State.
25. (25) Disability--A physical or mental impairment that substantially limits one or more of an individual's major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, socializing, or working.
26. (26) Dual eligible--A Medicaid recipient who is also eligible for Medicare.
27. (27) Elective enrollment--Selection of a primary care provider (PCP) and MCO by a client during the enrollment period established by HHSC.

28. (28) Emergency behavioral health condition--Any condition, without regard to the nature or cause of the condition, that in the opinion of a prudent layperson possessing an average knowledge of health and medicine:

    1. (A) requires immediate intervention and/or medical attention without which the client would present an immediate danger to themselves or others; or
    2. (B) renders the client incapable of controlling, knowing, or understanding the consequences of his or her actions.
29. (29) Emergency service--A covered inpatient and outpatient service, furnished by a network provider or out-of-network provider that is qualified to furnish such service, that is needed to evaluate or stabilize an emergency medical condition and/or an emergency behavioral health condition. For health care MCOs, the term "emergency service" includes post-stabilization care services.

30. (30) Emergency medical condition--A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

    1. (A) placing the patient's health in serious jeopardy;
    2. (B) serious impairment to bodily functions;
    3. (C) serious dysfunction of any bodily organ or part;
    4. (D) serious disfigurement; or
    5. (E) serious jeopardy to the health of a pregnant woman or her unborn child.
31. (31) Encounter--A covered service or group of covered services delivered by a provider to a member during a visit between the member and provider. This also includes value-added services.
32. (32) Enrollment--The process by which an individual determined to be eligible for Medicaid is enrolled in a Medicaid MCO serving the service area in which the individual resides.
33. (33) EPSDT--The federally mandated Early and Periodic Screening, Diagnosis and Treatment program defined in 25 TAC Chapter 33. The State of Texas has adopted the name Texas Health Steps (THSteps) for its EPSDT program.
34. (34) EPSDT-CCP--The Early and Periodic Screening, Diagnosis and Treatment-Comprehensive Care Program described in Chapter 363 of this title (relating to Texas Health Steps Comprehensive Care Program).
35. (35) Exclusive provider benefit plan (EPBP)--An MCO that complies with 28 TAC §§3.9201 - 3.9212, relating to the Texas Department of Insurance's requirements for EPBPs, and contracts with HHSC to provide Medicaid coverage.
36. (36) Experience rebate--The portion of the MCO's net income before taxes that is returned to the State in accordance with the MCO's contract with HHSC.
37. (37) Fair hearing--The process adopted and implemented by HHSC in Chapter 357, Subchapter A of this title (relating to Uniform Fair Hearing Rules) in compliance with federal regulations and state rules relating to Medicaid fair hearings.
38. (38) FPL--Federal Poverty Level Income Guidelines.
39. (39) Federally Qualified Health Center (FQHC)--An entity certified by CMS to meet the requirements of §1861(aa)(3) of the Social Security Act (42 U.S.C. §1395x(aa)(3)) as a Federally Qualified Health Center that is enrolled as a provider in the Texas Medicaid program.
40. (40) Federal waiver--Any waiver permitted under federal law and approved by CMS that allows states to implement Medicaid managed care.
41. (41) Health care managed care organization (health care MCO)--An entity that is licensed or approved by the Texas Department of Insurance to operate as a health maintenance organization or to issue an EPBP.
42. (42) Health care services--The acute care, behavioral health care, and health-related services that an enrolled population might reasonably require in order to be maintained in good health, including, at a minimum, emergency services and inpatient and outpatient services.
43. (43) Health and Human Services Commission (HHSC)--The single state agency charged with administration and oversight of the Texas Medicaid program. HHSC's authority is established in Chapter 531 of the Texas Government Code.
44. (44) Health maintenance organization (HMO)--An organization that holds a certificate of authority from the Texas Department of Insurance to operate as an HMO under Chapter 843 of the Texas Insurance Code, or a certified Approved Non-Profit Health Corporation formed in compliance with Chapter 844 of the Texas Insurance Code.
45. (45) Hospital--A licensed public or private institution as defined in the Texas Health and Safety Code at Chapter 241, relating to hospitals, or Chapter 261, relating to municipal hospitals.
46. (46) Intermediate care facility for people with intellectual and developmental disabilities--An intermediate care facility for the mentally retarded as defined in §1905(d) of the Social Security Act (42 U.S.C. 1396(d)).
47. (47) Long term service and support (LTSS)--A service provided to a qualified member in his or her home or other community-based settings necessary to provide assistance with activities of daily living to allow the member to remain in the most integrated setting possible. LTSS includes services provided to all SSI recipients under the Texas State Plan as well as services available only to persons who qualify for STAR+PLUS Home and Community-Based Waiver Services.
48. (48) Main dental home provider--See definition of "dental home" in this section.
49. (49) Main dentist--See definition of "dental home" in this section.
50. (50) Managed care--A health care delivery system or dental services delivery system in which the overall care of a patient is coordinated by or through a single provider or organization.
51. (51) Managed care organization (MCO)--A dental MCO or a health care MCO.
52. (52) Marketing--Any communication from an MCO to a client who is not enrolled with the MCO that can reasonably be interpreted as intended to influence the client's decision to enroll, not to enroll, or to disenroll from a particular MCO.
53. (53) Marketing materials--Materials that are produced in any medium by or on behalf of the MCO that can reasonably be interpreted as intending to market to potential members. Materials relating to the prevention, diagnosis or treatment of a medical or dental condition are not marketing materials.
54. (54) Medicaid--The medical assistance program authorized and funded pursuant to Title XIX of the Social Security Act (42 U.S.C. §1396 et seq) and administered by HHSC.
55. (55) Medical Assistance Only (MAO)--A person who qualifies financially for Medicaid but does not receive Supplemental Security Income (SSI) payments.
56. (56) Medical home--A PCP or specialty care provider who has accepted the responsibility for providing accessible, continuous, comprehensive, and coordinated care to members participating in an MCO contracted with HHSC.

57. (57) Medically necessary--Means:

    1. (A) For Medicaid members birth through age 20, the following Texas Health Steps services:

       1. (i) screening, vision, dental, and hearing services; and

       2. (ii) other health care services or dental services that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition:

          1. (I) must comply with the requirements of a final court order that applies to the Texas Medicaid program or the Texas Medicaid managed care program as a whole; and
          2. (II) may include consideration of other relevant factors, such as the criteria described in subparagraphs (B)(ii) - (vii) and (C)(ii) - (vii) of this paragraph.

    2. (B) For Medicaid members over age 20, non-behavioral health services that are:

       1. (i) reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life;
       2. (ii) provided at appropriate facilities and at the appropriate levels of care for the treatment of a member's health conditions;
       3. (iii) consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;
       4. (iv) consistent with the member's diagnoses;
       5. (v) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
       6. (vi) not experimental or investigative; and
       7. (vii) not primarily for the convenience of the member or provider.

    3. (C) For Medicaid members over age 20, behavioral health services that:

       1. (i) are reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;
       2. (ii) are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;
       3. (iii) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;
       4. (iv) are the most appropriate level or supply of service that can safely be provided;
       5. (v) could not be omitted without adversely affecting the member's mental and/or physical health or the quality of care rendered;
       6. (vi) are not experimental or investigative; and
       7. (vii) are not primarily for the convenience of the member or provider.
58. (58) Member--A person who is eligible for benefits under Title XIX of the Social Security Act and Medicaid, is in a Medicaid eligibility category included in the Medicaid managed care program, and is enrolled in a Medicaid MCO.

59. (59) Member education program--A planned program of education:

    1. (A) concerning access to health care services or dental services through the MCO and about specific health or dental topics;
    2. (B) that is approved by HHSC; and
    3. (C) that is provided to members through a variety of mechanisms that must include, at a minimum, written materials and face-to-face or audiovisual communications.
60. (60) Member materials--All written materials produced or authorized by the MCO and distributed to members or potential members containing information concerning the managed care program. Member materials include member ID cards, member handbooks, provider directories, and marketing materials.
61. (61) Non-capitated service--A benefit available to members under the Texas Medicaid program for which an MCO is not responsible for payment.
62. (62) Outside regular business hours--As applied to FQHCs and rural health clinics (RHCs), means before 8 a.m. and after 5 p.m. Monday through Friday, weekends, and federal holidays.
63. (63) Participating MCO--An MCO that has a contract with HHSC to provide services to members.
64. (64) Post-stabilization care service--A covered service, related to an emergency medical condition, that is provided after a Medicaid member is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 C.F.R. §438.114(b) and (e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve the Medicaid member's condition.
65. (65) Primary care provider (PCP)--A physician or other provider who has agreed with the health care MCO to provide a medical home to members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.
66. (66) Provider--A credentialed and licensed individual, facility, agency, institution, organization, or other entity, and its employees and subcontractors, that have a contract with the MCO for the delivery of covered services to the MCO's members.
67. (67) Provider education program--Program of education about the Medicaid managed care program and about specific health or dental care issues presented by the MCO to its providers through written materials and training events.
68. (68) Provider network or Network--All providers that have contracted with the MCO for the applicable managed care program.
69. (69) Quality improvement--A system to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.
70. (70) Risk--The potential for loss as a result of expenses and costs of the MCO exceeding payments made by HHSC under the contract.
71. (71) Rural Health Clinic (RHC)--An entity that meets all of the requirements for designation as a rural health clinic under §1861(aa)(1) of the Social Security Act (42 U.S.C. §1395x(aa)(1)) and is approved for participation in the Texas Medicaid program.
72. (72) Service area--The counties included in any HHSC-defined service area as applicable to each MCO.
73. (73) Significant traditional provider (STP)--A provider identified by HHSC as having provided a significant level of care to the target population, including a DSH.
74. (74) STAR--The State of Texas Access Reform (STAR) program that operates under a federal waiver.
75. (75) STAR Health--The STAR Health program that operates under the Medicaid state plan.
76. (76) STAR+PLUS--The STAR+PLUS program that operates under one or more federal waivers.
77. (77) STAR+PLUS Home and Community-Based Waiver Services--The program that provides home and community-based services, as authorized through a federal waiver under §1915(c) or §1115 of the Social Security Act, to qualified clients who are 65 years of age or older, are blind, or have a disability as cost-effective alternatives to institutional care in nursing facilities.
78. (78) State plan--The agreement between the CMS and HHSC regarding the operation of the Texas Medicaid program, in accordance with the requirements of Title XIX of the Social Security Act.
79. (79) Supplemental Security Income (SSI)--The federal cash assistance program of direct financial payments to people who are 65 years of age or older, are blind, or have a disability administered by the Social Security Administration (SSA) under Title XVI of the Social Security Act. All persons who are certified as eligible for SSI in Texas are eligible for Medicaid. Local SSA claims representatives make SSI eligibility determinations. The transactions are forwarded to the SSA in Baltimore, which then notifies the states through the State Data Exchange (SDX).
80. (80) Texas Health Steps (THSteps)--The name adopted by the State of Texas for the federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, described at 42 U.S.C. §1905d(r) and 42 CFR §440.40 and §§441.40 - 441.62.
81. (81) Value-added service--A service provided by an MCO that is not "medical assistance," as defined by §32.003 of the Human Resources Code.

Source Note:The provisions of this §353.2 adopted to be effective February 28, 1997, 22 TexReg 1799; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective July 1, 2007, 32 TexReg 2135; amended to be effective September 1, 2007, 32 TexReg 5333; amended to be effective March 1, 2012, 37 TexReg 1283; amended to be effective July 8, 2012, 37 TexReg 4851.