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

1. (1) Action--An action is defined as:

   1. (A) The denial or limited authorization of a requested Medicaid service, including the type or level of service;
   2. (B) the reduction, suspension, or termination of a previously authorized service;
   3. (C) the failure to provide services in a timely manner;
   4. (D) the denial in whole or in part of payment for a service;
   5. (E) the failure of a Managed Care Organization (MCO) to act within the timeframes set forth by the Commission and state and federal law; or
   6. (F) for a resident of a rural area with only one MCO, the denial of a Medicaid member's request to obtain services outside the Network.
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 and behavioral health care 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 the Commission and MCOs.
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 Services--Covered services for the treatment of mental health or chemical dependency disorders.
9. (9) 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.
10. (10) Client--Any Medicaid-eligible recipient.
11. (11) CMS--The Centers for Medicare & Medicaid Services, which is the federal agency responsible for administering Medicare and overseeing state administration of Medicaid and the Children's Health Insurance Program (CHIP).
12. (12) Commission--The Texas Health and Human Services Commission.
13. (13) Complainant--A member or a treating provider or other individual designated to act on behalf of the member who files a complaint.

14. (14) 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, but are not limited to:

    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 Medicaid member's rights.
15. (15) Contract--The formal, written, and legally enforceable agreement and any amendments and documents incorporated into the agreement between an MCO and HHSC.
16. (16) Core Service Area--The core set of service area counties defined by HHSC for the Medicaid Managed Care programs in which Medicaid eligibles will be required to enroll in the MCO.
17. (17) Covered Services--Health Care Services the MCO must arrange to provide to member, including all services required by the Commission, state and federal law, and all value added services negotiated by the Commission and an MCO. Covered services include behavioral health services.
18. (18) 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.
19. (19) Day--A calendar day, unless specified otherwise.
20. (20) Default Enrollment--The process established by HHSC to assign a mandatory Medicaid Managed Care enrollee to an MCO when an MCO has not been selected by the client.
21. (21) 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.
22. (22) 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 and/or working.
23. (23) Elective Enrollment--Selection of a PCP and MCO by a client during the enrollment period established by the Commission.

24. (24) Emergency Behavioral Health Condition--Any condition, without regard to the nature or cause of the condition, which 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.
25. (25) Emergency Services--Covered inpatient and outpatient services furnished by a Provider that is qualified to furnish such services that are needed to evaluate or stabilize an emergency medical condition and/or an emergency behavioral health condition, including Post-stabilization Care Services.

26. (26) 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.
27. (27) Encounter--A covered service or group of covered service delivered by a provider to a member during a visit between the member and provider. This also includes value added services.
28. (28) EPSDT--The federally mandated Early and Periodic Screening, Diagnosis and Treatment program defined in Chapter 33 of Title 25 of the Texas Administrative Code. The State of Texas has adopted the name Texas Health Steps (THSteps) for its EPSDT program.
29. (29) EPSDT-CCP--The Early and Periodic Screening, Diagnosis and Treatment-Comprehensive Care Program, includes medically necessary benefits for children under 21 years of age in addition to benefits available to the general Medicaid population.
30. (30) Exclusive Provider Benefit Plan (EPBP)--A Managed Care Plan that complies with 28 TAC §§3.9201 - 3.9212, relating to the Texas Department of Insurance's requirements for exclusive provider benefit plans, and contracts with the Commission to provide CHIP or Medicaid coverage.
31. (31) Experience Rebate--The portion of the MCO's net income before taxes that is returned to the State in accordance with 28 TAC Chapter 11, Subchapter S, relating to solvency standards for Medicaid managed care organizations.
32. (32) Fair Hearing--The process adopted and implemented by HHSC in Chapter 357 of this title, relating to Medical Fair Hearing rules, in compliance with federal regulations and state rules relating to Medicaid Fair Hearings.
33. (33) 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.
34. (34) Federal Waiver--Any waiver permitted under federal law and approved by CMS that allows states to implement Medicaid managed care.
35. (35) Health Care Services--The acute, 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.
36. (36) Health and Human Services Commission (HHSC)--The single state agency charged with administration and oversight of the state Medicaid program. The Commission's authority is established in Chapter 531 of the Government Code.
37. (37) 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 (ANHC) formed in compliance with Chapter 844 of the Texas Insurance Code.
38. (38) 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.
39. (39) Managed Care--A health delivery system in which the overall care of a patient is coordinated by or through a single provider or organization.
40. (40) MCO--An entity that has a valid Texas Department of Insurance certificate of authority to operate as a Health Maintenance Organization under Chapter 843 of the Texas Insurance Code, an approved nonprofit health corporation under Chapter 844 of the Texas Insurance Code, or an Exclusive Provider Benefit Plan issued by an insurer licensed by the Texas Department of Insurance, as described at 28 TAC Chapter 3, Subchapter KK, relating to exclusive provider benefit plans.
41. (41) Managed Care Plan--Includes Primary Care Case Management (PCCM), HMO, and Exclusive Provider Benefit Plans (EPBP).
42. (42) Marketing--Any communication from an MCO to a client who is not enrolled with an 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.
43. (43) 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. Health-related materials are not marketing materials.
44. (44) 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.
45. (45) 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 HHSC MCO.

46. (46) Medically Necessary Behavioral Health Services--Those behavioral health services that are documented and:

    1. (A) 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. (B) are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;
    3. (C) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;
    4. (D) are the most appropriate level or supply of service that can be safely provided;
    5. (E) could not have been omitted without adversely affecting the member's mental and/or physical health or the quality of care rendered;
    6. (F) are not experimental or investigational; and
    7. (G) are not primarily for the convenience of the Member or Provider.

47. (47) Medically Necessary Health Services--Health services other than behavioral health services that are documented and:

    1. (A) reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a member, or endanger life;
    2. (B) provided at appropriate facilities and at the appropriate levels of care for the treatment of the member's medical conditions;
    3. (C) consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies;
    4. (D) consistent with the diagnoses of the conditions;
    5. (E) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
    6. (F) are not experimental or investigative; and
    7. (G) are not primarily for the convenience of the member or provider.
48. (48) 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 the Medicaid Managed Care Program and a Medicaid MCO.

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

    1. (A) concerning access to health care through the managed care organization and about specific health topics;
    2. (B) that is approved by the Health and Human Services Commission; and
    3. (C) is provided to members through a variety of mechanisms that must include, at a minimum, written materials and face-to-face or audiovisual communications.
50. (50) Member Materials--All written materials produced or authorized by the MCO and distributed to members or potential members containing information concerning the MCO. Member materials include, but are not limited to, Member ID cards, Member handbooks, Provider directories, and Marketing Materials.
51. (51) Outside Regular Business Hours--As applied to FQHCs and RHCs, means before 8 a.m. and after 5 p.m. Monday through Friday, weekends, and federal holidays.
52. (52) Participating MCOs--Those MCOs that have a contract with the Commission to provide services to Medicaid managed care members.
53. (53) Primary Care Case Management (PCCM)--PCCM is a managed care model allowed under federal regulations in which the Commission contracts with providers to form a managed care provider network.
54. (54) Primary Care Provider (PCP)--A physician or other provider who has agreed with the 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.
55. (55) 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.
56. (56) Provider Education Program--Program of education about the Medicaid managed care program and about specific health care issues presented by the managed care organization to its providers through written materials and training events.
57. (57) Provider Network or Network--All providers that have contracted with the MCO for the applicable program.
58. (58) QAPI--Quality Assessment Performance Improvements.
59. (59) Quality Improvement--A system to continuously examine, monitor and revise processes and systems that support and improve administrative and clinical functions.
60. (60) Risk--The potential for loss as a result of expenses and costs of the MCO exceeding payments made by HHSC under the contract.
61. (61) 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.
62. (62) Service Area--The counties included in any HHSC-defined Core Service Area as applicable to each MCO.
63. (63) Significant Traditional Provider (STP)--Providers identified by HHSC as having provided a significant level of care to the target population. Disproportionate Share Hospitals (DSH) are also Medicaid STPs.
64. (64) Supplemental Security Income (SSI)--The federal cash assistance program of direct financial payments to the aged, blind, and disabled 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).
65. (65) TDI--Texas Department of Insurance.
66. (66) 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.
67. (67) Value-Added Services--Additional services for coverage beyond those specified in the Request For Proposal. Value-Added Services must be actual health care services or benefits rather than gifts, incentives, health assessments or educational classes. Best practice approaches to delivering covered services are not considered Value-Added Services. For foster children in a statewide Medicaid managed care program, value added services may include non-health care services and benefits that support the physical, mental and/or developmental well being of the child.

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.