1. (a) A health care MCO must allow a member age 20 or younger, who at the time of the member's enrollment into the health care MCO has complex medical needs and has and maintains healthcare coverage under a primary health benefit plan, to remain under the care of a Medicaid enrolled specialty provider with which the member is receiving care through the primary health benefit plan, even if the specialty provider is an out-of-network provider.
2. (b) For the purpose of this section "primary health benefit plan" has the meaning assigned by Texas Human Resources Code, §32.0422(a) but does not include a Medicaid plan.

3. (c) For the purpose of this section "complex medical needs" means a member receiving:

   1. (1) Level 1 Service Coordination as authorized in the STAR Kids managed care contract; or
   2. (2) Service Management as authorized in the STAR Health managed care contract.

4. (d) For the purpose of this section "specialty provider" means one of the following provider types:

   1. (1) a physician licensed under the Texas Occupations Code, Chapter 155, who has and maintains a specialty in:

      1. (A) Adolescent Medicine (Teenagers);
      2. (B) Allergist (Allergies);
      3. (C) Ambulatory Medicine (General Non-Emergency Care);
      4. (D) Cardiology, Cardiovascular (Heart, Blood Vessels);
      5. (E) Colon/Rectal (Bowels);
      6. (F) Dermatology (Skin);
      7. (G) Endocrinology (Glands);
      8. (H) Family Medicine (General Family Medical Care);
      9. (I) Gastroenterology (Stomach, Digestion);
      10. (J) Genetics (Inherited Diseases, Birth Defects);
      11. (K) Hematology (Blood);
      12. (L) Hepatology (Liver);
      13. (M) Immunology (Immune System);
      14. (N) Infectious Diseases (Viral/Bacterial Infections);
      15. (O) Internal Medicine (General Medical Care);
      16. (P) Neonatology/Perinatology (Fetus and Newborns);
      17. (Q) Nephrology (Kidney);
      18. (R) Neurology (Brain, Nervous System);
      19. (S) Neurosurgery (Operations of the Brain, Spinal Cord);
      20. (T) Nuclear Medicine (Testing, e.g., MRI, CAT scan);
      21. (U) Obstetrics/Gynecology (Pregnancy, Women's Health);
      22. (V) Occupational Medicine (Work-Related Injuries);
      23. (W) Oncology (Cancer);
      24. (X) Ophthalmology (Eyes);
      25. (Y) Oral-Maxillofacial Surgery (Jaw and Mouth);
      26. (Z) Orthopedics (Bones and Joints);
      27. (AA) Otolaryngology (Ear, Nose, and Throat);
      28. (BB) Otology (Ears);
      29. (CC) Pediatrician (Babies, Children);
      30. (DD) Perinatology (Fetus);
      31. (EE) Physical Medicine (Rehabilitation);
      32. (FF) Plastic Surgery (Corrective Surgery);
      33. (GG) Psychiatry (Mental Illness);
      34. (HH) Pulmonology (Lungs, Breathing);
      35. (II) Radiology (X-Rays);
      36. (JJ) Reproductive Endocrinology (Reproductive System Diseases);
      37. (KK) Rheumatologist (Joints, Muscles, Tendons);
      38. (LL) Sports Medicine (Sports Injuries);
      39. (MM) Surgery (Operations);
      40. (NN) Thoracic Surgery (Chest Surgery);
      41. (OO) Urology (Urinary Tract); or
      42. (PP) Vascular Surgery (Operations of the Blood Vessels);
   2. (2) an audiologist, as that term is defined in Texas Occupations Code, §401.001(1-a), licensed under the Texas Occupations Code, Chapter 401;
   3. (3) a chiropractor that holds a license issued by the board created under the Texas Occupations Code, Chapter 201;
   4. (4) a dietitian licensed under the Texas Occupations Code, Chapter 701;
   5. (5) an optometrist licensed under the Texas Occupations Code, Chapter 351; or
   6. (6) a podiatrist licensed under the Texas Occupations Code, Chapter 202.

5. (e) A health care MCO must comply with the reasonable reimbursement methodology for authorized services performed by out-of-network providers as described in §353.4(f)(2) of this chapter (relating to Managed Care Organization Requirements Concerning Out-of-Network Providers) until:

   1. (1) an alternate reimbursement agreement is reached with the member's specialty provider;
   2. (2) the member is no longer enrolled in a primary health benefit plan;
   3. (3) the member or the member's LAR agree to select an alternate specialty provider; or
   4. (4) the member is no longer enrolled in the health care MCO.

Source Note:The provisions of this §353.7 adopted to be effective September 1, 2021, 46 TexReg 5386.