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

1. (1) Access--The ability of an eligible client to obtain health and health-related services and other services related to nonmedical needs, as determined by factors such as:

   1. (A) the availability of Texas Health Steps services;
   2. (B) service acceptability to the eligible child, pregnant woman, or both;
   3. (C) the location of health care facilities and other resources;
   4. (D) transportation;
   5. (E) hours of facility operation; and
   6. (F) length of time available to see providers of health and health-related services or other services related to nonmedical needs.
2. (2) Applicant--An agency, organization, or individual who submits an application to enroll as a state Medicaid provider of Case Management for Children and Pregnant Women services.
3. (3) Case manager--An individual qualified under §257.19 of this title (relating to Case Manager Qualifications) who provides Case Management for Children and Pregnant Women services. A case manager may be an independent provider or an employee or contractor of a Medicaid-enrolled case management provider.
4. (4) Case management services--Services provided under this chapter to an eligible client to assist the client in gaining access to necessary medical, social, educational, and other services for a child with a health condition or health risk or a pregnant woman with a high-risk condition. In this chapter, these services are also referred to as Case Management for Children and Pregnant Women services.
5. (5) Child with a health condition or health risk--A child from birth through 20 years of age who has or is at risk for a medical condition, illness, injury, or disability that results in limitation of function, activities, or social roles in comparison with healthy peers of the same age in the general areas of physical, cognitive, emotional, or social growth and development.
6. (6) Client--An individual who is eligible for and enrolled in the Texas Medicaid Program and meets the eligibility requirements listed in §257.5 of this chapter (relating to Client Eligibility) or the client's parent or legal guardian.
7. (7) Client choice--A client is given the freedom to choose a provider, to the extent possible, from among providers available to the client.
8. (8) Face-to-face--A visit conducted by a case manager with a client in person or utilizing synchronous audiovisual communications.

9. (9) Family--A basic unit in society having at its nucleus:

   1. (A) one or more adults living together and cooperating in the care and rearing of the adult's or adults' biological or adopted children; or
   2. (B) a person or persons acting as an individual's family, foster family, guardian, or identifiable support person or persons.
10. (10) Health and health-related services--Services that are provided to meet the preventive, primary, tertiary, and specialty health needs of an eligible client, including, medical and dental checkups, immunizations, acute care visits, pediatric specialty consultations, physical therapy, occupational therapy, audiology, speech language services, mental health professional services, pharmaceuticals, medical supplies, prenatal care, family planning, adolescent preventive health, durable medical equipment, nutritional supplements, prosthetics, eyeglasses, and hearing aids.
11. (11) HHSC--The Texas Health and Human Services Commission or its designee, including a Medicaid managed care organization.
12. (12) High-risk condition--Applies to a woman who is pregnant and has a medical or psychosocial condition that places the woman and the woman's fetus at a greater than average risk for complications, either during pregnancy, delivery, or after birth.
13. (13) Medicaid--Medical assistance program implemented by the state under the provisions of Title XIX of the Social Security Act, as amended, at 42 U.S.C., §1396, et seq.
14. (14) Nonmedical need--Nonmedical drivers of health are the conditions in the place where a person lives, learns, works, and plays and that affect a wide range of health risks and outcomes.

15. (15) Provider--May be:

    1. (A) an agency approved by HHSC to provide Case Management for Children and Pregnant Women services and that is enrolled as a Medicaid provider; or
    2. (B) an individual approved by HHSC to provide Case Management for Children and Pregnant Women services and who is enrolled as a Medicaid provider.
16. (16) Quality assurance review--A review conducted by HHSC of a provider's client records, internal quality assurance policy, outreach materials, and compliance with HHSC's rules and policies, including the qualifications of the provider's case managers as listed in §257.19 of this chapter.
17. (17) TMPPM--Texas Medicaid Provider Procedures Manual.
18. (18) Utilization review--A review conducted by HHSC of a provider's claims data in which trends have been identified that could indicate potential concerns with the delivery of case management services.

Source Note:The provisions of this §257.3 adopted to be effective May 29, 2025, 50 TexReg 3129.