<<Prev Rule

Texas Administrative Code

Next Rule>>
TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353MEDICAID MANAGED CARE
SUBCHAPTER ESTANDARDS FOR MEDICAID MANAGED CARE
RULE §353.409Scope of Services

(a) A managed care organization (MCO) must provide covered services to members. The MCO is not responsible for providing or paying for non-capitated services or members' cost sharing obligations, if any.

(b) The Health and Human Services Commission (HHSC) will establish the scope and level of benefits, which all MCOs must agree to provide as a condition for participation. These requirements may exceed the scope and level of covered benefits and services available to fee-for-service Medicaid clients. These requirements will be contained in all contracts entered into by an MCO and HHSC.

(c) MCOs are encouraged to provide any value-added services or benefits beyond the level and scope required as a condition for participation in the competitive procurement process. These services and benefits must be approved by HHSC and cannot increase the cost borne or capitation rates paid by HHSC during any current contract term or in any subsequent contract term. These services or benefits cannot violate any other state or federal rule or regulation.

(d) A value-added service may be unique to an MCO, and limited to a member who meets the MCO's qualification criteria for the service.

(e) Before approving a value-added service, HHSC will determine whether it is an actual health care service, dental service, benefit, or positive incentive designed to promote a healthy lifestyle and improve a health or dental outcome. HHSC will not approve best practice approaches to delivering covered services as value-added services. Examples of potential value-added services include: health or dental-related programs; programs that encourage health-conscious behaviors; and for children enrolled in STAR Health, non-health care services and benefits that support the child's physical, mental, or developmental well being.


Source Note: The provisions of this §353.409 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283

Next Page Previous Page



Home TxReg TAC OM NewTac Public Footer Bar