|(a) An 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) HHSC will establish the scope and level of benefits,
which all MCOs must agree to provide as a condition for participation.
In accordance with 42 C.F.R. §438.210, the scope of benefits
must be provided at least in an amount, duration, and scope available
to Medicaid fee-for-service clients, unless otherwise explicitly authorized
by HHSC through a waiver. The amount, duration, and scope of benefits
may exceed the scope of fee-for-service in accordance with subsection
(f) of this section. 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.
(f) On a case-by-case basis, an MCO may offer to individual
members additional benefits that are outside the scope of services.
Case-by-case services may be based on medical necessity, cost-effectiveness,
the wishes of the member or the member's family, or the potential
for improving the member's health status. For STAR+PLUS members, these
case-by-case services may also be based on functional necessity. These
services and benefits cannot increase the cost borne or capitation
rates paid by HHSC during any current contract term or in any subsequent
contract term and cannot violate any other state or federal rule or
|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; amended to be effective September 1, 2014, 39 TexReg 5873