The following words and terms, when used in this chapter, have
the following meanings, unless the content clearly indicates otherwise.
(A) An action is defined as:
(i) the denial or limited authorization of a requested
Medicaid service, including the type or level of service;
(ii) the reduction, suspension, or termination of a
previously authorized service;
(iii) the failure to provide services in a timely manner;
(iv) the denial in whole or in part of payment for
(v) the failure of a managed care organization (MCO)
to act within the timeframes set forth by the Health and Human Services
Commission (HHSC) and state and federal law; or
(vi) for a resident of a rural area with only one MCO,
the denial of a member's request to obtain services outside the network.
(B) "Action" does not include expiration of a time-limited
(2) Acute care--Preventive care, primary care, and
other medical or behavioral health care provided by the provider or
under the direction of a provider for a condition having a relatively
(3) Acute care hospital--A hospital that provides acute
(4) Agreement or Contract--The formal, written, and
legally enforceable contract and amendments thereto between HHSC and
(5) 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
(6) Appeal--The formal process by which a member or
his or her representative requests a review of the MCO's action.
(7) Behavioral health service--A covered service for
the treatment of mental, emotional, or substance use disorders.
(8) Capitated service--A benefit available to members
under the Texas Medicaid program for which an MCO is responsible for
(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) Children's Medicaid Dental Services--The dental
services provided through a dental MCO to a client birth through age
(11) Clean claim--A claim submitted by a physician
or provider for health care services rendered to a member, with the
data necessary for the MCO or subcontracted claims processor to adjudicate
and accurately report the claim. A clean claim must meet all requirements
for accurate and complete data as further defined under the terms
of the contract executed between the MCO and HHSC.
(12) Client--Any Medicaid-eligible recipient.
(13) CMS--The Centers for Medicare and Medicaid Services,
which is the federal agency responsible for administering Medicare
and overseeing state administration of Medicaid.
(14) Complainant--A member, or a treating provider
or other individual designated to act on behalf of the member, who
files a complaint.
(15) 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:
(A) the quality of care of services provided;
(B) aspects of interpersonal relationships such as
rudeness of a provider or employee; and
(C) failure to respect the member's rights.
(16) Covered services--Unless a service or item is
specifically excluded under the terms of the state plan, a federal
waiver, a managed care services contract, or an amendment to any of
these, the phrase "covered services" means all health care or dental
services or items that the MCO must arrange to provide and pay for
on a member's behalf under the terms of the contract executed between
the MCO and HHSC, including:
(A) all services or items comprising "medical assistance"
as defined in §32.003 of the Human Resources Code; and
(B) all value-added services under such contract.
(17) 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.
(18) Day--A calendar day, unless specified otherwise.
(19) Default enrollment--The process established by
HHSC to assign a Medicaid managed care enrollee to an MCO when the
enrollee has not selected an MCO.
(20) Dental managed care organization (dental MCO)--A
dental indemnity insurance provider or dental health maintenance organization
licensed or approved by the Texas Department of Insurance.
(21) Dental contractor--A dental MCO that is under
contract with HHSC for the delivery of dental services.
(22) Dental home--A provider who has contracted with
a dental MCO to serve as a dental home to a member and who is responsible
for providing routine preventive, diagnostic, urgent, therapeutic,
initial, and primary care to patients, maintaining the continuity
of patient care, and initiating referral for care. Provider types
that can serve as dental homes are federally qualified health centers
and individuals who are general dentists or pediatric dentists.
(23) Dental service--The routine preventive, diagnostic,
urgent, therapeutic, initial, and primary care provided to a member
and included within the scope of HHSC's agreement with a dental contractor.
For purposes of this chapter, "dental service" does not include dental
devices for craniofacial anomalies; treatment rendered in a hospital,
urgent care center, or ambulatory surgical center setting for craniofacial
anomalies; or emergency services provided in a hospital, urgent care
center, or ambulatory surgical center setting involving dental trauma.
These types of services are treated as health care services in this
(24) 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, or working.
(25) 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.
(26) Dual eligible--A Medicaid recipient who is also
eligible for Medicare.
(27) Elective enrollment--Selection of a primary care
provider (PCP) and MCO by a client during the enrollment period established
(28) Emergency behavioral health condition--Any condition,
without regard to the nature or cause of the condition, that in the
opinion of a prudent layperson possessing an average knowledge of
health and medicine:
(A) requires immediate intervention and/or medical
attention without which the client would present an immediate danger
to themselves or others; or
(B) renders the client incapable of controlling, knowing,
or understanding the consequences of his or her actions.
(29) 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 to result in:
(A) placing the patient's health in serious jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) serious disfigurement; or
(E) serious jeopardy to the health of a pregnant woman
or her unborn child.
(30) Emergency service--A covered inpatient and outpatient
service, furnished by a network provider or out-of-network provider
that is qualified to furnish such service, that is needed to evaluate
or stabilize an emergency medical condition and/or an emergency behavioral
health condition. For health care MCOs, the term "emergency service"
includes post-stabilization care services.
(31) Encounter--A covered service or group of covered
services delivered by a provider to a member during a visit between
the member and provider. This also includes value-added services.
(32) Enrollment--The process by which an individual
determined to be eligible for Medicaid is enrolled in a Medicaid MCO
serving the service area in which the individual resides.
(33) EPSDT--The federally mandated Early and Periodic
Screening, Diagnosis and Treatment program defined in 25 TAC Chapter
33. The State of Texas has adopted the name Texas Health Steps (THSteps)
for its EPSDT program.
(34) EPSDT-CCP--The Early and Periodic Screening, Diagnosis
and Treatment-Comprehensive Care Program described in Chapter 363
of this title (relating to Texas Health Steps Comprehensive Care Program).
(35) Exclusive provider benefit plan (EPBP)--An MCO
that complies with 28 TAC §§3.9201 - 3.9212, relating to
the Texas Department of Insurance's requirements for EPBPs, and contracts
with HHSC to provide Medicaid coverage.
(36) Experience rebate--The portion of the MCO's net
income before taxes that is returned to the State in accordance with
the MCO's contract with HHSC.
(37) Fair hearing--The process adopted and implemented
by HHSC in Chapter 357, Subchapter A of this title (relating to Uniform
Fair Hearing Rules) in compliance with federal regulations and state
rules relating to Medicaid fair hearings.
(38) Federally Qualified Health Center (FQHC)--An entity
that is certified by CMS to meet the requirements of 42 U.S.C. §1395x(aa)(3)
as a Federally Qualified Health Center and is enrolled as a provider
in the Texas Medicaid program.
(39) Federal Poverty Level (FPL)--The household income
guidelines issued annually and published in the
Federal Register by the United States Department of Health
and Human Services under the authority of 42 U.S.C. §9902(2)
and as in effect for the applicable budget period determined in accordance
with 42 C.F.R. §435.603(h). HHSC uses the FPL to determine an
individual's eligibility for Medicaid.
(40) Federal waiver--Any waiver permitted under federal
law and approved by CMS that allows states to implement Medicaid managed
(41) Former Foster Care Children (FFCC) program--The
Medicaid program for young adults who aged out of the conservatorship
of Texas Department of Family and Protective Services (DFPS), administered
in accordance with Chapter 366, Subchapter J of this title (relating
to Former Foster Care Children's Program).
(42) Functional necessity--A member's need for services
and supports with activities of daily living or instrumental activities
of daily living to be healthy and safe in the most integrated setting
possible. This determination is based on the results of a functional
(43) Health care managed care organization (health
care MCO)--An entity that is licensed or approved by the Texas Department
of Insurance to operate as a health maintenance organization or to
issue an EPBP.
(44) Health care services--The acute care, 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
(45) Health and Human Services Commission (HHSC)--The
single state agency charged with administration and oversight of the
Texas Medicaid program or its designee.
(46) 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 formed
in compliance with Chapter 844 of the Texas Insurance Code.
(47) 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.
(48) Intermediate care facility for individuals with
an intellectual disability or related condition (ICF-IID)--A facility
providing care and services to individuals with intellectual disabilities
or related conditions as defined in §1905(d) of the Social Security
Act (42 U.S.C. 1396(d)).
(49) Long term service and support (LTSS)--A service
provided to a qualified member in his or her home or other community-based
settings necessary to provide assistance with activities of daily
living to allow the member to remain in the most integrated setting
possible. LTSS includes services provided to all SSI recipients under
the Texas State Plan as well as services available only to persons
who qualify for STAR+PLUS Home and Community-Based Waiver Services.