TITLE 1. ADMINISTRATION

PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 353. MEDICAID MANAGED CARE

The Texas Health and Human Services Commission (HHSC) proposes amendments to Title 1 of the Texas Administrative Code, Part 15, Chapter 353, Subchapter A (regarding General Provisions), §353.2, concerning Definitions; Subchapter G (regarding STAR+PLUS), §353.603, concerning Member Participation; Subchapter H (regarding STAR Health), §353.702, concerning Member Participation; Subchapter I (regarding STAR), §353.802, concerning Member Participation; and Subchapter N (regarding STAR Kids), §353.1203, concerning Member Participation. HHSC also proposes new Subchapter G (regarding STAR+PLUS), §353.609, concerning Service Coordination.

BACKGROUND AND JUSTIFICATION

Under the 2014-15 General Appropriations Act (Senate Bill 1, 83rd Legislature, Regular Session, 2013, Article II, Health and Human Services Commission, Rider 51(b)(15)), HHSC was directed to improve care coordination through a capitated managed care program for remaining Medicaid fee-for-service populations. As a result, HHSC will transfer the Adoption Assistance (AA), Permanency Care Assistance (PCA), and Medicaid Breast and Cervical Cancer (MBCC) populations from traditional fee-for-service Medicaid (FFS) to Medicaid managed care on September 1, 2017. The proposed amendments to §§353.603, 353.802, and 353.1203 add the AA, PCA, and MBCC populations as mandatory groups for the appropriate managed care programs.

Proposed amendments to §§353.603, 353.702, and 353.1203 also impact Former Foster Care Children (FFCC) in a 1915(c) waiver.

Adoption Assistance (AA)

The DFPS AA program facilitates the adoption of children with special needs by providing certain adoption assistance benefits to families. One of the benefits provided is Medicaid health coverage for the child being adopted. The Medicaid AA population consists of approximately 44,500 children who were adopted from DFPS conservatorship. This population currently receives Medicaid services through the FFS delivery model, and will start to receive Medicaid services through the managed care delivery model on September 1, 2017. Specifically, the child to be adopted will receive Medicaid services either through the STAR or STAR Kids program, as appropriate.

Permanency Care Assistance (PCA)

The DFPS PCA program provides benefits to certain individuals who assume managing conservatorship of a child who was previously in the temporary or permanent managing conservatorship of DFPS. One of the benefits provided is Medicaid health coverage for the child under conservatorship. The PCA program consists of approximately 1,935 children who were previously under the temporary or permanent managing conservatorship of DFPS. This population currently receives Medicaid services through the FFS delivery model and will start to receive Medicaid services through the managed care delivery model on September 1, 2017. Specifically, the child under conservatorship will receive Medicaid services either through the STAR or STAR Kids program, as appropriate.

Medicaid for Breast and Cervical Cancer (MBCC)

The HHSC MBCC program provides full Medicaid coverage to women who are screened and found to need treatment for breast or cervical cancer. Services are not limited to the treatment of breast and cervical cancer, and continue as long as the Medicaid provider certifies that active treatment is required for breast or cervical cancer. As of June 2015, there were approximately 4,785 MBCC recipients. This population currently receives Medicaid services through the FFS delivery model and will start to receive Medicaid services through the managed care delivery model on September 1, 2017. Specifically, the MBCC recipients will receive Medicaid services through the STAR+PLUS program.

Former Foster Care Children (FFCC)

The FFCC is a Medicaid eligibility type for young adults who aged out of the conservatorship of Texas Department of Family and Protective Services (DFPS). FFCC individuals ages 18-20 in a 1915(c) waiver are in STAR Health today. The proposed rule amendments allow this population to choose to remain in STAR Health or opt into STAR Kids. FFCC individuals ages 21-26 in a 1915(c) waiver are currently in fee-for-service Medicaid. The proposed rule amendments make this population mandatory for STAR+PLUS.

In addition to amending rules for the transition to managed care, HHSC is proposing new §353.609 regarding service coordination for the STAR+PLUS program.

SECTION-BY-SECTION SUMMARY

Proposed amended §353.2 adds definitions for person-centered care and person-centered planning.

Proposed amended §353.603 adds Medicaid Breast and Cervical Cancer program participants as a mandatory population in STAR+PLUS. FFCC members age 21 to 26 who are in a 1915(c) waiver or who are dual eligible (for Medicare and Medicaid) are also added as mandatory participants in STAR+PLUS.

Proposed new §353.609 describes the service coordination benefit available to all STAR+PLUS members, including the MBCC population as of September 1, 2017.

Proposed amended §353.702 adds that FFCC individuals have the option to transition from STAR Health to STAR Kids, if they meet STAR Kids participation criteria. This rule currently only lists STAR as an option for transitioning from STAR Health.

Proposed amended §353.802 adds Adoption Assistance and Permanency Care Assistance program participants as mandatory populations in STAR and makes other nonsubstantive changes.

Proposed amended §353.1203 adds Adoption Assistance and Permanency Care Assistance program participants as mandatory populations in STAR Kids. FFCC individuals are also added to the rule as optional STAR Kids members, if they meet criteria listed in the rule, such as participation in a 1915(c) waiver or being dual eligible.

FISCAL NOTE

Greta Rymal, Deputy Executive Commissioner for Financial Services, has determined that for each year of the first five years the proposed and amended rules are in effect, there is an anticipated fiscal impact to costs and revenues of state government.

The transitions of the Adoption Assistance (AA) and Permanency Care Assistance (PCA) programs, as well as the Medicaid Breast and Cervical Cancer (MBCC) program, are anticipated to result in a cost to state government of $4,892,764 General Revenue (GR) ($13,627,316 All Funds (AF)) for State Fiscal Year (SFY) 2018, $6,985,683 GR ($19,070,354 AF) for SFY 2019, $11,060,281 GR ($29,553,023 AF) for SFY 2020, $11,952,742 GR ($31,923,547 AF) for SFY 2021, and $12,928,361 GR ($34,511,786 AF) for SFY 2022.

In addition, for the same programs, there is an anticipated increase of revenue to the state for adopting and implementing this proposal. The increase results from premium tax paid by managed care organizations when the managed care policies are issued. There is no federal component of the anticipated revenues and all collections are deposited in the state general revenue fund. The expected collections are $4,611,730 GR for SFY 2018, $11,962,053 GR for SFY 2019, $8,590,626 GR for SFY 2020, $9,581,257 GR for SFY 2021, and $10,387,184 GR for SFY 2022. There are offsetting costs, such as those related to prior authorization and claims processing, that would be paid by HHSC or the Texas Medicaid & Healthcare Partnership were these clients not carved in to managed care. These costs are already included in the current capitation rate, so there is not an incremental per-client cost for these activities.

There is no anticipated impact to costs and revenues of state government related to the proposed transition of the FFCC individuals to managed care.

There is no anticipated impact to costs and revenues of local governments.

SMALL BUSINESS AND MICRO-BUSINESS IMPACT ANALYSIS

HHSC has determined that there will be no adverse economic effect on small businesses or micro-businesses to comply with proposed and amended rules, as they will not be required to alter their business practices because of the proposed and amended rules.

PUBLIC BENEFIT AND COST

Jami Snyder, State Medicaid Director, has determined that for each year of the first five years the rules are in effect, the public will benefit from the adoption of rules. The anticipated public benefit will be that individuals enrolled in the programs being carved in will be better served by the managed care model and by having a medical home, which will ensure enhanced quality of care.

Ms. Rymal has also determined that there are no probable economic costs to persons required to comply with the proposed and amended rules.

HHSC has determined that the proposed and amended rules will not affect a local economy. There is no anticipated negative impact on local employment.

REGULATORY ANALYSIS

HHSC has determined that this proposal is not a "major environmental rule" as defined by §2001.0225 of the Texas Government Code. A "major environmental rule" is defined to mean a rule the specific intent of which is to protect the environment or reduce risk to human health from environmental exposure and that may adversely affect, in a material way, the economy, a sector of the economy, productivity, competition, jobs, the environment, or the public health and safety of a state or a sector of the state. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that this proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under §2007.043 of the Texas Government Code.

PUBLIC COMMENT

Written comments on the proposal may be submitted to Jasmin Patel, Senior Policy Analyst, 4900 North Lamar Boulevard, Mail Code H130, Austin TX, 78751; or by e-mail to jasmin.patel@hhsc.state.tx.us within 30 days of publication of this proposal in the Texas Register.

SUBCHAPTER A. GENERAL PROVISIONS

1 TAC §353.2

STATUTORY AUTHORITY

The amendment is proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

The proposed amendment implements Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.

§353.2.Definitions.

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

(1) Action--

(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 a service; or

(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.

(B) "Action" does not include expiration of a time-limited service.

(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 short duration.

(3) Acute care hospital--A hospital that provides acute care services.

(4) Agreement or Contract--The formal, written, and legally enforceable contract and amendments thereto between HHSC and an MCO.

(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 networks.

(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 payment.

(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) CFR--Code of Federal Regulations.

(11) Children's Medicaid Dental Services--The dental services provided through a dental MCO to a client birth through age 20.

(12) 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.

(13) Client--Any Medicaid-eligible recipient.

(14) CMS--The Centers for Medicare & Medicaid Services, which is the federal agency responsible for administering Medicare and overseeing state administration of Medicaid.

(15) Complainant--A member, or a treating provider or other individual designated to act on behalf of the member, who files a complaint.

(16) 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.

(17) Consumer Directed Services (CDS) option--A service delivery option (also known as self-directed model with service budget) in which an individual or legally authorized representative employs and retains service providers and directs the delivery of certain program services.

(18) 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, long term services and supports, 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.

(19) Cultural competency--The ability of individuals and systems to provide services effectively to people of various disabilities, 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.

(20) Day--A calendar day, unless specified otherwise.

(21) 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.

(22) 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.

(23) Dental contractor--A dental MCO that is under contract with HHSC for the delivery of dental services.

(24) 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.

(25) 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 chapter.

(26) 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.

(27) 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.

(28) Dual eligible--A Medicaid recipient who is also eligible for Medicare.

(29) Elective enrollment--Selection of a primary care provider (PCP) and MCO by a client during the enrollment period established by HHSC.

(30) 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.

(31) 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.

(32) 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.

(33) 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.

(34) 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.

(35) 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.

(36) 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).

(37) 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.

(38) 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.

(39) 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.

(40) 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.

(41) 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.

(42) Federal waiver--Any waiver permitted under federal law and approved by CMS that allows states to implement Medicaid managed care.

(43) 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).

(44) 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 assessment.

(45) Habilitation--Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks based on the individual's person-centered service plan.

(46) 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.

(47) 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 services.

(48) Health and Human Services Commission (HHSC)--The single state agency charged with administration and oversight of the Texas Medicaid program or its designee.

(49) 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.

(50) 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.

(51) 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)).

(52) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, and may, depending on the circumstances, include a parent, guardian, or managing conservator of a minor, or the guardian of an adult, or a representative designated pursuant to 42 C.F.R. 435.923.

(53) Long term service and support (LTSS)--A service provided to a qualified member in his or her home or other community-based setting necessary to allow the member to remain in the most integrated setting possible. LTSS includes services provided under the Texas State Plan as well as services available to persons who qualify for STAR+PLUS Home and Community-Based Program services or Medicaid 1915(c) waiver services. LTSS available through an MCO in STAR+PLUS, STAR Health, and STAR Kids varies by program model.

(54) Main dental home provider--See definition of "dental home" in this section.

(55) Main dentist--See definition of "dental home" in this section.

(56) Managed care--A health care delivery system or dental services delivery system in which the overall care of a patient is coordinated by or through a single provider or organization.

(57) Managed care organization (MCO)--A dental MCO or a health care MCO.

(58) Marketing--Any communication from an MCO to a client who is not enrolled with the MCO that can reasonably be interpreted as intended to influence the client's decision to enroll, not to enroll, or to disenroll from a particular MCO.

(59) Marketing materials--Materials that are produced in any medium by or on behalf of the MCO that can reasonably be interpreted as intending to market to potential members. Materials relating to the prevention, diagnosis, or treatment of a medical or dental condition are not marketing materials.

(60) MDCP--Medically Dependent Children Program. A §1915(c) waiver program that provides community-based services to assist Medicaid beneficiaries under age 21 to live in the community and avoid institutionalization.

(61) Medicaid--The medical assistance program authorized and funded pursuant to Title XIX of the Social Security Act (42 U.S.C. §1396 et seq.) and administered by HHSC.

(62) Medical Assistance Only (MAO)--A person who qualifies financially and functionally for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits, as defined in Chapters 358, 360, and 361, of this title (relating to Medicaid Eligibility for the Elderly and People with Disabilities, Medicaid Buy-In Program and Medicaid Buy-In for Children Program).

(63) Medicaid for transitioning foster care youth (MTFCY) 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 F of this title (relating to Medicaid for Transitioning Foster Care Youth).

(64) Medical home--A PCP or specialty care provider who has accepted the responsibility for providing accessible, continuous, comprehensive, and coordinated care to members participating in an MCO contracted with HHSC.

(65) Medically necessary--

(A) For Medicaid members birth through age 20, the following Texas Health Steps services:

(i) screening, vision, dental, and hearing services; and

(ii) other health care services or dental services that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition:

(I) must comply with the requirements of a final court order that applies to the Texas Medicaid program or the Texas Medicaid managed care program as a whole; and

(II) may include consideration of other relevant factors, such as the criteria described in subparagraphs (B)(ii) - (vii) and (C)(ii) - (vii) of this paragraph.

(B) For Medicaid members over age 20, non-behavioral health services that are:

(i) reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a member, or endanger life;

(ii) provided at appropriate facilities and at the appropriate levels of care for the treatment of a member's health conditions;

(iii) consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;

(iv) consistent with the member's medical need;

(v) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;

(vi) not experimental or investigative; and

(vii) not primarily for the convenience of the member or provider.

(C) For Medicaid members over age 20, behavioral health services that:

(i) are reasonable and necessary for the diagnosis or treatment of a mental health or substance use disorder, or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;

(ii) are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;

(iii) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;

(iv) are the most appropriate level or supply of service that can safely be provided;

(v) could not be omitted without adversely affecting the member's mental and/or physical health or the quality of care rendered;

(vi) are not experimental or investigative; and

(vii) are not primarily for the convenience of the member or provider.

(66) Member--A person who is eligible for benefits under Title XIX of the Social Security Act and Medicaid, is in a Medicaid eligibility category included in the Medicaid managed care program, and is enrolled in a Medicaid MCO.

(67) Member education program--A planned program of education:

(A) concerning access to health care services or dental services through the MCO and about specific health or dental topics;

(B) that is approved by HHSC; and

(C) that is provided to members through a variety of mechanisms that must include, at a minimum, written materials and face-to-face or audiovisual communications.

(68) Member materials--All written materials produced or authorized by the MCO and distributed to members or potential members containing information concerning the managed care program. Member materials include member ID cards, member handbooks, provider directories, and marketing materials.

(69) Non-capitated service--A benefit available to members under the Texas Medicaid program for which an MCO is not responsible for payment.

(70) Outside regular business hours--As applied to FQHCs and rural health clinics (RHCs), means before 8 a.m. and after 5 p.m. Monday through Friday, weekends, and federal holidays.

(71) Participating MCO--An MCO that has a contract with HHSC to provide services to members.

(72) Person-centered care--An approach to care that focuses on members as individuals and supports caregivers working most closely with them. It involves a continual process of listening, testing new approaches, and changing routines and organizational approaches in an effort to individualize and de-institutionalize the care environment.

(73) Person-centered planning--A documented service planning process that includes people chosen by the individual, is directed by the individual to the maximum extent possible, enables the individual to make choices and decisions, is timely and occurs at times and locations convenient to the individual, reflects cultural considerations of the individual, includes strategies for solving conflict or disagreement within the process, offers choices to the individual regarding the services and supports they receive and from whom, includes a method for the individual to require updates to the plan, and records alternative settings that were considered by the individual.

(74) [(72)] Post-stabilization care service--A covered service, related to an emergency medical condition, that is provided after a Medicaid member is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 C.F.R. §438.114(b) and (e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve the Medicaid member's condition.

(75) [(73)] Primary care provider (PCP)--A physician or other provider who has agreed with the health care MCO to provide a medical home to members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care.

(76) [(74)] Provider--A credentialed and licensed individual, facility, agency, institution, organization, or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO's members.

(77) [(75)] Provider education program--Program of education about the Medicaid managed care program and about specific health or dental care issues presented by the MCO to its providers through written materials and training events.

(78) [(76)] Provider network or Network--All providers that have contracted with the MCO for the applicable managed care program.

(79) [(77)] Quality improvement--A system to continuously examine, monitor, and revise processes and systems that support and improve administrative and clinical functions.

(80) [(78)] Rural Health Clinic (RHC)--An entity that meets all of the requirements for designation as a rural health clinic under §1861(aa)(1) of the Social Security Act (42 U.S.C. §1395x(aa)(1)) and is approved for participation in the Texas Medicaid program.

(81) [(79)] Service area--The counties included in any HHSC-defined service area as applicable to each MCO.

(82) [(80)] Significant traditional provider (STP)--A provider identified by HHSC as having provided a significant level of care to the target population, including a DSH.

(83) [(81)] STAR--The State of Texas Access Reform (STAR) managed care program that operates under a federal waiver and primarily provides, arranges for, and coordinates preventive, primary, acute care, and pharmacy services for low-income families, children, and pregnant women.

(84) [(82)] STAR Health--The managed care program that operates under the Medicaid state plan and primarily serves:

(A) children and youth in Texas Department of Family and Protective Services (DFPS) conservatorship;

(B) young adults who voluntarily agree to continue in a foster care placement (if the state as conservator elects to place the child in managed care); and

(C) young adults who are eligible for Medicaid as a result of their former foster care status through the month of their 21st birthday.

(85) [(83)] STAR Kids--The program that operates under a federal waiver and primarily provides, arranges, and coordinates preventative, primary, acute care, and long-term services and supports to persons with disabilities under the age of 21 who qualify for Medicaid.

(86) [(84)] STAR+PLUS--The managed care program that operates under a federal waiver and primarily provides, arranges, and coordinates preventive, primary, acute care, and long-term services and supports to persons with disabilities and elderly persons age 65 and over who qualify for Medicaid by virtue of their SSI or MAO status.

(87) [(85)] STAR+PLUS Home and Community-Based Services Program--The program that provides person-centered care and services that are delivered in the home or in a community setting, as authorized through a federal waiver under §1115 of the Social Security Act, to qualified Medicaid-eligible clients who are age 21 or older, as cost-effective alternatives to institutional care in nursing facilities.

(88) [(86)] State plan--The agreement between the CMS and HHSC regarding the operation of the Texas Medicaid program, in accordance with the requirements of Title XIX of the Social Security Act.

(89) [(87)] Supplemental Security Income (SSI)--The federal cash assistance program of direct financial payments to people who are 65 years of age or older, are blind, or have a disability administered by the Social Security Administration (SSA) under Title XVI of the Social Security Act. All persons who are certified as eligible for SSI in Texas are eligible for Medicaid. Local SSA claims representatives make SSI eligibility determinations. The transactions are forwarded to the SSA in Baltimore, which then notifies the states through the State Data Exchange (SDX).

(90) [(88)] Texas Health Steps (THSteps)--The name adopted by the State of Texas for the federally mandated Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, described at 42 U.S.C. §1396d(r) and 42 CFR §440.40 and §§441.40 - 441.62.

(91) [(89)] Value-added service--A service provided by an MCO that is not "medical assistance," as defined by §32.003 of the Texas Human Resources Code.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on April 28, 2017.

TRD-201701722

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 11, 2017

For further information, please call: (512) 424-6902


SUBCHAPTER G. STAR+PLUS

1 TAC §353.603, §353.609

STATUTORY AUTHORITY

The amendment and new rule are proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

The proposed amendment and new rule implement Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.

§353.603.Member Participation.

(a) Enrollment [Except as provided in subsections (b) and (d) of this section, enrollment] in the STAR+PLUS program is mandatory for Medicaid recipients who meet one or more of the following criteria:

(1) have a physical or mental disability [, are age 21 or older,] and qualify for [receive] Supplemental Security Income (SSI) benefits or for Medicaid due to low income;

(2) qualify for [the] STAR+PLUS Home and Community-Based Waiver Services [Program, as described in §353.1153 of this title (relating to STAR+PLUS Home and Community Based Services (HCBS) Program)];

(3) are age 21 or older and receive Medicaid because they are in a Social Security Exclusion program and meet financial criteria for STAR+PLUS Home and Community-Based Services Program; [or]

(4) are age 21 or older and reside in a nursing facility; [.]

(5) are over 18 and under 65 and qualify for Medicaid for Breast and Cervical Cancer as described in Chapter 366, Subchapter D, of this title (relating to Medicaid for Breast and Cervical Cancer); or

(6) FFCC members age 21 through the month of his or her 26th birthday who meet the criteria in subsections (b) or (e) of this section.

(b) In addition to the Medicaid recipients who must enroll in the STAR+PLUS program under subsection (a) of this section, recipients age 21 or older residing in a community-based ICF-IID or receiving services under the following Medicaid 1915(c) waivers and not enrolled in Medicare must enroll in STAR+PLUS to receive acute care services:

(1) Home and Community-based Services (HCS);

(2) Community Living Assistance and Support Services (CLASS);

(3) Texas Home Living (TxHmL); and

(4) Deaf Blind with Multiple Disabilities (DBMD).

(c) Medicaid recipients will have a choice among at least two MCOs.

(d) The following Medicaid recipients cannot participate in the STAR+PLUS program:

(1) persons under age 21;

(2) residents of state supported living centers;

(3) persons not eligible for full Medicaid benefits; and

(4) persons enrolled in Programs of All-Inclusive Care for Elderly (PACE).

(e) Dual eligible individuals.

(1) Enrollment in Medicare does not affect eligibility for the STAR+PLUS program, except as specified in subsection (b) of this section.

(2) Dual eligible individuals who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, and STAR+PLUS Home and Community-Based Services Program through the STAR+PLUS MCO. Dual eligible individuals who participate in the STAR+PLUS program receive most acute care services through their Medicare provider, but may receive additional services through their STAR+PLUS MCO. The STAR+PLUS program does not change the way dual eligibles receive Medicare services.

§353.609.Service Coordination.

(a) All STAR+PLUS members have access to service coordination. Service coordination includes:

(1) face-to-face and telephonic contacts between the member and the service coordinator;

(2) development and maintenance of a comprehensive, person-centered individual service plan (ISP);

(3) coordination, including with providers, to assist the member in accessing services provided by the STAR+PLUS MCO; and

(4) coordination, including with providers as appropriate, to assist the member in accessing services provided by other community entities or service providers.

(b) STAR+PLUS members with a demonstrated need for more intensive service coordination are assigned a single, named service coordinator by the STAR+PLUS MCO. All STAR+PLUS members have access to a single, named service coordinator upon request.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on April 28, 2017.

TRD-201701723

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 11, 2017

For further information, please call: (512) 424-6902


SUBCHAPTER H. STAR HEALTH

1 TAC §353.702

STATUTORY AUTHORITY

The amendment is proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

The proposed amendment implements Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.

§353.702.Member Participation.

(a) Children and young adults in the following categories are eligible to participate in the STAR Health program:

(1) a child in the conservatorship of the Texas Department of Family and Protective Services (DFPS), if the state as conservator elects to place the child in the STAR Health program;

(2) a young adult from age 18 through the month of his or her 22nd birthday who voluntarily agrees to continue in foster care placement, if the state as conservator elects to place the child in the STAR Health program; and

(3) a young adult from age 18 through the month of his or her 21st birthday who is an FFCC member or participating in the MTFCY Program.

(b) A young adult described in subsection (a)(2) and (3) of this section may choose to transfer from the STAR Health program to the STAR program or STAR Kids program, if they meet the member participation requirements in §353.802 of this chapter (relating to Member Participation) or §353.1203 of this chapter (relating to Member Participation).

(c) The following Medicaid recipients cannot participate in the STAR Health program:

(1) Children and youth who have been adjudicated and placed with the Texas Juvenile Justice Department (TJJD);

(2) Children and youth from other states who are placed in Texas through the Interstate Compact Placement Commission (ICPC) as defined by DFPS in 40 TAC Chapter 700, Subchapter S (relating to Interstate Placement of Children);

(3) Children and youth in Medicaid-paid facilities such as nursing facilities or state supported living centers;

(4) Children and youth who are in the conservatorship of DFPS who are placed outside of Texas;

(5) Children and youth who are receiving adoption assistance Medicaid as defined by DFPS in 40 TAC Chapter 700, Subchapter H (relating to Adoption Assistance Program); and

(6) Children who are declared manifestly dangerous as defined by the Texas Department of Health Services in accordance with 25 TAC Chapter 415, Subchapter G (relating to Determination of Manifest Dangerousness).

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on April 28, 2017.

TRD-201701724

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 11, 2017

For further information, please call: (512) 424-6902


SUBCHAPTER I. STAR

1 TAC §353.802

STATUTORY AUTHORITY

The amendment is proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

The proposed amendment implements Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.

§353.802.Member Participation.

(a) Enrollment in the State of Texas Access Reform (STAR) program is mandatory for Medicaid recipients who meet the criteria in one or more of the following categories:

(1) individuals [Individuals] age 21 and over who are eligible for the Parents and Other Caretaker Relatives program outlined in Subchapter G of Chapter 366 of this title (relating to Medicaid for Parents and Caretaker Relatives Program);[.]

(2) pregnant [Pregnant] women receiving medical assistance with household income that meets the applicable income limits specified in Subchapter C of Chapter 366 of this title (relating to Pregnant Women's Medicaid);[.]

(3) newborns [Newborns] receiving medical assistance--Children through 12 months of age with household income equal to or less than the FPL level specified in Subchapter E of Chapter 366 of this title (relating to Children's Medicaid) or born to Medicaid-eligible mothers;[.]

(4) children [Children] receiving medical assistance age 13 months through the month of his or her 18th birthday with household income equal to or less than the FPL specified in Subchapter E of Chapter 366 of this title;[.]

(5) FFCC members age 21 through the month of his or her 26th birthday; and[.]

(6) children who meet both of the following criteria:

(A) are receiving medical assistance through the Texas Department of Family and Protective Services Adoption Assistance Program, as described in Title 40 of the Texas Administrative Code, Chapter 700, Subchapter H (relating to Adoption Assistance Program); or Permanency Care Assistance Program, as described in Title 40 of the Texas Administrative Code, Chapter 700, Subchapter J, Division 2 (relating to Permanency Care Assistance Program); and

(B) are not eligible for STAR Kids, as described in Subchapter N of this chapter (relating to STAR Kids).

(b) FFCC STAR Health members ages 18 through 20 may choose to transfer to the STAR program and remain enrolled through the month of his or her 26th birthday.

(c) MTFCY STAR Health members may transfer to the STAR program.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on April 28, 2017.

TRD-201701725

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 11, 2017

For further information, please call: (512) 424-6902


SUBCHAPTER N. STAR KIDS

1 TAC §353.1203

STATUTORY AUTHORITY

The amendment is proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority, and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

The proposed amendment implements Texas Human Resources Code, Chapter 32, and Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.

§353.1203.Member Participation.

(a) Except as provided in subsection (b) of this section, enrollment in the STAR Kids program is mandatory for a Medicaid client who is under the age of 21 and meets one or both of the following criteria:

(1) has a physical or mental disability and qualifies for Supplemental Security Income (SSI) or SSI-related Medicaid; or

(2) is enrolled in the Medically Dependent Children Program (MDCP) waiver.

(b) Clients birth through age 20 residing in a community-based ICF-IID or nursing facility or receiving services under the following Medicaid 1915(c) waivers must enroll in STAR Kids to receive acute care services and non-facility based state plan services:

(1) Home and Community-based Services (HCS);

(2) Community Living Assistance and Support Services (CLASS);

(3) Texas Home Living (TxHmL); or

(4) Deaf Blind with Multiple Disabilities (DBMD).

(c) Clients birth through age 20 receiving services under the Youth Empowerment Services (YES) Medicaid 1915(c) waiver must enroll in STAR Kids to receive acute care services and non-facility based state plan services other than Community First Choice state plan services.

(d) The following Medicaid clients cannot participate in the STAR Kids program:

(1) clients residing in the Truman W. Smith Children's Care Center;

(2) residents of state supported living centers;

(3) residents of state veterans' homes;

(4) persons not eligible for full Medicaid benefits; and

(5) children in the conservatorship of the Texas Department of Family and Protective Services.

(e) Dual eligible clients.

(1) Enrollment in Medicare does not affect eligibility for the STAR Kids program.

(2) Dual eligible clients who participate in the STAR Kids program receive most acute care services through their Medicare provider, and long term services and supports through the STAR Kids MCO. Participation in the STAR Kids program does not change the way dual eligible clients receive Medicare services.

(f) Individuals birth through 20 who participate in the Medicaid Buy-In for Children Program or the Medicaid Buy-In Program must enroll in STAR Kids.

(g) FFCC members ages 18 through 20 may choose to transfer from STAR Health to STAR Kids if they meet the criteria in subsections (b), (c), (e), or (f) of this section.

(h) Except as provided in subsection (d) of this section, children receiving medical assistance through the Texas Department of Family and Protective Services Adoption Assistance Program, as described under Title 40 of the Texas Administrative Code, Chapter 700, Subchapter H (relating to Adoption Assistance Program); or Permanency Care Assistance Program, as described under Title 40 of the Texas Administrative Code, Chapter 700, Subchapter J, Division 2 (relating to Permanency Care Assistance Program) must enroll in STAR Kids if they meet one or more of the criteria in subsections (a), (b), (c), or (e) of this section.

(i) [(g)] STAR Kids Medicaid clients have a choice among at least two MCOs.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on April 28, 2017.

TRD-201701726

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 11, 2017

For further information, please call: (512) 424-6902