HUMAN RESOURCES CODETITLE 2. DEPARTMENT OF HUMAN SERVICES AND DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICESSUBTITLE C. ASSISTANCE PROGRAMSCHAPTER 32. MEDICAL ASSISTANCE PROGRAMSUBCHAPTER A. GENERAL PROVISIONSSec. 32.001. PURPOSE OF CHAPTER. The purpose of this chapter is to enable the state to provide medical assistance on behalf of needy individuals and to enable the state to obtain all benefits for those persons authorized under the Social Security Act or any other federal act.
Acts 1979, 66th Leg., p. 2348, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.002. CONSTRUCTION OF CHAPTER. (a) This chapter shall be liberally construed and applied in relation to applicable federal laws and regulations so that adequate and high quality health care may be made available to all children and adults who need the care and are not financially able to pay for it.(b) If a provision of this chapter conflicts with a provision of the Social Security Act or any other federal act and renders the state program out of conformity with federal law to the extent that federal matching money is not available to the state, the conflicting provision of state law shall be inoperative to the extent of the conflict but shall not affect the remainder of this chapter.
Acts 1979, 66th Leg., p. 2348, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.003. DEFINITIONS. In this chapter:(1) "Board" means the Health and Human Services Commission or the governing body of an agency operating part of the medical assistance program, as appropriate.(2) "Commissioner" means the Health and Human Services Commission or the commissioner or executive director of an agency operating part of the medical assistance program, as appropriate.(3) "Department" means the Health and Human Services Commission or an agency operating part of the medical assistance program, as appropriate.(4) "Medical assistance" includes all of the health care and related services and benefits authorized or provided under federal law for needy individuals of this state.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1995, 74th Leg., ch. 6, Sec. 2, eff. March 23, 1995.
SUBCHAPTER B. ADMINISTRATIVE PROVISIONSSec. 32.021. ADMINISTRATION OF THE PROGRAM. (a) The department is the state agency designated to administer the medical assistance program provided in this chapter.(b) The department shall enter into agreements with any federal agency designated by federal law to administer medical assistance when the department determines the agreements to be compatible with the state's participation in the medical assistance program and within the limits of appropriated funds. The department shall cooperate with federal agencies designated by federal law to administer medical assistance in any reasonable manner necessary to qualify for federal funds.(c) The department shall establish methods of administration and adopt necessary rules for the proper and efficient operation of the program.(d) The department shall include in its contracts for the delivery of medical assistance by nursing facilities provisions for monetary penalties to be assessed for violations as required by 42 U.S.C. Section 1396r, including without limitation the Omnibus Budget Reconciliation Act (OBRA), P. L. 100-203, Nursing Home Reform Amendments of 1987, provided that the department shall:(1) provide for an informal dispute resolution process in the Health and Human Services Commission as provided by Section 531.058, Government Code; and(2) develop rules to adjudicate claims in contested cases, including claims unresolved by the informal dispute resolution process of the Health and Human Services Commission.(e) Rules governing the application of penalties shall include the following:(1) specific and objective criteria which describe the scope and severity of a contract violation which results in a recommendation for each specific penalty. Penalties must be appropriate to the violation, and the most severe financial penalties must be reserved for situations which create an immediate and serious threat to the health and safety of residents; "immediate and serious threat" means a situation in which there is a high probability that serious harm or injury to patients could occur at any time or already has occurred and may well occur again if patients are not protected effectively from the harm or if the threat is not removed;(2) a system to ensure standard and consistent application of penalties among surveyors and different areas of the state;(3) due process for nursing facilities providers, including an appeals procedure consistent with Chapter 2001, Government Code; and(4) per diem and/or minimum penalties. The department may by rule prescribe a minimum penalty period; however, once a facility gives the department notice that deficiencies have been corrected, if surveyors are unable to revisit the facility within five days and the deficiencies are later shown to be corrected, the per diem penalties cease as of the day the facility gave notice to the department or on the last day of the minimum penalty period established by the department, whichever is later.(f) To encourage facilities to provide the best possible care, the department shall develop an incentive program to recognize facilities providing the highest quality care to Medicaid residents.(g) Funds collected as a result of the imposition of penalties shall be applied to the protection of the health or property of residents of nursing facilities, including the cost of relocation of residents to other facilities and maintenance or operation of a facility pending correction of deficiencies or closure, or to incentive programs which recognize the highest quality care to residents who are entitled to Medicaid.(h) Medicaid nursing facilities shall also comply with state licensure rules, which may be more stringent than the requirements for certification. The department shall use appropriate civil, administrative, or criminal remedies authorized by state or federal law with respect to a facility that is in violation of a certification or licensing requirement.(i) Repealed by Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1).(j) Repealed by Acts 2001, 77th Leg., ch. 1284, Sec. 3.04, eff. June 15, 2001.(k) Repealed by Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1).(l) The department may not include as a reimbursable item to a nursing facility an administrative or civil penalty assessed against the facility under this chapter or under Chapter 242, Health and Safety Code.(m) Notwithstanding any provision of law to the contrary, the department shall terminate a nursing facility's provider agreement if the department has imposed required Category 2 or Category 3 remedies on the facility three times within a 24-month period. The executive commissioner of the Health and Human Services Commission by rule shall establish criteria under which the requirement to terminate the provider agreement may be waived. In this subsection, "Category 2 remedies" and "Category 3 remedies" have the meanings assigned by 42 C.F.R. Section 488.408.(n) An assessment of monetary penalties under this section is subject to arbitration under Subchapter J, Chapter 242, Health and Safety Code.(o) In any circumstance in which a nursing facility would otherwise be required to admit a resident transferred from another facility, because of an emergency or otherwise, the nursing facility may not admit a resident whose needs cannot be met through service from the facility's staff or in cooperation with community resources or other providers under contract. If a nursing facility refuses to admit a resident under this subsection, the nursing facility shall provide a written statement of the reasons for the refusal to the department within a period specified by department rule. A nursing facility that fails to provide the written statement, or that includes false or misleading information in the statement, is subject to monetary penalties assessed in accordance with this chapter.(p) In order to increase the personal needs allowance under Section 32.024(v), as added by Chapter 1333, Acts of the 76th Legislature, Regular Session, 1999, the department shall develop an early warning system to detect fraud in the handling of the personal needs allowance and other funds of residents of long-term care facilities.(q) The department shall include in its contracts for the delivery of medical assistance by nursing facilities clearly defined minimum standards that relate directly to the quality of care for residents of those facilities. The department shall consider the recommendations made by the nursing facility quality assurance team under Section 32.060 in establishing the standards. The department shall include in each contract:(1) specific performance measures by which the department may evaluate the extent to which the nursing facility is meeting the standards; and(2) provisions that allow the department to terminate the contract if the nursing facility is not meeting the standards.(r) The department may not award a contract for the delivery of medical assistance to a nursing facility that does not meet the minimum standards that would be included in the contract as required by Subsection (q). The department shall terminate a contract for the delivery of medical assistance by a nursing facility that does not meet or maintain the minimum standards included in the contract in a manner consistent with the terms of the contract.(s) Not later than November 15 of each even-numbered year, the department shall submit a report to the legislature regarding nursing facilities that contract with the department to provide medical assistance under this chapter and other nursing facilities with which the department was prohibited to contract as provided by Subsection (r). The department may include the report required under this section with the report made by the long-term care legislative oversight committee as required by Section 242.654, Health and Safety Code. The report must include:(1) recommendations for improving the quality of information provided to consumers about the facilities;(2) the minimum standards and performance measures included in the department's contracts with those facilities;(3) the performance of the facilities with regard to the minimum standards;(4) the number of facilities with which the department has terminated a contract or to which the department will not award a contract because the facilities do not meet the minimum standards; and(5) the overall impact of the minimum standards on the quality of care provided by the facilities, consumers' access to facilities, and cost of care.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1991, 72nd Leg., 1st C.S., ch. 15, Sec. 5.22, eff. Sept. 1, 1991; Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 1049, Sec. 1, eff. Sept. 1, 1995; Acts 1997, 75th Leg., ch. 1159, Sec. 2.01, eff. Sept. 1, 1997; Acts 2001, 77th Leg., ch. 974, Sec. 2, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1284, Sec. 3.01, 3.04, 7.04, eff. June 15, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.92(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1), eff. Sept. 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 809, Sec. 1, eff. September 1, 2007.
Sec. 32.0211. RESTRICTIONS ON MEMBERS OF THE BOARD, COMMISSIONERS, AND THEIR PARTNERS. (a) After service in the department ends, a former member of the board or a former commissioner may not knowingly represent a person before an agency or court:(1) in a matter related to the medical assistance program in which the department or the federal government has a direct interest and in which the board member or commissioner participated personally while employed with the department; or(2) for two years after the date on which service ends in a matter related to the medical assistance program if the department or the federal government has a direct interest in the matter, the matter was pending during his last year of service to the department, and the matter was one for which the board member or commissioner had responsibility.(b) Subsection (a) of this section does not apply to a former board member or commissioner who holds one of the following positions and is acting in the scope of that position:(1) employee or officer of federal, state, or local government;(2) employee of a nonprofit hospital or medical research organization; or(3) employee of an accredited degree-granting college or university.(c) A current board member or commissioner may not knowingly participate in the course of his service in a matter related to the medical assistance program in which the department or the federal government has a direct interest and in which he, his spouse, minor child, or business partner has a substantial financial interest.(d) A business partner of a current board member or commissioner may not knowingly represent a person before an agency or court in a matter related to the medical assistance program:(1) in which the board member or commissioner participates or has participated personally and substantially; or(2) that is under the official responsibility of the board member or commissioner.(e) Past or present board members or commissioners are subject to a civil penalty of $5,000 for each violation of this section. A partner of a current board member or commissioner is subject to a civil penalty of $2,500 for each violation of this section. Each appearance before an agency or court constitutes a separate offense.(f) If it appears that this section has been violated, the department may request the attorney general to conduct a suit in the name of the State of Texas to enjoin the prohibited activity and to recover the penalty provided for in this section.
Added by Acts 1981, 67th Leg., p. 755, ch. 287, Sec. 1, eff. Aug. 31, 1981.
Sec. 32.0212. DELIVERY OF MEDICAL ASSISTANCE. Notwithstanding any other law and subject to Section 533.0025, Government Code, the department shall provide medical assistance for acute care through the Medicaid managed care system implemented under Chapter 533, Government Code.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.95, eff. Sept. 1, 2003.
Sec. 32.0213. NURSING FACILITY BED CERTIFICATION AND DECERTIFICATION. (a) The department by rule shall establish procedures for:(1) controlling the number of Medicaid beds in nursing facilities;(2) decertification of unused Medicaid beds in nursing facilities; and(3) reallocation of nursing home beds decertified under Subdivision (2) to other nursing facilities.(b) The procedures established under this section must take into account the occupancy rate of the nursing facility.(c) The department may exempt a nursing facility from the procedures established under this section if the facility:(1) is affiliated with a state-supported medical school;(2) is located on land owned or controlled by the state-supported medical school; and(3) serves as a teaching facility for physicians and related health care professionals.
Added by Acts 1997, 75th Leg., ch. 1159, Sec. 2.02, eff. Sept. 1, 1997. Amended by Acts 1999, 76th Leg., ch. 1487, Sec. 1, eff. June 19, 1999.
Sec. 32.0214. DESIGNATIONS OF PRIMARY CARE PROVIDER BY CERTAIN RECIPIENTS. (a) If the department determines that it is cost-effective and feasible and subject to Subsection (b), the department shall require each recipient of medical assistance to designate a primary care provider with whom the recipient will have a continuous, ongoing professional relationship and who will provide and coordinate the recipient's initial and primary care, maintain the continuity of care provided to the recipient, and initiate any referrals to other health care providers.(b) A recipient who receives medical assistance through a Medicaid managed care model or arrangement under Chapter 533, Government Code, that requires the designation of a primary care provider shall designate the recipient's primary care provider as required by that model or arrangement.
Added by Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 15, eff. September 1, 2007.
Sec. 32.0215. HOME OR COMMUNITY CARE PROVIDERS: CIVIL MONETARY PENALTIES. (a) The department may include in a contract for the delivery of medical assistance by a home or community care provider a provision for monetary penalties to be assessed for a contract violation or any violation of home or community care requirements, as required by 42 U.S.C. Section 1396t(j).(b) The department shall develop rules governing the application of civil money penalties, including rules prescribing:(1) criteria that describe when and how a civil money penalty may be assessed and the amount of the penalty;(2) a system to ensure standard and consistent application of the penalties throughout the state; and(3) an administrative appeals process to adjudicate claims in contested cases in accordance with Chapter 2001, Government Code.(c) Rules adopted under this section must be designed to minimize the time between the identification of a violation and the final imposition of a penalty. Rules adopted under this section may authorize the imposition of a penalty that assesses and collects a monetary penalty, with interest, for a minimum penalty period and on a subsequent per diem basis.(d) A penalty must be appropriate to the violation. The department may assess incrementally more severe penalties for repeated or uncorrected violations.(e) The department shall review a penalized provider within 10 working days after the provider notifies the department that the deficiency that caused the imposition of the penalty has been corrected. If the department is unable to review the provider within that 10-working-day period, the penalty ceases on the earlier of the last day of the minimum penalty period or the date the provider gives notice to the department.(f) Money collected as a result of the imposition of penalties may be used for the protection of the health or property of an individual whose personal property was lost due to a failure of a home or community care provider to meet the requirements for participation as a provider of home or community care.
Added by Acts 1993, 73rd Leg., ch. 132, Sec. 1, eff. Sept. 1, 1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff. Sept. 1, 1995.
Sec. 32.022. MEDICAL AND HOSPITAL CARE ADVISORY COMMITTEES. (a) The board, on the recommendation of the commissioner, shall appoint a medical care advisory committee to advise the board and the department in developing and maintaining the medical assistance program and in making immediate and long-range plans for reaching the program's goal of providing access to high quality, comprehensive medical and health care services to medically indigent persons in the state. To ensure that qualified applicants receive services, the committee shall consider changes in the process the department uses to determine eligibility.(b) The board shall appoint the committee in compliance with the requirements of the federal agency administering medical assistance. The appointments shall provide for a balanced representation of the general public, providers, consumers, and other persons, state agencies, or groups with knowledge of and interest in the committee's field of work.(c) The department shall adopt rules for membership on the committee to provide for efficiency of operation, rotation, stability, and continuity.(d) The board, on the recommendation of the commissioner, may appoint regional and local medical care advisory committees and other advisory committees as considered necessary.(e) The board, on the recommendation of the commissioner, shall appoint a hospital payment advisory committee. The committee shall advise the board and the department on necessary changes in hospital payment methodologies for inpatient hospital prospective payments and on adjustments for disproportionate share hospitals that will ensure reasonable, adequate, and equitable payments to hospital providers and that will address the essential role of rural hospitals. The board shall appoint to the committee persons with knowledge of and an interest in hospital payment issues.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1987, 70th Leg., ch. 1052, Sec. 2.01, eff. Sept. 1, 1987; Acts 1989, 71st Leg., ch. 1027, Sec. 10, eff. Sept. 1, 1989.
Sec. 32.023. COOPERATION WITH OTHER STATE AGENCIES. (a) The department's plan for administering medical assistance must include procedures for using health services administered by other state agencies pursuant to cooperative arrangements.(b) The department may enter into agreements with appropriate state agencies that will enable the department to implement Title XIX of the federal Social Security Act to provide medical assistance for individuals in institutions or in alternate care arrangements. The agreements must comply with federal law and rules. The department may make medical assistance payments in accordance with the agreements. The agreements are not subject to the Interagency Cooperation Act (Article 4413(32), Vernon's Texas Civil Statutes).(c) State agencies responsible for the administration or supervision of facilities to which medical assistance payments may be made under federal law shall enter into the agreements with the department and maintain compliance with the agreements so that the department may receive federal matching funds to support the medical assistance program.(d) The department may pay medical assistance to other facilities as required under federal law and rules.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.0231. ANNOUNCEMENT OF FUNDING OR PROGRAM CHANGE. (a) The department shall publish notice in the Texas Register of:(1) any attempt to obtain a waiver of federal regulations in the medical assistance program;(2) any attempt to obtain or the receipt of funding under Title XIX of the federal Social Security Act (42 U.S.C. Section 301 et seq.) for a pilot program; and(3) any amendment to the state medical assistance plan.(b) The notice must include the name and telephone number of a department employee who can provide information relating to the matter for which notice was published under this section.(c) The department shall provide to any requestor information relating to a matter for which notice was published, including the effect and cost of the change, any possible cost savings, the criteria for receiving services, and the number of people to be served.
Added by Acts 1989, 71st Leg., ch. 1085, Sec. 2, eff. Sept. 1, 1989.
Sec. 32.024. AUTHORITY AND SCOPE OF PROGRAM; ELIGIBILITY. (a) The department shall provide medical assistance to all persons who receive financial assistance from the state under Chapter 31 of this code and to other related groups of persons if the provision of medical assistance to those persons is required by federal law and rules as a condition for obtaining federal matching funds for the support of the medical assistance program.(b) The department may provide medical assistance to other persons who are financially unable to meet the cost of medical services if federal matching funds are available for that purpose. The department shall adopt rules governing the eligibility of those persons for the services.(c) The department shall establish standards governing the amount, duration, and scope of services provided under the medical assistance program. The standards may not be lower than the minimum standards required by federal law and rule as a condition for obtaining federal matching funds for support of the program, and may not be lower than the standards in effect on August 27, 1967. Standards or payments for the vendor drug program may not be lower than those in effect on January 1, 1973.(d) The department may establish standards that increase the amount, duration, and scope of the services provided only if federal matching funds are available for the optional services and payments and if the department determines that the increase is feasible and within the limits of appropriated funds. The department may establish and maintain priorities for the provision of the optional medical services.(e) The department may not authorize the provision of any service to any person under the program unless federal matching funds are available to pay the cost of the service.(f) The department shall set the income eligibility cap for persons qualifying for nursing home care at an amount that is not less than $1,104 and that does not exceed the highest income for which federal matching funds are payable. The department shall set the cap at a higher amount than the minimum provided by this subsection if appropriations made by the legislature for a fiscal year will finance benefits at the higher cap for at least the same number of recipients of the benefits during that year as were served during the preceding fiscal year, as estimated by the department. In setting an income eligibility cap under this subsection, the department shall consider the cost of the adjustment required by Subsection (g) of this section.(g) During a fiscal year for which the cap described by Subsection (f) of this section has been set, the department shall adjust the cap in accordance with any percentage change in the amount of benefits being paid to social security recipients during the year.(h) Subject to the amount of the cap set as provided by Subsections (f) and (g) of this section, and to the extent permitted by federal law, the income eligibility cap for community care for aged and disabled persons shall be the same as the income eligibility cap for nursing home care. The department shall ensure that the eligibility requirements for persons receiving other services under the medical assistance program are not affected. Text of subsec. (i) as amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.96 (i) The department in its adoption of rules may establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses, subject to availability of appropriated funds. Text of subsec. (i) as amended by Acts 2003, 78th Leg., ch. 1251, Sec. 6 (i) Subject to appropriated state funds, the department in its adoption of rules shall establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses.(j) The department in its adoption of rules shall in fiscal year 1990 restore three percent of the 10 percent reduction in provider reimbursement.(k) The department in its adoption of rules shall in fiscal year 1991 restore 4.5 percent of the 10 percent reduction in provider reimbursement.(l) The department shall set the income eligibility cap for medical assistance for pregnant women and infants up to age one at not less than 130 percent of the federal poverty guidelines.(m) The department shall set the income eligibility cap for medical assistance for children up to age four at not less than 100 percent of the federal poverty guidelines for state fiscal year 1990 and for children up to age six for state fiscal year 1991.(n) The department in its adoption of rules and standards governing the scope of hospital and long-term services shall authorize the providing of respite care by hospitals.(o) The department, in its rules and standards governing the scope of hospital and long-term services, shall establish a swing bed program in accordance with federal regulations to provide reimbursement for skilled nursing patients who are served in hospital settings provided that the length of stay is limited to 30 days per year and the hospital is located in a county with a population of 100,000 or less. If the swing beds are used for more than one 30-day length of stay per year, per patient, the hospital must comply with the Minimum Licensing Standards as mandated by Chapter 242, Health and Safety Code, and the Medicaid standards for nursing home certification, as promulgated by the department.(p) The department shall provide home respiratory therapy services for ventilator-dependent persons to the extent permitted by federal law.(q) The department shall provide physical therapy services.(r) The department, from funds otherwise appropriated to the department for the early and periodic screening, diagnosis, and treatment program, shall provide to a child who is 14 years of age or younger, permanent molar sealants as dental service under that program as follows:(1) sealant shall be applied only to the occlusal buccal and lingual pits and fissures of a permanent molar within four years of its eruption;(2) teeth to be sealed must be free of proximal caries and free of previous restorations on the surface to be sealed;(3) if a second molar is the prime tooth to be sealed, a non-restored first molar may be sealed at the same sitting, if the fee for the first molar sealing is no more than half the usual sealant fee;(4) the sealing of premolars and primary molars will not be reimbursed; and(5) replacement sealants will not be reimbursed.(s) The department, in its rules governing the early and periodic screening, diagnosis, and treatment program, shall:(1) revise the periodicity schedule to allow for periodic visits at least as often as the frequency recommended by the American Academy of Pediatrics and allow for interperiodic screens without prior approval when there are indications that it is medically necessary; and(2) require, as a condition for eligibility for reimbursement under the program for the cost of services provided at a visit or screening, that a child younger than 15 years of age be accompanied at the visit or screening by:(A) the child's parent or guardian; or(B) another adult, including an adult related to the child, authorized by the child's parent or guardian to accompany the child.(s-1) Subsection (s)(2) does not apply to services provided by a school health clinic, Head Start program, or child-care facility, as defined by Section 42.002, if the clinic, program, or facility:(1) obtains written consent to the services from the child's parent or guardian within the one-year period preceding the date on which the services are provided, and that consent has not been revoked; and(2) encourages parental involvement in and management of the health care of children receiving services from the clinic, program, or facility.(t) The department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain authorization from the department or a person authorized to act on behalf of the department on the same day or the next business day following the day of transport when an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency and the request is for the authorization of the provision of transportation for only one day. If the request is for authorization of the provision of transportation on more than one day, the department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain a single authorization before an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency. The rules must provide that:(1) except as provided by Subdivision (3), a request for authorization must be evaluated based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition;(2) except as provided by Subdivision (3), a response to a request for authorization must be made not later than 48 hours after receipt of the request;(3) a request for authorization must be immediately granted and must be effective for a period of not more than 180 days from the date of issuance if the request includes a written statement from a physician that:(A) states that alternative means of transporting the recipient are contraindicated; and(B) is dated not earlier than the 60th day before the date on which the request for authorization is made;(4) a person denied payment for ambulance services rendered is entitled to payment from the nursing facility, health care provider, or other responsible party that requested the services if:(A) payment under the medical assistance program is denied because of lack of prior authorization; and(B) the person provides the nursing facility, health care provider, or other responsible party with a copy of the bill for which payment was denied;(5) a person denied payment for services rendered because of failure to obtain prior authorization or because a request for prior authorization was denied is entitled to appeal the denial of payment to the department; and(6) the department or a person authorized to act on behalf of the department must be available to evaluate requests for authorization under this subsection not less than 12 hours each day, excluding weekends and state holidays.(t-1) The department, in its rules governing the medical transportation program, may not prohibit a recipient of medical assistance from receiving transportation services through the program to obtain renal dialysis treatment on the basis that the recipient resides in a nursing facility.(u) The department by rule shall require a health care provider who arranges for durable medical equipment for a child who receives medical assistance under this chapter to:(1) ensure that the child receives the equipment prescribed, the equipment fits properly, if applicable, and the child or the child's parent or guardian, as appropriate considering the age of the child, receives instruction regarding the equipment's use; and(2) maintain a record of compliance with the requirements of Subdivision (1) in an appropriate location.(v) The department by rule shall provide a screening test for hearing loss in accordance with Chapter 47, Health and Safety Code, and any necessary diagnostic follow-up care related to the screening test to a child younger than 30 days old who receives medical assistance.(w) The department shall set a personal needs allowance of not less than $60 a month for a resident of a convalescent or nursing home or related institution licensed under Chapter 242, Health and Safety Code, personal care facility, ICF-MR facility, or other similar long-term care facility who receives medical assistance. The department may send the personal needs allowance directly to a resident who receives Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.). This subsection does not apply to a resident who is participating in a medical assistance waiver program administered by the department.(x) The department shall provide dental services annually to a resident of a nursing facility who is a recipient of medical assistance under this chapter. The dental services must include:(1) a dental examination by a licensed dentist;(2) a prophylaxis by a licensed dentist or licensed dental hygienist, if practical considering the health of the resident; and(3) diagnostic dental x-rays, if possible.(y) The department shall provide medical assistance to a person in need of treatment for breast or cervical cancer who is eligible for that assistance under the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Pub. L. No. 106-354) for a continuous period during which the person requires that treatment. The department shall simplify the provider enrollment process for a provider of that medical assistance and shall adopt rules to provide for certification of presumptive eligibility of a person for that assistance. In determining a person's eligibility for medical assistance under this subsection, the department, to the extent allowed by federal law, may not require a personal interview.(y-1) A woman who receives a breast or cervical cancer screening service under Title XV of the Public Health Service Act (42 U.S.C. Section 300k et seq.) and who otherwise meets the eligibility requirements for medical assistance for treatment of breast or cervical cancer as provided by Subsection (y) is eligible for medical assistance under that subsection, regardless of whether federal Medicaid matching funds are available for that medical assistance. A screening service of a type that is within the scope of screening services under that title is considered to be provided under that title regardless of whether the service was provided by a provider who receives or uses funds under that title.(z) In its rules and standards governing the vendor drug program, the department, to the extent allowed by federal law and if the department determines the policy to be cost-effective, may ensure that a recipient of prescription drug benefits under the medical assistance program does not, unless authorized by the department in consultation with the recipient's attending physician or advanced practice nurse, receive under the medical assistance program:(1) more than four different outpatient brand-name prescription drugs during a month; or(2) more than a 34-day supply of a brand-name prescription drug at any one time.(z-1) Subsection (z) does not affect any other limit on prescription medications otherwise prescribed by department rule.(aa) The department shall incorporate physician-oriented instruction on the appropriate procedures for authorizing ambulance service into current medical education courses.(bb) The department may not provide an erectile dysfunction medication under the Medicaid vendor drug program to a person required to register as a sex offender under Chapter 62, Code of Criminal Procedure, to the maximum extent federal law allows the department to deny that medication.(cc) In this subsection, "deaf" and "hard of hearing" have the meanings assigned by Section 81.001. Subject to the availability of funds, the department shall provide interpreter services as requested during the receipt of medical assistance under this chapter to:(1) a person receiving that assistance who is deaf or hard of hearing; or(2) a parent or guardian of a person receiving that assistance if the parent or guardian is deaf or hard of hearing.(dd) Nothwithstanding any other law, an inmate released on medically recommended intensive supervision under Section 508.146, Government Code, who otherwise meets the eligibility requirements for the medical assistance program is not ineligible for the program solely on the basis of the conviction or adjudication for which the inmate was sentenced to confinement.(ii) The department shall provide medical assistance reimbursement to a pharmacist who is licensed to practice pharmacy in this state, is authorized to administer immunizations in accordance with rules adopted by the Texas State Board of Pharmacy, and administers an immunization to a recipient of medical assistance to the same extent the department provides reimbursement to a physician or other health care provider participating in the medical assistance program for the administration of that immunization.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1027, Sec. 11, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1085, Sec. 3, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1107, Sec. 1, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1219, Sec. 1, eff. Sept. 1, 1989; Acts 1990, 71st Leg., 6th C.S., ch. 12, Sec. 2(11) to (13), eff. Sept. 6, 1990; Acts 1991, 72nd Leg., ch. 690, Sec. 1, eff. Aug. 26, 1991; Acts 1995, 74th Leg., ch. 6, Sec. 3, eff. March 23, 1995; Acts 1997, 75th Leg., ch. 1153, Sec. 2.01(a), 2.02(a), eff. June 20, 1997; Acts 1999, 76th Leg., ch. 766, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1333, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1347, Sec. 3, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1505, Sec. 1.06, eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 220, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 348, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 974, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1420, Sec. 21.001(81), eff. Sept. 1, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.96, 2.97(a), 2.207(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 215, Sec. 1, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 6, eff. June 20, 2003; Acts 2003, 78th Leg., ch. 1275, Sec. 2(97), eff. Sept. 1, 2003.Amended by: Acts 2005, 79th Leg., Ch. 349, Sec. 22, eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 728, Sec. 23.001(57), eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 1314, Sec. 1, eff. September 1, 2005.Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 16, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 442, Sec. 1, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 921, Sec. 17.001(50), eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 1308, Sec. 45, eff. June 15, 2007.Acts 2009, 81st Leg., R.S., Ch. 745, Sec. 2, eff. September 1, 2009.Acts 2009, 81st Leg., R.S., Ch. 858, Sec. 1, eff. June 19, 2009.
Sec. 32.0241. REVIEW OF WAIVER REQUEST. The department shall, at least biennially, review the feasibility of requesting a waiver for the elderly under Section 1915(c), federal Social Security Act (42 U.S.C. Section 1396n), if the reimbursement rates for nursing homes under the medical assistance program have increased since the preceding review.
Added by Acts 1989, 71st Leg., ch. 1085, Sec. 2, eff. Sept. 1, 1989.
Sec. 32.0242. VERIFICATION OF CERTAIN INFORMATION. To the extent possible, the department shall verify an applicant's residential address at the time the application for medical assistance is filed.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 1, eff. Sept. 1, 1999.
Sec. 32.0243. PERIODIC REVIEW OF ELIGIBILITY FOR CERTAIN RECIPIENTS. (a) The department, in cooperation with the United States Social Security Administration, shall periodically review the eligibility of a recipient of medical assistance who is eligible on the basis of the recipient's eligibility for Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq., as amended.(b) In reviewing the eligibility of a recipient as required by Subsection (a), the department shall ensure that only recipients who reside in this state and who continue to be eligible for Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq., as amended, remain eligible for medical assistance.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 1, eff. Sept. 1, 1999.
Sec. 32.0244. NURSING HOME BEDS IN CERTAIN COUNTIES. (a) At the request of the commissioners court of a county in which not more than two nursing facilities are certified to participate in the state Medicaid program, and subject to Subsection (d), the department may contract for additional nursing home beds under the state Medicaid program in the county without regard to the occupancy rate of available Medicaid beds.(b) A commissioners court that intends to make a request under Subsection (a) shall publish notice of its intent in the Texas Register and in a newspaper of general circulation in the county. The notice must request:(1) comments on whether the request should be made; and(2) proposals from persons interested in providing additional Medicaid beds in the county, including persons providing Medicaid beds in a nursing facility with a high occupancy rate.(c) A commissioners court shall determine whether to proceed with a request after considering all comments and proposals received in response to the notices provided under Subsection (b). If the commissioners court proceeds with the request, the court may recommend that the department contract with a specific nursing facility that submitted a proposal. In determining whether to proceed with the request and whether to recommend a specific nursing facility, the commissioners court shall consider:(1) the demographic and economic needs of the county;(2) the quality of existing nursing facility services under the state Medicaid program in the county;(3) the quality of the proposals submitted; and(4) the degree of community support for additional nursing facility services.(d) The department may not contract under this section for more than 120 additional nursing home beds per county per year and may not exceed 500 additional nursing home beds statewide in a calendar year.
Added by Acts 1997, 75th Leg., ch. 555, Sec. 1, eff. Sept. 1, 1997. Renumbered from Sec. 32.0246 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(73), eff. Sept. 1, 1999.
Sec. 32.0245. NURSING HOME BEDS FOR CERTAIN FACILITIES TREATING ALZHEIMER'S DISEASE. The department shall waive for a nursing facility a restriction imposed by state law on the authority to contract under the state Medicaid program for nursing home beds based on the percentage of beds that are occupied in a geographical area if the facility:(1) is affiliated with a medical school operated by the state;(2) is participating in a research program for the care and treatment of persons with Alzheimer's disease; and(3) is designed to separate and treat Alzheimer's disease by stage or functional level.
Added by Acts 1995, 74th Leg., ch. 841, Sec. 1, eff. Aug. 28, 1995.
Sec. 32.02451. REIMBURSEMENT FOR GUARDIANSHIP EXPENSES OF CERTAIN RECIPIENTS. To the extent allowed by federal law, the department shall provide medical assistance reimbursement for compensation and costs ordered under Section 670, Texas Probate Code, in a guardianship established for a medical assistance recipient. The executive commissioner of the Health and Human Services Commission shall adopt rules providing a procedure by which a person to whom amounts are ordered paid under that section may submit a claim to and receive reimbursement from the medical assistance program.
Added by Acts 2009, 81st Leg., R.S., Ch. 859, Sec. 1, eff. September 1, 2009.
Sec. 32.0246. PILOT PROGRAM FOR TREATMENT OF ALZHEIMER'S PATIENTS. (a) The Texas Department of Human Services, in cooperation with all appropriate state and federal agencies and with the advisory committee established in Subsection (b), shall develop and implement a pilot program for the treatment of individuals diagnosed with Alzheimer's disease. The pilot program shall:(1) be operated in one rural county and one urban county contiguous to the rural county;(2) provide a continuum of care and comprehensive case management, address gaps in services, and address the special needs of Alzheimer's patients; and(3) develop and implement counseling, education, and support services for the caregivers and family members of Alzheimer's patients.(b) The Texas Department of Human Services shall appoint an advisory committee to assist the department in developing and implementing the pilot program. The advisory committee shall be composed of:(1) four representatives from groups that advocate for Alzheimer's patients;(2) one representative from an institution of higher education;(3) one clinician;(4) one representative from the Texas Department on Aging;(5) one representative from the Texas Department of Human Services; and(6) one representative from the Texas Department of Mental Health and Mental Retardation.(c) The pilot program may not make eligible for medical assistance any individual not otherwise eligible for medical assistance.(d) The Texas Department of Human Services may seek and accept a gift, grant, or donation from any person for purposes of developing and implementing the pilot program provided that the person does not have a contested case pending before any agency participating in the pilot program.(e) Not later than January 15, 1999, the Texas Department of Human Services shall submit to the legislature a report concerning the effectiveness of the pilot program.
Added by Acts 1997, 75th Leg., ch. 415, Sec. 1, eff. Sept. 1, 1997.
Sec. 32.0247. MEDICAL ASSISTANCE FOR CERTAIN PERSONS MAKING TRANSITION FROM FOSTER CARE TO INDEPENDENT LIVING. (a) In this section, "independent foster care adolescent" has the meaning assigned by 42 U.S.C. Section 1396d(w)(1), as amended.(b) The department shall provide medical assistance, in accordance with department rules, to an independent foster care adolescent who:(1) is not otherwise eligible for medical assistance; and(2) is not covered by a health benefits plan offering adequate benefits, as determined by the Health and Human Services Commission.(c) The department shall by rule establish a specific set of income, assets, or resources allowable for recipients under this section. The income level shall not be less than 200 percent or more than 400 percent of the federal poverty level. Allowable asset or resource levels shall not be less than:(1) the levels allowed for individuals who are in foster care; and(2) the levels allowed for a person under 19 years of age who is eligible for the medical assistance program.(d) In setting allowable income, asset, or resource levels, the department shall exclude:(1) any financial benefit used for the purpose of educational or vocational training, such as scholarships, student loans, or grants;(2) any financial benefit used for the purpose of housing; and(3) any grants or subsidies obtained as a result of the Foster Care Independence Act of 1999 (Pub. L. No. 106-169).(e) The Department of Protective and Regulatory Services shall certify the income, assets, or resources of each individual on the date the individual exits substitute care. An individual qualifying for medical assistance as established by this section shall remain eligible for 12 calendar months after certification and after each recertification.(f) The recertification process for individuals who are eligible for medical assistance under this section shall include the option of recertifying by mail or phone.
Added by Acts 2001, 77th Leg., ch. 1218, Sec. 1, eff. Sept. 1, 2001.
Sec. 32.02471. MEDICAL ASSISTANCE FOR CERTAIN FORMER FOSTER CARE ADOLESCENTS ENROLLED IN HIGHER EDUCATION. (a) In this section, "independent foster care adolescent" has the meaning assigned by Section 32.0247.(b) The department shall provide medical assistance to a person who:(1) is 21 years of age or older but younger than 23 years of age;(2) would be eligible to receive assistance as an independent foster care adolescent under Section 32.0247 if the person were younger than 21 years of age; and(3) is enrolled in an institution of higher education, as defined by Section 61.003(8), Education Code, or a private or independent institution of higher education, as defined by Section 61.003(15), Education Code, that is located in this state and is making satisfactory academic progress as determined by the institution.
Added by Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 17, eff. September 1, 2007.
For expiration of this section, see Subsection (i).Sec. 32.0248. DEMONSTRATION PROJECT FOR WOMEN'S HEALTH CARE SERVICES. (a) The department shall establish a five-year demonstration project through the medical assistance program to expand access to preventive health and family planning services for women. A woman eligible under Subsection (b) to participate in the demonstration project may receive appropriate preventive health and family planning services, including:(1) medical history recording and evaluation;(2) physical examinations;(3) health screenings, including screening for:(A) diabetes;(B) cervical cancer;(C) breast cancer;(D) sexually transmitted diseases;(E) hypertension;(F) cholesterol; and(G) tuberculosis;(4) counseling and education on contraceptive methods emphasizing the health benefits of abstinence from sexual activity to recipients who are not married, except for counseling and education regarding emergency contraception;(5) provision of contraceptives, except for the provision of emergency contraception;(6) risk assessment; and(7) referral of medical problems to appropriate providers that are entities or organizations that do not perform or promote elective abortions or contract or affiliate with entities that perform or promote elective abortions.(b) A woman is eligible to participate in the demonstration project if the woman is at least 18 years of age and:(1) has a net family income that is at or below 185 percent of the federal poverty level;(2) participates in or receives benefits under any of the following:(A) the medical assistance program;(B) the financial assistance program under Chapter 31;(C) the nutritional assistance program under Chapter 33;(D) the Supplemental Food Program for Women, Infants and Children; or(E) another program administered by the state that:(i) requires documentation of income; and(ii) restricts eligibility to persons with income equal to or less than the income eligibility guidelines applicable to the medical assistance program;(3) is presumed eligible for one of the programs listed in Subdivision (2) pending completion of that program's eligibility process; or(4) is a member of a family that contains at least one person who participates in or receives benefits under one of the programs listed in Subdivision (2).(c) The department shall ensure that the standards of care provided to a woman participating in the demonstration project are consistent with the requirements of law and current best practices for provision of public health services.(d) The department shall develop procedures for determining and certifying eligibility for services under the demonstration project at the point of service delivery using integrated procedures that minimize duplication of effort by providers, the department, and other state agencies. The department may not use a procedure that would require a cost in excess of 10 percent of the total costs of actual preventive health and family planning services provided under the demonstration project. The eligibility procedure may provide for expedited determination and certification using a simplified form requiring only family income and family size.(e) The department shall compile a list of potential funding sources a woman participating in the demonstration project may be able to use to help pay for treatment for health problems:(1) identified using services provided under the demonstration project; and(2) for which the woman is not eligible to receive treatment under the medical assistance program or the demonstration project.(f) Providers of services under the demonstration project shall comply with requests made by the department for information necessary for the department to:(1) make efficient use of money spent for the operation and administration of the demonstration project;(2) report and provide information required by federal law; and(3) compile the report required by Subsection (g).(g) Not later than December 1 of each even-numbered year, the department shall submit a report to the legislature regarding the department's progress in establishing and operating the demonstration project.(h) The department shall ensure the money spent under the demonstration project, regardless of the funding source, is not used to perform or promote elective abortions. The department, for the purpose of the demonstration project, may not contract with entities that perform or promote elective abortions or are affiliates of entities that perform or promote elective abortions.(i) This section expires September 1, 2011.
Added by Acts 2005, 79th Leg., Ch. 816, Sec. 1, eff. June 17, 2005.
Sec. 32.025. APPLICATION FOR MEDICAL ASSISTANCE. (a) A recipient of benefits under Chapter 31 of this code or supplemental security income from the federal government is automatically eligible for medical assistance, and an application for benefits under these programs constitutes an application for medical assistance.(b) The department shall prescribe application forms for persons who are not recipients of benefits under Chapter 31 of this code or supplemental security income from the federal government and shall adopt rules for processing the applications.(c) The department shall inform applicants for nursing home care of any community services which might be available under the community care for the aged and disabled program.(d) The department shall adopt an application form and procedures for a request for medical assistance provided to a child under 19 years of age. To the extent allowed by federal law and except as otherwise provided by this section, the application form and procedures must be the same as the form and procedures adopted under Section 62.103, Health and Safety Code. The department shall coordinate the form and procedures adopted under this subsection with the form and procedures adopted under Section 62.103, Health and Safety Code, to ensure that there is a single consolidated application for a child under 19 years of age to seek medical assistance or to request coverage under the state child health plan under Chapter 62, Health and Safety Code.(e) The department shall permit an application requesting medical assistance for a child under 19 years of age to be conducted by mail instead of through a personal appearance at a department office, unless the department determines that the information needed to verify eligibility cannot be obtained in that manner. The department by rule may develop procedures requiring an application for a child described by this subsection to be conducted through a personal interview with a department representative only if the department determines that information needed to verify eligibility cannot be obtained in any other manner.(f) The commissioner by rule may develop procedures by which:(1) any office of a health and human services agency may accept an application requesting medical assistance for a child under 19 years of age; and(2) the department may contract with hospital districts, hospitals, including state-owned teaching hospitals, federally qualified health centers, and county health departments to accept applications requesting medical assistance for a child under 19 years of age.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1085, Sec. 5, eff. Sept. 1, 1989; Acts 2001, 77th Leg., ch. 584, Sec. 2; Acts 2003, 78th Leg., ch. 376, Sec. 2, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 7, eff. June 20, 2003.
Sec. 32.0251. ELIGIBILITY NOTIFICATION AND REVIEW FOR CERTAIN CHILDREN. (a) The department shall establish and implement procedures under which the department automatically reviews a child's eligibility for medical assistance if:(1) the child originally establishes eligibility for medical assistance on the basis of receipt of financial assistance under Chapter 31, as provided by Section 32.025(a); and(2) that receipt of financial assistance under Chapter 31 ceases.(b) If the review required by this section indicates that the child may be eligible for medical assistance on a basis other than receipt of financial assistance under Chapter 31, the department may provide for provisional eligibility for medical assistance for the child pending a recertification review. The provisional eligibility period authorized by this subsection may not exceed one month.(c) In addition to the review required by this section, the department shall also promote continued medical assistance for a child described by Subsection (a) through:(1) revising client education and notification policies relating to a child's eligibility for medical assistance; and(2) providing specific notification of a child's potential eligibility for medical assistance to the child's parent or other caretaker at the time the parent or caretaker is notified of:(A) a scheduled eligibility recertification review; or(B) the termination of financial assistance.
Added by Acts 1999, 76th Leg., ch. 704, Sec. 1, eff. June 18, 1999.
Sec. 32.0255. TRANSITIONAL MEDICAL ASSISTANCE. (a) The state shall provide transitional medical assistance, in accordance with state rules and federal law, to a person who was receiving financial assistance under Chapter 31 but is no longer eligible to receive the assistance because:(1) the person's household income has increased; or(2) the person has exhausted the person's benefits under Section 31.0065.(b) Except as provided by Section 31.012(c), the state may provide the medical assistance only until the earlier of:(1) the end of the applicable period prescribed by Section 31.0065 for the provision of transitional benefits; or(2) the first anniversary of the date on which the person becomes ineligible for financial assistance because of increased household income.
Added by Acts 1995, 74th Leg., ch. 655, Sec. 3.03, eff. Sept. 1, 1995.
Sec. 32.026. CERTIFICATION OF ELIGIBILITY AND NEED FOR MEDICAL ASSISTANCE. (a) The department shall promulgate rules for determining and certifying a person's eligibility and need for medical assistance.(b) The department shall promulgate rules to provide for determination and certification of presumptive eligibility for any pregnant woman who applies for Medicaid and who meets the basic eligibility requirements under Title XIX of the federal Social Security Act.(c) Medical assistance payments may not be made on a person's behalf until the person's eligibility and need for medical assistance have been certified in accordance with the department's rules.(d) In adopting rules under this section, the department shall ensure, to the extent allowed by federal law, that documentation and verification procedures used in determining and certifying the eligibility and need for medical assistance of a child under 19 years of age, including the documentation and verification procedures used to evaluate the assets and resources of the child, the child's parents, or the child's other caretaker for that purpose, are the same as the documentation and verification procedures used to determine and certify a child's eligibility for coverage under Chapter 62, Health and Safety Code, except that the documentation and verification procedures adopted in accordance with this subsection may not be more stringent than the documentation and verification procedures existing on January 1, 2001, for determination and certification of a child's eligibility for coverage under Chapter 62, Health and Safety Code.(d-1) In adopting rules under this section, the executive commissioner of the Health and Human Services Commission shall, to the extent allowed by federal law, develop and implement an expedited process for determining eligibility for and enrollment in the medical assistance program for an active duty member of the United States armed forces, reserves, or National Guard or of the state military forces, or the spouse or dependent of that person.(e) The department shall permit a recertification review of the eligibility and need for medical assistance of a child under 19 years of age to be conducted by telephone or mail instead of through a personal appearance at a department office, unless the department determines that the information needed to verify eligibility cannot be obtained in that manner. The department by rule may develop procedures to determine whether there is a need for a recertification review of a child described by this subsection to be conducted through a personal interview with a department representative. Procedures developed under this subsection shall be based on objective, risk-based factors and conditions and shall focus on a targeted group of recertification reviews for which there is a high probability that eligibility will not be recertified.(f) In adopting rules under this section, the department shall ensure, to the extent allowed by federal law, that forms and procedures used in conducting a recertification review of the eligibility and need for medical assistance of a child under 19 years of age, including documentation and verification procedures, are the same as the forms and procedures used to determine and certify a child's renewal of coverage under Chapter 62, Health and Safety Code.(g) Notwithstanding any other provision of this code, the department may use information obtained from a third party to verify the assets and resources of a person for purposes of determining the person's eligibility and need for medical assistance. Third-party information includes information obtained from:(1) a consumer reporting agency, as defined by Section 20.01, Business & Commerce Code;(2) an appraisal district; or(3) the Texas Department of Motor Vehicles vehicle registration record database.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1
HUMAN RESOURCES CODETITLE 2. DEPARTMENT OF HUMAN SERVICES AND DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICESSUBTITLE C. ASSISTANCE PROGRAMSCHAPTER 32. MEDICAL ASSISTANCE PROGRAMSUBCHAPTER A. GENERAL PROVISIONSSec. 32.001. PURPOSE OF CHAPTER. The purpose of this chapter is to enable the state to provide medical assistance on behalf of needy individuals and to enable the state to obtain all benefits for those persons authorized under the Social Security Act or any other federal act.
Acts 1979, 66th Leg., p. 2348, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.002. CONSTRUCTION OF CHAPTER. (a) This chapter shall be liberally construed and applied in relation to applicable federal laws and regulations so that adequate and high quality health care may be made available to all children and adults who need the care and are not financially able to pay for it.(b) If a provision of this chapter conflicts with a provision of the Social Security Act or any other federal act and renders the state program out of conformity with federal law to the extent that federal matching money is not available to the state, the conflicting provision of state law shall be inoperative to the extent of the conflict but shall not affect the remainder of this chapter.
Acts 1979, 66th Leg., p. 2348, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.003. DEFINITIONS. In this chapter:(1) "Board" means the Health and Human Services Commission or the governing body of an agency operating part of the medical assistance program, as appropriate.(2) "Commissioner" means the Health and Human Services Commission or the commissioner or executive director of an agency operating part of the medical assistance program, as appropriate.(3) "Department" means the Health and Human Services Commission or an agency operating part of the medical assistance program, as appropriate.(4) "Medical assistance" includes all of the health care and related services and benefits authorized or provided under federal law for needy individuals of this state.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1995, 74th Leg., ch. 6, Sec. 2, eff. March 23, 1995.
SUBCHAPTER B. ADMINISTRATIVE PROVISIONSSec. 32.021. ADMINISTRATION OF THE PROGRAM. (a) The department is the state agency designated to administer the medical assistance program provided in this chapter.(b) The department shall enter into agreements with any federal agency designated by federal law to administer medical assistance when the department determines the agreements to be compatible with the state's participation in the medical assistance program and within the limits of appropriated funds. The department shall cooperate with federal agencies designated by federal law to administer medical assistance in any reasonable manner necessary to qualify for federal funds.(c) The department shall establish methods of administration and adopt necessary rules for the proper and efficient operation of the program.(d) The department shall include in its contracts for the delivery of medical assistance by nursing facilities provisions for monetary penalties to be assessed for violations as required by 42 U.S.C. Section 1396r, including without limitation the Omnibus Budget Reconciliation Act (OBRA), P. L. 100-203, Nursing Home Reform Amendments of 1987, provided that the department shall:(1) provide for an informal dispute resolution process in the Health and Human Services Commission as provided by Section 531.058, Government Code; and(2) develop rules to adjudicate claims in contested cases, including claims unresolved by the informal dispute resolution process of the Health and Human Services Commission.(e) Rules governing the application of penalties shall include the following:(1) specific and objective criteria which describe the scope and severity of a contract violation which results in a recommendation for each specific penalty. Penalties must be appropriate to the violation, and the most severe financial penalties must be reserved for situations which create an immediate and serious threat to the health and safety of residents; "immediate and serious threat" means a situation in which there is a high probability that serious harm or injury to patients could occur at any time or already has occurred and may well occur again if patients are not protected effectively from the harm or if the threat is not removed;(2) a system to ensure standard and consistent application of penalties among surveyors and different areas of the state;(3) due process for nursing facilities providers, including an appeals procedure consistent with Chapter 2001, Government Code; and(4) per diem and/or minimum penalties. The department may by rule prescribe a minimum penalty period; however, once a facility gives the department notice that deficiencies have been corrected, if surveyors are unable to revisit the facility within five days and the deficiencies are later shown to be corrected, the per diem penalties cease as of the day the facility gave notice to the department or on the last day of the minimum penalty period established by the department, whichever is later.(f) To encourage facilities to provide the best possible care, the department shall develop an incentive program to recognize facilities providing the highest quality care to Medicaid residents.(g) Funds collected as a result of the imposition of penalties shall be applied to the protection of the health or property of residents of nursing facilities, including the cost of relocation of residents to other facilities and maintenance or operation of a facility pending correction of deficiencies or closure, or to incentive programs which recognize the highest quality care to residents who are entitled to Medicaid.(h) Medicaid nursing facilities shall also comply with state licensure rules, which may be more stringent than the requirements for certification. The department shall use appropriate civil, administrative, or criminal remedies authorized by state or federal law with respect to a facility that is in violation of a certification or licensing requirement.(i) Repealed by Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1).(j) Repealed by Acts 2001, 77th Leg., ch. 1284, Sec. 3.04, eff. June 15, 2001.(k) Repealed by Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1).(l) The department may not include as a reimbursable item to a nursing facility an administrative or civil penalty assessed against the facility under this chapter or under Chapter 242, Health and Safety Code.(m) Notwithstanding any provision of law to the contrary, the department shall terminate a nursing facility's provider agreement if the department has imposed required Category 2 or Category 3 remedies on the facility three times within a 24-month period. The executive commissioner of the Health and Human Services Commission by rule shall establish criteria under which the requirement to terminate the provider agreement may be waived. In this subsection, "Category 2 remedies" and "Category 3 remedies" have the meanings assigned by 42 C.F.R. Section 488.408.(n) An assessment of monetary penalties under this section is subject to arbitration under Subchapter J, Chapter 242, Health and Safety Code.(o) In any circumstance in which a nursing facility would otherwise be required to admit a resident transferred from another facility, because of an emergency or otherwise, the nursing facility may not admit a resident whose needs cannot be met through service from the facility's staff or in cooperation with community resources or other providers under contract. If a nursing facility refuses to admit a resident under this subsection, the nursing facility shall provide a written statement of the reasons for the refusal to the department within a period specified by department rule. A nursing facility that fails to provide the written statement, or that includes false or misleading information in the statement, is subject to monetary penalties assessed in accordance with this chapter.(p) In order to increase the personal needs allowance under Section 32.024(v), as added by Chapter 1333, Acts of the 76th Legislature, Regular Session, 1999, the department shall develop an early warning system to detect fraud in the handling of the personal needs allowance and other funds of residents of long-term care facilities.(q) The department shall include in its contracts for the delivery of medical assistance by nursing facilities clearly defined minimum standards that relate directly to the quality of care for residents of those facilities. The department shall consider the recommendations made by the nursing facility quality assurance team under Section 32.060 in establishing the standards. The department shall include in each contract:(1) specific performance measures by which the department may evaluate the extent to which the nursing facility is meeting the standards; and(2) provisions that allow the department to terminate the contract if the nursing facility is not meeting the standards.(r) The department may not award a contract for the delivery of medical assistance to a nursing facility that does not meet the minimum standards that would be included in the contract as required by Subsection (q). The department shall terminate a contract for the delivery of medical assistance by a nursing facility that does not meet or maintain the minimum standards included in the contract in a manner consistent with the terms of the contract.(s) Not later than November 15 of each even-numbered year, the department shall submit a report to the legislature regarding nursing facilities that contract with the department to provide medical assistance under this chapter and other nursing facilities with which the department was prohibited to contract as provided by Subsection (r). The department may include the report required under this section with the report made by the long-term care legislative oversight committee as required by Section 242.654, Health and Safety Code. The report must include:(1) recommendations for improving the quality of information provided to consumers about the facilities;(2) the minimum standards and performance measures included in the department's contracts with those facilities;(3) the performance of the facilities with regard to the minimum standards;(4) the number of facilities with which the department has terminated a contract or to which the department will not award a contract because the facilities do not meet the minimum standards; and(5) the overall impact of the minimum standards on the quality of care provided by the facilities, consumers' access to facilities, and cost of care.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1991, 72nd Leg., 1st C.S., ch. 15, Sec. 5.22, eff. Sept. 1, 1991; Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 1049, Sec. 1, eff. Sept. 1, 1995; Acts 1997, 75th Leg., ch. 1159, Sec. 2.01, eff. Sept. 1, 1997; Acts 2001, 77th Leg., ch. 974, Sec. 2, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1284, Sec. 3.01, 3.04, 7.04, eff. June 15, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.92(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1), eff. Sept. 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 809, Sec. 1, eff. September 1, 2007.
Sec. 32.0211. RESTRICTIONS ON MEMBERS OF THE BOARD, COMMISSIONERS, AND THEIR PARTNERS. (a) After service in the department ends, a former member of the board or a former commissioner may not knowingly represent a person before an agency or court:(1) in a matter related to the medical assistance program in which the department or the federal government has a direct interest and in which the board member or commissioner participated personally while employed with the department; or(2) for two years after the date on which service ends in a matter related to the medical assistance program if the department or the federal government has a direct interest in the matter, the matter was pending during his last year of service to the department, and the matter was one for which the board member or commissioner had responsibility.(b) Subsection (a) of this section does not apply to a former board member or commissioner who holds one of the following positions and is acting in the scope of that position:(1) employee or officer of federal, state, or local government;(2) employee of a nonprofit hospital or medical research organization; or(3) employee of an accredited degree-granting college or university.(c) A current board member or commissioner may not knowingly participate in the course of his service in a matter related to the medical assistance program in which the department or the federal government has a direct interest and in which he, his spouse, minor child, or business partner has a substantial financial interest.(d) A business partner of a current board member or commissioner may not knowingly represent a person before an agency or court in a matter related to the medical assistance program:(1) in which the board member or commissioner participates or has participated personally and substantially; or(2) that is under the official responsibility of the board member or commissioner.(e) Past or present board members or commissioners are subject to a civil penalty of $5,000 for each violation of this section. A partner of a current board member or commissioner is subject to a civil penalty of $2,500 for each violation of this section. Each appearance before an agency or court constitutes a separate offense.(f) If it appears that this section has been violated, the department may request the attorney general to conduct a suit in the name of the State of Texas to enjoin the prohibited activity and to recover the penalty provided for in this section.
Added by Acts 1981, 67th Leg., p. 755, ch. 287, Sec. 1, eff. Aug. 31, 1981.
Sec. 32.0212. DELIVERY OF MEDICAL ASSISTANCE. Notwithstanding any other law and subject to Section 533.0025, Government Code, the department shall provide medical assistance for acute care through the Medicaid managed care system implemented under Chapter 533, Government Code.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.95, eff. Sept. 1, 2003.
Sec. 32.0213. NURSING FACILITY BED CERTIFICATION AND DECERTIFICATION. (a) The department by rule shall establish procedures for:(1) controlling the number of Medicaid beds in nursing facilities;(2) decertification of unused Medicaid beds in nursing facilities; and(3) reallocation of nursing home beds decertified under Subdivision (2) to other nursing facilities.(b) The procedures established under this section must take into account the occupancy rate of the nursing facility.(c) The department may exempt a nursing facility from the procedures established under this section if the facility:(1) is affiliated with a state-supported medical school;(2) is located on land owned or controlled by the state-supported medical school; and(3) serves as a teaching facility for physicians and related health care professionals.
Added by Acts 1997, 75th Leg., ch. 1159, Sec. 2.02, eff. Sept. 1, 1997. Amended by Acts 1999, 76th Leg., ch. 1487, Sec. 1, eff. June 19, 1999.
Sec. 32.0214. DESIGNATIONS OF PRIMARY CARE PROVIDER BY CERTAIN RECIPIENTS. (a) If the department determines that it is cost-effective and feasible and subject to Subsection (b), the department shall require each recipient of medical assistance to designate a primary care provider with whom the recipient will have a continuous, ongoing professional relationship and who will provide and coordinate the recipient's initial and primary care, maintain the continuity of care provided to the recipient, and initiate any referrals to other health care providers.(b) A recipient who receives medical assistance through a Medicaid managed care model or arrangement under Chapter 533, Government Code, that requires the designation of a primary care provider shall designate the recipient's primary care provider as required by that model or arrangement.
Added by Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 15, eff. September 1, 2007.
Sec. 32.0215. HOME OR COMMUNITY CARE PROVIDERS: CIVIL MONETARY PENALTIES. (a) The department may include in a contract for the delivery of medical assistance by a home or community care provider a provision for monetary penalties to be assessed for a contract violation or any violation of home or community care requirements, as required by 42 U.S.C. Section 1396t(j).(b) The department shall develop rules governing the application of civil money penalties, including rules prescribing:(1) criteria that describe when and how a civil money penalty may be assessed and the amount of the penalty;(2) a system to ensure standard and consistent application of the penalties throughout the state; and(3) an administrative appeals process to adjudicate claims in contested cases in accordance with Chapter 2001, Government Code.(c) Rules adopted under this section must be designed to minimize the time between the identification of a violation and the final imposition of a penalty. Rules adopted under this section may authorize the imposition of a penalty that assesses and collects a monetary penalty, with interest, for a minimum penalty period and on a subsequent per diem basis.(d) A penalty must be appropriate to the violation. The department may assess incrementally more severe penalties for repeated or uncorrected violations.(e) The department shall review a penalized provider within 10 working days after the provider notifies the department that the deficiency that caused the imposition of the penalty has been corrected. If the department is unable to review the provider within that 10-working-day period, the penalty ceases on the earlier of the last day of the minimum penalty period or the date the provider gives notice to the department.(f) Money collected as a result of the imposition of penalties may be used for the protection of the health or property of an individual whose personal property was lost due to a failure of a home or community care provider to meet the requirements for participation as a provider of home or community care.
Added by Acts 1993, 73rd Leg., ch. 132, Sec. 1, eff. Sept. 1, 1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff. Sept. 1, 1995.
Sec. 32.022. MEDICAL AND HOSPITAL CARE ADVISORY COMMITTEES. (a) The board, on the recommendation of the commissioner, shall appoint a medical care advisory committee to advise the board and the department in developing and maintaining the medical assistance program and in making immediate and long-range plans for reaching the program's goal of providing access to high quality, comprehensive medical and health care services to medically indigent persons in the state. To ensure that qualified applicants receive services, the committee shall consider changes in the process the department uses to determine eligibility.(b) The board shall appoint the committee in compliance with the requirements of the federal agency administering medical assistance. The appointments shall provide for a balanced representation of the general public, providers, consumers, and other persons, state agencies, or groups with knowledge of and interest in the committee's field of work.(c) The department shall adopt rules for membership on the committee to provide for efficiency of operation, rotation, stability, and continuity.(d) The board, on the recommendation of the commissioner, may appoint regional and local medical care advisory committees and other advisory committees as considered necessary.(e) The board, on the recommendation of the commissioner, shall appoint a hospital payment advisory committee. The committee shall advise the board and the department on necessary changes in hospital payment methodologies for inpatient hospital prospective payments and on adjustments for disproportionate share hospitals that will ensure reasonable, adequate, and equitable payments to hospital providers and that will address the essential role of rural hospitals. The board shall appoint to the committee persons with knowledge of and an interest in hospital payment issues.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1987, 70th Leg., ch. 1052, Sec. 2.01, eff. Sept. 1, 1987; Acts 1989, 71st Leg., ch. 1027, Sec. 10, eff. Sept. 1, 1989.
Sec. 32.023. COOPERATION WITH OTHER STATE AGENCIES. (a) The department's plan for administering medical assistance must include procedures for using health services administered by other state agencies pursuant to cooperative arrangements.(b) The department may enter into agreements with appropriate state agencies that will enable the department to implement Title XIX of the federal Social Security Act to provide medical assistance for individuals in institutions or in alternate care arrangements. The agreements must comply with federal law and rules. The department may make medical assistance payments in accordance with the agreements. The agreements are not subject to the Interagency Cooperation Act (Article 4413(32), Vernon's Texas Civil Statutes).(c) State agencies responsible for the administration or supervision of facilities to which medical assistance payments may be made under federal law shall enter into the agreements with the department and maintain compliance with the agreements so that the department may receive federal matching funds to support the medical assistance program.(d) The department may pay medical assistance to other facilities as required under federal law and rules.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.0231. ANNOUNCEMENT OF FUNDING OR PROGRAM CHANGE. (a) The department shall publish notice in the Texas Register of:(1) any attempt to obtain a waiver of federal regulations in the medical assistance program;(2) any attempt to obtain or the receipt of funding under Title XIX of the federal Social Security Act (42 U.S.C. Section 301 et seq.) for a pilot program; and(3) any amendment to the state medical assistance plan.(b) The notice must include the name and telephone number of a department employee who can provide information relating to the matter for which notice was published under this section.(c) The department shall provide to any requestor information relating to a matter for which notice was published, including the effect and cost of the change, any possible cost savings, the criteria for receiving services, and the number of people to be served.
Added by Acts 1989, 71st Leg., ch. 1085, Sec. 2, eff. Sept. 1, 1989.
Sec. 32.024. AUTHORITY AND SCOPE OF PROGRAM; ELIGIBILITY. (a) The department shall provide medical assistance to all persons who receive financial assistance from the state under Chapter 31 of this code and to other related groups of persons if the provision of medical assistance to those persons is required by federal law and rules as a condition for obtaining federal matching funds for the support of the medical assistance program.(b) The department may provide medical assistance to other persons who are financially unable to meet the cost of medical services if federal matching funds are available for that purpose. The department shall adopt rules governing the eligibility of those persons for the services.(c) The department shall establish standards governing the amount, duration, and scope of services provided under the medical assistance program. The standards may not be lower than the minimum standards required by federal law and rule as a condition for obtaining federal matching funds for support of the program, and may not be lower than the standards in effect on August 27, 1967. Standards or payments for the vendor drug program may not be lower than those in effect on January 1, 1973.(d) The department may establish standards that increase the amount, duration, and scope of the services provided only if federal matching funds are available for the optional services and payments and if the department determines that the increase is feasible and within the limits of appropriated funds. The department may establish and maintain priorities for the provision of the optional medical services.(e) The department may not authorize the provision of any service to any person under the program unless federal matching funds are available to pay the cost of the service.(f) The department shall set the income eligibility cap for persons qualifying for nursing home care at an amount that is not less than $1,104 and that does not exceed the highest income for which federal matching funds are payable. The department shall set the cap at a higher amount than the minimum provided by this subsection if appropriations made by the legislature for a fiscal year will finance benefits at the higher cap for at least the same number of recipients of the benefits during that year as were served during the preceding fiscal year, as estimated by the department. In setting an income eligibility cap under this subsection, the department shall consider the cost of the adjustment required by Subsection (g) of this section.(g) During a fiscal year for which the cap described by Subsection (f) of this section has been set, the department shall adjust the cap in accordance with any percentage change in the amount of benefits being paid to social security recipients during the year.(h) Subject to the amount of the cap set as provided by Subsections (f) and (g) of this section, and to the extent permitted by federal law, the income eligibility cap for community care for aged and disabled persons shall be the same as the income eligibility cap for nursing home care. The department shall ensure that the eligibility requirements for persons receiving other services under the medical assistance program are not affected. Text of subsec. (i) as amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.96 (i) The department in its adoption of rules may establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses, subject to availability of appropriated funds. Text of subsec. (i) as amended by Acts 2003, 78th Leg., ch. 1251, Sec. 6 (i) Subject to appropriated state funds, the department in its adoption of rules shall establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses.(j) The department in its adoption of rules shall in fiscal year 1990 restore three percent of the 10 percent reduction in provider reimbursement.(k) The department in its adoption of rules shall in fiscal year 1991 restore 4.5 percent of the 10 percent reduction in provider reimbursement.(l) The department shall set the income eligibility cap for medical assistance for pregnant women and infants up to age one at not less than 130 percent of the federal poverty guidelines.(m) The department shall set the income eligibility cap for medical assistance for children up to age four at not less than 100 percent of the federal poverty guidelines for state fiscal year 1990 and for children up to age six for state fiscal year 1991.(n) The department in its adoption of rules and standards governing the scope of hospital and long-term services shall authorize the providing of respite care by hospitals.(o) The department, in its rules and standards governing the scope of hospital and long-term services, shall establish a swing bed program in accordance with federal regulations to provide reimbursement for skilled nursing patients who are served in hospital settings provided that the length of stay is limited to 30 days per year and the hospital is located in a county with a population of 100,000 or less. If the swing beds are used for more than one 30-day length of stay per year, per patient, the hospital must comply with the Minimum Licensing Standards as mandated by Chapter 242, Health and Safety Code, and the Medicaid standards for nursing home certification, as promulgated by the department.(p) The department shall provide home respiratory therapy services for ventilator-dependent persons to the extent permitted by federal law.(q) The department shall provide physical therapy services.(r) The department, from funds otherwise appropriated to the department for the early and periodic screening, diagnosis, and treatment program, shall provide to a child who is 14 years of age or younger, permanent molar sealants as dental service under that program as follows:(1) sealant shall be applied only to the occlusal buccal and lingual pits and fissures of a permanent molar within four years of its eruption;(2) teeth to be sealed must be free of proximal caries and free of previous restorations on the surface to be sealed;(3) if a second molar is the prime tooth to be sealed, a non-restored first molar may be sealed at the same sitting, if the fee for the first molar sealing is no more than half the usual sealant fee;(4) the sealing of premolars and primary molars will not be reimbursed; and(5) replacement sealants will not be reimbursed.(s) The department, in its rules governing the early and periodic screening, diagnosis, and treatment program, shall:(1) revise the periodicity schedule to allow for periodic visits at least as often as the frequency recommended by the American Academy of Pediatrics and allow for interperiodic screens without prior approval when there are indications that it is medically necessary; and(2) require, as a condition for eligibility for reimbursement under the program for the cost of services provided at a visit or screening, that a child younger than 15 years of age be accompanied at the visit or screening by:(A) the child's parent or guardian; or(B) another adult, including an adult related to the child, authorized by the child's parent or guardian to accompany the child.(s-1) Subsection (s)(2) does not apply to services provided by a school health clinic, Head Start program, or child-care facility, as defined by Section 42.002, if the clinic, program, or facility:(1) obtains written consent to the services from the child's parent or guardian within the one-year period preceding the date on which the services are provided, and that consent has not been revoked; and(2) encourages parental involvement in and management of the health care of children receiving services from the clinic, program, or facility.(t) The department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain authorization from the department or a person authorized to act on behalf of the department on the same day or the next business day following the day of transport when an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency and the request is for the authorization of the provision of transportation for only one day. If the request is for authorization of the provision of transportation on more than one day, the department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain a single authorization before an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency. The rules must provide that:(1) except as provided by Subdivision (3), a request for authorization must be evaluated based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition;(2) except as provided by Subdivision (3), a response to a request for authorization must be made not later than 48 hours after receipt of the request;(3) a request for authorization must be immediately granted and must be effective for a period of not more than 180 days from the date of issuance if the request includes a written statement from a physician that:(A) states that alternative means of transporting the recipient are contraindicated; and(B) is dated not earlier than the 60th day before the date on which the request for authorization is made;(4) a person denied payment for ambulance services rendered is entitled to payment from the nursing facility, health care provider, or other responsible party that requested the services if:(A) payment under the medical assistance program is denied because of lack of prior authorization; and(B) the person provides the nursing facility, health care provider, or other responsible party with a copy of the bill for which payment was denied;(5) a person denied payment for services rendered because of failure to obtain prior authorization or because a request for prior authorization was denied is entitled to appeal the denial of payment to the department; and(6) the department or a person authorized to act on behalf of the department must be available to evaluate requests for authorization under this subsection not less than 12 hours each day, excluding weekends and state holidays.(t-1) The department, in its rules governing the medical transportation program, may not prohibit a recipient of medical assistance from receiving transportation services through the program to obtain renal dialysis treatment on the basis that the recipient resides in a nursing facility.(u) The department by rule shall require a health care provider who arranges for durable medical equipment for a child who receives medical assistance under this chapter to:(1) ensure that the child receives the equipment prescribed, the equipment fits properly, if applicable, and the child or the child's parent or guardian, as appropriate considering the age of the child, receives instruction regarding the equipment's use; and(2) maintain a record of compliance with the requirements of Subdivision (1) in an appropriate location.(v) The department by rule shall provide a screening test for hearing loss in accordance with Chapter 47, Health and Safety Code, and any necessary diagnostic follow-up care related to the screening test to a child younger than 30 days old who receives medical assistance.(w) The department shall set a personal needs allowance of not less than $60 a month for a resident of a convalescent or nursing home or related institution licensed under Chapter 242, Health and Safety Code, personal care facility, ICF-MR facility, or other similar long-term care facility who receives medical assistance. The department may send the personal needs allowance directly to a resident who receives Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.). This subsection does not apply to a resident who is participating in a medical assistance waiver program administered by the department.(x) The department shall provide dental services annually to a resident of a nursing facility who is a recipient of medical assistance under this chapter. The dental services must include:(1) a dental examination by a licensed dentist;(2) a prophylaxis by a licensed dentist or licensed dental hygienist, if practical considering the health of the resident; and(3) diagnostic dental x-rays, if possible.(y) The department shall provide medical assistance to a person in need of treatment for breast or cervical cancer who is eligible for that assistance under the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Pub. L. No. 106-354) for a continuous period during which the person requires that treatment. The department shall simplify the provider enrollment process for a provider of that medical assistance and shall adopt rules to provide for certification of presumptive eligibility of a person for that assistance. In determining a person's eligibility for medical assistance under this subsection, the department, to the extent allowed by federal law, may not require a personal interview.(y-1) A woman who receives a breast or cervical cancer screening service under Title XV of the Public Health Service Act (42 U.S.C. Section 300k et seq.) and who otherwise meets the eligibility requirements for medical assistance for treatment of breast or cervical cancer as provided by Subsection (y) is eligible for medical assistance under that subsection, regardless of whether federal Medicaid matching funds are available for that medical assistance. A screening service of a type that is within the scope of screening services under that title is considered to be provided under that title regardless of whether the service was provided by a provider who receives or uses funds under that title.(z) In its rules and standards governing the vendor drug program, the department, to the extent allowed by federal law and if the department determines the policy to be cost-effective, may ensure that a recipient of prescription drug benefits under the medical assistance program does not, unless authorized by the department in consultation with the recipient's attending physician or advanced practice nurse, receive under the medical assistance program:(1) more than four different outpatient brand-name prescription drugs during a month; or(2) more than a 34-day supply of a brand-name prescription drug at any one time.(z-1) Subsection (z) does not affect any other limit on prescription medications otherwise prescribed by department rule.(aa) The department shall incorporate physician-oriented instruction on the appropriate procedures for authorizing ambulance service into current medical education courses.(bb) The department may not provide an erectile dysfunction medication under the Medicaid vendor drug program to a person required to register as a sex offender under Chapter 62, Code of Criminal Procedure, to the maximum extent federal law allows the department to deny that medication.(cc) In this subsection, "deaf" and "hard of hearing" have the meanings assigned by Section 81.001. Subject to the availability of funds, the department shall provide interpreter services as requested during the receipt of medical assistance under this chapter to:(1) a person receiving that assistance who is deaf or hard of hearing; or(2) a parent or guardian of a person receiving that assistance if the parent or guardian is deaf or hard of hearing.(dd) Nothwithstanding any other law, an inmate released on medically recommended intensive supervision under Section 508.146, Government Code, who otherwise meets the eligibility requirements for the medical assistance program is not ineligible for the program solely on the basis of the conviction or adjudication for which the inmate was sentenced to confinement.(ii) The department shall provide medical assistance reimbursement to a pharmacist who is licensed to practice pharmacy in this state, is authorized to administer immunizations in accordance with rules adopted by the Texas State Board of Pharmacy, and administers an immunization to a recipient of medical assistance to the same extent the department provides reimbursement to a physician or other health care provider participating in the medical assistance program for the administration of that immunization.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1027, Sec. 11, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1085, Sec. 3, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1107, Sec. 1, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1219, Sec. 1, eff. Sept. 1, 1989; Acts 1990, 71st Leg., 6th C.S., ch. 12, Sec. 2(11) to (13), eff. Sept. 6, 1990; Acts 1991, 72nd Leg., ch. 690, Sec. 1, eff. Aug. 26, 1991; Acts 1995, 74th Leg., ch. 6, Sec. 3, eff. March 23, 1995; Acts 1997, 75th Leg., ch. 1153, Sec. 2.01(a), 2.02(a), eff. June 20, 1997; Acts 1999, 76th Leg., ch. 766, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1333, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1347, Sec. 3, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1505, Sec. 1.06, eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 220, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 348, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 974, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1420, Sec. 21.001(81), eff. Sept. 1, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.96, 2.97(a), 2.207(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 215, Sec. 1, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 6, eff. June 20, 2003; Acts 2003, 78th Leg., ch. 1275, Sec. 2(97), eff. Sept. 1, 2003.Amended by: Acts 2005, 79th Leg., Ch. 349, Sec. 22, eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 728, Sec. 23.001(57), eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 1314, Sec. 1, eff. September 1, 2005.Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 16, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 442, Sec. 1, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 921, Sec. 17.001(50), eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 1308, Sec. 45, eff. June 15, 2007.Acts 2009, 81st Leg., R.S., Ch. 745, Sec. 2, eff. September 1, 2009.Acts 2009, 81st Leg., R.S., Ch. 858, Sec. 1, eff. June 19, 2009.
Sec. 32.0241. REVIEW OF WAIVER REQUEST. The department shall, at least biennially, review the feasibility of requesting a waiver for the elderly under Section 1915(c), federal Social Security Act (42 U.S.C. Section 1396n), if the reimbursement rates for nursing homes under the medical assistance program have increased since the preceding review.
Added by Acts 1989, 71st Leg., ch. 1085, Sec. 2, eff. Sept. 1, 1989.
Sec. 32.0242. VERIFICATION OF CERTAIN INFORMATION. To the extent possible, the department shall verify an applicant's residential address at the time the application for medical assistance is filed.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 1, eff. Sept. 1, 1999.
Sec. 32.0243. PERIODIC REVIEW OF ELIGIBILITY FOR CERTAIN RECIPIENTS. (a) The department, in cooperation with the United States Social Security Administration, shall periodically review the eligibility of a recipient of medical assistance who is eligible on the basis of the recipient's eligibility for Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq., as amended.(b) In reviewing the eligibility of a recipient as required by Subsection (a), the department shall ensure that only recipients who reside in this state and who continue to be eligible for Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq., as amended, remain eligible for medical assistance.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 1, eff. Sept. 1, 1999.
Sec. 32.0244. NURSING HOME BEDS IN CERTAIN COUNTIES. (a) At the request of the commissioners court of a county in which not more than two nursing facilities are certified to participate in the state Medicaid program, and subject to Subsection (d), the department may contract for additional nursing home beds under the state Medicaid program in the county without regard to the occupancy rate of available Medicaid beds.(b) A commissioners court that intends to make a request under Subsection (a) shall publish notice of its intent in the Texas Register and in a newspaper of general circulation in the county. The notice must request:(1) comments on whether the request should be made; and(2) proposals from persons interested in providing additional Medicaid beds in the county, including persons providing Medicaid beds in a nursing facility with a high occupancy rate.(c) A commissioners court shall determine whether to proceed with a request after considering all comments and proposals received in response to the notices provided under Subsection (b). If the commissioners court proceeds with the request, the court may recommend that the department contract with a specific nursing facility that submitted a proposal. In determining whether to proceed with the request and whether to recommend a specific nursing facility, the commissioners court shall consider:(1) the demographic and economic needs of the county;(2) the quality of existing nursing facility services under the state Medicaid program in the county;(3) the quality of the proposals submitted; and(4) the degree of community support for additional nursing facility services.(d) The department may not contract under this section for more than 120 additional nursing home beds per county per year and may not exceed 500 additional nursing home beds statewide in a calendar year.
Added by Acts 1997, 75th Leg., ch. 555, Sec. 1, eff. Sept. 1, 1997. Renumbered from Sec. 32.0246 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(73), eff. Sept. 1, 1999.
Sec. 32.0245. NURSING HOME BEDS FOR CERTAIN FACILITIES TREATING ALZHEIMER'S DISEASE. The department shall waive for a nursing facility a restriction imposed by state law on the authority to contract under the state Medicaid program for nursing home beds based on the percentage of beds that are occupied in a geographical area if the facility:(1) is affiliated with a medical school operated by the state;(2) is participating in a research program for the care and treatment of persons with Alzheimer's disease; and(3) is designed to separate and treat Alzheimer's disease by stage or functional level.
Added by Acts 1995, 74th Leg., ch. 841, Sec. 1, eff. Aug. 28, 1995.
Sec. 32.02451. REIMBURSEMENT FOR GUARDIANSHIP EXPENSES OF CERTAIN RECIPIENTS. To the extent allowed by federal law, the department shall provide medical assistance reimbursement for compensation and costs ordered under Section 670, Texas Probate Code, in a guardianship established for a medical assistance recipient. The executive commissioner of the Health and Human Services Commission shall adopt rules providing a procedure by which a person to whom amounts are ordered paid under that section may submit a claim to and receive reimbursement from the medical assistance program.
Added by Acts 2009, 81st Leg., R.S., Ch. 859, Sec. 1, eff. September 1, 2009.
Sec. 32.0246. PILOT PROGRAM FOR TREATMENT OF ALZHEIMER'S PATIENTS. (a) The Texas Department of Human Services, in cooperation with all appropriate state and federal agencies and with the advisory committee established in Subsection (b), shall develop and implement a pilot program for the treatment of individuals diagnosed with Alzheimer's disease. The pilot program shall:(1) be operated in one rural county and one urban county contiguous to the rural county;(2) provide a continuum of care and comprehensive case management, address gaps in services, and address the special needs of Alzheimer's patients; and(3) develop and implement counseling, education, and support services for the caregivers and family members of Alzheimer's patients.(b) The Texas Department of Human Services shall appoint an advisory committee to assist the department in developing and implementing the pilot program. The advisory committee shall be composed of:(1) four representatives from groups that advocate for Alzheimer's patients;(2) one representative from an institution of higher education;(3) one clinician;(4) one representative from the Texas Department on Aging;(5) one representative from the Texas Department of Human Services; and(6) one representative from the Texas Department of Mental Health and Mental Retardation.(c) The pilot program may not make eligible for medical assistance any individual not otherwise eligible for medical assistance.(d) The Texas Department of Human Services may seek and accept a gift, grant, or donation from any person for purposes of developing and implementing the pilot program provided that the person does not have a contested case pending before any agency participating in the pilot program.(e) Not later than January 15, 1999, the Texas Department of Human Services shall submit to the legislature a report concerning the effectiveness of the pilot program.
Added by Acts 1997, 75th Leg., ch. 415, Sec. 1, eff. Sept. 1, 1997.
Sec. 32.0247. MEDICAL ASSISTANCE FOR CERTAIN PERSONS MAKING TRANSITION FROM FOSTER CARE TO INDEPENDENT LIVING. (a) In this section, "independent foster care adolescent" has the meaning assigned by 42 U.S.C. Section 1396d(w)(1), as amended.(b) The department shall provide medical assistance, in accordance with department rules, to an independent foster care adolescent who:(1) is not otherwise eligible for medical assistance; and(2) is not covered by a health benefits plan offering adequate benefits, as determined by the Health and Human Services Commission.(c) The department shall by rule establish a specific set of income, assets, or resources allowable for recipients under this section. The income level shall not be less than 200 percent or more than 400 percent of the federal poverty level. Allowable asset or resource levels shall not be less than:(1) the levels allowed for individuals who are in foster care; and(2) the levels allowed for a person under 19 years of age who is eligible for the medical assistance program.(d) In setting allowable income, asset, or resource levels, the department shall exclude:(1) any financial benefit used for the purpose of educational or vocational training, such as scholarships, student loans, or grants;(2) any financial benefit used for the purpose of housing; and(3) any grants or subsidies obtained as a result of the Foster Care Independence Act of 1999 (Pub. L. No. 106-169).(e) The Department of Protective and Regulatory Services shall certify the income, assets, or resources of each individual on the date the individual exits substitute care. An individual qualifying for medical assistance as established by this section shall remain eligible for 12 calendar months after certification and after each recertification.(f) The recertification process for individuals who are eligible for medical assistance under this section shall include the option of recertifying by mail or phone.
Added by Acts 2001, 77th Leg., ch. 1218, Sec. 1, eff. Sept. 1, 2001.
Sec. 32.02471. MEDICAL ASSISTANCE FOR CERTAIN FORMER FOSTER CARE ADOLESCENTS ENROLLED IN HIGHER EDUCATION. (a) In this section, "independent foster care adolescent" has the meaning assigned by Section 32.0247.(b) The department shall provide medical assistance to a person who:(1) is 21 years of age or older but younger than 23 years of age;(2) would be eligible to receive assistance as an independent foster care adolescent under Section 32.0247 if the person were younger than 21 years of age; and(3) is enrolled in an institution of higher education, as defined by Section 61.003(8), Education Code, or a private or independent institution of higher education, as defined by Section 61.003(15), Education Code, that is located in this state and is making satisfactory academic progress as determined by the institution.
Added by Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 17, eff. September 1, 2007.
For expiration of this section, see Subsection (i).Sec. 32.0248. DEMONSTRATION PROJECT FOR WOMEN'S HEALTH CARE SERVICES. (a) The department shall establish a five-year demonstration project through the medical assistance program to expand access to preventive health and family planning services for women. A woman eligible under Subsection (b) to participate in the demonstration project may receive appropriate preventive health and family planning services, including:(1) medical history recording and evaluation;(2) physical examinations;(3) health screenings, including screening for:(A) diabetes;(B) cervical cancer;(C) breast cancer;(D) sexually transmitted diseases;(E) hypertension;(F) cholesterol; and(G) tuberculosis;(4) counseling and education on contraceptive methods emphasizing the health benefits of abstinence from sexual activity to recipients who are not married, except for counseling and education regarding emergency contraception;(5) provision of contraceptives, except for the provision of emergency contraception;(6) risk assessment; and(7) referral of medical problems to appropriate providers that are entities or organizations that do not perform or promote elective abortions or contract or affiliate with entities that perform or promote elective abortions.(b) A woman is eligible to participate in the demonstration project if the woman is at least 18 years of age and:(1) has a net family income that is at or below 185 percent of the federal poverty level;(2) participates in or receives benefits under any of the following:(A) the medical assistance program;(B) the financial assistance program under Chapter 31;(C) the nutritional assistance program under Chapter 33;(D) the Supplemental Food Program for Women, Infants and Children; or(E) another program administered by the state that:(i) requires documentation of income; and(ii) restricts eligibility to persons with income equal to or less than the income eligibility guidelines applicable to the medical assistance program;(3) is presumed eligible for one of the programs listed in Subdivision (2) pending completion of that program's eligibility process; or(4) is a member of a family that contains at least one person who participates in or receives benefits under one of the programs listed in Subdivision (2).(c) The department shall ensure that the standards of care provided to a woman participating in the demonstration project are consistent with the requirements of law and current best practices for provision of public health services.(d) The department shall develop procedures for determining and certifying eligibility for services under the demonstration project at the point of service delivery using integrated procedures that minimize duplication of effort by providers, the department, and other state agencies. The department may not use a procedure that would require a cost in excess of 10 percent of the total costs of actual preventive health and family planning services provided under the demonstration project. The eligibility procedure may provide for expedited determination and certification using a simplified form requiring only family income and family size.(e) The department shall compile a list of potential funding sources a woman participating in the demonstration project may be able to use to help pay for treatment for health problems:(1) identified using services provided under the demonstration project; and(2) for which the woman is not eligible to receive treatment under the medical assistance program or the demonstration project.(f) Providers of services under the demonstration project shall comply with requests made by the department for information necessary for the department to:(1) make efficient use of money spent for the operation and administration of the demonstration project;(2) report and provide information required by federal law; and(3) compile the report required by Subsection (g).(g) Not later than December 1 of each even-numbered year, the department shall submit a report to the legislature regarding the department's progress in establishing and operating the demonstration project.(h) The department shall ensure the money spent under the demonstration project, regardless of the funding source, is not used to perform or promote elective abortions. The department, for the purpose of the demonstration project, may not contract with entities that perform or promote elective abortions or are affiliates of entities that perform or promote elective abortions.(i) This section expires September 1, 2011.
Added by Acts 2005, 79th Leg., Ch. 816, Sec. 1, eff. June 17, 2005.
Sec. 32.025. APPLICATION FOR MEDICAL ASSISTANCE. (a) A recipient of benefits under Chapter 31 of this code or supplemental security income from the federal government is automatically eligible for medical assistance, and an application for benefits under these programs constitutes an application for medical assistance.(b) The department shall prescribe application forms for persons who are not recipients of benefits under Chapter 31 of this code or supplemental security income from the federal government and shall adopt rules for processing the applications.(c) The department shall inform applicants for nursing home care of any community services which might be available under the community care for the aged and disabled program.(d) The department shall adopt an application form and procedures for a request for medical assistance provided to a child under 19 years of age. To the extent allowed by federal law and except as otherwise provided by this section, the application form and procedures must be the same as the form and procedures adopted under Section 62.103, Health and Safety Code. The department shall coordinate the form and procedures adopted under this subsection with the form and procedures adopted under Section 62.103, Health and Safety Code, to ensure that there is a single consolidated application for a child under 19 years of age to seek medical assistance or to request coverage under the state child health plan under Chapter 62, Health and Safety Code.(e) The department shall permit an application requesting medical assistance for a child under 19 years of age to be conducted by mail instead of through a personal appearance at a department office, unless the department determines that the information needed to verify eligibility cannot be obtained in that manner. The department by rule may develop procedures requiring an application for a child described by this subsection to be conducted through a personal interview with a department representative only if the department determines that information needed to verify eligibility cannot be obtained in any other manner.(f) The commissioner by rule may develop procedures by which:(1) any office of a health and human services agency may accept an application requesting medical assistance for a child under 19 years of age; and(2) the department may contract with hospital districts, hospitals, including state-owned teaching hospitals, federally qualified health centers, and county health departments to accept applications requesting medical assistance for a child under 19 years of age.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1085, Sec. 5, eff. Sept. 1, 1989; Acts 2001, 77th Leg., ch. 584, Sec. 2; Acts 2003, 78th Leg., ch. 376, Sec. 2, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 7, eff. June 20, 2003.
Sec. 32.0251. ELIGIBILITY NOTIFICATION AND REVIEW FOR CERTAIN CHILDREN. (a) The department shall establish and implement procedures under which the department automatically reviews a child's eligibility for medical assistance if:(1) the child originally establishes eligibility for medical assistance on the basis of receipt of financial assistance under Chapter 31, as provided by Section 32.025(a); and(2) that receipt of financial assistance under Chapter 31 ceases.(b) If the review required by this section indicates that the child may be eligible for medical assistance on a basis other than receipt of financial assistance under Chapter 31, the department may provide for provisional eligibility for medical assistance for the child pending a recertification review. The provisional eligibility period authorized by this subsection may not exceed one month.(c) In addition to the review required by this section, the department shall also promote continued medical assistance for a child described by Subsection (a) through:(1) revising client education and notification policies relating to a child's eligibility for medical assistance; and(2) providing specific notification of a child's potential eligibility for medical assistance to the child's parent or other caretaker at the time the parent or caretaker is notified of:(A) a scheduled eligibility recertification review; or(B) the termination of financial assistance.
Added by Acts 1999, 76th Leg., ch. 704, Sec. 1, eff. June 18, 1999.
Sec. 32.0255. TRANSITIONAL MEDICAL ASSISTANCE. (a) The state shall provide transitional medical assistance, in accordance with state rules and federal law, to a person who was receiving financial assistance under Chapter 31 but is no longer eligible to receive the assistance because:(1) the person's household income has increased; or(2) the person has exhausted the person's benefits under Section 31.0065.(b) Except as provided by Section 31.012(c), the state may provide the medical assistance only until the earlier of:(1) the end of the applicable period prescribed by Section 31.0065 for the provision of transitional benefits; or(2) the first anniversary of the date on which the person becomes ineligible for financial assistance because of increased household income.
Added by Acts 1995, 74th Leg., ch. 655, Sec. 3.03, eff. Sept. 1, 1995.
Sec. 32.026. CERTIFICATION OF ELIGIBILITY AND NEED FOR MEDICAL ASSISTANCE. (a) The department shall promulgate rules for determining and certifying a person's eligibility and need for medical assistance.(b) The department shall promulgate rules to provide for determination and certification of presumptive eligibility for any pregnant woman who applies for Medicaid and who meets the basic eligibility requirements under Title XIX of the federal Social Security Act.(c) Medical assistance payments may not be made on a person's behalf until the person's eligibility and need for medical assistance have been certified in accordance with the department's rules.(d) In adopting rules under this section, the department shall ensure, to the extent allowed by federal law, that documentation and verification procedures used in determining and certifying the eligibility and need for medical assistance of a child under 19 years of age, including the documentation and verification procedures used to evaluate the assets and resources of the child, the child's parents, or the child's other caretaker for that purpose, are the same as the documentation and verification procedures used to determine and certify a child's eligibility for coverage under Chapter 62, Health and Safety Code, except that the documentation and verification procedures adopted in accordance with this subsection may not be more stringent than the documentation and verification procedures existing on January 1, 2001, for determination and certification of a child's eligibility for coverage under Chapter 62, Health and Safety Code.(d-1) In adopting rules under this section, the executive commissioner of the Health and Human Services Commission shall, to the extent allowed by federal law, develop and implement an expedited process for determining eligibility for and enrollment in the medical assistance program for an active duty member of the United States armed forces, reserves, or National Guard or of the state military forces, or the spouse or dependent of that person.(e) The department shall permit a recertification review of the eligibility and need for medical assistance of a child under 19 years of age to be conducted by telephone or mail instead of through a personal appearance at a department office, unless the department determines that the information needed to verify eligibility cannot be obtained in that manner. The department by rule may develop procedures to determine whether there is a need for a recertification review of a child described by this subsection to be conducted through a personal interview with a department representative. Procedures developed under this subsection shall be based on objective, risk-based factors and conditions and shall focus on a targeted group of recertification reviews for which there is a high probability that eligibility will not be recertified.(f) In adopting rules under this section, the department shall ensure, to the extent allowed by federal law, that forms and procedures used in conducting a recertification review of the eligibility and need for medical assistance of a child under 19 years of age, including documentation and verification procedures, are the same as the forms and procedures used to determine and certify a child's renewal of coverage under Chapter 62, Health and Safety Code.(g) Notwithstanding any other provision of this code, the department may use information obtained from a third party to verify the assets and resources of a person for purposes of determining the person's eligibility and need for medical assistance. Third-party information includes information obtained from:(1) a consumer reporting agency, as defined by Section 20.01, Business & Commerce Code;(2) an appraisal district; or(3) the Texas Department of Motor Vehicles vehicle registration record database.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1
HUMAN RESOURCES CODETITLE 2. DEPARTMENT OF HUMAN SERVICES AND DEPARTMENT OF PROTECTIVE AND REGULATORY SERVICESSUBTITLE C. ASSISTANCE PROGRAMSCHAPTER 32. MEDICAL ASSISTANCE PROGRAMSUBCHAPTER A. GENERAL PROVISIONSSec. 32.001. PURPOSE OF CHAPTER. The purpose of this chapter is to enable the state to provide medical assistance on behalf of needy individuals and to enable the state to obtain all benefits for those persons authorized under the Social Security Act or any other federal act.
Acts 1979, 66th Leg., p. 2348, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.002. CONSTRUCTION OF CHAPTER. (a) This chapter shall be liberally construed and applied in relation to applicable federal laws and regulations so that adequate and high quality health care may be made available to all children and adults who need the care and are not financially able to pay for it.(b) If a provision of this chapter conflicts with a provision of the Social Security Act or any other federal act and renders the state program out of conformity with federal law to the extent that federal matching money is not available to the state, the conflicting provision of state law shall be inoperative to the extent of the conflict but shall not affect the remainder of this chapter.
Acts 1979, 66th Leg., p. 2348, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.003. DEFINITIONS. In this chapter:(1) "Board" means the Health and Human Services Commission or the governing body of an agency operating part of the medical assistance program, as appropriate.(2) "Commissioner" means the Health and Human Services Commission or the commissioner or executive director of an agency operating part of the medical assistance program, as appropriate.(3) "Department" means the Health and Human Services Commission or an agency operating part of the medical assistance program, as appropriate.(4) "Medical assistance" includes all of the health care and related services and benefits authorized or provided under federal law for needy individuals of this state.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1995, 74th Leg., ch. 6, Sec. 2, eff. March 23, 1995.
SUBCHAPTER B. ADMINISTRATIVE PROVISIONSSec. 32.021. ADMINISTRATION OF THE PROGRAM. (a) The department is the state agency designated to administer the medical assistance program provided in this chapter.(b) The department shall enter into agreements with any federal agency designated by federal law to administer medical assistance when the department determines the agreements to be compatible with the state's participation in the medical assistance program and within the limits of appropriated funds. The department shall cooperate with federal agencies designated by federal law to administer medical assistance in any reasonable manner necessary to qualify for federal funds.(c) The department shall establish methods of administration and adopt necessary rules for the proper and efficient operation of the program.(d) The department shall include in its contracts for the delivery of medical assistance by nursing facilities provisions for monetary penalties to be assessed for violations as required by 42 U.S.C. Section 1396r, including without limitation the Omnibus Budget Reconciliation Act (OBRA), P. L. 100-203, Nursing Home Reform Amendments of 1987, provided that the department shall:(1) provide for an informal dispute resolution process in the Health and Human Services Commission as provided by Section 531.058, Government Code; and(2) develop rules to adjudicate claims in contested cases, including claims unresolved by the informal dispute resolution process of the Health and Human Services Commission.(e) Rules governing the application of penalties shall include the following:(1) specific and objective criteria which describe the scope and severity of a contract violation which results in a recommendation for each specific penalty. Penalties must be appropriate to the violation, and the most severe financial penalties must be reserved for situations which create an immediate and serious threat to the health and safety of residents; "immediate and serious threat" means a situation in which there is a high probability that serious harm or injury to patients could occur at any time or already has occurred and may well occur again if patients are not protected effectively from the harm or if the threat is not removed;(2) a system to ensure standard and consistent application of penalties among surveyors and different areas of the state;(3) due process for nursing facilities providers, including an appeals procedure consistent with Chapter 2001, Government Code; and(4) per diem and/or minimum penalties. The department may by rule prescribe a minimum penalty period; however, once a facility gives the department notice that deficiencies have been corrected, if surveyors are unable to revisit the facility within five days and the deficiencies are later shown to be corrected, the per diem penalties cease as of the day the facility gave notice to the department or on the last day of the minimum penalty period established by the department, whichever is later.(f) To encourage facilities to provide the best possible care, the department shall develop an incentive program to recognize facilities providing the highest quality care to Medicaid residents.(g) Funds collected as a result of the imposition of penalties shall be applied to the protection of the health or property of residents of nursing facilities, including the cost of relocation of residents to other facilities and maintenance or operation of a facility pending correction of deficiencies or closure, or to incentive programs which recognize the highest quality care to residents who are entitled to Medicaid.(h) Medicaid nursing facilities shall also comply with state licensure rules, which may be more stringent than the requirements for certification. The department shall use appropriate civil, administrative, or criminal remedies authorized by state or federal law with respect to a facility that is in violation of a certification or licensing requirement.(i) Repealed by Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1).(j) Repealed by Acts 2001, 77th Leg., ch. 1284, Sec. 3.04, eff. June 15, 2001.(k) Repealed by Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1).(l) The department may not include as a reimbursable item to a nursing facility an administrative or civil penalty assessed against the facility under this chapter or under Chapter 242, Health and Safety Code.(m) Notwithstanding any provision of law to the contrary, the department shall terminate a nursing facility's provider agreement if the department has imposed required Category 2 or Category 3 remedies on the facility three times within a 24-month period. The executive commissioner of the Health and Human Services Commission by rule shall establish criteria under which the requirement to terminate the provider agreement may be waived. In this subsection, "Category 2 remedies" and "Category 3 remedies" have the meanings assigned by 42 C.F.R. Section 488.408.(n) An assessment of monetary penalties under this section is subject to arbitration under Subchapter J, Chapter 242, Health and Safety Code.(o) In any circumstance in which a nursing facility would otherwise be required to admit a resident transferred from another facility, because of an emergency or otherwise, the nursing facility may not admit a resident whose needs cannot be met through service from the facility's staff or in cooperation with community resources or other providers under contract. If a nursing facility refuses to admit a resident under this subsection, the nursing facility shall provide a written statement of the reasons for the refusal to the department within a period specified by department rule. A nursing facility that fails to provide the written statement, or that includes false or misleading information in the statement, is subject to monetary penalties assessed in accordance with this chapter.(p) In order to increase the personal needs allowance under Section 32.024(v), as added by Chapter 1333, Acts of the 76th Legislature, Regular Session, 1999, the department shall develop an early warning system to detect fraud in the handling of the personal needs allowance and other funds of residents of long-term care facilities.(q) The department shall include in its contracts for the delivery of medical assistance by nursing facilities clearly defined minimum standards that relate directly to the quality of care for residents of those facilities. The department shall consider the recommendations made by the nursing facility quality assurance team under Section 32.060 in establishing the standards. The department shall include in each contract:(1) specific performance measures by which the department may evaluate the extent to which the nursing facility is meeting the standards; and(2) provisions that allow the department to terminate the contract if the nursing facility is not meeting the standards.(r) The department may not award a contract for the delivery of medical assistance to a nursing facility that does not meet the minimum standards that would be included in the contract as required by Subsection (q). The department shall terminate a contract for the delivery of medical assistance by a nursing facility that does not meet or maintain the minimum standards included in the contract in a manner consistent with the terms of the contract.(s) Not later than November 15 of each even-numbered year, the department shall submit a report to the legislature regarding nursing facilities that contract with the department to provide medical assistance under this chapter and other nursing facilities with which the department was prohibited to contract as provided by Subsection (r). The department may include the report required under this section with the report made by the long-term care legislative oversight committee as required by Section 242.654, Health and Safety Code. The report must include:(1) recommendations for improving the quality of information provided to consumers about the facilities;(2) the minimum standards and performance measures included in the department's contracts with those facilities;(3) the performance of the facilities with regard to the minimum standards;(4) the number of facilities with which the department has terminated a contract or to which the department will not award a contract because the facilities do not meet the minimum standards; and(5) the overall impact of the minimum standards on the quality of care provided by the facilities, consumers' access to facilities, and cost of care.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1991, 72nd Leg., 1st C.S., ch. 15, Sec. 5.22, eff. Sept. 1, 1991; Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff. Sept. 1, 1995; Acts 1995, 74th Leg., ch. 1049, Sec. 1, eff. Sept. 1, 1995; Acts 1997, 75th Leg., ch. 1159, Sec. 2.01, eff. Sept. 1, 1997; Acts 2001, 77th Leg., ch. 974, Sec. 2, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1284, Sec. 3.01, 3.04, 7.04, eff. June 15, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.92(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 204, Sec. 16.03(1), eff. Sept. 1, 2003.Amended by: Acts 2007, 80th Leg., R.S., Ch. 809, Sec. 1, eff. September 1, 2007.
Sec. 32.0211. RESTRICTIONS ON MEMBERS OF THE BOARD, COMMISSIONERS, AND THEIR PARTNERS. (a) After service in the department ends, a former member of the board or a former commissioner may not knowingly represent a person before an agency or court:(1) in a matter related to the medical assistance program in which the department or the federal government has a direct interest and in which the board member or commissioner participated personally while employed with the department; or(2) for two years after the date on which service ends in a matter related to the medical assistance program if the department or the federal government has a direct interest in the matter, the matter was pending during his last year of service to the department, and the matter was one for which the board member or commissioner had responsibility.(b) Subsection (a) of this section does not apply to a former board member or commissioner who holds one of the following positions and is acting in the scope of that position:(1) employee or officer of federal, state, or local government;(2) employee of a nonprofit hospital or medical research organization; or(3) employee of an accredited degree-granting college or university.(c) A current board member or commissioner may not knowingly participate in the course of his service in a matter related to the medical assistance program in which the department or the federal government has a direct interest and in which he, his spouse, minor child, or business partner has a substantial financial interest.(d) A business partner of a current board member or commissioner may not knowingly represent a person before an agency or court in a matter related to the medical assistance program:(1) in which the board member or commissioner participates or has participated personally and substantially; or(2) that is under the official responsibility of the board member or commissioner.(e) Past or present board members or commissioners are subject to a civil penalty of $5,000 for each violation of this section. A partner of a current board member or commissioner is subject to a civil penalty of $2,500 for each violation of this section. Each appearance before an agency or court constitutes a separate offense.(f) If it appears that this section has been violated, the department may request the attorney general to conduct a suit in the name of the State of Texas to enjoin the prohibited activity and to recover the penalty provided for in this section.
Added by Acts 1981, 67th Leg., p. 755, ch. 287, Sec. 1, eff. Aug. 31, 1981.
Sec. 32.0212. DELIVERY OF MEDICAL ASSISTANCE. Notwithstanding any other law and subject to Section 533.0025, Government Code, the department shall provide medical assistance for acute care through the Medicaid managed care system implemented under Chapter 533, Government Code.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.95, eff. Sept. 1, 2003.
Sec. 32.0213. NURSING FACILITY BED CERTIFICATION AND DECERTIFICATION. (a) The department by rule shall establish procedures for:(1) controlling the number of Medicaid beds in nursing facilities;(2) decertification of unused Medicaid beds in nursing facilities; and(3) reallocation of nursing home beds decertified under Subdivision (2) to other nursing facilities.(b) The procedures established under this section must take into account the occupancy rate of the nursing facility.(c) The department may exempt a nursing facility from the procedures established under this section if the facility:(1) is affiliated with a state-supported medical school;(2) is located on land owned or controlled by the state-supported medical school; and(3) serves as a teaching facility for physicians and related health care professionals.
Added by Acts 1997, 75th Leg., ch. 1159, Sec. 2.02, eff. Sept. 1, 1997. Amended by Acts 1999, 76th Leg., ch. 1487, Sec. 1, eff. June 19, 1999.
Sec. 32.0214. DESIGNATIONS OF PRIMARY CARE PROVIDER BY CERTAIN RECIPIENTS. (a) If the department determines that it is cost-effective and feasible and subject to Subsection (b), the department shall require each recipient of medical assistance to designate a primary care provider with whom the recipient will have a continuous, ongoing professional relationship and who will provide and coordinate the recipient's initial and primary care, maintain the continuity of care provided to the recipient, and initiate any referrals to other health care providers.(b) A recipient who receives medical assistance through a Medicaid managed care model or arrangement under Chapter 533, Government Code, that requires the designation of a primary care provider shall designate the recipient's primary care provider as required by that model or arrangement.
Added by Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 15, eff. September 1, 2007.
Sec. 32.0215. HOME OR COMMUNITY CARE PROVIDERS: CIVIL MONETARY PENALTIES. (a) The department may include in a contract for the delivery of medical assistance by a home or community care provider a provision for monetary penalties to be assessed for a contract violation or any violation of home or community care requirements, as required by 42 U.S.C. Section 1396t(j).(b) The department shall develop rules governing the application of civil money penalties, including rules prescribing:(1) criteria that describe when and how a civil money penalty may be assessed and the amount of the penalty;(2) a system to ensure standard and consistent application of the penalties throughout the state; and(3) an administrative appeals process to adjudicate claims in contested cases in accordance with Chapter 2001, Government Code.(c) Rules adopted under this section must be designed to minimize the time between the identification of a violation and the final imposition of a penalty. Rules adopted under this section may authorize the imposition of a penalty that assesses and collects a monetary penalty, with interest, for a minimum penalty period and on a subsequent per diem basis.(d) A penalty must be appropriate to the violation. The department may assess incrementally more severe penalties for repeated or uncorrected violations.(e) The department shall review a penalized provider within 10 working days after the provider notifies the department that the deficiency that caused the imposition of the penalty has been corrected. If the department is unable to review the provider within that 10-working-day period, the penalty ceases on the earlier of the last day of the minimum penalty period or the date the provider gives notice to the department.(f) Money collected as a result of the imposition of penalties may be used for the protection of the health or property of an individual whose personal property was lost due to a failure of a home or community care provider to meet the requirements for participation as a provider of home or community care.
Added by Acts 1993, 73rd Leg., ch. 132, Sec. 1, eff. Sept. 1, 1993. Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(49), eff. Sept. 1, 1995.
Sec. 32.022. MEDICAL AND HOSPITAL CARE ADVISORY COMMITTEES. (a) The board, on the recommendation of the commissioner, shall appoint a medical care advisory committee to advise the board and the department in developing and maintaining the medical assistance program and in making immediate and long-range plans for reaching the program's goal of providing access to high quality, comprehensive medical and health care services to medically indigent persons in the state. To ensure that qualified applicants receive services, the committee shall consider changes in the process the department uses to determine eligibility.(b) The board shall appoint the committee in compliance with the requirements of the federal agency administering medical assistance. The appointments shall provide for a balanced representation of the general public, providers, consumers, and other persons, state agencies, or groups with knowledge of and interest in the committee's field of work.(c) The department shall adopt rules for membership on the committee to provide for efficiency of operation, rotation, stability, and continuity.(d) The board, on the recommendation of the commissioner, may appoint regional and local medical care advisory committees and other advisory committees as considered necessary.(e) The board, on the recommendation of the commissioner, shall appoint a hospital payment advisory committee. The committee shall advise the board and the department on necessary changes in hospital payment methodologies for inpatient hospital prospective payments and on adjustments for disproportionate share hospitals that will ensure reasonable, adequate, and equitable payments to hospital providers and that will address the essential role of rural hospitals. The board shall appoint to the committee persons with knowledge of and an interest in hospital payment issues.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1987, 70th Leg., ch. 1052, Sec. 2.01, eff. Sept. 1, 1987; Acts 1989, 71st Leg., ch. 1027, Sec. 10, eff. Sept. 1, 1989.
Sec. 32.023. COOPERATION WITH OTHER STATE AGENCIES. (a) The department's plan for administering medical assistance must include procedures for using health services administered by other state agencies pursuant to cooperative arrangements.(b) The department may enter into agreements with appropriate state agencies that will enable the department to implement Title XIX of the federal Social Security Act to provide medical assistance for individuals in institutions or in alternate care arrangements. The agreements must comply with federal law and rules. The department may make medical assistance payments in accordance with the agreements. The agreements are not subject to the Interagency Cooperation Act (Article 4413(32), Vernon's Texas Civil Statutes).(c) State agencies responsible for the administration or supervision of facilities to which medical assistance payments may be made under federal law shall enter into the agreements with the department and maintain compliance with the agreements so that the department may receive federal matching funds to support the medical assistance program.(d) The department may pay medical assistance to other facilities as required under federal law and rules.
Acts 1979, 66th Leg., p. 2349, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979.
Sec. 32.0231. ANNOUNCEMENT OF FUNDING OR PROGRAM CHANGE. (a) The department shall publish notice in the Texas Register of:(1) any attempt to obtain a waiver of federal regulations in the medical assistance program;(2) any attempt to obtain or the receipt of funding under Title XIX of the federal Social Security Act (42 U.S.C. Section 301 et seq.) for a pilot program; and(3) any amendment to the state medical assistance plan.(b) The notice must include the name and telephone number of a department employee who can provide information relating to the matter for which notice was published under this section.(c) The department shall provide to any requestor information relating to a matter for which notice was published, including the effect and cost of the change, any possible cost savings, the criteria for receiving services, and the number of people to be served.
Added by Acts 1989, 71st Leg., ch. 1085, Sec. 2, eff. Sept. 1, 1989.
Sec. 32.024. AUTHORITY AND SCOPE OF PROGRAM; ELIGIBILITY. (a) The department shall provide medical assistance to all persons who receive financial assistance from the state under Chapter 31 of this code and to other related groups of persons if the provision of medical assistance to those persons is required by federal law and rules as a condition for obtaining federal matching funds for the support of the medical assistance program.(b) The department may provide medical assistance to other persons who are financially unable to meet the cost of medical services if federal matching funds are available for that purpose. The department shall adopt rules governing the eligibility of those persons for the services.(c) The department shall establish standards governing the amount, duration, and scope of services provided under the medical assistance program. The standards may not be lower than the minimum standards required by federal law and rule as a condition for obtaining federal matching funds for support of the program, and may not be lower than the standards in effect on August 27, 1967. Standards or payments for the vendor drug program may not be lower than those in effect on January 1, 1973.(d) The department may establish standards that increase the amount, duration, and scope of the services provided only if federal matching funds are available for the optional services and payments and if the department determines that the increase is feasible and within the limits of appropriated funds. The department may establish and maintain priorities for the provision of the optional medical services.(e) The department may not authorize the provision of any service to any person under the program unless federal matching funds are available to pay the cost of the service.(f) The department shall set the income eligibility cap for persons qualifying for nursing home care at an amount that is not less than $1,104 and that does not exceed the highest income for which federal matching funds are payable. The department shall set the cap at a higher amount than the minimum provided by this subsection if appropriations made by the legislature for a fiscal year will finance benefits at the higher cap for at least the same number of recipients of the benefits during that year as were served during the preceding fiscal year, as estimated by the department. In setting an income eligibility cap under this subsection, the department shall consider the cost of the adjustment required by Subsection (g) of this section.(g) During a fiscal year for which the cap described by Subsection (f) of this section has been set, the department shall adjust the cap in accordance with any percentage change in the amount of benefits being paid to social security recipients during the year.(h) Subject to the amount of the cap set as provided by Subsections (f) and (g) of this section, and to the extent permitted by federal law, the income eligibility cap for community care for aged and disabled persons shall be the same as the income eligibility cap for nursing home care. The department shall ensure that the eligibility requirements for persons receiving other services under the medical assistance program are not affected. Text of subsec. (i) as amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.96 (i) The department in its adoption of rules may establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses, subject to availability of appropriated funds. Text of subsec. (i) as amended by Acts 2003, 78th Leg., ch. 1251, Sec. 6 (i) Subject to appropriated state funds, the department in its adoption of rules shall establish a medically needy program that serves pregnant women, children, and caretakers who have high medical expenses.(j) The department in its adoption of rules shall in fiscal year 1990 restore three percent of the 10 percent reduction in provider reimbursement.(k) The department in its adoption of rules shall in fiscal year 1991 restore 4.5 percent of the 10 percent reduction in provider reimbursement.(l) The department shall set the income eligibility cap for medical assistance for pregnant women and infants up to age one at not less than 130 percent of the federal poverty guidelines.(m) The department shall set the income eligibility cap for medical assistance for children up to age four at not less than 100 percent of the federal poverty guidelines for state fiscal year 1990 and for children up to age six for state fiscal year 1991.(n) The department in its adoption of rules and standards governing the scope of hospital and long-term services shall authorize the providing of respite care by hospitals.(o) The department, in its rules and standards governing the scope of hospital and long-term services, shall establish a swing bed program in accordance with federal regulations to provide reimbursement for skilled nursing patients who are served in hospital settings provided that the length of stay is limited to 30 days per year and the hospital is located in a county with a population of 100,000 or less. If the swing beds are used for more than one 30-day length of stay per year, per patient, the hospital must comply with the Minimum Licensing Standards as mandated by Chapter 242, Health and Safety Code, and the Medicaid standards for nursing home certification, as promulgated by the department.(p) The department shall provide home respiratory therapy services for ventilator-dependent persons to the extent permitted by federal law.(q) The department shall provide physical therapy services.(r) The department, from funds otherwise appropriated to the department for the early and periodic screening, diagnosis, and treatment program, shall provide to a child who is 14 years of age or younger, permanent molar sealants as dental service under that program as follows:(1) sealant shall be applied only to the occlusal buccal and lingual pits and fissures of a permanent molar within four years of its eruption;(2) teeth to be sealed must be free of proximal caries and free of previous restorations on the surface to be sealed;(3) if a second molar is the prime tooth to be sealed, a non-restored first molar may be sealed at the same sitting, if the fee for the first molar sealing is no more than half the usual sealant fee;(4) the sealing of premolars and primary molars will not be reimbursed; and(5) replacement sealants will not be reimbursed.(s) The department, in its rules governing the early and periodic screening, diagnosis, and treatment program, shall:(1) revise the periodicity schedule to allow for periodic visits at least as often as the frequency recommended by the American Academy of Pediatrics and allow for interperiodic screens without prior approval when there are indications that it is medically necessary; and(2) require, as a condition for eligibility for reimbursement under the program for the cost of services provided at a visit or screening, that a child younger than 15 years of age be accompanied at the visit or screening by:(A) the child's parent or guardian; or(B) another adult, including an adult related to the child, authorized by the child's parent or guardian to accompany the child.(s-1) Subsection (s)(2) does not apply to services provided by a school health clinic, Head Start program, or child-care facility, as defined by Section 42.002, if the clinic, program, or facility:(1) obtains written consent to the services from the child's parent or guardian within the one-year period preceding the date on which the services are provided, and that consent has not been revoked; and(2) encourages parental involvement in and management of the health care of children receiving services from the clinic, program, or facility.(t) The department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain authorization from the department or a person authorized to act on behalf of the department on the same day or the next business day following the day of transport when an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency and the request is for the authorization of the provision of transportation for only one day. If the request is for authorization of the provision of transportation on more than one day, the department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain a single authorization before an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency. The rules must provide that:(1) except as provided by Subdivision (3), a request for authorization must be evaluated based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition;(2) except as provided by Subdivision (3), a response to a request for authorization must be made not later than 48 hours after receipt of the request;(3) a request for authorization must be immediately granted and must be effective for a period of not more than 180 days from the date of issuance if the request includes a written statement from a physician that:(A) states that alternative means of transporting the recipient are contraindicated; and(B) is dated not earlier than the 60th day before the date on which the request for authorization is made;(4) a person denied payment for ambulance services rendered is entitled to payment from the nursing facility, health care provider, or other responsible party that requested the services if:(A) payment under the medical assistance program is denied because of lack of prior authorization; and(B) the person provides the nursing facility, health care provider, or other responsible party with a copy of the bill for which payment was denied;(5) a person denied payment for services rendered because of failure to obtain prior authorization or because a request for prior authorization was denied is entitled to appeal the denial of payment to the department; and(6) the department or a person authorized to act on behalf of the department must be available to evaluate requests for authorization under this subsection not less than 12 hours each day, excluding weekends and state holidays.(t-1) The department, in its rules governing the medical transportation program, may not prohibit a recipient of medical assistance from receiving transportation services through the program to obtain renal dialysis treatment on the basis that the recipient resides in a nursing facility.(u) The department by rule shall require a health care provider who arranges for durable medical equipment for a child who receives medical assistance under this chapter to:(1) ensure that the child receives the equipment prescribed, the equipment fits properly, if applicable, and the child or the child's parent or guardian, as appropriate considering the age of the child, receives instruction regarding the equipment's use; and(2) maintain a record of compliance with the requirements of Subdivision (1) in an appropriate location.(v) The department by rule shall provide a screening test for hearing loss in accordance with Chapter 47, Health and Safety Code, and any necessary diagnostic follow-up care related to the screening test to a child younger than 30 days old who receives medical assistance.(w) The department shall set a personal needs allowance of not less than $60 a month for a resident of a convalescent or nursing home or related institution licensed under Chapter 242, Health and Safety Code, personal care facility, ICF-MR facility, or other similar long-term care facility who receives medical assistance. The department may send the personal needs allowance directly to a resident who receives Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.). This subsection does not apply to a resident who is participating in a medical assistance waiver program administered by the department.(x) The department shall provide dental services annually to a resident of a nursing facility who is a recipient of medical assistance under this chapter. The dental services must include:(1) a dental examination by a licensed dentist;(2) a prophylaxis by a licensed dentist or licensed dental hygienist, if practical considering the health of the resident; and(3) diagnostic dental x-rays, if possible.(y) The department shall provide medical assistance to a person in need of treatment for breast or cervical cancer who is eligible for that assistance under the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Pub. L. No. 106-354) for a continuous period during which the person requires that treatment. The department shall simplify the provider enrollment process for a provider of that medical assistance and shall adopt rules to provide for certification of presumptive eligibility of a person for that assistance. In determining a person's eligibility for medical assistance under this subsection, the department, to the extent allowed by federal law, may not require a personal interview.(y-1) A woman who receives a breast or cervical cancer screening service under Title XV of the Public Health Service Act (42 U.S.C. Section 300k et seq.) and who otherwise meets the eligibility requirements for medical assistance for treatment of breast or cervical cancer as provided by Subsection (y) is eligible for medical assistance under that subsection, regardless of whether federal Medicaid matching funds are available for that medical assistance. A screening service of a type that is within the scope of screening services under that title is considered to be provided under that title regardless of whether the service was provided by a provider who receives or uses funds under that title.(z) In its rules and standards governing the vendor drug program, the department, to the extent allowed by federal law and if the department determines the policy to be cost-effective, may ensure that a recipient of prescription drug benefits under the medical assistance program does not, unless authorized by the department in consultation with the recipient's attending physician or advanced practice nurse, receive under the medical assistance program:(1) more than four different outpatient brand-name prescription drugs during a month; or(2) more than a 34-day supply of a brand-name prescription drug at any one time.(z-1) Subsection (z) does not affect any other limit on prescription medications otherwise prescribed by department rule.(aa) The department shall incorporate physician-oriented instruction on the appropriate procedures for authorizing ambulance service into current medical education courses.(bb) The department may not provide an erectile dysfunction medication under the Medicaid vendor drug program to a person required to register as a sex offender under Chapter 62, Code of Criminal Procedure, to the maximum extent federal law allows the department to deny that medication.(cc) In this subsection, "deaf" and "hard of hearing" have the meanings assigned by Section 81.001. Subject to the availability of funds, the department shall provide interpreter services as requested during the receipt of medical assistance under this chapter to:(1) a person receiving that assistance who is deaf or hard of hearing; or(2) a parent or guardian of a person receiving that assistance if the parent or guardian is deaf or hard of hearing.(dd) Nothwithstanding any other law, an inmate released on medically recommended intensive supervision under Section 508.146, Government Code, who otherwise meets the eligibility requirements for the medical assistance program is not ineligible for the program solely on the basis of the conviction or adjudication for which the inmate was sentenced to confinement.(ii) The department shall provide medical assistance reimbursement to a pharmacist who is licensed to practice pharmacy in this state, is authorized to administer immunizations in accordance with rules adopted by the Texas State Board of Pharmacy, and administers an immunization to a recipient of medical assistance to the same extent the department provides reimbursement to a physician or other health care provider participating in the medical assistance program for the administration of that immunization.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1027, Sec. 11, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1085, Sec. 3, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1107, Sec. 1, eff. Sept. 1, 1989; Acts 1989, 71st Leg., ch. 1219, Sec. 1, eff. Sept. 1, 1989; Acts 1990, 71st Leg., 6th C.S., ch. 12, Sec. 2(11) to (13), eff. Sept. 6, 1990; Acts 1991, 72nd Leg., ch. 690, Sec. 1, eff. Aug. 26, 1991; Acts 1995, 74th Leg., ch. 6, Sec. 3, eff. March 23, 1995; Acts 1997, 75th Leg., ch. 1153, Sec. 2.01(a), 2.02(a), eff. June 20, 1997; Acts 1999, 76th Leg., ch. 766, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1333, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1347, Sec. 3, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1505, Sec. 1.06, eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 220, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 348, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 974, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1420, Sec. 21.001(81), eff. Sept. 1, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 2.96, 2.97(a), 2.207(a), eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 215, Sec. 1, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 6, eff. June 20, 2003; Acts 2003, 78th Leg., ch. 1275, Sec. 2(97), eff. Sept. 1, 2003.Amended by: Acts 2005, 79th Leg., Ch. 349, Sec. 22, eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 728, Sec. 23.001(57), eff. September 1, 2005.Acts 2005, 79th Leg., Ch. 1314, Sec. 1, eff. September 1, 2005.Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 16, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 442, Sec. 1, eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 921, Sec. 17.001(50), eff. September 1, 2007.Acts 2007, 80th Leg., R.S., Ch. 1308, Sec. 45, eff. June 15, 2007.Acts 2009, 81st Leg., R.S., Ch. 745, Sec. 2, eff. September 1, 2009.Acts 2009, 81st Leg., R.S., Ch. 858, Sec. 1, eff. June 19, 2009.
Sec. 32.0241. REVIEW OF WAIVER REQUEST. The department shall, at least biennially, review the feasibility of requesting a waiver for the elderly under Section 1915(c), federal Social Security Act (42 U.S.C. Section 1396n), if the reimbursement rates for nursing homes under the medical assistance program have increased since the preceding review.
Added by Acts 1989, 71st Leg., ch. 1085, Sec. 2, eff. Sept. 1, 1989.
Sec. 32.0242. VERIFICATION OF CERTAIN INFORMATION. To the extent possible, the department shall verify an applicant's residential address at the time the application for medical assistance is filed.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 1, eff. Sept. 1, 1999.
Sec. 32.0243. PERIODIC REVIEW OF ELIGIBILITY FOR CERTAIN RECIPIENTS. (a) The department, in cooperation with the United States Social Security Administration, shall periodically review the eligibility of a recipient of medical assistance who is eligible on the basis of the recipient's eligibility for Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq., as amended.(b) In reviewing the eligibility of a recipient as required by Subsection (a), the department shall ensure that only recipients who reside in this state and who continue to be eligible for Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq., as amended, remain eligible for medical assistance.
Added by Acts 1999, 76th Leg., ch. 1289, Sec. 1, eff. Sept. 1, 1999.
Sec. 32.0244. NURSING HOME BEDS IN CERTAIN COUNTIES. (a) At the request of the commissioners court of a county in which not more than two nursing facilities are certified to participate in the state Medicaid program, and subject to Subsection (d), the department may contract for additional nursing home beds under the state Medicaid program in the county without regard to the occupancy rate of available Medicaid beds.(b) A commissioners court that intends to make a request under Subsection (a) shall publish notice of its intent in the Texas Register and in a newspaper of general circulation in the county. The notice must request:(1) comments on whether the request should be made; and(2) proposals from persons interested in providing additional Medicaid beds in the county, including persons providing Medicaid beds in a nursing facility with a high occupancy rate.(c) A commissioners court shall determine whether to proceed with a request after considering all comments and proposals received in response to the notices provided under Subsection (b). If the commissioners court proceeds with the request, the court may recommend that the department contract with a specific nursing facility that submitted a proposal. In determining whether to proceed with the request and whether to recommend a specific nursing facility, the commissioners court shall consider:(1) the demographic and economic needs of the county;(2) the quality of existing nursing facility services under the state Medicaid program in the county;(3) the quality of the proposals submitted; and(4) the degree of community support for additional nursing facility services.(d) The department may not contract under this section for more than 120 additional nursing home beds per county per year and may not exceed 500 additional nursing home beds statewide in a calendar year.
Added by Acts 1997, 75th Leg., ch. 555, Sec. 1, eff. Sept. 1, 1997. Renumbered from Sec. 32.0246 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(73), eff. Sept. 1, 1999.
Sec. 32.0245. NURSING HOME BEDS FOR CERTAIN FACILITIES TREATING ALZHEIMER'S DISEASE. The department shall waive for a nursing facility a restriction imposed by state law on the authority to contract under the state Medicaid program for nursing home beds based on the percentage of beds that are occupied in a geographical area if the facility:(1) is affiliated with a medical school operated by the state;(2) is participating in a research program for the care and treatment of persons with Alzheimer's disease; and(3) is designed to separate and treat Alzheimer's disease by stage or functional level.
Added by Acts 1995, 74th Leg., ch. 841, Sec. 1, eff. Aug. 28, 1995.
Sec. 32.02451. REIMBURSEMENT FOR GUARDIANSHIP EXPENSES OF CERTAIN RECIPIENTS. To the extent allowed by federal law, the department shall provide medical assistance reimbursement for compensation and costs ordered under Section 670, Texas Probate Code, in a guardianship established for a medical assistance recipient. The executive commissioner of the Health and Human Services Commission shall adopt rules providing a procedure by which a person to whom amounts are ordered paid under that section may submit a claim to and receive reimbursement from the medical assistance program.
Added by Acts 2009, 81st Leg., R.S., Ch. 859, Sec. 1, eff. September 1, 2009.
Sec. 32.0246. PILOT PROGRAM FOR TREATMENT OF ALZHEIMER'S PATIENTS. (a) The Texas Department of Human Services, in cooperation with all appropriate state and federal agencies and with the advisory committee established in Subsection (b), shall develop and implement a pilot program for the treatment of individuals diagnosed with Alzheimer's disease. The pilot program shall:(1) be operated in one rural county and one urban county contiguous to the rural county;(2) provide a continuum of care and comprehensive case management, address gaps in services, and address the special needs of Alzheimer's patients; and(3) develop and implement counseling, education, and support services for the caregivers and family members of Alzheimer's patients.(b) The Texas Department of Human Services shall appoint an advisory committee to assist the department in developing and implementing the pilot program. The advisory committee shall be composed of:(1) four representatives from groups that advocate for Alzheimer's patients;(2) one representative from an institution of higher education;(3) one clinician;(4) one representative from the Texas Department on Aging;(5) one representative from the Texas Department of Human Services; and(6) one representative from the Texas Department of Mental Health and Mental Retardation.(c) The pilot program may not make eligible for medical assistance any individual not otherwise eligible for medical assistance.(d) The Texas Department of Human Services may seek and accept a gift, grant, or donation from any person for purposes of developing and implementing the pilot program provided that the person does not have a contested case pending before any agency participating in the pilot program.(e) Not later than January 15, 1999, the Texas Department of Human Services shall submit to the legislature a report concerning the effectiveness of the pilot program.
Added by Acts 1997, 75th Leg., ch. 415, Sec. 1, eff. Sept. 1, 1997.
Sec. 32.0247. MEDICAL ASSISTANCE FOR CERTAIN PERSONS MAKING TRANSITION FROM FOSTER CARE TO INDEPENDENT LIVING. (a) In this section, "independent foster care adolescent" has the meaning assigned by 42 U.S.C. Section 1396d(w)(1), as amended.(b) The department shall provide medical assistance, in accordance with department rules, to an independent foster care adolescent who:(1) is not otherwise eligible for medical assistance; and(2) is not covered by a health benefits plan offering adequate benefits, as determined by the Health and Human Services Commission.(c) The department shall by rule establish a specific set of income, assets, or resources allowable for recipients under this section. The income level shall not be less than 200 percent or more than 400 percent of the federal poverty level. Allowable asset or resource levels shall not be less than:(1) the levels allowed for individuals who are in foster care; and(2) the levels allowed for a person under 19 years of age who is eligible for the medical assistance program.(d) In setting allowable income, asset, or resource levels, the department shall exclude:(1) any financial benefit used for the purpose of educational or vocational training, such as scholarships, student loans, or grants;(2) any financial benefit used for the purpose of housing; and(3) any grants or subsidies obtained as a result of the Foster Care Independence Act of 1999 (Pub. L. No. 106-169).(e) The Department of Protective and Regulatory Services shall certify the income, assets, or resources of each individual on the date the individual exits substitute care. An individual qualifying for medical assistance as established by this section shall remain eligible for 12 calendar months after certification and after each recertification.(f) The recertification process for individuals who are eligible for medical assistance under this section shall include the option of recertifying by mail or phone.
Added by Acts 2001, 77th Leg., ch. 1218, Sec. 1, eff. Sept. 1, 2001.
Sec. 32.02471. MEDICAL ASSISTANCE FOR CERTAIN FORMER FOSTER CARE ADOLESCENTS ENROLLED IN HIGHER EDUCATION. (a) In this section, "independent foster care adolescent" has the meaning assigned by Section 32.0247.(b) The department shall provide medical assistance to a person who:(1) is 21 years of age or older but younger than 23 years of age;(2) would be eligible to receive assistance as an independent foster care adolescent under Section 32.0247 if the person were younger than 21 years of age; and(3) is enrolled in an institution of higher education, as defined by Section 61.003(8), Education Code, or a private or independent institution of higher education, as defined by Section 61.003(15), Education Code, that is located in this state and is making satisfactory academic progress as determined by the institution.
Added by Acts 2007, 80th Leg., R.S., Ch. 268, Sec. 17, eff. September 1, 2007.
For expiration of this section, see Subsection (i).Sec. 32.0248. DEMONSTRATION PROJECT FOR WOMEN'S HEALTH CARE SERVICES. (a) The department shall establish a five-year demonstration project through the medical assistance program to expand access to preventive health and family planning services for women. A woman eligible under Subsection (b) to participate in the demonstration project may receive appropriate preventive health and family planning services, including:(1) medical history recording and evaluation;(2) physical examinations;(3) health screenings, including screening for:(A) diabetes;(B) cervical cancer;(C) breast cancer;(D) sexually transmitted diseases;(E) hypertension;(F) cholesterol; and(G) tuberculosis;(4) counseling and education on contraceptive methods emphasizing the health benefits of abstinence from sexual activity to recipients who are not married, except for counseling and education regarding emergency contraception;(5) provision of contraceptives, except for the provision of emergency contraception;(6) risk assessment; and(7) referral of medical problems to appropriate providers that are entities or organizations that do not perform or promote elective abortions or contract or affiliate with entities that perform or promote elective abortions.(b) A woman is eligible to participate in the demonstration project if the woman is at least 18 years of age and:(1) has a net family income that is at or below 185 percent of the federal poverty level;(2) participates in or receives benefits under any of the following:(A) the medical assistance program;(B) the financial assistance program under Chapter 31;(C) the nutritional assistance program under Chapter 33;(D) the Supplemental Food Program for Women, Infants and Children; or(E) another program administered by the state that:(i) requires documentation of income; and(ii) restricts eligibility to persons with income equal to or less than the income eligibility guidelines applicable to the medical assistance program;(3) is presumed eligible for one of the programs listed in Subdivision (2) pending completion of that program's eligibility process; or(4) is a member of a family that contains at least one person who participates in or receives benefits under one of the programs listed in Subdivision (2).(c) The department shall ensure that the standards of care provided to a woman participating in the demonstration project are consistent with the requirements of law and current best practices for provision of public health services.(d) The department shall develop procedures for determining and certifying eligibility for services under the demonstration project at the point of service delivery using integrated procedures that minimize duplication of effort by providers, the department, and other state agencies. The department may not use a procedure that would require a cost in excess of 10 percent of the total costs of actual preventive health and family planning services provided under the demonstration project. The eligibility procedure may provide for expedited determination and certification using a simplified form requiring only family income and family size.(e) The department shall compile a list of potential funding sources a woman participating in the demonstration project may be able to use to help pay for treatment for health problems:(1) identified using services provided under the demonstration project; and(2) for which the woman is not eligible to receive treatment under the medical assistance program or the demonstration project.(f) Providers of services under the demonstration project shall comply with requests made by the department for information necessary for the department to:(1) make efficient use of money spent for the operation and administration of the demonstration project;(2) report and provide information required by federal law; and(3) compile the report required by Subsection (g).(g) Not later than December 1 of each even-numbered year, the department shall submit a report to the legislature regarding the department's progress in establishing and operating the demonstration project.(h) The department shall ensure the money spent under the demonstration project, regardless of the funding source, is not used to perform or promote elective abortions. The department, for the purpose of the demonstration project, may not contract with entities that perform or promote elective abortions or are affiliates of entities that perform or promote elective abortions.(i) This section expires September 1, 2011.
Added by Acts 2005, 79th Leg., Ch. 816, Sec. 1, eff. June 17, 2005.
Sec. 32.025. APPLICATION FOR MEDICAL ASSISTANCE. (a) A recipient of benefits under Chapter 31 of this code or supplemental security income from the federal government is automatically eligible for medical assistance, and an application for benefits under these programs constitutes an application for medical assistance.(b) The department shall prescribe application forms for persons who are not recipients of benefits under Chapter 31 of this code or supplemental security income from the federal government and shall adopt rules for processing the applications.(c) The department shall inform applicants for nursing home care of any community services which might be available under the community care for the aged and disabled program.(d) The department shall adopt an application form and procedures for a request for medical assistance provided to a child under 19 years of age. To the extent allowed by federal law and except as otherwise provided by this section, the application form and procedures must be the same as the form and procedures adopted under Section 62.103, Health and Safety Code. The department shall coordinate the form and procedures adopted under this subsection with the form and procedures adopted under Section 62.103, Health and Safety Code, to ensure that there is a single consolidated application for a child under 19 years of age to seek medical assistance or to request coverage under the state child health plan under Chapter 62, Health and Safety Code.(e) The department shall permit an application requesting medical assistance for a child under 19 years of age to be conducted by mail instead of through a personal appearance at a department office, unless the department determines that the information needed to verify eligibility cannot be obtained in that manner. The department by rule may develop procedures requiring an application for a child described by this subsection to be conducted through a personal interview with a department representative only if the department determines that information needed to verify eligibility cannot be obtained in any other manner.(f) The commissioner by rule may develop procedures by which:(1) any office of a health and human services agency may accept an application requesting medical assistance for a child under 19 years of age; and(2) the department may contract with hospital districts, hospitals, including state-owned teaching hospitals, federally qualified health centers, and county health departments to accept applications requesting medical assistance for a child under 19 years of age.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1979. Amended by Acts 1989, 71st Leg., ch. 1085, Sec. 5, eff. Sept. 1, 1989; Acts 2001, 77th Leg., ch. 584, Sec. 2; Acts 2003, 78th Leg., ch. 376, Sec. 2, eff. June 18, 2003; Acts 2003, 78th Leg., ch. 1251, Sec. 7, eff. June 20, 2003.
Sec. 32.0251. ELIGIBILITY NOTIFICATION AND REVIEW FOR CERTAIN CHILDREN. (a) The department shall establish and implement procedures under which the department automatically reviews a child's eligibility for medical assistance if:(1) the child originally establishes eligibility for medical assistance on the basis of receipt of financial assistance under Chapter 31, as provided by Section 32.025(a); and(2) that receipt of financial assistance under Chapter 31 ceases.(b) If the review required by this section indicates that the child may be eligible for medical assistance on a basis other than receipt of financial assistance under Chapter 31, the department may provide for provisional eligibility for medical assistance for the child pending a recertification review. The provisional eligibility period authorized by this subsection may not exceed one month.(c) In addition to the review required by this section, the department shall also promote continued medical assistance for a child described by Subsection (a) through:(1) revising client education and notification policies relating to a child's eligibility for medical assistance; and(2) providing specific notification of a child's potential eligibility for medical assistance to the child's parent or other caretaker at the time the parent or caretaker is notified of:(A) a scheduled eligibility recertification review; or(B) the termination of financial assistance.
Added by Acts 1999, 76th Leg., ch. 704, Sec. 1, eff. June 18, 1999.
Sec. 32.0255. TRANSITIONAL MEDICAL ASSISTANCE. (a) The state shall provide transitional medical assistance, in accordance with state rules and federal law, to a person who was receiving financial assistance under Chapter 31 but is no longer eligible to receive the assistance because:(1) the person's household income has increased; or(2) the person has exhausted the person's benefits under Section 31.0065.(b) Except as provided by Section 31.012(c), the state may provide the medical assistance only until the earlier of:(1) the end of the applicable period prescribed by Section 31.0065 for the provision of transitional benefits; or(2) the first anniversary of the date on which the person becomes ineligible for financial assistance because of increased household income.
Added by Acts 1995, 74th Leg., ch. 655, Sec. 3.03, eff. Sept. 1, 1995.
Sec. 32.026. CERTIFICATION OF ELIGIBILITY AND NEED FOR MEDICAL ASSISTANCE. (a) The department shall promulgate rules for determining and certifying a person's eligibility and need for medical assistance.(b) The department shall promulgate rules to provide for determination and certification of presumptive eligibility for any pregnant woman who applies for Medicaid and who meets the basic eligibility requirements under Title XIX of the federal Social Security Act.(c) Medical assistance payments may not be made on a person's behalf until the person's eligibility and need for medical assistance have been certified in accordance with the department's rules.(d) In adopting rules under this section, the department shall ensure, to the extent allowed by federal law, that documentation and verification procedures used in determining and certifying the eligibility and need for medical assistance of a child under 19 years of age, including the documentation and verification procedures used to evaluate the assets and resources of the child, the child's parents, or the child's other caretaker for that purpose, are the same as the documentation and verification procedures used to determine and certify a child's eligibility for coverage under Chapter 62, Health and Safety Code, except that the documentation and verification procedures adopted in accordance with this subsection may not be more stringent than the documentation and verification procedures existing on January 1, 2001, for determination and certification of a child's eligibility for coverage under Chapter 62, Health and Safety Code.(d-1) In adopting rules under this section, the executive commissioner of the Health and Human Services Commission shall, to the extent allowed by federal law, develop and implement an expedited process for determining eligibility for and enrollment in the medical assistance program for an active duty member of the United States armed forces, reserves, or National Guard or of the state military forces, or the spouse or dependent of that person.(e) The department shall permit a recertification review of the eligibility and need for medical assistance of a child under 19 years of age to be conducted by telephone or mail instead of through a personal appearance at a department office, unless the department determines that the information needed to verify eligibility cannot be obtained in that manner. The department by rule may develop procedures to determine whether there is a need for a recertification review of a child described by this subsection to be conducted through a personal interview with a department representative. Procedures developed under this subsection shall be based on objective, risk-based factors and conditions and shall focus on a targeted group of recertification reviews for which there is a high probability that eligibility will not be recertified.(f) In adopting rules under this section, the department shall ensure, to the extent allowed by federal law, that forms and procedures used in conducting a recertification review of the eligibility and need for medical assistance of a child under 19 years of age, including documentation and verification procedures, are the same as the forms and procedures used to determine and certify a child's renewal of coverage under Chapter 62, Health and Safety Code.(g) Notwithstanding any other provision of this code, the department may use information obtained from a third party to verify the assets and resources of a person for purposes of determining the person's eligibility and need for medical assistance. Third-party information includes information obtained from:(1) a consumer reporting agency, as defined by Section 20.01, Business & Commerce Code;(2) an appraisal district; or(3) the Texas Department of Motor Vehicles vehicle registration record database.
Acts 1979, 66th Leg., p. 2350, ch. 842, art. 1, Sec. 1, eff. Sept. 1, 1
