Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003 Page: 2,853
2821-2988 p. ; 28 cm.View a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
family of an individual; a foster family or identifiable support person
or persons.
(14) Health and health-related services--Services which
are provided to meet the comprehensive (preventive, primary, tertiary
and specialty) health needs of the eligible recipient, including but
not limited to, well care and dental check ups, immunizations, acute
care visits, pediatric specialty consultations, physical therapy, occu-
pational therapy, audiology, speech language services, mental health
professional services, pharmaceuticals, medical supplies, prenatal
care, family planning, adolescent preventive health, durable medical
equipment, nutritional supplements, prosthetics, eye glasses, and
hearing aids.
(15) High risk pregnant women--Women who are pregnant
and have one or more high-risk medical and/or personal/psychosocial
condition(s) during pregnancy.
(16) Preventive services--Services that include health
counseling and education, immunizations, wellness care, nutritional
supplementation, family planning and screening aimed at avoiding
illness and/or disability.
(17) Primary services--Services that include care for minor
illnesses, injuries and abnormalities discovered through screenings.
(18) State--The State of Texas.
(19) Tertiary services--Services that include care for major
illnesses and injuries, and chronic or disabling conditions.
(20) Texas Health Steps Program (THSteps)--In Texas, the
federal program known as EPSDT, which is required of states partici-
pating in the Medicaid program, is called Texas Health Steps.
27.3. Eligible Recipients.
Clients eligible for case management services under this subchapter
must be either children with a health condition/health risk or high-risk
pregnant women who are:
(1) Medicaid eligible in Texas;
(2) in need of services to prevent illness(es) or medical con-
dition(s), to maintain function or slow further deterioration; and
(3) desire case management.
27.5. Case Management for Children and Pregnant Women.
Case Management for Children and Pregnant Women's services, as de-
fined in 27.1 of this title (relating to Definitions), are provided to assist
eligible recipients in gaining access to medically necessary medical,
social, educational and other services for which federal financial par-
ticipation is available in order to: encourage the use of cost-effective
health and health-related care; make referrals to appropriate commu-
nity resources; discourage over utilization or duplication of services;
and reduce morbidity and mortality. Case Management for Children
and Pregnant Women is not a "gatekeeper" function.
(1) The following contacts are billable:
(A) Comprehensive Visit--a face-to-face visit that in-
cludes the development of:
(i) Family Needs Assessment--a written evaluation
of all issues that impact the short and long term health and well being
of the eligible recipient and his/her family. Together, the case manager
and family shall assess the medical, social, educational and other med-
ically necessary service needs of the eligible recipient. Documentation
of the Family Needs Assessment should include, at a minimum:(I) the assessment of the medical, social/family,
nutritional, educational, vocational, developmental and health care
transportation needs;
(II) individualized assessment of the client; and
(III) the case manager's dated signature.
(ii) Service Plan--the written summary which:
(I) documents the services to be accessed;
(II) identifies the individual responsible for con-
tacting the appropriate health and human service providers;
(III) designates the time frame within which the
eligible recipient should access services;
(IV) may be sent to the medical provider or oth-
ers as appropriate in accordance with the limits of confidentiality;
(V) includes, at a minimum: the interventions
and referrals for addressing needs identified in the Family Needs As-
sessment; the time frame for the client to access services; the client/par-
ent/guardian's and case manager's dated signatures.
(B) Follow-up contact--a face-to-face or telephone con-
tact with the eligible recipient and his/her family. The case manager
and the client/family review and reassess the client/family's needs, de-
termine what referrals and services specified in the Service Plan have
been received by the client/family, and develop appropriate modifica-
tions to the Service Plan. The Follow-up contact includes the review
of the referrals that have occurred or are still needed to complete the
Service Plan and meet the client/family's needs. Follow-up contacts
for children should occur as needed. Follow-up contacts for pregnant
women should occur as needed through the 59th day post partum. Doc-
umentation of the Follow-up contacts should include, at a minimum:
(i) a review of complete Service Plan;
(ii) efforts to ascertain on an ongoing basis which
needs specified in the Service Plan have been addressed with appropri-
ate referrals provided and services accessed; and
(iii) evidence of problem solving with client/par-
ent/guardian when needs are not addressed or referrals not accessed.
(2) Case Management for Children and Pregnant Women
services will include a non-billable intake with each client/family. The
intake will include the collection of demographic information and de-
termination of the client's eligibility.
(3) Only one billable contact per client shall be billed per
day.
27.7. Service Limitations.
(a) Case Management for Children and Pregnant Women ser-
vices are not reimbursable if they are duplicative of other billed, com-
prehensive Medicaid case management services.
(b) Following intake completion, the initial prior authoriza-
tion request for billable Case Management for Children and Pregnant
Women services must be supported by required documentation and
submitted to the department for review and disposition. The amount of
Comprehensive Visits and Follow-up contacts that are prior authorized
will be based on the client's level of need, level of medical involvement
and complicating psychosocial factors.
(c) Any additional requests for Case Management for Children
and Pregnant Women services must also be prior authorized. Required
documentation must be submitted to the department for review and dis-
position before any additional services may be prior authorized.PROPOSED RULES April 4, 2003 28 TexReg 2853
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
Texas. Secretary of State. Texas Register, Volume 28, Number 14, Pages 2821-2988, April 4, 2003, periodical, April 4, 2003; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth101027/m1/32/: accessed May 26, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.