SECTION 354.4003. Definitions  


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  • The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:

    (1) Centers for Medicare & Medicaid Services (CMS)--The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs.

    (2) Claims administrator--The entity HHSC has designated to perform functions such as processing certain Medicaid program provider claims, managing the EVV aggregator, and performing EVV vendor management functions.

    (3) Community Attendant Services Program--A Medicaid state plan program operating under Title XIX of the Social Security Act, as described in 40 TAC Chapter 47 (relating to Primary Home Care, Community Attendant Services, and Family Care Programs).

    (4) Community First Choice (CFC)--A Medicaid state plan option governed by Code of Federal Regulations, Title 42, Part 441, Subpart K, Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice). This includes STAR members who receive these services through the traditional Medicaid service model also referred to as fee-for-service. CFC services include:

    (A) Community First Choice Habilitation (CFC HAB), a Medicaid state plan service that provides habilitation through CFC;

    (B) Community First Choice Personal Assistance Services (CFC PAS), a Medicaid state plan service that provides personal assistance services through CFC; and

    (C) Community First Choice Personal Assistance Services/Habilitation (CFC PAS/HAB), a Medicaid state plan service provided through CFC that provides both personal assistance services and habilitation combined into one service.

    (5) Community Living Assistance and Support Services (CLASS) Program--The Medicaid waiver program approved by CMS under Title XIX, Section 1915(c) of the Social Security Act, as described in 40 TAC Chapter 45 (relating to Community Living Assistance and Support Services and Community First Choice (CFC) Services).

    (6) Consumer Directed Services (CDS) employer--A member or legally authorized representative (LAR) who chooses to participate in the CDS option. A CDS employer, the member or LAR, is responsible for hiring and retaining a service provider who delivers a service described in §354.4005 of this subchapter (relating to Applicability).

    (7) Consumer Directed Services option (CDS option)--A service delivery option in which a member or LAR employs and retains a service provider and directs the delivery of a service described in §354.4005 of this subchapter.

    (8) Deaf Blind with Multiple Disabilities (DBMD) Program--The Medicaid waiver program approved by CMS under Title XIX, Section 1915(c) of the Social Security Act, as described in 40 TAC Chapter 42 (relating to Deaf Blind with Multiple Disabilities (DBMD) Program and Community First Choice (CFC) Services).

    (9) Electronic visit verification (EVV)--The documentation and verification of service delivery through an EVV system.

    (10) EVV aggregator--A centralized database that collects, validates, and stores statewide EVV visit data transmitted by an EVV system.

    (11) EVV Policy Handbook--The HHSC handbook that provides EVV standards and policy requirements.

    (12) EVV proprietary system--An HHSC-approved EVV system that a program provider or financial management services agency (FMSA) may opt to use instead of an EVV vendor system that:

    (A) is purchased or developed by a program provider or an FMSA;

    (B) is used to exchange EVV information with HHSC or a managed care organization (MCO); and

    (C) complies with the requirements of Texas Government Code §531.024172 or its successors.

    (13) EVV system--An EVV vendor system or an EVV proprietary system used to electronically document and verify the data elements described in §354.4007 of this subchapter (relating to EVV System) for a visit conducted to provide a service described in §354.4005 of this subchapter.

    (14) EVV vendor system--An EVV system provided by an EVV vendor selected by the claims administrator, on behalf of HHSC that a program provider or FMSA may opt to use instead of an EVV proprietary system.

    (15) EVV visit transaction--A data record generated by an EVV system that contains the data elements described in §354.4007 of this subchapter for a visit conducted to provide a service described in §354.4005 of this subchapter.

    (16) Family Care (FC) Program--A program funded under Title XX, Subtitle A of the Social Security Act, as described in 40 TAC Chapter 47.

    (17) Financial Management Services Agency (FMSA)--An entity that contracts with HHSC or an MCO to provide financial management services to a CDS employer as described in 40, TAC Chapter 41 (relating to Consumer Directed Services Option).

    (18) HHSC--Texas Health and Human Services Commission.

    (19) Home and Community-Based Services (HCBS) Adult Mental Health Program--A Medicaid state plan option approved by CMS under Title XIX, Section 1915(i) of the Social Security Act, as described in 26 TAC Chapter 307, Subchapter B (relating to Home and Community-Based Services--Adult Mental Health Program).

    (20) Home and Community-based Services (HCS) Program--A Medicaid waiver program approved by CMS under Title XIX, Section 1915(c) of the Social Security Act, as described in 40 TAC Chapter 9, Subchapter D (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC)).

    (21) Managed care organization (MCO)--Has the meaning set forth in Texas Government Code §536.001.

    (22) Medically Dependent Children Program (MDCP)--A Medicaid waiver program approved by CMS under Title XIX, Section 1915(c) of the Social Security Act, as described in Chapter 353, Subchapter M of this title (relating to Home and Community Based Services in Managed Care).

    (23) Medically Dependent Children Program STAR Health (MDCP STAR Health) covered service--A service provided to a member eligible to receive MDCP benefits under the STAR Health Program.

    (24) Medically Dependent Children Program STAR Kids (MDCP STAR Kids) covered service --A service provided to a member eligible to receive MDCP benefits under the STAR Kids Program.

    (25) Member--A person eligible to receive a service described in §354.4005 of this subchapter.

    (26) Primary Home Care Program--A Medicaid state plan program operating under Title XIX of the Social Security Act, as described in 40 TAC Chapter 47.

    (27) Program provider--An entity that contracts with HHSC or an MCO to provide a service described in §354.4005 of this subchapter.

    (28) Reason code--A standardized HHSC-approved code entered into an EVV system to explain the specific reason a change was made to an EVV visit transaction.

    (29) Service provider--A person who provides a service described in §354.4005 of this subchapter and who is employed or contracted by:

    (A) a program provider;

    (B) a CDS employer; or

    (C) a member who has selected the service responsibility option (SRO).

    (30) Service responsibility option (SRO)--A service delivery option in which a member or LAR selects, trains, and provides daily management of a service provider, while the fiscal, personnel, and service back-up plan responsibilities remain with the program provider.

    (31) STAR--State of Texas Access Reform.

    (32) STAR Program--A Medicaid program operating under Title XIX, Section 1115 of the Social Security Act. The program provides services through a managed care delivery model to a member enrolled in STAR as described in Chapter 353, Subchapter I of this title (relating to STAR).

    (33) STAR Health Program--The Medicaid program operating under Title XIX, Section 1915(a) of the Social Security Act and Texas Family Code, Chapter 266. The program provides services through a managed care delivery model to a member enrolled in STAR Health as described in Chapter 353, Subchapter H of this title (relating to STAR Health).

    (34) STAR Kids Program--The Medicaid program operating under Title XIX, Section 1115 of the Social Security Act and Texas Government Code, Chapter 533. The program provides services through a managed care delivery model to a member enrolled in STAR Kids as described in Chapter 353, Subchapter N of this title (relating to STAR Kids).

    (35) STAR+PLUS Home and Community-Based Services Program (STAR+PLUS HCBS Program)--A Medicaid program operating through a federal waiver under Title XIX, Section 1115 of the Social Security Act. The program provides services to a member eligible to receive HCBS benefits under the STAR+PLUS Program, as described in Chapter 353, Subchapter M of this title (relating to Home and Community Based Services in Managed Care).

    (36) STAR+PLUS Medicare-Medicaid Plan (STAR+PLUS MMP)--A managed care program operating under Title XIX, Section 1115A of the Social Security Act that provides the authority to test and evaluate a fully integrated care model for clients who are dual eligible. The STAR+PLUS MMPs are contracted with CMS and HHSC to participate in the Dual Demonstration Program described in Chapter 353, Subchapter L of this title (relating to Texas Dual Eligibles Integrated Care Demonstration Project).

    (37) STAR+PLUS Program--A Medicaid program operating under Title XIX, Section 1115 of the Social Security Act, and Texas Government Code, Chapter 533. The program provides services through a managed care delivery model to a member enrolled in STAR+PLUS as described in Chapter 353, Subchapter G of this title (relating to STAR+PLUS).

    (38) TAC--Texas Administrative Code.

    (39) Texas Health Steps Comprehensive Care Program--A Medicaid comprehensive program approved by CMS under Title XIX, Section 1905 of the Social Security Act, as described in Chapter 363, Subchapter F of this title (relating to Personal Care Services). This includes STAR members who receive these services through the traditional Medicaid service model also referred to as fee-for-service.

    (40) Texas Home Living (TxHmL) Program--A Medicaid waiver program approved by CMS under Title XIX, Section 1915(c) of the Social Security Act, as described in 40 TAC Chapter 9, Subchapter N (relating to Texas Home Living (TxHmL) Program and Community First Choice (CFC)).

    (41) Youth Empowerment Services Program--A Medicaid waiver approved by CMS under Title XIX, Section 1915(c) of the Social Security Act as described in 26 TAC Chapter 307, Subchapter A (relating to Youth Empowerment Services (YES)).

Source Note: The provisions of this §354.4003 adopted to be effective December 23, 2020, 45 TexReg 9178