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Texas Administrative Code (Last Updated: March 27,2024) |
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TITLE 1. ADMINISTRATION |
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PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION |
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CHAPTER 353. MEDICAID MANAGED CARE |
| SUBCHAPTER A. GENERAL PROVISIONS |
| § 353.1. Purpose |
| § 353.2. Definitions |
| § 353.3. Experience Rebate in the Managed Care Program |
| § 353.4. Managed Care Organization Requirements Concerning Out-of-Network Providers |
| § 353.5. Internet Posting of Sanctions Imposed For Contractual Violations |
| § 353.6. Audit of Managed Care Organizations |
| § 353.7. Continuity of Care with Out-of-Network Specialty Providers |
| § 353.8. Certification of Managed Care Organizations Prior to Contract Awards |
| SUBCHAPTER B. PROVIDER AND MEMBER EDUCATION PROGRAMS |
| § 353.101. Purpose |
| § 353.102. Provider and Member Education Programs Generally |
| § 353.104. Member Education Program |
| § 353.105. Provider Education Program |
| SUBCHAPTER C. MEMBER BILL OF RIGHTS AND RESPONSIBILITIES |
| § 353.201. Purpose |
| § 353.202. Member Bill of Rights |
| § 353.203. Member Bill of Responsibilities |
| SUBCHAPTER E. STANDARDS FOR MEDICAID MANAGED CARE |
| § 353.403. Enrollment and Disenrollment |
| § 353.405. Marketing |
| § 353.407. Requirements of Managed Care Plans |
| § 353.409. Scope of Services |
| § 353.411. Accessibility of Services |
| § 353.413. Managed Care Benefits and Services for Children Under 21 Years of Age |
| § 353.415. Member Complaint and Appeal Procedures |
| § 353.417. Quality Assessment and Performance Improvement |
| § 353.419. Financial Standards |
| § 353.421. Special Disease Management for Health Care MCOs |
| § 353.423. Expedited Credentialing |
| § 353.425. MCO Processing of Prior Authorization Requests Received with Incomplete or Insufficient Documentation |
| § 353.427. Accessibility of Information Regarding Medicaid Prior Authorization Requirements |
| SUBCHAPTER F. SPECIAL INVESTIGATIVE UNITS |
| § 353.501. Purpose |
| § 353.502. Managed Care Organization's Plans and Responsibilities in Preventing and Reducing Waste, Abuse, and Fraud |
| § 353.503. Managed Care Organization's Contracts |
| § 353.504. Review of Managed Care Organization's Records |
| § 353.505. Recovery of Funds |
| SUBCHAPTER G. STAR+PLUS |
| § 353.601. General Provisions |
| § 353.603. Member Participation |
| § 353.605. Participating Providers |
| § 353.607. STAR+PLUS Handbook |
| § 353.608. Minimum Payment Amounts to Qualified Nursing Facilities |
| § 353.609. Service Coordination |
| § 353.610. Minimum Performance Standards for Nursing Facilities that Participate in the STAR+PLUS Program |
| SUBCHAPTER H. STAR HEALTH |
| § 353.701. General Provisions |
| § 353.702. Member Participation |
| SUBCHAPTER I. STAR |
| § 353.801. General Provisions |
| § 353.802. Member Participation |
| SUBCHAPTER J. OUTPATIENT PHARMACY SERVICES |
| § 353.901. Purpose |
| § 353.903. Definitions |
| § 353.905. Managed Care Organization Requirements |
| § 353.907. Prior Authorization Requirements |
| § 353.909. Participating Pharmacy Providers |
| § 353.911. Members |
| § 353.913. Managed Care Organization Requirements Concerning Out-of-Network Outpatient Pharmacy Services |
| § 353.915. Access to Network Pharmacies |
| SUBCHAPTER K. CHILDREN'S MEDICAID DENTAL SERVICES |
| § 353.1001. General Provisions |
| § 353.1003. Member Participation |
| SUBCHAPTER L. TEXAS DUAL ELIGIBLES INTEGRATED CARE DEMONSTRATION PROJECT |
| § 353.1101. Purpose |
| § 353.1103. General Provisions |
| § 353.1105. Eligibility |
| § 353.1107. Member Enrollment and Disenrollment |
| § 353.1109. Participating Providers |
| § 353.1111. Benefits |
| § 353.1113. Appeals and Fair Hearings |
| § 353.1115. Network Adequacy for Certain Service Providers |
| SUBCHAPTER M. HOME AND COMMUNITY BASED SERVICES IN MANAGED CARE |
| § 353.1151. General Provisions |
| § 353.1153. STAR+PLUS Home and Community Based Services (HCBS) Program |
| § 353.1155. Medically Dependent Children Program |
| SUBCHAPTER N. STAR KIDS |
| § 353.1201. General Provisions |
| § 353.1203. Member Participation |
| § 353.1205. Service Coordination |
| § 353.1207. Participating Providers |
| § 353.1209. STAR Kids Handbook |
| SUBCHAPTER O. DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES |
| § 353.1301. General Provisions |
| § 353.1302. Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019 |
| § 353.1303. Quality Incentive Payment Program for Nursing Facilities before September 1, 2019 |
| § 353.1304. Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019 |
| § 353.1305. Uniform Hospital Rate Increase Program |
| § 353.1306. Comprehensive Hospital Increase Reimbursement Program for Program Periods on or after September 1, 2021 |
| § 353.1307. Quality Metrics for the Comprehensive Hospital Increase Reimbursement Program |
| § 353.1309. Texas Incentives for Physicians and Professional Services |
| § 353.1311. Quality Metrics for the Texas Incentives for Physicians and Professional Services Program |
| § 353.1315. Rural Access to Primary and Preventive Services Program |
| § 353.1317. Quality Metrics for Rural Access to Primary and Preventive Services Program |
| § 353.1320. Directed Payment Program for Behavioral Health Services |
| § 353.1322. Quality Metrics for the Directed Payment Program for Behavioral Health Services |
| SUBCHAPTER P. MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION |
| § 353.1401. Purpose |
| § 353.1403. Definitions |
| § 353.1405. Managed Care Organization Responsibilities |
| § 353.1407. Information Systems and Medical Records Systems |
| § 353.1409. Patient Safety, Rights, and Protections |
| § 353.1411. Access to Mental Health Services |
| § 353.1413. Staff Member Competency |
| § 353.1415. Staff Member Credentialing |
| § 353.1417. Comprehensive Provider Agency Requirements for Staff Member Credentialing and Appeals |
| § 353.1419. Supervision Requirements |
| SUBCHAPTER Q. PROCESS TO RECOUP CERTAIN OVERPAYMENTS |
| § 353.1451. Purpose and Authority |
| § 353.1452. Definitions |
| § 353.1453. Due Process Procedures to Recoup an Overpayment Related to an EVV Visit Transaction that is not Fraud or Abuse and Limitation on Audit Period |
| § 353.1454. Due Process Procedures to Recoup an Overpayment Because of a Discovery of Fraud or Abuse |
| SUBCHAPTER R. TELECOMMUNICATIONS IN MANAGED CARE SERVICE COORDINATION AND ASSESSMENTS |
| § 353.1501. Purpose |
| § 353.1502. Definitions |
| § 353.1503. Use of Telecommunications in Assessments |
| § 353.1504. Use of Telecommunications in Service Coordination and Service Management |
| § 353.1505. Additional Requirements for Assessments and Service Coordination in STAR+PLUS and STAR Kids |
| § 353.1506. Additional Requirements for Assessments and Service Management in STAR Health |