SECTION 353.409. Scope of Services

(a) An MCO must provide covered services to members. The MCO is not responsible for providing or paying for non-capitated services or members' cost sharing obligations, if any.

(b) HHSC will establish the scope and level of benefits, which all MCOs must agree to provide as a condition for participation. In accordance with 42 C.F.R. §438.210, the scope of benefits must be provided at least in an amount, duration, and scope available to Medicaid fee-for-service clients, unless otherwise explicitly authorized by HHSC through a waiver. The amount, duration, and scope of benefits may exceed the scope of fee-for-service in accordance with subsection (f) of this section. These requirements will be contained in all contracts entered into by an MCO and HHSC.

(c) MCOs are encouraged to provide any value-added services or benefits beyond the level and scope required as a condition for participation in the competitive procurement process. These services and benefits must be approved by HHSC and cannot increase the cost borne or capitation rates paid by HHSC during any current contract term or in any subsequent contract term. These services or benefits cannot violate any other state or federal rule or regulation.

(d) A value-added service may be unique to an MCO, and limited to a member who meets the MCO's qualification criteria for the service.

(e) Before approving a value-added service, HHSC will determine whether it is an actual health care service, dental service, benefit, or positive incentive designed to promote a healthy lifestyle and improve a health or dental outcome. HHSC will not approve best practice approaches to delivering covered services as value-added services. Examples of potential value-added services include: health or dental-related programs; programs that encourage health-conscious behaviors; and for children enrolled in STAR Health, non-health care services and benefits that support the child's physical, mental, or developmental well being.

(f) On a case-by-case basis, an MCO may offer to individual members additional benefits that are outside the scope of services. Case-by-case services may be based on medical necessity, cost-effectiveness, the wishes of the member or the member's family, or the potential for improving the member's health status. For STAR+PLUS members, these case-by-case services may also be based on functional necessity. These services and benefits cannot increase the cost borne or capitation rates paid by HHSC during any current contract term or in any subsequent contract term and cannot violate any other state or federal rule or regulation.

Source Note: The provisions of this §353.409 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective March 1, 2012, 37 TexReg 1283; amended to be effective September 1, 2014, 39 TexReg 5873