CHAPTER 354. MEDICAID HEALTH SERVICES  


SUBCHAPTER A. PURCHASED HEALTH SERVICES
DIVISION 1. MEDICAID PROCEDURES FOR PROVIDERS
§ 354.1001. Claim Information Requirements
§ 354.1002. Compliance with Civil Rights Act
§ 354.1003. Time Limits for Submitted Claims
§ 354.1004. Retention of Records
§ 354.1005. Unauthorized Charges
DIVISION 2. MEDICAID VISION CARE PROGRAM
§ 354.1015. Benefits and Limitations
§ 354.1017. Specifications for Eyewear
§ 354.1021. Additional Claims Information Requirements
§ 354.1023. Optometric Services Provider
§ 354.1025. Competitive Procurement of Vision Care Services
DIVISION 3. MEDICAID HOME HEALTH SERVICES
§ 354.1031. General
§ 354.1033. Provider Participation Requirements
§ 354.1035. Recipient Qualifications for Home Health Services
§ 354.1037. Written Plan of Care
§ 354.1039. Home Health Services Benefits and Limitations
§ 354.1040. Requirements for Wheeled Mobility Systems
§ 354.1041. Benefits for Medicare/Medicaid Recipients
§ 354.1042. Supplies Provided by a Pharmacy
§ 354.1043. Competitive Procurement of Durable Medical Equipment (DME) and Supplies
DIVISION 4. MEDICAID CHIROPRACTIC SERVICES
§ 354.1051. Additional Claim Information Requirements
§ 354.1052. Authorized Chiropractic Services
DIVISION 5. PHYSICIAN AND PHYSICIAN ASSISTANT SERVICES
§ 354.1060. Definitions
§ 354.1061. Additional Claim Information Requirements
§ 354.1062. Authorized Physician Services
§ 354.1063. Preventable Adverse Events
§ 354.1064. Anesthesiologist Assistant Conditions of Participation
§ 354.1065. Anesthesiologist Assistant Benefits and Limitations
§ 354.1066. Physician Assistant Conditions of Participation
§ 354.1067. Physician Assistant Benefits and Limitations
§ 354.1069. Sign Language Interpreter Services
DIVISION 6. HOSPITAL SERVICES
§ 354.1070. Definitions
§ 354.1071. Additional Claim Information Requirements
§ 354.1072. Authorized Inpatient Hospital Services
§ 354.1073. Authorized Outpatient Hospital Services
§ 354.1075. Hospitalization (Dental Care Only) for Individuals under Age 21 Years
§ 354.1077. Provider Participation Requirements
DIVISION 7. LABORATORY, X-RAY, AND RADIATION THERAPY
§ 354.1091. Additional Claim Information Requirements
§ 354.1092. Authorized Services
DIVISION 8. PODIATRY SERVICES
§ 354.1101. Additional Claim Information Requirements
§ 354.1102. Authorized Podiatry Services
DIVISION 9. AMBULANCE SERVICES
§ 354.1111. Definitions
§ 354.1113. Additional Claim Information Requirements
§ 354.1115. Authorized Ambulance Services
DIVISION 10. DEFINITIONS
§ 354.1121. Definitions
DIVISION 11. GENERAL ADMINISTRATION
§ 354.1131. Payments to Eligible Providers
§ 354.1133. Parental Accompaniment Requirement
§ 354.1135. Claims Procedures
§ 354.1137. Review of Questionable Claims
§ 354.1139. Verification of Cost Data
§ 354.1141. Notification to Eligible Providers
§ 354.1143. Coordination of Medicaid with Medicare Parts A, B, and C
§ 354.1145. Nonliability
§ 354.1147. Medicaid Fee Schedule
§ 354.1149. Exclusions and Limitations
§ 354.1151. Freedom of Choice
§ 354.1153. Subrogation
§ 354.1155. Confidentiality of Information
§ 354.1157. Potential Fraud, Program Abuse, and Other Misutilization
§ 354.1159. Utilization Review
§ 354.1161. Provider Re-enrollment or Provider Contract or Agreement Modification
§ 354.1163. Fair Hearings
§ 354.1165. Free Services for Recipients
§ 354.1167. Reimbursement for Abortions
§ 354.1169. Ectopic Pregnancy
§ 354.1171. Use of Drugs or Devices to Prevent Implantation of the Fertilized Ovum
§ 354.1175. Organ Transplants
§ 354.1177. Electronic Visit Verification (EVV) System
§ 354.1181. Provider Compliance with the Clinical Laboratory Improvement Amendments of 1988
§ 354.1183. Provider Compliance with the Mammography Quality Standards Act of 1992
§ 354.1185. Provider Compliance with Durable Medical Equipment (DME) Certification Requirements
§ 354.1186. Requirements for the Health Passport
§ 354.1187. Responsibilities of Third-Party Billing Vendors
§ 354.1189. Acute Care Medicaid Billing Coordination System
§ 354.1190. Medicaid Provider Database
DIVISION 12. RURAL HEALTH CLINICS
§ 354.1201. Authorized Services by Rural Health Clinics
§ 354.1202. Conditions for Payments to Rural Health Clinics
§ 354.1203. Relationship of Recipient's Treating Physician to Rural Health Clinics
DIVISION 13. AMBULATORY SURGICAL CENTERS
§ 354.1211. Conditions for Participation
§ 354.1212. Services and Limitations
DIVISION 14. DENTISTS' SERVICES
§ 354.1221. Authorized Dentists' Services
DIVISION 15. HEARING AID SERVICES
§ 354.1231. Benefits and Limitations
§ 354.1233. Requirements for Hearing Aid Services
§ 354.1235. Requirements for Provider Participation
DIVISION 16. MIDWIFE SERVICES
§ 354.1251. Benefits and Limitations
§ 354.1252. Certified Nurse Midwife: Conditions for Participation
§ 354.1253. Licensed Midwife: Conditions for Participation
DIVISION 17. BIRTHING CENTER SERVICES
§ 354.1261. Benefits and Limitations
§ 354.1262. Conditions for Participation
DIVISION 18. MATERNITY CLINIC SERVICES
§ 354.1271. Benefits and Limitations
§ 354.1272. Conditions for Participation
§ 354.1275. Monitoring
DIVISION 19. PSYCHOLOGISTS' SERVICES
§ 354.1281. Benefits and Limitations
§ 354.1282. Conditions of Participation
DIVISION 20. PHYSICAL THERAPISTS' SERVICES
§ 354.1291. Benefits and Limitations
§ 354.1292. Conditions for Participation
DIVISION 21. CERTIFIED REGISTERED NURSE ANESTHETISTS' SERVICES
§ 354.1301. Benefits and Limitations
§ 354.1302. Conditions for Participation
DIVISION 22. SUBSTANCE ABUSE AND DEPENDENCY TREATMENT SERVICES
§ 354.1311. Benefits and Limitations
§ 354.1312. Conditions for Participation
DIVISION 23. FEDERALLY QUALIFIED HEALTH CENTER SERVICES
§ 354.1321. Benefits and Limitations
§ 354.1322. Provider Participation Requirements
§ 354.1323. Reviews/Appeals
DIVISION 24. NURSE PRACTITIONER AND CLINICAL NURSE SPECIALIST SERVICES
§ 354.1331. Benefits and Limitations
§ 354.1332. Conditions for Participation
DIVISION 25. SCHOOL HEALTH AND RELATED SERVICES
§ 354.1341. Benefits and Limitations
§ 354.1342. Conditions for Participation
DIVISION 26. COORDINATED CARE
§ 354.1351. Coordinated Care Pilot Project
DIVISION 27. COMMUNITY FIRST CHOICE
§ 354.1360. Purpose
§ 354.1361. Definitions
§ 354.1362. Eligibility
§ 354.1363. Assessment
§ 354.1364. Services and Limitations
§ 354.1365. Provider Qualifications
§ 354.1366. Consumer Directed Services and Service Responsibility Option
§ 354.1367. Person-Centered Service Plan
§ 354.1368. Fair Hearing
§ 354.1369. Attendant Base Wage
DIVISION 28. TUBERCULOSIS
§ 354.1371. Tuberculosis Clinic Benefits and Limitations
DIVISION 29. LICENSED PROFESSIONAL COUNSELORS, LICENSED CLINICAL SOCIAL WORKERS, AND LICENSED MARRIAGE AND FAMILY THERAPISTS
§ 354.1381. Benefits and Limitations
§ 354.1382. Conditions for Participation
DIVISION 30. IN-HOME TOTAL PARENTERAL HYPERALIMENTATION SERVICES
§ 354.1391. In-home Total Parenteral Hyperalimentation Services
DIVISION 31. IN-HOME RESPIRATORY THERAPY SERVICES FOR VENTILATOR-DEPENDENT PERSONS
§ 354.1401. In-home Respiratory Therapy Services for Ventilator-Dependent Persons
DIVISION 32. TEXAS MEDICAID WELLNESS PROGRAM
§ 354.1415. Vendor Requirements and Conditions for Participation
§ 354.1416. Eligibility Criteria
§ 354.1417. Definitions for Wellness Services
DIVISION 33. ADVANCED TELECOMMUNICATIONS SERVICES
§ 354.1430. Definitions
§ 354.1432. Telemedicine and Telehealth Benefits and Limitations
§ 354.1434. Home Telemonitoring Benefits and Limitations
DIVISION 34. OUT-OF-STATE SERVICES
§ 354.1440. Medical Care or Services Provided to Medicaid Recipients Outside of Texas
DIVISION 35. REIMBURSEMENT ADJUSTMENTS FOR POTENTIALLY PREVENTABLE EVENTS
§ 354.1445. Potentially Preventable Readmissions
§ 354.1446. Potentially Preventable Complications
SUBCHAPTER B. GENERAL PROVISIONS
§ 354.1450. Audits of Medicaid Providers
§ 354.1451. Medicaid Recovery Audit Contractor Program
§ 354.1452. Provider Marketing
SUBCHAPTER D. TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM
DIVISION 1. GENERAL
§ 354.1601. Introduction
§ 354.1602. Definitions
DIVISION 2. REGIONAL HEALTHCARE PARTNERSHIPS
§ 354.1611. Organization
§ 354.1612. Anchors
§ 354.1613. Participants
DIVISION 3. RHP PLAN CONTENTS AND APPROVAL
§ 354.1621. RHP Plan
§ 354.1622. RHP Plan Assessment
§ 354.1623. RHP Plan Modifications and the Addition of Three-Year DSRIP Projects
§ 354.1624. Independent Assessment of DSRIP Projects
DIVISION 4. DSRIP
§ 354.1631. DSRIP Categories
§ 354.1632. DSRIP Requirements for Regional Healthcare Partnerships
§ 354.1633. DSRIP Requirements for Performers
§ 354.1634. Waiver Pool Allocation
§ 354.1635. DSRIP Project Valuation
§ 354.1636. Payment for DSRIP Performance
§ 354.1637. DSRIP Project Termination and Payment Recoupment
DIVISION 5. ACTIONS IN PREPARATION FOR EXTENSION OF THE DSRIP PROGRAM
§ 354.1641. Definitions
§ 354.1643. Medicaid and Low-income or Uninsured (MLIU) Quantifiable Patient Impact (QPI)
§ 354.1645. Electing to Continue a DSRIP Project in the Waiver Extension Period
§ 354.1647. Requests for Adjustments to Certain DSRIP Projects
§ 354.1649. Certain Requirements for the Planned Transition Year and their Exceptions
DIVISION 6. DSRIP PROGRAM DEMONSTRATION YEAR 6
§ 354.1661. Definitions
§ 354.1663. Medicaid and Low-income or Uninsured (MLIU) Quantifiable Patient Impact (QPI)
§ 354.1665. Demonstration Year 6 DSRIP Pool Funding and Distribution
§ 354.1667. Requirements for Continuing DSRIP Projects
§ 354.1669. Requirements for Combining Certain DSRIP Projects
§ 354.1671. DSRIP Requirements for Uncompensated Care Hospitals
§ 354.1673. Remaining DSRIP Funds
§ 354.1675. Anchor Requirements
DIVISION 7. DSRIP PROGRAM DEMONSTRATION YEARS 7-8
§ 354.1691. Definitions
§ 354.1693. Regional Healthcare Partnerships (RHPs)
§ 354.1695. Participants
§ 354.1697. RHP Plan Update
§ 354.1699. RHP Plan Update Review
§ 354.1701. RHP Plan Update Modifications
§ 354.1703. Independent Assessor
§ 354.1705. Categories
§ 354.1707. Performer Valuations
§ 354.1709. Category A Requirements for Performers
§ 354.1711. Category B Requirements for Performers
§ 354.1713. Category C Requirements for Performers
§ 354.1715. Category D Requirements for Performers
§ 354.1717. Uncompensated Care (UC) Hospital Requirements
§ 354.1719. Disbursement of Funds
§ 354.1721. Remaining Funds for Demonstration Years (DYs) 7-8
DIVISION 8. DSRIP PROGRAM DEMONSTRATION YEARS 9-10
§ 354.1729. Definitions
§ 354.1731. Medicaid and Low-income or Uninsured Patient Population by Provider
§ 354.1733. Regional Healthcare Partnerships (RHPs)
§ 354.1735. Participants
§ 354.1737. RHP Plan Update for DY9-10
§ 354.1739. RHP Plan Update Review
§ 354.1741. RHP Plan Update Modifications
§ 354.1743. Independent Assessor
§ 354.1745. Categories
§ 354.1747. Performer Valuations
§ 354.1749. Category A Requirements for Performers
§ 354.1751. Category B Requirements for Performers
§ 354.1753. Category C Requirements for Performers
§ 354.1755. Category D Requirements for Performers
§ 354.1757. Disbursement of Funds
SUBCHAPTER F. PHARMACY SERVICES
DIVISION 1. PARTICIPATION
§ 354.1801. Requirements for Participation
§ 354.1803. Confidentiality
§ 354.1805. Nondiscrimination
§ 354.1807. Access to Records
§ 354.1809. Denial or Termination of Participation
§ 354.1811. Sanctions
§ 354.1813. Placing a Pharmacy Provider on Vendor Hold
DIVISION 2. ADMINISTRATION
§ 354.1831. Covered Drugs
§ 354.1832. Prior Authorization Procedures
§ 354.1833. Pharmacy Services
§ 354.1835. Prescriber Identification Numbers
§ 354.1837. Evidence of Eligibility
DIVISION 3. MEDICATIONS
§ 354.1851. Substitution of One Drug for Another in a Prescription
§ 354.1853. Specialty Drugs
DIVISION 4. LIMITATIONS
§ 354.1861. Availability of Funds
§ 354.1863. Prescription Requirements
§ 354.1867. Refills
§ 354.1868. Exceptions in Disasters
§ 354.1871. Advertising
§ 354.1873. Freedom of Choice
§ 354.1875. Limitations on Provider Charges to Recipients
§ 354.1877. Quantity Limitations
DIVISION 5. AUDITS
§ 354.1891. Vendor Drug Providers Subject to Audit
§ 354.1892. Exception Notification
DIVISION 6. PHARMACY CLAIMS
§ 354.1901. Pharmacy Claims
§ 354.1905. Claim Adjustments
§ 354.1907. Unacknowledged Claims
§ 354.1909. Submittal of Special Claims
§ 354.1911. Electronic Data Transmission Vendors (Switches)
DIVISION 7. TEXAS DRUG CODE INDEX--ADDITIONS, RETENTIONS, AND DELETIONS
§ 354.1921. Addition of Drugs to the Texas Drug Code Index
§ 354.1923. Review and Evaluation
§ 354.1924. Preferred Drug List
§ 354.1925. Resubmittal of a Denied Request
§ 354.1927. Retention and Deletion of Drugs
DIVISION 8. DRUG UTILIZATION REVIEW BOARD
§ 354.1941. Drug Utilization Review Board
§ 354.1942. Conflict of Interest Policy
SUBCHAPTER I. MEDICAID PROGRAM APPEALS PROCEDURES
DIVISION 1. GENERAL
§ 354.2201. Definitions
§ 354.2203. Recipients with Special Needs or Disabilities
DIVISION 2. RECIPIENT NOTICE AND FAIR HEARING
§ 354.2211. Recipient Notice and Fair Hearing Request
§ 354.2213. Maintaining Benefits or Services
§ 354.2215. Fair Hearing
DIVISION 3. APPEALS
§ 354.2217. Provider Appeals and Reviews
SUBCHAPTER J. MEDICAID THIRD PARTY RECOVERY
DIVISION 1. GENERAL PROVISIONS
§ 354.2301. Basis and Purpose
§ 354.2302. Definitions
DIVISION 2. APPLICANT AND RECIPIENT REQUIREMENTS
§ 354.2311. Applicant and Recipient Assignment of Rights
§ 354.2313. Duty of Applicant or Recipient to Inform and Cooperate
§ 354.2315. Duty of Attorney or Representative of a Recipient
DIVISION 3. PROVIDER REQUIREMENTS
§ 354.2321. Provider Billing and Recovery From Third Party Health Insurer
§ 354.2322. Provider Billing and Recovery from Other Third Parties
DIVISION 4. DUTIES OF THE COMMISSION
§ 354.2331. Requests for Information
§ 354.2332. Distribution of Recoveries
§ 354.2333. Waiver Authority of the Commissioner
§ 354.2334. Notices and Payments
DIVISION 5. HEALTH INSURER REQUIREMENTS
§ 354.2341. Third Party Health Insurer Information Requirements
§ 354.2343. Administrative Penalties for Failure to Provide Information
§ 354.2344. Notice and Appeal of Administrative Penalty
DIVISION 6. BILLING AND PAYMENT GUIDELINES
§ 354.2354. Billing Medicare Intermediaries
§ 354.2355. Long Term Care Providers
§ 354.2356. Provider Requirements to Bill Third Party Health Coverage
DIVISION 7. HEALTH INSURANCE PREMIUM PAYMENT GUIDELINES
§ 354.2361. Medicaid Health Insurance Premium Payment Program
SUBCHAPTER K. MEDICAID RECIPIENT UTILIZATION REVIEW AND CONTROL
§ 354.2401. Definitions
§ 354.2403. Monitoring and Review
§ 354.2405. Utilization Control
§ 354.2407. Recipient Rights
SUBCHAPTER L. QUALITY IMPROVEMENT PROCESS FOR CLINICAL INITIATIVES
§ 354.2501. Definitions
§ 354.2503. Clinical Initiative Evaluation Process
§ 354.2505. Action on Approved Clinical Initiatives
§ 354.2507. Internet Website
SUBCHAPTER M. MENTAL HEALTH TARGETED CASE MANAGEMENT AND MENTAL HEALTH REHABILITATION
DIVISION 1. GENERAL PROVISIONS
§ 354.2601. Purpose and Applicability
§ 354.2603. Definitions
§ 354.2605. Fair Hearings and Appeal Processes
§ 354.2607. Assessment and Service Authorization
§ 354.2609. Recovery/Treatment Planning, Recovery/Treatment Plan Review, and Discharge Summary
§ 354.2611. Pharmacological Management, Psychiatric Diagnostic Evaluations, and Psychotherapy
§ 354.2613. Criminal History Background Checks
DIVISION 2. MENTAL HEALTH TARGETED CASE MANAGEMENT
§ 354.2651. Eligible Individuals
§ 354.2653. Continued Eligibility
§ 354.2655. Mental Health Targeted Case Management Services
§ 354.2657. Documentation Requirements
§ 354.2659. Exclusions
DIVISION 3. MENTAL HEALTH REHABILITATION
§ 354.2701. Eligible Individuals
§ 354.2703. Continued Eligibility
§ 354.2705. Mental Health Rehabilitative Services
§ 354.2707. Crisis Intervention Services
§ 354.2709. Medication Training and Support Services
§ 354.2711. Psychosocial Rehabilitative Services
§ 354.2713. Skills Training and Development Services
§ 354.2715. Day Programs for Acute Needs
§ 354.2717. Exclusions
SUBCHAPTER N. PEER SPECIALIST SERVICES
DIVISION 1. GENERAL PROVISIONS
§ 354.3001. Purpose and Applicability
§ 354.3003. Definitions
DIVISION 2. SERVICE PROVISION
§ 354.3011. Eligibility to Receive Services
§ 354.3013. Services Provided
§ 354.3015. Medicaid Reimbursement
DIVISION 3. PEER SPECIALISTS
§ 354.3051. Minimum Qualifications
§ 354.3053. Scope of Work
§ 354.3055. Ethical Responsibilities
DIVISION 4. ORGANIZATIONS IN WHICH PEER SPECIALISTS DELIVER SERVICES
§ 354.3101. Requirements
§ 354.3103. Supervision of Peer Specialists
§ 354.3105. Peer Specialist Supervisor Minimum Qualifications
DIVISION 5. TRAINING
§ 354.3151. Training Entity Minimum Requirements
§ 354.3153. Instructor Requirements
§ 354.3155. Orientation and Self-Assessment
§ 354.3157. Application for Training
§ 354.3159. Core and Supplemental Training
§ 354.3161. Peer Specialist Certification Renewal Training
§ 354.3163. Supervisor Training
§ 354.3165. Peer Specialist Supervisor Certification Renewal Training
DIVISION 6. PEER SPECIALIST AND PEER SPECIALIST SUPERVISOR CERTIFICATION
§ 354.3201. Criminal History and Registry Checks
§ 354.3203. Procedures for Peer Specialist Certification
§ 354.3205. Initial Peer Specialist Certification
§ 354.3207. Peer Specialist Certification Renewal
§ 354.3209. Procedures for Peer Specialist Supervisor Certification
§ 354.3211. Peer Specialist Supervisor Certification Renewal
DIVISION 7. CERTIFICATION ENTITIES
§ 354.3251. Certification Entity Minimum Requirements
§ 354.3253. Certification Entity Application Process
§ 354.3255. Certification Entity Ongoing Requirements
DIVISION 8. COMPLAINTS, APPEALS, AND HEARINGS
§ 354.3301. Recipient Complaints
§ 354.3303. Peer Specialist or Peer Specialist Supervisor: Denial, Suspension, or Revocation of Certification or Renewal
§ 354.3305. Training Entity: Denial, Suspension, or Revocation of Certification
§ 354.3307. Certification Entity: Denial, Suspension, or Revocation of Approval