SECTION 354.1416. Eligibility Criteria

(a) The Texas Medicaid Wellness Program serves people with disabilities who receive Medicaid services and people who receive Temporary Assistance for Needy Families (TANF) who:

(1) Receive medical services through fee-for-service;

(2) Are able, or have a caregiver who is able, to respond actively to health information and care coordination activities; and

(3) Are identified by the Health and Human Services Commission (HHSC) and the Texas Medicaid Wellness Program vendor as being high-cost and/or high-risk due to chronic illness or condition.

(b) Texas Medicaid Wellness Program client population exclusions:

(1) Medicaid clients that are programmatically excluded from the Texas Medicaid Wellness Program:

(A) Dual Eligible client populations age 21 and older that are eligible for Medicare and Medicaid services;

(B) Clients with Third Party Insurance;

(C) Clients in a Medicaid waiver program;

(D) Clients in a managed care program;

(E) Clients in a Medicare pilot;

(F) Clients in a hospice program; or

(G) Clients in institutional or community-based long term care service programs (except previously enrolled Texas Medicaid Wellness Program clients in a skilled nursing facility less than 60 consecutive days in a 12 month period); and

(2) Undocumented aliens.

(c) Texas Medicaid Wellness Program client disenrollment:

(1) Clients enrolled in the Texas Medicaid Wellness Program can opt-out of the program at any time.

(2) Clients may be disenrolled from the Texas Medicaid Wellness Program for the following reasons:

(A) Loss of Medicaid eligibility: clients that regain Medicaid eligibility are automatically re-enrolled into the Texas Medicaid Wellness Program during their first month of renewed eligibility; or

(B) The client is unresponsive to, fails to participate in, or cannot be reached for interventions by the Texas Medicaid Wellness Program vendor. HHSC's contract with the Texas Medicaid Health Wellness Program vendor will specify the number of attempts that the vendor must make to reach a client before disenrollment.

Source Note: The provisions of this §354.1416 adopted to be effective February 20, 2005, 30 TexReg 666; amended to be effective September 1, 2007, 32 TexReg 1904; amended to be effective July 19, 2011, 36 TexReg 4555; amended to be effective March 1, 2012, 37 TexReg 1300; amended to be effective February 2, 2014, 39 TexReg 395