SECTION 354.1417. Definitions for Wellness Services

The following terms are specific to the Texas Medicaid Wellness Program, when used in this division, have the following meanings, unless the context clearly indicates otherwise.

(1) Care management--An approach or process for persons with complex needs and/or chronic illness that is focused on preventing acute or urgent care utilization through the use of accepted clinical and non-clinical interventions. These interventions include services such as care coordination; telephone access to nurses skilled in monitoring and providing consultation on how to address disease symptoms and complications, including answering medication questions; providing patient education; self-management care skills; and providing physician-coordinated treatment plans.

(2) Case management--A process whereby covered persons with specific healthcare needs are identified and a care plan is developed and implemented that efficiently utilizes health care resources to achieve the optimum outcome in the most cost-effective manner.

(3) Claim--A request for payment for authorized benefits submitted on the applicable approved form that meets the established itemization requirements.

(4) Texas Medicaid Wellness Program--A holistic approach to health care delivery designed to identify and provide services to Medicaid fee-for-service clients with, or who are at risk for, incurring high-cost medical services due to chronic illness or complex conditions.

(5) Eligible client--An individual who has been designated by the State as eligible for medical care and services under the Medicaid program and meets the requirements for the Texas Medicaid Wellness Program.

(6) Fee-for-Service Reimbursement--The traditional health care payment system under which physicians and other providers receive a payment for each unit of service they provide or an insurance product in which clients are allowed total freedom to choose their health care providers.

(7) Health severity level assessment--An assessment by the Texas Medicaid Wellness Program vendor that determines the appropriate interventions.

(8) Medical assistance program--The program implemented by the State of Texas under the provisions of Title XIX of the Social Security Act, as amended.

(9) Medical home--A community-based system of health care delivery that provides individual patients a known resource (primary care provider or clinic) for all primary and preventive care services. It also provides continuity of care for acute care needs 24 hours a day, including consultative, specialty, and health-related services.

(10) Physician--A doctor of medicine or doctor of osteopathy (MD or DO) legally authorized to practice medicine or osteopathy at the time and place the service is provided.

(11) Preventive care--Comprehensive care emphasizing prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, well-person care, and age-appropriate screening exams.

(12) Primary care provider (PCP)--A physician or provider who has agreed to provide a medical home to Medicaid clients and who is responsible for providing care to patients, maintaining the continuity of patient care and initiating referral for care.

(13) Stratify--A method used by the Texas Medicaid Wellness Program vendor to organize interventions based on the client's specific needs at a given time.

Source Note: The provisions of this §354.1417 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