SECTION 354.2401. Definitions

The following words and terms, when used in the sections under this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Abuse--Practices that are inconsistent with sound fiscal, business, or medical practices and that result in unnecessary program cost or in reimbursement for services that are not medically necessary, do not meet professionally recognized standards for health care, or do not meet standards required by contract, statute, regulation, previously sent interpretations of any of the items listed, or authorized governmental explanations of any of the foregoing.

(2) Conflicting--Incompatible, unsuitable for use together because of undesirable chemical or physiological effects. For example, the recipient may receive drugs and/or health care services which may be inadvisable in the presence of certain medical conditions or which conflict with the care ordered by another provider.

(3) Contraindicated--Condition or factor that indicates the inadvisability of a medical treatment or procedure.

(4) Designated Provider--A provider enrolled in the Texas Medicaid program that is not on payment review status; under administrative action, sanction, or investigation for failure to comply with Medicaid rules or acceptable Medicaid practices; or under sanction or inactive or other limited administrative status by a state licensing board or other regulatory entity. The designated provider oversees the Medicaid benefits or services provided to a recipient in lock-in status. A designated provider includes:

(A) a primary health care provider who provides and/or directs all medically necessary health care benefits or services for which the recipient is eligible. The primary health care provider may include a physician, physician group, dentist, dental home, advanced practice nurse, physician assistant, outpatient clinic, Rural Health Clinic, or Federally Qualified Health Center; or

(B) a pharmacy that monitors medications prescribed to a recipient in lock-in status for contraindicative, conflicting, duplicative, or excessive use and that ensures the recipient's use does not represent abuse, misuse, or fraud.

(5) Emergency medical condition--A medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:

(A) placing the patient's health in serious jeopardy;

(B) serious impairment to bodily functions;

(C) serious dysfunction of any bodily organ or part;

(D) serious disfigurement; or

(E) serious jeopardy to the health of the fetus of a pregnant Medicaid recipient.

(6) Emergency services--Covered inpatient and outpatient services that are furnished by a provider who is qualified to furnish such services under a Medicaid provider agreement and are services which are needed to evaluate or stabilize an emergency medical condition.

(7) Excessive Use or Overuse--Exceeding what is usual, medically necessary or customary use of Medicaid services and benefits. Also defined as, but not limited to, the following:

(A) receipt of Medicaid benefits or services from one or multiple providers of service in an amount, duration, or scope in excess of which would reasonably be expected to result in a medical or health benefit to the patient; or

(B) use exceeding the standards and criteria for utilization of outpatient drugs or products, as listed in the compendia and peer reviewed medical literature and/or criteria and standards approved by the Texas Medicaid Drug Utilization Review Board.

(8) Fraud--Any act that constitutes fraud under applicable federal or state law, including any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person. Fraud may include any acts prohibited by the Texas Human Resources Code, Chapter 36, or Texas Penal Code, Chapter 35A. Fraudulent activities include, but are not limited to:

(A) lending or altering a Medicaid card for the purpose of obtaining Medicaid benefits or services for which a person is not legitimately entitled;

(B) falsely representing medical coverage;

(C) using the Medicaid Identification card of another or altering or duplicating Medicaid identification;

(D) furnishing incorrect eligibility or false information to a vendor to obtain treatment;

(E) possessing blank or forged prescription pads;

(F) forging, duplicating or altering a prescription;

(G) assisting providers in rendering services or defrauding the Medicaid program; or

(H) selling or trading, or attempting to sell or trade, drugs, products, or supplies acquired independently or through Medicaid that results in duplicative services.

(9) Lock-in--An action taken by the Health and Human Services Commission (HHSC) restricting a Medicaid recipient to a designated pharmacy or health care provider.

(10) Lock-in period--The effective time period of a lock-in measured in cumulative eligibility time frames of 36 months, 60 months, or lifetime. Eligibility time frames may or may not be contiguous.

(11) Misuse--To use incorrectly, misapply, or illegally use Medicaid benefits or services. To seek or obtain medical services from a number of like providers and in quantities that exceed the levels considered medically necessary by current medical practices, standards and policies.

(12) Recipient--Any individual who is deemed eligible to receive Medicaid benefits and services under the Texas Medicaid Program.

(13) Referrals--Complaint information regarding recipient use of Medicaid benefits or services supplied to HHSC for lock-in review. Sources may include, but are not limited to, providers, state agencies, law enforcement officials, Medicaid managed care organizations, or members of the general public. HHSC may make referrals to other state agencies and/or Medicaid managed care plans.

(14) Waste--Practices that a reasonably prudent person would deem careless or that would allow inefficient use of resources, items, or services.

Source Note: The provisions of this §354.2401 adopted to be effective April 2, 2000, 25 TexReg 2817; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4563; amended to be effective April 6, 2003, 28 TexReg 2738; amended to be effective April 2, 2013, 38 TexReg 2095