SECTION 363.303. Definitions

The following words and terms apply only to this subchapter and have the following meanings, unless the context clearly indicates otherwise.

(1) Contractor--The entity with which HHSC contracts, pursuant to the requirements of the Code of Federal Regulations, Title 42, Part 434.

(2) Correct or ameliorate--To improve, maintain, or slow the deterioration of the recipient's health status.

(3) Day--A calendar day.

(4) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)--The child and adolescent health component of the Medicaid program for recipients under 21 years of age, defined in the United States Code, Title 42, §1396d(r), and the Code of Federal Regulations, Title 42, §440.40(b). EPSDT means screening, vision, dental, hearing, laboratory, health care, treatment, diagnostic services, and other measures necessary to correct or ameliorate defects and physical and mental illnesses and conditions.

(5) Federal financial participation (FFP)--The federal government's share of a Medicaid expenditure made by a state agency, as defined in the Code of Federal Regulations, Title 45, §95.4.

(6) HHSC--The Texas Health and Human Services Commission or its designee, including a contractor or MCO.

(7) Home and Community Support Services Agency (HCSSA)--A public or private agency or organization licensed by the Texas Department of Aging and Disability Services under 40 TAC Chapter 97 (relating to Licensing Standards for Home and Community Support Services Agencies).

(8) Identified contingency plan--A structured process, developed by the recipient or the responsible adult and the Medicaid-enrolled provider, by which a recipient will receive care when a scheduled health care provider is unexpectedly unavailable, as required by 40 TAC §97.290 (relating to Backup Services and After Hours Care).

(9) Licensed Vocational Nurse (LVN)--An individual who is recognized by the Texas Board of Nursing to practice vocational nursing in Texas at the time and place the service is provided, pursuant to Texas Occupations Code §301.002(5) and 22 TAC, Part 11 (relating to Texas Board of Nursing).

(10) Medicaid--The Texas Medical Assistance Program, a joint federal and state program provided for in Chapter 32, Texas Human Resources Code, and subject to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

(11) Medicaid managed care organization (MCO)--Any entity with which HHSC contracts to provide Medicaid managed care services and that complies with Chapter 353 of this title (relating to Medicaid Managed Care).

(12) Medical Director--HHSC's, its contractor's, or MCO's medical director or associate medical director.

(13) Notice--A letter provided by HHSC, its contractor, or MCO to a recipient informing the recipient of any reduction, denial, or termination of a requested service, as described in the Code of Federal Regulations, Title 42, §431.206 and §431.210.

(14) Physician--A doctor of medicine (MD) or osteopathy (DO) who is licensed in the state in which they practice.

(15) Private duty nursing (PDN) Services--Nursing, described by the Texas Occupations Code Chapter 301, and its implementing regulations at 22 TAC, Part 11 (relating to Texas Board of Nursing), when the recipient requires more individual and continuous care than is available from a visiting nurse or than is routinely provided by the nursing staff of a hospital or skilled nursing facility. PDN services include observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a recipient who has a disability or chronic health condition or who is experiencing a change in normal health processes.

(16) Private duty nursing services provider--An independently practicing registered nurse, a licensed vocational nurse (LVN) under the supervision of a registered nurse, or a home and community support services agency (HCSSA) enrolled in the Texas Medicaid Program to provide private duty nursing services.

(17) Qualified Aide--An aide providing services consistent with the requirements of:

(A) 40 TAC Chapter 94 (relating to Nurse Aides);

(B) 40 TAC Chapter 95 (relating to Medication Aides--Program Requirements); or

(C) home health aide outlined in 40 TAC Chapter 97 (relating to Licensing Standards for Home and Community Support Services Agencies).

(18) Recipient--An individual who is eligible to receive services through the Texas Medicaid Program.

(19) Registered Nurse (RN)--An individual who is recognized by the Texas Board of Nursing to practice professional nursing in Texas at the time and place the service is provided, pursuant to the Texas Occupations Code §301.002.

(20) Responsible adult--An individual who is an adult, as defined by the Texas Family Code, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a recipient who is a minor under the age of 18; or is over 18 years of age and the responsible adult is the managing conservator or legal guardian. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage.

(21) Texas Health Steps - Comprehensive Care Program--Medical, dental, and treatment services available as a federally mandated service for eligible EPSDT Medicaid recipients in Texas under the age of 21 years, pursuant to the EPSDT provision of Title XIX of the Social Security Act, 42 U.S.C. §1396d(r), and the Code of Federal Regulations, Title 42, §440.40(b).

(22) Treating physician--A physician who provides ongoing medical care of the recipient and ongoing medical supervision of the recipient's plan of care.

Source Note: The provisions of this §363.303 adopted to be effective October 15, 2015, 40 TexReg 7056