SECTION 419.374. Eligible Population

(a) IMD provider reimbursement is limited to IMD services provided to individuals:

(1) who are age 65 years or older;

(2) who have one or more mental disease;

(3) who have no acceptable alternate placement as determined by the individual's treatment team;

(4) who are eligible for participation in the Texas Medicaid program;

(5) who are not eligible for medical compensation from other payment sources;

(6) who have been certified by a licensed physician to need inpatient hospitalization for the care and treatment of a mental disease;

(7) who meet all other federal, state, and local regulations applicable to admission to a mental hospital; and

(8) for whom the department has authorized IMD services based on medical necessity, as follows:

(A) Requests for initial authorization for IMD services must be submitted to the department within seven calendar days after the first day for which Medicaid reimbursement for the provision of IMD services will be requested.

(B) Requests for authorization of continued stay must be submitted no later than seven calendar days prior to the end date of the initial and all subsequent authorizations. Initial and continued stay authorizations are valid for up to 31 calendar days.

(b) Any Medicaid eligible individual whose request for eligibility for IMD services is denied or is not acted upon with reasonable promptness, or whose IMD services have been terminated, suspended, or reduced by the department is entitled to a fair hearing, conducted in accordance with rules for fair hearings described in Title 1, Texas Administrative Code, Chapter 357, Subchapter A (relating to Medicaid Fair Hearings). A request for a fair hearing must be submitted to the department and received within 90 days from the date the notice of denial of eligibility for IMD services or notice of termination, suspension, or reduction of IMD services is mailed.

Source Note: The provisions of this §419.374 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010