SECTION 351.4. Covered Services

(a) Introduction. The program provides no direct medical services, but reimburses for services rendered by program providers or contractors. Clients must receive services as close to their home communities as possible unless program contracts or policies require treatment at specific facilities or specialty centers or the clients' conditions require specific specialty care.

(b) Types of service.

(1) Early identification. The program may conduct outreach activities to identify children for program enrollment, increase their access to care, and help them use services appropriately. Outreach services may include, but are not limited to:

(A) promotion of the program to the general public or targeted to potential clients and providers;

(B) development and distribution of educational materials to assist applicants and clients in the access and use of program services;

(C) development and distribution of population-based educational materials concerning children with special health care needs;

(D) integration with programs which screen for or provide treatment of newborn congenital anomalies or other specialty care; and

(E) links with community, regional, or school-based clinics to identify, assess needs, and provide appropriate resources for children with special health care needs.

(2) Diagnosis and evaluation services. These services may be covered for the purpose of determining whether an applicant meets the program definition of a child with special health care needs in order to receive health care benefits. Diagnosis and evaluation services must be prior authorized and coverage is limited in duration. If a physician or dentist requests coverage of diagnosis and evaluation services to determine if the applicant meets the definition of a "child with special health care needs" and the applicant meets all other eligibility criteria, then the applicant may be given up to 60 days of program coverage for diagnosis and evaluation services only. The program medical director or other designated medical staff may prior authorize limited coverage of diagnosis and evaluation services for waiting list clients if needed to help determine "urgent need for health care benefits" as described in §38.16(e) of this title (relating to Procedures to Address Program Budget Alignment). Only program providers may be reimbursed for diagnosis and evaluation services.

(3) Rehabilitation services. Rehabilitation services means a process of physical restoration, improvement, or maintenance of a body function destroyed or impaired by congenital defect, disease, or injury which includes the following acute and chronic or rehabilitative services: facility care, medical and dental care, occupational, speech, and physical therapies, the provision of medications, braces, orthotic and prosthetic devices, durable medical equipment, other medical supplies, and other services specified in this chapter. To be eligible for program reimbursement, treatment must be for a client and must have been prescribed by a practitioner in compliance with all applicable laws and regulations of the State of Texas. Services may be limited and the availability of certain services described in the following subparagraphs is contingent upon implementation of automation procedures and systems.

(A) Medical or dental assessment and treatment. A physician or dentist must provide medical or dental assessment and treatment services, including necessary laboratory and radiology studies. All practitioners must be licensed by the State of Texas, enrolled as providers in the program, and practicing within the scope of their respective licenses or registrations.

(B) Outpatient mental health services. Outpatient mental health services are limited to no more than 30 encounters in a calendar year by all professionals licensed to provide mental or behavioral health services including psychiatrists, psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors per eligible client per calendar year. Coverage includes, but is not limited to psychological or neuropsychological testing, psychotherapy, and counseling.

(C) Preventive and therapeutic dental services (including oral and maxillofacial surgery). Preventive and therapeutic dental services must be provided by licensed dentists enrolled to participate in the program. Coverage for therapeutic dental services, including prosthetics and oral and maxillofacial surgery, follows the Texas Medicaid program guidelines. Orthodontic care must be prior authorized and may be provided only for CSHCN Services Program eligible clients with diagnoses of cleft-craniofacial abnormalities, dentofacial abnormalities, or late effects of fractures of the skull and face bones.

(D) Podiatric services. Podiatric services must be provided by licensed practitioners enrolled to participate in the program. Podiatrists are limited to services medically necessary to treat conditions of the foot and ankle. Podiatric services follow the Texas Medicaid program guidelines. Supportive devices, such as molds, inlays, shoes, or supports, must comply with coverage limitations for foot orthoses.

(E) Treatment in program participating facilities. Hospital care must be provided in facilities that are enrolled as program providers. The length of stay is limited according to diagnosis, procedures required, and the client's condition.

(i) Inpatient hospital care, coverage limitations, and inpatient psychiatric care.

(I) Inpatient hospital care. Coverage excludes the following:

(-a-) maternity care, newborn care, infertility treatment, or other reproductive services unless directly related to a covered chronic physical or developmental condition;

(-b-) personal comfort items, such as television or newspaper delivery; and

(-c-) private duty nursing or attendant care.

(II) Coverage limitations. Coverage is limited to 60 days per calendar year. For stem cell transplantation, an additional 60 days coverage may be allowed.

(III) Inpatient psychiatric care. Coverage is limited to inpatient assessment and crisis stabilization and is to be followed by referral to an appropriate public or private mental health program. Admission must be prior authorized. Services include those medically necessary and furnished by a Medicaid psychiatric hospital or facility under the direction of a psychiatrist.

(ii) Inpatient rehabilitation care. Medically necessary inpatient rehabilitation care is limited to an initial admission not to exceed 30 days based on the functional status and potential of the client as certified by a physician participating in the program. Services beyond the initial 30 days may be approved by the program based upon the client's medical condition, plan of treatment, and progress. Payment for inpatient rehabilitation care is limited to 90 days during a calendar year.

(iii) Ambulatory surgical care. Ambulatory surgical care is limited to the medically necessary treatment of a client and may be performed only in program approved ambulatory surgical centers as defined in §38.7 of this title (relating to Ambulatory Surgical Care Facilities).

(iv) Emergency care. Care including, but not limited to hospital emergency departments, ancillary, and physician services, is limited to medical conditions manifested by acute symptoms of sufficient severity (including severe pain) such that a prudent person with average knowledge of health and medicine could reasonably expect that the absence of immediate medical care could result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. If a client is admitted to a non-participating program hospital provider following care in that provider's emergency room and the admitting facility declines to enroll or does not qualify as a program provider, the client must be discharged or transferred to a program provider as soon as the client's medical condition permits. All providers must enroll in order to receive reimbursement.

(v) Care for renal disease. Renal dialysis is limited to the treatment of acute renal disease or chronic (end stage) renal disease. Treatment may be provided through a renal dialysis facility, inpatient or outpatient hospital, or in the client's home. Covered services include, but are not limited to dialysis, laboratory services, drugs and supplies, declotting shunts, on-site physician services, and appropriate access surgery. Renal transplants must be prior authorized, and approval is subject to the availability of funds. If funding is available, renal transplants may be covered in approved renal transplant centers if the projected cost of the transplant and follow-up care is less than that of continuing renal dialysis. Estimated cost of the renal transplant over a one-year period versus the cost of renal dialysis for one year at their facility must be documented. For each client 18 years of age and older, the transplant team must also provide a plan of care to be implemented after the client reaches 21 years of age and is no longer eligible for program services.

(F) Orthotic and prosthetic devices. Orthotic and prosthetic devices must be prescribed by a practitioner licensed to do so and supplied by an orthotist or prosthetist licensed by the State of Texas.

(G) Medications. Outpatient medications available through pharmacy providers, including over-the-counter products, must be prescribed by practitioners licensed to do so.

(H) Nutrition services and nutritional products, excluding hyperalimentation and total parenteral nutrition (TPN).

(i) Nutrition services. Nutrition services must be prescribed by a practitioner licensed to do so.

(ii) Nutritional products. Nutritional products, including over-the-counter products, are limited to those covered by the program and prescribed by a practitioner licensed to do so, for the treatment of an identified metabolic disorder or other medical condition and serving as a medically necessary therapeutic agent for life and health or when part or all nutritional intake is through a tube.

(I) Hyperalimentation and TPN Services. Services include, but are not limited to solutions and additives, supplies and equipment, customary and routine laboratory work, enteral supplies, and nursing visits. These services may be provided on a daily basis when oral intake cannot maintain adequate nutrition. Covered services must be reasonable, medically necessary, appropriate, and prescribed by a practitioner licensed to do so.

(J) Medical foods. Coverage for medical foods is limited to the treatment of inborn metabolic disorders. Treatment for any other condition with medical foods requires documentation of medical necessity and prior authorization.

(K) Durable medical equipment. All equipment must be prescribed by a practitioner licensed to do so. Some equipment may be ordered from a specific supplier.

(L) Medical supplies. Supplies must be medically necessary for the treatment of an eligible client.

(M) Professional vision services. Vision services medically necessary for the treatment of a client include, but are not limited to:

(i) medically necessary eye examinations with refraction for diagnoses of refractive error, aphakia, diseases of the eye, or eye surgery;

(ii) one eye examination with refraction for the purpose of obtaining eyewear during a calendar year; and

(iii) one pair of non-prosthetic eye wear per calendar year prescribed by a practitioner licensed to do so.

(N) Speech-language pathology and audiology. Speech-language pathology and audiology services medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a speech-language pathologist or audiologist licensed by the State of Texas. Program coverage of speech-language pathology and audiology services may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.

(O) Hearing services include, but are not limited to, hearing screening, audiological assessment, otological examination, hearing aid evaluation, hearing aid devices, hearing aid fitting and repair, hearing aid batteries and supplies, and ear molds.

(P) Occupational and physical therapy. Occupational and physical therapy medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a therapist licensed by the State of Texas. Program coverage of physical and occupational therapy may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.

(Q) Certified respiratory care practitioner services. Respiratory therapy medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a certified respiratory care practitioner. Program coverage of respiratory therapy may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.

(R) Home health nursing services. Home health nursing services must be medically necessary, be prescribed by a physician, and be provided only by a licensed and certified home and community support services agency participating in the program. Home health nursing services are limited to 200 hours per client per calendar year. Up to 200 additional hours of service per client per calendar year may be approved with documented justification of need and cost effectiveness.

(S) Hospice care. Hospice care includes palliative care for clients with a presumed life expectancy of six months or less during the last weeks and months before death. Services apply to care for the hospice terminal diagnosis condition or illnesses. Treatment for conditions unrelated to the terminal condition or illnesses is unaffected. Hospice care must be prescribed by a practitioner licensed to do so who also is enrolled as a program provider.

(4) Care management.

(A) Medical home. Each program client should receive care in the context of a medical home.

(i) Comprehensive, coordinated health care of infants, children, and adolescents should encompass the following services:

(I) provision of preventive care, including but not limited to, immunizations, growth and development assessments, appropriate screening health care supervision, client and parental counseling about health care supervision, and client and parental counseling about health and psychological issues;

(II) assurance of ambulatory and inpatient care for acute illness, 24 hours a day, seven days a week (including after hours and weekends);

(III) provision of care over an extended period of time to enhance continuity;

(IV) identification of the need for sub-specialty consultation and referrals, provision of medical information about the client to the consultant, evaluation of the consultant's recommendations, implementation of recommendations that are indicated and appropriate, and interpretation of the consultant's recommendations for the family;

(V) interaction with school and community agencies to assure that the special health needs of the client are addressed;

(VI) guidance and assistance needed to make the transition to all aspects of adult life, including adult health care, work, and independence; and

(VII) maintenance of a central record and database containing all pertinent medical information about the client including information about hospitalizations.

(ii) The CSHCN Services Program may require periodic reports from the medical home.

(B) Case management. Case management services may be made available to program clients through public health regional offices or other resources to assist clients and their families in obtaining adequate and appropriate services to meet the client's health and related services needs. The program will make available case management as needed or desired to all clients who are eligible for health care benefits (includes clients who are on the waiting list for health care benefits). The program also may make available case management services to clients who are not eligible for the program's health care benefits.

(5) Family support services. Family support services include disability-related support, resources, or other assistance and may be provided to the family of a client with special health care needs.

(A) Eligibility. A client is eligible to receive family support services if:

(i) the client is not receiving services from a Medicaid waiver program, and the family support needs cannot be met by services from other family support programs, such as the Department of Aging and Disability Services or the In-Home and Family Support Program; and

(ii) the client's family collaborates with the assigned case manager to identify and pursue other sources of support and to develop a family assessment and service plan.

(B) Processing and evaluation of requests.

(i) Families of clients indicate their need for family support services by completing and signing an approved request form.

(ii) Requests for family support services are processed in chronological order by the date of the request.

(iii) All requests for family support services must be prior authorized (approved by the program prior to delivery).

(iv) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title.

(v) Some services or items may require a written statement from a physician, physical therapist, occupational therapist, or other healthcare professional to establish the disability-related nature of the request.

(vi) Some services or items may require written bids.

(vii) Persons requesting assistance are responsible for collaborating with their case managers to obtain information as necessary so that an accurate determination can be made in a timely manner.

(viii) Families shall be notified in writing of the outcome of their requests for family support services.

(ix) Families have the right to appeal a denial or partial approval as described in §38.13 of this title (relating to Right of Appeal).

(C) Service plan and cost allowances.

(i) The case manager and the client or family must develop a family assessment and service plan and complete a Family Support Services request packet to request a prior authorization for family support services.

(ii) The program may establish annual cost allowances based upon the client's or family's level of assessed need for family support services not to exceed:

(I) lifetime benefit of up to $3,600 per eligible client for minor home modifications; and

(II) annual benefit of up to $3,600 per calendar year per eligible client for allowable family support services.

(-a-) The annual benefit may increase to no more than $7,200 per eligible client for the purchase of vehicle lifts and modifications.

(-b-) The lifetime benefit for minor home modifications and the annual benefit may be used in the same calendar year.

(iii) Service plan cost allowances may be prorated for plans that cover less than one calendar year.

(iv) Reimbursement:

(I) may be made to the family or to the vendor enrolled as a program provider; and

(II) may be reduced by the amount of a cost-sharing requirement, if applicable.

(v) Reimbursement rates for respite providers are established by the client or family and the selected provider in collaboration with the case manager.

(vi) The annual family assessment and service plan may be amended at any time, but must be reevaluated by the client or family and case manager at least annually.

(D) Allowable services.

(i) Family support services for program clients and their families include those allowable services and items that:

(I) are above and beyond the scope of usual needs (i.e., basic clothing, food, shelter, medical care, and education);

(II) are necessitated by the client's medical condition or disability; and

(III) directly support the client's living in his or her natural home and participating in family life and community activities.

(ii) Family support services may not be used to supplant services available through other public or private programs, but may be used to supplement services provided by other programs.

(iii) Allowable services include:

(I) respite care;

(II) specialized child care costs for a client that are expenses directly related to the client's disability and special needs that are beyond the scope of community-based child care centers, including specialized training for the child care provider;

(III) counseling, training programs, or conferences to obtain specific skills or knowledge related to the client's care that assists family members or caregiver(s) in maintaining the client in their home and to increase their knowledge and ability to care for the client;

(IV) minor home modifications such as installation of a ramp, widening of doorways, bathroom modifications, and other home modifications to increase accessibility and safety;

(V) vehicle lifts and modifications, such as wheelchair lifts or ramps, wheelchair tie-downs, occupant restraints, accessories, modifications such as raising roofs or doors if necessary for lift installation or usage, hand controls, and repairs of covered modifications not related to inappropriate handling or misuse of equipment and not covered by other resources;

(VI) specialized equipment, including porch or stair lifts, air purification systems or air conditioners, positioning equipment, bath aids, supplies prescribed by licensed practitioners that are not covered through other systems, and other non-medical disability-related equipment that assists with family activities, promotes the client's self-reliance, or otherwise supports the family; and

(VII) other disability-related services that support permanency planning, independence, or participation in family life and integrated or inclusive community activities.

(E) Unallowable services. Family support funds may not be used to provide those services that do not relate to the client's disability and do not directly support the client's living in his or her natural home and participating in family life and integrated or inclusive community activities. Examples of unallowable services include, but are not limited to:

(i) items for which a less expensive alternative of comparable quality is available;

(ii) purchase or lease of vehicles or vehicle maintenance and repair;

(iii) home mortgage or rent expenses or basic home maintenance and repair;

(iv) income taxes;

(v) medical services;

(vi) services in segregated settings other than respite facilities or camps;

(vii) insurance premiums;

(viii) death benefits, burial policies, and funeral expenses;

(ix) costs for allowable services incurred before the requested family support service is prior authorized;

(x) non-medical foods, routine shelter, routine utilities, routine home repairs, routine home appliances, routine furnishings, fences, and yard work;

(xi) medical benefit items or services paid for or reimbursed by private insurance, Medicaid, Medicare, CHIP, the CSHCN Services Program or other health insurance programs for which the client is eligible;

(xii) services, equipment, or supplies that have been denied by Medicaid, CHIP, or the program because a claim was received after the filing deadline, because insufficient information was submitted, or because an item was considered inappropriate or experimental;

(xiii) over-the-counter or prescription medications;

(xiv) architectural modifications to a public facility;

(xv) school tuition or fees, or equipment, items, or services that should be provided through the public school system;

(xvi) items that could endanger the health and safety of the client;

(xvii) routine child care;

(xviii) computers and software unless for use as an assistive technology device or necessary to perform a critical or essential function, such as environmental control or written or oral communication, which the client is unable to perform without the computer;

(xix) services provided by an individual under the age of 18 years or by the client's parent(s), guardian, or other individual(s) residing with the client; and

(xx) services exclusively to support the care of siblings or other individual(s) residing with the client, but which are not necessary to meet the medical needs of the client.

(F) Reduction or termination of services. Reasons for terminating or reducing family support services may include, but are not limited to:

(i) the client no longer meets the eligibility criteria for the program;

(ii) services available through the program are discontinued due to budget restrictions;

(iii) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title;

(iv) the client's family indicates that the need for family support services no longer exists;

(v) the client moves out of Texas;

(vi) the client is placed in a nursing facility or other institutional setting for an indefinite period of time;

(vii) the client dies;

(viii) the client's designated case manager is unable to locate the client and family; or

(ix) the family knowingly does not comply with the family assessment and service plan in which case the family may also be liable for restitution.

(6) Other types of services. The following services also are available through the program.

(A) Ambulance services. Emergency ground, non-emergency ground and air ambulance services are covered for the medically necessary transportation of a client. Non-emergency ambulance transport is covered if the client cannot be transported by any other means without endangering the health or safety of the client and when there is a scheduled medical appointment for medically necessary care at the nearest appropriate facility. Transportation by air ambulance is limited to instances when the client's pickup point is inaccessible by land or when great distance interferes with immediate admission to the nearest appropriate medical treatment facility. Transports to out-of-locality providers are covered if a local facility is not adequately equipped to treat the client. Out-of-locality refers to one-way transfers 50 miles or more from point of pickup to point of destination.

(B) Transportation. The program may provide transportation for a client and, if needed, a responsible adult, to and from the nearest medically appropriate facility (in Texas or in the United States 50 or fewer miles from the Texas border) to obtain medically necessary and appropriate health care services that are within the scope of coverage of the program and are provided by a program enrolled provider. The lowest-cost appropriate conveyance should be used. The program shall not assist if transportation is the responsibility of the client's school district or can be obtained through Medicaid. Transportation to out-of-state services located more than 50 miles from the Texas border will not be approved except as specified in §38.6(e) of this title (relating to Providers).

(C) Meals and lodging. The program may provide meals and lodging to enable a client, accompanied by a parent, guardian, or their designee as needed, to obtain inpatient or outpatient care at a facility located away from their home. The reason for the inpatient or outpatient visit must be directly related to medically necessary treatment for the client that is provided by program enrolled providers and covered by the program. Meals and lodging associated with travel to services that are provided more than 50 miles from the Texas border will not be approved except as specified in §38.6(e) of this title.

(D) Transportation of deceased. The program may provide the following services:

(i) transportation cost for the remains of a client who expires in a program-approved facility while receiving program health care benefits, if the client was not in the family's city of residence in Texas, and the transportation cost of a parent or other person accompanying the remains from the facility to the place of burial in Texas that is designated by the parent or other person legally responsible for interment;

(ii) embalming of the deceased if required by law for transportation;

(iii) a coffin meeting minimum requirements if required by law for transportation; and

(iv) any other necessary expenses directly related to the care and return of the client's remains.

(E) Payment of insurance premiums, coinsurance, co-payments, and deductibles. The program may pay public or private health insurance premiums to maintain or acquire a health benefit plan or other third party coverage for the client, and if paying for such health insurance can reasonably be expected to be cost effective for the program. The program may pay for coinsurance and deductible amounts when the total amount paid (including all payers) to the provider does not exceed the amount allowed by the program for the covered service. The program may reimburse clients for co-payments paid for covered drugs. The program will not pay premiums, deductibles, coinsurance, or co-payments for clients enrolled in CHIP.

(c) Services not covered. Services which are not covered by the program even though they may be medically necessary for and provided to a client include, but are not limited to:

(1) treatments which are considered experimental or investigational;

(2) chiropractic services;

(3) care for premature infants;

(4) care for alcohol or substance abuse;

(5) pregnancy prevention, except when medically necessary for the specific treatment of a condition meeting the parameters of the "child with special health care needs" definition;

(6) maternity care services specific to routine pregnancy care, labor and delivery, and maternal post-partum care;

(7) infertility treatment;

(8) services provided by a nursing home or facility; and

(9) services provided while the client is in the custody of or incarcerated by any municipal, county, state, or federal governmental entity. Case management or prior approved family support services not provided by the governmental entity that are needed during the time when a client is transitioning from custody or incarceration into a community living setting may be covered.

(d) Authorization and prior authorization of selected services.

(1) Provider's responsibility. A program provider must request services in specific terms on department-prepared forms so that an authorization may be issued and sufficient monies encumbered to cover the cost of the service. If a service is authorized, payment may be made to the provider as long as the service is not covered by a third party resource and all billing requirements are met. Program authorization should not be considered an absolute guarantee of payment. Once a service is delivered and if the service requires authorization for payment, the authorization request for that service must be submitted within 95 days of the date of service.

(2) Required prior authorization for selected services. At the program's option, selected services may require authorization prior to the delivery of services in order for payment to be made. Prior authorization requests must be submitted prior to the date of service.

(3) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title.

(4) Denied authorization requests are authorization requests which are incomplete, submitted on the wrong form, lack necessary documentation, contain inaccurate information, fail to meet authorization request submission deadlines, are for ineligible persons, services, or providers, or are for clients who do not qualify for the health care benefit requested. Denied authorization requests may be corrected and resubmitted for reconsideration. Authorization requests must meet authorization request submission deadlines. Denied authorization requests may be appealed according to §38.13 of this title.

(e) Pilot projects. The program may initiate and participate in pilot projects. New projects are possible only if funds are available in the current fiscal year. All pilot projects are limited to no more than 10% of the fiscal year appropriation.

Source Note: The provisions of this §351.4 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982