SECTION 365.2. Definitions

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

(1) Access surgery--The surgical procedure which creates or maintains the access site necessary to perform dialysis.

(2) Action--A suspension, modification, denial, or termination of program eligibility, benefits, or participation.

(3) Administrative review--A process that allows applicants, clients, or providers the opportunity to request an informal review of any intended program action that would suspend, modify, deny, or terminate their eligibility, benefits or participation in the program.

(4) Allowable amount--The maximum amount that the program will pay or reimburse for a covered benefit or service.

(5) Applicant--A person who has submitted an application for program benefits and has not received a final determination of eligibility.

(6) Authorized entity--Any individual or organization approved by the program to submit applications for benefits or travel verification reports on behalf of an applicant or client.

(7) Claim--A request for payment or reimbursement of services.

(8) Client--A person who has applied for program services and who meets all program eligibility requirements and is determined to be eligible for program services.

(9) CMS--The Centers for Medicare and Medicaid Services.

(10) Co-insurance--A cost-sharing arrangement in which a covered person is responsible for paying a specified percentage of the charge for a covered service or product.

(11) Commissioner--The commissioner of the Department of State Health Services.

(12) Co-pay/Co-payment--A cost-sharing arrangement in which a covered person is responsible for paying a specified or fixed charge for a covered service or product.

(13) CRNA--Certified registered nurse anesthetist.

(14) Date of service (DOS)--The date a service is rendered.

(15) Denial--An action by the program that disallows program eligibility, benefits, or provider enrollment.

(16) Department--The Department of State Health Services.

(17) Effective date--The date a program client or enrolled provider is approved to receive program benefits or reimbursements.

(18) End-Stage Renal Disease (ESRD)--The final stage of renal failure that requires dialysis or kidney transplant to reduce uremic symptoms and prevent the death of the patient.

(19) Enrolled provider--Any individual or entity who has completed all the requirements located in the Texas Health and Human Services Commission rule at 1 TAC §392.605, Kidney Health Care Provider Requirements and Effective Dates, and is deemed enrolled by the program to furnish covered services to program clients including:

(A) outpatient dialysis facilities;

(B) out-of-state outpatient dialysis facilities;

(C) hospitals and ambulatory surgical centers (ASCs) located in Texas and operating in compliance with applicable law;

(D) out-of-state hospitals and ASCs;

(E) military or Veterans Administration hospitals located in Texas which have a renal unit;

(F) pharmacies approved as Texas Medicaid providers and licensed to operate within the United States and its territories, including mail order pharmacies;

(G) physicians and certified registered nurse anesthetists (CRNAs) licensed in Texas;

(H) out-of-state physicians and CRNAs; and

(I) Medicare Prescription Drug Plan (PDP) providers.

(20) Explanation of benefits (EOB)--A form, in paper or electronic format, which provides an explanation of benefits. It is used to explain a payment or denial of a claim.

(21) Fair hearing--The informal hearing process the department follows under §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).

(22) Filing deadline--The last date that a claim may be received by the program and still be considered eligible for benefit.

(23) Final decision--A decision that is made by a decision maker after conducting a fair hearing under §§1.51 - 1.55 of this title.

(24) Incomplete claim--A claim that is submitted to the program without the required information to enable determination of program liability or payment.

(25) KHC--Kidney Health Care.

(26) KHC formulary--A list of general therapeutic categories of drugs, over-the-counter products, and limited diabetic supplies that are covered for reimbursement by the program.

(27) Low Income Subsidy (LIS)--The subsidy provided under the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 for Medicare Part D plan premiums and related costs, at varying levels, for some low-income Medicare beneficiaries.

(28) Medical benefit--Any medical treatment or procedure approved by the program as a covered service.

(29) Medicare Advantage Plan--A Medicare health plan that is similar to a health maintenance organization, participating provider organization, or other Medicare health plan, and includes medical, drug coverage and other benefits.

(30) Medicare Part A--Hospital insurance for people age 65 or older, or under age 65 with certain disabilities, that helps cover inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

(31) Medicare Part B--Health insurance for people age 65 or older, or under age 65 with certain disabilities, and any age with ESRD, that helps cover medically necessary services, such as doctors' services and outpatient care, and some preventive services.

(32) Medicare Part D--Established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), it provides members with prescription drug coverage, expanded health plan options, improved health care access for rural Americans, and preventive care services.

(33) Medicare Part D out-of-pocket expenses--Include premiums, deductibles, co-payments, or co-insurance amounts.

(34) Medicare Part D Premium--The amount paid monthly under a Medicare Part D contract to insure coverage.

(35) Medicare Prescription Drug Plan (PDP)--A stand-alone drug plan offered by insurers and other private companies to individuals eligible for Medicare Part D.

(36) Medigap plan--A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Medicare coverage.

(37) Modification--A change made to a client or provider account that can affect program benefits, eligibility, or enrollment.

(38) Program--Kidney Health Care.

(39) Provider--Any individual or entity who furnishes benefits or services to program clients.

(40) Qualified Individual (QI) Program--A Medicaid program for beneficiaries who need help in paying for Medicare Part B premiums. The beneficiary must be entitled to Medicare Part A, have limited income and resources as calculated using federal and state guidelines, and not be otherwise eligible for Medicaid. For those who qualify, the Medicaid program pays full Medicare Part B premiums only.

(41) Qualified Medicare Beneficiary (QMB) Program--A Medicaid program for beneficiaries who need help in paying for Medicare services. The beneficiary must be entitled to Medicare Part A, have limited income and resources as calculated using federal and state guidelines. For those who qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.

(42) Reimbursement--Payment of a claim for covered benefits or services.

(43) Reimbursement rate--The program payment rate for covered benefits or services.

(44) Resubmitted claim--A claim that is submitted to the program more than once to correct errors.

(45) Specified Low Income Medicare Beneficiary (SLMB) Program--A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources as calculated using federal and state guidelines.

(46) Suspension--An action by the program, which holds client benefits or reimbursement to enrolled providers pending satisfaction of a program request or requirement.

(47) Termination--A final action by the program, which ends client or enrolled provider participation in the program.

(48) Veterans programs--Health care programs authorized and administered by the United States Department of Veterans Affairs and the United States Department of Defense.

Source Note: The provisions of this §365.2 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421