PART 1. HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 257. CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes new §257.1, concerning Purpose and Application; §257.3, concerning Definitions; §257.5, concerning Client Eligibility; §257.7, concerning Client Rights; §257.9, concerning Client Confidentiality; §257.11, concerning Components of Case Management for Children and Pregnant Women Services; §257.15, concerning Provider Qualifications and Approval Process; §257.17, concerning Provider Responsibilities; §257.19, concerning Case Manager Qualifications; §257.21, concerning Case Manager Responsibilities; and §257.23, concerning Compliance with Utilization Reviews and Quality Assurance Reviews and Overpayments.
BACKGROUND AND PURPOSE
Case Management for Children and Pregnant Women (CPW) services assist eligible Medicaid clients in gaining access to necessary medical, social, educational, and other services related to the client's health conditions and health risks. To be eligible for services, a client must be either a child with a health condition or health risk or a pregnant woman with a high-risk condition. The client must also be Medicaid-eligible in Texas, need case management for CPW services, and choose such services.
HHSC proposes to repeal Chapter 27, Case Management for Children and Pregnant Women, in Title 25, Part 1, Texas Administrative Code (TAC), and proposes a new Chapter 257, Case Management for Children and Pregnant Women, in Title 26, Part 1, TAC. The purpose for moving the CPW rules from Title 25 to Title 26 is to conform administrative rules to current HHSC practices based on Senate Bill (S.B.) 200, 84th Legislature, Regular Session, 2015. S.B. 200 consolidated functions in the Texas Health and Human Services delivery system and transferred programs, to include CPW, from the Department of State Health Services (DSHS) to HHSC. The repeal of the CPW rules in 25 TAC Chapter 27 is proposed elsewhere in this issue of the Texas Register.
In addition to relocating the CPW rules from DSHS to HHSC, the proposal makes amendments to the CPW rules in accordance with House Bill (H.B.) 133, 87th Legislature, Regular Session, 2021, that directs HHSC to deliver CPW services through managed care organizations (MCOs). The proposal also makes amendments to the CPW rules to implement certain requirements of House Bill (H.B.) 1575, 88th Legislature, Regular Session, 2023. H.B. 1575 authorizes case management services to pregnant women with a high-risk condition to address nonmedical needs; adds two new provider types, doula and community health worker, as eligible to provide CPW services; and establishes CPW provider qualifications for doulas and community health workers. The proposal also updates the CPW rules with appropriate references and terminology and includes organizational and minor editing changes for clarity.
SECTION-BY-SECTION SUMMARY
Sections 27.1 through 27.27 in Title 25, Part 1, TAC are repealed and replaced by sections 257.1 through 257.23 in Title 26, Part 1, TAC, except that sections 27.13 and 27.27 were repealed and not replaced.
New Subchapter A, General Provisions
Proposed new §257.1, Purpose and Application, replaces repealed §27.1 and summarizes the purpose of CPW services. The proposed rule differs from the repealed rule by removing references to the Department State Health Services and clarifying that the rules apply to fee-for-service and managed care clients.
Proposed new §257.3, Definitions, replaces repealed §27.3 and explains the meaning of terms used in the rules. The proposed rule differs from the repealed rule by adding new definitions for face-to-face, HHSC, nonmedical need, and provider. The proposed rule amends the definition for access by adding a reference to nonmedical needs. The proposed rule also removes definitions for active providers, application process, prior authorization, and state because the terms are no longer used in the proposed new Chapter 257.
New Subchapter B, Client Services
Proposed new §257.5, Client Eligibility, replaces repealed §27.5 and defines who qualifies to receive the services. The proposed rule differs from the repealed rule by clarifying that a client chooses, rather than desires, to receive CPW services.
Proposed new §257.7, Client Rights, replaces repealed §27.7 and establishes that a client's use of case management services in CPW is voluntary. The proposed rule provides a client the right to actively participate in case management decisions, receive services free from abuse or harm, have the freedom to choose a provider, and request a fair hearing. The proposed rule differs from the repealed rule by clarifying that a client who receives CPW services through an MCO must exhaust internal MCO appeals before requesting a fair hearing.
Proposed new §257.9, Client Confidentiality, replaces repealed §27.9 and defines the circumstances in which client information can and cannot be shared.
Proposed new §257.11, Components of Case Management for Children and Pregnant Women Services and Reimbursement, replaces repealed §27.11 and outlines the services that are provided and the components that are billable. The proposed rule differs from the repealed rule by adding that a service plan must be signed by the Medicaid provider. The proposal also adds nonmedical needs as a component of CPW and updates requirements for follow-up visits by a case manager. The proposal also removes references to prior authorization and adds that services are not reimbursable when a client is an inpatient at a hospital or other treatment facility.
New Subchapter C, Provider Qualifications and Responsibilities
Proposed new §257.15, Provider Qualifications and Approval Process, replaces repealed §§27.15 and 27.17 and indicates the steps necessary to become a provider of services. The proposed rule differs from the repealed rule by updating a reference to the U.S. HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE); clarifying that interested providers must complete a pre-planning process with HHSC; adding a requirement that providers must complete the HHSC standardized case management training provided by HHSC; and generally condensing the approval process. The proposed rule also differs from the repealed rule by removing references to response times and Medicaid claims administrator and the requirement for a new application if twelve months have lapsed since initial approval was received.
Proposed new §257.17, Provider Responsibilities, replaces repealed §27.19 and specifies what providers must do to maintain the duties of providing services through CPW, including outreach activities.
Proposed new §257.19, Case Manager Qualifications, replaces repealed §27.21 and specifies qualifications to be a case manager in CPW. The proposed rule differs from the repealed rule by adding references to the Texas Occupations Code for advanced practice registered nurse, registered nurse, and social worker and adding community health worker and doula to the list of provider qualifications as required by H.B. 1575.
Proposed new §257.21, Case Manager Responsibilities, replaces repealed §27.23 and describes the requirement to have appropriate and current licensure or certification, provide services convenient to a client, and coordinate services.
Proposed new §257.23, Compliance with Utilization Reviews and Quality Assurance Reviews and Overpayments, replaces repealed §27.25 and explains that the purpose of a utilization review is to ensure fiscal integrity and describes the providers' responsibility in participating in quality and utilization reviews. The proposed rule differs from the repealed rule by requiring providers to ensure services to a client are within the scope of the client's service plan; referencing quality assurance and utilization reviews without specifying frequency or timeline for the reviews as compared to reviews being conducted each fiscal year; and removing reference to reviews of inactive providers. The proposed rule also replaces references to "the department" with references to HHSC.
FISCAL NOTE
Trey Wood, HHSC Chief Financial Officer, has determined that for each year of the first five years that the rule will be in effect, there will be an estimated additional cost to state government as a result of enforcing and administering the rules as proposed. Enforcing or administering the rules does have foreseeable implications relating to costs or revenues of local government.
The effect on state government for each year of the first five years the proposed rules are in effect is an estimated cost of $665,000 in State Funds and $665,000 in Federal Funds for fiscal year (FY) 2024, $0 in FY 2025, $0 in FY 2026, $0 in FY 2027, and $0 in FY 2028.
GOVERNMENT GROWTH IMPACT STATEMENT
HHSC has determined that during the first five years that the rules will be in effect:
(1) the proposed rules will not create or eliminate a government program;
(2) implementation of the proposed rules will not affect the number of HHSC employee positions;
(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;
(4) the proposed rules will not affect fees paid to HHSC;
(5) the proposed rules will create new regulations;
(6) the proposed rules will not expand, limit or repeal existing regulations;
(7) the proposed rules will increase the number of individuals subject to the rules; and
(8) the proposed rules will not affect the state's economy.
SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS
Trey Wood has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities to comply with the proposed new rules because provider and client participation in CPW is optional.
LOCAL EMPLOYMENT IMPACT
The proposed rules will not affect a local economy.
COSTS TO REGULATED PERSONS
Texas Government Code §2001.0045 does not apply to these rules because the rules do not impose a cost on regulated persons and are necessary to implement legislation that does not specifically state that §2001.0045 applies to the rules.
PUBLIC BENEFIT AND COSTS
Emily Zalkovsky, State Medicaid Director, has determined that for each year of the first five years the rules are in effect, the public benefit will be having a greater number of providers available for CPW clients to choose from.
Trey Wood has also determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules because provider and client participation in CPW services is optional.
TAKINGS IMPACT ASSESSMENT
HHSC has determined that the proposal does not restrict or limit an owner's right to the owner's property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.
PUBLIC COMMENT
Written comments on the proposal may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 4601 West Guadalupe Street, Austin, Texas 78751; or emailed to HHSRulesCoordinationOffice@hhs.texas.gov.
To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When faxing or emailing comments, please indicate "Comments on Proposed Rule 24R049" in the subject line.
SUBCHAPTER A. GENERAL PROVISIONS
STATUTORY AUTHORITY
The new sections are authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules as necessary to carry out the commission's duties; and Human Resources Code §32.021 and Texas Government Code §531.021(a), which authorize HHSC to administer the federal medical assistance (Medicaid) program.
The new sections implement Texas Government Code §531.651, §531.652, §531.653, §531.654, §531.655, and §531.656.
§257.1.Purpose and Application.
(a) Case Management for Children and Pregnant Women is a Medicaid benefit that assists an eligible client in gaining access to the necessary medical, social, educational, and other service needs related to a child with a health condition or health risk or a pregnant woman with a high-risk condition.
(b) The rules in this chapter apply to Case Management for Children and Pregnant Women services delivered in fee-for-service and through a Medicaid managed care organization.
§257.3.Definitions.
The following words or terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.
(1) Access--The ability of an eligible client to obtain health and health-related services and other services related to nonmedical needs, as determined by factors such as:
(A) the availability of Texas Health Steps services;
(B) service acceptability to the eligible child, pregnant woman, or both;
(C) the location of health care facilities and other resources;
(D) transportation;
(E) hours of facility operation; and
(F) length of time available to see providers of health and health-related services or other services related to nonmedical needs.
(2) Applicant--An agency, organization, or individual who submits an application to enroll as a state Medicaid provider of Case Management for Children and Pregnant Women services.
(3) Case manager--An individual qualified under §257.19 of this title (relating to Case Manager Qualifications) who provides Case Management for Children and Pregnant Women services. A case manager may be an independent provider or an employee or contractor of a Medicaid-enrolled case management provider.
(4) Case management services--Services provided under this chapter to an eligible client to assist the client in gaining access to necessary medical, social, educational, and other services for a child with a health condition or health risk or a pregnant woman with a high-risk condition. In this chapter, these services are also referred to as Case Management for Children and Pregnant Women services.
(5) Child with a health condition or health risk--A child from birth through 20 years of age who has or is at risk for a medical condition, illness, injury, or disability that results in limitation of function, activities, or social roles in comparison with healthy peers of the same age in the general areas of physical, cognitive, emotional, or social growth and development.
(6) Client--An individual who is eligible for and enrolled in the Texas Medicaid Program and meets the eligibility requirements listed in §257.5 of this chapter (relating to Client Eligibility) or the client's parent or legal guardian.
(7) Client choice--A client is given the freedom to choose a provider, to the extent possible, from among providers available to the client.
(8) Face-to-face--A visit conducted by a case manager with a client in person or utilizing synchronous audiovisual communications.
(9) Family--A basic unit in society having at its nucleus:
(A) one or more adults living together and cooperating in the care and rearing of the adult's or adults' biological or adopted children; or
(B) a person or persons acting as an individual's family, foster family, guardian, or identifiable support person or persons.
(10) Health and health-related services--Services that are provided to meet the preventive, primary, tertiary, and specialty health needs of an eligible client, including, medical and dental checkups, immunizations, acute care visits, pediatric specialty consultations, physical therapy, occupational therapy, audiology, speech language services, mental health professional services, pharmaceuticals, medical supplies, prenatal care, family planning, adolescent preventive health, durable medical equipment, nutritional supplements, prosthetics, eyeglasses, and hearing aids.
(11) HHSC--The Texas Health and Human Services Commission or its designee, including a Medicaid managed care organization.
(12) High-risk condition--Applies to a woman who is pregnant and has a medical or psychosocial condition that places the woman and the woman's fetus at a greater than average risk for complications, either during pregnancy, delivery, or after birth.
(13) Medicaid--Medical assistance program implemented by the state under the provisions of Title XIX of the Social Security Act, as amended, at 42 U.S.C., §1396, et seq.
(14) Nonmedical need--Nonmedical drivers of health are the conditions in the place where a person lives, learns, works, and plays and that affect a wide range of health risks and outcomes.
(15) Provider--May be:
(A) an agency approved by HHSC to provide Case Management for Children and Pregnant Women services and that is enrolled as a Medicaid provider; or
(B) an individual approved by HHSC to provide Case Management for Children and Pregnant Women services and who is enrolled as a Medicaid provider.
(16) Quality assurance review--A review conducted by HHSC of a provider's client records, internal quality assurance policy, outreach materials, and compliance with HHSC's rules and policies, including the qualifications of the provider's case managers as listed in §257.19 of this chapter.
(17) TMPPM--Texas Medicaid Provider Procedures Manual.
(18) Utilization review--A review conducted by HHSC of a provider's claims data in which trends have been identified that could indicate potential concerns with the delivery of case management services.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on February 5, 2025.
TRD-202500397
Karen Ray
Chief Counsel
Health and Human Services Commission
Earliest possible date of adoption: March 23, 2025
For further information, please call: (512) 438-2910
26 TAC §§257.5, 257.7, 257.9, 257.11
STATUTORY AUTHORITY
The new sections are authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules as necessary to carry out the commission's duties; and Human Resources Code §32.021 and Texas Government Code §531.021(a), which authorize HHSC to administer the federal medical assistance (Medicaid) program.
The new sections implement Texas Government Code §531.651, §531.652, §531.653, §531.654, §531.655, and §531.656.
§257.5.Client Eligibility.
A client eligible for services under this chapter must be either a child with a health condition or health risk or a pregnant woman with a high-risk condition who:
(1) is Medicaid-eligible in Texas;
(2) is in need of Case Management for Children and Pregnant Women services; and
(3) chooses such services.
§257.7.Client Rights.
(a) Use of services is voluntary. Acceptance or refusal of services does not affect eligibility for or receipt of any other Medicaid services, or for future case management services.
(b) All records about a client are considered confidential information, in accordance with the standards and requirements described in §257.9 of this subchapter (relating to Client Confidentiality).
(c) A client has the right to:
(1) actively participate in case management decisions, including the right to refuse services from a case manager;
(2) receive services free from abuse or harm from a case manager;
(3) have freedom of choice to choose a provider in the client's county of residence or service area, as applicable;
(4) have freedom to request a transfer to another available case manager at any time; and
(5) except as described in subsection (d) of this section, request a fair hearing, conducted in accordance with the rules in 1 TAC, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), within 90 days after receiving written notification that services have been denied, reduced, suspended, or terminated.
(d) A client receiving Case Management for Children and Pregnant Women services through a Medicaid managed care organization (MCO) must:
(1) use the MCO's complaint and appeal procedure as prescribed in 1 TAC §353.415 (relating to Member Complaint and Appeal Procedures); and
(2) exhaust internal MCO appeals before requesting a fair hearing as described in subsection (c)(5) of this section.
§257.9.Client Confidentiality.
(a) Federal and state laws and regulations prohibit the disclosure of information about a Medicaid client without effective consent by the client or the client's parent or legal guardian, except for purposes directly connected with the administration of the Medicaid program, as described in:
(1) 42 U.S.C. §1396a(a)(7);
(2) 42 C.F.R. §§431.301 - 431.306;
(3) Texas Human Resources Code §12.003 and §21.012; and
(4) Texas Government Code §552.101.
(b) A provider is not considered directly connected with the administration of the program. Although a provider is not entitled to confidential information without prior consent, the provider may verify a client's eligibility status.
(c) An entity with which HHSC contracts to perform certain administrative functions, including contractors for outreach, informing, and transportation services, may receive confidential information without a client's consent, but only to the extent necessary to perform and administer the contract. A contracted entity is bound by the same standards of confidentiality applicable to the Medicaid program, and the entity must provide effective safeguards to ensure confidentiality.
§257.11.Components of Case Management for Children and Pregnant Women Services.
The following are the essential components of Case Management for Children and Pregnant Women services and an explanation of billable components.
(1) Intake--A case manager's visit with a client, family, or guardian that includes the case manager collecting demographic information, health information, and other information relevant to determining the client's eligibility.
(2) Comprehensive visit--A required visit conducted by a case manager face-to-face with a client, family, or guardian that includes the case manager completing the following:
(A) Family Needs Assessment. A comprehensive assessment completed by a case manager to determine a client's need for any medical, educational, social, or other services required to address the client's short- and long-term health and well-being. A case manager must document this assessment on a Family Needs Assessment form, which must include:
(i) taking a client's history;
(ii) identifying the client's needs, assessing and addressing family issues that impact the client's health condition, health risk, high-risk condition, or nonmedical needs; and
(iii) gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the client.
(B) Service Plan. A plan for case management services completed by a case manager with a client or the client's parent or legal guardian that determines a planned course of action based on the information collected through the assessment required in paragraph (2)(A) of this section. A case manager must document the Service Plan on a Service Plan form, which must:
(i) include activities and goals developed by the client in consultation with the case manager to address the medical, social, educational, and other services needed by the client;
(ii) identify a course of action to respond to the assessed needs of the client, including identifying the individual responsible for contacting the appropriate service providers, and designating the time frame within which the client should access services; and
(iii) be dated and signed by the Medicaid provider.
(3) Referral and related activities. To help manage a client's care, a case manager making referrals and conducting related activities, such as scheduling appointments for the client, conducting collateral contacts with a non-eligible individual that are directly related to identify and help the client obtain needed services and link the client with:
(A) medical, social, and educational providers; and
(B) other programs and services that can provide services the client needs.
(4) Follow-up visits by a case manager.
(A) A case manager must make a follow-up visit:
(i) as frequently as necessary to ensure a client's Service Plan is implemented and adequately addresses the client's needs;
(ii) annually for a client who is eligible for case management for longer than 12 consecutive months; and
(iii) as needed during the eligible postpartum period for a client who is a pregnant woman with a high-risk condition who may also have nonmedical needs.
(B) During a follow up visit, a case manager must:
(i) determine if:
(I) services have been furnished to a client in accordance with the client's Service Plan; and
(II) services in the initial Service Plan are adequate to address the client's needs; and
(ii) complete a Service Plan Addendum form if the case manager identifies there has been a change in the client's needs or status and the initial Service plan needs to be revised.
(5) The essential components of Case Management for Children and Pregnant Women services that are eligible for Medicaid reimbursement are the comprehensive visit and each follow-up visit performed in accordance with this section.
(6) Case management services are not reimbursable if the services are provided:
(A) to a client who does not meet the client eligibility requirements in §257.5 of this subchapter (relating to Client Eligibility);
(B) to a client who has already received another case management service on the same day from the same billing provider; or
(C) when a client is an inpatient at a hospital or other treatment facility.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on February 5, 2025.
TRD-202500398
Karen Ray
Chief Counsel
Health and Human Services Commission
Earliest possible date of adoption: March 23, 2025
For further information, please call: (512) 438-2910
26 TAC §§257.15, 257.17, 257.19, 257.21, 257.23
STATUTORY AUTHORITY
The new sections are authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules as necessary to carry out the commission's duties; and Human Resources Code §32.021 and Texas Government Code §531.021(a), which authorize HHSC to administer the federal medical assistance (Medicaid) program.
The new sections implement Texas Government Code §531.651, §531.652, §531.653, §531.654, §531.655, and §531.656.
§257.15.Provider Qualifications and Approval Process.
(a) To be approved by HHSC as a provider, an applicant must:
(1) not be listed on the HHSC Office of Inspector General's Excluded Individual/Entities nor on the U.S. HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE);
(2) complete:
(A) a pre-planning process with HHSC that includes a review of case manager qualifications listed in §257.19 of this subchapter (relating to Case Manager Qualifications) and an overview of case management activities as listed in §257.21 (Case Manager Responsibilities); and
(B) the HHSC standardized case management training provided by HHSC; and
(3) agree to:
(A) employ or contract with one or more case managers who each meet at least one of the qualifications listed in §257.19 of this subchapter (relating to Case Manager Qualifications); and
(B) comply with:
(i) the rules, policies, and procedures of HHSC relating to Case Management for Children and Pregnant Women; and
(ii) applicable state and federal laws governing participation of providers in the Medicaid program and enrollment as a state Medicaid provider.
(b) HHSC notifies an applicant that complies with subsection (a) of this section whether HHSC approves the applicant's enrollment to be a Medicaid provider of Case Management for Children and Pregnant Women services.
§257.17.Provider Responsibilities.
A provider must:
(1) operate in accordance with the laws, rules, regulations, and standards of care relating to the practice of the provider's respective license or certifications;
(2) ensure the provider's case managers operate:
(A) within the laws, rules, regulations, and standards of care relating to the practice of the case manager's respective license, or certification; and
(B) only within the scope of the case manager's respective license or certification;
(3) provide services:
(A) according to policies and procedures as published in the TMPPM and Medicaid bulletins; and
(B) in accordance with the policies and procedures of HHSC;
(4) cease providing services and notify HHSC if the professional license of a case manager is suspended or revoked, with such notification to be provided to HHSC no later than seven calendar days after the date that the suspension or revocation is imposed;
(5) assure that the provider's case managers attend required trainings provided by HHSC;
(6) develop and maintain a quality management system for the provision of services with the primary goal of assisting clients in accessing necessary medical, social, educational, and other services related to the client's health condition, health risk, high-risk condition, or nonmedical need;
(7) ensure that outreach activities:
(A) do not impede freedom of client choice; and
(B) comply with 1 TAC §371.27 (relating to Prohibition against Solicitation of Medicaid or CHIP Recipients); and
(8) ensure that a client is given freedom of choice to choose a provider for case management.
§257.19.Case Manager Qualifications.
A provider that is an agency or an individual approved by HHSC to provide case management services must ensure a case manager meets at least one of the following qualifications:
(1) an advanced practice registered nurse who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 301;
(2) a registered nurse who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 301 and:
(A) has a baccalaureate degree in nursing; or
(B) has an associate degree in nursing and has:
(i) at least two years of cumulative paid full-time work experience; or
(ii) at least two years of cumulative, supervised full-time educational internship or practicum experience obtained in the last 10 years that included assessing the psychosocial and health needs of and making community referrals for:
(I) children up to age 21; or
(II) pregnant women;
(3) a social worker who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 505, appropriate for the individual's practice, including the independent practice of social work;
(4) a community health worker, as defined by Texas Health and Safety Code §48.001, that is certified as a community health worker by the Department of State Health Services; or
(5) a doula who is certified in alignment with nationally recognized standards, as determined by HHSC, unless the doula qualifies as a certified community health worker under paragraph (4) of this subsection.
§257.21.Case Manager Responsibilities.
A case manager must:
(1) comply with all licensure or certification requirements of the appropriate issuing agency or state licensure or examining board, including the obligation to report all suspected child abuse or neglect;
(2) cease providing services and notify HHSC if the case manager's professional license or certification is suspended or revoked, with such notification to be provided to HHSC no later than seven calendar days after the date that the suspension or revocation is imposed;
(3) provide services convenient to a client, either in the client's home, an office setting, or other place of the client's preference; and
(4) have knowledge of, and coordinate services with, providers of health and health-related services, non-covered services, and other active community resources.
§257.23.Compliance with Utilization Reviews and Quality Assurance Reviews and Overpayments.
(a) The purpose of a utilization review and a quality assurance review is:
(1) to ensure program fiscal integrity;
(2) to address the federal mandate requiring program funds be spent only as allowed under federal and state laws and regulations; and
(3) to ensure that a case manager provided Case Management for Children and Pregnant Women services to a client within the scope of the client's Service Plan.
(b) HHSC conducts quality assurance and utilization reviews of all active providers to monitor claims, the quality of case management services, and compliance with Case Management for Children and Pregnant Women rule and policy.
(c) A provider must cooperate with the quality assurance and utilization reviews. A provider will be given notification of upcoming reviews in accordance with the policies and procedures established by HHSC.
(d) If the results of a provider's utilization review or quality assurance review as determined by HHSC, indicates overpayment, HHSC notifies the provider of the overpayment and gives the provider information about how to arrange for repayment.
(e) If a provider becomes aware that the provider received an overpayment, the provider must notify the Medicaid claims administrator to arrange for repayment.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on February 5, 2025.
TRD-202500399
Karen Ray
Chief Counsel
Health and Human Services Commission
Earliest possible date of adoption: March 23, 2025
For further information, please call: (512) 438-2910