PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353. MEDICAID MANAGED CARE
SUBCHAPTER A. GENERAL PROVISIONS
The Texas Health and Human Services Commission (HHSC) adopts amendments to §353.2, concerning Definitions; and §353.4, concerning Managed Care Organization Requirements Concerning Out-of-Network Providers.
Sections 353.2 and 353.4 are adopted without changes to the proposed text as published in the December 8, 2023, issue of the Texas Register (48 TexReg 7113). These rules will not be republished.
BACKGROUND AND JUSTIFICATION
The adopted amendment to Section 353.4 requires Medicaid health care managed care organizations (MCOs) to reimburse an out-of-network physician for providing Medicaid telemedicine medical services to a child in a primary or secondary school-based setting without prior authorization, even if the physician is not the child's primary care provider. This requirement is in accordance with Texas Government Code Section 531.0217(c-4) and is currently implemented through contracts between MCOs and HHSC. Texas Government Code Section 531.0217(c-4) was added by House Bill 1878, 84th Legislature, Regular Session, 2015, and amended by Senate Bill 670, 86th Legislature, Regular Session, 2019.
The adopted amendment to Section 353.2 adds the definitions for "nursing facility," "nursing facility add-on services," "nursing facility services," and "nursing facility unit rate" to provide definitions of terms used in Section 353.4 and to align the definitions with language in managed care contracts. The adopted amendment removes the definition for "Main dental home provider" because this term is not used in the chapter.
COMMENTS
The 31-day comment period ended January 8, 2024.
During this period, HHSC did not receive any comments regarding the proposed rules.
STATUTORY AUTHORITY
The amendments are adopted under 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; Human Resources Code §32.021 and Texas Government Code §531.021(a), which authorize HHSC to administer the federal medical assistance (Medicaid) program; and Texas Government Code §533.002, which authorizes HHSC to implement the Medicaid managed care program.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on March 13, 2024.
TRD-202401157
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: April 2, 2024
Proposal publication date: December 8, 2023
For further information, please call: (512) 221-6857