The Texas Health and Human Services Commission has adopted the following rules:
Medicaid Health Services
Senate Bill (SB) 1542, 83rd Legislature, Regular Session, 2013 adds Chapter 538 to the Texas Government Code. The new chapter requires the commission to develop and implement a quality improvement process to receive clinical suggestions that improve the quality of care and cost-effectiveness under the Medicaid program, conduct a preliminary review of each suggestion, and conduct an analysis of clinical initiative suggestions that are selected for analysis. Additionally, the commission is required to prepare a final report on each clinical initiative that has received a full analysis, and potentially implement clinical initiatives that are cost-effective and improve quality of care under Medicaid.
HHSC gave the following responses to public comment:
- As HHSC's internal process, potential costs to providers will be considered and outlined in the report, HHSC feels that adding the language proposed would create an overly narrow rule and therefore the proposed rules remain unchanged.
- Clinical suggestions can only come from the authorized submitters outlined in the bill (§538.052). These authorized submitters can only submit suggestions that have the potential to improve the quality of care and cost-effectiveness of the Medicaid program (§538.051). Stakeholders will have a 30-day window to comment on a clinical suggestion that warrants further analysis once the suggestion is posted on the website.
- HHSC will make effort to align where and when possible to align suggested clinical initiatives with other initiatives in Texas.
Medicaid Eligibility for Women, Children, Youth and Needy Families
HHSC adopts new rules and amendments to existing rules to implement federally required Medicaid eligibility changes. In general, the adopted rules implement Medicaid eligibility changes that are required by federal law, effective January 1, 2014.
HHSC gave the following responses to public comment:
- The rules do not specifically list the applications that are "prescribed by HHSC," and HHSC will accept the federal streamlined application from applicants.
- Section 366.505, concerning General Eligibility Requirements for the Children's Medicaid Program, states that a person is eligible for that program if, among other things, the person "meets the criteria…of Subchapter K of this chapter (relating to Modified Adjusted Gross Income Methodology)." Section 366.1109(b) of Subchapter K states that "(a)ssets tests do not apply" to a member of a group whose eligibility is determined, in part, in accordance with Subchapter K. In HHSC's view, this makes sufficiently clear that HHSC will not use assets information to determine eligibility for children's Medicaid.
- This rule harmonizes federal and state requirements by providing a children's Medicaid recipient with an initial six-month period of eligibility, with the subsequent six-month period subject to the requirement that a recipient advise HHSC of any changes that affect eligibility. A new continuous eligibility period cannot begin under state law until a new eligibility determination is made at the federally required 12 months.
- Extending coverage to children who aged out of foster care in other states is an optional expansion of Medicaid. The Texas Legislature considered expansion options, but did not adopt them. Thus, consistent with direction from state leadership, HHSC is not extending the state option to cover former foster care youth who aged out of foster care in other states.
- HHSC declines to either delete the language or add language indicating that the provision of asset information is optional. HHSC has a significant interest in analyzing the impact of federal eligibility changes on state expenditures, and, pursuant to that interest, HHSC will collect information regarding an applicant's assets and resources. HHSC will not use the information to determine an applicant's or recipient's eligibility.
State Children’s Health Insurance Program
HHSC adopts new rules and amendments to existing rules to implement federally required CHIP eligibility changes. In general, the adopted rules implement the following CHIP eligibility changes that are required by federal law, effective January 1, 2014.
HHSC gave the following response to public comment:
- Comments on the application are beyond the scope of the rules. HHSC intends to collect information regarding an applicant's assets and resources. The information will not be used as part of federally required eligibility determinations, but will be used to research the impact of federal eligibility changes on state expenditures.
Medicaid and Other Health and Human Services Fraud and Abuse Program Integrity
Existing 1 TAC §§371.200, 371.201, 371.203, 371.204, 371.206, and 371.210 describe HHSC Office of Inspector General's (HHSC-OIG) processes for hospital utilization review (HUR) case selection, hospital screening criteria, denials and recoupments, and inpatient utilization review. The existing rules are inconsistent with current Texas Medicaid program policy, which extends outpatient observation time from 24 to 48 hours; add present-on-admission (POA) reporting requirements; and specifies that a claim for an inpatient admission that lacks medical necessity may be denied. The adopted amendments will bring the rules into compliance with existing policies.
HHSC gave the following responses to public comment:
- Adding the requested language would inappropriately impose policy on the Medicaid program, which is outside the purpose of these rules.
- The term non-physician includes both advanced practice registered nurses and physician assistants and may include other professionals who may be afforded authority to practice in their professional capacity. HHSC-OIG believes using the suggested wording would unduly restrict who may be a non-physician.
