HEALTH & SAFETY CODE
CHAPTER 35. CHILDREN WITH SPECIAL HEALTH CARE NEEDS
§ 35.001. SHORT TITLE. This chapter may be cited as the
Children with Special Health Care Needs Services Act.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1999, 76th Leg., ch. 1505, § 3.01, eff. Sept. 1, 1999.
§ 35.0021. DEFINITIONS. In this chapter:
(1) "Case management services" includes:
(A) coordinating medical services, marshaling
available assistance, serving as a liaison between the child and
the child's family and caregivers, insurance services, and other
services needed to improve the well-being of the child and the
child's family; and
(B) counseling for the child and the child's
family about measures to prevent the transmission of AIDS or HIV and
the availability in the geographic area of any appropriate health
care services, such as mental health care, psychological health
care, and social and support services.
(2) "Child with special health care needs" has the
meaning assigned by Section 35.0022.
(3) "Dentist" means a person licensed by the State
Board of Dental Examiners to practice dentistry in this state.
(4) "Facility" includes a hospital, an ambulatory
surgical center, and an outpatient clinic.
(5) "Family support services" means support,
resources, or other assistance provided to the family of a child
with special health care needs. The term may include services
described by Part A of the Individuals with Disabilities Education
Act (20 U.S.C. Section 1400 et seq.), as amended, and permanency
planning, as that term is defined by Section 531.151, Government
Code.
(6) "Other benefit" means a benefit, other than a
benefit provided under this chapter, to which a person is entitled
for payment of the costs of services provided under the program,
including benefits available from:
(A) an insurance policy, group health plan,
health maintenance organization, or prepaid medical or dental care
plan;
(B) Title XVIII, Title XIX, or Title XXI of the
Social Security Act (42 U.S.C. § 1395 et seq., 42 U.S.C. §
1396 et seq., and 42 U.S.C. § 1397aa et seq.), as amended;
(C) the Department of Veterans Affairs;
(D) the Civilian Health and Medical Program of
the Uniformed Services;
(E) workers' compensation or any other
compulsory employers' insurance program;
(F) a public program created by federal or state
law or the ordinances or rules of a municipality or other political
subdivision of the state, excluding benefits created by the
establishment of a municipal or county hospital, a joint
municipal-county hospital, a county hospital authority, a hospital
district, or the facilities of a publicly supported medical school;
or
(G) a cause of action for the cost of care,
including medical care, dental care, facility care, and medical
supplies, required for a person applying for or receiving services
from the department, or a settlement or judgment based on the cause
of action, if the expenses are related to the need for services
provided under this chapter.
(7) "Physician" means a person licensed by the Texas
State Board of Medical Examiners to practice medicine in this
state.
(8) "Program" means the services program for children
with special health care needs.
(9) "Provider" means a person who delivers services
purchased by the department for the purposes of this chapter.
(10) "Rehabilitation services" means the process of
the physical restoration, improvement, or maintenance of a body
function destroyed or impaired by congenital defect, disease, or
injury and includes:
(A) facility care, medical and dental care, and
occupational, speech, and physical therapy;
(B) the provision of braces, artificial
appliances, durable medical equipment, and other medical supplies;
and
(C) other types of care specified by the board in
the program rules.
(11) "Services" means the care, activities, and
supplies provided under this chapter or program rules, including
medical care, dental care, facility care, medical supplies,
occupational, physical, and speech therapy, and other care
specified by program rules.
(12) "Specialty center" means a facility and staff
that meet minimum standards established under the program and are
designated by the board for program use in the comprehensive
diagnostic and treatment services for a specific medical condition.
(13) "Support" means to contribute money or services
necessary for a person's maintenance, including food, clothing,
shelter, transportation, and health care.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.02, eff. Sept. 1,
1999.
§ 35.0022. CHILD WITH SPECIAL HEALTH CARE
NEEDS. (a) In this chapter, "child with special health care
needs" means a person who:
(1) is younger than 21 years of age and who has a
chronic physical or developmental condition; or
(2) has cystic fibrosis, regardless of the person's
age.
(b) The term "child with special health care needs" may
include a person who has a behavioral or emotional condition that
accompanies the person's physical or developmental condition. The
term does not include a person who has a behavioral or emotional
condition without having an accompanying physical or developmental
condition.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.02, eff. Sept. 1,
1999.
§ 35.003. SERVICES PROGRAM FOR CHILDREN WITH SPECIAL
HEALTH CARE NEEDS. (a) The program is in the department to
provide services to eligible children with special health care
needs. The program shall provide:
(1) early identification of children with special
health care needs;
(2) diagnosis and evaluation of children with special
health care needs;
(3) rehabilitation services to children with special
health care needs;
(4) development and improvement of standards and
services for children with special health care needs;
(5) case management services;
(6) other family support services; and
(7) access to health benefits plan coverage under
Section 35.0031.
(b) The board by rule shall:
(1) specify the type, amount, and duration of services
to be provided under this chapter; and
(2) permit the payment of insurance premiums for
eligible children.
(c) If budgetary limitations exist, the board by rule shall
establish a system of priorities relating to the types of services
or the classes of persons eligible for the services. A waiting list
of eligible persons may be established if necessary for the program
to remain within the budgetary limitations. The department shall
collect from each applicant for services who is placed on a waiting
list appropriate information to facilitate contacting the
applicant when services become available and to allow efficient
enrollment of the applicant in those services. The information
collected must include:
(1) the applicant's name, address, and phone number;
(2) the name, address, and phone number of a contact
person other than the applicant;
(3) the date of the applicant's earliest application
for services;
(4) the applicant's functional needs;
(5) the range of services needed by the applicant; and
(6) a date on which the applicant is scheduled for
reassessment.
(d) The program may provide:
(1) transportation and subsistence for an eligible
child with special health care needs and the child's parent,
managing conservator, guardian, or other adult caretaker approved
by the program to obtain services provided by the program; and
(2) the following services to an eligible child with
special health care needs who dies in an approved facility outside
the child's municipality of residence while receiving program
services:
(A) the transportation of the child's remains,
and the transportation of a parent or other person accompanying the
remains, from the facility to the place of burial in this state that
is designated by the parent or other person legally responsible for
interment;
(B) the expense of embalming, if required for
transportation;
(C) the cost of a coffin purchased at a minimum
price, if a coffin is required for transportation; and
(D) any other necessary expenses directly
related to the care and return of the child's remains to the place
of burial in this state.
(e) The department may:
(1) develop methods to improve the efficiency and
effectiveness of the program; and
(2) conduct pilot studies.
(f) The program is separate from the financial or medical
assistance program established by Chapters 31 and 32, Human
Resources Code.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1999, 76th Leg., ch. 1505, § 3.03, eff. Sept. 1, 1999.
§ 35.0031. HEALTH BENEFITS PLAN COVERAGE FOR CERTAIN
ELIGIBLE CHILDREN. The department shall obtain coverage under a
health benefits plan for a child who:
(1) is eligible for services under this chapter; and
(2) is not eligible for assistance under:
(A) a program established under Title XXI of the
Social Security Act (42 U.S.C. Section 1397aa et seq.), as amended;
or
(B) the medical assistance program under Chapter
32, Human Resources Code.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.04, eff. Sept. 1,
1999.
§ 35.0032. BENEFITS COVERAGE REQUIRED. To the extent
possible, the health benefits plan required by Section 35.0031 must
provide benefits comparable to the benefits provided under the
state child health plan established by this state to implement
Title XXI of the Social Security Act (42 U.S.C. Section 1397aa et
seq.), as amended.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.04, eff. Sept. 1,
1999.
§ 35.0033. HEALTH BENEFITS PLAN PROVIDER. (a) A
health benefits plan provider who provides coverage for benefits
under Section 35.0031 must:
(1) hold a certificate of authority or other
appropriate license issued by the Texas Department of Insurance
that authorizes the health benefits plan provider to provide the
type of coverage to be offered under Section 35.0031; and
(2) satisfy, except as provided by Subsection (b), any
other applicable requirement of the Insurance Code or another
insurance law of this state.
(b) Except as required by the department, a health benefits
plan provider under this chapter is not subject to a law that
requires coverage or the offer of coverage of a health care service
or benefit.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.04, eff. Sept. 1,
1999.
§ 35.0034. COST-SHARING PAYMENTS. (a) Except as
provided by Subsection (b), the department may not require a child
who is provided health benefits plan coverage under Section 35.0031
and who meets the income eligibility requirement of the medical
assistance program under Chapter 32, Human Resources Code, to pay a
premium, deductible, coinsurance, or other cost-sharing payment as
a condition of health benefits plan coverage under this chapter.
(b) The department may require a child described by
Subsection (a) to pay a copayment as a condition of health benefits
plan coverage under Section 35.0031 that is equal to any copayment
required under the state child health plan established by this
state to implement Title XXI of the Social Security Act (42 U.S.C.
Section 1397aa et seq.), as amended.
(c) The department may require a child who is provided
health benefits plan coverage under Section 35.0031 and who meets
the income eligibility requirement of a program established under
Title XXI of the Social Security Act (42 U.S.C. Section 1397aa et
seq.), as amended, to pay a premium, deductible, coinsurance, or
other cost-sharing payment as a condition of health benefits plan
coverage. The payment must be equal to any premium, deductible,
coinsurance, or other cost-sharing payment required under the state
child health plan established by this state to implement Title XXI
of the Social Security Act (42 U.S.C. Section 1397aa et seq.), as
amended.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.04, eff. Sept. 1,
1999.
§ 35.0035. DISALLOWANCE OF MATCHING FUNDS FROM FEDERAL
GOVERNMENT. Expenditures made to provide health benefits plan
coverage under Section 35.0031 may not be included for the purpose
of determining the state children's health insurance expenditures,
as that term is defined by 42 U.S.C. Section 1397ee(d)(2)(B), as
amended.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.04, eff. Sept. 1,
1999.
§ 35.004. SERVICE PROVIDERS. (a) The board shall
adopt substantive and procedural rules for the selection of
providers to participate in the program, including rules for the
selection of specialty centers and rules requiring that providers
accept program payments as payment in full for services provided.
(b) The board shall approve physicians, dentists, licensed
dietitians, facilities, specialty centers, and other providers to
participate in the program according to the criteria and following
the procedures prescribed by the board.
(c) The department may pay only for services delivered by an
approved provider, except in an emergency.
(d) Except as specified in the program rules, a recipient of
services may select any provider approved by the board. If the
recipient is a minor, the person legally authorized to consent to
the treatment may select the provider.
(e) The board shall adopt substantive and procedural rules
for the modification, suspension, or termination of the approval of
a provider.
(f) The board shall provide a due process hearing procedure
for the resolution of conflicts between the department and a
provider. Chapter 2001, Government Code, do not apply to conflict
resolution procedures adopted under this section.
(g) The department may not terminate the approval of a
provider while a hearing is pending under this section. The
department may withhold payments while the hearing is pending, but
shall pay the withheld payments and resume contract payments if the
final determination is favorable to the provider.
(h) Subsection (f) does not apply if a contract:
(1) is canceled by the department because services are
restricted to conform to budgetary limitations and service
priorities are adopted by the board regarding types of services to
be provided; or
(2) expires according to its terms.
(i) The Interagency Cooperation Act (Article 4413(32),
Vernon's Texas Civil Statutes) does not apply to a payment made by
the department for services provided by a publicly supported
medical school facility to an eligible child. A publicly supported
medical school facility receiving payment under this chapter shall
deposit the payment in local funds.
(j) This section does not apply to services for which
coverage is provided under the health benefits plan established
under Section 35.0031.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(66), eff. Sept. 1, 1995;
Acts 1997, 75th Leg., ch. 393, § 1, eff. Sept. 1, 1997; Acts
1999, 76th Leg., ch. 1505, § 3.05, eff. Sept. 1, 1999.
§ 35.0041. PARTICIPATION AND REIMBURSEMENT OF
TELEMEDICINE MEDICAL SERVICE PROVIDERS. (a) The department by
rule shall develop and implement policies permitting reimbursement
of a provider for services under the program performed using
telemedicine medical services.
(b) The policies must provide for reimbursement of:
(1) providers using telemedicine medical services and
telehealth services in a cost-effective manner that ensures the
availability to a child with special health care needs of services
appropriately performed using telemedicine medical services and
telehealth services that are comparable to the same types of
services available to that child without use of telemedicine
medical services and telehealth services;
(2) a provider for a service performed using
telemedicine medical services and telehealth services at an amount
equal to the amount paid to a provider for performing the same
service without using telemedicine medical services and telehealth
services;
(3) multiple providers of different services who
participate in a single telemedicine medical services or telehealth
services session for a child with special health care needs, if the
department determines that reimbursing each provider for the
session is cost-effective in comparison to the costs that would be
involved in obtaining the services from providers without the use
of telemedicine medical services and telehealth services,
including the costs of transportation and lodging and other direct
costs; and
(4) providers using telemedicine medical services and
telehealth services included in the school health and related
services program.
(c) In developing and implementing the policies required by
this section, the department shall consult with:
(1) The University of Texas Medical Branch at
Galveston;
(2) Texas Tech University Health Sciences Center;
(3) the Health and Human Services Commission,
including the state Medicaid office;
(4) providers of telemedicine medical services and
telehealth services hub sites in this state;
(5) providers of services to children with special
health care needs; and
(6) representatives of consumer or disability groups
affected by changes to services for children with special health
care needs.
(d) This section applies to services for which coverage is
provided under the health benefits plan established under Section
35.0031.
Added by Acts 2001, 77th Leg., ch. 959, § 4, eff. June 14, 2001.
§ 35.005. ELIGIBILITY FOR SERVICES. (a) The board by
rule shall:
(1) define medical, financial, and other criteria for
eligibility to receive services; and
(2) establish a system for verifying eligibility
information submitted by an applicant for or recipient of services.
(b) In defining medical and financial criteria for
eligibility under Subsection (a), the board may not:
(1) establish an exclusive list of coverable medical
conditions; or
(2) consider as a source of support to provide
services assets legally owned or available to a child's household.
(c) A child is not eligible to receive rehabilitation
services unless:
(1) the child is a resident of this state;
(2) at least one physician or dentist certifies to the
department that the physician or dentist has examined the child and
finds the child to be a child with special health care needs whose
disability meets the medical criteria established by the board;
(3) the department determines that the persons who
have any legal obligation to provide services for the child are
unable to pay for the entire cost of the services;
(4) the child has a family income that is less than or
equal to 200 percent of the federal poverty level; and
(5) the child meets all other eligibility criteria
established by board rules.
(d) A child is not eligible to receive services, other than
rehabilitation services, unless the child:
(1) is a resident of this state; and
(2) meets all other eligibility criteria established
by board rules.
(e) Notwithstanding Subsection (c)(4), a child with special
health care needs who has a family income that is greater than 200
percent of the federal poverty level and who meets all other
eligibility criteria established by this section and by board rules
is eligible for services if the department determines that the
child's family is or will be responsible for medical expenses that
are equal to or greater than the amount by which the family's income
exceeds 200 percent of the federal poverty level.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1999, 76th Leg., ch. 1505, § 3.06, eff. Sept. 1, 1999.
§ 35.006. DENIAL, MODIFICATION, SUSPENSION, OR
TERMINATION OF SERVICES. (a) The board shall adopt substantive
and procedural rules for the denial of applications and the
modification, suspension, or termination of services.
(b) The department may deny services to an applicant and
modify, suspend, or terminate services to a recipient after:
(1) notice to the child or the person who is legally
obligated to support the child;
(2) a preliminary program review; and
(3) an opportunity for a fair hearing.
(c) The board by rule shall provide criteria for action by
the department under this section.
(d) The department shall conduct hearings under this
section in accordance with the board's due process hearing rules.
Chapter 2001, Government Code, do not apply to the granting,
denial, modification, suspension, or termination of services.
(e) This section does not apply if the department restricts
services to conform to budgetary limitations that require the board
to adopt service priorities regarding types of services to be
provided.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(66), eff. Sept. 1, 1995.
§ 35.0061. REFERRAL FOR BEHAVIORAL OR EMOTIONAL
CONDITIONS. If a child with special health care needs who is
eligible for services under this chapter has a behavioral or
emotional condition and the child is eligible for services from
another provider of services that would address the behavioral or
emotional condition, the department shall refer the child to that
provider for those services.
Added by Acts 1999, 76th Leg., ch. 1505, § 3.07, eff. Sept. 1,
1999.
§ 35.007. FINANCIAL ELIGIBILITY; OTHER
BENEFITS. (a) The board shall require a child receiving
services, or the person who has a legal obligation to support the
child, to pay for or reimburse the department for that part of the
cost of the services that the child or person is financially able to
pay.
(b) A child is not eligible to receive services under this
chapter to the extent that the child or a person with a legal
obligation to support the child is eligible for some other benefit
that would pay for all or part of the services. The board may waive
this subsection if its enforcement will deny services to a class of
children because of conflicting state and federal laws or rules and
regulations.
(c) When the application is made under this chapter or at
any time before, during, or after the receipt of services, an
applicant for or recipient of services shall inform the department
of any other benefit to which the child or any person who has a legal
obligation to support the child may be entitled.
(d) A child who has received services that are covered by
some other benefit, or any other person with a legal obligation to
support the child, shall reimburse the department to the extent of
the services provided when the other benefit is received.
(e) The department may collect the cost of services provided
under this chapter directly:
(1) in accordance with Title XVIII, Title XIX, or
Title XXI of the Social Security Act (42 U.S.C. § 1395 et seq.,
42 U.S.C. § 1396 et seq., and 42 U.S.C. § 1397aa et seq.), as
amended; or
(2) from any personal insurance, a health maintenance
organization, or any other third party who has a legal obligation to
pay other benefits.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1999, 76th Leg., ch. 1505, § 3.08, eff. Sept. 1, 1999.
§ 35.008. RECOVERY OF COSTS. (a) The department may
recover the cost of services provided under this chapter from a
person who does not pay or reimburse the department as required by
Section 35.007 or from any third party who has a legal obligation to
pay other benefits.
(b) This section creates a separate cause of action, and the
commissioner may request the attorney general to bring suit in the
appropriate court of Travis County on behalf of the department.
(c) In a judgment in favor of the department, the court may
award attorney's fees, court costs, and interest accruing from the
date on which the department provides the service to the date on
which the department is reimbursed.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
§ 35.009. FEES. The board may adopt reasonable
procedures and standards for the determination of fees and charges
for program services.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
§ 35.010. FUNDING. The department may receive and
spend:
(1) gifts made for the purposes of this chapter; and
(2) funds appropriated or granted by the state or
federal government to provide services for children.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
§ 35.011. CONTRACTS. The department may enter into
contracts and agreements necessary to carry out this chapter,
including interagency agreements to provide for the efficient and
uninterrupted provision of necessary services to children who are
eligible to receive services from two or more public programs.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
§ 35.012. RECORDS. (a) The department may take a
census, make surveys, and establish permanent records of children
with special health care needs.
(b) The department shall maintain a record of orthotic and
prosthetic devices, durable medical equipment, and medical
supplies purchased by the department for children with special
health care needs. Those items are not state-owned personal
property and are exempt from the personal property inventory
requirements of Subtitle D, Title 10, Government Code.
(c) The purchase of the items described by Subsection (b) is
subject to audit by the state auditor in accordance with Chapter
321, Government Code.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989. Amended
by Acts 1991, 72nd Leg., ch. 14, § 11, eff. Sept. 1, 1991; Acts
1997, 75th Leg., ch. 165, § 17.19(4), eff. Sept. 1, 1997; Acts
1999, 76th Leg., ch. 1505, § 3.09, eff. Sept. 1, 1999.
§ 35.013. LIMITATIONS ON AUTHORITY. (a) This chapter
does not limit the authority of a parent, managing conservator, or
guardian over a minor.
(b) This chapter does not entitle an employee, agent, or
representative of the department or other official agent to enter a
home over the objection of a child or, if the child is a minor, over
the objection of the child's parent, managing conservator, or
guardian.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
