HEALTH & SAFETY CODE
CHAPTER 62. CHILD HEALTH PLAN FOR CERTAIN LOW-INCOME CHILDREN
SUBCHAPTER A. GENERAL PROVISIONS
§ 62.001. OBJECTIVE OF THE STATE CHILD HEALTH PLAN. The
principal objective of the state child health plan is to provide
primary and preventative health care to low-income, uninsured
children of this state, including children with special health care
needs, who are not served by or eligible for other state assisted
health insurance programs.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.002. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services
Commission.
(2) "Commissioner" means the commissioner of health
and human services.
(3) "Health plan provider" means an insurance company,
health maintenance organization, or other entity that provides
health benefits coverage under the child health plan program. The
term includes a primary care case management provider network.
(4) "Gross family income" means the total amount of
income established without consideration of any reduction for
offsets that may be available to the family under any other program.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.45, eff. Sept. 1,
2003.
§ 62.003. NOT AN ENTITLEMENT; TERMINATION OF
PROGRAM. (a) This chapter does not establish an entitlement to
assistance in obtaining health benefits for a child.
(b) The program established under this chapter terminates
at the time that federal funding terminates under Title XXI of the
Social Security Act (42 U.S.C. Section 1397aa et seq.), as amended,
unless a successor program providing federal funding for a
state-designed child health plan program is created.
(c) Unless the legislature authorizes the expenditure of
other revenue for the program established under this chapter, the
program terminates on the date that money obtained by the state as a
result of the Comprehensive Settlement Agreement and Release filed
in the case styled The State of Texas v. The American Tobacco Co.,
et al., No. 5-96CV-91, in the United States District Court, Eastern
District of Texas, is no longer available to provide state funding
for the program.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.004. FEDERAL LAW AND REGULATIONS. The
commissioner shall monitor federal legislation affecting Title XXI
of the Social Security Act (42 U.S.C. Section 1397aa et seq.) and
changes to the federal regulations implementing that law. If the
commissioner determines that a change to Title XXI of the Social
Security Act (42 U.S.C. Section 1397aa et seq.) or the federal
regulations implementing that law conflicts with this chapter, the
commissioner shall report the changes to the governor, lieutenant
governor, and speaker of the house of representatives, with
recommendations for legislation necessary to implement the federal
law or regulations, seek a waiver, or withdraw from participation.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
SUBCHAPTER B. ADMINISTRATION OF CHILD HEALTH PLAN PROGRAM
§ 62.051. DUTIES OF COMMISSION. (a) The commission
shall develop a state-designed child health plan program to obtain
health benefits coverage for children in low-income families. The
commission shall ensure that the child health plan program is
designed and administered in a manner that qualifies for federal
funding under Title XXI of the Social Security Act (42 U.S.C.
Section 1397aa et seq.), as amended, and any other applicable law or
regulations.
(b) The commission is the agency responsible for making
policy for the child health plan program, including policy related
to covered benefits provided under the child health plan. The
commission may not delegate this duty to another agency or entity.
(c) The commission shall oversee the implementation of the
child health plan program and coordinate the activities of each
agency necessary to the implementation of the program, including
the Texas Department of Health, Texas Department of Human Services,
and Texas Department of Insurance.
(d) The commission shall adopt rules as necessary to
implement this chapter. The commission may require the Texas
Department of Health, the Texas Department of Human Services, or
any other health and human services agency to adopt, with the
approval of the commission, any rules that may be necessary to
implement the program. With the consent of another agency,
including the Texas Department of Insurance, the commission may
delegate to that agency the authority to adopt, with the approval of
the commission, any rules that may be necessary to implement the
program.
(e) The commission shall conduct a review of each entity
that enters into a contract under Section 62.055 or Section 62.155,
to ensure that the entity is available, prepared, and able to
fulfill the entity's obligations under the contract in compliance
with the contract, this chapter, and rules adopted under this
chapter.
(f) The commission shall ensure that the amounts spent for
administration of the child health plan program do not exceed any
limit on those expenditures imposed by federal law.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.052. DUTIES OF TEXAS DEPARTMENT OF
HEALTH. (a) The commission may direct the Texas Department of
Health to:
(1) implement contracts with health plan providers
under Section 62.155;
(2) monitor the health plan providers, through
reporting requirements and other means, to ensure performance under
the contracts and quality delivery of services;
(3) monitor the quality of services delivered to
enrollees through outcome measurements including:
(A) rate of hospitalization for ambulatory
sensitive conditions, including asthma, diabetes, epilepsy,
dehydration, gastroenteritis, pneumonia, and UTI/kidney infection;
(B) rate of hospitalization for injuries;
(C) percent of enrolled adolescents reporting
risky health behavior such as injuries, tobacco use, alcohol/drug
use, dietary behavior, physical activity, or other health related
behaviors; and
(D) percent of adolescents reporting attempted
suicide; and
(4) provide payment under the contracts to the health
plan providers.
(b) The commission, or the Texas Department of Health under
the direction of and in consultation with the commission, shall
adopt rules as necessary to implement this section.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.053. DUTIES OF TEXAS DEPARTMENT OF HUMAN
SERVICES. (a) Under the direction of the commission, the Texas
Department of Human Services may:
(1) accept applications for coverage under the child
health plan and implement the child health plan program eligibility
screening and enrollment procedures;
(2) resolve grievances relating to eligibility
determinations; and
(3) coordinate the child health plan program with the
Medicaid program.
(b) If the commission contracts with a third party
administrator under Section 62.055, the commission may direct the
Texas Department of Human Services to:
(1) implement the contract;
(2) monitor the third party administrator, through
reporting requirements and other means, to ensure performance under
the contract and quality delivery of services; and
(3) provide payment under the contract to the third
party administrator.
(c) The commission, or the Texas Department of Human
Services under the direction of and in consultation with the
commission, shall adopt rules as necessary to implement this
section.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.054. DUTIES OF TEXAS DEPARTMENT OF
INSURANCE. (a) At the request of the commission, the Texas
Department of Insurance shall provide any necessary assistance with
the development of the child health plan. The department shall
monitor the quality of the services provided by health plan
providers and resolve grievances relating to the health plan
providers.
(b) The commission and the Texas Department of Insurance may
adopt a memorandum of understanding that addresses the
responsibilities of each agency in developing the plan.
(c) The Texas Department of Insurance, in consultation with
the commission, shall adopt rules as necessary to implement this
section.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.055. CONTRACTS FOR IMPLEMENTATION OF CHILD HEALTH
PLAN. (a) It is the intent of the legislature that the commission
maximize the use of private resources in administering the child
health plan created under this chapter. In administering the child
health plan, the commission may contract with a third party
administrator to provide enrollment and related services under the
state child health plan.
(b), (c) Repealed by Acts 2003, 78th Leg., ch. 198, §
2.156(a)(1).
(d) A third party administrator may perform tasks under the
contract that would otherwise be performed by the Texas Department
of Health or Texas Department of Human Services under this chapter.
(e) The commission shall:
(1) retain all policymaking authority over the state
child health plan;
(2) procure all contracts with a third party
administrator through a competitive procurement process in
compliance with all applicable federal and state laws or
regulations; and
(3) ensure that all contracts with child health plan
providers under Section 62.155 are procured through a competitive
procurement process in compliance with all applicable federal and
state laws or regulations.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.43, 2.156(a)(1),
eff. Sept. 1, 2003.
§ 62.058. FRAUD PREVENTION. The commission shall
develop and implement rules for the prevention and detection of
fraud in the child health plan program.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.0582. THIRD-PARTY BILLING VENDORS.
Text of section effective January 1, 2006
(a) A third-party billing vendor may not submit a claim with
the commission for payment on behalf of a health plan provider under
the program unless the vendor has entered into a contract with the
commission authorizing that activity.
(b) To the extent practical, the contract shall contain
provisions comparable to the provisions contained in contracts
between the commission and health plan providers, with an emphasis
on provisions designed to prevent fraud or abuse under the program.
At a minimum, the contract must require the third-party billing
vendor to:
(1) provide documentation of the vendor's authority to
bill on behalf of each provider for whom the vendor submits claims;
(2) submit a claim in a manner that permits the
commission to identify and verify the vendor, any computer or
telephone line used in submitting the claim, any relevant user
password used in submitting the claim, and any provider number
referenced in the claim; and
(3) subject to any confidentiality requirements
imposed by federal law, provide the commission, the office of the
attorney general, or authorized representatives with:
(A) access to any records maintained by the
vendor, including original records and records maintained by the
vendor on behalf of a provider, relevant to an audit or
investigation of the vendor's services or another function of the
commission or office of attorney general relating to the vendor;
and
(B) if requested, copies of any records described
by Paragraph (A) at no charge to the commission, the office of the
attorney general, or authorized representatives.
(c) On receipt of a claim submitted by a third-party billing
vendor, the commission shall send a remittance notice directly to
the provider referenced in the claim. The notice must include
detailed information regarding the claim submitted on behalf of the
provider.
(d) The commission shall take all action necessary,
including any modifications of the commission's claims processing
system, to enable the commission to identify and verify a
third-party billing vendor submitting a claim for payment under the
program, including identification and verification of any computer
or telephone line used in submitting the claim, any relevant user
password used in submitting the claim, and any provider number
referenced in the claim.
(e) The commission shall audit each third-party billing
vendor subject to this section at least annually to prevent fraud
and abuse under the program.
Added by Acts 2003, 78th Leg., ch. 198, § 2.44(a), eff. Jan. 1,
2006.
§ 62.059. HEALTH INSURANCE PREMIUM ASSISTANCE PROGRAM
FOR CHILDREN ELIGIBLE FOR CHILD HEALTH PLAN. (a) In this section,
"group health benefit plan" has the meaning assigned by Article
21.52K, Insurance Code.
(b) The commission shall identify children, otherwise
eligible to enroll in the state child health plan under this
chapter, who are eligible to enroll in a group health benefit plan.
(c) For a child identified under Subsection (b), the
commission shall determine whether it is cost-effective to enroll
the child in the group health benefit plan under this section. The
commission may determine cost-effectiveness on an aggregate basis
for the premium assistance program as a whole.
(d) If the commission determines that it is cost-effective
to enroll the child in the group health benefit plan, the commission
shall:
(1) inform the child and the child's parent or guardian
of the availability of the premium assistance program under this
section;
(2) offer, as an optional alternative to enrollment in
the commission's state child health plan program, a premium
assistance payment to assist with the employee's or member's share
of the required premiums for the group health benefit plan that is
available to the child; and
(3) provide written notice to the issuer of the group
health benefit plan in accordance with Article 21.52K, Insurance
Code.
(e) The commission shall determine the amount of the premium
assistance payment. The premium assistance payment shall be paid
only for the reimbursement of the employee's or member's share of
required premiums for coverage of a child enrolled in the group
health benefit plan.
(f) The premium assistance payment paid under Subsection
(e) may provide assistance for the payment of a group health benefit
plan premium that includes the child's parent or other individuals
who are members of the child's family.
(g) The commission may not provide for the payment of any
deductible, copayment, coinsurance, or other cost-sharing
obligation for the child or another individual enrolled in a group
health benefit plan under Subsection (f).
(h) Repealed by Acts 2003, 78th Leg., ch. 198, § 2.07(b).
(i) Redesignated as subsec. (h) by Acts 2003, 78th Leg., ch.
11, § 1.
Added by Acts 2001, 77th Leg., ch. 1165, § 1, eff. Aug. 31, 2001.
Amended by Acts 2003, 78th Leg., ch. 11, § 1, eff. Sept. 1, 2003;
Acts 2003, 78th Leg., ch. 198, § 2.07(b), eff. Sept. 1, 2003.
SUBCHAPTER C. ELIGIBILITY FOR COVERAGE UNDER CHILD HEALTH PLAN
§ 62.101. ELIGIBILITY. (a) A child is eligible for
health benefits coverage under the child health plan if the child:
(1) is younger than 19 years of age;
(2) is not eligible for medical assistance under the
Medicaid program;
(3) is not covered by a health benefits plan offering
adequate benefits, as determined by the commission;
(4) has a family income that is less than or equal to
the income eligibility level established under Subsection (b); and
(5) satisfies any other eligibility standard imposed
under the child health plan program in accordance with 42 U.S.C.
Section 1397bb, as amended, and any other applicable law or
regulations.
(b) The commission shall establish income eligibility
levels consistent with Title XXI, Social Security Act (42 U.S.C.
Section 1397aa et seq.), as amended, and any other applicable law or
regulations, and subject to the availability of appropriated money,
so that a child who is younger than 19 years of age and whose gross
family income is at or below 200 percent of the federal poverty
level is eligible for health benefits coverage under the program.
In addition, the commission may establish eligibility standards
regarding the amount and types of allowable assets for a family
whose gross family income is above 150 percent of the federal
poverty level.
(c) The commissioner shall evaluate enrollment levels and
program impact every six months during the first 12 months of
implementation and at least annually thereafter and shall submit a
finding of fact to the Legislative Budget Board and the Governor's
Office of Budget and Planning as to the adequacy of funding and the
ability of the program to sustain enrollment at the eligibility
level established by Subsection (b). In the event that
appropriated money is insufficient to sustain enrollment at the
authorized eligibility level, the commissioner shall:
(1) suspend enrollment in the child health plan;
(2) establish a waiting list for applicants for
coverage; and
(3) establish a process for periodic or continued
enrollment of applicants in the child health plan program as the
availability of money allows.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.46, eff. Sept. 1,
2003.
§ 62.1015. ELIGIBILITY OF CERTAIN CHILDREN;
DISALLOWANCE OF MATCHING FUNDS. (a) In this section, "charter
school," "employee," and "regional education service center" have
the meanings assigned by Section 2, Article 3.50-7, Insurance Code.
(b) A child of an employee of a charter school, school
district, other educational district whose employees are members of
the Teacher Retirement System of Texas, or regional education
service center may be enrolled in health benefits coverage under
the child health plan. A child enrolled in the child health plan
under this section:
(1) participates in the same manner as any other child
enrolled in the child health plan; and
(2) is subject to the same requirements and
restrictions relating to income eligibility, continuous coverage,
and enrollment, including applicable waiting periods, as any other
child enrolled in the child health plan.
(c) The cost of health benefits coverage for children
enrolled in the child health plan under this section shall be paid
as provided in the General Appropriations Act. Expenditures made
to provide health benefits coverage under this section 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, unless the Health and Human
Services Commission, after consultation with the appropriate
federal agencies, determines that the expenditures may be included
without adversely affecting federal matching funding for the child
health plan provided under this chapter.
Added by Acts 2001, 77th Leg., ch. 1187, § 1.04, eff. Sept. 1,
2001. Amended by Acts 2003, 78th Leg., ch. 198, § 2.47, eff.
Sept. 1, 2003.
§ 62.102. CONTINUOUS COVERAGE. (a) The commission
shall provide that an individual who is determined to be eligible
for coverage under the child health plan remains eligible for those
benefits until the earlier of:
(1) the end of a period, not to exceed 12 months,
following the date of the eligibility determination; or
(2) the individual's 19th birthday.
(b) The period of continuous eligibility may be established
at an interval of 6 months beginning immediately upon passage of
this Act and ending September 1, 2005, at which time an interval of
12 months of continuous eligibility will be re-established.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.48, eff. Sept. 1,
2003.
§ 62.103. APPLICATION FORM AND PROCEDURES. (a) The
commission, or the Texas Department of Human Services at the
direction of and in consultation with the commission, shall adopt
an application form and application procedures for requesting child
health plan coverage under this chapter.
(b) The form and procedures must be coordinated with forms
and procedures under the Medicaid program to ensure that there is a
single consolidated application to seek assistance under this
chapter or the Medicaid program.
(c) To the extent possible, the application form shall be
made available in languages other than English.
(d) The commission may permit application to be made by
mail, over the telephone, or through the Internet.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2001, 77th Leg., ch. 584, § 1.
§ 62.104. ELIGIBILITY SCREENING AND
ENROLLMENT. (a) The commission, or the Texas Department of Human
Services at the direction of and in consultation with the
commission, shall develop eligibility screening and enrollment
procedures for children that comply with the requirements of 42
U.S.C. Section 1397bb, as amended, and any other applicable law or
regulations. The procedures shall ensure that Medicaid-eligible
children are identified and referred to the Medicaid program.
(b) The Texas Integrated Enrollment Services eligibility
determination system or a compatible system may be used to screen
and enroll children under the child health plan.
(c) The eligibility screening and enrollment procedures
shall ensure that children who appear to be Medicaid-eligible are
identified and that their families are assisted in applying for
Medicaid coverage.
(d) A child who applies for enrollment in the child health
plan, who is denied Medicaid coverage after completion of a
Medicaid application under Subsection (c), but who is eligible for
enrollment in the child health plan, shall be enrolled in the child
health plan without further application or qualification.
(e) The commission shall report semi-annually to the
committees of both houses of the legislature with jurisdiction over
the child health plan:
(1) the number of individuals referred for Medicaid
application under this section who are enrolled in the Medicaid
program; and
(2) the number of individuals who are denied coverage
under the Medicaid program because they failed to complete the
application process.
(f) A determination of whether a child is eligible for child
health plan coverage under the program and the enrollment of an
eligible child with a health plan provider must be completed, and
information on the family's available choice of health plan
providers must be provided, in a timely manner, as determined by the
commission. The commission must require that the determination be
made and the information be provided not later than the 30th day
after the date a complete application is submitted on behalf of the
child, unless the child is referred for Medicaid application under
this section.
(g) In the first year of implementation of the child health
plan, enrollment shall be open. Thereafter, the commission may
establish enrollment periods.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.105. COVERAGE FOR QUALIFIED ALIENS. The
commission shall provide coverage under the state Medicaid program
and under the program established under this chapter to a child who
is a qualified alien, as that term is defined by 8 U.S.C. Section
1641(b), if the federal government authorizes the state to provide
that coverage. The commission shall comply with any prerequisite
imposed under the federal law to providing that coverage.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
SUBCHAPTER D. CHILD HEALTH PLAN
§ 62.151. CHILD HEALTH PLAN COVERAGE. (a) The child
health plan must comply with this chapter and the coverage
requirements prescribed by 42 U.S.C. Section 1397cc, as amended,
and any other applicable law or regulations.
(b) In developing the covered benefits, the commission
shall consider the health care needs of healthy children and
children with special health care needs.
(c) In developing the plan, the commission shall ensure that
primary and preventive health benefits do not include reproductive
services, other than prenatal care and care related to diseases,
illnesses, or abnormalities related to the reproductive system.
(d) The child health plan must allow an enrolled child with
a chronic, disabling, or life-threatening illness to select an
appropriate specialist as a primary care physician.
(e) In developing the covered benefits, the commission
shall seek input from the Public Assistance Health Benefit Review
and Design Committee established under Section 531.067, Government
Code.
(f) The commission, if it determines the policy to be
cost-effective, may ensure that an enrolled child does not, unless
authorized by the commission in consultation with the child's
attending physician or advanced practice nurse, receive under the
child health plan:
(1) more than four different outpatient brand-name
prescription drugs during a month; or
(2) more than a 34-day supply of a brand-name
prescription drug at any one time.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.49, eff. Sept. 1,
2003.
§ 62.152. APPLICATION OF INSURANCE LAW. To provide the
flexibility necessary to satisfy the requirements of Title XXI of
the Social Security Act (42 U.S.C. Section 1397aa et seq.), as
amended, and any other applicable law or regulations, the child
health plan is not subject to a law that requires:
(1) coverage or the offer of coverage of a health care
service or benefit;
(2) coverage or the offer of coverage for the
provision of services by a particular health care services
provider, except as provided by Section 62.155(b); or
(3) the use of a particular policy or contract form or
of particular language in a policy or contract form.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.153. COST SHARING. (a) To the extent permitted
under 42 U.S.C. Section 1397cc, as amended, and any other
applicable law or regulations, the commission shall require
enrollees to share the cost of the child health plan, including
provisions requiring enrollees under the child health plan to pay:
(1) a copayment for services provided under the plan;
(2) an enrollment fee; or
(3) a portion of the plan premium.
(b) Subject to Subsection (d), cost-sharing provisions
adopted under this section shall ensure that families with higher
levels of income are required to pay progressively higher
percentages of the cost of the plan.
(c) If cost-sharing provisions imposed under Subsection (a)
include requirements that enrollees pay a portion of the plan
premium, the commission shall specify the manner in which the
premium is paid. The commission may require that the premium be
paid to the Texas Department of Health, the Texas Department of
Human Services, or the health plan provider.
(d) Cost-sharing provisions adopted under this section may
be determined based on the maximum level authorized under federal
law and applied to income levels in a manner that minimizes
administrative costs.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.50, eff. Sept. 1,
2003.
§ 62.154. WAITING PERIOD; CROWD OUT. (a) To the
extent permitted under Title XXI of the Social Security Act (42
U.S.C. Section 1397aa et seq.), as amended, and any other
applicable law or regulations, the child health plan must include a
waiting period. The child health plan may include copayments and
other provisions intended to discourage:
(1) employers and other persons from electing to
discontinue offering coverage for children under employee or other
group health benefit plans; and
(2) individuals with access to adequate health benefit
plan coverage, other than coverage under the child health plan,
from electing not to obtain or to discontinue that coverage for a
child.
(b) A child is not subject to a waiting period adopted under
Subsection (a) if:
(1) the family lost coverage for the child as a result
of:
(A) termination of employment because of a layoff
or business closing;
(B) termination of continuation coverage under
the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub.
L. No. 99-272);
(C) change in marital status of a parent of the
child;
(D) termination of the child's Medicaid
eligibility because:
(i) the child's family's earnings or
resources increased; or
(ii) the child reached an age at which
Medicaid coverage is not available; or
(E) a similar circumstance resulting in the
involuntary loss of coverage;
(2) the family terminated health benefits plan
coverage for the child because the cost to the child's family for
the coverage exceeded 10 percent of the family's net income;
(3) the child has access to group-based health
benefits plan coverage and is required to participate in the health
insurance premium payment reimbursement program administered by
the commission; or
(4) the commission has determined that other grounds
exist for a good cause exception.
(c) A child described by Subsection (b) may enroll in the
child health plan program at any time, without regard to any open
enrollment period established under the enrollment procedures.
(d) The waiting period required by Subsection (a) must
extend for a period of 90 days after:
(1) the first day of the month in which the applicant
is enrolled under the child health plan, if the date of enrollment
is on or before the 15th day of the month; or
(2) the first day of the month after which the
applicant is enrolled under the child health plan, if the date of
enrollment is after the 15th day of the month.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.51(a), (b), eff.
Sept. 1, 2003.
§ 62.155. HEALTH PLAN PROVIDERS. (a) The commission,
or the Texas Department of Health at the direction of and in
consultation with the commission, shall select the health plan
providers under the program through a competitive procurement
process. A health plan provider, other than a state administered
primary care case management network, must hold a certificate of
authority or other appropriate license issued by the Texas
Department of Insurance that authorizes the health plan provider to
provide the type of child health plan offered and must satisfy,
except as provided by this chapter, any applicable requirement of
the Insurance Code or another insurance law of this state.
(b) A managed care organization or other entity shall seek
to obtain, in the organization's or entity's provider network, the
participation of significant traditional providers, as defined by
commission rule, if that organization or entity:
(1) contracts with the commission or with another
agency or entity to operate a part of the child health plan under
this chapter; and
(2) uses a provider network to provide or arrange for
health care services under the child health plan.
(c) In selecting a health plan provider, the commission:
(1) may give preference to a person who provides
similar coverage under the Medicaid program; and
(2) shall provide for a choice of at least two health
plan providers in each service area.
(d) The commissioner may authorize an exception to
Subsection (c)(2) if there is only one acceptable applicant to
become a health plan provider in the service area.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
Amended by Acts 2003, 78th Leg., ch. 198, § 2.52, eff. Sept. 1,
2003.
§ 62.156. HEALTH CARE PROVIDERS. Health care providers
who provide health care services under the child health plan must
satisfy certification and licensure requirements, as required by
the commission, consistent with law.
Added by Acts 1999, 76th Leg., ch. 235, § 1, eff. Aug. 30, 1999.
§ 62.157. TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH
SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS.
Text of section as added by Acts 2001, 77th Leg., ch. 959, § 5
(a) In providing covered benefits to a child with special
health care needs, a health plan provider must permit benefits to be
provided through telemedicine medical services and telehealth
services in accordance with policies developed by the commission.
(b) The policies must provide for:
(1) the availability of covered benefits
appropriately provided through telemedicine medical services and
telehealth services that are comparable to the same types of
covered benefits provided without the use of telemedicine medical
services and telehealth services; and
(2) the availability of covered benefits for different
services performed by multiple health care providers during a
single telemedicine medical services and telehealth services
session, if the commission determines that delivery of the covered
benefits in that manner 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.
(c) In developing the policies required by Subsection (a),
the commission shall consult with:
(1) The University of Texas Medical Branch at
Galveston;
(2) Texas Tech University Health Sciences Center;
(3) the Texas Department of Health;
(4) providers of telemedicine 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.
Added by Acts 2001, 77th Leg., ch. 959, § 5, eff. June 14, 2001.
For text of section as added by Acts 2001, 77th Leg., ch. 1255, §
4, see § 62.157, post
§ 62.157. TELEMEDICINE MEDICAL SERVICES.
Text of section as added by Acts 2001, 77th Leg., ch. 1255, § 4
(a) In providing covered benefits to a child, a health plan
provider must permit benefits to be provided through telemedicine
medical services in accordance with policies developed by the
commission.
(b) The policies must provide for:
(1) the availability of covered benefits
appropriately provided through telemedicine medical services that
are comparable to the same types of covered benefits provided
without the use of telemedicine medical services; and
(2) the availability of covered benefits for different
services performed by multiple health care providers during a
single session of telemedicine medical services, if the commission
determines that delivery of the covered benefits in that manner 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, including the costs of
transportation and lodging and other direct costs.
(c) In developing the policies required by Subsection (a),
the commission shall consult with the telemedicine advisory
committee.
(d) In this section, "telemedicine medical service" has the
meaning assigned by Section 57.042, Utilities Code.
Added by Acts 2001, 77th Leg., ch. 1255, § 4, eff. June 15, 2001.
For text of section as added by Acts 2001, 77th Leg., ch. 959, §
5, see § 62.157, ante
§ 62.158. STATE TAXES. The commission shall ensure that
any experience rebate or profit-sharing for health plan providers
under the child health plan is calculated by treating premium,
maintenance, and other taxes under the Insurance Code and any other
taxes payable to this state as allowable expenses for purposes of
determining the amount of the experience rebate or profit-sharing.
Added by Acts 2003, 78th Leg., ch. 198, § 2.53, eff. Sept. 1,
2003.
§ 62.159. DISEASE MANAGEMENT SERVICES. (a) In this
section, "disease management services" means services to assist a
child manage a disease or other chronic health condition, such as
heart disease, diabetes, respiratory illness, end-stage renal
disease, HIV infection, or AIDS, and with respect to which the
commission identifies populations for which disease management
would be cost-effective.
(b) The child health plan must provide disease management
services or coverage for disease management services in the manner
required by the commission, including:
(1) patient self-management education;
(2) provider education;
(3) evidence-based models and minimum standards of
care;
(4) standardized protocols and participation
criteria; and
(5) physician-directed or physician-supervised care.
(c) The commission shall conduct a study that evaluates the
savings to the state as a result of implementation of the
comprehensive disease management programs described by Subsections
(a) and (b). The commission shall evaluate the clinical outcomes of
children enrolled in a disease management program. The commission
shall report the progress of the study to the governor, lieutenant
governor, and speaker of the house of representatives not later
than December 1, 2004, and the final results of the study not later
than December 1, 2005.
(d) The commission may conduct the study under Subsection
(c) in conjunction with an academic center.
(e) Subsections (c) and (d) and this subsection expire
January 1, 2006.
Added by Acts 2003, 78th Leg., ch. 589, § 1, eff. June 20, 2003.
