Title GV, Government Code

Sec. 532.0403. NOTICE REQUIREMENTS REGARDING COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS. (a) The commission shall ensure that a notice the commission or a Medicaid managed care organization sends to a recipient or Medicaid provider regarding the denial, partia…

Sec. 532.0404. EXTERNAL MEDICAL REVIEW. (a) In this section, "external medical reviewer" means a third-party medical review organization that provides objective, unbiased medical necessity determinations conducted by clinical staff with education and practice in the same or simil…

Sec. 532.0451. HOSPITAL EMERGENCY ROOM USE REDUCTION INITIATIVES. (a) The commission shall develop and implement a comprehensive plan to reduce recipients' use of hospital emergency room services. The plan may include: (1) a pilot program that is designed to assist a program part…

Sec. 532.0452. PHYSICIAN INCENTIVE PROGRAM TO REDUCE HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS. (a) If cost-effective, the executive commissioner by rule shall establish a physician incentive program designed to reduce recipients' use of hospital emergency room serv…

Sec. 532.0453. CONTINUED IMPLEMENTATION OF CERTAIN INTERVENTIONS AND BEST PRACTICES BY PROVIDERS; BIENNIAL REPORT. (a) The commission shall encourage Medicaid providers to continue implementing effective interventions and best practices associated with improvements in the health …

Sec. 532.0454. HEALTH SAVINGS ACCOUNT PILOT PROGRAM. (a) If the commission determines that it is cost-effective and feasible, the commission shall develop and implement a Medicaid health savings account pilot program that is consistent with federal law to: (1) encourage adult rec…

Sec. 532.0455. DURABLE MEDICAL EQUIPMENT REUSE PROGRAM. (a) In this section: (1) "Complex rehabilitation technology equipment": (A) means equipment that is: (i) classified as durable medical equipment under the Medicare program on January 1, 2013; (ii) configured specifically for…

Sec. 532.0501. DEFINITIONS. In this subchapter: (1) "Case management for children and pregnant women program" means the "children and pregnant women program," as defined by Section 540.0702. (2) "Nonmedical health-related needs screening" means a screening performed using the sta…

Sec. 532.0502. MEDICAID MANAGED CARE ORGANIZATION SERVICE COORDINATION BENEFITS NOT AFFECTED. The provision of program services to a recipient does not preempt or otherwise affect a Medicaid managed care organization's obligation to provide service coordination benefits to the re…

Sec. 532.0503. CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM: PROVIDER QUALIFICATIONS. Program services may be provided only by a provider who completes the standardized case management training required by the commission under Section 532.0504 and who is: (1) an advanc…

Sec. 532.0504. CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM: PROVIDER TRAINING. The commission shall require that each provider of program services complete training prescribed by the commission. The training must be trauma-informed and include instruction on: (1) soci…

Sec. 532.0505. INITIAL MEDICAL AND NONMEDICAL HEALTH-RELATED SCREENINGS OF CERTAIN RECIPIENTS. (a) A Medicaid managed care organization that provides health care services to a pregnant woman under the STAR Medicaid managed care program shall conduct an initial health needs screen…

Sec. 532.0506. SCREENING AND PROGRAM SERVICES OPTIONAL. A Medicaid managed care organization providing screenings under Section 532.0505 must inform each pregnant woman who is referred for program services or for whom screening is conducted under that section that: (1) the woman …