2000, Program Authorization, Services and Definitions

Body

Revision 20-0; Effective December 18, 2020

 

2100 Program Authorization and Services

Revision 20-0; Effective December 18, 2020

 

Purpose of the Program

The Epilepsy Program provides comprehensive outpatient care (diagnosis and treatment of epilepsy; management for continuity of care; integration of personal, social and vocational support services into the treatment plan; and epilepsy education) to eligible persons who have epilepsy and/or seizure-like symptoms through subrecipient providers in selected service areas in Texas.

 

Legislative and Statutory Authorization

The enacting legislation for the Epilepsy Program is House Bill 1685, 67th Regular Session, 1981. The Texas Health and Safety Code, Chapter 40, is the statutory authority for the Epilepsy Program administered by Texas Health and Human Services Commission (HHSC).

 

Rules

The state rules for epilepsy services in Texas can be found in the Texas Administrative Code (TAC), Title 25, Part 1, Chapter 37, Subchapter K.

 

Funding Sources

Epilepsy Program services are funded by State General Revenue. HHSC epilepsy funds are allocated through a competitive application process, after which selected applicants negotiate contracts with HHSC to provide services. A variety of types of organizations provide Epilepsy Program services, such as medical schools, hospital districts, private nonprofit agencies and community-based clinics. Providers must enroll with the Texas Medicaid & Healthcare Partnership (TMHP) to provide the HHSC Epilepsy Program.

 

2200 Definitions

Revision 20-0; Effective December 18, 2020

 

The following words and terms, when used in this manual, have the following meanings:

Barrier to Care – A factor that hinders a person from receiving health care (e.g., proximity or distance, lack of transportation, documentation requirements, co-payment amount, etc.)

Caretaker – An adult who is present in the home and supervises and cares for a child.

Client – An individual who has been screened, determined to be eligible for services and has successfully completed the eligibility process. “Client” and “patient” may be used interchangeably throughout this policy manual.

Contractor – Any entity that Texas Health and Human Services Commission has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who actually provides the services.

Co-Payment (Co-pay) – Monies collected directly from clients for services. The amount collected each month should be deducted from Form 4116, Authorization for Expenditures, and is considered program income.

Diagnosis – The practitioner’s main tool in diagnosing epilepsy is a careful medical history with as much information as possible about what the seizures looked like and what happened just before they began. The practitioner will also perform a thorough physical exam and may require microscopic (i.e., culture), chemical (i.e., blood tests), EEG and/or radiological examinations (CAT, MRI, etc.).

Eligibility Date – Date the contractor determines an individual to be eligible for the program. The eligibility expiration date will be 12 months after the eligibility date.

Family Composition/Household – A person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person.

Federal Poverty Level (FPL) – The set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Public assistance programs, such as Medicaid, define eligibility income limits as some percentage of FPL.

Fiscal Year (FY) – State fiscal year from September 1 through August 31 of each year.

Health and Human Services Commission (HHSC) – State agency with administration and oversight responsibilities for designated Health and Human Services agencies.

Laboratory (Lab) – Facility that measures or examines materials derived from the human body for the purpose of providing information on diagnosis, monitoring prevention or treatment of disease.

Laboratory, X-Ray or other Appropriate Diagnostic Services – Studies or tests ordered by the client’s health care practitioner(s) (e.g., physicians and mid-level providers) to evaluate an individual’s health status for diagnostic purposes.

Managing Conservator – A person designated by a court to have daily legal responsibility for a child.

Medicaid – Title XIX of the Social Security Act; reimburses for health care services delivered to low-income clients who meet eligibility guidelines.

Minor – In Texas, a person under 18 years of age who has never been married and never been declared an adult by a court (emancipated). See Texas Family Code Sections 101.003, 31.001-31.007, 32.003-004, 32.202. In this manual, “minor” and “child” may be used interchangeably.

Outreach – Activities conducted with the purpose of informing and educating the community about services and increasing the number of program participants.

Patient – An individual who is eligible to receive medical care, treatment or services. “Client” and “patient” may be used interchangeably in this manual.

Payer Source – Programs, benefits or insurance that pays for the service provided.

Program Income – Monies collected directly by the contractor/subcontractor/provider for services provided under the contract award (i.e., third-party reimbursements, such as Title XIX, private insurance and patient co-pay fees). Program income also includes client donations.

Provider – An individual clinician or group of clinicians who provide services.

Recertification – The process of rescreening and determining eligibility for the next year.

Referral – The process of directing or redirecting (as a medical case or a patient) to an appropriate specialist or agency for definitive treatment; or direct to a source for help or information.

Service – Any client encounter at a facility that results in the client having a medical or health-related need met.

Telehealth – Health care services delivered by a health professional to a patient at a different physical location than the health professional, using telecommunications or information technology.

Texas Resident – An individual who resides within the geographic boundaries of the state.

Treatment – Any specific procedure used for the cure or the improvement of a disease or pathological condition.

Unduplicated Client – Clients are counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive (e.g., one client seen four times during the year is counted as one unduplicated client.)