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Revision 21-5; Effective April 22, 2021
Abuse — The infliction of injury, unreasonable confinement, intimidations, punishment, mental anguish, sexual abuse or exploitation of an individual.
Types of abuse include:
- Physical abuse (a physical act by an individual that may cause physical injury to another individual).
- Psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual).
- Sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual exploitation, sexual harassment or inappropriate or unwanted touching of an individual by another).
- Verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or humiliate an individual).
Action — An action is defined as the:
- denial or limited authorization of a requested Medicaid service, including the type or level of service;
- reduction, suspension or termination of a previously authorized service;
- failure to provide services in a timely manner;
- denial in whole or in part of payment for a service; or
- failure of a managed care organization (MCO) to act within the time frames set forth by the Texas Health and Human Services Commission (HHSC) and state and federal law.
An "action" does not include expiration of a time-limited service.
Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.
Acute Care — Preventive care, primary care, and other medical care provided under the direction of a provider for a condition having a relatively short duration.
Adult — A person 18 years of age or older, or an emancipated minor.
Adverse Action — A termination, suspension or reduction of Medicaid eligibility or covered services.
Agency Option (AO) — A service delivery option under which the provider is responsible for managing the day-to-day activities of the attendant and all business details.
Appeal — A request for a state fair hearing concerning an HHSC action.
Applicant — A person who has applied for Medicaid benefits or has been assessed for the Medically Dependent Children Program (MDCP) or STAR+PLUS Home and Community Based Services (HCBS) program.
Authorized Representative (AR) — For medical programs, the individual designated with written consent by an applicant, member or recipient to:
- sign an application on the applicant’s behalf;
- complete and submit a renewal form;
- receive copies of the applicant’s/individual’s notices and other communications from the agency; and
- act on behalf of the applicant/individual in all other matters with the agency.
Behavioral Health Service — A covered service for the treatment of mental, emotional or substance use disorders.
Business Day — Any day except a Saturday, Sunday, or legal holiday listed in the Texas Government Code, §662.021.
Capitated Service — A benefit available to members under the Texas Medicaid program for which an MCO is responsible for payment.
Capitation Rate — A fixed predetermined fee paid by HHSC to the MCO each month, in accordance with the contract, for each enrolled member in exchange for which the MCO arranges for, or provides, a defined set of covered services to the member, regardless of the amount of covered services used by the enrolled member.
Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.
Centers for Medicare and Medicaid Services (CMS) — The federal agency that administers Medicare and Medicaid.
Client — Any Medicaid-eligible recipient.
Code of Federal Regulations (CFR) — The codified federal regulatory law that governs most federal programs, including Medicaid.
Community Care for Aged and Disabled (CCAD) — A group of services purchased by the Texas Health and Human Services Commission (HHSC) in response to recommendations of the Texas Legislature. CCAD provides services in a person's own home or community for aged or disabled Texans who are not self-sufficient, and who might otherwise be subject to premature institutionalization or to abuse, neglect or exploitation.
Community Care Services Eligibility (CCSE) — Community Care for Aged and Disabled (CCAD) staff.
Community First Choice (CFC) Option — Personal assistance services (PAS); habilitation services focused on the acquisition, maintenance and enhancement of skills; emergency response services; and support management provided in a community setting for eligible Medicaid members in the Medically Dependent Children Program (MDCP) and STAR+PLUS Home and Community Based Services (HCBS) program who have received an institutional level of care (LOC) determination.
Community Living Assistance and Support Services (CLASS) — A non-capitated 1915(c) waiver which provides home and community-based services to people with intellectual or developmental disabilities, other than intellectual disability, as an alternative to residing in an intermediate care facility.
Complaint — Any dissatisfaction expressed by a complainant, orally or in writing, to the MCO about any matter related to the MCO other than an action. Subjects for complaints may include:
- the quality of care of services provided;
- aspects of interpersonal relationships such as rudeness of a provider or employee; and
- failure to respect the member's rights.
Comprehensive Care Program (CCP) — A package of Medicaid services available to clients based on medical necessity that goes beyond regular Medicaid services for all ages and is part of the Texas Health Steps (THSteps) benefit for clients under age 21.
Consumer Directed Services (CDS) Employer — A member or legally authorized representative (LAR), parent, or court appointed guardian who chooses to participate in the CDS option and therefore is responsible for hiring and retaining service providers to deliver program services.
Consumer Directed Services (CDS) Option — A service delivery option in which a member, AR or legally authorized representative (LAR) employs and retains service providers and directs the delivery of STAR+PLUS HCBS program PAS and respite services. A member participating in the CDS option is required to use a financial management services agency (FMSA) chosen by the member, AR or LAR to provide financial management services.
Continued Benefits — Continuing or restoring benefits to the level authorized immediately before the notice of adverse action.
Co-payment — The amount of personal income a person must pay toward the cost of his or her care. Co-payment was formerly known as applied income.
Covered services — Unless a service or item is specifically excluded under the terms of the Medicaid state plan, a federal waiver, a managed care services contract or an amendment to any of these, the phrase "covered services" means all health care, long term services and supports, or dental services or items that the MCO must arrange to provide and pay on a member's behalf under the terms of the contract executed between the MCO and HHSC, including:
- all services or items comprising "medical assistance" as defined in §32.003 of the Human Resources Code; and
- all value-added services under such contract.
Day — A calendar day, unless otherwise specified in the text. A calendar day includes weekends and legal holidays.
Day Activity and Health Services (DAHS) — Licensed DAHS facilities provide daytime services, up to 10 hours per day, Monday through Friday, to people who live in the community. Services address physical, mental, medical and social needs. People may attend up to five days per week, depending on their eligibility.
Deaf Blind with Multiple Disabilities (DBMD) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals who are deaf and blind and have a third disability.
Denial — Closure of an application with a finding of ineligibility.
Designated Representative (DR) — A willing adult appointed by the CDS employer to assist with, or perform, the employer's required responsibilities to the extent approved by the employer. A DR, usually a family member, is not a paid service provider and is at least age 18.
Disability — A physical or mental impairment that substantially limits one or more of an individual's major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, socializing or working.
Dual Eligible — A Medicaid recipient who is also eligible for Medicare.
Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in an individual's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — A federal Medicaid benefit for individuals under 21 years (called Texas Health Steps in Texas).
Eligibility Date — The first date all eligibility criteria are met.
Emergency Response Services (ERS) — Services provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the individual can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps to ensure that the appropriate person or service provider responds to an alarm call from an individual.
Emergency Service — A covered inpatient and outpatient service, furnished by a network provider or out-of-network provider that is qualified to furnish such service, that is needed to evaluate or stabilize an emergency medical condition and/or an emergency behavioral health condition. For health care MCOs, the term "emergency service" includes post-stabilization care services.
Enrollment — The process by which an individual determined to be eligible for Medicaid is enrolled in a Medicaid MCO serving the service area in which the individual resides.
Enrollment Broker — A contracted entity that assists individuals in selecting and enrolling with an MCO. If requested, the enrollment broker also may assist the member in choosing a primary care physician (PCP).
Exploitation — An act of depriving, defrauding or otherwise obtaining the personal property of an individual by taking advantage of an individual's disability or impairment.
Fair Hearing — An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by HHSC.
Family Member — A person who is related by blood, affinity or law to an individual.
Federal Waiver — Any waiver permitted under federal law and approved by CMS that allows states to implement Medicaid managed care.
Financial Management Services (FMS) — Services delivered by the FMSA to the member, LAR or AR who chooses the CDS option, such as orientation, training, support, assistance with and approval of budgets, and processing payroll and payables on behalf of the member, LAR or AR.
Financial Management Services Agency (FMSA) — An agency that contracts with the MCO to provide FMS to members who choose the CDS option.
Functional Necessity — A member's need for services and supports with ADLs or instrumental activities of daily living (IADLs) to be healthy and safe in the most integrated setting possible. This determination is based on the results of a functional assessment.
Guardian — A person appointed as a guardian of the estate or of the person by a court.
Habilitation — Acquisition, maintenance and enhancement of skills necessary for the individual to accomplish ADLs, IADLs and health-related tasks based on the individual's person-centered service plan.
Health Information — Any information, whether oral or recorded in any form or medium, that:
- is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
- relates to the past, present, or future physical or mental health or condition of any individual, the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual.
Health Maintenance Activity (HMA) — A task that may be exempt from delegation based on the registered nurse assessment that enables the member to remain in an independent living environment, and goes beyond activities of daily living because of the higher skill level required to perform.
Health Insurance Portability and Accountability Act (HIPAA) — A federal law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.
Home and Community-based Services (HCS) — A non-capitated 1915(c) waiver which provides home and community-based services to individuals with intellectual or developmental disabilities as cost-effective alternatives to institutional care.
Income — Any item a person receives in cash or in-kind that can be used to meet his or her need for food or shelter. For purposes of determining MEPD financial eligibility, income includes the receipt of any item that can be applied, either directly or by sale or conversion, to meet the basic needs of food or shelter.
Individual — Any person who is not an MDCP or STAR+PLUS HCBS program applicant or member.
Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.
Individual Service Plan (ISP) — An individualized and person-centered plan in which a member enrolled in the STAR+PLUS HCBS program operated by the MCO, with assistance as needed, identifies and documents his or her preferences, strengths, and health and wellness needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The ISP is supported by the results of the member's program-specific assessment and must meet the requirements of 42 CFR §441.301.
Individual Service Plan (ISP) Service Tracking Tool — This tool is developed at least annually by the member, MCO and family members to document necessary MDCP services determined by the member’s team and the budget associated with delivering the services. The total cost of the member’s budget provided on this tool must be below the determined cost limit. This is also known as Form 2604.
Institutional Care — Long-term nursing care, treatment or services received in a Medicaid-certified long-term care facility.
Institutional Setting — A living arrangement in which a person applying for, or receiving, Medicaid lives in a Medicaid-certified long-term care facility or receives services under an HCBS waiver program. Formerly known as a vendor living arrangement.
Instrumental Activities of Daily Living (IADLs) — Activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, doing laundry and using a telephone.
Intellectual and Developmental Disability (IDD) — A disability with onset during the developmental period that includes limitations in both intellectual and adaptive functioning, which covers many everyday conceptual, social and practical skills. IDD can begin at any time, up to age 22. It usually lasts throughout a person's lifetime.
Interdisciplinary Team (IDT) — All individuals/entities involved in planning the member’s plan of care (POC). This typically includes the member, member’s AR, service coordinator and primary care physician, etc.
Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) — A Medicaid-certified facility that provides care in a 24-hour specialized residential setting for individuals with an intellectual disability or related conditions. An ICF/IID includes a state supported living center and a state center.
Interest List (IL) — A list of people who have contacted HHSC and expressed an interest in receiving waiver services, but who have not applied for, or been determined eligible for, services.
Legal Holiday — A legal holiday, including national and state holidays, as defined in the Texas Government Code, §662.003.
Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of a member, including a parent of a minor, guardian of a minor, managing conservator of a minor or the guardian of an adult, as defined by state or federal law, including Texas Occupations Code §151.002(6), Texas Health and Safety Code §166.164, and Texas Estates Code §752.
Level of Care (LOC) — The type of care a person is eligible to receive in an ICF/IID based upon an assessment of the person's need for care.
Local Intellectual and Developmental Disability Authorities (LIDDAs) — Authorities that serve as the point of entry for publicly funded IDD programs, whether the program is provided by a public or private entity. LIDDAs:
- provide or contract to provide an array of services and supports for persons with IDD;
- are responsible for enrolling eligible individuals into the following Medicaid programs:
- ICF/IID, which includes state supported living centers;
- Texas Home Living (TxHmL); and
- are responsible for permanency planning for consumers under 22 years of age who live in an ICF/IID, state supported living center or a residential setting of the HCS Program.
Long Term Services and Supports (LTSS) — A service provided to a qualified member in his or her home or other community-based setting necessary to allow the member to remain in the most integrated setting possible; and to assist members in living in the community as opposed to an institutionalized setting. LTSS includes services provided under the Medicaid state plan, as well as services available to persons who qualify for STAR+PLUS HCBS or Medicaid 1915(c) waiver services. LTSS available through an MCO in STAR+PLUS, STAR Health and STAR Kids varies by program model.
Managed Care Compliance & Operations (MCCO) — A unit within the Medicaid/Children's Health Insurance Program (CHIP) Division of HHSC that is responsible for administrative and operational aspects of administering the Medicaid managed care programs.
Managed Care Organization (MCO) — An established health maintenance organization or Approved Non-Profit Health Corporation (ANHC) that arranges for the delivery of health care services. In accordance with §843 of the Texas Insurance Code, it is currently licensed as such in the state of Texas.
Medicaid — A program administered by the federal CMS, and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.
Medicaid Eligible — A person who is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHSC to be financially eligible for Medicaid.
Medicaid Estate Recovery Program (MERP) — A program that requires HHSC, as the state Medicaid agency, to recover the costs of Medicaid long-term care benefits received by certain Medicaid recipients. For further information, see the MERP website at https://hhs.texas.gov/laws-regulations/legal-information/medicaid-estate-recovery-program/merp-rules-statutes-forms.
Medicaid for the Elderly and People with Disabilities (MEPD) — A public assistance program providing medical assistance, institutional and community-based health-related care, and Medicare cost-sharing assistance for the elderly and people with disabilities. MEPD does not provide cash assistance. Examples of MEPD services and programs are:
- primary home care services;
- HCBS waiver programs, which provide community-based care as an alternative to institutional care;
- care in a Medicaid-certified long-term care facility;
- the Program of All-Inclusive Care for the Elderly (PACE);
- Medicaid Buy-In programs; and
- Medicare Savings Programs.
Medical Assistance Only (MAO) — A person who qualifies financially and functionally for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits, as defined in Title 1 Texas Administrative Code (TAC) §358, §360 and §361 (relating to MEPD, Medicaid Buy-In Program and Medicaid Buy-In for Children Program).
Medical Necessity (MN) — The medical criteria a person must meet for admission to a Texas nursing facility (NF), as defined in Title 26 TAC §554.2401.
Medically Dependent Children Program (MDCP) — A §1915(c) Medicaid waiver program that provides LTSS HCS to help the primary caregiver care for individuals with a nursing facility level of need and their families in the community.
Medicare — The federal health insurance program for people age 65 or older, certain younger people with disabilities and people with end-stage renal disease (ESRD).
Member — An individual who is enrolled in, and receiving services through, a STAR Kids or STAR+PLUS MCO.
Money Follows the Person (MFP) — A process whereby the funds used for payment of institutional care follows the person when transitioning; used when a member in a Medicaid-certified NF requests to move to the community is Medicaid-eligible and approved for the MDCP or STAR+PLUS HCBS program before leaving the NF.
Mutually Exclusive Services — Two or more services that may not be authorized for the same individual during the same time period.
Neglect — The failure to provide an individual the reasonable care required, including but not limited to:
- medical care;
- personal hygiene; and
- protection from harm.
Non-capitated Service — A benefit available to members under the Texas Medicaid program for which an MCO is not responsible for payment.
Non-institutional Setting — A living arrangement in which a person applying for, or receiving, Medicaid does not live in a long-term care facility or receive services under an HCBS waiver program. Formerly known as a non-vendor living arrangement.
Nursing Facility (NF) — A residential institution that primarily provides:
- skilled nursing care and related services for residents who require medical or nursing care;
- rehabilitation services for the rehabilitation of injured, disabled or sick people; or
- health-related care and services, on a regular basis, to individuals who, because of their mental or physical condition, require care and services above the level of room and board, which can be made available to them only through institutional facilities.
Person-centered Planning — A documented service planning process that:
- includes people chosen by the individual;
- is directed by the individual to the maximum extent possible;
- enables the individual to make choices and decisions;
- is timely and occurs at times and locations convenient to the individual;
- reflects cultural considerations of the individual;
- includes strategies for solving conflict or disagreement within the process;
- offers choices to the individual regarding the services and supports they receive and from whom;
- includes a method for the individual to require updates to the plan; and
- records alternative settings that were considered by the individual.
Personal Assistance Services (PAS) — A range of services provided by one or more persons designed to assist an individual with a disability to perform daily living activities on or off the job that the individual would typically perform without assistance if the individual did not have a disability.
Personal Care Services (PCS) — Services that include bathing, dressing, preparing meals, feeding, grooming, taking self-administered medication, toileting, ambulation, and assistance with other personal needs or maintenance.
Personal Identifiable Information (PII) — Information that is a subset of health information, including demographic information collected from an individual, and:
- is created or received by a health care provider, health plan, employer or health care clearinghouse; and
- relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
- that identifies the individual; or
- with respect to which there is a reasonable basis to believe the information can be used to identify the individual.
Plan of Care (POC) — A care plan the MCO develops for its members that includes acute care and LTSS. The POC is not the same as the ISP.
Primary care provider (PCP) — A physician or other provider who has agreed with the health care MCO to provide a medical home to members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care and initiating referral for care.
Program Support Unit (PSU) Staff — An HHSC unit of staff who support and handle certain aspects of the STAR Kids program and STAR+PLUS program.
Protected Health Information (PHI) — The HIPAA Privacy Rule provides federal protections for PHI held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.
Provider — An appropriately credentialed and licensed individual, facility, agency, institution, organization or other entity, and its employees and subcontractors, that has a contract with the MCO for the delivery of covered services to the MCO’s members.
Qualified Income Trust (QIT) (a.k.a. Miller Trust) — An irrevocable trust specially designed to legally divert an individual or married couple’s income into a trust resulting in the income being excluded for purposes of determining eligibility for nursing home (“institutional”) Medicaid and §1915(c) home and community-based waiver services.
Respite Care Services — Direct care services needed because of an individual's disability that provide a primary caregiver temporary relief from caregiving activities when the primary caregiver would usually perform such activities.
Responsible Adult — An adult, as defined by Texas Family Code §101.003, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for a participant. Responsible adults include biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage. If the participant is age 18 years or older, the responsible adult must be the participant's managing conservator or legal guardian.
Responsible Party — An individual who:
- assists and/or represents an applicant or member in the application or eligibility redetermination process; or
- is familiar with the applicant or member and his or her financial affairs and functional condition.
Service Area — The counties included in any HHSC-defined service area as applicable to each MCO.
Service Coordinator — The MCO staff person with primary responsibility for providing service coordination and care management to STAR+PLUS members.
Service Responsibility Option (SRO) — A service delivery option that empowers the member to manage most day-to-day activities. This includes supervision of the individual providing PAS. The member decides how services are provided. It leaves the business details to a provider of the member's choosing.
Social Security Administration (SSA) — A federal agency that administers the social insurance programs in the U.S and authorizes Medicaid and waiver services.
Suspension — A temporary cessation of any waiver service without the loss of Medicaid or program eligibility.
State of Texas Access Reform (STAR) — STAR managed care program that operates under a federal waiver and primarily provides, arranges for, and coordinates preventive, primary, acute care, and pharmacy services for low-income families, children and pregnant women.
STAR Health — The managed care program that operates under the Medicaid state plan and primarily serves:
- children and youth in Texas Department of Family and Protective Services (DFPS) conservatorship;
- young adults who voluntarily agree to continue in a foster care placement (if the state as conservator elects to place the child in managed care); and
- young adults who are eligible for Medicaid as a result of their former foster care status through the month of their 21st birthday.
STAR Kids — Authority granted to the state of Texas to allow delivery of LTSS and acute care services to children and young adults with disabilities under the age of 21. The STAR Kids program assists members to live in the community in lieu of an NF.
STAR+PLUS Home and Community Based Services (HCBS) program — Authority granted to the state of Texas to allow delivery of community-based LTSS to adults with disabilities over the age of 21. The STAR+PLUS program assists members to live in the community in lieu of an NF.
STAR+PLUS program — The STAR+PLUS Medicaid managed care program in which HHSC contracts with MCOs to provide, arrange and coordinate preventive, primary, acute and long term care covered services to adult persons with disabilities and elderly persons age 65 and over who qualify for Medicaid through the SSI program and/or the MAO program. Children under age 21, who qualify for Medicaid through the SSI program, may voluntarily participate in the STAR+PLUS program. The STAR+PLUS program is the umbrella designation that includes both the STAR+PLUS services and STAR+PLUS HCBS program.
STAR+PLUS Program Specialist — The staff person responsible, along with MCCO, for STAR+PLUS policy development.
State Plan — The agreement between the CMS and HHSC regarding the operation of the Texas Medicaid program, in accordance with the requirements of Title XIX of the Social Security Act.
Supplemental Security Income (SSI) — A federal income supplement program funded by general tax revenues (not Social Security taxes) designed to help aged, blind and disabled people with little or no income by providing cash to meet basic needs for food, clothing and shelter.
Support Advisor — An employee who provides support consultation to an employer, DR or member receiving services through the CDS Option.
Support Consultation — An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.
Supported Employment (SE) — Services that assist the member with sustaining competitive employment or self-employment.
Transition Assistance Services (TAS) Agency — An agency that provides a one-time service to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community.
Termination — Closure of an ongoing case due to a finding of ineligibility. Texas Administrative Code (TAC) — A compilation of all the state rules in Texas that implement state programs and services.
Texas Health and Human Services Commission (HHSC) — Administrative agency within the executive department of the state of Texas established under Texas Government Code §531. HHSC is the single state agency charged with administration and oversight of the Texas Medicaid program, including Medicaid managed care.
Texas Home Living (TxHmL) — The Texas Home Living Program, operated by HHSC and approved by CMS in accordance with §1915(c) of the Social Security Act, that provides community-based services and supports to eligible individuals who live in their own homes or in their family homes.
Texas Medicaid & Healthcare Partnership (TMHP) — The Texas contractor administering Medicaid provider enrollment and fee-for-service (FFS) claims processing. TMHP is responsible for processing Medical Necessity and Level of Care (MN/LOC) Assessments for Medicaid waiver programs.
Third-Party Resource (TPR) — Any individual, entity or program that is, or may be, liable to pay for, or provide, any medical assistance or supports to a recipient under the approved Medicaid state plan, or as part of their caregiving arrangement without pay.
Texas Health Steps (THSteps) — The EPSDT benefit in Texas.
Texas Health Steps-Comprehensive Care Program (THSteps-CCP) — THSteps is also known as the EPSDT service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for individuals from birth through age 20. THSteps is dedicated to:
- expanding recipient awareness of existing medical, dental and case management services through outreach and informing efforts; and
- recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and case management services.
TxMedCentral — A secure internet bulletin board the state and MCOs use to share PII and PHI.
Unlicensed Assistive Person (UAP) — A paraprofessional who assists individuals with physical disabilities, mental impairments, and other health care needs with their ADLs, and provides bedside care. A UAP may perform nursing tasks only in specific situations, as governed by the Title 22 TAC §224 and Title 22 TAC §225.
Upgrade — An existing STAR+PLUS member who requests STAR+PLUS HCBS program services, or if the MCO determines the member would benefit from the STAR+PLUS HCBS program and is granted services after meeting waiver eligibility criteria.
Utilization Review (UR) — A formal assessment of the medical necessity, efficiency or appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.
Value-added Service (VAS) — A service provided by an MCO that is not "medical assistance," as defined by §32.003 of the Texas Human Resources Code.