Sec. 533.001. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services Commission or an agency operating part of the state Medicaid managed care program, as appropriate.
(2) "Executive commissioner" means the executive commissioner of the Health and Human Services Commission.
(3) "Health and human services agencies" has the meaning assigned by Section 531.001.
(4) "Managed care organization" means a person who is authorized or otherwise permitted by law to arrange for or provide a managed care plan.
(5) "Managed care plan" means a plan under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services. A part of the plan must consist of arranging for or providing health care services as distinguished from indemnification against the cost of those services on a prepaid basis through insurance or otherwise. The term includes a primary care case management provider network. The term does not include a plan that indemnifies a person for the cost of health care services through insurance.
(6) "Recipient" means a recipient of Medicaid.
(7) "Health care service region" or "region" means a Medicaid managed care service area as delineated by the commission.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.209, eff. April 2, 2015.
Structure Texas Statutes
Subtitle I - Health and Human Services
Chapter 533 - Medicaid Managed Care Program
Subchapter A. General Provisions
Section 533.0025. Delivery of Services
Section 533.00253. Star Kids Medicaid Managed Care Program
Section 533.00254. Star Kids Managed Care Advisory Committee
Section 533.00255. Behavioral Health and Physical Health Services Network
Section 533.002551. Monitoring of Compliance With Behavioral Health Integration
Section 533.002553. Behavioral Health Services Provided Through Third Party or Subsidiary
Section 533.00256. Managed Care Clinical Improvement Program
Section 533.00258. Nonmedical Transportation Services Under Medicaid Managed Care Program
Section 533.0027. Procedures to Ensure Certain Recipients Are Enrolled in Same Managed Care Plan
Section 533.0028. Evaluation of Certain Star + Plus Medicaid Managed Care Program Services
Section 533.00281. Utilization Review for Star + Plus Medicaid Managed Care Organizations
Section 533.00282. Utilization Review and Prior Authorization Procedures
Section 533.002821. Prior Authorization Procedures for Hospitalized Recipient
Section 533.00283. Annual Review of Prior Authorization Requirements
Section 533.002841. Maximum Period for Prior Authorization Decision; Access to Care
Section 533.0029. Promotion and Principles of Patient-Centered Medical Homes for Recipients
Section 533.003. Considerations in Awarding Contracts
Section 533.0031. Medicaid Managed Care Plan Accreditation
Section 533.0035. Certification by Commission
Section 533.004. Mandatory Contracts
Section 533.005. Required Contract Provisions
Section 533.0051. Performance Measures and Incentives for Value-Based Contracts
Section 533.00511. Quality-Based Enrollment Incentive Program for Managed Care Organizations
Section 533.00515. Medication Therapy Management
Section 533.0052. Star Health Program: Trauma-Informed Care Training
Section 533.00521. Star Health Program: Health Care for Foster Children
Section 533.00522. Star Health Program: Mental Health Providers
Section 533.0053. Compliance With Texas Health Steps
Section 533.00531. Medicaid Benefits for Certain Children Formerly in Foster Care
Section 533.0054. Health Screening Requirements for Enrollee Under Star Health Program
Section 533.0055. Provider Protection Plan
Section 533.0056. Star Health Program: Notification of Placement Change
Section 533.006. Provider Networks
Section 533.0061. Provider Access Standards; Report
Section 533.0062. Penalties and Other Remedies for Failure to Comply With Provider Access Standards
Section 533.0063. Provider Network Directories
Section 533.0064. Expedited Credentialing Process for Certain Providers
Section 533.0065. Frequency of Provider Credentialing
Section 533.0066. Provider Incentives
Section 533.0067. Eye Health Care Service Providers
Section 533.007. Contract Compliance
Section 533.0071. Administration of Contracts
Section 533.0072. Internet Posting of Sanctions Imposed for Contractual Violations
Section 533.0073. Medical Director Qualifications
Section 533.0075. Recipient Enrollment
Section 533.00751. Recipient Directory
Section 533.0076. Limitations on Recipient Disenrollment
Section 533.0077. Statewide Effort to Promote Maintenance of Eligibility
Section 533.008. Marketing Guidelines
Section 533.009. Special Disease Management
Section 533.010. Special Protocols
Section 533.011. Public Notice
Section 533.012. Information for Fraud Control
Section 533.013. Premium Payment Rate Determination; Review and Comment
Section 533.0131. Use of Encounter Data in Determining Premium Payment Rates
Section 533.01315. Reimbursement for Services Provided Outside of Regular Business Hours
Section 533.014. Profit Sharing
Section 533.015. Coordination of External Oversight Activities
Section 533.016. Provider Reporting of Encounter Data
Section 533.0161. Monitoring of Psychotropic Drug Prescriptions for Certain Children
Section 533.017. Qualifications of Certifier of Encounter Data
Section 533.018. Certification of Encounter Data
Section 533.019. Value-Added Services
Section 533.020. Managed Care Organizations: Fiscal Solvency and Complaint System Guidelines
Section 533.038. Coordination of Benefits; Continuity of Specialty Care for Certain Recipients
Section 533.039. Delivery of Benefits Using Telecommunications and Information Technology