The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
  (1) Action--
    (A) In the context of an eligibility or disenrollment determination by HHSC or its designee, action is defined as:
      (i) denial of Children's Health Insurance Program (CHIP) eligibility;
      (ii) disenrollment from CHIP; or
      (iii) the failure of HHSC or its designee to act within 45 days on an applicant's request for CHIP eligibility determination.
    (B) "Action" does not include expiration of a time-limited service.
  (2) Acute care--Preventive care, primary care, and other medical or behavioral health care provided for a condition having a relatively short duration.
  (3) Acute care hospital--A hospital that provides acute care services.
  (4) Adverse determination--A determination by a managed care organization (MCO) that the health care services or dental services furnished, or proposed to be furnished, to a patient are not medically necessary or appropriate.
  (5) Agreement or Contract--The formal, written, and legally enforceable contract and amendments thereto between HHSC and an MCO.
  (6) Alien--A person who is not a native born or naturalized citizen of the United States of America.
  (7) Allowable revenue--All managed care revenue received by the MCO pursuant to the contract during the contract period, including retroactive adjustments made by HHSC. This would include any revenue earned on CHIP managed care funds such as investment income, earned interest, or third party administrator earnings from services to delegated networks.
  (8) Appeal--The formal process by which a member or his or her representative requests a review of the MCO's action.
  (9) Applicant--An individual who applies for health and dental care coverage on behalf of the child. An applicant can only be:
    (A) a child's parent, whether biological or adoptive;
    (B) a child's grandparent, relative or other adult who provides care for the child;
    (C) a minor not living with an adult applying for himself/herself;
    (D) a child's step-parent; or
    (E) a taxpayer who expects to claim the child on a federal income tax return for the taxable year in which CHIP eligibility is requested
  (10) Application--The standardized, written document that an applicant must complete to apply for health and dental care coverage through CHIP.
  (11) Behavioral health service--A covered service for the treatment of mental, emotional, or chemical dependency disorders.
  (12) 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.
  (13) Child--An adoptive, step, or natural child who is under the age of 19.
  (14) Children's Health Insurance Program or CHIP or Program--The Texas State Children's Health Insurance Program established under Title XXI of the federal Social Security Act (42 U.S.C. §§1397aa, et seq.) the Texas Health and Safety Code, Chapters 62 (relating to Child Health Plan For Certain Low-Income Children) and 63 (relating to Health Benefits Plan for Certain Children).
  (15) CHIP Dental Services--The dental services provided through a dental MCO to a CHIP member.
  (16) Claims processing entity--The MCO or its subcontractor that processes claims for CHIP.
  (17) CMS--The Centers for Medicare and Medicaid Services, which is the federal agency responsible for administering Medicare and overseeing state administration of Medicaid and CHIP.
  (18) HHSC--The Texas Health and Human Services Commission.
  (19) Complainant--A member, or a treating provider or other individual designated to act on behalf of the member, who files a complaint.
  (20) Complaint--Any dissatisfaction, expressed by a complainant, orally or in writing, to the MCO, with any aspect of the MCO's operation, including dissatisfaction with plan administration; procedures related to review or appeal of an adverse determination, as set forth in Texas Insurance Code, Chapter 843, Subchapter G (relating to Dispute Resolution); the denial, reduction, or termination of a service for reasons not related to medical necessity; the way a service is provided; or disenrollment decisions. The term does not include misinformation that is resolved promptly by supplying the appropriate information or clearing up the misunderstanding to the satisfaction of the member.
  (21) Cost Sharing--Any enrollment fees or co-payments the member is responsible for paying.
  (22) Covered service--A health care service or a dental service or item that the MCO must arrange to provide and pay for on a member's behalf under the terms of the contract executed between the MCO and HHSC. This includes all covered services and benefits identified in the Texas CHIP State Plan, and all value-added services approved by HHSC.
  (23) Cultural competency--The ability of individuals and systems to provide services effectively to people of various cultures, races, ethnic backgrounds, and religions in a manner that recognizes, values, affirms, and respects the worth of the individuals and protects and preserves their dignity.
  (24) Day--Calendar day, unless otherwise specified.
  (25) Default enrollment--The process established by HHSC to assign a CHIP managed care enrollee to an MCO when the enrollee has not selected an MCO.
  (26) Dental contractor--A dental MCO that is under contract with HHSC for the delivery of dental services.
  (27) Dental home--A provider who has contracted with a dental MCO to serve as a dental home to a member and who is responsible for providing routine preventive, diagnostic, urgent, therapeutic, initial, and primary care to patients, maintaining the continuity of patient care, and initiating referral for care. Provider types that can serve as dental homes are federally qualified health centers and individuals who are general dentists or pediatric dentists.
  (28) Dental managed care organization (dental MCO)--A dental indemnity insurance provider or dental health maintenance organization licensed or approved by the Texas Department of Insurance.
  (29) Dental service--The routine preventive, diagnostic, urgent, therapeutic, initial, and primary care provided to a member and included within the scope of HHSC's agreement with a dental contractor. For purposes of this chapter, "dental service" does not include dental devices for craniofacial anomalies; treatment rendered in a hospital, urgent care center, or ambulatory surgical center setting for craniofacial anomalies; or emergency services provided in a hospital, urgent care center, or ambulatory surgical center setting involving dental trauma. These types of emergency services are treated as health care services in this chapter.
  (30) Designee--A contractor of HHSC authorized to act on behalf of HHSC under this chapter.
  (31) 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.
  (32) Eligible provider--A network provider who provides medical services to a member or a non-network provider who agrees with an MCO to see a member for an agreed-upon rate on a case-by-case basis.
  (33) Emergency behavioral health condition--Any condition, without regard to the nature or cause of the condition, that in the opinion of a prudent layperson possessing an average knowledge of health and medicine:
    (A) requires immediate intervention and/or medical attention without which the client would present an immediate danger to themselves or others; or
    (B) renders the client incapable of controlling, knowing, or understanding the consequences of his or her actions.
  (34) Emergency Medical Condition--A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in:
    (A) placing the patient's health in serious jeopardy;
    (B) serious impairment to bodily functions;
    (C) serious dysfunction of any bodily organ or part;
    (D) serious disfigurement; or
Cont'd...