Partial Settlement Agreement – Texas EPSDT Case to Cover Home-based Services

Executive Summary

This partial settlement agreement in Alberto N. v. Hawkins is regarding home-based services.

The Parties acknowledge that the purpose of this Agreement is to facilitate Defendants? compliance with Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. The Parties further acknowledge that federal law and the terms of this Agreement will govern any future action under this Agreement. The terms of this Agreement apply only to Medicaid-funded services provided to Medicaid beneficiaries under the age of 21 years who have been determined eligible to participate in the Early and Periodic Screening, Diagnosis, and Treatment (?EPSDT?) program. To the extent that this Agreement encompasses categories of Medicaid-funded benefits that are also provided to other Medicaid beneficiaries who have not been determined eligible to participate in the EPSDT program, the Parties acknowledge that nothing in this Agreement changes the type, definition, amount, duration, or scope of services provided to these other Medicaid beneficiaries.
1.1 ?Agency? means the Health and Human Services Commission and, when appropriate, the agency operating the relevant part of the Texas Medical Assistance Program.

1.2 ?Beneficiary? means any individual under the age of 21 years who has been determined eligible to participate in the Early and Periodic Screening, Diagnosis, and Treatment program (currently known as Texas Health Steps), established by the Texas Medical Assistance Program.

1.3 ?Contractor? means the entity with which the Agency contracts to administer prior authorization of the categories of benefits encompassed by this Agreement, pursuant to the requirements of 42 C.F.R. Part 434. Currently, the Contractor for the Texas Medical Assistance program is ACS State Healthcare. 
1.4 ?Day? means a calendar day, unless otherwise noted herein.
1.5 ?DME list? refers to any and all lists of DME the Agency has, or may develop, to expedite the prior authorization or approval process. 
1.6 ?Durable medical equipment (DME)? includes medical supplies, equipment, and appliances, as these terms are used in 42 C.F.R. § 440.70(b)(3) and further defined in 1 TAC § 354.1031(11)-(12). To the extent the Agency defines items of DME or describes the purpose of items of DME in policy, guidelines, and manuals, it will do so consistent with applicable law, the definitions and descriptions generally accepted by health care practitioners, and generally accepted standards of medical practice. The Agency will define items of DME, or describe their purpose, in a manner that does not exclude medically necessary DME. 
1.7 ?Home Health Skilled Nursing services? are nursing services, as described by the Texas Nursing Practice Act and its implementing regulations, that are authorized when a Beneficiary requires nursing services that can be met on a per-visit basis. Home Health
Skilled Nursing services may be provided to meet acute needs or on an on-going basis to meet chronic needs, and may be provided on consecutive days. The Agency will identify the maximum length of a Home Health Skilled Nursing visit and the permissible number of visits per day. Once identified, this temporal component will be incorporated into the definition of ?Home Health Skilled Nursing services.? Until the Agency identifies the temporal component, as an interim measure, they will not deny requests for 28 hours or more per week of Private Duty Nursing services on the basis that the services could be provided through Home Health Skilled Nursing services.

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