Section 363.101 - Basic and Optional Services(a) Except as specified in the Health and Human Services Commission-established service exclusions and limitations, counties are required to provide the following basic health care services to eligible households by reimbursing providers of services who meet the requirements of this chapter and the responsible county. (1) Inpatient hospital services. Services must be medically necessary and:(A) provided in an acute care hospital;(B) provided to hospital inpatients;(C) provided by or under the direction of a physician; and(D) provided for the care and treatment of patients.(2) Outpatient hospital services. Services must be medically necessary and:(A) provided in an acute care hospital or hospital-based ambulatory surgical center;(B) provided to hospital outpatients;(C) provided by or under the direction of a physician; and(D) are diagnostic, therapeutic, or rehabilitative.(3) Physician services. Services must be medically necessary and provided by a physician in the doctor's office, a hospital, a skilled nursing facility, or elsewhere.(4) Up to three prescriptions for drugs per recipient per month. New and refilled prescriptions count equally toward this total prescription limit. Drugs must be prescribed by a physician or other practitioner within the scope of practice under law. The quantity of drugs prescribed depends on the prescribing practice of the physician or other practitioner and the needs of the patient.(5) Skilled nursing facility services (SNF). Services must be medically necessary, ordered by a physician, and provided in a SNF that provides daily services on an inpatient basis.(6) Rural health clinic services. Rural health clinic services must be provided in a rural health clinic by a physician, a physician assistant (PA), an advanced practice registered nurse (APRN) licensed by the Texas Board of Nursing, such as a certified nurse practitioner, a certified nurse midwife, or other specialized nurse practitioner.(7) Family planning services. These are preventive health and medical services that assist an individual in controlling fertility and achieving optimal reproductive and general health.(8) Laboratory and x-ray services. These are technical laboratory and radiological services ordered and provided by, or under the direction of, a physician in an office or a similar facility other than a hospital outpatient department or clinic.(9) Immunizations. These are given when appropriate.(10) Medical screening services. These medical services include blood pressure, blood sugar, and cholesterol screening.(11) Annual physical examinations. These are examinations provided once per calendar year by a physician or a PA. Associated testing, such as mammograms, can be covered with a physician's referral. These services may also be provided by an APRN if the services are within the scope of practice of the APRN in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(b) The following services are optional health care services. (1) Ambulatory surgical center (ASC) services. These services must be provided in a freestanding ASC, and are limited to items and services provided in reference to an ambulatory surgical procedure, including those services on the Center for Medicare & Medicaid Services-approved list and selected Medicaid-only procedures.(2) Federally Qualified Health Center (FQHC) services. These services must be provided in an FQHC by a physician, a PA, an APRN, a clinical psychologist, or a clinical social worker.(3) PA services. These services must be medically necessary and provided by a PA under the direction of a physician and may be billed by and paid to the supervising physician.(4) APRN services. These services must be provided by an APRN licensed by the Texas Board of Nursing as a certified nurse practitioner, a clinical nurse specialist, a certified nurse midwife, or a certified registered nurse anesthetist. APRN services must be medically necessary, provided within the scope of practice of an APRN, and covered in the Texas Medicaid Program.(5) Counseling services. Psychotherapy services must be medically necessary based on a physician referral, and provided by a licensed professional counselor, a licensed master social worker-advanced clinical practitioner, a licensed marriage family therapist, or a doctorate-level psychologist. These services may also be provided based on an APRN referral if the referral is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(6) Diabetic medical supplies and equipment. These supplies and equipment must be medically necessary and prescribed by a physician. The county may require the supplier to receive prior authorization. Items covered are lancets, alcohol prep pads, syringes, test strips, Humulin pens, and glucometers. These supplies and equipment may also be prescribed by an APRN if this is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(7) Colostomy medical supplies and equipment. These supplies and equipment must be medically necessary and prescribed by a physician. The county may require the supplier to receive prior authorization. Items covered are colostomy bags/pouches; cleansing irrigation kits, paste, or powder; and skin barriers with flange (wafers). These supplies and equipment may also be prescribed by an APRN if this is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(8) Durable medical equipment. This equipment must be medically necessary; meet the Medicare/Medicaid requirements; and provided under a written, signed, and dated physician's prescription. The county may require the supplier to receive prior authorization. Items can be rented or purchased, whichever is the least costly. Items covered are crutches, canes, walkers, standard wheel chairs, hospital beds, home oxygen equipment (including masks, oxygen hose, and nebulizers), and reasonable and appropriate appliances for measuring blood pressure. These supplies and equipment may also be prescribed by an APRN if this is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(9) Home and community health care services. These services must be medically necessary; meet the Medicare/Medicaid requirements; and provided by a certified home health agency. A plan of care must be recommended, signed, and dated by the recipient's attending physician prior to care being given. A plan of care may also be recommended, signed, and dated by a PA or APRN who is licensed by the Texas Board of Nursing as a certified nurse practitioner or clinical nurse specialist. The county may require prior authorization. Items covered are registered nurse (RN) visits for skilled nursing observation, assessment, evaluation, and treatment provided a physician specifically requests the RN visit for this purpose. A home health aide to assist with administering medication is also covered. Visits made for performing housekeeping services are not covered.(10) Dental care. These services must be medically necessary and provided by a doctor of dental surgery, a doctor of medicine in dentistry, or a doctor of dental medicine. The county may require prior authorization. Items covered are an annual routine dental exam and the least costly service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection, or extreme pain.(11) Vision care, including eyeglasses. The county may require prior authorization. Items covered are one examination of the eyes by refraction and one pair of prescribed glasses every 24 months.(12) Emergency medical services. These services are ground ambulance transport services. When the client's condition is life-threatening and requires the use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, ground ambulance transport is an emergency service.(13) Physical therapy services. These services must be medically necessary and may be covered if provided in a physician's office, a therapist's office, in an outpatient rehabilitation or freestanding rehabilitation facility, or in a licensed hospital. Services must be within the provider's scope of practice, as defined by Texas Occupations Code Chapter 453.(14) Occupational therapy services. These services must be medically necessary and may be covered if provided in a physician's office, a therapist's office, in an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider's scope of practice, as defined by Texas Occupations Code Chapter 454.(15) Other medically necessary services or supplies that the local governmental municipality/entity determines to be cost effective.26 Tex. Admin. Code § 363.101
The provisions of this §363.101 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; amended to be effective November 13, 2012, 37 TexReg 8975; transferred from Title 25, Pt. 1, Ch. 14 by Texas Register, Volume 47, Number 06, February 11, 2022, TexReg 0673, eff. 3/1/2022; Amended by Texas Register, Volume 49, Number 37, September 13, 2024, TexReg 7329, eff. 9/18/2024