CHAPTER 31. PRIMARY HEALTH CARE - Texas Statutes

HEALTH AND SAFETY CODE

TITLE 2. HEALTH

SUBTITLE B. TEXAS DEPARTMENT OF HEALTH PROGRAMS

CHAPTER 31. PRIMARY HEALTH CARE

Sec. 31.001. SHORT TITLE. This chapter may be cited as the

Texas Primary Health Care Services Act.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.002. DEFINITIONS. (a) In this chapter:

(1) "Facility" includes a hospital, ambulatory surgical center,

public health clinic, birthing center, outpatient clinic, and

community health center.

(2) "Medical transportation" means transportation services that

are required to obtain appropriate and timely primary health care

services for eligible individuals.

(3) "Other benefit" means a benefit, other than a benefit

provided under this chapter, to which an individual is entitled

for payment of the costs of primary health care services,

including benefits available from:

(A) an insurance policy, group health plan, or prepaid medical

care plan;

(B) Title XVIII or XIX of the Social Security Act (42 U.S.C.

Section 1395 et seq. or Section 1396 et seq.);

(C) the Veterans Administration;

(D) the Civilian Health and Medical Program of the Uniformed

Services;

(E) workers' compensation or any other compulsory employers'

insurance program;

(F) a public program created by federal or state law, or by an

ordinance or rule of a municipality or political subdivision of

the state, excluding benefits created by the establishment of a

municipal or county hospital, a joint municipal-county hospital,

a county hospital authority, a hospital district, or the

facilities of a publicly supported medical school; or

(G) a cause of action for medical, facility, or medical

transportation expenses, or a settlement or judgment based on the

cause of action, if the expenses are related to the need for

services provided under this chapter.

(4) "Primary health care services" includes:

(A) diagnosis and treatment;

(B) emergency services;

(C) family planning services;

(D) preventive health services, including immunizations;

(E) health education;

(F) laboratory, X-ray, nuclear medicine, or other appropriate

diagnostic services;

(G) nutrition services;

(H) health screening;

(I) home health care;

(J) dental care;

(K) transportation;

(L) prescription drugs and devices and durable supplies;

(M) environmental health services;

(N) podiatry services; and

(O) social services.

(5) "Program" means the primary health care services program

authorized by this chapter.

(6) "Provider" means a person who, through a grant or a contract

with the department, provides primary health care services that

are purchased by the department for the purposes of this chapter.

(7) "Support" means the contribution of money or services

necessary for a person's maintenance, including food, clothing,

shelter, transportation, and health care.

(b) The board by rule may define a word or term not defined by

Subsection (a) as necessary to administer this chapter. The board

may not define a word or term so that the word or term is

inconsistent or in conflict with the purposes of this chapter, or

is in conflict with the definition and conditions of practice

governing a provider who is required to be licensed, registered,

certified, identified, or otherwise sanctioned under the laws of

this state.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.003. PRIMARY HEALTH CARE SERVICES PROGRAM. (a) The

board may establish a program in the department to provide

primary health care services to eligible individuals.

(b) If the program is established, the board shall adopt rules

relating to:

(1) the type, amount, and duration of services to be provided

under this chapter; and

(2) the determination by the department of the services needed

in each service area.

(c) If budgetary limitations exist, the board by rule shall

establish a system of priorities relating to the types of

services provided, geographic areas covered, or classes of

individuals eligible for services.

(d) The board shall adopt rules under Subsection (c) relating to

the geographic areas covered and the classes of individuals

eligible for services according to a statewide determination of

the need for services.

(e) The board shall adopt rules under Subsection (c) relating to

the types of services provided according to the set of service

priorities established under this subsection. Initial service

priorities shall focus on the funding of, provision of, and

access to:

(1) diagnosis and treatment;

(2) emergency services;

(3) family planning services;

(4) preventive health services, including immunizations;

(5) health education; and

(6) laboratory, X-ray, nuclear medicine, or other appropriate

diagnostic services.

(f) Except as limited by this section, the department shall

develop an integrated framework for the equitable provision of

services throughout the state and shall use existing public and

private health, transportation, and education resources.

(g) The board should require that the services provided under

this chapter be reserved to the greatest extent possible for

low-income individuals who are not eligible for similar services

through any other publicly funded program.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.004. ADMINISTRATION. (a) The board shall adopt rules

necessary to administer this chapter, and the department shall

administer the program in accordance with board rules.

(b) With the advice and assistance of the commissioner and the

department, the board by rule shall:

(1) establish the administrative structure of the program;

(2) establish a plan of areawide administration to provide

authorized services;

(3) designate, if possible, local public and private resources

as providers; and

(4) prevent duplication by coordinating authorized primary

health care services with existing federal, state, and local

programs.

(c) The department shall prescribe the design and content of all

necessary forms used in the program.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.005. PROVISION OF PROGRAM SERVICES BY DEPARTMENT. (a)

The board shall adopt rules relating to the department's

determination of whether program services are to be provided

through a network of approved providers, directly by the

department, or by a combination of the department and approved

providers as prescribed by this section.

(b) The department shall provide services only as prescribed by

board rule.

(c) The department may provide primary health care services

directly to eligible individuals to the extent that the board

determines that existing private or public providers or other

resources in the service area are unavailable or unable to

provide those services. In making that determination, the

department shall:

(1) initially determine the proposed need for services in the

service area;

(2) notify existing private and public providers and other

resources in the service area of the department's initial

determination of need and the services the department proposes to

provide directly to eligible individuals;

(3) provide existing private and public providers and other

resources in the service area a reasonable opportunity to comment

on the department's initial determination of need and the

availability and ability of existing private or public providers

or other resources in the service area to satisfy the need;

(4) provide existing private and public providers and other

resources in the service area a reasonable opportunity to obtain

approval as providers under the program; and

(5) eliminate, reduce, or otherwise modify the proposed scope or

type of services the department proposes to provide directly to

the extent that those services may be provided by existing

private or public providers or other resources in the service

area that meet the board's criteria for approval as providers.

(d) The department shall maintain a continuing review of the

services it provides directly to the eligible individuals who

participate in the program. At least annually, the department

shall review and determine the continued need for the services it

provides directly in each service area, in accordance with the

methods and procedures used to make the initial determination as

prescribed by this section.

(e) If after a review the board determines that a private or

public provider or other resource is available to provide

services and has been approved as a provider, the department

shall, immediately after approving the provider, eliminate,

reduce, or modify the scope and type of services the department

provides directly to the extent the private or public provider or

other resource is available and able to provide the service.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.006. SERVICE PROVIDERS. (a) The board shall adopt

rules relating to:

(1) the selection and expedited selection of providers,

including physicians, registered nurses, and facilities; and

(2) the denial, modification, suspension, and termination of

program participation.

(b) The department shall select and approve providers to

participate in the program according to the criteria and

following the procedures prescribed by board rules.

(c) The department shall pay only for program services provided

by approved providers, except in an emergency.

(d) The board may not adopt facility approval criteria that

discriminate against a facility solely because it is operated for

profit.

(e) The department may not exclude a provider solely because the

provider receives federal funds if the federal funds are

inadequate to provide the services authorized by this chapter to

all eligible individuals seeking services from that provider.

(f) The board shall provide a due process hearing procedure for

the resolution of conflicts between the department and a

provider. Chapter 2001, Government Code, do not apply to conflict

resolution procedures adopted under this section.

(g) The department shall render the final administrative

decision in a due process hearing to modify, suspend, or

terminate the approval of a provider.

(h) The department may not terminate a grant or contract while a

due process hearing is pending under this section. The department

may withhold payments while the hearing is pending but shall pay

the withheld payments and resume grant or contract payments if

the final determination is in favor of the provider.

(i) The notice and hearing required by this section do not apply

if a grant or contract:

(1) is canceled by the department because of exhaustion of funds

or because insufficient funds require the board to adopt service

priorities; or

(2) expires according to its terms.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(65), eff.

Sept. 1, 1995.

Sec. 31.007. APPLICATION FOR SERVICES. (a) The board shall

adopt rules relating to application procedures for admission to

the program.

(b) An applicant must complete or cause to be completed an

application form prescribed by the department.

(c) The application form must be accompanied by:

(1) a statement by the applicant, or by the person with a legal

obligation to provide for the applicant's support, that the

applicant or person is financially unable to pay for all or part

of the cost of the necessary services; and

(2) any other assurances from the applicant or any documentary

evidence required by the board that is necessary to support the

applicant's eligibility.

(d) Except as permitted by program rules, the department may not

provide services or authorize payment for services delivered to

an individual before the eligibility date assigned to the

individual by the department.

(e) The department shall determine or cause to be determined the

eligibility date in accordance with board rules. The date may not

be later than the date on which the individual submits a properly

completed application form and all supporting documents required

by this chapter or board rules.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.008. ELIGIBILITY FOR SERVICES. (a) The board shall

adopt rules relating to eligibility criteria for an individual to

receive services under the program, including health, medical,

and financial criteria. The department shall determine or cause

to be determined an applicant's eligibility in accordance with

this chapter and board rules.

(b) Except as modified by other rules adopted under this

chapter, the board by rule shall provide that to be eligible to

receive services, the individual must be a resident of this

state.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.009. DENIAL, MODIFICATION, SUSPENSION, OR TERMINATION OF

SERVICES. (a) The department for cause may deny an application

for services after notice to the applicant and an opportunity for

a fair hearing.

(b) The department may modify, suspend, or terminate services to

an individual eligible for or receiving services after notice to

the individual and an opportunity for a fair hearing.

(c) The board by rule shall provide criteria for action by the

department under this section.

(d) Chapter 2001, Government Code, do not apply to the granting,

denial, modification, suspension, or termination of services. The

department shall conduct hearings in accordance with the board's

due process hearing rules.

(e) The department shall render the final administrative

decision in a due process hearing to deny, modify, suspend, or

terminate the receipt of services.

(f) The notice and hearing required by this section do not apply

if the department restricts program services to conform to

budgetary limitations that require the board to establish service

priorities.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(65), eff.

Sept. 1, 1995.

Sec. 31.010. FINANCIAL ELIGIBILITY; OTHER BENEFITS. (a) The

department shall require an individual receiving services under

this chapter, or the person with a legal obligation to support

the individual, to pay for or reimburse the department for that

part of the cost of the services that the individual or person is

financially able to pay.

(b) Except as provided by board rules, an individual is not

eligible to receive services under this chapter to the extent

that the individual, or a person with a legal obligation to

support the individual, is eligible for some other benefit that

would pay for all or part of the services.

(c) When an application is made under this chapter or when

services are received, the individual applying for or receiving

services shall inform the department of any other benefit to

which the individual, or a person with a legal obligation to

support the individual, may be entitled.

(d) An individual who has received services that are covered by

some other benefit, or a person with a legal obligation to

support that individual, shall reimburse the department to the

extent of the services provided when the other benefit is

received.

(e) The commissioner may waive enforcement of Subsections

(b)-(d) of this section as prescribed by board rules in certain

individually considered cases in which enforcement will deny

services to a class of otherwise eligible individuals because of

conflicting federal, state, or local laws or rules.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.011. RECOVERY OF COSTS. (a) The department may recover

the cost of services provided under this chapter from a person

who does not reimburse the department as required by Section

31.010 or from any third party who has a legal obligation to pay

other benefits and to whom notice of the department's interest

has been given.

(b) At the request of the commissioner, the attorney general may

bring suit in the appropriate court of Travis County on behalf of

the department.

(c) In a judgment in favor of the department, the court may

award attorney's fees, court costs, and interest accruing from

the date on which the department provides the services to the

date on which the department is reimbursed.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.012. FEES. (a) The board may charge fees for the

services provided directly by the department or through approved

providers in accordance with Subchapter D, Chapter 12.

(b) The board shall adopt standards and procedures to develop

and implement a schedule of allowable charges for program

services.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.013. FUNDING. (a) Except as provided by this chapter

or by other law, the board may seek, receive, and spend funds

received through an appropriation, grant, donation, or

reimbursement from any public or private source to administer

this chapter.

(b) The department is not required to provide primary health

care services unless funds are appropriated to the department to

administer this chapter.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.014. CONTRACTS. The department shall enter into

contracts and agreements or award grants necessary to facilitate

the efficient and economical provision of services under this

chapter, including contracts and grants for the purchase of

services, equipment, and supplies from approved providers.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.015. RECORDS AND REVIEW. (a) The department shall

require each provider receiving reimbursement under this chapter

to maintain records and information for each applicant for or

recipient of services.

(b) The board shall adopt rules relating to the information a

provider is required to report to the department and shall adopt

procedures to prevent unnecessary and duplicative reporting of

data.

(c) The department shall review records, information, and

reports prepared by program providers and shall annually prepare

a report for submission to the governor and the legislature

relating to the status of the program. The department shall make

the report available to the public.

(d) The report required under Subsection (c) must include:

(1) the number of individuals receiving care under this chapter;

(2) the total cost of the program, including a delineation of

the total administrative costs and the total cost for each

service authorized under Section 31.003(e);

(3) the average cost per recipient of services;

(4) the number of individuals who received services in each

public health region; and

(5) any other information required by the board.

(e) In computing the number of individuals to be reported under

Subsection (d)(1), the department shall ensure that no individual

is counted more than once.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 31.016. PROGRAM PLANS. (a) The department shall have a

long-range plan, covering at least six years, that includes at

least the following elements:

(1) quantifiable indicators of effort and success;

(2) identification of priority client population and the minimum

types of services necessary for that population;

(3) a description of the appropriate use of providers, including

the role of providers, and considering the type, location, and

specialization of the providers;

(4) criteria for phasing out unnecessary services;

(5) a comprehensive assessment of needs and inventory of

resources; and

(6) coordination of administration and service delivery with

federal, state, and local public and private programs that

provide similar services.

(b) The department shall revise the plan by January 1 of each

even-numbered year.

(c) The department shall develop a short-range plan that is

derived from the long-range plan and that identifies and projects

the costs relating to implementing the short-range plan.

(d) As part of the department's budget preparation process, the

department shall biennially assess its achievement of the goals

identified in each plan. The department's biennial budget shall

be made according to the results of the assessment and the

short-range plan. The department shall make its requests for new

program funding and for continued funding according to

demonstrated need.

(e) The department shall use the information collected under

Section 31.015 to develop the long-range and short-range plans.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Text of section effective until August 31, 2009, but only if a

specific appropriation is provided as described by Acts 2009,

81st Leg., R.S., Ch. 127, Sec. 2, which states: This Act does not

make an appropriation. This Act takes effect only if a specific

appropriation for the implementation of the Act is provided in a

general appropriations act of the 81st Legislature.

Sec. 31.017. FEDERALLY QUALIFIED HEALTH CENTERS. (a) The

department may make grants to establish new or expand existing

facilities that can qualify as federally qualified health

centers, as defined by 42 U.S.C. Section 1396d(l)(2)(B), in this

state, including:

(1) planning grants;

(2) development grants;

(3) capital improvement grants; and

(4) grants for transitional operating support.

(b) This section expires September 1, 2009.

Added by Acts 2003, 78th Leg., ch. 860, Sec. 1, eff. Sept. 1,

2003.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

127, Sec. 1, eff. August 31, 2009.

Text of section effective on August 31, 2009, but only if a

specific appropriation is provided as described by Acts 2009,

81st Leg., R.S., Ch. 127, Sec. 2, which states: This Act does not

make an appropriation. This Act takes effect only if a specific

appropriation for the implementation of the Act is provided in a

general appropriations act of the 81st Legislature.

Sec. 31.017. FEDERALLY QUALIFIED HEALTH CENTERS. The

department may make grants to establish new or expand existing

facilities and to support new or expanded services at facilities

that can qualify as federally qualified health centers, as

defined by 42 U.S.C. Section 1396d(l)(2)(B), in this state,

including:

(1) planning grants;

(2) development grants;

(3) capital improvement grants; and

(4) grants for transitional operating support.

Added by Acts 2003, 78th Leg., ch. 860, Sec. 1, eff. Sept. 1,

2003.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

127, Sec. 1, eff. August 31, 2009.