HEALTH & SAFETY CODE
SUBTITLE B. TEXAS DEPARTMENT OF HEALTH PROGRAMS
CHAPTER 31. PRIMARY HEALTH CARE
§ 31.001. SHORT TITLE. This chapter may be cited as the
Texas Primary Health Care Services Act.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(65), eff. Sept. 1, 1995.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(65), eff. Sept. 1, 1995.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 31.017. FEDERALLY QUALIFIED HEALTH CENTERS.
Text of section effective until September 1, 2009
(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, § 1, eff. Sept. 1, 2003.
