PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 351. COORDINATED PLANNING AND DELIVERY OF HEALTH AND HUMAN SERVICES
SUBCHAPTER A. GENERAL PROVISIONS
The Texas Health and Human Services Commission (HHSC) adopts an amendment to §351.3, concerning Recognition of Out-of-State License of Military Service Members and Military Spouses, and new §351.6, concerning Alternative Licensing for Military Service Members, Military Spouses, and Military Veterans, in Texas Administrative Code Title 1, Chapter 351, Subchapter A. The amendment of §351.3 and new rule §351.6 are adopted with changes to the proposed text as published in the September 29, 2023, issue of the Texas Register (48 TexReg 5596). These rules will be republished.
BACKGROUND AND JUSTIFICATION
The amendment and new rule implement Senate Bill (S.B.) 422, 88th Legislature, Regular Session, 2023, which amended Texas Occupations Code Chapter 55, Licensing of Military Service Members, Military Veterans, and Military Spouses. Amended §351.3 allows military service members who are currently licensed in good standing by another jurisdiction to engage in a business or occupation in Texas if the other jurisdiction has licensing requirements substantially equivalent to the requirements for the license in Texas. New §351.6 creates an alternative licensing process for military service members, military spouses, and military veterans. Both rules establish requirements and procedures authorized or required by Texas Occupations Code Chapter 55 and do not modify or alter rights that may be provided under federal law.
The amendment to §351.3 replaces "military spouse" in the title with "military service members and military spouses" and otherwise makes the rule applicable to military service members in addition to military spouses. The proposed amendment also adds a requirement that HHSC verify the licensure and issue a verification letter recognizing the licensure within 30 days of the date a military service member or military spouse submits the information required by the rule. The amendment further provides that, in the event of a divorce or similar event that affects a person's status as a military spouse, the spouse may continue to engage in the business or occupation until the third anniversary of the date the spouse received the verification letter.
New §351.6 establishes alternative licensing for military service members, military spouses, and military veterans. Alternative licensing is appropriate when the military service member, military spouse, or military veteran is currently licensed in good standing with another jurisdiction that has licensing requirements substantially equivalent to the requirements of a license in Texas or held the same license in Texas within the preceding five years. The new rule provides that HHSC has 30 days from the date a military service member, military spouse, or military veteran submits an application for alternative licensing to process the application and issue a license to a qualified applicant.
COMMENTS
The 21-day comment period ended October 20, 2023.
During this period, HHSC received one comment regarding the proposed rules from an individual commenter. A summary of the comment relating to the rules and HHSC's response follows.
Comment: An individual stakeholder commented that the military spouse waiver fee should apply to retired military spouses as well as retired servicemen/women.
Response: HHSC declines to revise §351.3 or §351.6 because both rules incorporate the definitions found in Texas Occupations Code §55.001. With respect to military spouses, these statutory definitions limit the applicability of both rules to persons married to military service members who are on active duty.
HHSC made changes to §351.3(e)(3) and §351.6(f) to be consistent with 25 TAC §1.81, Recognition of Out-of-State License of a Military Service Member and Military Spouse, and §1.91, Alternative Licensing for Military Service Members, Military Spouses, and Military Veterans.
STATUTORY AUTHORITY
The amendment and new rule are adopted under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas health and Safety Code §1001.075, which authorizes the Executive Commissioner of HHSC to adopt rules and policies necessary for the operation and provision of services by HHSC for the administration of Texas Health and Safety Code Chapter 1001.
§351.3.Recognition of Out-of-State License of Military Service Members and Military Spouses.
(a) For the purposes of this section, the definitions found in Texas Occupations Code §55.001 are hereby adopted by reference. This section establishes requirements and procedures authorized or required by Texas Occupations Code, Chapter 55, and does not modify or alter rights that may be provided under federal law.
(b) This section applies to all licenses to engage in a business or occupation which the Texas Health and Human Services Commission (HHSC) issues to an individual under authority granted by the laws of the State of Texas. A more specific rule concerning recognition of out-of-state licenses of military service members and military spouses may also apply but only to the extent the more specific rule does not conflict with this rule. Any conflicts between this rule and the more specific rule are resolved in favor of this rule.
(c) A military service member or military spouse may engage in a business or occupation as if licensed in the State of Texas without obtaining the applicable license in Texas if the military service member or military spouse:
(1) is currently licensed in good standing with another jurisdiction that has licensing requirements substantially equivalent to the requirements of a license in this state;
(2) notifies HHSC in writing of the military service member's or military spouse's intent to practice in this state;
(3) submits to HHSC proof of the military service member's or military spouse's residency in this state and a copy of the military service member's or military spouse's military identification card; and
(4) receives a verification letter from HHSC that:
(A) HHSC has verified the military service member's or military spouse's license in another jurisdiction; and
(B) the military service member or military spouse is authorized to engage in the business or occupation in accordance with Texas Occupations Code §55.0041 and rules for that business or occupation.
(d) HHSC will review and evaluate the following criteria, if relevant to a Texas license, when determining whether another state's licensing requirements are substantially equivalent to the requirements for a license under the statutes and regulations of this state:
(1) whether the other state requires an applicant to pass an examination that demonstrates competence in the field to obtain the license;
(2) whether the other state requires an applicant to meet any experience qualifications to obtain the license;
(3) whether the other state requires an applicant to meet any education qualifications to obtain the license; and
(4) the other state's license requirements, including the scope of work authorized to be performed under the license issued by the other state.
(e) The military service member or military spouse must submit:
(1) a written request to HHSC for recognition of the military service member's or military spouse's license issued by the other state; no fee will be required;
(2) any form and additional information regarding the license issued by the other state required by the rules of the specific program or division within HHSC that licenses the business or occupation;
(3) proof of residency in this state, which may include a copy of the permanent change-of-station order for the military service member;
(4) a copy of the military service member's or military spouse's identification card; and
(5) proof the military service member or, with respect to a military spouse, the military service member to whom the spouse is married is stationed at a military installation in Texas.
(f) HHSC has 30 days from the date a military service member or military spouse submits the information required by subsection (e) of this section to:
(1) verify that the member or spouse is licensed in good standing in a jurisdiction that has licensing requirements that are substantially equivalent to the requirements for a license under the statutes and regulations of this state; and
(2) issue a verification letter recognizing the licensure as the equivalent license in this state.
(g) The verification letter will expire three years from date of issuance or when the military service member or, with respect to a military spouse, the military service member to whom the spouse is married is no longer stationed at a military installation in Texas, whichever comes first. The verification letter may not be renewed.
(h) In the event of a divorce or similar event that affects a person's status as a military spouse, the spouse may continue to engage in the business or occupation under the authority of this section until the third anniversary of the date the spouse received the verification described by subsection (f) of this section. A similar event includes the death of the military service member or the military service member's discharge from the military.
(i) A replacement letter may be issued after receiving a request for a replacement letter in writing or on a form, if any, required by the rules of the specific program or division within HHSC that licenses the business or occupation; no fee will be required.
(j) The military service member or military spouse shall comply with all applicable laws, rules, and standards of this state, including applicable Texas Health and Safety Code chapters and all relevant Texas Administrative Code provisions.
(k) HHSC may withdraw or modify the verification letter for reasons including the following:
(1) the military service member or military spouse fails to comply with subsection (j) of this section; or
(2) the military service member's or military spouse's licensure required under subsection (c)(1) of this section expires or is suspended or revoked in another jurisdiction.
§351.6.Alternative Licensing for Military Service Members, Military Spouses, and Military Veterans.
(a) For the purposes of this section, the definitions found in Texas Occupations Code §55.001 are hereby adopted by reference. This section establishes requirements and procedures authorized or required by Texas Occupations Code, Chapter 55, and does not modify or alter rights that may be provided under federal law.
(b) This section applies to all licenses to engage in a business or occupation which the Texas Health and Human Services Commission (HHSC) issues to an individual under authority granted by the laws of the State of Texas. A more specific rule concerning alternative licensing for military service members, military spouses, and military veterans may also apply but only to the extent the more specific rule does not conflict with this rule. Any conflicts between this rule and the more specific rule are resolved in favor of this rule.
(c) Notwithstanding any other rule, HHSC may issue a license to an applicant who is a military service member, military spouse, or military veteran if the military service member, military spouse, or military veteran:
(1) is currently licensed in good standing with another jurisdiction that has licensing requirements substantially equivalent to the requirements of a license in this state; or
(2) held the same license in Texas within the preceding five years.
(d) HHSC may waive any requirement to obtaining a license for an applicant described by subsection (c) of this section after reviewing the applicant's credentials.
(e) If an applicant described by subsection (c) of this section must demonstrate competency to meet the requirements for obtaining the license, HHSC may accept alternate forms of competency including:
(1) proof of a passing score for any national exams required to obtain the occupational license;
(2) if specific professional experience is required, proof of duration or hours that meet the professional experience requirement; and
(3) if specific training hours are required for obtaining the license, proof of verified hours related to training experience.
(f) If required by the specific program or division within HHSC that licenses the business or occupation, a military service member or military spouse must provide proof of residency in this state, which may include a copy of the permanent change-of-station order for the military service member or any other documentation HHSC deems appropriate to verify residency.
(g) HHSC has 30 days from the date a military service member, military spouse, or military veteran submits an application for alternative licensing to process the application and issue a license to an applicant who qualifies for the license.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on November 9, 2023.
TRD-202304128
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: December 1, 2023
Proposal publication date: September 29, 2023
For further information, please call: (512) 574-2228
SUBCHAPTER A. PURCHASED HEALTH SERVICES
DIVISION 9. AMBULANCE SERVICES
1 TAC §§354.1111, 354.1113, 354.1115
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §354.1111, concerning Definitions; §354.1113, concerning Additional Claim Information Requirements; and §354.1115, concerning Authorized Ambulance Services. Section 354.1111 and §354.1115 are adopted with changes to the proposed text as published in the July 21, 2023, issue of the Texas Register (48 TexReg 3955). These rules will be republished. Section 354.1113 is adopted without changes to the proposed text as published in the July 21, 2023, issue of the Texas Register (48 TexReg 3955). This rule will not be republished.
BACKGROUND AND JUSTIFICATION
The purpose of the adoption is to implement legislation related to Medicaid ambulance services as directed by Senate Bill 1, Article II, Rider 42, 87th Legislature, Regular Session, 2021. The adoption implements emergency triage, treat, and transport (ET3) services to allow Medicaid-enrolled ambulance providers to address health care needs assessed as non-emergency, but medically necessary, by initiating and facilitating appropriate treatment in place at the scene; initiating and facilitating appropriate treatment in place via telemedicine or telehealth; and transporting a Medicaid recipient to an alternative non-hospital destination, such as a primary care physician office or an urgent care clinic. The adoption allows ET3 services similar to those put in place with the Centers for Medicare & Medicaid Services' ET3 Pilot project. The adoption amendments also update and clarify language in the rules.
COMMENTS
The 31-day comment period ended August 21, 2023.
During this period, HHSC received comments regarding the proposed rules from one stakeholder. Comments were received from Texas EMS Alliance. A summary of the comments relating to the rules and HHSC's responses follow.
Comment: Texas EMS Alliance commented that while the definition in §354.1111(9) of "nonemergency transport" includes valid examples, such as scheduled appointments and discharges from a medical facility, the language describing the Medicaid recipient's medical condition that would make nonemergency transport appropriate should be changed from "such that the use of an ambulance is medically required, e.g., bed confinement, and alternate means of transport are medically contraindicated" to "such that the use of an ambulance is medically required, e.g., bed confinement or alternate means of transport are medically contraindicated." The commenter explained that while it would be rare, it is possible for a patient who is not bed confined to still require stretcher transport, such as a patient who is dependent on a ventilator.
Response: HHSC respectfully declines to make the suggested change. The Medicaid recipient's medical condition must be such that both the use of an ambulance is medically required and alternate means of transport are medically contraindicated. Bed confinement is cited as an example of when the use of an ambulance is medically required.
Comment: Texas EMS Alliance also commented that emergency medical services providers would provide treatment as described in §354.1115(2)(A),(B), or (C), but not all three for the same response. The commenter suggested changing the last word in §354.1115(2)(B) to "or."
Response: HHSC disagrees and respectfully declines to make the suggested change. HHSC's decision to use "and" instead of "or" is because ambulance providers may be reimbursed for all of the ET3 services listed in §354.1115(2)(A), (B), and (C). The rule is not intended to specify that §354.1115(2)(A), (B), and (C) must be provided as part of the same treatment event in order for the provider to be reimbursed.
Minor editorial changes were made to §354.1111(5)(B) and (C) and §354.1115(2)(B) and (C) to use "initiating and facilitating" in the description of treatment in place.
STATUTORY AUTHORITY
The amendments are adopted under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, Texas Government Code §531.033, which provides Executive Commissioner of HHSC with broad rulemaking authority; Texas Human Resource Code §32.021, which provides HHSC with the authority to administer the federal medical assistance program in Texas and to adopt rules and standards for program administration.
§354.1111.Definitions.
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
(1) Ambulance provider--A provider of ambulance services who:
(A) is enrolled as an ambulance provider in the Texas Medicaid Program to provide ambulance services for Medicaid recipients;
(B) is licensed with the Department of State Health Services, Emergency Medical Services Division;
(C) is enrolled in Medicare;
(D) agrees to accept assignment on all Medicare/Medicaid claims; and
(E) agrees to provide these services according to state and local laws, regulations, and guidelines governing ambulance services.
(2) Appropriate facility--The nearest medical facility that is equipped to provide medical care for the illness or injury of the Medicaid recipient involved. It is the institution, equipment, personnel, and capability to provide the services necessary to support the required medical care that determine whether a facility is appropriate.
(3) Designee--The contractor responsible for reimbursing Medicaid providers of ambulance transport services for Medicaid recipients.
(4) Emergency medical condition--A medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, or symptoms of substance abuse) such that a prudent layperson with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following:
(A) placing the recipient's health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(5) Emergency triage, treat and transport (ET3) services--ET3 services are emergency ground ambulance services and include:
(A) transporting Medicaid recipients to alternative destination sites other than an emergency department, including primary care physician offices and urgent care clinics;
(B) initiating and facilitating appropriate treatment in place at the scene; or
(C) initiating and facilitating appropriate treatment in place via telemedicine or telehealth.
(6) Emergency transport--Transport provided by an ambulance provider for a Medicaid recipient whose condition meets the definition of an emergency medical condition. Facility-to-facility transports are appropriate as emergencies if the required treatment for the emergency medical condition is not available at the first facility.
(7) HHSC--The Texas Health and Human Services Commission or its designee.
(8) Medically necessary--When the condition of the Medicaid recipient meets the definition of emergency medical condition or meets the requirements for nonemergency transport.
(9) Nonemergency transport--Transport provided by an ambulance provider for a Medicaid recipient to or from a scheduled medical appointment, to or from another licensed facility for treatment, or to the recipient's home after discharge from a hospital. Nonemergency transport is appropriate when the Medicaid recipient's medical condition is such that the use of an ambulance is medically required, e.g., bed confinement, and alternate means of transport are medically contraindicated.
§354.1115.Authorized Ambulance Services.
In addition to the requirements stated in this section, a provider must comply with §354.1001 of this subchapter (relating to Claim Information Requirements), and §354.1113 of this division (relating to Additional Claim Information Requirements).
(1) Emergency ambulance transportation. HHSC will reimburse a Medicaid-enrolled ambulance provider for the emergency transport of a Medicaid recipient with an emergency medical condition in accordance with the following criteria.
(A) Transport must be to an appropriate facility. If the transport is made to a facility other than an appropriate facility, payment is limited to the amount that would be payable to an appropriate facility.
(B) Transport by air or boat ambulance is reimbursable if the time and distance required to reach an appropriate facility make the transport by ground ambulance impractical or would endanger the life or safety of the recipient. If the recipient's medical condition does not meet the emergency air or boat criteria, but does meet the emergency ground transportation criteria, the payment to the provider is limited to the amount that would be payable at the emergency ground transportation rate.
(2) Emergency triage, treat and transport (ET3) services. HHSC may reimburse a Medicaid-enrolled ambulance provider responding to a call initiated by an emergency response system and upon arrival at the scene the ambulance provider determines the recipient's needs are nonemergent, but medically necessary. ET3 services may be reimbursed for:
(A) transporting Medicaid recipients to alternative destination sites other than an emergency department;
(B) initiating and facilitating treatment in place at the scene; and
(C) initiating and facilitating treatment in place via telemedicine or telehealth.
(3) Nonemergency ambulance transportation. HHSC may reimburse a Medicaid-enrolled ambulance provider for nonemergency transport when the following requirements are met:
(A) A physician, nursing facility, health care provider, or other responsible party, must obtain prior authorization from HHSC when an ambulance is used to transport a recipient in circumstances not involving an emergency.
(i) Except as provided by clause (iii) of this subparagraph, a request for prior authorization must be evaluated by HHSC based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition;
(ii) Except as provided by clause (iii) of this subparagraph, a response to a request for prior authorization must be made by HHSC not later than 48 hours after receipt of the request; and
(iii) A request for prior authorization must be granted immediately by HHSC and must be effective for a period of not more than 180 days from the date of issuance if the request includes a written statement from a physician that:
(I) states that alternative means of transporting the recipient are contraindicated; and
(II) is dated not earlier than the 60th day before the date on which the request for authorization is made.
(B) If the request is for authorization of ambulance transportation for only one day in circumstances not involving an emergency, a physician, nursing facility, health care provider, or other responsible party must obtain authorization from HHSC no later than the next business day following the day of transport;
(C) If the request is for authorization of ambulance transportation for more than one day in circumstances not involving an emergency, a physician, nursing facility, health care provider, or other responsible party must obtain a single authorization before an ambulance is used to transport a recipient;
(D) A person denied payment for ambulance services rendered is entitled to payment from the nursing facility, healthcare provider, or other responsible party that requested the services if:
(i) payment under the Medicaid program is denied because of lack of prior authorization; and
(ii) the person provides the nursing facility, healthcare provider, or other responsible party with a copy of the bill for which payment was denied.
(E) HHSC must be available to evaluate requests for authorization under this section not less than 12 hours each day, excluding weekends and state holidays.
(4) Hearings. For information about recipient fair hearings, refer to HHSC's fair hearing rules, Chapter 357 of this title (relating to Hearings).
(5) Provider appeal. An ambulance provider denied payment for services rendered because of failure to obtain prior authorization, or because a request for prior authorization was denied, is entitled to appeal the denial of payment to HHSC. A denial of a claim may be appealed by a provider under HHSC's appeals procedures contained in the Texas Medicaid Provider Procedures Manual and §354.1003 of this subchapter (relating to Time Limits for Submitted Claims).
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on November 7, 2023.
TRD-202304103
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: November 27, 2023
Proposal publication date: July 21, 2023
For further information, please call: (512) 438-4651