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Attachment B: (MAP Program Plan)
Handbook for the
Travis County Healthcare District
MEDICAL ASSISTANCE PROGRAM (MAP)
SUBROGATION
Subrogation is the right to recover amounts paid by a government-sponsored plan that are the obligation
of other payers (such as an insurance company). If you are injured or become ill under circumstances in
which a third party may legally be obligated to pay the medical, dental and/or pharmacy expenses, MAP
will pay your covered expenses. MAP reserves the right, however, to be reimbursed for all medical
expenses from the settlement or judgment made by the third party.
EXCLUSIONS
Services and related items excluded from coverage by the Medical Assistance Program (MAP) include
but are not limited to the following list. MAP does not cover items on this list.
1.
Services or supplies not specifically covered by the Medical Assistance Program;
2.
All services that have been denied through pre-authorization by the Medical Assistance Program;
3.
Services not provided within the MAP designated network, unless pre-authorized;
4.
Services, supplies and equipment provided or primarily utilized outside the boundaries of Travis
County unless provided under an agreement between the Travis County Healthcare District and the
provider;
5.
Services and supplies for persons whose primary residence is outside the boundaries of Travis
County;
6.
Services, supplies or equipment provided without active MAP coverage;
7.
Services and supplies to any individual who is a resident or inmate in a public institution;
8.
In-patient hospital and related services for a patient in an institution for tuberculosis, mental
disease, or a nursing section of a public institution for the mentally retarded;
9.
Services provided for any work-related illness, injury or complication thereof arising out of the
course of employment for which Worker's Compensation Benefits or any other similar regulation
of the United States are provided or should be provided according to the laws of the state, territory
or subdivision thereof governing the employer under which such illness or injury occurred;
10.
Services or supplies provided in connection with cosmetic surgery except as required for the repair
of accidental injury if the initial treatment is received within 12 months of the accident in which
the injury was sustained, or for improvement of the functioning of a malformed body member, or
when prior authorization is obtained for other medically necessary purposes;
11.
Services, supplies and medications for which benefits are available under a manufacturer’s Patient
Benefit Program, or any other contract policy or insurance which would have been available in the
absence of the Medical Assistance Program;
12.
Services payable by any health, accident, or other insurance coverage; or by any private or other
governmental benefit system, or any legally liable third party;
13.
Services, supplies or medications considered experimental or investigational, i.e., services and
items which have not been approved for marketing by the Food and Drug Administration Services;
The Medical Assistance Program serves the healthcare needs of eligible residents in Travis County
and is funded by the Travis County Healthcare District.
Exclusions Page 1 – Revised 01/02/2009
Page 1 of 8
Attachment B: (MAP Program Plan)
Handbook for the
Travis County Healthcare District
MEDICAL ASSISTANCE PROGRAM (MAP)
14.
Supplies or medication related to infertility;
15.
Any services to include, but not be limited to, drugs, surgery, medical or psychiatric care or
treatment for transsexualism, gender dysphoria, sexual re-assignment or sex change;
16.
Procedures that relate to obesity, obesity therapy and/or special diets (including medically
supervised fasting and liquid nutrition) related to weight reduction whether necessitated by surgery
or a specifically identified medical condition;
17.
Services provided by an interpreter;
18.
Services provided by a relative of the enrollee or a member of his or her household;
19.
Services and supplies that are provided under any governmental plan or law under which the
individual is or could be covered (e.g., Victims of Crime, Texas Rehabilitation Commission,
Veteran's Benefits, Medicare, Medicaid, TRICARE, CHAMPUS, etc.);
20.
Co-insurance fees and deductibles. MAP is not a secondary payer for any other insurance or
governmental health care program;
21.
Charges for services not medically necessary, which are not incident to and necessary for the
treatment of an injury or illness;
22.
Charges for acute hospital services and supplies provided as an inpatient to the extent that it is
established upon review of the claim submitted that the enrollee’s condition did not require a
hospital level of care and could have been provided safely at a lesser level of care;
23.
Charges for hospital care and services rendered after the patient has been discharged from the
hospital by the attending physician, or for hospital care and services when a registered bed patient
is absent from the hospital;
24.
Charges resulting from or in connection with the commission of any illegal act, occupation or
event (including the commission of a crime or violation of conditions of probation) if the covered
individual is incarcerated;
25.
Charges resulting from or in connection with any acts of war, declared or undeclared, or any type
of military conflict, charges incurred due to diseases contracted or injuries sustained in any country
while such country is at war or while en route to or from any such country at war, charges resulting
from illness/injuries incurred while engaged in military services;
26.
Inpatient and outpatient comprehensive rehabilitation;
27.
Charges for custodial or sanitaria care, rest cures, or for respite care;
28.
Charges for care and treatment of mental and/or nervous disorders, psychiatric treatment or
individual, family, or group counseling services unless as a co-morbidity or secondary diagnosis
during an inpatient stay;
29.
Charges for treatment programs for substance abuse and/or detoxification. (Note: Even though
this is not a MAP-covered service, you may ask the staff for low cost or free resources in the
community if you need substance abuse treatment and/or detoxification.)
30.
Charges that related to in-born errors of metabolism;
31.
Charges for air ambulance;
32.
Charges for private room except when appropriate documentation of medical necessity is provided;
The Medical Assistance Program serves the healthcare needs of eligible residents in Travis County
and is funded by the Travis County Healthcare District.
Exclusions Page 2 – Revised 01/02/2009
Page 2 of 8
Attachment B: (MAP Program Plan)
Handbook for the
Travis County Healthcare District
MEDICAL ASSISTANCE PROGRAM (MAP)
33.
Charges for Chiropractic services/treatment;
34.
Charges for Rolfing;
35.
Charges for acupuncture, acupressure, or biofeedback;
36.
Charges for services rendered by a massage therapist;
37.
Charges for hypnosis;
38.
Charges for eye refractions, eye glasses, eye exercises, contact lenses, or other corrective devices,
including materials and supplies, or for the fitting or examinations for prescribing, fitting or
changing of these items;
39.
Charges for whole blood or packed red cells that are available at no cost to the client;
40.
Charges for autologous blood donations;
41.
Charges for blood clotting factors;
42.
Charges for luxury/entertainment items (e.g., TV, video, beauty aids, etc.);
43.
Charges/fees for completing or filing required forms/pre-authorizations;
44.
Charges which accumulate during any period of time in which the client removes rental equipment
from the delivery site and fails to immediately notify the Medical Assistance Programs of the new
location;
45.
Autopsies;
46.
Cellular Therapy;
47.
Chemolase injections (Chemodiactin, Chymopapain);
48.
Chemonucleolysis intervertebral disc;
49.
Cognitive therapy;
50.
Dermabrasion;
51.
Dialysis (in-patient or out-patient) or supplies related to dialysis, except for acute conditions not
related to chronic renal failure while in the inpatient setting;
52.
Educational counseling;
53.
Ergonovine provocation test;
54.
Fabric wrapping of abdominal aneurysms;
55.
Hair analysis;
56.
Histamine therapy - intravenous;
57.
Hospice care;
58.
Hyperactivity testing;
59.
Hyperthermia;
60.
Immunotherapy for malignant disease;
61.
Immunizations required for travel outside the United States;
The Medical Assistance Program serves the healthcare needs of eligible residents in Travis County
and is funded by the Travis County Healthcare District.
Exclusions Page 3 – Revised 01/02/2009
Page 3 of 8
Attachment B: (MAP Program Plan)
Handbook for the
Travis County Healthcare District
MEDICAL ASSISTANCE PROGRAM (MAP)
62.
Implantations (e.g., silicone, saline, penile, etc.);
63.
Joint sclerotherapy;
64.
Laetrile therapy;
65.
Organ transplants, medications and/or treatments associated with the transplant;
66.
Orthodontic treatment, crown, and bridge procedures;
67.
Specialized pain management programs and/or treatment designed to provide chronic pain care
unless provided through the CHC setting;
68.
Penile prosthesis;
69.
Prosthetic eye or facial quarter;
70.
Radial and hexagonal keratotomy or refractive surgeries; keratoprosthesis/refractive keratoplasty;
71.
Routine circumcision for clients one year of age or older;
72.
Sterilization reversal;
73.
Tattooing and/or tattoo removal;
74.
Thermogram;
75.
TORCH screen;
76.
Adaptive equipment for daily living such as eating utensils, reachers, handheld shower extensions,
etc.;
77.
Admission kits;
78.
Air cleaners/purifiers;
79.
Any equipment, supplements, or supplies not ordered by a physician or provider and/or considered
appropriate and necessary to treat a documented medical condition/disease process;
80.
Augmentive communication devices, e.g., TTY device, artificial voice box, and machinery of this
nature;
81.
Bed cradles;
82.
Bladder stimulators (pacemakers);
83.
Car seats;
84.
Cervical pillows;
85.
Electric wheelchairs or scooters (outpatient);
86.
Enuresis monitors;
87.
Equipment or services not primarily and customarily used to serve a medical purpose (e.g., an air
conditioner might be used to lower room temperature to reduce fluid loss in a cardiac patient or a
whirlpool bath might be used in the treatment of osteoarthritis, however because the primary and
customary use of these items is a non-medical one, they cannot be considered as medical
equipment);
88.
Evaluations for learning disabilities;
The Medical Assistance Program serves the healthcare needs of eligible residents in Travis County
and is funded by the Travis County Healthcare District.
Exclusions Page 4 – Revised 01/02/2009
Page 4 of 8
Attachment B: (MAP Program Plan)
Handbook for the
Travis County Healthcare District
MEDICAL ASSISTANCE PROGRAM (MAP)
89.
Feeding supplements (e.g., Ensure, Osmolyte) and supplies for long-term use;
90.
Hearing aids;
91.
Home and vehicle modifications, including ramps, tub rails/bars;
92.
Humidifiers, except when used with respiratory equipment (e.g., oxygen concentrators,
CPAP/BIPAP, nebulizers, or for clients with a tracheostomy (requires pre-authorization);
93.
Implantable medication pumps and related supplies;
94.
Over bed tables;
95.
Prosthetic breasts and mastectomy bras;
96.
Thermometers;
97.
Vocational, educational, exercise, and recreational equipment;
98.
Waist/gait belts;
99.
Whirlpool baths and saunas;
100. Treatment or correction of temporomandibular joint (TMJ) dysfunction;
101. Refills or prescriptions in excess of the number specified by the Doctor, or refills dispensed one
year or more after the date of the Doctor’s original order.
The Medical Assistance Program serves the healthcare needs of eligible residents in Travis County
and is funded by the Travis County Healthcare District.
Exclusions Page 5 – Revised 01/02/2009
Page 5 of 8
Attachment B: CommUnityCare Plan
Table 1: Demographic Information (Unduplicated Patients)
October 2007-September 2008
Demographic
Information
Gender
Total MAP and CommUnityCare
Number
Female
Male
Total
Age Group
17 and younger
18-24
25-34
35-44
45-54
55-64
65+
Total
Ethnicity
African American
Anglo
Asian
Hispanic
Native American
Other
Total
Page 6 of 8
Percent of
Total
36,343
30,390
66,733
(54.5%)
(45.5%)
100%
11,995
9,487
18,956
12,275
8,507
4,424
1,089
66,733
(18.0%)
(14.2%)
(28.4%)
(18.4%)
(12.7%)
(6.6%)
(1.6%)
(100.0%)
4,810
6,889
942
52,448
31
1,613
66,733
(7.2%)
(10.3%)
(1.4%)
(78.6%)
(0.05%)
(2.4%)
(100.0%)
Attachment B: CommUnityCare Plan
Table 2: Net Paid Claims by Zip Code (MAP and CommUnityCare Lines of Business)
October 2007-September 2008
ZIP
78745
78768
78741
78744
78753
78702
78660
78767
78704
78758
78723
78724
78617
78721
78752
78748
78653
78728
78701
78747
78757
78749
78759
78645
78734
78727
78641
78751
78756
78754
78735
78736
78669
78610
78719
78725
78722
blank
78703
78731
78733
78621
78726
78652
78664
78612
78729
MAP net paid
claims
6,596
6,155
5,979
5,473
5,392
5,298
4,221
4,097
4,024
3,786
3,221
2,922
2,810
2,442
2,342
1,996
1,448
1,209
1,167
1,110
1,098
1,054
1,036
991
958
916
603
574
537
528
432
418
403
402
368
360
354
287
251
241
238
210
201
177
173
159
146
ZIP
78746
78705
78738
78750
78742
78739
78737
78620
78760
78730
78642
78644
78715
78640
78761
78732
78615
78764
78755
76530
78654
78711
78613
78646
78655
78681
78766
78133
78680
78709
78740
78763
78219
78616
78634
78639
78716
78717
78155
78718
78765
78942
77566
78602
78614
78708
78957
Grand Total
MAP net paid
claims
146
145
142
135
130
117
112
85
73
55
50
44
39
38
38
35
31
28
25
23
19
19
18
18
17
12
10
8
8
5
4
4
3
3
3
3
3
3
2
2
2
2
1
1
1
1
1
86,467
ZIP
78744
78741
78753
78745
78758
78723
78660
78724
78704
78752
78702
78617
78721
78748
78747
78757
78727
78653
78754
78751
78728
78734
78736
78735
78645
78759
78725
78749
78621
78719
78669
78733
78722
78742
78641
78767
Page 7 of 8
CommUnityCare line
of business net paid
claims
ZIP
3901
78746
3879
78737
3724 blank
2781
78756
2588
78644
2226
78701
1862
78703
1753
78739
1738
78705
1738
78664
1613
78750
1499
78768
1134
78729
846
78610
598
78613
567
78654
441
78652
424
78726
416
78731
412
78612
411
78711
349
78615
302
78616
301
78715
291
78732
287
78730
266
78709
258
78681
249
78761
188
78602
135
78691
127
78620
119
78707
104
78764
101
78766
101 Grand Total
CommUnityCare line of
business net paid
claims
96
89
88
70
68
65
65
63
56
55
50
49
47
44
38
38
36
35
33
28
24
20
16
15
14
7
6
5
5
4
4
3
1
1
1
38,968
Attachment B: CommUnityCare Plan
CommUnityCare’s program plan is the 340B Drug Pricing Program, administered by the U.S.
Department of Health and Human Services, Health Resources and Services Administration
(HRSA) – Office of Pharmacy Affairs (OPA).
Program details may be found at http://www.hrsa.gov/opa
Page 8 of 8