(iii) consistent with health care practice guidelines
and standards that are endorsed by professionally recognized health
care organizations or governmental agencies;
      (iv) consistent with the member's diagnoses;
      (v) no more intrusive or restrictive than necessary
to provide a proper balance of safety, effectiveness, and efficiency;
      (vi) not experimental or investigative; and
      (vii) not primarily for the convenience of the member
or provider.
    (B) Behavioral health services that:
      (i) are reasonable and necessary for the diagnosis
or treatment of a mental health or chemical dependency disorder, or
to improve, maintain, or prevent deterioration of functioning resulting
from such a disorder;
      (ii) are in accordance with professionally accepted
clinical guidelines and standards of practice in behavioral health
care;
      (iii) are furnished in the most appropriate and least
restrictive setting in which services can be safely provided;
      (iv) are the most appropriate level or supply of service
that can safely be provided;
      (v) could not be omitted without adversely affecting
the member's mental and/or physical health or the quality of care
rendered;
      (vi) are not experimental or investigative; and
      (vii) are not primarily for the convenience of the
member or provider.
  (53) Member education program--A planned program of
education:
    (A) concerning access to health care services or dental
services through the MCO and about specific health or dental topics;
    (B) that is approved by HHSC; and
    (C) that is provided to members through a variety of
mechanisms that must include, at a minimum, written materials and
face-to-face or audiovisual communications.
  (54) Member materials--All written materials produced
or authorized by the MCO and distributed to members or potential members
containing information concerning the managed care program. Member
materials include member ID cards, member handbooks, provider directories,
and marketing materials.
  (55) Member--A child enrolled in a CHIP MCO.
  (56) Participating MCO--An MCO that has a contract
with HHSC to provide services to members.
  (57) Primary care provider (PCP)--A physician or other
provider who has agreed with the health care MCO to provide a medical
home to members and who is responsible for providing initial and primary
care to patients, maintaining the continuity of patient care, and
initiating referral for care.
  (58) Provider--A credentialed and licensed individual,
facility, agency, institution, organization or other entity, and its
employees and subcontractors, that has a contract with the MCO for
the delivery of covered services to the MCO's members.
  (59) Provider education program--Program of education
about the CHIP managed care program and about specific health or dental
care issues presented by the MCO to its providers through written
materials and training events.
  (60) Provider network or network--All providers that
have contracted with the MCO for the CHIP program.
  (61) Quality improvement--A system to continuously
examine, monitor, and revise processes and systems that support and
improve administrative and clinical functions.
  (62) Recipient--An individual receiving CHIP services,
including a person who is renewing eligibility for CHIP.
  (63) Risk--The potential for loss as a result of expenses
and costs of the MCO exceeding payments made by HHSC under the contract.
  (64) Service area--The counties included in any HHSC-defined
service area as applicable to each MCO.
  (65) Qualified Alien--An alien who, at the time of
application, satisfies the criteria established under 8 U.S.C. §1641(b).

  (66) Significant traditional provider (STP)--A provider
identified by HHSC as having provided a significant level of care
to the target population.
  (67) SSI--Supplemental Security Income.
  (68) State Fiscal Year--The 12-month period beginning
September 1 of each calendar year and ending August 31 of the following
calendar year.
  (69) State Plan--The plan permitted under federal law
and approved by CMS that allows the state to implement the CHIP program.
  (70) Value-added service--A service provided by an
MCO that is in addition to the covered services included within the
scope of the CHIP State Plan and the MCO's contract with HHSC.