Tex. Government Code § 531.02164 — TX Code / Code gv / Chapter 531 / Section 531.02164
§ 531.02164. MEDICAID SERVICES PROVIDED THROUGH HOME TELEMONITORING SERVICES.
Status: in_force

(a) In this section:

(1) "Federally qualified health center" has the meaning assigned by 42 U.S.C. Section 1396d(l)(2)(B).

(1-a) "Home and community support services agency" means a person licensed under Chapter 142, Health and Safety Code, to provide home health, hospice, or personal assistance services as defined by Section 142.001, Health and Safety Code.

(2) "Hospital" means a hospital licensed under Chapter 241, Health and Safety Code.

(3) "Rural health clinic" has the meaning assigned by 42 U.S.C. Section 1396d(l)(1).

(b) The executive commissioner shall adopt rules for the provision and reimbursement of home telemonitoring services under Medicaid as provided under this section.

(c) For purposes of adopting rules under this section, the commission shall:

(1) identify and provide home telemonitoring services to persons diagnosed with conditions for which the commission determines the provision of home telemonitoring services would be cost-effective and clinically effective;

(2) consider providing home telemonitoring services under Subdivision (1) to Medicaid recipients who:

(A) are diagnosed with one or more of the following conditions:

(i) pregnancy;

(ii) diabetes;

(iii) heart disease;

(iv) cancer;

(v) chronic obstructive pulmonary disease;

(vi) hypertension;

(vii) congestive heart failure;

(viii) mental illness or serious emotional disturbance;

(ix) asthma;

(x) myocardial infarction;

(xi) stroke;

(xii) end stage renal disease; or

(xiii) a condition that requires renal dialysis treatment; and

(B) exhibit at least one of the following risk factors:

(i) two or more hospitalizations in the prior 12-month period;

(ii) frequent or recurrent emergency room admissions;

(iii) a documented history of poor adherence to ordered medication regimens;

(iv) a documented risk of falls; and

(v) a documented history of care access challenges;

(3) ensure that clinical information gathered by the following providers while providing home telemonitoring services is shared with the recipient's physician:

(A) a home and community support services agency;

(B) a federally qualified health center;

(C) a rural health clinic; or

(D) a hospital;

(4) ensure that the home telemonitoring services provided under this section do not duplicate disease management program services provided under Section 32.057, Human Resources Code; and

(5) require a provider to:

(A) establish a plan of care that includes outcome measures for each recipient who receives home telemonitoring services under this section; and

(B) share the plan and outcome measures with the recipient's physician.

(c-1) Notwithstanding any other provision of this section, the commission shall ensure that home telemonitoring services are available to pediatric persons who:

(1) are diagnosed with end-stage solid organ disease;

(2) have received an organ transplant; or

(3) require mechanical ventilation.

(c-2) In addition to determining whether to provide home telemonitoring services to Medicaid recipients with the conditions described under Subsection (c)(2), the commission shall determine whether high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective. If the commission determines that high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective:

(1) the commission shall, to the extent permitted by state and federal law, provide recipients experiencing a high-risk pregnancy with clinically appropriate home telemonitoring services equipment for temporary use in the recipient's home; and

(2) the executive commissioner by rule shall:

(A) establish criteria to identify recipients experiencing a high-risk pregnancy who would benefit from access to home telemonitoring services equipment;

(B) ensure that, if cost-effective, feasible, and clinically appropriate, the home telemonitoring services equipment provided includes uterine remote monitoring services equipment and pregnancy-induced hypertension remote monitoring services equipment;

(C) subject to Subsection (c-3), require that a provider obtain:

(i) prior authorization from the commission before providing home telemonitoring services equipment to a recipient during the first month the equipment is provided to the recipient; and

(ii) an extension of the authorization under Subparagraph (i) from the commission before providing the equipment in a subsequent month based on the ongoing medical need of the recipient; and

(D) prohibit payment or reimbursement for home telemonitoring services equipment during any period that the equipment was not in use because the recipient was hospitalized or away from the recipient's home regardless of whether the equipment remained in the recipient's home while the recipient was hospitalized or away.

(c-3) For purposes of Subsection (c-2), the commission shall require that:

(1) a request for prior authorization under Subsection (c-2)(2)(C)(i) be based on an in-person assessment of the recipient; and

(2) documentation of the recipient's ongoing medical need for the equipment is provided to the commission before the commission grants an extension under Subsection (c-2)(2)(C)(ii).

(d) If, after implementation, the commission determines that a condition for which the commission has authorized the provision and reimbursement of home telemonitoring services under Medicaid under this section is not cost-effective and clinically effective, the commission may discontinue the availability of home telemonitoring services for that condition and stop providing reimbursement under Medicaid for home telemonitoring services for that condition, notwithstanding Section 531.0216 or any other law.

(e) The commission shall determine whether the provision of home telemonitoring services to persons who are eligible to receive benefits under both Medicaid and the Medicare program achieves cost savings for the Medicare program.

(f) To comply with state and federal requirements to provide access to medically necessary services under Medicaid, including the Medicaid managed care program, and if the commission determines it is cost-effective and clinically effective, the commission or a Medicaid managed care organization, as applicable, may reimburse providers for home telemonitoring services provided to persons who have conditions and exhibit risk factors other than those expressly authorized by this section.