Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 1 - PARTICIPATION › Section 354.1801 - Requirements for Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) For
					 the purposes of this subchapter, "pharmacy provider" means a provider of
					 outpatient pharmacy services enrolled in the Medicaid program.
(b) Any pharmacy who has a current license or
					 registration with the Texas State Board of Pharmacy or is licensed under the
					 laws of another state and is free from any pharmacy board restriction may apply
					 to become a pharmacy provider. Prescribing practitioners who are authorized and
					 licensed to practice the healing arts, as defined and limited by federal and
					 state laws, and choose to provide their own pharmaceuticals may also apply to
					 become pharmacy providers.
(c)
					 Except as stated in §
											RSA
					 354.1809 of this title (relating to
					 Termination of Participation), Chapter 352 of this title (relating to Medicaid
					 and Children's Health Insurance Program Provider Enrollment), and Chapter 371
					 of this title (relating to Medicaid and Other Health and Human Services Fraud
					 and Abuse Program Integrity), the Health and Human Services Commission (HHSC)
					 and its designee maintain open enrollment for in-state pharmacies licensed as
					 Class A or C by the Texas State Board of Pharmacy. Pharmacies holding any other
					 class of pharmacy license may be subject to special application
					 procedures.
(d) A pharmacy must be
					 enrolled as a pharmacy provider to participate as a provider in the Children's
					 Health Insurance Program (CHIP), the Kidney Health Care (KHC) program, or the
					 Children with Special Health Care Needs (CSHCN) program.
(e) A pharmacy does not have to be enrolled
					 in the Medicare program to dispense covered outpatient drugs or certain
					 supplies as defined in §
											RSA
					 354.1042 of this title (relating to Supplies
					 Provided by a Pharmacy) to clients enrolled in the Medicaid program.
(f) A pharmacy that fills prescriptions for
					 Medicaid clients on behalf of an enrolled Medicaid pharmacy that submits
					 Medicaid claims (e.g., a central fill pharmacy or a pharmacy that provides
					 medication fulfillment services) may be required to enroll in accordance with
					 Chapters 352 and 371 of this title and is subject to other participation
					 requirements in this division, including §354.1807 of this division
					 (relating to Access to Records).
(g) A pharmacy applying for enrollment as a
					 pharmacy provider is subject to the enrollment and application requirements in
					 Chapters 352 and 371 of this title.
(h) Claims are subject to post-payment review
					 for compliance with state and federal laws and regulations and HHSC policy.
					 Reimbursement paid to a pharmacy provider for claims that do not comply may be
					 subject to recoupment of overpayment.
(i) HHSC may enter into special negotiated
					 reimbursement arrangements with other state or local entities, such as a
					 Department of State Health Services hospital, to maximize federal financial
					 participation in state or locally funded programs. If a state or local entity
					 is unwilling to participate in such an arrangement, a contract or agreement may
					 be denied.