reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10 › Section 354.1745 - Categories

Current through Reg. 49, No. 28; July 12, 2024
There are four categories for demonstration years (DYs)
						9-10:
(1) Category A - Required
					 Reporting, which requires performers to report their progress on core
					 activities, alternative payment model arrangements, costs and savings, and
					 collaborative activities, as described in §354.1749 of this division
					 (relating to Category A Requirements for Performers);
(2) Category B - Medicaid and Low-income or
					 Uninsured (MLIU) Patient Population by Provider (PPP), which requires
					 performers to maintain or increase the number of MLIU individuals served, as
					 described in §354.1751 of this division (relating to Category B
					 Requirements for Performers);
(3)
					 Category C - Measure Bundles and Measures, which requires performers to improve
					 their performance on clinical outcome and process measures, as described in
					 §354.1753 of this division (relating to Category C Requirements for
					 Performers); and
(4) Category D -
					 Statewide Reporting Measure Bundles, which requires performers to report on
					 certain measures based on their provider type, as described in §354.1755
					 of this division (relating to Category D Requirements for
					 Performers).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10 › Section 354.1747 - Performer Valuations

Current through Reg. 49, No. 28; July 12, 2024
(a) A performer's
					 total valuation per demonstration year (DY) for DY9 and DY10 is calculated as
					 follows:
(1) If a performer has a DY8 total
					 valuation that is less than or equal to $1 million, its total valuation for
					 each demonstration year of DY9 and DY10 is equal to its total valuation for
					 DY8. These valuations are subtracted from the DY9 and DY10 DSRIP pool
					 amounts.
(2) If a performer has a
					 DY8 total valuation that is greater than $1 million, its total valuation for
					 each demonstration year of DY9 and DY10 is calculated as follows:
(A) The remaining DY9 and DY10 DSRIP pool
					 amounts are divided by the DY8 valuation for all performers with a DY8 total
					 valuation greater than $1 million to determine the percentage reductions for
					 DY9 and DY10;
(B) The performer's
					 DY8 valuation is multiplied by the percentage reduction in valuation from DY8
					 for the applicable DY to determine the total valuation for each demonstration
					 year of DY9 and DY10; and
(C) The
					 performer's total valuation for each demonstration year of DY9 and DY10 is not
					 reduced to less than $1 million.
(3) If a performer withdrew from
					 participating in DSRIP during DY8 or withdraws during the RHP Plan Update for
					 DY9-10, the performer's valuation is proportionately distributed among the
					 remaining performers in its RHP based on each performer's percent share of DY8
					 valuation in the RHP.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10 › Section 354.1749 - Category A Requirements for Performers

Current through Reg. 49, No. 28; July 12, 2024
A performer must fulfill the following Category A -
						Required Reporting requirements for each demonstration year (DY).
(1) Core activities. A performer must select
					 at least one core activity in the RHP plan update for its RHP that supports the
					 achievement of its Category C measure goals, as described in the Measure Bundle
					 Protocol. The performer must report progress on, and updates to, its selected
					 core activities during the second reporting period of each DY.
(2) Alternative Payment Models (APMs). A
					 performer must report progress toward, or implementation of, APM arrangements
					 with Medicaid managed care organizations or other payers during the second
					 reporting period of each DY.
(3)
					 Costs and savings. A performer with a total valuation greater than or equal to
					 $1 million per DY must report the costs of at least one core activity, as well
					 as the forecasted or generated savings from that core activity.
(A) For DY9-10, a performer must report costs
					 and savings for a different core activity than the performer reported for DY7-8
					 or a different aspect of the same core activity the performer reported for
					 DY7-8.
(B) The performer must
					 report the costs and savings associated with its selected core activity at the
					 level of the performer's system, to the extent possible.
(C) The performer must submit a progress
					 update on the costs and savings associated with its selected core activity
					 during the second reporting period of DY9.
(D) The performer must submit a final report
					 on the costs and savings associated with its selected core activity during the
					 second reporting period of DY10.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10 › Section 354.1751 - Category B Requirements for Performers

Current through Reg. 49, No. 28; July 12, 2024
(a) A performer must provide the following
					 information in the RHP plan update for DY9-10 for its RHP:
(1) its updated total PPP for DY5, DY6, DY7,
					 or DY8, if needed;
(2) its updated
					 MLIU PPP for DY5, DY6, DY7, or DY8, if needed;
(3) its Medicaid PPP for DY7 and DY8;
					 and
(4) its LIU PPP for DY7 and
					 DY8.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10 › Section 354.1755 - Category D Requirements for Performers

Current through Reg. 49, No. 28; July 12, 2024
(a) There is a Category D - Statewide
					 Reporting Measure Bundle for each provider type, as described in the Measure
					 Bundle Protocol.
(b) Each Category
					 D - Statewide Reporting Measure Bundle consists of one or more measures, as
					 described in the Measure Bundle Protocol.
(c) The valuation for each measure in a
					 performer's Category D - Statewide Reporting Measure Bundle for each DY is
					 equal to the valuation of the performer's Category D - Statewide Reporting
					 Measure Bundle for the DY divided by the number of measures in the Category D -
					 Statewide Reporting Measure Bundle, so that the valuations of the measures are
					 equal.
(d) A performer must report
					 on a measure in the Category D - Statewide Reporting Measure Bundle for its
					 provider type as described in the Measure Bundle Protocol for a DY no later
					 than the second reporting period of the DY to be eligible for payment of the
					 measure for the DY.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10 › Section 354.1757 - Disbursement of Funds

Current through Reg. 49, No. 28; July 12, 2024
(a) Category A and
					 DSRIP payments. If a performer fails to fulfill all of the Category A
					 requirements described in §354.1749 of this division (relating to Category
					 A Requirements for Performers) for a demonstration year (DY), any DSRIP
					 payments the performer received for the DY will be recouped, and prospective
					 DSRIP payments to the performer will be withheld.
(1) DSRIP payments for DY9 include payments
					 for DY9 Category B, Category C, or Category D milestones.
(2) DSRIP payments for DY10 include payments
					 for DY10 Category B, Category C, or Category D milestones.
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 354.1803 - Confidentiality

Current through Reg. 49, No. 28; July 12, 2024
A pharmacy provider must comply with all privacy
						requirements in the Health Insurance Portability and Accountability Act of 1996
						(HIPAA) and any other state or federal law related to client confidentiality.
						Federal and state laws provide criminal penalties for
						violation.
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 354.1805 - Nondiscrimination

Current through Reg. 49, No. 28; July 12, 2024
The provider must provide services without discriminating
						on the basis or race, color, national origin, age, sex, or
						handicap.
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 354.1807 - Access to Records

Current through Reg. 49, No. 28; July 12, 2024
On request, a pharmacy provider must allow staff of the
						Health and Human Services Commission, the Texas Office of the Attorney
						General's Medicaid Fraud Control Unit, and the U.S. Department of Health and
						Human Services, or their designees, immediate access to financial and other
						records that pertain to the Medicaid program for review or audit.
(1) The pharmacy provider must give the staff
					 access to and a sample of the prescription files of the provider's non-Medicaid
					 customers to determine the provider's usual and customary price.
(2) The pharmacy provider may remove
					 information that can be used to identify a particular Medicaid client or
					 non-Medicaid customer.
(3) The
					 pharmacy provider must cooperate in regular reviews (general audits and
					 utilization reviews) of the records of its customers who are Medicaid
					 clients.
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 354.1809 - Denial or Termination of Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and Human Services Commission
					 (HHSC) reserves the right to deny an application for participation in the
					 Medicaid program or to immediately suspend or terminate participation in the
					 program should the pharmacy provider conduct pharmaceutical practices in
					 violation of HHSC's Vendor Drug Program rules, state or federal laws, or the
					 ethics adopted by the profession.
(b) HHSC or its designee, on receipt of
					 written request, provides an appeal to the provider if HHSC or its designee
					 suspends or terminates the pharmacy provider's participation in the program for
					 a violation described in subsection (a) of this section.
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 354.1811 - Sanctions

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and Human Services Commission
					 (HHSC) reserves the right to impose administrative sanctions on a pharmacy
					 provider who conducts pharmaceutical practices in violation of the ethics
					 adopted by the profession, any applicable federal or state laws, or the
					 criteria of HHSC's Vendor Drug Program. Sanctions include, but are not limited
					 to, termination or suspension from participation, suspension of payments, and
					 recoupment of overpayments.
(b) On
					 receipt of a written request, HHSC provides an appeal to a pharmacy provider on
					 whom HHSC sanctions have been placed for a violation described in subsection
					 (a) of this section.
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 354.1813 - Placing a Pharmacy Provider on Vendor Hold

Current through Reg. 49, No. 28; July 12, 2024
(a) Definition. In the context of this
					 subchapter, the term vendor hold means detaining accrued vendor payments from
					 the effective date of the hold until the release date.
(b) Reasons for placing a pharmacy provider
					 on vendor hold are as follows:
(1) violation
					 of the provisions of the pharmacy provider agreements and/or
					 amendments;
(2) failure to pay,
					 within the allotted period of time, the amount of restitution as revealed by an
					 audit of the pharmacy provider;
(3)
					 a request by the Office of Inspector General or the Office of Attorney General,
					 pursuant to an investigation of a pharmacy provider for possible
					 fraud;
(4) failure to file a
					 required cost report according to applicable instructions and within the
					 prescribed time period;
(5) failure
					 to allow access to financial and other records in accordance with
					 §354.1807 of this division (relating to Access to Records); or
(6) a credible allegation of fraud, as
					 defined in
					 RSA
					 455.2.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 2 - ADMINISTRATION › Section 354.1831 - Covered Drugs

Current through Reg. 49, No. 28; July 12, 2024
(a) Only those
					 drugs and Limited Home Health Supplies listed in the latest edition of the
					 Texas Drug Code Index (TDCI) are covered by the program and are payable.
					 Venosets, catheters, and other medical accessories are not covered and are not
					 included when claiming for intravenous and irrigating solutions.
(b) The Commission may limit coverage of
					 drugs listed in the TDCI. Procedures used to limit utilization may include
					 prior approval, cost containment caps, or adherence to specific dosage
					 limitations recommended by manufacturers. Limitations placed on the specific
					 drugs are indicated in the TDCI.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 2 - ADMINISTRATION › Section 354.1832 - iPrior Authorization Procedures

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Requests for prior authorization. Except as provided in subsection (b) of this
					 section, a health care practitioner who prescribes a drug that is not included
					 on the Preferred Drug List (PDL) for a Medicaid recipient must request prior
					 authorization of the drug to the Health and Human Services Commission (HHSC) or
					 its designee. Specific procedures for the submission of requests for prior
					 authorization are available on HHSC's web site. A health care practitioner may
					 request a printed copy of the procedures and forms from HHSC.
(b) New Medicaid recipients. The PDL-related
					 prior authorization requirement of this section does not apply if the
					 prescription for the non-preferred drug is for a newly enrolled Medicaid
					 recipient, until the 31st calendar day after the date of the recipient's
					 Medicaid eligibility determination.
(c) Special Considerations. When HHSC
					 determines based on clinical considerations, cost considerations, or guidance
					 from the Drug Utilization Review Board that the prior authorization requirement
					 could adversely impact Medicaid recipients' health or safety, it may be
					 administratively more efficient to deem the approved prior authorization for a
					 particular client for a certain period of time, or for an indefinite
					 period.
(d) Disposition of requests
					 for prior authorization. HHSC or its designee will notify the requesting
					 practitioner of the approval or disapproval of the request within 24 hours of
					 the receipt of the request.
(e)
					 Emergency requests for prior authorization. HHSC will authorize up to a 72-hour
					 supply of a product subject to prior authorization if:
(1) The prescribing practitioner notifies
					 HHSC of an emergency need for the product when submitting the request for prior
					 authorization; and
(2) HHSC or its
					 designee is unable to provide its approval or disapproval within 24 hours
					 following the receipt of the request.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 2 - ADMINISTRATION › Section 354.1833 - Pharmacy Services

Current through Reg. 49, No. 28; July 12, 2024
Under the Vendor Drug Program, pharmacy services include
						the dispensing to eligible recipients of covered legend and nonlegend drugs
						that appear in the latest revision of the Texas Drug Code Index. For purposes
						of this chapter, dispensing is defined as preparation, packaging, compounding
						and/or labeling the medication. Pharmacy services under this chapter are
						limited to dispensing to recipients in outpatient settings.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 2 - ADMINISTRATION › Section 354.1835 - Prescriber Identification Numbers

Current through Reg. 49, No. 28; July 12, 2024
Unless an exception is needed during a disaster, as
						described in § 354.1868 of this subchapter (relating to Exceptions in
						Disasters), vendors must enter the identification number of the prescriber, as
						listed with the appropriate medical specialty board, on each
						claim.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 2 - ADMINISTRATION › Section 354.1837 - Evidence of Eligibility

Current through Reg. 49, No. 28; July 12, 2024
Eligible individuals present the medical care
						identification card to the vendor each time a prescription is
						filled.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 3 - MEDICATIONS › Section 354.1851 - Substitution of One Drug for Another in a Prescription

Current through Reg. 49, No. 28; July 12, 2024
(a) Substitution of one drug for another in a
					 prescription must follow all state and federal rules and laws.
(b) When generic equivalents or
					 interchangeable biological products are dispensed, the Health and Human
					 Services Commission pays the claim based on the acquisition cost (AC), in
					 accordance with §
											RSA
					 355.8541 of this title (relating to Legend
					 and Nonlegend Medications).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 3 - MEDICATIONS › Section 354.1853 - Specialty Drugs

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health and
					 Human Services Commissions (HHSC) will develop, maintain, and publish a list of
					 specialty drugs on the Texas Medicaid Vendor Drug Program website.
(b) HHSC will include a drug on the specialty
					 drug list if HHSC determines that the drug meets all of the following criteria:
(1) The drug is used to treat and is
					 prescribed for a person with a complex, chronic, or rare medical condition that
					 is progressive, can be debilitating or fatal if left untreated or undertreated,
					 or for which there is no known cure. Examples of such conditions include
					 multiple sclerosis, cystic fibrosis, hemophilia, and rheumatoid
					 arthritis.
(2) The drug is not
					 routinely stocked at a majority of community retail pharmacies.
(3) The drug has special handling, storage,
					 inventory, or distribution requirements.
(4) Patients receiving the drug require
					 complex education and treatment maintenance, such as complex dosing, intensive
					 monitoring, or clinical oversight.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1861 - Availability of Funds

Current through Reg. 49, No. 28; July 12, 2024
The vendor drug program is limited by the availability of
						appropriated funds. Services may be adjusted periodically depending on current
						availability of funds.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1863 - Prescription Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Payment for
					 pharmaceuticals can be made only when these pharmaceuticals are prescribed by a
					 practitioner that is either:
(1) licensed to
					 prescribe legend drugs and enrolled as a Texas Medicaid provider; or
(2) a physician resident participating in a
					 postgraduate training program and under the supervision of a teaching physician
					 who is enrolled as a Texas Medicaid provider.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1867 - Refills

Current through Reg. 49, No. 28; July 12, 2024
(a) As many as eleven refills may be
					 authorized by the prescriber, but the total amount authorized must be dispensed
					 within one year of the original prescription. Refills for controlled substances
					 must conform to Drug Enforcement Administration and Texas State Board of
					 Pharmacy rules. All refills are counted when determining compliance with the
					 authorized refill limitation. In the absence of specific refill instructions,
					 the prescription must be interpreted as not refillable. If a prescription notes
					 specific refill instructions, any future dispensings must be considered refills
					 of the original prescription, unless the prescriber has been contacted for
					 authorization to dispense a new supply of medication. If authorization is
					 granted, a new and separate prescription is prepared.
(b) In accordance with Texas Insurance Code
					 1369, Subchapter J, early refills of drugs used to treat chronic conditions
					 included in a Medication Synchronization Plan may be jointly approved by HHSC,
					 the applicable pharmacist, enrollee, and the prescribing physician or health
					 care provider. A pharmacist requesting an early refill for the purpose of
					 medication synchronization must adhere to the process described in the Vendor
					 Drug Program pharmacy provider procedure manual. Dispensing fees will not be
					 prorated.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1868 - Exceptions in Disasters

Current through Reg. 49, No. 28; July 12, 2024
(a) In the case of
					 a disaster, a pharmacy is reimbursed for dispensing a refill medication without
					 prescriber authorization if:
(1) failure to
					 refill the prescription might result in an interruption of a therapeutic
					 regimen or create patient suffering;
(2) the natural or manmade disaster prohibits
					 the pharmacist from being able to contact the prescribing practitioner or
					 original filling pharmacy;
(3) the
					 Governor has declared a state of disaster under Chapter 418, Texas Government
					 Code; and
(4) the Texas State Board
					 of Pharmacy has notified pharmacies that pharmacists may dispense up to a
					 30-day supply of a dangerous drug, as defined in Chapter 483 of the Texas
					 Health and Safety Code.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1871 - Advertising

Current through Reg. 49, No. 28; July 12, 2024
(a) No advertising is used to influence a
					 recipient's free choice of a pharmacy and no advertising is used that, in the
					 opinion of the Commission, is designed to or has the effect of promoting the
					 volume of prescriptions provided under the Vendor Drug Program.
(b) Advertisements should convey only
					 participation in the program.
(c)
					 The sign supplied by the Commission may be used at the discretion of the
					 pharmacy. Announcements of the participation in the Vendor Drug Program may be
					 made on radio, on television, in newspapers, or in the media. Bargains,
					 premiums, or other considerations on prescriptions may not be advertised in any
					 manner that would increase the provider's volume of Medicaid
					 prescriptions.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1873 - Freedom of Choice

Current through Reg. 49, No. 28; July 12, 2024
Medicaid recipients may obtain pharmaceutical services
						from any qualified pharmacy that contracts with the Commission to provide
						services through the Vendor Drug Program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1875 - Limitations on Provider Charges to Recipients

Current through Reg. 49, No. 28; July 12, 2024
(a) A provider of Medicaid vendor drug
					 services agrees to accept the vendor payment as payment in full for
					 pharmaceutical services provided each recipient.
(b) The provider may neither charge nor take
					 other recourse against Medicaid recipients, their family members, or their
					 representatives for any claims denied or reduced by HHSC because of the
					 provider's failure to comply with any HHSC rule, regulation, or
					 procedure.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 4 - LIMITATIONS › Section 354.1877 - Quantity Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Quantity. The
					 quantity of drugs prescribed depends on the prescribing practice of the
					 prescriber and the needs of the patient.
(1)
					 For recipients with monthly prescription limitations, the Vendor Drug Program
					 (VDP) reimburses the provider for the prescribed quantity, up to but not
					 exceeding a six-month supply.
(2)
					 For recipients with access to unlimited prescriptions, the VDP reimburses the
					 provider dispensing a medication for a quantity that does not exceed a
					 one-month (34-day) supply.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 5 - AUDITS › Section 354.1891 - Vendor Drug Providers Subject to Audit

Current through Reg. 49, No. 28; July 12, 2024
(a) All providers participating in the Vendor
					 Drug Program (Program) are subject to periodic audits by the Texas Health and
					 Human Services Commission (the Commission) or contractors for the Centers for
					 Medicare & Medicaid Services.
(b) Audits determine provider compliance with
					 all state and federal program policies, procedures, and limitations as well as
					 compliance with the requirements outlined in the provider's contract. Data for
					 transactions selected for audit are compared with data on the corresponding
					 prescriptions. Erroneous payments and overpayments that occur because of
					 noncompliance with Program requirements are considered exceptions subject to
					 restitution to the Commission.
(c)
					 If a provider disagrees with the initial findings of an audit, the provider may
					 present additional documentation to the auditor for review within 15 calendar
					 days of the provider's receipt of the draft audit report. No additional
					 documentation is accepted after this time. The auditor considers the additional
					 documentation before issuing the Final Audit Report.
(d) If the provider disagrees with the Final
					 Audit Report and wants to appeal, and the findings of the audit do not include
					 findings that the pharmacy engaged in Medicaid fraud, the Commission's Appeals
					 Division, upon receipt of written request, provides an informal hearing. The
					 Commission's Appeals Division must receive the written request for an informal
					 hearing within 15 calendar days of the provider's receipt of the Final Audit
					 Report.
(e) An administrative law
					 judge (ALJ) from the Commission's Appeals Division conducts hearings requested
					 under subsection (d) of this section in an informal manner. Unless specified by
					 the ALJ and at the ALJ's sole discretion, neither the Texas Rules of Civil
					 Procedure nor the Texas Rules of Evidence or any other procedural or
					 evidentiary rules apply. The ALJ only considers data or documentation provided
					 to the auditors on or before the time specified in subsection (c) of this
					 section. The ALJ makes the final decision. Vendor Drug Program staff who have
					 expertise in the law governing pharmacies' participation in Medicaid are
					 available to the ALJ to answer questions.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 5 - AUDITS › Section 354.1892 - Exception Notification

Current through Reg. 49, No. 28; July 12, 2024
The Commission advises the vendor by certified letter of
						the audit results, detailing the exceptions and requesting payment within 30
						days. If restitution is not received within this time period, a vendor hold is
						placed on the payment claims. If the vendor is no longer participating in the
						program, all unpaid claims are held and payments are placed on vendor hold
						until restitution is made. If no unpaid claims that can be held exist and
						restitution is not made, the case is referred for collection
						action.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 6 - PHARMACY CLAIMS › Section 354.1901 - Pharmacy Claims

Current through Reg. 49, No. 28; July 12, 2024
(a) To receive
					 payment from the Health and Human Services Commission (Commission), the
					 provider must submit a pharmacy claim through the electronic adjudication
					 system. A separate entry is submitted for each prescription or refill. For the
					 original dispensing and each subsequent refill, the provider indicates on the
					 corresponding pharmacy claim submitted to the Commission the usual and
					 customary price, the purchasing method, and the National Drug Code (NDC).
					 Claims received over 90 days after the date of service are rejected. For claims
					 on behalf of an individual who has applied for Medicaid coverage but has not
					 yet been assigned a recipient number on the date of service, the filing period
					 does not commence until the date the individual has been assigned a number. The
					 requirements in §
											RSA
					 354.1863 of this subchapter (relating to
					 Prescription Requirements) are also waived for retroactive claims. The provider
					 must ensure, however, that a prescription submitted for a prior eligibility
					 period conformed to Texas State Board of Pharmacy and Commission regulations on
					 the date of service, or a claim cannot be submitted.
(b) Providers must dispense the quantity
					 prescribed or ordered by the prescriber except as limited by the policies and
					 procedures described in the Commission's pharmacy provider procedure manual, or
					 as allowed by § 354.1868 of this subchapter (relating to Exceptions in
					 Disasters). Where the actual quantity dispensed deviates from the prescribed
					 quantity, the provider must bill for the amount actually dispensed. The
					 quantity of drugs must be entered in the metric decimal quantity field. The
					 quantity shown as the metric decimal quantity unit must be calculated after
					 referencing the pricing unit shown in the Texas Drug Code Index.
(c) If all necessary information is not
					 supplied, a claim will not be processed or paid.
(d) The provider must submit claims as the
					 prescription is dispensed through the on-line system. Providers who supply a
					 large volume of medications to nursing facility recipients may submit these
					 claims through their data transmission company after the point of
					 sale.
(e) Overcharged prescription
					 claims are not denied. The Commission pays the appropriate drug cost. The
					 appropriate drug cost is the acquisition cost, as determined by the Commission
					 or other source in accordance with §
											RSA
					 355.8541 of this title (relating to Legend
					 and Nonlegend Medications), plus the professional dispensing fee. The amount
					 claimed and the amount paid are shown on the payment register.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 6 - PHARMACY CLAIMS › Section 354.1905 - Claim Adjustments

Current through Reg. 49, No. 28; July 12, 2024
The pharmacy provider must completely reverse the
						original submission and resubmit the claims to receive an adjustment for an
						overpayment or underpayment of a pharmacy claim. The Commission must receive an
						adjustment within 90 days of the date of adjudication.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 6 - PHARMACY CLAIMS › Section 354.1907 - Unacknowledged Claims

Current through Reg. 49, No. 28; July 12, 2024
The Commission must receive a request for research on
						unacknowledged claims within the 90-day filing deadline.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 6 - PHARMACY CLAIMS › Section 354.1909 - Submittal of Special Claims

Current through Reg. 49, No. 28; July 12, 2024
Providers must bill for compounds using the drug code and
						metric decimal quantity for each National Drug Code in the compound. Providers
						may bill for up to ten ingredients through the on-line system. Payment requests
						for ingredients exceeding ten must be submitted to the Vendor Drug Program help
						desk.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 6 - PHARMACY CLAIMS › Section 354.1911 - Electronic Data Transmission Vendors (Switches)

Current through Reg. 49, No. 28; July 12, 2024
Providers must use contracted data transmission companies
						(switches) to send claims to the Commission. The provider is responsible for
						the information supplied to the Commission through the
						switch.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 7 - TEXAS DRUG CODE INDEX - ADDITIONS, RETENTIONS, AND DELETIONS › Section 354.1921 - Addition of Drugs to the Texas Drug Code Index

Current through Reg. 49, No. 28; July 12, 2024
(a) A drug company that has a valid rebate
					 agreement under
					 RSA
					 1396r-8 may apply to the Health and Human
					 Services Commission (Commission) to add a drug to the Texas Drug Code Index
					 (TDCI). The term "drug company" includes any manufacturer, repackager, or
					 private labeler.
(b) To apply for
					 the addition of a drug to the TDCI, a drug company must complete each section
					 of the Certification of Information for the Addition of a Drug Product to the
					 TDCI provided by the Commission.
(c) A drug company must also:
(1) update the Commission with changes to
					 formulation, product status, or availability; and
(2) submit changes to the prices requested in
					 the Price Certification section of the Certification of Information, if
					 requested by the Commission, within 10 calendar days of receiving the
					 request.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 7 - TEXAS DRUG CODE INDEX - ADDITIONS, RETENTIONS, AND DELETIONS › Section 354.1923 - Review and Evaluation

Current through Reg. 49, No. 28; July 12, 2024
(a) The Health
					 and Human Services Commission (Commission) reviews Certifications of
					 Information to determine the need for a drug to be added to the Texas Drug Code
					 Index and to determine the need for restrictions, when appropriate. In
					 determining need, the Commission considers the following:
(1) expansion of the prescriber's
					 armamentarium by a new drug entity or an additional multiple source
					 drug;
(2) the predominant use of
					 the drug in an outpatient setting;
(3) the cost of the drug to pharmacies
					 compared to:
(A) relevant costs as published
					 in price reporting compendia;
(B)
					 the drug company's prices for the drug in other packaging sizes;
(C) the Average Manufacturer Price (AMP) as
					 defined by
					 RSA
					 1396r-8(k), as amended;
					 and
(D) other generically
					 equivalent drug products; and
(4) whether the drug is part of a category
					 that is subject to inclusion in a preferred drug list (PDL) under §
												RSA 354.1924
					 of this division (relating to Preferred Drug List). If a drug is subject to
					 inclusion in the PDL, the manufacturer or labeler's provision of supplemental
					 rebates will be considered when determining whether the product is subject to
					 prior authorization.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 7 - TEXAS DRUG CODE INDEX - ADDITIONS, RETENTIONS, AND DELETIONS › Section 354.1924 - Preferred Drug List

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. This
					 section implements the provisions of §
											RSA
					 531.072, Government Code, which directs the
					 Health and Human Services Commission (HHSC) to develop and implement a
					 preferred drug list (PDL) for the Texas Medical Assistance Program.
(b) Applicability. This section applies to
					 drugs included in the Texas Drug Code Index (TDCI) established under §
											RSA
					 354.1921 of this title (relating to Addition
					 of Drugs to the Texas Drug Code Index).
(c) Selection of drugs for the PDL. HHSC will
					 include a drug listed on the TDCI in the PDL on the basis of:
(1) The recommendations of the Drug
					 Utilization Review Board (DUR Board) established under §
												RSA
					 354.1941 of this subchapter (relating to Drug
					 Utilization Review Board);
(2) The
					 clinical efficacy of the drug, consistent with the determination of the Food
					 and Drug Administration and the recommendations of the DUR Board ;
(3) Comparison of the price of the drug and
					 the price of competing drugs. For purposes of this section, the price of a drug
					 is determined by reference to the reimbursement for the drug established under
					 §
												RSA
					 355.8541 of this title (relating to Legend
					 and Nonlegend Medications) and after deducting Texas and federal
					 rebates;
(4) A program benefit
					 offered by the manufacturer or labeler of the drug and accepted by HHSC in
					 accordance with §
												RSA
					 531.070, Government Code; and
(5) Written evidence offered by a
					 manufacturer or labeler supporting the inclusion of a product on the
					 PDL.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 7 - TEXAS DRUG CODE INDEX - ADDITIONS, RETENTIONS, AND DELETIONS › Section 354.1925 - Resubmittal of a Denied Request

Current through Reg. 49, No. 28; July 12, 2024
(a) Upon
					 initial denial, the drug company may seek reconsideration of the decision. The
					 request is presented to the Commission for reconsideration.
(b) If a request for reconsideration for an
					 addition is denied, the drug company may not resubmit the request for six
					 months. At its option, however, the Commission may reconsider a denied request
					 at any time.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 7 - TEXAS DRUG CODE INDEX - ADDITIONS, RETENTIONS, AND DELETIONS › Section 354.1927 - Retention and Deletion of Drugs

Current through Reg. 49, No. 28; July 12, 2024
The Health and Human Services Commission (Commission)
						reviews the Texas Drug Code Index to evaluate the need for retaining or
						deleting drugs according to the following criteria.
(1) If the drug company fails to remove from
					 pharmacies any drug recalled by the Food and Drug Administration (FDA) or fails
					 to meet other federal requirements, the Commission has the right to request
					 that the U.S. Department of Health and Human Services (HHS) allow deletion of
					 the drug. If the drug company repeatedly fails to meet FDA or other federal
					 requirements, the Commission may request permission to delete all drugs
					 manufactured by the company.
(2)
					 The Commission may request that HHS allow deletion of a drug if:
(A) the drug company or companies' actions
					 with respect to a drug violate state or federal law; or
(B) the drug company fails to provide to the
					 Commission the information required under §
												RSA
					 354.1921(c) of this division (relating to
					 Addition of Drugs to the Texas Drug Code Index).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 8 - DRUG UTILIZATION REVIEW BOARD › Section 354.1941 - Drug Utilization Review Board

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 The Drug Utilization Review Board (DUR Board) must :
(1) develop recommendations for preferred
					 drug lists to be adopted by the Texas Health and Human Services Commission
					 (HHSC) under Texas Government Code §
												RSA
					 531.072;
(2) suggest to HHSC restrictions or clinical
					 prior authorizations on prescription drugs;
(3) recommend to HHSC educational
					 interventions for Medicaid providers;
(4) review drug utilization across Medicaid;
					 and
(5) perform other duties that
					 may be specified by law and otherwise make recommendations to HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter F - PHARMACY SERVICES › Division 8 - DRUG UTILIZATION REVIEW BOARD › Section 354.1942 - Conflict of Interest Policy

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Definitions. The following words or phrases have the meaning indicated for
					 purposes of this section:
(1) Board member--A
					 person who is appointed to the DUR Board.
(2) Conflict of interest-- A situation that
					 arises wherein a board member or any family member or relative has a financial
					 relationship with an entity, ownership or financial interest with an entity, or
					 any other interest where the member is in a position to derive a personal
					 benefit from action or decisions made in their professional capacity, with an
					 entity.
(3) DUR Board--Drug
					 Utilization Review Board.
(4)
					 Entity--Includes an individual, a corporation, organization, business trust,
					 estate, trust, partnership, association, and any other legal entity that may
					 have business come before the DUR Board or before the Medicaid Vendor Drug
					 Program. The term includes:
(A) a
					 pharmaceutical manufacturer or labeler with a product on the Texas Drug Code
					 Index and any other entity the Texas Health and Human Services Commission
					 (HHSC) has engaged to assist in developing the preferred drug list or in
					 administering of the DUR Program; and
(B) an "affiliate" or "associate," as defined
					 in Texas Business Organizations Code §
													RSA
					 1.002, of an entity.
(5) Family member or relative--An individual
					 who is related within the third degree by consanguinity or within the second
					 degree by affinity, as defined by the Government Code, Chapter 573, Subchapter
					 B (concerning Relationships by Consanguinity or by Affinity).
(6) Financial relationship--A written or oral
					 agreement between a board member and an entity that results in the payment of
					 federally reportable income to the board member (i.e., income reported on IRS
					 Form 1099 or Form W-2).
(7) Other
					 interest--Involvement in the affairs of an entity that impairs or may be
					 perceived as impairing a board member's independence of judgment regarding the
					 board member's performance of duties for the DUR Board.
(8) Ownership or financial interest--An
					 equity interest in where a board member exercises control over the selection of
					 investments and any other financial interest whose value cannot be readily
					 determined through reference to public records.