Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 23 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 355.8441 - Reimbursement Methodologies for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 following are reimbursement methodologies for services provided under the Early
					 and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, delivered to
					 Medicaid clients under age 21, also known as Texas Health Steps (THSteps) and
					 the THSteps Comprehensive Care Program (CCP). Reimbursement methodologies for
					 services provided to all Medicaid clients, including clients under age 21, are
					 located elsewhere in this chapter.
(1)
					 Counseling and psychotherapy services are reimbursed to freestanding
					 psychiatric facilities in accordance with §
												RSA
					 355.8060 of this subchapter (relating to
					 Reimbursement Methodology for Freestanding Psychiatric Facilities).
(2) Durable medical equipment, prosthetics,
					 orthotics and supplies (DMEPOS) are reimbursed in accordance with §
					 355.8023 of this subchapter (relating to Reimbursement Methodology for Durable
					 Medical Equipment, Prosthetics, Orthotics and Supplies(DMEPOS)).
(3) Nursing services, including, but not
					 limited to, private duty nursing, registered nurse (RN) services, licensed
					 vocational nurse/licensed practical nurse (LVN/LPN) services, skilled nursing
					 services delegated to qualified aides by RNs in accordance with the licensure
					 standards promulgated by the Texas Board of Nursing, and nursing assessment
					 services, are reimbursed the lesser of the provider's billed charges or fees
					 established by the Texas Health and Human Services Commission (HHSC) for each
					 of the applicable provider types as follows:
(A) Independently enrolled RNs and LVNs/LPNs,
					 under §
													RSA
					 355.8085 of this subchapter (relating to
					 Reimbursement Methodology for Physicians and Other Practitioners);
(B) Home health agencies (HHAs), under §
													RSA
					 355.8021 of this subchapter (relating to
					 Reimbursement Methodology for Home Health Services); and
(C) Advanced Practice Registered Nurses
					 (APRNs), under §
													RSA
					 355.8281(a) of this
					 subchapter (relating to Reimbursement Methodology for Nurse Practitioners and
					 Clinical Nurse Specialists).
(4) Physician Assistants (PA), under §
												RSA
					 355.8093 of this subchapter (relating to
					 Reimbursement Methodology for Physician Assistants).
(5) Physical therapy services are reimbursed
					 in accordance with the Medicaid reimbursement methodologies for the applicable
					 provider type as follows:
(A) independently
					 enrolled therapists, under § 355.8097 of this subchapter;
(B) HHAs, under § 355.8097 of this
					 subchapter;
(C) Medicare-certified
					 outpatient facilities known as comprehensive outpatient rehabilitation
					 facilities (CORFs) and outpatient rehabilitation facilities (ORFs), under
					 § 355.8097 of this subchapter;
(D) freestanding psychiatric facilities,
					 under §
													RSA
					 355.8060 of this subchapter; and
(E) outpatient hospitals, under §
													RSA
					 355.8061 of this subchapter (relating to
					 Outpatient Hospital Reimbursement).
(6) Occupational therapy services are
					 reimbursed in accordance with the Medicaid reimbursement methodologies for the
					 applicable provider type as follows:
(A)
					 independently enrolled therapists, under § 355.8097 of this
					 subchapter;
(B) HHAs, under §
					 355.8097 of this subchapter;
(C)
					 CORFs and ORFs, under § 355.8097 of this subchapter;
(D) freestanding psychiatric facilities,
					 under §
													RSA
					 355.8060 of this subchapter; and
(E) outpatient hospitals, under §
													RSA
					 355.8061 of this
					 subchapter.
(7)
					 Speech-language pathology services are reimbursed in accordance with the
					 Medicaid reimbursement methodologies for the applicable provider type as
					 follows:
(A) independently enrolled
					 therapists, under § 355.8097 of this subchapter;
(B) HHAs, under § 355.8097 of this
					 subchapter;
(C) CORFs and ORFs,
					 under § 355.8097 of this subchapter;
(D) freestanding psychiatric facilities,
					 under §
													RSA
					 355.8060 of this subchapter; and
(E) outpatient hospitals, under §
													RSA
					 355.8061 of this
					 subchapter.
(8)
					 Nutritional services provided by licensed dietitians are reimbursed the lesser
					 of the provider's billed charges or fees determined by HHSC in accordance with
					 §
												RSA
					 355.8085 of this subchapter.
(9) Providers are reimbursed for the
					 administration of immunizations the lesser of the provider's billed charges or
					 fees determined by HHSC in accordance with §
												RSA
					 355.8085 of this subchapter.
(10) Vaccines are reimbursed the lesser of
					 the provider's billed charges or the fees determined by HHSC in accordance with
					 §
												RSA
					 355.8085 of this subchapter.
(11) Dental services are reimbursed in
					 accordance with the following Medicaid reimbursement methodologies:
(A) Dental services provided by enrolled
					 dental providers are reimbursed in accordance with §
													RSA
					 355.8085 of this subchapter.
(B) Dental services provided by federally
					 qualified health centers (FQHCs) are reimbursed in accordance with §
													RSA
					 355.8261 of this subchapter (relating to
					 Federally Qualified Health Center Services Reimbursement).
(C) For services provided through September
					 30, 2019, publicly owned dental providers may be eligible to receive
					 Uncompensated Care (UC) payments for dental services under the Texas Healthcare
					 Transformation and Quality Improvement 1115 Waiver, as described in this
					 section. For services provided beginning October 1, 2019, eligibility for
					 publicly owned dental providers to receive waiver payments, and the methodology
					 for calculating payment amounts, is described in section 355.8208 of this
					 title. For purposes of this section, Uncompensated Care payments are payments
					 intended to defray the uncompensated costs of services that meet the definition
					 of "medical assistance" contained in §1905(a) of the Social Security Act.
					 HHSC will calculate UC payments using the following methodology:
(i) Eligible dental providers must submit an
					 annual cost report based on the federal fiscal year. HHSC will provide the cost
					 report form with detailed instructions to enrolled dental providers. Cost
					 reports are due to HHSC 180 days after the close of the applicable reporting
					 period. Providers must certify that expenditures submitted on the cost report
					 have not been claimed on any other cost report.
(ii) Payments to eligible providers will be
					 based on cost and payment data reported on the cost report along with
					 supporting documentation. As defined in the cost report and detailed
					 instructions, a cost-to-billed-charges ratio will be used to calculate total
					 allowable cost. The total allowable cost minus any payments will be the UC
					 payment due to the provider. The UC payment is calculated yearly and is
					 contingent on receipt of funds as specified in clause (iii) of this
					 subparagraph.
(iii) The funding for
					 the state share of UC payments is limited to, and obtained through,
					 intergovernmental transfers of funds from the governmental entity that owns and
					 operates the dental provider. An intergovernmental transfer that is not
					 received in the manner and by the date specified by HHSC may not be
					 accepted.
(iv) UC payments are
					 limited by the publicly owned dental provider pool aggregate limit as
					 determined by §
														RSA
					 355.8201 of this subchapter (relating to
					 Waiver Payments to Hospitals for Uncompensated Care).
(v) If actual UC costs for all eligible
					 publicly owned dental providers is greater than the publicly owned dental
					 provider pool aggregate limit as described in clause (iv) of this subparagraph,
					 then HHSC will reduce the UC payments for all eligible publicly owned dental
					 providers proportionately.
(vi) If
					 a UC payment results in an overpayment or if the federal government disallows
					 federal financial participation related to the receipt or use of supplemental
					 payments under this section, HHSC may recoup an amount equal to the federal
					 share of supplemental payments overpaid or disallowed. To satisfy the amount
					 owed, HHSC may recoup from any current or future Medicaid
					 payments.
(12)
					 Personal care services (PCS) are reimbursed in accordance with the following
					 Medicaid reimbursement methodologies for the applicable provider type:
(A) School districts delivering PCS under
					 School Health and Related Services (SHARS) are reimbursed in accordance with
					 §RSA
					 355.8443 of this division (relating to
					 Reimbursement Methodology for School Health and Related Services (SHARS));
					 and
(B) Providers other than school
					 districts delivering PCS are reimbursed as follows:
(i) PCS and PCS delivered in conjunction with
					 delegated nursing services are reimbursed fees determined by HHSC. HHSC reviews
					 the fees for individual services at least every two years based upon:
(I) analysis of Medicare fees for the same or
					 similar item or service;
(II)
					 analysis of Medicaid fees for the same or similar item or service in other
					 states; or
(III) analysis of
					 commercial fees for the same or similar item or service.
(ii) HHSC may use data sources or
					 methodologies other than those listed in clause (i) of this subparagraph to
					 establish Medicaid fees for physicians and other practitioners when HHSC
					 determines that those methodologies are unreasonable or insufficient.
(iii) PCS delivered through the Consumer
					 Directed Services payment option are reimbursed in accordance with §
														RSA
					 355.114 of this chapter (relating to Consumer
					 Directed Services Payment Option).