reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 2 - MEDICAID HOME HEALTH PROGRAM › Section 355.8023 - Reimbursement Methodology for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Current through Reg. 49, No. 28; July 12, 2024
(a) Authorized
					 items provided to eligible Medicaid recipients are reimbursed the lesser of the
					 billed amount or the Medicaid reimbursement rate established by HHSC.
(b) HHSC reviews the fees for individual
					 items at least every two years as follows.
(1) If Medicare reimburses for a durable
					 medical equipment, prosthetics, orthotics and supplies (DMEPOS) item, the
					 Medicaid reimbursement rate is equal to, or a percentage of, the Medicare
					 reimbursement rate for the procedure code. If HHSC determines that the Medicare
					 reimbursement rate is insufficient, the methodologies in paragraphs (2) or (3)
					 of this subsection apply.
(2) If
					 Medicare does not reimburse for a DMEPOS item, other sources are used to
					 determine the Medicaid payment rate as follows:
(A) analysis of Medicaid fees for the same or
					 similar items in other states;
(B)
					 eighty-two percent of the manufacturer's suggested retail price
					 (MSRP);
(C) cost shown on a
					 manufacturer's invoice submitted by the provider to HHSC; or
(D) analysis of fees paid under commercial
					 insurance for the same or similar item or service.
(3) HHSC may use data sources or
					 methodologies other than those listed in paragraph (2) of this subsection to
					 establish Medicaid fees for DMEPOS when HHSC determines that those
					 methodologies are unreasonable or insufficient.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 3 - PHYSICIAN SERVICES › Section 355.8041 - Recipient-Initiated Second Opinions

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
					 Medicaid Program may now reimburse physicians when a Medicaid recipient
					 requests a second opinion regarding surgery. Payment will be made for the
					 second opinion according to the physician's profile allowance for initial
					 office visit procedures and difficulty of the examination.
(b) Recipients are encouraged to have their
					 medical records made available to the second physician to avoid duplication of
					 diagnostic testing. However, payment may be made for covered diagnostic
					 services deemed necessary by the second physician.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 4 - MEDICAID HOSPITAL SERVICES › Section 355.8056 - State-Owned Teaching Hospital Reimbursement Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) For cost reporting periods beginning on
					 or after September 1, 2008, HHSC or its designee reimburses state-owned
					 teaching hospitals under methods and procedures described in the Tax Equity and
					 Fiscal Responsibility Act of 1982 (TEFRA).
(b) For dates of admission on or after
					 September 1, 2003, state-owned teaching hospitals with allowable Direct
					 Graduate Medical Education (DGME) costs will receive a pro rata share of their
					 annual DGME cost based on availability of appropriated funds. DGME expenses are
					 not considered costs associated with inpatient hospital services and are not
					 settled to cost.
(c) Interim
					 payments are determined by multiplying a hospital's charges allowed under
					 Medicaid by the interim rate effective on the date of admission derived from
					 the hospital's most recent Medicaid cost report settlement, whether tentative
					 or final.
(d) The amount and
					 frequency of interim payments will be subject to the availability of funds
					 appropriated for that purpose. Interim payments are subject to settlement at
					 both tentative and final audit of a hospital's cost report.
(e) Cost Settlement.
(1) The cost settlement process is limited by
					 the TEFRA target cap set pursuant to the Social Security Act §1886(b)
					 (RSA
					 1395ww(b)).
(2) Notwithstanding the process in (1) of
					 this subsection, HHSC or its designee uses each hospital's final audited cost
					 report, which covers a fiscal year ending during a base year period, for
					 calculating the TEFRA target cap for a hospital.
(3) HHSC or its designee selects a new base
					 year period for calculating the TEFRA target cap at least every three
					 years.
(4) HHSC or its designee
					 increases a hospital's TEFRA target cap in years in which the target cap is not
					 reset under this paragraph, by multiplying the target cap by the CMS
					 Prospective Payment System Hospital Market Basket Index adjusted to the
					 hospital's fiscal year.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 4 - MEDICAID HOSPITAL SERVICES › Section 355.8061 - Outpatient Hospital Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Introduction. The Texas Health and Human Services Commission (HHSC), or its
					 designee reimburses outpatient hospital services under the reimbursement
					 methodology described in this section.
(1)
					 For services provided on and after the date that the modernized Medicaid
					 Management Information System (MMIS) becomes operational, HHSC, or its
					 designee, will reimburse all hospital providers based on an outpatient
					 prospective payment system (OPPS). This includes all hospitals as defined in
					 §355.8052 of this division (relating to Inpatient Hospital Reimbursement),
					 including rural, urban, and Children's. The OPPS used for reimbursement is the
					 3MT Enhanced Ambulatory Patient Groups (EAPG) calculator. EAPGs are a
					 visit-based classification system intended to reflect the type of resources
					 utilized in outpatient encounters for patients with similar clinical
					 characteristics.
(2) The following
					 are exceptions to the OPPS reimbursement methodology.
(A) Reimbursement for Long-Acting Reversible
					 Contraceptive devices.
(B) Human
					 Breast Milk Processing, Storage and Distribution.
(C) Certain Drugs Paid to Managed Care
					 Organizations on a Non-Risk Basis, as determined by HHSC.
(D) Cochlear implant devices and certain high
					 cost nerve stimulators.
(E)
					 Non-Emergent emergency room services as described in subsection (b)(1)(C) of
					 this section.
(F) State owned
					 teaching hospitals outpatient reimbursement is based on cost principals as
					 described in subsection (b) of this section.
(3) For services prior to the date that the
					 modernized MMIS becomes operational, reimbursement is outlined below in
					 subsection (b) of this section except as described in subsections (c) and (d)
					 of this section, HHSC will reimburse for outpatient hospital services based on
					 a percentage of allowable charges and an outpatient interim
					 rate.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8085 - Reimbursement Methodology for Physicians and Other Practitioners

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. This section describes the
					 Texas Medicaid reimbursement methodology that the Texas Health and Human
					 Services Commission (HHSC) uses to calculate payment for covered services
					 provided by physicians and other practitioners.
(1) There is no geographical or specialty
					 reimbursement differential for individual services.
(2) HHSC reviews the fees for individual
					 services at least every two years based upon:
(A) analysis of Medicare fees for the same or
					 similar item or service;
(B)
					 analysis of Medicaid fees for the same or similar item or service in other
					 states; or
(C) analysis of
					 commercial fees for the same or similar item or service.
(3) HHSC may use data sources or
					 methodologies other than those listed in paragraph (2) of this subsection to
					 establish Medicaid fees for physicians and other practitioners when HHSC
					 determines that those methodologies are unreasonable or insufficient.
(4) Fees for these services are
					 adjusted within available funding as described in §
												RSA
					 355.201 of this title (relating to
					 Establishment and Adjustment of Reimbursement Rates by the Health and Human
					 Services Commission).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8087 - In-Home Total Parenteral Hyperalimentation Services

Current through Reg. 49, No. 28; July 12, 2024
HHSC or its designee shall reimburse each provider for
						providing total parenteral hyperalimentation services on a monthly basis.
						Reimbursement shall be based on one-twelfth of the maximum yearly fee
						established by HHSC or its designee. Reimbursement to hospital outpatient
						departments furnishing in-home total parenteral nutrition services may not
						exceed the maximum yearly fee established by HHSC or its designee. The maximum
						yearly fee will be reviewed at least every two years, with any adjustments made
						within available funding.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8089 - In-Home Respiratory Therapy Services for Ventilator-Dependent Persons

Current through Reg. 49, No. 28; July 12, 2024
HHSC or its designee shall reimburse each respiratory
						therapy provider on a per-visit basis. Reimbursement for the visit shall be
						based on the lesser of the provider's customary charge or the maximum allowable
						fee or rate established by HHSC or its designee. Maximum visit fees/rates will
						be reviewed at least every two years, with any adjustments made within
						available funding.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8091 - Reimbursement to Licensed Professional Counselors, Licensed Clinical Social Workers, and Licensed Marriage and Family Therapists

Current through Reg. 49, No. 28; July 12, 2024
Counseling services provided by a licensed professional
						counselor, a licensed clinical social worker, or a licensed marriage and family
						therapist in compliance with applicable professional licensing laws and
						regulations are reimbursed at 70 percent of the existing fee for similar
						services provided by psychiatrists and psychologists as described in §
											RSA
						355.8085 of this title (relating to
						Reimbursement Methodology for Physicians and Other
						Practitioners).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8093 - Reimbursement Methodology for Physician Assistants

Current through Reg. 49, No. 28; July 12, 2024
(a) Covered professional services provided by
					 a physician assistant (PA) are reimbursed the lesser of the PA's billed charges
					 or 92 percent of the reimbursement for the same professional service paid to a
					 physician (M.D. or D.O.). The claim for reimbursement must either be:
(1) billed under the PA's provider number;
					 or
(2) a physician claim noting
					 that the physician was supervising the activity of the PA and did not, on the
					 date the service was rendered, make a decision about the patient's
					 care.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8095 - Medicaid Administrative Claiming Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Medicaid Administrative
					 Claiming (MAC) is a joint federal-state funded health care program which
					 provides reimbursement for the costs of Medicaid administrative activities that
					 refer eligible or potentially eligible Medicaid recipients to appropriate
					 Medicaid and health-related services.
(b) Definitions. The following definitions
					 apply when the terms are used in this section.
(1) CMS--Centers for Medicare & Medicaid
					 Services. The federal agency within the United States Department of Health and
					 Human Services responsible for overseeing and directing Medicare and Medicaid,
					 or its successor.
(2) FFY--Federal
					 fiscal year. Begins October 1 and ends September 30 of the following calendar
					 year.
(3) Governmental entity--A
					 state agency or a political subdivision of the state. A governmental entity
					 includes a city, county, school district, special district, community mental
					 health center, or other unit of government.
(4) HHSC--The Texas Health and Human Services
					 Commission or its designee.
(5) MAC
					 Financial Claim--The claim for reimbursement submitted to HHSC by a
					 governmental entity each federal fiscal quarter.
(6) Participant--A governmental entity
					 employee or contractor position, including a federally funded position,
					 responsible for performing MAC activities in support of Medicaid or medical
					 services as a weekly part of the position's job duties. These activities must
					 directly support efforts to identify, enroll, and maintain Medicaid eligibility
					 for eligible and potentially-eligible children and adults.
(7) PL--Participant list. A comprehensive
					 list of all participants eligible for inclusion in the Random Moment Time
					 Study, as defined in paragraph (9) of this subsection.
(8) QSI--Quarterly Summary Invoice. An
					 invoice of costs reimbursable to a MAC participating governmental
					 entity.
(9) RMTS--Random Moment
					 Time Study. A federally-approved, statistical sampling technique administered
					 by HHSC to identify the percentage of time that is reimbursable under the MAC
					 program versus the percentage of time that is directly or indirectly related to
					 covered services and other activities.
(10) STAIRS--State of Texas Automated
					 Information Reporting System. HHSC's online application for submitting cost
					 reports and accountability reports.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 5 - GENERAL ADMINISTRATION › Section 355.8097 - Reimbursement Methodology for Physical, Occupational, and Speech Therapy Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
					 This section describes the Texas Medicaid reimbursement methodology that the
					 Texas Health and Human Services Commission (HHSC) uses to calculate payments
					 for covered therapy services provided by home health agencies, comprehensive
					 outpatient rehabilitation facilities or outpatient rehabilitation facilities,
					 independent therapists (including Early Childhood Intervention) and physicians
					 and other practitioners.
(b) HHSC
					 reviews the fees for individual services at least every two years based upon:
(1) analysis of Medicare fees for the same or
					 similar item or service;
(2)
					 analysis of Medicaid fees for the same or similar item or service in other
					 states; and
(3) analysis of fees
					 paid under commercial insurance for the same or similar item or
					 service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 7 - AMBULATORY SURGICAL CENTERS › Section 355.8121 - Reimbursement to Ambulatory Surgical Centers

Current through Reg. 49, No. 28; July 12, 2024
(a) For dates of service on and after the
					 date that the modernized Medicaid Management Information System (MMIS) becomes
					 operational, providers will be reimbursed based on an outpatient prospective
					 payment system (OPPS).
(1) The OPPS utilized
					 is 3MT Enhanced Ambulatory Patient Groups (EAPG) calculator.
(2) EAPGs are a visit-based classification
					 system intended to reflect the type of resources utilized in outpatient
					 encounters for patients with similar clinical
					 characteristics.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 8 - HEARING AID SERVICES › Section 355.8141 - Reimbursement for Hearing Aid Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 The Texas Department of Health or its designee shall make direct vendor
					 payments to providers of hearing aid services participating in the Texas
					 Medical Assistance (Medicaid) Program. Participating providers are reimbursed
					 within the limits defined by the maximum allowable fee schedule for hearing aid
					 services established by the Texas Board of Health.
(b) Reimbursement for a hearing aid shall be
					 based on the lowest of the invoice cost of the hearing aid, the acquisition
					 cost of the hearing aid, or the department's maximum allowable fee.
(1) Providers must include on the claim form
					 the model number, serial number, and warranty date of the hearing
					 aid.
(2) The department may
					 authorize reimbursement for a hearing aid that exceeds the maximum allowable
					 fee under the following conditions:
(A) the
					 recipient shall certify in writing a preference for a specific hearing aid;
					 and
(B) the recipient shall
					 acknowledge in the certification the responsibility to pay the difference
					 between the acquisition cost of the preferred instrument and the department's
					 maximum allowable fee.
(3) The department or its designee shall
					 establish a fee schedule to set the upper limits of reimbursement for
					 authorized hearing aid services. The fee schedule shall include costs for
					 hearing aids, earmolds, evaluation, fitting and dispensing, and follow-up
					 visits.
(A) The maximum allowable fee
					 schedule is subject to periodic review by the department or its designee to
					 determine if adjustment to the fee schedule is necessary. The fee schedule is
					 compared to the aggregate of providers' billed charges and invoice or
					 acquisition costs to determine the necessity for and extent of adjustment. Any
					 adjustment to the fee schedule is subject to the availability of legislatively
					 appropriated funds. The department or its designee informs participating
					 providers of changes to the fee schedule through the Texas Medicaid Bulletin
					 which is distributed to all providers enrolled in the Texas Medicaid
					 Program.
(B) Reimbursement for a
					 physician's examination to determine the need for a hearing aid shall not be
					 subject to the fee schedule. The department shall consider the examination a
					 physician service and shall reimburse physicians according to the methodology
					 described in § 29.1104 of this title (relating to Texas Medicaid
					 Reimbursement Methodology (TMRM)).
(4) The department or its designee does not
					 reimburse institutions or hospitals for hearing aid services and supplies as
					 separate items of service if these supplies and services are included in their
					 reimbursement formula.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 9 - MIDWIVES › Section 355.8161 - Reimbursement Methodology for Midwife Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Certified Nurse Midwives. Covered
					 professional services provided by a certified nurse midwife (CNM) are
					 reimbursed the lesser of the CNM's billed charges or 92 percent of the
					 reimbursement for the same professional service paid to a physician (M.D. or
					 D.O.). The claim for reimbursement must either be:
(1) billed under the CNM's provider number;
					 or
(2) a physician claim indicating
					 that the physician was supervising the activity of the CNM and did not, on the
					 date the service was rendered, make a decision about the patient's
					 care.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 10 - BIRTHING CENTER SERVICES › Section 355.8181 - Birthing Center Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Subject to the specifications, conditions, limitations, and requirements
					 established by the Health and Human Services Commission (HHSC), payment for
					 covered birthing center services provided by a participating birthing center is
					 limited to the lesser of the provider's customary charge or the maximum
					 allowable fee listed on a fee schedule established by HHSC.
(b) The birthing center must bill for the
					 covered services that it provides. The attending physician, certified nurse
					 midwife (CNM), or licensed midwife (LM) will be reimbursed separately. Unless
					 approved by HHSC, the birthing center may not bill for services provided by
					 another type of provider. The birthing center must be enrolled and approved for
					 participation in the Medicaid program at the time the services are
					 provided.
(c) Reimbursement for
					 services provided by a physician is described in §
											RSA
					 355.8085 of this subchapter (relating to
					 Reimbursement Methodology for Physicians and Other Practitioners).
					 Reimbursement for services provided by a CNM or an LM is described in §
											RSA
					 355.8161 of this subchapter (relating to
					 Reimbursement Methodology for Midwife Services).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8200 - Retained Funds for the Uncompensated Care Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Texas Healthcare
					 Transformation and Quality Improvement Program under §1115(a), Medicaid
					 demonstration waiver payments available under this division help to defray the
					 uncompensated cost of charity care provided by eligible hospitals and physician
					 practices on or after October 1, 2019. Participation in the Texas Healthcare
					 Transformation and Quality Improvement Program is subject to an application
					 fee.
(b) Definition. A non-public
					 provider, when the term is used in this section, is defined as a provider who
					 is owned by any entity other than a unit of local, state, or federal
					 government.
(c) Applicability. The
					 requirement to submit an application fee applies to all non-public providers in
					 the state.
(d) Application Fee. An
					 application fee will be required with the submission of the application
					 described in §
											RSA
					 355.8212(c)(2) of this
					 subchapter.
(1) The application fee will be
					 determined annually based upon an estimate of the amount equal to the estimated
					 costs necessary to administer the program and will be posted on the Texas
					 Health and Human Services Commission Provider Finance Department
					 website.
(2) Payment is due at the
					 time of the submission of the application. If no payment is received with the
					 application, an account receivable will be established. HHSC will offset the
					 next applicable payment to the provider against the account receivable until
					 the obligation to the state is discharged.
(3) Payment must be made in the manner
					 determined by HHSC and in compliance with payment instructions that will be
					 posted on the HHSC Provider Finance Department website.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8203 - Delivery System Reform Incentive Payments

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Texas Healthcare
					 Transformation and Quality Improvement Program §1115(a) Medicaid
					 demonstration waiver payments are available under this section for eligible
					 performers described in subsection (c) of this section. Waiver payments to
					 performers must be in compliance with the Centers for Medicare and Medicaid
					 Services approved waiver Program Funding and Mechanics Protocol, HHSC waiver
					 instructions and this section.
(b)
					 Definitions.
(1) Centers for Medicare and
					 Medicaid Services (CMS)--The federal agency within the United States Department
					 of Health and Human Services responsible for overseeing and directing Medicare
					 and Medicaid, or its successor.
(2)
					 Delivery System Reform Incentive Payments (DSRIP)--Payments related to the
					 development or implementation of a program of activity that supports a
					 performer's efforts to enhance access to health care, the quality of care, and
					 the health of patients and families it serves.
(3) Demonstration year--The 12-month period
					 beginning October 1 for which the payments calculated under this section are
					 made.
(4) Governmental entity--A
					 state agency or a political subdivision of the state. A governmental entity
					 includes a hospital authority, hospital district, city, county, or state
					 entity.
(5) HHSC--The Texas Health
					 and Human Services Commission or its designee.
(6) Intergovernmental transfer (IGT)--A
					 transfer of public funds from a governmental entity to HHSC.
(7) Performer--A Medicaid provider that
					 implements one or more DSRIP projects.
(8) Public funds--Funds derived from taxes,
					 assessments, levies, investments, and other public revenues within the sole and
					 unrestricted control of a governmental entity. Public funds do not include
					 gifts, grants, trusts, or donations, the use of which is conditioned on
					 supplying a benefit solely to the donor or grantor of the funds.
(9) Regional Healthcare Partnership (RHP)--A
					 collaboration of interested participants that work collectively to develop and
					 submit to the state a regional plan for health care delivery system reform.
					 Regional Healthcare Partnerships will support coordinated, efficient delivery
					 of quality care and a plan for investments in system transformation that is
					 driven by the needs of local hospitals, communities, and populations.
(10) RHP plan--A multi-year plan within which
					 participants propose their portion of waiver funding and DSRIP
					 projects.
(11) Waiver--The Texas
					 Healthcare Transformation and Quality Improvement Program Medicaid
					 demonstration waiver under §1115 of the Social Security Act.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8204 - Funding for DSRIP Monitoring Program

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Introduction. The Texas Healthcare Transformation and Quality Improvement
					 Program §1115(a) Medicaid demonstration waiver provides for supplemental
					 payments to many types of providers. In order to ensure that such payments are
					 made properly, HHSC will contract with one or more independent entities to
					 monitor the Delivery System Reform Incentive Payment (DSRIP) program. This
					 section describes the method by which HHSC will gain the source of the
					 non-federal share of payments to reimburse the independent entity for its
					 administrative expenses. For purposes of this rule, the definitions in §
											RSA 354.1602 of this
					 title (relating to Definitions) apply, except where otherwise
					 indicated.
(b) Funding for Delivery
					 System Reform Incentive Payment program monitoring. HHSC will allocate an
					 intergovernmental transfer (IGT) amount to each DSRIP IGT entity to fund DSRIP
					 monitoring activities.
(1) HHSC will
					 determine the amount of the IGT allocation in each demonstration year for each
					 IGT entity. The amount of the IGT allocation for each IGT entity will be
					 calculated using the following formula: IGT Allocation =
					 (AffiliatedValue/DYValue) x TotalIGT, where:
(A) "AffiliatedValue" is the portion of the
					 value for which the IGT entity agreed to fund the non-federal share for all
					 DSRIP projects that the IGT entity is affiliated with for a particular
					 demonstration year; and
(B)
					 "DYValue" is the value for all DSRIP projects in the state for the same
					 demonstration year as used in subparagraph (A) of this paragraph.
(C) "TotalIGT" is the total amount of IGT
					 necessary for monitoring activities in a demonstration year, as determined by
					 HHSC. This amount may not be greater than $5 million.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8205 - Delivery System Reform Incentive Payments for Demonstration Years 7-8

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Texas Healthcare
					 Transformation and Quality Improvement Program §1115(a) Medicaid
					 demonstration waiver Delivery System Reform Incentive Payment (DSRIP) program
					 payments for demonstration year (DY) 7 and DY8 are available under this section
					 for eligible performers described in subsection (c) of this section. DSRIP
					 payments to performers must be in compliance with the Centers for Medicare
					 & Medicaid Services (CMS) approved Program Funding and Mechanics Protocol,
					 Health and Human Services Commission (HHSC) instructions, and this
					 section.
(b) Definitions.
(1) Demonstration Year (DY) 6--Federal fiscal
					 year 2017 (October 1, 2016 - September 30, 2017).
(2) Demonstration Year (DY) 7--Federal fiscal
					 year 2018 (October 1, 2017 - September 30, 2018).
(3) Demonstration Year (DY) 8--Federal fiscal
					 year 2019 (October 1, 2018 - September 30, 2019).
(4) Performer--A provider enrolled in Texas
					 Medicaid that participates in DSRIP and receives DSRIP payments.
(5) Regional Healthcare Partnership (RHP)
					 Plan Update--An RHP plan for the initial demonstration period and DY6 that is
					 updated for DY7-8, as further described in § 354.1697 of this title
					 (relating to RHP Plan Update).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8206 - Funding for DSRIP Monitoring Program for Demonstration Years 7-8

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. The Texas Healthcare
					 Transformation and Quality Improvement Program §1115(a) Medicaid
					 demonstration waiver provides for Delivery System Reform Incentive Payment
					 (DSRIP) program payments to eligible performers. In order to ensure that such
					 payments are made properly, the Health and Human Services Commission (HHSC)
					 will contract with one or more independent entities to monitor the DSRIP
					 program. This section describes the method by which HHSC will gain the source
					 of the non-federal share of payments to reimburse the independent entity for
					 its administrative expenses. For purposes of this section, the definitions in
					 § 354.1691 of this title (relating to Definitions) apply, except where
					 otherwise indicated.
(b) Funding
					 for DSRIP program monitoring. HHSC will allocate an intergovernmental transfer
					 (IGT) amount to each DSRIP IGT entity to fund DSRIP monitoring activities.
(1) HHSC will determine the amount of the IGT
					 allocation in each demonstration year (DY) for each IGT entity. The amount of
					 the IGT allocation for each IGT entity will be calculated using the following
					 formula: IGT Allocation = (AffiliatedValue divided by DYValue) multiplied by
					 TotalIGT, where:
(A) "AffiliatedValue" is the
					 portion of the value for which the IGT entity agreed to fund the non-federal
					 share for all DSRIP performers that the IGT entity is affiliated with for a
					 particular DY;
(B) "DYValue" is the
					 value for all DSRIP performers in the state for the same DY as used in
					 subparagraph (A) of this paragraph; and
(C) "TotalIGT" is the total amount of IGT
					 necessary for monitoring activities in a DY, as determined by HHSC, which may
					 not be greater than $5 million.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8216 - Delivery System Reform Incentive Payments for Demonstration Years 9-10

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Texas Healthcare
					 Transformation and Quality Improvement Program §1115(a) Medicaid
					 demonstration waiver Delivery System Reform Incentive Payment (DSRIP) program
					 payments for demonstration year (DY) 9-10 are available under this section for
					 eligible performers described in subsection (c) of this section. DSRIP payments
					 to performers must be in compliance with the Centers for Medicare &
					 Medicaid Services (CMS) approved Program Funding and Mechanics Protocol, Health
					 and Human Services Commission (HHSC) instructions, and this section.
(b) Definitions.
(1) Demonstration Year (DY) 7--Federal fiscal
					 year 2018 (October 1, 2017 - September 30, 2018).
(2) Demonstration Year (DY) 8--Federal fiscal
					 year 2019 (October 1, 2018 - September 30, 2019).
(3) Demonstration Year (DY) 9--Federal fiscal
					 year 2020 (October 1, 2019 - September 30, 2020).
(4) Demonstration Year (DY) 10--Federal
					 fiscal year 2021 (October 1, 2020 - September 30, 2021).
(5) Performer--A provider enrolled in Texas
					 Medicaid that participates in DSRIP and receives DSRIP payments.
(6) Regional Healthcare Partnership (RHP)
					 Plan Update--An RHP plan for DY7-8 that is updated for DY9-10, as further
					 described in § 354.1737 of this title (relating to RHP Plan Update for
					 DY9-10).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8218 - Funding for DSRIP Monitoring Program for Demonstration Years 9-10

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. The Texas Healthcare
					 Transformation and Quality Improvement Program §1115(a) Medicaid
					 demonstration waiver provides for Delivery System Reform Incentive Payment
					 (DSRIP) program payments to eligible performers. In order to ensure that such
					 payments are made properly, the Health and Human Services Commission (HHSC)
					 will contract with one or more independent entities to monitor the DSRIP
					 program. This section describes the method by which HHSC will gain the source
					 of the non-federal share of payments to reimburse the independent entity for
					 its administrative expenses. For purposes of this section, the definitions in
					 § 354.1729 of this title (relating to Definitions) apply, except where
					 otherwise indicated.
(b) Funding
					 for DSRIP program monitoring. HHSC will allocate an intergovernmental transfer
					 (IGT) amount to each DSRIP IGT entity to fund DSRIP monitoring activities.
(1) HHSC will determine the amount of the IGT
					 allocation in each demonstration year (DY) for each IGT entity. The amount of
					 the IGT allocation for each IGT entity will be calculated using the following
					 formula: IGT Allocation = (AffiliatedValue divided by DYValue) multiplied by
					 TotalIGT, where:
(A) "AffiliatedValue" is the
					 portion of the value for which the IGT entity agreed to fund the non-federal
					 share for all DSRIP performers that the IGT entity is affiliated with for a
					 particular DY;
(B) "DYValue" is the
					 value for all DSRIP performers in the state for the same DY as used in
					 subparagraph (A) of this paragraph; and
(C) "TotalIGT" is the total amount of IGT
					 necessary for monitoring activities in a DY, as determined by HHSC, which may
					 not be greater than $5 million.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 12 - CERTIFIED REGISTERED NURSE ANESTHETISTS AND ANESTHESIOLOGIST ASSISTANTS › Section 355.8221 - Reimbursement Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) Effective for
					 services delivered on and after November 1, 2017, covered anesthesia services
					 provided by a certified registered nurse anesthetist (CRNA) or an
					 anesthesiologist assistant (AA) under the supervision of an anesthesiologist
					 are reimbursed the lesser of the CRNA's or AA's billed charges or 50 percent of
					 the calculated payment for a supervised anesthesia service. For example, if the
					 calculated payment for a supervised anesthesia service is $100, the payment to
					 the CRNA or AA would be $50.
(b)
					 Effective for services delivered on and after November 1, 2017, covered
					 anesthesia services provided by a CRNA under the supervision of a physician,
					 other than an anesthesiologist, are reimbursed at 92 percent of the calculated
					 payment for an anesthesia service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 13 - CHEMICAL DEPENDENCY TREATMENT FACILITY SERVICES › Section 355.8241 - Reimbursement Methodology for Chemical Dependency Treatment Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the specifications,
					 conditions, limitations, and requirements established by the Health and Human
					 Services Commission (HHSC), payment for covered chemical dependency treatment
					 facility services provided by a participating chemical dependency treatment
					 facility (CDTF) is limited to the lesser of the provider's customary charge or
					 the maximum allowable fee established by HHSC.
(b) A CDTF must bill for the covered services
					 that it provides. Services provided by an attending physician or laboratory
					 will be reimbursed separately. The CDTF must be enrolled and approved for
					 participation in the Medicaid program at the time the services are
					 provided.
(c) HHSC will conduct
					 periodic rate reviews and will update the Medicaid CDTF fee schedule as needed.
					 HHSC may adjust rates based on an analysis of:
(1) the Centers for Medicare and Medicaid
					 Services fees for similar services;
(2) Medicaid fees paid by other
					 states;
(3) a survey of costs
					 reported by CDTFs;
(4) data
					 provided by the United States Department of Labor;
(5) previous Medicaid payments for
					 Medicaid-reimbursable CDTF services; or
(6) a combination of sources described in
					 paragraphs (1) - (5) of this subsection.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 14 - FEDERALLY QUALIFIED HEALTH CENTER SERVICES › Section 355.8261 - Federally Qualified Health Center Services Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
(a) Prospective Payment System (PPS)
					 Methodology. Federally Qualified Health Centers (FQHCs) selecting the PPS
					 methodology, in accordance with section 1902(bb) of the Social Security Act, as
					 amended by the Benefits Improvement and Protection Act (BIPA) of 2000
					 (RSA
					 1396a(bb)), effective for
					 the FQHC's fiscal year that includes dates of service occurring January 1,
					 2001, and after, will be reimbursed a PPS per visit encounter rate for Medicaid
					 covered services. FQHCs are reimbursed a prospective per visit encounter rate
					 for a visit that meets the requirements of subsections (b)(12) and (13) of this
					 section. The final base rate for each FQHC existing in 2000 was calculated
					 based on one hundred percent (100%) of the average of the FQHC's reasonable
					 costs for providing Medicaid covered services as determined from audited cost
					 reports for the FQHC's 1999 and 2000 fiscal years. The final base rate was
					 calculated by adding the total audited reimbursable costs as determined from
					 the 1999 and 2000 cost reports and dividing by the total audited visits for
					 these same two periods. The reimbursement methodologies described in subsection
					 (b) of this section apply to the PPS methodology, except for the following:
(1) The effective rate for APPS described in
					 subsection (b)(4) of this section does not apply to PPS. Increases in the final
					 base rate or the effective rate for a PPS-reimbursed FQHC shall be the rate of
					 change in the Medicare Economic Index (MEI) for primary care. If the increase
					 in an FQHC's costs is greater than the MEI for PPS, an FQHC may request an
					 adjustment of its effective rate as described in subsection (b)(6) of this
					 section.
(2) State initiated
					 reviews, described in subsection (b)(10)(D) of this section, are not applicable
					 for providers who select the PPS methodology.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 15 - NURSE PRACTITIONERS AND CLINICAL NURSE SPECIALISTS › Section 355.8281 - Reimbursement Methodology for Nurse Practitioners and Clinical Nurse Specialists

Current through Reg. 49, No. 28; July 12, 2024
(a) Covered
					 professional services provided by a nurse practitioner (NP) or a clinical nurse
					 specialist (CNS) are reimbursed the lesser of the NP's or CNS' billed charges
					 or 92 percent of the reimbursement for the same professional service paid to a
					 physician (M.D. or D.O.). The claim for reimbursement must either be:
(1) billed under the NP's or CNS' provider
					 number; or
(2) a physician claim
					 noting that the physician was supervising the activity of the NP or CNS and did
					 not, on the date the service was rendered, make a decision about the patient's
					 care.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 19 - MEDICAID MANAGED CARE: STANDARDS FOR THE STATE OF TEXAS ACCESS REFORM (STAR) › Section 355.8361 - Rates and Payment Structures

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 department shall develop payment methodologies based on state maximum
					 capitation amounts or negotiated rates to determine payments for providing STAR
					 Program services.
(b) In a service
					 arrangement in which the state contracts with a hospital to provide services
					 for STAR Program members, the department may negotiate with hospitals to
					 establish payment rates for inpatient and outpatient services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 21 - CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN › Section 355.8401 - Reimbursement Methodology for Case Management for Children and Pregnant Women

Current through Reg. 49, No. 28; July 12, 2024
(a) Qualified providers. Payments are made to
					 qualified providers delivering case management services to Medicaid-eligible
					 individuals who are eligible for Case Management for Children and Pregnant
					 Women according to Department of State Health Services (DSHS) rules at 25 TAC
					 Chapter 27 (relating to Case Management for Children and Pregnant
					 Women).
(b) Unit of service. Case
					 Management for Children and Pregnant Women services are limited to one contact
					 per day per client. Qualified providers are reimbursed based on a prospective
					 and uniform statewide rate for the following types of services:
(1) comprehensive visit;
(2) face-to-face case management visit;
					 and
(3) telephone case management
					 visit.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 22 - REIMBURSEMENT METHODOLOGY FOR THE EARLY CHILDHOOD INTERVENTION PROGRAM › Section 355.8421 - Reimbursement for Case Management Services for Infants and Toddlers with Developmental Disabilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Authority.
					 Payments are made to qualified providers delivering case management services to
					 Medicaid-eligible individuals who are eligible for services in the Early
					 Childhood Intervention Program (ECI) according to the program rules established
					 by the Department of Assistive and Rehabilitative Services (DARS). The
					 reimbursement determination authority is specified in §
											RSA 355.101 of this
					 title (relating to Introduction).
(b) Unit of service. Qualified providers are
					 reimbursed based on a 15-minute unit of service that is a prospective and
					 uniform statewide rate for the following types of services:
(1) face-to-face case management visit;
					 and
(2) telephone case management
					 visit.