Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 6 - HOSPITAL SERVICES › Section 354.1072 - Authorized Inpatient Hospital Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Inpatient hospital services. Inpatient
					 hospital services include those items and services that are ordinarily
					 furnished by the hospital for the care and treatment of inpatients and are
					 provided under the direction of a physician in a Title XIX hospital or a Title
					 XVIII or XIX out-of-state hospital approved for participation. Except as
					 otherwise specified, and subject to the qualifications, limitations, and
					 exclusions set forth, benefits are provided for hospital services set forth as
					 follows when provided to eligible recipients.
(1) Duration of care. Except as otherwise
					 specified in §
												RSA 354.1175 of
					 this subchapter (relating to Organ Transplants), when an eligible recipient is
					 confined as an inpatient in a Title XIX hospital, or a Title XVIII or XIX
					 out-of-state hospital approved for participation, the Health and Human Services
					 Commission (HHSC) or its designee pays for medically necessary inpatient
					 hospital services actually furnished to the recipient during the first 30 days
					 of each Title XIX spell of illness. The Title XIX spell-of-illness limitations
					 are waived for medically necessary inpatient services provided to recipients
					 less than age twenty one. The services are subject to the utilization review
					 requirements of the Texas Medical Assistance (Medicaid) Program.
(2) Benefits for inpatient hospital care. The
					 hospital services for which benefits are provided under paragraph (1) of this
					 subsection consist of the following:
(A) bed
					 and board in semiprivate accommodations or in an intensive or coronary care
					 unit, including meals, special diets, and general nursing services; or an
					 allowance for bed and board in private accommodations, including meals, special
					 diets, and general nursing service, to the extent of the hospital's charge for
					 its most prevalent semiprivate accommodations, except that bed and board in
					 private accommodations are provided in full if required for medical
					 reasons;
(B) all other care in the
					 nature of usual hospital services; and
(C) maternity care, including the usual and
					 customary care for female recipients.
(3) HHSC will impose reimbursement denials or
					 reductions for potentially preventable events and preventable adverse events as
					 defined in §354.1070 of this division (relating to Definitions).
(4) HHSC will categorize patients based on
					 severity of illness, risk of mortality and other criteria defined by HHSC or
					 its designee to identify potentially preventable events as defined in
					 §354.1070 of this division and apply corresponding reimbursement
					 adjustments as described in Division 35 of this subchapter (relating to
					 Reimbursement Adjustment for Potentially Preventable Events).