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 22 - REIMBURSEMENT METHODOLOGY FOR THE EARLY CHILDHOOD INTERVENTION PROGRAM › Section 355.8422 - Reimbursement for Specialized Rehabilitation 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 specialized rehabilitation 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 §
											355.101 of this title (relating to
					 Introduction).
(b) Unit of service.
					 The unit of service is one hour and will be pro-rated for 15-minute intervals
					 for specialized rehabilitation services on an individual and group
					 basis.
(c) Rate methodology.
(1) Initial rates. The rate effective October
					 1, 2011, will be the initial statewide rate.
(2) Cost report-based rates. After the Health
					 and Human Services Commission (HHSC) determines that cost data collected as
					 described in subsection (d) of this section is reliable and sufficient to
					 support development of a cost report-based rate, HHSC will develop statewide
					 reimbursement rates using that data to replace the initial rates as follows:
(A) Project each provider's total allowable
					 cost per type of service from the historical cost reporting period to the
					 prospective reimbursement period, using inflation factors according to §
													355.108 of this title (relating to
					 Determination of Inflation Indices), to arrive at the projected cost per type
					 of service;
(B) For each provider,
					 divide the projected cost per type of service, determined in subparagraph (A)
					 of this paragraph, by the provider's total units of service per type of service
					 delivered during the historical cost reporting period, to arrive at the
					 provider's projected cost per unit of service for each type of service;
					 and
(C) For each type of service:
(i) Arrange all providers' projected cost per
					 unit of service in an array from low to high, with the corresponding total
					 number of units of service for each provider;
(ii) Sum the total number of units of service
					 for each provider in the array progressively from low to high to create a
					 running total;
(iii) Divide the
					 total number of units of service by two;
(iv) Identify the value, from the running
					 total sums calculated in clause (ii) of this subparagraph, that is closest to
					 the result in clause (iii) of this subparagraph; and
(v) Identify the cost per unit of service
					 that corresponds to the value identified in clause (iv) of this subparagraph,
					 to arrive at the recommended rate for that 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 23 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 355.8443 - Reimbursement Methodology for School Health and Related Services (SHARS)

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Reimbursement is available
					 to a Local Education Agency (LEA) for providing certain direct medical and
					 transportation services, known as SHARS, to a Medicaid-enrolled student with a
					 disability age 20 years of age or younger. SHARS services are described in and
					 must be prescribed in accordance with §
											RSA
					 354.1341 of this title (relating to Benefits
					 and Limitations).
(b) Definitions.
					 The following words and terms, when used in this section, have the following
					 meanings, unless the context clearly indicates otherwise.
(1) Cost report--An annual report documenting
					 the LEA's Medicaid-allowable costs for all SHARS delivered during the previous
					 federal fiscal year. The cost report is due on or before April 1 of the year
					 following the reporting period and must be certified in a manner specified by
					 the Texas Health and Human Services Commission (HHSC). The primary purposes of
					 the cost report are to:
(A) document the
					 LEA's total Medicaid-allowable costs for delivering SHARS, including direct
					 costs and indirect costs, based on federally mandated cost allocation
					 methodologies; and
(B) reconcile
					 interim payments to total Medicaid-allowable costs based on approved cost
					 allocation methodology procedures.
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 355.8445 - Reimbursement for Environmental Lead Investigations

Current through Reg. 49, No. 28; July 12, 2024
(a) A rate is established per completed
					 environmental lead investigation.
(b) The initial rate is based on the
					 estimated cost to perform an inspection of a child's primary dwelling. The
					 estimated costs used to develop this initial rate include: estimated salary and
					 fringe benefits cost and estimated indirect costs.
(1) Estimated Salary and Fringe Benefits
					 Cost. The estimated number of staff hours required per environmental lead
					 investigation is multiplied by the estimated salary and fringe benefits per
					 hour to determine the estimated salary and fringe benefits cost per
					 investigation.
(2) Estimated
					 Indirect Cost. The estimated annual equipment cost is calculated by dividing
					 the equipment cost by the estimated life in years of the equipment. The
					 estimated annual supply cost is calculated by multiplying the cost of lead
					 testing supplies necessary for each instrument by the total number of
					 instruments. This estimated annual equipment cost is then added to the
					 estimated annual supply cost and the total is divided by the estimated number
					 of environmental lead investigations that will be completed annually to
					 determine the estimated indirect cost per investigation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 24 - EPSDT: EYEGLASS PROGRAM › Section 355.8461 - Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
The Health and Human Services Commission (HHSC)
						determines and may adjust the reimbursement rate or methodologies for vision
						care services according to the provisions as described in §
											RSA
						355.8085 of this title (relating to Texas
						Medicaid Reimbursement Methodology).
(1) Examination. Reimbursement for eye
					 examinations is determined in accordance with §
											RSA
					 355.8085 of this title (relating to Texas
					 Medicaid Reimbursement Methodology)
(2) Eyeglasses. Reimbursement for eyeglasses
					 is based on:
(A) the unit cost for each pair
					 of eyeglasses rather than costs for components; or
(B) a fixed-unit price determined by
					 competitive procurement, as authorized in §
												RSA
					 354.1025 of this title (relating to
					 Competitive Procurement of Vision Care Services). If eyewear is provided under
					 competitive procurement, a dispensing fee may be paid to the dispensing
					 provider in accordance with §
												RSA
					 355.8085 of this title (relating to Texas
					 Medicaid Reimbursement 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 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8541 - Legend and Nonlegend Medications

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Legend and nonlegend drug reimbursement. A pharmaceutical provider is
					 reimbursed for legend and nonlegend drugs based on the lesser of the:
(1) acquisition cost (AC) plus the Health and
					 Human Services Commission's (HHSC's) currently established professional
					 dispensing fee per prescription;
(2) usual and customary price charged the
					 general public; or
(3) Gross Amount
					 Due, if provided.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8542 - Drug Price Effective Date

Current through Reg. 49, No. 28; July 12, 2024
Subject to the requirements of Chapter 354, Subchapter F
						of this title (relating to Pharmacy Services), new prices and price updates are
						effective for reimbursement purposes on the day the Health and Human Services
						Commission receives the new prices and price updates from drug companies,
						wholesalers, or other reliable sources.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8543 - Nonlegend Drug Restrictions

Current through Reg. 49, No. 28; July 12, 2024
Except insulin, nonlegend drugs and nutritional products
						are not reimbursed when dispensed to recipients in nursing facilities and other
						institutions where those drugs are included in the reimbursement formula. Also,
						these drugs are not allowed to be charged to a recipient or a person authorized
						to act for the recipient.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8544 - Usual and Customary Prices

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 usual and customary price is the price the provider most frequently charges the
					 general public for the same drug. If the department cannot determine a most
					 frequent price, the median price is used. Items that the provider must consider
					 when determining the usual and customary price include the following:
(1) The term general public does not include
					 any person whose prescriptions are paid by third-party payors, including health
					 insurers, governmental entities, and the Texas Medical Assistance (Medicaid)
					 Program.
(2) When a discount is
					 given (including, but not limited to, cash rebate, monetary price discount,
					 coupon of value) or advertised for any segment of the general public, the
					 discount must be included in the usual and customary price determination for
					 Medicaid prescriptions if the Medicaid recipient would otherwise have qualified
					 as a member of that same segment of the general public. Some providers give
					 discounts to non-Medicaid customers based on requirements similar to those
					 specified in subparagraphs (A) and (B) of this paragraph. Providers must not
					 use the following types of requirements as reasons to disqualify Medicaid
					 recipients as members of the same segment of the general public receiving the
					 discount:
(A) possessing or presenting a
					 special identification card or document, or making a verbal request for a
					 discount;
(B) paying for the
					 prescription by a particular method.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8546 - Brand-Name Drugs

Current through Reg. 49, No. 28; July 12, 2024
(a) Physicians who
					 want a brand name drug dispensed on a prescription for a multisource drug must
					 handwrite the phrase "Brand necessary" on the face of the prescription. This
					 procedure enables payment for the drug at the more expensive brand name
					 acquisition cost. To indicate this certification (override) on the pharmacy
					 claim form, the pharmacy provider must enter "1" in the field for "Dispense as
					 Written." For telephone orders involving physician overrides, a written
					 prescription must be obtained from the prescribing physician within 30 days
					 from the time the order was placed.
(b) A physician override for a prescription
					 is valid only for the life of the prescription. The life of the prescription is
					 defined as the original dispensing and any authorized refills, not to exceed
					 eleven refills or a twelve-month supply. The physician override cannot be
					 forwarded or transferred to any other prescription for the same drug.
(c) A pharmacy provider that dispenses a
					 brand drug that is subject to a generic reimbursement and bills HHSC for the
					 service must accept Medicaid reimbursement as payment in full. No additional
					 dispensing fee or product cost amounts may be billed to the Medicaid
					 recipient.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8547 - Reimbursement for Compound Prescriptions

Current through Reg. 49, No. 28; July 12, 2024
Reimbursement for compounded prescriptions is based on
						acquisition cost of the ingredients used, verifiable by invoice audit, plus
						HHSC's currently established professional dispensing fee per prescription or
						the usual and customary price charged to the general public, whichever is
						lower. Only drugs listed in the latest revision of the Texas Drug Code Index
						are considered for reimbursement. There is no provision for a compounding fee
						over and above the professional dispensing fee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8548 - 340B Covered Entities

Current through Reg. 49, No. 28; July 12, 2024
(a) Scope. This
					 section applies to each manufacturer of outpatient drugs that has executed an
					 agreement with the Secretary of the United States Department of Health and
					 Human Services under Section 340B of the Public Health Service Act
					 (RSA
					 256b).
(b) Definitions. For purposes of this
					 section, the following terms are defined as follows:
(1) 340B covered entity--A health-care
					 organization enrolled in the 340B Program.
(2) 340B covered outpatient drug--A drug
					 eligible for purchase through the 340B Program, as defined in 42 C.F.R. §
					 10.20 and § 10.21.
(3) 340B
					 price--The maximum price that the United States Health Resources and Services
					 Administration will allow a drug manufacturer to charge a 340B covered entity
					 for a 340B covered outpatient drug purchased through the 340B program. The 340B
					 price is also known as the "ceiling price."
(4) 340B program--A drug-pricing program
					 established under Section 340B of the Public Health Service Act (RSA
					 256b) under which a manufacturer of covered
					 outpatient drugs agrees that it will not charge a 340B covered entity more than
					 the 340B price for a 340B covered outpatient drug.
(5) HHSC--The Texas Health and Human Services
					 Commission or its designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8549 - Reimbursement to Hospitals and Physicians Who Dispense Drugs

Current through Reg. 49, No. 28; July 12, 2024
Reimbursements to licensed physicians who dispense their
						own drugs and to hospitals with outpatient pharmacies are based on actual
						invoice cost, verifiable by audit, plus a dispensing fee assigned by the
						department or the provider's usual and customary charge to the general public,
						whichever is lower.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8550 - Third-Party Resources

Current through Reg. 49, No. 28; July 12, 2024
The Texas Vendor Drug Program assumes liability after
						Medicare or other third-party benefits are exhausted. Benefits available under
						the Texas Medical Assistance (Medicaid) Program are reduced to the extent that
						they are payable through other federal, state, or local program, insurance
						coverage, or third-party coverage to which the eligible recipient may be
						entitled, or to the extent coverage is provided under federal or state law.
						When these benefits are available, they are considered a resource. In agreement
						with the department, exceptions must be on an individual claim basis. Free
						benefits to recipients from other sources are considered a resource when
						determining what benefits, if any, are available under the Medicaid
						program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 28 - PHARMACY SERVICES: REIMBURSEMENT › Section 355.8551 - Professional Dispensing Fee

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 following words and terms, when used in this section, have the following
					 meanings, unless the context clearly indicates otherwise.
(1) Acquisition Cost--As defined in
					 §355.8541 of this division (relating to Legend and Nonlegend
					 Medications).
(2) Delivery
					 Incentive--An incentive for offering no-charge prescription delivery to all
					 Medicaid recipients, in accordance with subsection (d) of this
					 section.
(3) Professional
					 Dispensing Fee--The portion of the reimbursement paid to a pharmacy under
					 §355.8541 of this division, in accordance with 42 C.F.R., Subpart I and
					 the Medicaid State Plan, to provide a reasonable payment for the cost of
					 dispensing a prescription drug, including the pharmacist's professional
					 services, and which may include incentive amounts for providers that qualify
					 under this section.
(4) Fixed
					 Component--A component that provides the base reimbursement to a pharmacy for
					 the cost of dispensing a prescription; it includes reimbursement for
					 professional services costs and overhead costs.
(5) Preferred Generic Incentive--An incentive
					 to fill a Medicaid prescription with a premium preferred generic drug for which
					 a drug manufacturer has agreed to pay a supplemental rebate.
(6) Variable Component--A component that is
					 expressed as a percentage of the acquisition cost, and provides an incentive to
					 a pharmacy to stock and dispense higher-cost drugs by covering additional
					 expenses incurred when providing those drugs.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 29 - MEDICAL TRANSPORTATION › Section 355.8561 - Billing

Current through Reg. 49, No. 28; July 12, 2024
(a) Claims. To be paid, the transportation
					 provider must complete and submit documentation as specified by the Texas
					 Department of Health (department) to the regional medical transportation
					 manager or designee, after department-authorized services have been provided.
					 The department determines whether the provider submits claims electronically or
					 manually. The medical transportation manager or designee receives all requests
					 for payment from the provider. If a provider has any outstanding debts with the
					 State of Texas, he will not be reimbursed until the debt is resolved.
(b) Usual and customary charges. The provider
					 must not bill the department at a unit rate that exceeds the provider's
					 customary charges to the general public for equivalent services.
(c) Individual provider reimbursement.
					 Individual providers are reimbursed for an authorized round trip from the city
					 where the client resides to the city where the medical provider is located. If
					 the individual provider transports a client to a medical provider within the
					 same city, the individual provider submits mileage based on his vehicle's
					 odometer reading for a round trip from the client's residence to the medical
					 provider. If a client lives in a rural location, the individual provider's
					 odometer reading to and from the city nearest the client's residence will be
					 added to the distance between cities. Mileage is computed by Medical
					 Transportation Program (MTP) staff. The mileage reimbursement rate will be the
					 vehicle mile rate set by the legislature for state employees.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 30 - FAMILY PLANNING › Section 355.8581 - Reimbursement Methodology for Family Planning Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Family planning services described in 25
					 TAC Chapter 56 (relating to Family Planning) are reimbursed as follows:
(1) For physician and other practitioner
					 services, physician-administered drugs and biologicals, and the administration
					 of immunizations, providers are reimbursed the lesser of:
(A) the provider's billed charges;
					 or
(B) fees determined by the Texas
					 Health and Human Services Commission in accordance with §
													RSA
					 355.8085 of this subchapter (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 31 - AMBULANCE SERVICES › Section 355.8600 - Reimbursement Methodology for Ambulance Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Authority. Payments are made to private
					 and governmental providers of ground and air ambulance services as specified in
					 the ambulance program rules in Chapter 354, Subchapter A, Division 9 of this
					 title (relating to Ambulance Services). The reimbursement determination
					 authority is specified in §
											RSA 355.101 of this
					 chapter (relating to Introduction).
(b) Definitions. The following words and
					 terms, when used in this section, have the following meanings unless the
					 context clearly indicates otherwise.
(1)
					 Allowable costs--Expenses that are reasonable and necessary for the normal
					 conduct of operations relating to the provision of ground and air ambulance
					 services.
(2) Average Commercial
					 Rate--The average amount payable by commercial payers for the same
					 service.
(3) 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.
(4) Governmental ambulance provider--An
					 ambulance provider that uses paid government employees to provide ambulance
					 services. The ambulance services must be directly funded by a unit of
					 government that has taxing authority or has direct access to tax revenues, such
					 as a local government, hospital authority, hospital district, city, county, or
					 state. A private ambulance provider under contract with a governmental entity
					 to provide ambulance services is not considered a governmental ambulance
					 provider for the purposes of this section.
(5) Medicaid shortfall--The unreimbursed cost
					 to an ambulance provider of providing Medicaid ambulance services to Medicaid
					 clients.
(6) Private ambulance
					 provider--An ambulance provider that uses paid employees associated and
					 financed through a private entity to provide ambulance services and may be
					 under contract with a local, state, or federal government.
(7) Uncompensated care costs--The sum of the
					 Medicaid shortfall and the uninsured costs.
(8) Uninsured costs--The unreimbursed cost to
					 an ambulance provider of providing ambulance services that meet the definition
					 of "medical assistance" in Social Security Act §1905(a) to uninsured
					 patients as defined by CMS.
(9)
					 Unit of service--A unit of service based on one or more allowable ambulance
					 services provided to a client by all modes of approved
					 transportation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 32 - CLINICAL LABORATORY SERVICES › Section 355.8610 - Reimbursement for Clinical Laboratory Service

Current through Reg. 49, No. 28; July 12, 2024
(a) Clinical diagnostic laboratory tests
					 performed in a practitioner's office or by an independent laboratory, shall be
					 reimbursed as follows.
(1) The lower of the
					 provider's usual customary charge for that service or a maximum fee determined
					 by the Texas Health and Human Services Commission (HHSC), or its
					 designee.
(2) Fees for services
					 provided will be established at a percentage of the Medicare fee
					 schedule.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 33 - INDIAN HEALTH SERVICES › Section 355.8620 - Reimbursement Methodology for Services Provided in Indian Health Service and Tribal Facilities

Current through Reg. 49, No. 28; July 12, 2024
For inpatient and outpatient services provided to Native
						Americans by a qualified facility operated by the Indian Health Service (IHS)
						or a tribe, the applicable rate will be paid as published and specified by the
						IHS in the
Federal Register.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 34 - WOMEN'S HEALTH PROGRAM › Section 355.8641 - Reimbursement Methodology for the Women's Health Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Services provided through the Women's
					 Health Program (WHP) will be reimbursed on a fee-for-service basis in
					 accordance with §
											RSA
					 355.8581 of this chapter (relating to
					 Reimbursement Methodology for Family Planning Services).
(b) If a service provided through WHP is not
					 addressed in §
											RSA
					 355.8581 of this chapter, it will be
					 reimbursed as follows:
(1) For physician
					 services, physician-administered drugs and biologicals, and the administration
					 of immunizations, a provider is reimbursed the lesser of:
(A) the provider's billed charges;
					 or
(B) fees determined by the Texas
					 Health and Human Services Commission (HHSC) in accordance with §
													RSA
					 355.8085 of this chapter (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 35 - RENAL DIALYSIS SERVICES › Section 355.8660 - Renal Dialysis Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
(a) For
					 services provided on or after the date that the modernized Medicaid Management
					 Information System (MMIS) becomes operational, the reimbursement methodology
					 for in-facility renal dialysis treatment services and home renal dialysis
					 treatment services is an outpatient prospective payment system (OPPS). The OPPS
					 used for reimbursement is the 3MT Enhanced Ambulatory Patient Grouping (EAPG)
					 payment methodology. EAPGs are a visit-based classification system intended to
					 reflect the type of resources utilized in outpatient encounters for patients
					 with similar clinical characteristics.
(b) For services prior to the date that the
					 modernized MMIS becomes operational, payment for in-facility renal dialysis
					 treatment services and home renal dialysis treatment services is based upon the
					 composite rate reimbursement methodology previously used by Medicare. The
					 composite rates reflect all changes enacted by the Balanced Budget Refinement
					 Act of 1999 (BBRA). Rates are based on available funds and are subject to
					 legislative appropriations.
(c) All
					 required items and services included under the composite rate must be made
					 available by the facility, either directly or under arrangements, for each
					 dialysis patient. If the facility fails to make available (either directly or
					 under arrangements) any item or service listed in this subsection, or any part
					 of an item or service listed in this subsection, then the facility cannot be
					 reimbursed any amount for items and services that the facility provides.
					 Required items and services include:
(1)
					 medically necessary dialysis equipment and dialysis support
					 equipment;
(2) home dialysis
					 support services including the delivery, installation, maintenance, repair, and
					 testing of home dialysis equipment, and home support equipment;
(3) purchase and delivery of all necessary
					 dialysis supplies, except blood which is separately reimbursable under this
					 chapter;
(4) routine end-stage
					 renal dialysis (ESRD) related laboratory tests; and
(5) all dialysis services furnished by the
					 facility's staff.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter L - LOCAL FUNDS MONITORING › Section 355.8701 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) As part of the oversight required by
				  federal and state law, the Texas Health and Human Services Commission (HHSC)
				  requires all non-federal share funds that are provided by local governmental
				  entities, including funds transferred or certified by governmental entities as
				  the non-federal share of Medicaid supplemental and directed payments, to report
				  the source of such funds.
(b) HHSC
				  will use the information reported under this subchapter along with information
				  already collected by HHSC to comply with state and federal law and associated
				  reporting requirements. HHSC may publish the information on the HHSC website at
				  HHSC's discretion.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter L - LOCAL FUNDS MONITORING › Section 355.8702 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Centers for Medicare
				  & Medicaid Services (CMS)--The federal agency within the United States
				  Department of Health and Human Services responsible for overseeing and
				  directing Medicare and Medicaid.
(2) Certified Public Expenditure (CPE)--An
				  expenditure certified by a governmental entity to represent its contribution of
				  public funds in providing services that are eligible for federal matching
				  Medicaid funds.
(3) Federal Fiscal
				  Year--A 12-month period beginning October 1 and ending September 30.
(4) Governmental Entity--A state agency or a
				  political subdivision of the state, or a hospital authority, hospital district,
				  health district, city, county, school district, or other unit of local
				  government as established by Texas statute.
(5) Health care provider--The individual or
				  entity that receives a Medicaid payment or payments for health care items or
				  services provided or an entity related to such a health care
				  provider.
(6) HHSC--The Texas
				  Health and Human Services Commission.
(7) Interested party--A governmental entity
				  that has non-federal share funds under review, as contemplated by this
				  chapter.
(8) Intergovernmental
				  Transfer (IGT)--A transfer of public funds from a governmental entity to
				  HHSC.
(9) Non-federal share--The
				  portion of Medicaid program expenditures that is not federal funds. The
				  non-federal share is equal to 100 percent minus the federal medical assistance
				  percentage (FMAP) for Texas for the state fiscal year corresponding to the
				  program year and for the population served.
(10) Post-determination review--The informal
				  re-examination of an action or determination by HHSC under this chapter
				  requested by an interested party.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter L - LOCAL FUNDS MONITORING › Section 355.8703 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter applies to the following
				  categories of local funds:
(1) beginning
				  April 1, 2022: intergovernmental transfer (IGT) of Local Provider Participation
				  Funds (LPPFs) or other provider taxes;
(2) beginning October 1, 2022: in addition to
				  paragraph (1) of this subsection, IGT of funds to support Medicaid payment
				  programs for hospital services (other than funds from LPPFs or other provider
				  taxes);
(3) beginning April 1,
				  2023: in addition to paragraphs (1) and (2) of this subsection, IGT of funds to
				  support Medicaid payment programs for non-hospital services, including nursing
				  facility services, intermediate care facility services, and other acute or
				  long-term care services (other than funds from LPPFs or other provider taxes);
				  and
(4) beginning October 1, 2023:
				  in addition to paragraphs (1) - (3) of this subsection, certified public
				  expenditures (CPEs).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter L - LOCAL FUNDS MONITORING › Section 355.8704 - Reporting and Monitoring

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  governmental entity that provides funds for use as the non-federal share in the
				  Medicaid program must report information to the Texas Health and Human Services
				  Commission (HHSC) in a form and format to be determined by HHSC.
(b) The information must be reported at least
				  annually, no later than October 31st, or upon request by HHSC.
(c) HHSC will open the information reporting
				  system prior to the end of the federal fiscal year and will review reported
				  information based on governmental entity funding sources, including:
(1) local provider participation funds
				  (LPPFs) authorized by the Texas Health and Safety Code Chapter 288
et
				  seq.
or other provider tax structures;
(2) non-LPPF provider taxes;
(3) ad valorem tax revenue;
(4) patient revenue;
(5) other local funding sources;
				  and
(6) donations.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter L - LOCAL FUNDS MONITORING › Section 855.8706 - State and Federal Reporting

Current through Reg. 49, No. 28; July 12, 2024
The Texas Health and Human Services Commision (HHSC) may
					 adjust the frequency and content of reports requested by HHSC related to local
					 funds monitoring efforts in this subchapter as necessary to comply with any
					 state or federal reporting requirements.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter M - MISCELLANEOUS PROGRAMS › Division 4 - YOUTH EMPOWERMENT SERVICES WAIVER PROGRAM › Section 355.9060 - Reimbursement Methodology for the Youth Empowerment Services Waiver Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Payment rate determination. Payment rates
					 are developed based on rates determined for other programs that provide similar
					 services. If payment rates are not available from other programs that provide
					 similar services, payment rates are determined using a pro forma approach in
					 accordance with §
											RSA
					 355.105(h) of this title
					 (relating to General Reporting and Documentation Requirements, Methods, and
					 Procedures).
(b) Related
					 information. The information in §
											RSA 355.101 of this
					 title (relating to Introduction) and §
											RSA
					 355.105(g) of this title
					 also applies.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter M - MISCELLANEOUS PROGRAMS › Division 5 - DEPARTMENT OF STATE HEALTH SERVICES HOME AND COMMUNITY-BASED SERVICES - ADULT MENTAL HEALTH › Section 355.9070 - Reimbursement Methodology for Home and Community-Based Services - Adult Mental Health Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Payment rate
					 determination. Payment rates are developed based on payment rates determined
					 for other programs that provide similar services. If payment rates are not
					 available from other programs that provide similar services, payment rates are
					 determined using a pro-forma analysis in accordance with §
											RSA
					 355.105(h) of this chapter
					 (relating to General Reporting and Documentation Requirements, Methods, and
					 Procedures).
(b) Related
					 information. The information in §
											RSA 355.101 of this
					 chapter (relating to Introduction) and §
											RSA
					 355.105(g) of this chapter
					 applies to this section.
(c)
					 Reporting of cost. To gather adequate financial and statistical information
					 upon which to base reimbursement, HHSC may require a contracted provider to
					 submit a cost report for any service provided through the Home and
					 Community-Based Services - Adult Mental Health (HCBS-AMH) program.
(1) If HHSC requires the provider to submit a
					 cost report, the provider must follow the cost reporting guidelines in §
												RSA
					 355.105 of this chapter and the guidelines
					 for determining whether a cost is allowable or unallowable in §
												RSA
					 355.102 of this chapter (relating to General
					 Principles of Allowable and Unallowable Costs) and §
												RSA
					 355.103 of this chapter (relating to
					 Specifications for Allowable and Unallowable Costs).
(2) A provider is excused from the
					 requirement to submit a cost report if the provider meets one or more of the
					 conditions in §
												RSA
					 355.105(b)(4)(D) of this
					 chapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter M - MISCELLANEOUS PROGRAMS › Division 6 - PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS › Section 355.9080 - Reimbursement Methodology for Prescribed Pediatric Extended Care Centers

Current through Reg. 49, No. 28; July 12, 2024
(a) Payment rate determination. Payment rates
					 for the Prescribed Pediatric Extended Care Centers program are developed based
					 on payment rates determined for other programs that provide similar services.
					 If payment rates are not available from other programs providing similar
					 services, payment rates are determined using a pro forma analysis in accordance
					 with §
											355.105(h) of this
					 chapter (relating to General Reporting and Documentation Requirements, Methods,
					 and Procedures).
(b) Related
					 information. The information in §
											355.101 of this chapter (relating
					 to Introduction) and §
											355.105(g) of this
					 chapter applies to this section.
(c) Reporting of cost. To gather adequate
					 financial and statistical information upon which to base reimbursement, the
					 Health and Human Services Commission (HHSC) may require a contracted provider
					 to submit a cost report for any service provided through the Prescribed
					 Pediatric Extended Care Centers program.
(1)
					 If HHSC requires the provider to submit a cost report, the provider must follow
					 the cost reporting guidelines in §
												355.105 of this chapter and the
					 guidelines for determining whether a cost is allowable or unallowable in §
												355.102 of this chapter (relating
					 to General Principles of Allowable and Unallowable Costs) and §
												355.103 of this chapter (relating
					 to Specifications for Allowable and Unallowable Costs).
(2) A provider is excused from the
					 requirement to submit a cost report if the provider meets one or more of the
					 conditions in §
												355.105(b)(4)(D)
					 of this chapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter M - MISCELLANEOUS PROGRAMS › Division 7 - COMMUNITY FIRST CHOICE › Section 355.9090 - Reimbursement Methodology for Community First Choice

Current through Reg. 49, No. 28; July 12, 2024
(a) General information. The Texas Health and
					 Human Services Commission (HHSC) applies the general principles of cost
					 determination as specified in §
											RSA 355.101 of this
					 title (relating to Introduction).
(b) Reimbursement Methodology. Community
					 First Choice (CFC) rates are established using pre-existing rates as follows.
(1) CFC State Plan Rate--Attendant and
					 Habilitation: Rates will be equal to a weighted average of rates established
					 for Community Living Assistance and Support Services (CLASS) habilitation
					 services according to the reimbursement methodology for the CLASS program under
					 §
												RSA
					 355.505 of this title (relating to
					 Reimbursement Methodology for the Community Living Assistance and Support
					 Services Waiver Program) and proxy rates for attendant services used in the
					 calculation of the STAR+PLUS managed care capitation rates for the Home and
					 Community-based Services (HCBS) risk group. The weighted average will include
					 applicable attendant compensation rate enhancements.
(A) Proxy rates are equal to rates
					 established for attendant services under the Community Based Alternatives (CBA)
					 waiver prior to its termination, updated for changes in allowable reported
					 expenses and units of service.
(B)
					 Weighting factors assume that 30 percent of personal attendant services
					 historically provided to existing recipients in the STAR+PLUS HCBS risk group
					 and 100 percent of personal attendant services provided to newly eligible
					 recipients under CFC will be for habilitation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 356 - MEDICAID AND CHIP ELECTRONIC HEALTH INFORMATION › Subchapter A - MEDICAID ELECTRONIC HEALTH RECORD › Section 356.101 - Data for the Medicaid Eligibility and Health Information System

Current through Reg. 49, No. 28; July 12, 2024
(a) The Medicaid Eligibility and Health
				  Information System (MEHIS) is a statewide system designed to improve the
				  quality, safety, and efficiency of health-care services provided under the
				  Medicaid program. The Texas Health and Human Services Commission (HHSC) will
				  utilize the system to replace the paper Medicaid identification form with a
				  permanent plastic card, automate eligibility verification, provide an
				  electronic health record (EHR) for Medicaid recipients, offer electronic
				  prescribing functionality, and establish a foundation for future health
				  information exchange for improved efficiency, continuity of care, and health
				  outcomes.
(b) The MEHIS EHR
				  includes the following key data elements as they become available
				  electronically to HHSC:
(1) Eligibility data
				  to include the same data found on the former paper Medicaid identification
				  form, which is described by the Health Insurance Portability and Accountability
				  Act of 1996 (HIPAA) 270/271 eligibility transaction;
(2) Claims and encounter data for
				  Medicaid-enrolled clients;
(3)
				  Immunization data;
(4) Prescription
				  drug history;
(5) Texas Health
				  Steps (THSteps) information, including completed, pending, and past due THSteps
				  services;
(6) Laboratory data;
				  and
(7) Other health history
				  information.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 356 - MEDICAID AND CHIP ELECTRONIC HEALTH INFORMATION › Subchapter B - MEDICAID ELECTRONIC HEALTH RECORD INCENTIVE PAYMENT PROGRAM › Section 356.201 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
The American Reinvestment and Recovery Act of 2009
					 (Pub.L.
					 111-5), Division B, title IV, section 4201,
					 Medicaid Providers Health Information Technology (HIT) Adoption and Operation
					 Payments, authorizes states, at their option, to provide incentive payments to
					 Medicaid providers for the meaningful use of certified electronic health record
					 (EHR) technology. On or after January 1, 2011, the Texas Health and Human
					 Services Commission will implement a Medicaid EHR incentive payment program in
					 accordance with the applicable provisions in 42 Code of Federal Regulations
					 Part 495. The purpose of the incentive program is to promote the adoption and
					 meaningful use of interoperable health information technology and qualified
					 electronic health records. Detailed information on how to qualify for this
					 program and receive EHR incentive payments will be found in the
Texas
					 Medicaid Provider Procedures Manual.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 356 - MEDICAID AND CHIP ELECTRONIC HEALTH INFORMATION › Subchapter B - MEDICAID ELECTRONIC HEALTH RECORD INCENTIVE PAYMENT PROGRAM › Section 356.202 - Audit Review and Recoupment

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Introduction. This section describes the policies HHSC will follow related to
				  the review of audit findings and recoupment of overpayments in the Texas
				  Medicaid Electronic Health Record (EHR) Incentive Program.
(b) Review of audit findings. A review of
				  audit findings is limited to the reviews provided for in §
										RSA
				  354.1450 of this title (relating to Audits of
				  Medicaid Providers).
(c)
				  Recoupment. HHSC will recoup an EHR incentive payment if it was paid in excess
				  of what a Medicaid provider is eligible to receive under the Texas Medicaid EHR
				  Incentive Program, including a payment resulting from HHSC error or a payment
				  that is identified as part of an audit.