| (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 §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).
(b) Charges for hospital services provided before admission.
(1) Except as provided in paragraph (2) of this subsection,
a hospital or any entity that is wholly owned or wholly operated by
a hospital must include in its inpatient charges the cost of all reimbursable
services provided by the hospital to a patient on the date of admission
and during the three calendar days immediately preceding the date
of the patient's admission, if the services are:
(A) diagnostic services, including clinical diagnostic
lab tests; or
(B) non-diagnostic services related to the inpatient
stay, except ambulance and maintenance renal dialysis services.
(2) A hospital that is not a "subsection (d) hospital"
as defined in Social Security Act §1886(d)(1)(B) (42 U.S.C. 1396ww(d)(1)(B))
must include in its charges the cost of services described in paragraph
(1) of this subsection provided by the hospital to a patient during
the one calendar day immediately preceding the date of admission.
Hospitals that are not "subsection (d) hospitals" include children's,
psychiatric, and rehabilitation hospitals.
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| Source Note: The provisions of this §354.1072 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective April 13, 1988, 13 TexReg 1392; amended to be effective July 1, 1989, 14 TexReg 2685; amended to be effective July 1, 1990, 15 TexReg 4648; amended to be effective July 1, 1991, 16 TexReg 3943; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 1, 2010, 35 TexReg 6649; amended to be effectiveSeptember 1, 2012, 37 TexReg 4852; amended to be effective April 21, 2013, 38 TexReg 2315 |
