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RULE §354.1440Medical Care or Services Provided to Medicaid Recipients Outside of Texas

(a) Subject to certain conditions, limitations, and exclusions, the Texas Medicaid program covers medical assistance services provided to an eligible Texas recipient while away from Texas in another state if the recipient does not leave Texas for the purpose of receiving out-of-state medical care that the recipient can receive in Texas. Services provided outside of Texas but within the United States are covered to the same extent they are covered in Texas when:

  (1) the medical services are needed because of a medical emergency documented by the attending physician or other provider;

  (2) the services are medically necessary, and, in the opinion of the attending physician or other provider, the recipient's health would be endangered if the recipient were required to travel to Texas;

  (3) HHSC or its designee determines that the medically necessary services are more readily available in the state where the recipient is located;

  (4) the customary or general practice for recipients in a particular locality within Texas is to use medical resources in the other state; or

  (5) the Texas Department of Family and Protective Services makes Title IV-E adoption assistance or Title IV-E foster care maintenance payments to an out-of-state provider for a child who is also eligible for Texas medical assistance benefits.

(b) Except as provided in subsection (a) of this section or otherwise specified by the Texas Health and Human Services Commission (HHSC) or its designee, the Texas Medicaid program does not pay for medical care and services furnished outside Texas unless prior authorization is obtained from HHSC or its designee. Prior authorization is required for utilization control and to ensure the appropriate use of medical resources. Prior authorization may be obtained by submitting medical justification or documentation to HHSC or its designee indicating the reason the recipient must obtain medical care outside Texas. Prior authorization must be obtained before providing the medical care or service.

(c) HHSC or its designee determines the basis and amount of reimbursement for medical services provided outside Texas but within the United States in accordance with Chapter 355 of this title (relating to Reimbursement Rates).

Source Note: The provisions of this §354.1440 adopted to be effective January 30, 2011, 36 TexReg 231

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