| (a) Definitions. The terms in this section have the
same meaning as those defined in Title 25, Part 1, §61.2 (relating
to Definitions).
(b) Requirements. To qualify as a provider for the
Kidney Health Care (KHC) program, as described in Title 25, Part 1,
Chapter 61, Subchapter A (related to Kidney Health Care), a provider
must do as follows.
(1) Outpatient dialysis facilities must:
(A) execute an agreement with the program;
(B) have Medicare certification and a Medicare End-Stage
Renal Disease (ESRD) provider number;
(C) be a current Texas Medicaid provider;
(D) be licensed by the department as an ESRD facility;
(E) reimburse the program for any overpayments upon
request; and
(F) not be on suspension as a KHC provider, as a Texas
Medicaid provider, as a Medicare certified ESRD facility, or as a
licensed Texas ESRD facility.
(2) An out-of-state outpatient dialysis facility must:
(A) meet all the requirements in paragraph (1)(A) -
(C) and (E) of this subsection;
(B) be licensed by its state, if applicable;
(C) be a Medicaid provider in its state; and
(D) not be on suspension as a KHC provider, as a Texas
Medicaid provider, as a Medicaid provider in its state, as a Medicare-certified
ESRD facility, or by the ESRD licensing authority of its state.
(3) Any outpatient dialysis facility may be given interim
approval according to the following:
(A) client applications for KHC benefits may be submitted
by the facility during the period of interim approval.
(B) interim approval extends no longer than six months
from the date the program mails the agreement to the facility.
(C) if interim approval lapses, the unexecuted agreement
is nullified and a new agreement with term dates and the period of
interim approval may be initiated by the program.
(D) claims for outpatient dialysis services shall not
be considered for payment by the program until the program has a fully
executed agreement with the facility.
(E) claim filing deadlines apply, as contained in Title
25, Part 1 §61.8 (relating to Claim Filing Deadlines).
(4) A pharmacy, including a mail order pharmacy, must
execute an agreement as a KHC provider through the Health and Human
Services Commission Pharmacy Contracts and Rebates unit or designated
contractor.
(5) A physician or certified registered nurse anesthetist
(CRNA) must:
(A) execute an agreement with the program;
(B) be licensed to practice medicine in the State of
Texas, if a physician;
(C) be certified to practice within the scope of his
or her certification in the State of Texas, if a CRNA;
(D) be a Texas Medicaid provider;
(E) not be on suspension as a KHC provider, as a physician
licensed to practice medicine in the State of Texas, as a CRNA certified
to practice within the scope of the certification in the State of
Texas, or as a Texas Medicaid provider; and
(F) reimburse the program for any overpayments upon
request.
(6) An out-of-state physician and a CRNA must:
(A) meet all the requirements in paragraph (5)(A),
(D) and (F) of this subsection;
(B) be licensed to practice medicine in the state in
which services are provided, if a physician; or
(C) be certified to practice within the scope of his
or her certification in the state in which services are provided,
if a CRNA; and
(D) not be on suspension as a KHC provider, as a Texas
Medicaid provider, as a physician licensed to practice medicine in
the state in which services are provided, as a CRNA certified to practice
within the scope of the certification in the state in which services
are provided.
(7) A hospital or ambulatory surgical center (ASC)
must:
(A) execute an agreement with the program;
(B) be in compliance with all applicable laws to provide
hospital or ASC services in the State of Texas;
(C) be a current Texas Medicaid provider;
(D) have Medicare certification;
(E) not be on suspension as a KHC provider, as a hospital
authorized under applicable law to provide hospital services in the
State of Texas, as an ASC licensed to provide ASC services in the
State of Texas, as a Texas Medicaid provider, or as a Medicare certified
hospital or ASC; and
(F) reimburse the program for any overpayments upon
request.
(8) An out-of-state hospital or ASC must:
(A) meet all the requirements in paragraph (7)(A),
(C), (D) and (F) of this subsection;
(B) be licensed to provide hospital or ASC services
in the state in which services are provided;
(C) not be on suspension as a KHC provider, as a Texas
Medicaid provider, as a Medicaid provider in its state, as a hospital
licensed to provide hospital services in the state in which services
are provided, as an ASC licensed to provide ASC services in the state
in which services are to be provided, or as a Medicare certified hospital
or ASC;
(9) A Medicare Prescription Drug Plan (PDP) must:
(A) execute an agreement with the program;
(B) be Medicare approved as a PDP and maintain approval;
(C) share and exchange data in an acceptable format
with the program for the coordination of drug benefits under the Medicare
PDP (Part D);
(D) accept a program payment for premiums; and
(E) reimburse the program for any overpayments upon
request.
(c) Effective dates.
(1) The effective date of all outpatient dialysis facility
agreements shall be on or after the Medicare ESRD certification date.
(2) The effective date of all pharmacy agreements shall
be determined by the Health and Human Services Commission Pharmacy
Contracts and Rebates unit or its designated contractor.
(3) The effective date of all other provider agreements,
listed in subsection (a)(5) - (9) of this section, shall be the first
day of the sixth month prior to the program's receipt of the completed
and signed provider agreement.
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