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RULE §355.201Establishment and Adjustment of Reimbursement Rates for Medicaid

(a) Definitions. Unless the context clearly indicates otherwise, the following words and terms when used in this section are defined as follows:

  (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) HHSC--The Texas Health and Human Services Commission or its designee.

  (3) Medical assistance--A medical or health care related service, item, or supply that is delivered to a Medicaid recipient and is approved and authorized for payment or reimbursement by HHSC or CMS pursuant to state and federal law.

  (4) Program--A specific component of the Medicaid program for which HHSC establishes either a methodology to reimburse a provider or a specific fee, payment rate, or charge that is paid to a provider for medical assistance in accordance with state and federal law.

  (5) Provider--A health care practitioner, institution, or other entity that is enrolled in the medical assistance program and is authorized to submit claims for payment or reimbursement of medical assistance.

(b) Purpose. This section implements Texas Government Code §531.021(d) and (e), and applies to all programs that provide medical assistance and to all reimbursement methodologies related to medical assistance prescribed under this chapter.

(c) Establishment of fees, rates, and charges. HHSC establishes fees, rates, and charges to be paid for medical assistance in accordance with:

  (1) the formulas, procedures, or methodologies prescribed in this chapter;

  (2) applicable state or federal law, policies, rules, regulations, or guidelines;

  (3) economic conditions that, in HHSC's determination, substantially and materially affect provider participation; or

  (4) available levels of appropriated state and federal funds.

(d) Adjustment of fees, rates, and charges. Notwithstanding any other provision of this chapter, HHSC may adjust fees, rates, and charges paid for medical assistance as necessary to achieve the objectives of Medicaid in a manner consistent with the considerations described in subsection (c) of this section.

(e) Notice. If HHSC establishes or adjusts fees, rates, or charges under this section, HHSC will hold a public hearing and provide notice of the hearing in accordance with §355.105(g) of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures).

Source Note: The provisions of this §355.201 adopted to be effective September 1, 2003, 28 TexReg 7302; amended to be effective September 1, 2011, 36 TexReg 4652; amended to be effective December 26, 2018, 43 TexReg 8281

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