(a) This section applies only to an out-of-state Medicaid
applicant or re-enrolling provider. An applicant or re-enrolling provider
is considered out-of-state if:
(1) the physical address where services are or will
be rendered is located outside the Texas state border and within the
United States;
(2) the physical address where the services or products
originate or will originate is located outside the Texas state border
and within the United States when providing services, products, equipment,
or supplies to a Medicaid recipient in the state of Texas; or
(3) the physical address where services are or will
be rendered is located within the Texas state border, but:
(A) the applicant or re-enrolling provider maintains
all patient records, billing records, or both, outside the Texas state
border; and
(B) the applicant or re-enrolling provider is unable
to produce the originals or exact copies of the patient records or
billing records, or both, from the location within the Texas state
border where services are rendered.
(b) An applicant or re-enrolling provider that is considered
out-of-state under subsection (a) of this section is ineligible to
participate in Medicaid unless HHSC or its designee approves the applicant
or re-enrolling provider for enrollment on the basis of a determination
that the applicant or re-enrolling provider has provided, is providing,
or will provide services under one or more of the following criteria:
(1) The services are medically necessary emergency
services provided to a recipient who is located outside the Texas
state border, in which case the enrollment will be time-limited for
an appropriate period as determined by HHSC or its designee, not to
exceed one year.
(2) The services are medically necessary services provided
to a recipient who is located outside the Texas state border, and
in the expert opinion of the recipient's attending physician or other
provider, the recipient's health would be or would have been endangered
if the recipient were required to travel to Texas, in which case the
enrollment will be time-limited for an appropriate period as determined
by HHSC or its designee, not to exceed one year.
(3) The services are medically necessary services that
are more readily available to a recipient in the state where the recipient
is located, in which case the enrollment will be time-limited for
an appropriate period as determined by HHSC or its designee.
(4) The services are medically necessary to a recipient
who is eligible on the basis of participation in an adoption assistance
or foster care program administered by the Texas Department of Family
and Protective Services under Title IV-E of the Social Security Act,
in which case the enrollment may be time-limited for an appropriate
period as determined by HHSC or its designee.
(5) The services are medically necessary and have been
prior authorized by HHSC or its designee, and documented medical justification
indicating the reasons the recipient must obtain medical care outside
Texas is furnished to HHSC or its designee before providing the services
and before payment, in which case the enrollment may be time-limited
for an appropriate period as determined by HHSC or its designee.
(6) The services are medically necessary and it is
the customary or general practice of recipients in a particular locality
within Texas to obtain services from the out-of-state provider, if
the provider is located in the United States and within 50 miles driving
distance from the Texas state border, or as otherwise demonstrated
on a case-by-case basis.
(A) Enrollment under this paragraph may be time-limited
for an appropriate period as determined by HHSC or its designee.
(B) An out-of-state provider does not meet the criterion
in this paragraph merely on the basis of having established business
relationships with one or more providers that participate in Medicaid.
(7) The services are medically necessary and the nature
of the service is such that providers for this service are limited
or not readily available within the state of Texas.
(8) The services are medically necessary services to
one or more dually eligible recipients (i.e., recipients who are enrolled
in both Medicare and Medicaid) and the out-of-state provider may be
considered for reimbursement of co-payments, deductibles, and co-insurance,
in which case the enrollment may be time-limited for an appropriate
period as determined by HHSC or its designee, and the enrollment will
be restricted to receiving reimbursement only for the Medicaid-covered
portion of Medicare crossover claims.
(9) The services are provided by a pharmacy that is
a distributor of a drug that is classified by the U.S. Food and Drug
Administration (FDA) as a limited distribution drug.
(10) The services are medically necessary and one or
more of the following exceptions for good cause exist and can be documented:
(A) Texas Medicaid enrolled providers rely on the services
provided by the applicant.
(B) Applicant maintains existing agreements as a participating
provider through one or more Medicaid managed care organizations (MCO)
and enrollment of the applicant leads to more cost-effective delivery
of Medicaid services.
(c) An out-of-state provider that applies for enrollment
in Medicaid must submit documentation along with the enrollment application
to demonstrate that the provider meets one or more of the criteria
in subsection (b) of this section. The provider must submit any additional
requested information to HHSC or its designee before enrollment may
be approved.
(d) If HHSC or its designee determines that an out-of-state
provider meets one or more of the criteria in subsection (b) of this
section, the provider must meet all other applicable enrollment eligibility
requirements, including those specified in Chapter 371 of this title
(relating to Medicaid and Other Health and Human Services Fraud and
Abuse Program Integrity) before enrollment may be approved.
(e) Other applicable requirements.
(1) An out-of-state provider that is enrolled pursuant
to subsections (b) (d) of this section must follow all other applicable
Medicaid participation requirements identified by HHSC or its designee
for each service provided. Other applicable requirements that must
be followed may include:
(A) service benefits and limitations;
(B) documentation procedures;
(C) obtaining prior authorization for the service whenever
required; and
(D) claims filing deadlines as specified in §354.1003
of this title (relating to Time Limits for Submitted Claims).
(2) Certain out-of-state providers are not entitled
to utilize the extended 365-day claim filing deadline provided in §354.1003(a)(5)(H)
of this title that is otherwise available to out-of-state providers,
and must comply with the same claims filing deadlines that apply to
in-state providers under that section. Those out-of-state providers
are:
(A) providers that are approved for enrollment under
the criterion specified in subsection (b)(6) of this section, where
the specific basis for approval is that the provider is located within
50 miles driving distance from the Texas state border; and
(B) providers that are approved for enrollment under
the criterion specified in subsection (b)(8) of this section regarding
dually eligible recipients.
(f) An out-of-state provider that is enrolled pursuant
to subsections (b) - (d) of this section must:
(1) comply with the terms of the Medicaid provider
agreement;
(2) provide services in compliance with all applicable
federal, state, and local laws and regulations related to licensure
and certification in the state where the out-of-state provider is
located; and
(3) comply with all state and federal laws and regulations
relating to Medicaid in the state of Texas.
(g) HHSC or its designee determines the basis and amount
of reimbursement for medical services provided outside Texas and within
the United States in accordance with Chapter 355 of this title (relating
to Reimbursement Rates).
(h) A laboratory may participate as an in-state provider
under any program administered by a health and human services agency,
including HHSC, that involves laboratory services, regardless of the
location where any specific service is performed or where the laboratory's
facilities are located if:
(1) the laboratory or an entity that is a parent, subsidiary,
or other affiliate of the laboratory maintains laboratory operations
in Texas;
(2) the laboratory and each entity that is a parent,
subsidiary, or other affiliate of the laboratory, individually or
collectively, employ at least 1,000 persons at places of employment
located in this state; and
(3) the laboratory is otherwise qualified to provide
the services under the program and is not prohibited from participating
as a provider under any benefits programs administered by a health
and human services agency, including HHSC, based on conduct that constitutes
fraud, waste, or abuse.
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