| (a) Authorized items provided to eligible Medicaid
recipients are reimbursed the lesser of the billed amount or the Medicaid
reimbursement rate established by HHSC.
(b) HHSC reviews the fees for individual items at least
every two years as follows.
(1) If Medicare reimburses for a durable medical equipment,
prosthetics, orthotics and supplies (DMEPOS) item, the Medicaid reimbursement
rate is equal to, or a percentage of, the Medicare reimbursement rate
for the procedure code. If HHSC determines that the Medicare reimbursement
rate is insufficient, the methodologies in paragraphs (2) or (3) of
this subsection apply.
(2) If Medicare does not reimburse for a DMEPOS item,
other sources are used to determine the Medicaid payment rate as follows:
(A) analysis of Medicaid fees for the same or similar
items in other states;
(B) eighty-two percent of the manufacturer's suggested
retail price (MSRP);
(C) cost shown on a manufacturer's invoice submitted
by the provider to HHSC; or
(D) analysis of fees paid under commercial insurance
for the same or similar item or service.
(3) HHSC may use data sources or methodologies other
than those listed in paragraph (2) of this subsection to establish
Medicaid fees for DMEPOS when HHSC determines that those methodologies
are unreasonable or insufficient.
(c) Fees for DMEPOS items are adjusted within available
funding as described in §355.201 of this title (relating to Establishment
and Adjustment of Reimbursement Rates by the Health and Human Services
Commission).
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