| (a) The following are reimbursement methodologies for
services provided under the Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) program, delivered to Medicaid clients under
age 21, also known as Texas Health Steps (THSteps) and the THSteps
Comprehensive Care Program (CCP). Reimbursement methodologies for
services provided to all Medicaid clients, including clients under
age 21, are located elsewhere in this chapter.
(1) Counseling and psychotherapy services are reimbursed
to freestanding psychiatric facilities in accordance with §355.8060
of this subchapter (relating to Reimbursement Methodology for Freestanding
Psychiatric Facilities).
(2) Durable medical equipment, prosthetics, orthotics
and supplies (DMEPOS) are reimbursed in accordance with §355.8023
of this subchapter (relating to Reimbursement Methodology for Durable
Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)).
(3) Nursing services, including, but not limited to,
private duty nursing, registered nurse (RN) services, licensed vocational
nurse/licensed practical nurse (LVN/LPN) services, skilled nursing
services delegated to qualified aides by RNs in accordance with the
licensure standards promulgated by the Texas Board of Nursing, and
nursing assessment services, are reimbursed the lesser of the provider's
billed charges or fees established by the Texas Health and Human Services
Commission (HHSC) for each of the applicable provider types as follows:
(A) Independently enrolled RNs and LVNs/LPNs, under §355.8085
of this subchapter (relating to Reimbursement Methodology for Physicians
and Other Practitioners);
(B) Home health agencies (HHAs), under §355.8021
of this subchapter (relating to Reimbursement Methodology for Home
Health Services); and
(C) Advanced Practice Registered Nurses (APRNs), under §355.8281(a)
of this subchapter (relating to Reimbursement Methodology for Nurse
Practitioners and Clinical Nurse Specialists).
(4) Physician Assistants (PA), under §355.8093
of this subchapter (relating to Reimbursement Methodology for Physician
Assistants).
(5) Physical therapy services are reimbursed in accordance
with the Medicaid reimbursement methodologies for the applicable provider
type as follows:
(A) independently enrolled therapists, under §355.8097
of this subchapter;
(B) HHAs, under §355.8097 of this subchapter;
(C) Medicare-certified outpatient facilities known
as comprehensive outpatient rehabilitation facilities (CORFs) and
outpatient rehabilitation facilities (ORFs), under §355.8097
of this subchapter;
(D) freestanding psychiatric facilities, under §355.8060
of this subchapter; and
(E) outpatient hospitals, under §355.8061 of this
subchapter (relating to Outpatient Hospital Reimbursement).
(6) Occupational therapy services are reimbursed in
accordance with the Medicaid reimbursement methodologies for the applicable
provider type as follows:
(A) independently enrolled therapists, under §355.8097
of this subchapter;
(B) HHAs, under §355.8097 of this subchapter;
(C) CORFs and ORFs, under §355.8097 of this subchapter;
(D) freestanding psychiatric facilities, under §355.8060
of this subchapter; and
(E) outpatient hospitals, under §355.8061 of this
subchapter.
(7) Speech-language pathology services are reimbursed
in accordance with the Medicaid reimbursement methodologies for the
applicable provider type as follows:
(A) independently enrolled therapists, under §355.8097
of this subchapter;
(B) HHAs, under §355.8097 of this subchapter;
(C) CORFs and ORFs, under §355.8097 of this subchapter;
(D) freestanding psychiatric facilities, under §355.8060
of this subchapter; and
(E) outpatient hospitals, under §355.8061 of this
subchapter.
(8) Nutritional services provided by licensed dietitians
are reimbursed the lesser of the provider's billed charges or fees
determined by HHSC in accordance with §355.8085 of this subchapter.
(9) Providers are reimbursed for the administration
of immunizations the lesser of the provider's billed charges or fees
determined by HHSC in accordance with §355.8085 of this subchapter.
(10) Vaccines are reimbursed the lesser of the provider's
billed charges or the fees determined by HHSC in accordance with §355.8085
of this subchapter.
(11) Dental services are reimbursed in accordance with
the following Medicaid reimbursement methodologies:
(A) Dental services provided by enrolled dental providers
are reimbursed in accordance with §355.8085 of this subchapter.
(B) Dental services provided by federally qualified
health centers (FQHCs) are reimbursed in accordance with §355.8261
of this subchapter (relating to Federally Qualified Health Center
Services Reimbursement).
(C) For services provided through September 30, 2019,
publicly owned dental providers may be eligible to receive Uncompensated
Care (UC) payments for dental services under the Texas Healthcare
Transformation and Quality Improvement 1115 Waiver, as described in
this section. For services provided beginning October 1, 2019, eligibility
for publicly owned dental providers to receive waiver payments, and
the methodology for calculating payment amounts, is described in section
355.8208 of this title. For purposes of this section, Uncompensated
Care payments are payments intended to defray the uncompensated costs
of services that meet the definition of "medical assistance" contained
in §1905(a) of the Social Security Act. HHSC will calculate UC
payments using the following methodology:
(i) Eligible dental providers must submit an annual
cost report based on the federal fiscal year. HHSC will provide the
cost report form with detailed instructions to enrolled dental providers.
Cost reports are due to HHSC 180 days after the close of the applicable
reporting period. Providers must certify that expenditures submitted
on the cost report have not been claimed on any other cost report.
(ii) Payments to eligible providers will be based on
cost and payment data reported on the cost report along with supporting
documentation. As defined in the cost report and detailed instructions,
a cost-to-billed-charges ratio will be used to calculate total allowable
cost. The total allowable cost minus any payments will be the UC payment
due to the provider. The UC payment is calculated yearly and is contingent
on receipt of funds as specified in clause (iii) of this subparagraph.
(iii) The funding for the state share of UC payments
is limited to, and obtained through, intergovernmental transfers of
funds from the governmental entity that owns and operates the dental
provider. An intergovernmental transfer that is not received in the
manner and by the date specified by HHSC may not be accepted.
(iv) UC payments are limited by the publicly owned
dental provider pool aggregate limit as determined by §355.8201
of this subchapter (relating to Waiver Payments to Hospitals for Uncompensated
Care).
(v) If actual UC costs for all eligible publicly owned
dental providers is greater than the publicly owned dental provider
pool aggregate limit as described in clause (iv) of this subparagraph,
then HHSC will reduce the UC payments for all eligible publicly owned
dental providers proportionately.
(vi) If a UC payment results in an overpayment or if
the federal government disallows federal financial participation related
to the receipt or use of supplemental payments under this section,
HHSC may recoup an amount equal to the federal share of supplemental
payments overpaid or disallowed. To satisfy the amount owed, HHSC
may recoup from any current or future Medicaid payments.
(12) Personal care services (PCS) are reimbursed in
accordance with the following Medicaid reimbursement methodologies
for the applicable provider type:
(A) School districts delivering PCS under School Health
and Related Services (SHARS) are reimbursed in accordance with §355.8443
of this division (relating to Reimbursement Methodology for School
Health and Related Services (SHARS)); and
(B) Providers other than school districts delivering
PCS are reimbursed as follows:
(i) PCS and PCS delivered in conjunction with delegated
nursing services are reimbursed fees determined by HHSC. HHSC reviews
the fees for individual services at least every two years based upon:
(I) analysis of Medicare fees for the same or similar
item or service;
(II) analysis of Medicaid fees for the same or similar
item or service in other states; or
(III) analysis of commercial fees for the same or similar
item or service.
(ii) HHSC may use data sources or methodologies other
than those listed in clause (i) of this subparagraph to establish
Medicaid fees for physicians and other practitioners when HHSC determines
that those methodologies are unreasonable or insufficient.
(iii) PCS delivered through the Consumer Directed Services
payment option are reimbursed in accordance with §355.114 of
this chapter (relating to Consumer Directed Services Payment Option).
(b) Fees for EPSDT services 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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| Source Note: The provisions of this §355.8441 adopted to be effective January 1, 2006, 30 TexReg 8658; amended to be effective September 1, 2007, 32 TexReg 5352; amended to be effective February 1, 2011, 35 TexReg 11848; amended to be effective October 1, 2011, 36 TexReg 6148; amended to be effective April 8, 2013, 38 TexReg 2219; amended to be effective April 6, 2014, 39 TexReg 2273; amended to be effective September 1, 2014, 39 TexReg 6407; amended to be effective December 1, 2017, 42 TexReg 5431; amended to beeffective January 10, 2019, 44 TexReg 230 |
