| (a) Introduction. The Texas Health and Human Services
Commission (HHSC), or its designee reimburses outpatient hospital
services under the reimbursement methodology described in this section.
(1) For services provided on and after the date that
the modernized Medicaid Management Information System (MMIS) becomes
operational, HHSC, or its designee, will reimburse all hospital providers
based on an outpatient prospective payment system (OPPS). This includes
all hospitals as defined in §355.8052 of this division (relating
to Inpatient Hospital Reimbursement), including rural, urban, and
Children's. The OPPS used for reimbursement is the 3M™ Enhanced
Ambulatory Patient Groups (EAPG) calculator. EAPGs are a visit-based
classification system intended to reflect the type of resources utilized
in outpatient encounters for patients with similar clinical characteristics.
(2) The following are exceptions to the OPPS reimbursement
methodology.
(A) Reimbursement for Long-Acting Reversible Contraceptive
devices.
(B) Human Breast Milk Processing, Storage and Distribution.
(C) Certain Drugs Paid to Managed Care Organizations
on a Non-Risk Basis, as determined by HHSC.
(D) Cochlear implant devices and certain high cost
nerve stimulators.
(E) Non-Emergent emergency room services as described
in subsection (b)(1)(C) of this section.
(F) State owned teaching hospitals outpatient reimbursement
is based on cost principals as described in subsection (b) of this
section.
(3) For services prior to the date that the modernized
MMIS becomes operational, reimbursement is outlined below in subsection
(b) of this section except as described in subsections (c) and (d)
of this section, HHSC will reimburse for outpatient hospital services
based on a percentage of allowable charges and an outpatient interim
rate.
(b) Interim reimbursement.
(1) HHSC will determine a percentage of allowable charges,
which are charges for covered Medicaid services determined through
claims adjudication.
(A) For high volume providers that received Medicaid
outpatient payments equaling at least $200,000 during calendar year
2004.
(i) For children's hospitals and state-owned hospitals
as defined in §355.8052 of this division, the percentage of allowable
charges is 76.03 percent, except as described in subparagraph (C)
of this paragraph.
(ii) For rural hospitals as defined in §355.8052
of this division, the percentage of allowable charges is 100 percent.
(iii) For all other providers, the percentage of allowable
charges is 72.00 percent.
(B) For all providers not considered high volume providers
as determined in paragraph (1)(A) of this subsection.
(i) For children's hospitals and state-owned hospitals
as defined in §355.8052 of this division, the percentage of allowable
charges is 72.27 percent.
(ii) For rural hospitals as defined in §355.8052
of this division, the percentage of allowable charges is 100 percent.
(iii) For all other providers, the percentage of allowable
charges is 68.44 percent.
(C) For outpatient emergency department (ED) services
that do not qualify as emergency visits are exempt from the OPPS reimbursement
described in subsection (a)(1) of this section. For these services,
which are listed in the Texas Medicaid Provider Procedures Manual
and other updates on the claims administrator's website, HHSC will
reimburse:
(i) rural hospitals, as defined in §355.8052 of
this division, an amount not to exceed 65 percent of allowable charges
after application of the methodology in paragraph (1)(A) and (1)(B)
of this subsection, which will result in a payment that does not exceed
65 percent of allowable cost; and
(ii) all other hospitals, a flat fee set at a percentage
of the Medicaid acute care physician office visit amount for adults.
(2) HHSC will determine an outpatient interim rate
for each non-rural hospital, which is the ratio of Medicaid allowable
outpatient costs to Medicaid allowable outpatient charges derived
from the hospital's Medicaid cost report.
(A) For a non-rural hospital with at least one tentative
cost report settlement completed prior to September 1, 2013, the interim
rate is the rate in effect on August 31, 2013, except the hospital
will be assigned the interim rate calculated upon completion of any
future cost report settlement if that interim rate is lower.
(B) For a non-rural new hospital that does not have
at least one tentative cost report settlement completed prior to September
1, 2013, the default interim rate is 50 percent until the interim
rate is adjusted as follows.
(i) If the non-rural hospital files a short-period
cost report for its first cost report, the hospital will be assigned
the interim rate calculated upon completion of the hospital's first
tentative cost report settlement.
(ii) The hospital will be assigned the interim rate
calculated upon completion of the hospital's first full-year tentative
cost report settlement.
(iii) The hospital will retain the interim rate calculated
as described in clause (ii) of this subparagraph, except it will be
assigned the interim rate calculated upon completion of any future
cost report settlement if that interim rate is lower.
(C) Interim claim reimbursement for non-rural hospitals
is determined by multiplying the amount of a hospital's outpatient
allowable charges after applying any reductions to allowable charges
made under paragraph (1) of this subsection by the outpatient interim
rate in effect on the date of service.
(D) Interim claim reimbursement determined in subparagraph
(C) of this paragraph will be cost-settled at both tentative and final
audit of a non-rural hospital's cost report. The calculation of allowable
costs will be determined based on the amount of allowable charges
after applying any reductions to allowable charges made under paragraph
(1) of this subsection.
(i) Interim payments for claims with a date of service
prior to September 1, 2013, will be cost settled.
(ii) Interim payments for claims with a date of service
on or after September 1, 2013, will be included in the cost report
interim rate calculation, but will not be adjusted due to cost settlement
unless the settlement calculation indicates an overpayment.
(iii) HHSC will calculate an interim rate at tentative
and final cost settlement for the purposes described in subparagraph
(B) of this paragraph.
(iv) If a hospital's interim claim reimbursement for
all outpatient services, excluding imaging, clinical lab and outpatient
emergency department services that do not qualify as emergency visits,
for the hospital's fiscal year exceeded the allowable costs for those
services, HHSC will recoup the amount paid to the hospital in excess
of allowable costs.
(v) If a hospital's interim claim reimbursement for
all outpatient services, excluding imaging, clinical lab and outpatient
emergency department services that do not qualify as emergency visits,
for the hospital's fiscal year was less than the allowable costs for
those services, HHSC will not make additional payments through cost
settlement to the hospital for service dates on or after September
1, 2013.
(3) HHSC will determine an outpatient interim rate
for each rural hospital, which is the ratio of Medicaid allowable
outpatient costs to Medicaid allowable outpatient charges derived
from the hospital's Medicaid cost report.
(A) For a rural hospital with at least one tentative
cost report settlement completed prior to September 1, 2021, the interim
rate effective on September 1, 2021, is the rate calculated in the
latest initial cost report with an additional percentage increase,
not to exceed an interim rate of 100 percent. After September 1, 2021,
a rural hospital will be assigned the interim rate calculated upon
completion of each initial or amended initial cost report, with an
additional percentage increase, not to exceed an interim rate of 100
percent.
(B) For a new rural hospital that does not have at
least one initial cost report completed prior to September 1, 2021,
the default interim rate is 50 percent until the interim rate is adjusted
as follows.
(i) If the rural hospital files a short-period cost
report for their first cost report, the hospital will continue to
receive the default rate until completion of the first full-year initial
cost report.
(ii) The rural hospital will be assigned the interim
rate calculated upon completion of a review of the hospital's first
full-year initial or amended initial cost report, with an additional
percentage increase, not to exceed an interim rate of 100 percent.
Cont'd... |
