| (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).
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| 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 |
