(a)Subject to the specifications, conditions, and limitations established by the Health and Human Services Commission (HHSC) [department], organ transplant services are covered as follows: (1)Coverage is limited to those services, as approved by HHSC [the department] or its designee, that are determined to be reasonable, medically necessary, and standard medical procedures. (2)Coverage includes solid and nonsolid organ procurement (including acquiring/harvesting, processing, preserving, storing, distributing, and tissue typing). If a hospital obtains an organ outside of the hospital, the hospital must obtain it from an organ procurement organization designated by the secretary of the Department of Health and Human Services. Coverage does not include donor expenses. (3)Coverage of each type of solid organ transplant [ transplants] is limited to an initial transplant and one subsequent retransplant because of rejection as a lifetime benefit. (b)As specified by HHSC [the department] or its designee, prior authorization is required for certain organ transplant services. If a covered organ transplant has been prior authorized as medically necessary by HHSC [the department ] or its designee because of an emergent, life-threatening situation, a maximum of 30 days of inpatient hospital services during a Title XIX spell of illness may be covered beginning with the actual first day of the transplant. This coverage is in addition to covered inpatient hospital days provided before the actual first day of the transplant. This 30-day period is considered a separate inpatient hospital admission for reimbursement purposes. Physician services that HHSC [ the department] or its designee determines to be reasonable and medically necessary are also covered during the 30-day period. (c)If expenditures for a single inpatient hospital admission exceed the $200, 000 limit on hospitalization-related services specified in §354.1149 [§29.1112] of this title (relating to Exclusions and Limitations), expenditures for that admission are excluded in calculating expenditures toward the limit. This policy only applies to an inpatient hospital admission to perform a covered organ transplant procedure determined to be medically necessary because of an emergent, life-threatening situation. (d)To be reimbursed for transplant services, a hospital must meet the requirements included in the Social Security Act, §1138 and be approved and designated by HHSC [the department] as an organ transplant facility. (e)For purposes of this section, the term "organ" means a human heart, kidney, liver, cornea, or bone marrow, and any other human organ or tissue specified by HHSC [the department].
This agency hereby certifies that the proposal has
been reviewed by legal counsel and found to be within the agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on July 17, 2013
TRD-201302920 Steve Aragon
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: September 1, 2013
For further information, please call: (512) 424-6900
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