The Texas Health and Human Services Commission (HHSC) proposes to amend §354.1149, concerning Exclusions and Limitations, and §354.1175, concerning Organ Transplants.

Background and Justification

Section 6507 of the Patient Protection and Affordable Care Act (PPACA) requires a state Medicaid program, for claims filed on or after October 1, 2010, to use mechanized claims processing and information retrieval systems that are compatible with National Correct Coding Initiative (NCCI) methodologies that have been identified by the Secretary of Health and Human Services. HHSC accordingly implemented the specified NCCI medical coding edits for claims processing.

HHSC proposes to amend §354.1149 and §354.1175 to be consistent with claims processing system processes that have been implemented as part of the new methodologies. Specifically, the claims processing system now processes inpatient hospitalization and related expenditures on all claims that exceed the annual individual inpatient cap of $200,000 sequentially, based on the date of service, rather than based on the date billings are received

In addition to the amendments proposed to effectuate section 6507 of the PPACA, HHSC proposes to amend §354.1175 to correct rule and agency references.

Section-by-Section Summary

Proposed amended §354.1149(a)(15) replaces "in order of receipt" with "based on the sequential date of service" to reflect that claims are processed in order of service date and not in order of receipt.

Proposed amended §354.1175(c) replaces the reference to §29.1112 with a reference to §354.1149. The substance of §29.1112 was transferred to §354.1149 in 2002. See the May 24, 2002, issue of the Texas Register (27 TexReg 4561). In the same year, several Medicaid programs previously administered by the Texas Department of Health were transferred to HHSC, see id., so current references to "the department" are confusing and are proposed to be changed to "HHSC."

Fiscal Note

Greta Rymal, Deputy Executive Commissioner for Financial Services, has determined that during the first five-year period the amended rules are in effect, there will be no fiscal impact to state government. Local governments will not incur additional costs.

Ms. Rymal anticipates that, for each year of the first five years the rules will be in effect, there will be no economic costs to persons who are required to comply with the proposed rules. There is no anticipated negative impact on local employment.

Small and Micro-business Impact Analysis

HHSC has determined that there will be no adverse economic effect on small businesses or micro-businesses to comply with the amendments, because the number of inpatient Medicaid cases with charges amounting to more than $200,000 is very small and unlikely to affect small or micro-businesses. Only 26 such cases occurred from September 2011 through January 2013, and no hospital or attending physician involved in those cases met the definition of a small business or a micro-business.

Public Benefit

Chris Traylor, Chief Deputy Commissioner, has determined that for each year of the first five years the sections are in effect, the public will benefit from the adoption of the rules. The anticipated public benefit of enforcing the proposed amended rules is that claims are currently being processed based on sequential date of service and not based on the date of receipt.

Regulatory Analysis

HHSC has determined that this proposal is not a "major environmental rule" as defined by §2001.0225 of the Texas Government Code. A "major environmental rule" is defined to mean a rule that is specifically intended to protect the environment or reduce risk to human health from environmental exposure and that may adversely affect, in a material way, the economy, a sector of the economy, productivity, competition, jobs, the environment, or the public health and safety of a state or a sector of the state. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure.

Takings Impact Assessment

HHSC has determined that this proposal does not restrict or limit an owner's right to his or her private real property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under §2007.043 of the Government Code.

Public Comment

Written comments on the proposal may be submitted to Pat Boone, Senior Program Specialist, Medicaid/CHIP Division, Health and Human Services Commission, Mail Code H-390, 4900 N. Lamar Boulevard, P.O. Box 13247, Austin, Texas 78711; by fax to (512) 249-3707; or by email to pat.boone@hhsc.state.tx.us within 30 days of publication of this proposal in the Texas Register.

Statutory Authority

The amendments are proposed under Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with broad rulemaking authority; and Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

The proposed amendments affect Texas Human Resources Code, Chapter 32, and the Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.