PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER J. PURCHASED HEALTH SERVICES
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §355.8061, concerning Outpatient Hospital Reimbursement, §355.8121, concerning Reimbursement, §355.8610, concerning Reimbursement for Clinical Laboratory Services, and §355.8660, concerning Renal Dialysis Reimbursement.
BACKGROUND AND PURPOSE
The purpose of the proposal is to implement the outpatient prospective payment system (OPPS) reimbursement as required by Texas Government Code §536.005, (enacted in the 82nd Texas Legislature, 1st Called Session, 2011) which requires that HHSC "convert outpatient hospital reimbursement systems to an appropriate prospective payment system." In addition, the 2014-15 General Appropriations Act, 83rd Legislature, Regular Session, 2013 (Article II, HHSC, Rider 38) stated that "in order to ensure that access to emergency and outpatient services remain in rural parts of Texas, it is the intent of the Legislature that when HHSC changes its outpatient reimbursement methodology to a 3M™ Enhanced Ambulatory Patient Groups or similar methodology, HHSC shall promulgate a separate or modified payment level for the above defined providers." HHSC has been unable to implement EAPGs in the current Medicaid Management Information System (MMIS) without significant technology costs. Now that the agency is moving to a modernized MMIS, EAPGs are being implemented on the same timeframe. The contracts related to the modernized MMIS anticipated the new system would become operational on September 1, 2023. However, the date may be amended to a later date if necessary for system readiness.
The OPPS that HHSC is proposing to implement is the EAPG grouper methodology. EAPGs are a visit-based classification system intended to reflect the type of resources utilized in outpatient encounters for patients with similar clinical characteristics. EAPGs are used in outpatient prospective payment systems for a variety of outpatient settings, including hospital emergency rooms, outpatient clinics and same day surgery. EAPGs are proprietary to 3M Health Information Systems and 3M initially developed Ambulatory Patient Groups prior to 2000. In 2007, 3M made significant changes to its earlier variant of the grouper to reflect current clinical practice including coding and billing practices and to describe a broader, non-Medicare population which resulted in what we now call EAPGs. EAPGs group procedures and medical visits that share similar clinical characteristics, resource utilization patterns and cost so that payment is based on the relative intensity of the entire visit. The EAPG grouping system is designed to recognize clinical and resource variations in severity, which results in higher payments for higher intensity services and lower payments for less intensive services. While each claim may receive multiple EAPGS, each procedure is assigned to only one EAPG.
HHSC is working through the evaluation of the potential impacts in payments to hospitals and other impacted providers and expects to share those impacts in May as the evaluation is completed. The rule amendments update the reimbursement methodology in each of the four rules to clarify the transition to EAPGs.
SECTION-BY-SECTION SUMMARY
The proposed amendment to §355.8061(a) adds new paragraph (1) to define how outpatient hospitals will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. New paragraph (2) is added to specify certain services that are excluded from the OPPS reimbursement as described in subsection (a)(1). Language from subsection (a) is used to create new paragraph (3) to specify that the paragraph applies to services provided prior to the date that the modernized MMIS becomes operational.
The proposed amendment to §355.8061(b) deletes two references for formatting purposes and deletes paragraph (1)(C) as it describes outdated legislation that was previously approved. Section 355.8061(b)(1)(D) is changed to (C) and the subparagraph is amended to provide clarification on exemption of emergency department (ED) services from OPPS reimbursement described in subsection (a) of this section. It also corrects references to paragraphs within the rule.
The proposed amendment to §355.8061(d) adds paragraph (1) to define how outpatient hospital imaging will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. The paragraphs are renumbered and subsection (d)(2) is updated to specify that it applies to services provided prior to the date that the modernized MMIS becomes operational. Subsection (d)(3) is updated to specify that it applies to services provided prior to the date that the modernized MMIS becomes operational.
The proposed amendment to §355.8121 revises the name of the section from "Reimbursement" to "Reimbursement to Ambulatory Surgical Centers" and adds (a)(1) and (a)(2) to define how ambulatory surgical centers will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. The subsections are relabeled and new subsection (b) is updated to specify that it applies to services provided prior to the date that the modernized MMIS becomes operational.
The proposed amendment to §355.8610(a) removes the reference to services provided "by a hospital laboratory for its outpatients" and the language regarding HHSC or its designee reviewing maximum fees at least every two years from subsection (a). A slight modification is made to the name of the section by making "services" singular. Subsection (a) is reorganized for clarification and to align it with the subsequent subsection. New subsection (b)(1) defines how clinical diagnostic laboratory services will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. New subsection (b)(2) specifies that it applies to services provided prior to the date that the modernized MMIS becomes operational, and fees for services during that time were established at a percentage of the Medicaid fee schedule.
The proposed amendment to §355.8660 adds new paragraph (a) to define how outpatient renal dialysis centers will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs.
FISCAL NOTE
Trey Wood, Chief Financial Officer, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules does not have foreseeable implications relating to costs or revenues of state or local governments.
GOVERNMENT GROWTH IMPACT STATEMENT
HHSC has determined that during the first five years that the rules will be in effect:
(1) the proposed rules will not create or eliminate a government program;
(2) implementation of the proposed rules will not affect the number of HHSC employee positions;
(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;
(4) the proposed rules will not affect fees paid to HHSC;
(5) the proposed rules will not create a new rule;
(6) the proposed rules will expand an existing rule;
(7) the proposed rules will not change the number of individuals subject to the rule; and
(8) the proposed rules will not affect the state's economy.
SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS
Trey Wood has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities. The rules do not impose any additional costs on small businesses, micro-businesses, or rural communities that are required to comply with the rules.
LOCAL EMPLOYMENT IMPACT
The proposed rules will not affect a local economy.
COSTS TO REGULATED PERSONS
The rule is necessary to implement legislation that does not specifically state that Texas Government Code Section 2001.0045, pertaining to requirements for rules increasing the costs to regulated persons, applies to the rule.
PUBLIC BENEFIT AND COSTS
Victoria Grady, Director of Provider Finance, has determined that for each year of the first five years the rules are in effect, the public will benefit from the adoption of the rules due to the avoidance of recoupments that might otherwise occur, improved alignment of payments with their intended purpose, and increased transparency with the new details included in the rules.
Trey Wood has also determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules because the rules do not impose any additional fees or costs on those who are required to comply.
TAKINGS IMPACT ASSESSMENT
HHSC has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.
PUBLIC HEARING
A public hearing to receive comments on the proposal will be held by HHSC through a webinar. The meeting date and time will be posted on the HHSC Communications and Events Website at https://hhs.texas.gov/about-hhs/communications-events and the HHSC Provider Finance Hospitals website at https://pfd.hhs.texas.gov/hospitals-clinic/hospital-services/disproportionate-share-hospitals.
Please contact the Provider Finance Department Hospital Finance section at pfd_hospitals@hhsc.state.tx.us if you have questions.
PUBLIC COMMENT
Questions about the content of this proposal may be directed to Christina Nip in the HHSC Provider Finance for Hospitals department at pfd_hospitals@hhsc.state.tx.us.
Written comments on the proposal may be submitted to the HHSC Provider Finance Department, Mail Code H-400, P.O. Box 149030, Austin Texas 78714-9030, or by email to pfd_hospitals@hhsc.state.tx.us.
To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be: (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 23R026" in the subject line.
DIVISION 4. MEDICAID HOSPITAL SERVICES
STATUTORY AUTHORITY
The amendment is proposed under Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; 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; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code §531.0055, Chapter 531, and Texas Human Resources Code Chapter 32.
§355.8061.Outpatient Hospital Reimbursement.
(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 [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 [(relating to Inpatient
Hospital Reimbursement)], 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[, 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 68.44 percent.
[(C) For children's hospitals:]
[(i) The percentage of allowable charges described in subparagraphs (A)(i) and (B)(i) of this paragraph are subject to the prior written approval of the Legislative Budget Board and the Governor, as required by the 2014-2015 General Appropriations Act (Article II, Health and Human Services Comm., S.B. 1, 83rd Leg., Regular Session, 2013, Rider 83 and Special Provisions Relating to All Health and Human Services Agencies, Section 44, Rate Limitations and Reporting Requirements).]
[(ii) If the percentages of allowable charges described in subparagraphs (A)(i) and (B)(i) of this paragraph are not approved as described in clause (i) of this subparagraph, the percentages of allowable charges described in subparagraphs (A)(iii) and (B)(iii) of this paragraph apply.]
(C) [(D)] 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) [(2)(C)] 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) [Cost settlement.] 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.
(C) Interim claim reimbursement for a rural hospital 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 as described in subparagraph (A) of this paragraph.
(D) Interim claim reimbursement determined in subparagraph (C) of this paragraph will not be cost-settled for services rendered on or after September 1, 2021.
(c) Outpatient hospital surgery. Outpatient hospital non-emergency surgery is reimbursed in accordance with the methodology for ambulatory surgical centers as described in §355.8121 of this subchapter (relating to Reimbursement).
(d) Outpatient hospital imaging.
(1) For services provided on and after the date that the modernized MMIS becomes operational, all hospitals will be reimbursed based on an outpatient prospective payment system (OPPS). The OPPS used for reimbursement is the 3M™ Enhanced Ambulatory Patient Groups (EAPG) calculator.
(2) [(1)] For services prior
to the date that the modernized MMIS becomes operational, for [For] all hospitals except rural hospitals, as defined in §355.8052
of this division, outpatient hospital imaging services are not reimbursed
under the outpatient reimbursement methodology described in subsection
(b) of this section. Outpatient hospital imaging services are reimbursed
according to an outpatient hospital imaging service fee schedule that
is based on a percentage of the Medicare Outpatient Prospective Payment
System fee schedule for similar services. If a resulting fee for a
service provided to any Medicaid beneficiary is greater than 125 percent
of the Medicaid adult acute care fee for a similar service, the fee
is reduced to 125 percent of the Medicaid adult acute care fee.
(3) [(2)] For services prior
to the date that the modernized MMIS becomes operational, for [For] rural hospitals, outpatient hospital imaging services are
reimbursed based on a percentage of the Medicare Outpatient Prospective
Payment System fee schedule for similar services.
(e) Minimum Fee Schedule. Effective September 1, 2020, Managed Care Organizations are required to reimburse rural hospitals based on a minimum fee schedule. The minimum fee schedules are the rates specific to rural hospitals, as described in subsections (b) - (d) of this section.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on June 6, 2023.
TRD-202302087
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: July 23, 2023
For further information, please call: (512) 487-3480
STATUTORY AUTHORITY
The amendment is proposed under Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; 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; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code §531.0055, Chapter 531, and Texas Human Resources Code Chapter 32.
§355.8121.Reimbursement to Ambulatory Surgical Centers.
(a) For dates of service on and after the date that the modernized Medicaid Management Information System (MMIS) becomes operational, providers will be reimbursed based on an outpatient prospective payment system (OPPS).
(1) The OPPS utilized is 3M™ Enhanced Ambulatory Patient Groups (EAPG) calculator.
(2) EAPGs are a visit-based classification system intended to reflect the type of resources utilized in outpatient encounters for patients with similar clinical characteristics.
(b) [(a)] For services provided
prior to the date that the modernized MMIS becomes operational, subject [Subject] to the specifications, conditions, and limitations
established by the Texas Health and Human Services Commission [the department], payment for ambulatory surgical center facility
services is made based on Medicare rules and prospectively determined
rates, unless otherwise specified by the department.
(c) Payment for services provided in or by an ambulatory surgical center, other than ambulatory surgical center facility services, is made under other provisions of the state plan, as appropriate to the service and the provider performing the service.
(d) [(b)] Physicians must bill
the Medicaid Program separately for services they provide in an ambulatory
surgical center.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on June 6, 2023.
TRD-202302088
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: July 23, 2023
For further information, please call: (512) 487-3480
STATUTORY AUTHORITY
The amendment is proposed under Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; 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; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code §531.0055, Chapter 531, and Texas Human Resources Code Chapter 32.
§355.8610.Reimbursement for Clinical Laboratory Service [Services].
(a) Clinical diagnostic laboratory tests
performed in a practitioner's office or[,] by
an independent laboratory, [or by a hospital laboratory for its
outpatients] shall be reimbursed as follows.
(1) The [the] lower
of the provider's usual customary charge for that service or a maximum
fee determined by the Texas Health and Human Services Commission (HHSC), or its designee. [HHSC or its designee will review maximum
fees at least every two years, with any adjustments made within available funding.]
(2) Fees for services provided will be established at a percentage of the Medicare fee schedule.
(b) Clinical diagnostic laboratory tests performed by a hospital laboratory for outpatient services shall be reimbursed as follows.
(1) For services provided on and after the date that the modernized Medicaid Management Information System (MMIS) becomes operational, providers will be reimbursed based on an outpatient prospective payment system (OPPS). 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) For services provided prior to the date that the modernized MMIS becomes operational, the lower of the provider's usual customary charge for that service or a maximum fee determined by HHSC, or its designee. Fees for services provided will be established at a percentage of the Medicare fee schedule.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on June 6, 2023.
TRD-202302089
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: July 23, 2023
For further information, please call: (512) 487-3480
STATUTORY AUTHORITY
The amendment is proposed under Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; 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; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code §531.0055, Chapter 531, and Texas Human Resources Code Chapter 32.
§355.8660.Renal Dialysis Reimbursement.
(a) For services provided on or after the date that the modernized Medicaid Management Information System (MMIS) becomes operational, the reimbursement methodology for in-facility renal dialysis treatment services and home renal dialysis treatment services is an outpatient prospective payment system (OPPS). The OPPS used for reimbursement is the 3M™ Enhanced Ambulatory Patient Grouping (EAPG) payment methodology. EAPGs are a visit-based classification system intended to reflect the type of resources utilized in outpatient encounters for patients with similar clinical characteristics.
(b) [(a)] For services prior
to the date that the modernized MMIS becomes operational, payment [Payment] for in-facility renal dialysis treatment services and
home renal dialysis treatment services is based upon the composite
rate reimbursement methodology previously used by Medicare.
The composite rates reflect all changes enacted by the Balanced Budget
Refinement Act of 1999 (BBRA). Rates are based on available funds[,]
and are subject to legislative appropriations.
(c) [(b)] All required items
and services included under the composite rate must be made available
by the facility, either directly or under arrangements, for each dialysis
patient. If the facility fails to make available (either directly
or under arrangements) any item or service listed in this subsection,
or any part of an item or service listed in this subsection, then
the facility cannot be reimbursed any amount for items and services
that the facility provides. Required items and services include:
(1) medically necessary dialysis equipment and dialysis support equipment;
(2) home dialysis support services including the delivery, installation, maintenance, repair, and testing of home dialysis equipment, and home support equipment;
(3) purchase and delivery of all necessary dialysis supplies, except blood which is separately reimbursable under this chapter;
(4) routine end-stage renal dialysis (ESRD) related laboratory tests; and
(5) all dialysis services furnished by the facility's staff.
(d) [(c)] The following items
and services also are included in the composite rate and may not be
billed separately when provided by a dialysis facility:
(1) cardiac monitoring;
(2) catheter changes;
(3) crash cart usage for cardiac arrest;
(4) declotting of shunts by facility staff and any supplies used to declot shunts;
(5) dialysate used during treatment;
(6) oxygen and administration of oxygen;
(7) staff time used to administer blood, inject separately billable drugs, blood collection, and nonroutine peritoneal items;
(8) suture removal and dressing changes; and
(9) other items and services related to dialysis treatment, as determined by HHSC.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on June 6, 2023.
TRD-202302091
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: July 23, 2023
For further information, please call: (512) 487-3480