Current through Reg. 49, No. 38; September 20, 2024
(a) This section applies only to an
out-of-state Medicaid applicant or re-enrolling provider. An applicant or
re-enrolling provider is considered out-of-state if:
(1) the physical address where services are
or will be rendered is located outside the Texas state border and within the
United States;
(2) the physical
address where the services or products originate or will originate is located
outside the Texas state border and within the United States when providing
services, products, equipment, or supplies to a Medicaid recipient in the state
of Texas; or
(3) the physical
address where services are or will be rendered is located within the Texas
state border, but:
(A) the applicant or
re-enrolling provider maintains all patient records, billing records, or both,
outside the Texas state border; and
(B) the applicant or re-enrolling provider is
unable to produce the originals or exact copies of the patient records or
billing records, or both, from the location within the Texas state border where
services are rendered.
(b) An applicant or re-enrolling provider
that is considered out-of-state under subsection (a) of this section is
ineligible to participate in Medicaid unless HHSC or its designee approves the
applicant or re-enrolling provider for enrollment on the basis of a
determination that the applicant or re-enrolling provider has provided, is
providing, or will provide services under one or more of the following
criteria:
(1) The services are medically
necessary emergency services provided to a recipient who is located outside the
Texas state border, in which case the enrollment will be time-limited for an
appropriate period as determined by HHSC or its designee, not to exceed one
year.
(2) The services are
medically necessary services provided to a recipient who is located outside the
Texas state border, and in the expert opinion of the recipient's attending
physician or other provider, the recipient's health would be or would have been
endangered if the recipient were required to travel to Texas, in which case the
enrollment will be time-limited for an appropriate period as determined by HHSC
or its designee, not to exceed one year.
(3) The services are medically necessary
services that are more readily available to a recipient in the state where the
recipient is located, in which case the enrollment will be time-limited for an
appropriate period as determined by HHSC or its designee.
(4) The services are medically necessary to a
recipient who is eligible on the basis of participation in an adoption
assistance or foster care program administered by the Texas Department of
Family and Protective Services under Title IV-E of the Social Security Act, in
which case the enrollment may be time-limited for an appropriate period as
determined by HHSC or its designee.
(5) The services are medically necessary and
have been prior authorized by HHSC or its designee, and documented medical
justification indicating the reasons the recipient must obtain medical care
outside Texas is furnished to HHSC or its designee before providing the
services and before payment, in which case the enrollment may be time-limited
for an appropriate period as determined by HHSC or its designee.
(6) The services are medically necessary and
it is the customary or general practice of recipients in a particular locality
within Texas to obtain services from the out-of-state provider, if the provider
is located in the United States and within 50 miles driving distance from the
Texas state border, or as otherwise demonstrated on a case-by-case basis.
(A) Enrollment under this paragraph may be
time-limited for an appropriate period as determined by HHSC or its
designee.
(B) An out-of-state
provider does not meet the criterion in this paragraph merely on the basis of
having established business relationships with one or more providers that
participate in Medicaid.
(7) The services are medically necessary and
the nature of the service is such that providers for this service are limited
or not readily available within the state of Texas.
(8) The services are medically necessary
services to one or more dually eligible recipients (i.e., recipients who are
enrolled in both Medicare and Medicaid) and the out-of-state provider may be
considered for reimbursement of co-payments, deductibles, and co-insurance, in
which case the enrollment may be time-limited for an appropriate period as
determined by HHSC or its designee, and the enrollment will be restricted to
receiving reimbursement only for the Medicaid-covered portion of Medicare
crossover claims.
(9) The services
are provided by a pharmacy that is a distributor of a drug that is classified
by the U.S. Food and Drug Administration (FDA) as a limited distribution
drug.
(10) The services are
medically necessary and one or more of the following exceptions for good cause
exist and can be documented:
(A) Texas
Medicaid enrolled providers rely on the services provided by the
applicant.
(B) Applicant maintains
existing agreements as a participating provider through one or more Medicaid
managed care organizations (MCO) and enrollment of the applicant leads to more
cost-effective delivery of Medicaid services.
(c) An out-of-state provider that applies for
enrollment in Medicaid must submit documentation along with the enrollment
application to demonstrate that the provider meets one or more of the criteria
in subsection (b) of this section. The provider must submit any additional
requested information to HHSC or its designee before enrollment may be
approved.
(d) If HHSC or its
designee determines that an out-of-state provider meets one or more of the
criteria in subsection (b) of this section, the provider must meet all other
applicable enrollment eligibility requirements, including those specified in
Chapter 371 of this title (relating to Medicaid and Other Health and Human
Services Fraud and Abuse Program Integrity) before enrollment may be
approved.
(e) Other applicable
requirements.
(1) An out-of-state provider
that is enrolled pursuant to subsections (b) (d) of this section must follow
all other applicable Medicaid participation requirements identified by HHSC or
its designee for each service provided. Other applicable requirements that must
be followed may include:
(A) service benefits
and limitations;
(B) documentation
procedures;
(C) obtaining prior
authorization for the service whenever required; and
(D) claims filing deadlines as specified in
§
RSA
354.1003 of this title (relating to Time
Limits for Submitted Claims).
(2) Certain out-of-state providers are not
entitled to utilize the extended 365-day claim filing deadline provided in
§
RSA
354.1003(a)(5)(H) of this
title that is otherwise available to out-of-state providers, and must comply
with the same claims filing deadlines that apply to in-state providers under
that section. Those out-of-state providers are:
(A) providers that are approved for
enrollment under the criterion specified in subsection (b)(6) of this section,
where the specific basis for approval is that the provider is located within 50
miles driving distance from the Texas state border; and
(B) providers that are approved for
enrollment under the criterion specified in subsection (b)(8) of this section
regarding dually eligible recipients.
(f) An out-of-state provider that is enrolled
pursuant to subsections (b) - (d) of this section must:
(1) comply with the terms of the Medicaid
provider agreement;
(2) provide
services in compliance with all applicable federal, state, and local laws and
regulations related to licensure and certification in the state where the
out-of-state provider is located; and
(3) comply with all state and federal laws
and regulations relating to Medicaid in the state of Texas.
(g) HHSC or its designee
determines the basis and amount of reimbursement for medical services provided
outside Texas and within the United States in accordance with Chapter 355 of
this title (relating to Reimbursement Rates).
(h) A laboratory may participate as an
in-state provider under any program administered by a health and human services
agency, including HHSC, that involves laboratory services, regardless of the
location where any specific service is performed or where the laboratory's
facilities are located if:
(1) the laboratory
or an entity that is a parent, subsidiary, or other affiliate of the laboratory
maintains laboratory operations in Texas;
(2) the laboratory and each entity that is a
parent, subsidiary, or other affiliate of the laboratory, individually or
collectively, employ at least 1,000 persons at places of employment located in
this state; and
(3) the laboratory
is otherwise qualified to provide the services under the program and is not
prohibited from participating as a provider under any benefits programs
administered by a health and human services agency, including HHSC, based on
conduct that constitutes fraud, waste, or abuse.
