Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter A - PURCHASED HEALTH SERVICES
Division 11 - GENERAL ADMINISTRATION
Section 354.1175 - Organ Transplants

Universal Citation: 1 TX Admin Code ยง 354.1175

Current through Reg. 49, No. 38; September 20, 2024

(a) Subject to the specifications, conditions, and limitations established by the Health and Human Services Commission (HHSC), organ transplant services are covered as follows:

(1) Coverage is limited to those services, as approved by HHSC 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 is limited to an initial transplant and one subsequent retransplant because of rejection as a lifetime benefit.

(b) As specified by HHSC 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 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 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 § RSA 354.1149 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 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.

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