Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter J - PURCHASED HEALTH SERVICES
Division 2 - MEDICAID HOME HEALTH PROGRAM
Section 355.8023 - Reimbursement Methodology for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
Universal Citation: 1 TX Admin Code ยง 355.8023
Current through Reg. 49, No. 38; September 20, 2024
(a) Authorized items provided to eligible Medicaid recipients are reimbursed the lesser of the billed amount or the Medicaid reimbursement rate established by HHSC.
(b) HHSC reviews the fees for individual items at least every two years as follows.
(1) If Medicare reimburses for a durable
medical equipment, prosthetics, orthotics and supplies (DMEPOS) item, the
Medicaid reimbursement rate is equal to, or a percentage of, the Medicare
reimbursement rate for the procedure code. If HHSC determines that the Medicare
reimbursement rate is insufficient, the methodologies in paragraphs (2) or (3)
of this subsection apply.
(2) If
Medicare does not reimburse for a DMEPOS item, other sources are used to
determine the Medicaid payment rate as follows:
(A) analysis of Medicaid fees for the same or
similar items in other states;
(B)
eighty-two percent of the manufacturer's suggested retail price
(MSRP);
(C) cost shown on a
manufacturer's invoice submitted by the provider to HHSC; or
(D) analysis of fees paid under commercial
insurance for the same or similar item or service.
(3) HHSC may use data sources or
methodologies other than those listed in paragraph (2) of this subsection to
establish Medicaid fees for DMEPOS when HHSC determines that those
methodologies are unreasonable or insufficient.
(c) Fees for DMEPOS items are adjusted within available funding as described in § RSA 355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).
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