Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section describes the
Texas Medicaid reimbursement methodology that the Texas Health and Human
Services Commission (HHSC) uses to calculate payment for covered services
provided by physicians and other practitioners.
(1) There is no geographical or specialty
reimbursement differential for individual services.
(2) HHSC reviews the fees for individual
services at least every two years based upon:
(A) analysis of Medicare fees for the same or
similar item or service;
(B)
analysis of Medicaid fees for the same or similar item or service in other
states; or
(C) analysis of
commercial fees 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 physicians and other practitioners when HHSC
determines that those methodologies are unreasonable or insufficient.
(4) Fees for these services 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).
(b) Eligible Providers. Eligible providers
include:
(1) Providers of Laboratory and X-ray
Services;
(2) Providers of
Radiation Therapy;
(3) Physical,
Occupational, and Speech Therapists;
(4) Physical, Occupational, and Speech
Therapy Assistants;
(5)
Physicians;
(6)
Podiatrists;
(7)
Chiropractors;
(8)
Optometrists;
(9)
Dentists;
(10)
Psychologists;
(11) Licensed
Psychological Associates;
(12)
Provisionally Licensed Psychologists;
(13) Licensed Psychological Interns and
Fellows;
(14) Maternity clinics;
(15) State Supported Living
Centers;
(16) Tuberculosis clinics;
and
(17) Peer
Specialists.
(c)
Definitions. The following words and terms, when used in this section, have the
following meanings, unless the context clearly indicates otherwise.
(1) Access-based fees (ABF)--Fees for
individual services, where HHSC deems necessary, to account for deficiencies
relating to the adequacy of access to health care services.
(2) Biological--A substance that is made from
a living organism or its products and is used in the prevention, diagnosis, or
treatment of cancer and other diseases.
(3) Conversion factor--The dollar amount by
which the sum of the three cost component relative value units (RVUs) is
multiplied to obtain a reimbursement fee for each individual service.
(4) Drug--Any substance, that is used to
prevent, diagnose, treat or relieve symptoms of a disease or abnormal
condition.
(5) HHSC--The Texas
Health and Human Services Commission or its designee.
(6) Relative value units (RVUs)--The relative
value assigned to each of the three individual components that comprise the
cost of providing individual Medicaid services. The three cost components of
each reimbursement fee are intended to reflect the work, overhead, and
professional liability expense required to provide each individual
service.
(7) Resource-based fees
(RBF)--Fees for individual services based upon HHSC's determination of the
resources that an economically efficient provider requires to provide
individual services.
(8)
Vaccine--An immunogen, the administration of which is intended to stimulate the
immune system to result in the prevention, amelioration or therapy of any
disease or infection.
(d) Calculating the payment amounts. Subject
to qualifications, limitations, and exclusions as provided in this chapter,
payment to eligible providers must not exceed the lesser of the provider's
billed amount or the amount derived from the methodology described in this
section. The fee schedule that results from the reimbursement methodology may
be composed of both access-based fees (ABFs) and resource-based fees (RBFs).
(1) ABF methodology allows the state to:
(A) reimburse for procedure codes not covered
by Medicare;
(B) account for
inadequate reimbursement rates for particularly difficult procedures;
(C) encourage participation in the Medicaid
program by physicians and other practitioners; and
(D) set reimbursement to allow eligible
Medicaid population to receive adequate health care services in an appropriate
setting.
(2) An RBF is
calculated using the following formula: RBF = (total RVU * CF), where RBF =
Resource-Based Fee, total RVU = the sum of the three Relative Value Units that
comprise the cost of providing individual Medicaid services, and CF =
Conversion Factor.
(A) Except as otherwise
specified, HHSC bases the RVUs that are employed in the Texas Medicaid
reimbursement methodology upon the RVUs of the individual services as specified
in the Medicare Fee Schedule. HHSC reviews any changes to, or revisions of, the
various Medicare RVUs and, if applicable, adopts the changes as part of the
reimbursement methodology within available funding.
(B) HHSC may develop and apply multiple
conversion factors for various classes of service, such as obstetrics,
pediatrics, general surgeries, and/or primary care services.
(e)
Reimbursement for physician-administered drugs, vaccines, and biologicals. In
determining the reimbursement methodology for physician-administered drugs,
vaccines, and biologicals, HHSC may consider information such as costs,
utilization, data sufficiency, and public input. Reimbursement for
physician-administered drugs, vaccines, and biologicals are based on the lesser
of the billed amount, a percentage of the Medicare rate, or one of the
following methodologies:
(1) If the drug or
biological is considered a new drug or biological (that is, approved for
marketing by the Food and Drug Administration within 12 months of
implementation as a benefit of Texas Medicaid), it may be reimbursed at an
amount equal to 89.5 percent of average wholesale price (AWP).
(2) If the drug or biological does not meet
the definition of a new drug or biological, it may be reimbursed at an amount
equal to 85 percent of AWP.
(3)
Vaccines may be reimbursed at an amount equal to 89.5 percent of AWP.
(4) Infusion drugs furnished through an item
of implanted Durable Medical Equipment may be reimbursed at an amount equal to
89.5 percent of AWP.
(5) Drugs,
other than vaccines and infusion drugs, may be reimbursed at an amount equal to
106 percent of the average sales price (ASP).
(6) HHSC may use other data sources or
methodologies to establish Medicaid fees for physician-administered drugs,
vaccines, and biologicals when HHSC determines that the above methodologies are
unreasonable or insufficient.
(f) Reimbursement for services provided under
the supervision of a licensed psychologist. Reimbursement for services provided
under the supervision of a licensed psychologist by a licensed psychological
associate (LPA) or a provisionally licensed psychologist (PLP) is reimbursed to
the licensed psychologist at 70 percent of the fee paid to the licensed
psychologist for the same service. Reimbursement for services provided under
the supervision of a licensed psychologist by a licensed psychology intern or
fellow are reimbursed at 50 percent of the fee paid to a licensed psychologist
for the same service.
(g)
Reimbursement for certain other providers. The descriptions for reimbursement
of certain other providers are described in sections of this chapter.
(1) Reimbursement for physician assistants is
described in §
RSA
355.8093 of this title (relating to
Reimbursement Methodology for Physician Assistants).
(2) Reimbursement for nurse practitioners and
clinical nurse specialists is described in §
RSA
355.8281 of this title (relating to
Reimbursement Methodology for Nurse Practitioners and Clinical Nurse
Specialists).
(3) Reimbursement for
services provided under Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) is described in §
RSA
355.8441 of this title (relating to
Reimbursement Methodologies for Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Services).
(4)
Reimbursement for Licensed Professional Counselors, Licensed Clinical Social
Workers, and Licensed Marriage and Family Therapists is described in §
RSA
355.8091 of this title (relating to
Reimbursement to Licensed Professional Counselors, Licensed Clinical Social
Workers, and Licensed Marriage and Family Therapists).
(5) Reimbursement for Physical, Occupational,
and Speech Therapy Services is described in § 355.8097 of this title
(relating to Reimbursement for Physical, Occupational, and Speech Therapy
Services).
(h) Fees for
services provided by physicians or other practitioners 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).
