EMERGENCY RULES An agency may adopt a new or amended section or repeal an existing section on an emergency basis if it determines that such action is necessary for the public health, safety, or welfare of this state. The section may become effective immediately upon filing with the Texas Register, or on a stated date less than 20 days after filing and remaining in effect no more than 120 days. The emergency action is renewable once for no more than 60 additional days. Symbology in amended emergency sections. New language added to an existing section is indicated by the use of bold text. [Brackets] indicate deletion of existing material within a section. TITLE 25. HEALTH SERVICES Part I. Texas Department of Health Chapter 29. Purchased Health Services On behalf of the State Medicaid Director, the Texas Department of Health (department) adopts on an emergency basis amendments to sec.sec.29.601, 29.1104, 29.1126, and 29.1127, concerning purchased health services. Specifically, the sections cover payment for hospital services; Texas Medicaid reimbursement methodology; reimbursement for in-home total parenteral hyperalimentation services; and reimbursement for in-home respiratory therapy services for ventilator-dependent persons. The amendment to sec.29.601 states that outpatient hospital services will be reimbursed at 83.65% of cost during fiscal year 1996 and 77.6% of cost during fiscal year 1997. Based on appropriated funding, outpatient hospital rates continue to be reduced by approximately 5.0% per year which results in the compounded percentages indicated above. The amendments to sec.sec.29.1104, 29. 1126, and 29.1127 remove references to the governor's cost containment provisions which expire August 31, 1995. The existing language stipulates future cost-of-living adjustments (COLAs) and will be dependent on available funding. These amendments are required to comply with the fiscal year 1996-1997 appropriations act adopted by the 74th Legislature which did not include funding for COLAs. The sections are being adopted on an emergency basis to comply with the fiscal year 1996-1997 appropriations act adopted by the 74th Legislature. The department is simultaneously proposing these amendments in this issue of the Texas Register for permanent adoption. Subchapter G. Hospital Services 25 TAC sec.29.601 The amendment is adopted on an emergency basis under the Human Resources Code, sec.32.021, the Government Code, sec.2001.034, and Texas Civil Statutes, Article 4413 (502), sec.16, which provide the Health and Human Services Commission with the authority to adopt rules to administer the state's medical assistance program and is submitted by the Texas Department of Health under its agreement with the Health and Human Services Commission to operate the purchased health services program and authorized under Chapter 15, sec.1.07, Acts of the 72nd Legislature, First Called Session (1991). sec.29.601. Payment for Hospital Services. (a) The Department of Health or its designated agent shall reimburse
    [reimburses] hospitals approved for participation in the Texas Medical Assistance Program for covered Title XIX hospital services provided to eligible Medicaid recipients. The Texas Title XIX State Plan for Medical Assistance provides for reimbursement of covered hospital services to be determined as specified in paragraphs (1)-(3) of this subsection. (1) The amount payable for inpatient hospital services shall be
      [is] determined as specified in sec.29.606 of this title (relating to Reimbursement Methodology for Inpatient Hospital Services). (2) The amount payable for outpatient hospital services shall be
        [is] determined under similar methods and procedures used in the Social Security Act, Title XVIII, as amended, effective October 1, 1982, by Public Law 97-248, except as may be otherwise specified by the department. Medicaid reimbursement for fiscal year 1996
          [1994] will be at 83.65%
            [94.6%] of cost and for fiscal year 1997
              [1995] at 77.6%
                [89. 4%] of cost. Reimbursement for outpatient hospital surgery is limited to the lesser of the amount reimbursed to ambulatory surgical centers (ASCs) for similar services, the hospital's actual charge, the hospital's customary charge, or the allowable cost determined by the department or its designee. (3) Variances shall be
                  [are] accounted for in the Texas State Plan for Medical Assistance or as otherwise specified by the department. (b) (No change.) (c) The direct and indirect costs of caring for charity patients shall
                    have no relationship to eligible recipients of the Texas Medical Assistance program and [have never been and] are not allowable costs under the Texas Title XIX Medical Assistance program. Obligations by hospitals to provide free care, under the Hill-Burton Act or any other arrangement as a condition to secure federal grants or loans, are not recognized as a cost under the Texas Medical Assistance program. (d) (No change.) Issued in Austin, Texas, on August 11, 1995. TRD-9510328 Susan K. Steeg General Counsel Texas Department of Health Effective date: September 1, 1995 Expiration date: December 30, 1995 For further information, please call: (512) 458-7236 Subchapter L. General Administration 25 TAC sec.sec.29.1104, 29.1126, 29.1127 The amendments are adopted on an emergency basis under the Human Resources Code, sec.32.021, the Government Code, sec.2001.034, and Texas Civil Statutes, Article 4413 (502), sec.16, which provide the Health and Human Services Commission with the authority to adopt rules to administer the state's medical assistance program and is submitted by the Texas Department of Health under its agreement with the Health and Human Services Commission to operate the purchased health services program and authorized under Chapter 15, sec.1.07, Acts of the 72nd Legislature, First Called Session (1991). sec.29.1104. Texas Medicaid Reimbursement Methodology (TMRM). (a) Reimbursement for physicians and certain other practitioners. (1) Introduction. Except as otherwise specified, the TMRM for covered services provided by physicians and certain other practitioners shall employ
                      [employs] a prospective payment system which shall be
                        [is] based upon the Texas Department of Health's (department's) determination of adequacy of access to health care services as described in this section, or the actual resources required by an economically efficient provider to provide each individual service. (A)-(B) (No change.) (2) Definitions. The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise. (A)-(C) (No change.) (D) Conversion factor-The dollar amount by which the sum of the three cost component RVUs is multiplied in order to obtain a reimbursement fee for each individual service. The initial value of the conversion factor is $26.873 for fiscal years 1992 and 1993. If funding is available, the conversion factor will be updated based on the adjustments described in subparagraph (E) of this paragraph at the beginning of each state fiscal year biennium. [Unless the cost savings specified in the Appropriations Act for the 1994-1995 biennium are realized, there will be no adjustment of the conversion factor for the 1994-1995 biennium.] The department may, at its discretion, develop and apply multiple conversion factors for various classes of service such as obstetrics, pediatrics, general surgeries, and/or primary care services. (E)-(F) (No change.) (3) (No change.) (b) Reimbursement for ambulance services. Ambulance services shall be
                          [are] reimbursed in accordance with a reasonable charge methodology. The department or its designee shall define
                            [defines] and determine
                              [determines] reasonable charges and payments based on reasonable charges as follows. (1) A reasonable charge shall be
                                [is] a charge for a specific service which shall be
                                  [is] the lowest of: (A)-(C) (No change.) (2) The department or its designee shall use
                                    [uses] a statistical base for making reasonable charge determinations. The statistical base is comprised of individual charges gathered from available sources, including Medicare (Title XVIII) and Medicaid (Title XIX). (3) Determination of reasonable charges, as set forth in this section and established by the department, shall be
                                      [is] made in accordance with applicable federal requirements. Payments for services provided must not exceed the Medicare allowable charges. (c) Reimbursement for clinical diagnostic laboratory services. Clinical diagnostic laboratory tests performed in a physician's office, by an independent laboratory, or by a hospital laboratory for its outpatients shall be
                                        [are] reimbursed on the basis of the Medicare-established fee schedule. sec.29.1126. In-home Total Parenteral Hyperalimentation Services. (a) Subject to the specifications, conditions, limitations, and requirements established by the Texas Department of Health (department)
                                          [department], in-home total parenteral hyperalimentation services shall be made
                                            [are] available to eligible recipients who require long-term support because of extensive bowel resection and/or severe advanced bowel disease in which the bowel cannot support nutrition. Covered services must be reasonable, medically necessary, and prescribed by the recipient's physician (M.D. or D.O.). The physician must be licensed in the state in which the physician practices. (b) (No change.) (c) Covered services include, but are not necessarily limited to: (1)-(3) (No change.) (4) visits by a registered nurse appropriately trained in the administration of hyperalimentation. The nurse must visit the recipient at least once per month to monitor the recipient's status and to provide ongoing education to the recipient and/or family members/support persons regarding the administration of hyperalimentation; and (5) (No change.) (d) (No change.) (e) The department
                                              [Texas Department of Health (department)] or its designee shall reimburse
                                                [reimburses] each provider on a monthly basis. Reimbursement shall be
                                                  [is] based on one-twelfth of the maximum yearly fee established by the department. If funding is available, the department will adjust the allowable fees or rates each state fiscal year by applying the projected rate of change of the implicit price deflator for personal consumption expenditures (IPD-PCE). The department shall use
                                                    [uses] the lowest feasible IPD-PCE forecast consistent with the forecasts of nationally-recognized sources available to the department at the time rates are prepared. [The first adjustment will be effective January 1, 1993. Unless the cost savings specified in the Appropriations Act for the 1994-1995 biennium are realized, there will be no adjustment for the 1994 and 1995 fiscal years.] The department or its designee shall
                                                      [does] not reimburse more than a one-week supply of solutions and additives if the solutions and additives are shipped and not used because of the recipient's loss of eligibility, change in treatment, or inpatient hospitalization. The provider must exclude from its monthly billing any days that the recipient is an inpatient in a hospital or other medical facility or institution. Payment for partial months will be prorated based upon actual days of administration. Hospital outpatient departments furnishing in- home total parenteral nutrition must be separately enrolled as a provider meeting all requirements stipulated in subsection (d) of this section. Reimbursement to hospital outpatient departments furnishing in-home total parenteral nutrition may not exceed the maximum yearly fee established by the department. sec.29.1127. In-home Respiratory Therapy Services for Ventilator-Dependent Persons. (a) Subject to the specifications, conditions, limitations, and requirements established by the department, in-home respiratory therapy services shall be made
                                                        [are] available to eligible recipients who: (1)-(6) (No change.) (b)-(c) (No change.) (d) Covered services include, but are not necessarily limited to the following: (1) (No change.) (2) supplies, including but not necessarily limited to disposable circuits, suction catheters, tracheal care kits, sterile water, non-sterile disposable gloves, and dressings/tracheal tapes that are necessary in the administration of the therapy and treatment. Supplies do not include drugs; and (3) (No change.) (e) Providers of respiratory therapy services must meet the following requirements: (1)-(3) (No change.) (4) sign a written provider agreement with the department or its designee. By signing the agreement, the provider agrees to comply with the terms of the agreement and all requirements of the Texas Medical Assistance Program including regulations, rules, handbooks, standards, and guidelines published by the department or its designee; and (5) (No change.) (f) The department or its designee shall reimburse
                                                          [reimburses] each respiratory therapy provider on a per-visit basis. Reimbursement for the visit shall be
                                                            [is] based on the lesser of the provider's customary charge or the maximum allowable fee or rate established by the department or its designee. Reimbursement for supplies furnished by the respiratory care practitioner shall be
                                                              [is] the lesser of the provider's customary charges or the maximum allowable fees or rates established by the department or its designee. If funding is available, the department shall update
                                                                [updates] its allowable fees or rates each state fiscal year by applying the implicit price deflator for personal consumption expenditures. [Unless the cost savings specified in the Appropriations Act for the 1994-1995 biennium are realized, there will be no adjustment for the 1994 and 1995 state fiscal years.] Issued in Austin, Texas, on August 11, 1995. TRD-9510329 Susan K. Steeg General Counsel Texas Department of Health Effective date: September 1, 1995 Expiration date: December 30, 1995 For further information, please call: (512) 458-7236