Part 2.
DEPARTMENT OF ASSISTIVE AND REHABILITATIVE SERVICES
Chapter 101.
ADMINISTRATIVE RULES AND PROCEDURES
The Texas Health and Human Services Commission proposes changes to
Title 40, Part 2, Chapter 101, §§101.3611, 101.4525, and 101.4527
of the rules of the Department of Assistive and Rehabilitative Services, concerning
rates for medical services. The changes are being proposed to conform standards
governing the rates paid for medical services to the requirements of H. B.
No. 1912, 79th Legislature, Regular Session.
Bill Wheeler, Chief Financial Officer, Department of Assistive and Rehabilitative
Services, estimates that for the first five-year period the amended sections
are in effect, there will be no material fiscal implications for state or
local government.
Mr. Wheeler also estimates that for each year of the first five years the
sections are in effect the public benefit anticipated as a result of enforcing
the sections will be the agency's compliance with House Bill 2292, 78th Legislature,
Regular Session, and other existing provision of law pertaining to provision
of health and human services in Texas. There should be no material effect
to small or micro businesses. There should be no material economic cost to
persons who are required to comply with the sections as proposed. In accordance
with Government Code §2001.022, the Health and Human Services Commission
has determined that the proposed rule changes will not affect a local economy.
Comments on the proposal may be submitted to Roger Darley, Deputy General
Counsel, Department of Assistive and Rehabilitative Services, 4800 North Lamar
Boulevard, Suite 300, Austin, Texas 78756.
Subchapter F. ADMINISTRATIVE RULES AND PROCEDURES PERTAINING TO BLIND SERVICES
1.
GENERAL RULES
40 TAC §101.3611
The amendments are proposed under the Government Code, Chapter
531, §531.0055(e), which provides the Executive Commissioner of the Health
and Human Services Commission with the authority to promulgate rules for the
operation and provision of health and human services by health and human services
agencies.
No other statute, article, or code is affected by this proposal.
§101.3611.Rates for Medical Services.
(a)
Pursuant to Human Resources Code
§117.074, this
rule adopts standards governing the determination of rates paid for medical
services provided by the Division for Blind Services. The rates determined
under these standards will be reevaluated annually.
[
(1)
Subject to any limitations and exceptions specified in
this section, eye-medical and related services purchased by the
division
[
(2)
Rates for eye-medical and related services shall be established
at a level adequate to insure availability of qualified providers in adequate
numbers to provide assessment and treatment within a geographic distribution
that mirrors consumer distribution.
(3)
Rates for eye-medical and related services shall be adopted
after comparing proposed rates to other cost-based rates for medical services,
including Medicaid and Medicare rates. The
division
[
(4)
Rates for eye-medical and related services shall be administered
uniformly in all
division
[
(A)
is not so low as to effectively deny an individual a necessary
service;
(B)
permits exceptions so that individual needs can be addressed;
and
(C)
takes into consideration the consumer's informed choice.
(5)
The
Division
[
(6)
Until rates are adopted pursuant to this section, the
division
[
(b)
Rate schedule. Based on the standards set forth in subsection
(a) of this section, the
Division
[
(1)
The
Division
[
(2)
When there are no HCFA RVU rates established for eye-prosthetics
and related items, the
Division
[
(3)
When there is no HCFA RVU and no established Medicare rate
for eye-prosthetics and related items, the
Division
[
(4)
When there is no rate established by Medicare and Medicaid
for optical low-vision devices, the
Division
[
(5)
The
Division
[
(6)
For services and items for which there is neither a rate
nor an industry standard that takes into consideration the unique needs of
persons with vision loss, the
Division
[
(A)
Low vision evaluation: $243;
(B)
Hand-held and other nonspectacle-mounted optical low vision
devices: national supplier catalog price with an add-on of a 25% processing
fee when purchased through a low vision specialist;
(C)
Spectacle-mounted optical low vision devices--single element
systems: national supplier catalog price, with an add-on of a 30% prescriptive/processing
fee when purchased through a low vision specialist;
(D)
Spectacle mounted optical low vision devices--Telescopic
and other compound optical low vision device systems, including distance vision
telescopes, and near vision telescopes: national supplier catalog price, with
an add-on of a 40% prescriptive processing fee when purchased through a low
vision specialist;
(E)
Poly carbonate safety lens: base prescription, with a $15
add for single vision lens, and a $25 add for bifocal lens;
(F)
Beecher telescopic systems: national supplier catalog price,
with an add-on of a 40% prescriptive processing fee when purchased through
a low vision specialist: Total allowable payment $595, which includes Beecher
device up to $350 plus 40% ($490), and special fitting fee of $105;
(G)
Helm System for clip-on filters, which includes Noir filters,
clip-on frame, and UV tint cut and mount: Up to $114;
(H)
Fitting, spectacle prosthesis, when used in conjunction
with other low vision components: $105;
(I)
Fitting of spectacle-mounted low vision aid, when used
in conjunction with other low vision components: $240;
(J)
Deluxe frames (heavy duty; to support lens(es) with +4D
bifocal add or greater, optical low vision lens(es) at or above plus or minus
8D, or spectacle-mounted optical devices greater than plus or minus 8D): $100.00;
(K)
Psychological service, Comprehensive Vocational Evaluation
System (CVES) used as Vocational Evaluation: $500.00.
(L)
High index aspheric lenses allowable if RX is equal or
greater than +/- 8D. Pay at $45 per lens.
(c)
The
Division for Blind Services Assistant Commissioner
[
(1)
when a consumer's eye-medical condition requires medical
services or a combination of eye-medical services unique to the consumer and
rates adopted under subsection (b) of this section are not applicable or do
not sufficiently describe the needed service; and
(2)
when the service or combination of services is not expected
to reoccur because of its uniqueness and adopting a standard rate serves no
useful future purpose.
(3)
when a new medical service or procedure has become FDA
approved or when a related service or procedure has become available, and
for which there are no established rates yet in any other payment systems.
(d)
Maximum Affordable Payment Schedule (MAPS). A compilation
of rates and detailed descriptions of the services are contained in the Maximum
Affordable Payment Schedule (MAPS), which is available for viewing according
to agency rules on access to public information. Because the compilation contains
copyrighted information, the MAPS may not be duplicated for public use.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the
Office of the Secretary of State on June 21, 2005.
TRD-200502552
Sylvia F. Hardman
General Counsel
Department of Assistive and Rehabilitative Services
Earliest possible date of adoption: August 7, 2005
For further information, please call: (512) 424-4050
4.
PURCHASE OF GOODS AND SERVICES
§91.029
the following rules and standards shall govern the rates the commission will
pay for medical services:
]
commission
] for consumers served by its various programs
shall be paid for at rates not to exceed rates established by Health Care
Finance Administration's (HCFA) relative value units (RVUs) adjusted by the
Medicare conversion factor as applied to the Current Procedural Terminology
(CPT). Where no HCFA RVU exists, a maximum payment shall be set that represents
best value based upon factors that include reasonable and customary industry
standards for each specific service. Subject to the same limitations and exceptions,
noneye-medical and related services shall be paid at the rates established
by the
Division for Rehabilitation Services
[
Texas Rehabilitation
Commission
].
commission
] shall document the reasons that any adopted rate exceeds the Medicaid
or Medicare rate for the same service.
commission
] programs in accordance
with federal regulations governing payment for vocational rehabilitation services,
which allows the agency to establish and maintain written policies to govern
the rates of payment for all purchased services insofar as the schedule:
Board
] shall review
its rate schedule for eye-medical and related services annually after a public
hearing to consider whether adjustments are necessary. If between annual reviews
it becomes necessary to set the amount of payment for a medical service because
a payment rate is not established in these rules or is not otherwise available,
the
Assistant Commissioner, Division for Blind Services or designee
[
Executive Director
] is authorized to set the amount on an individual
basis with the advice of the agency's medical and optometric consultants.
The interim amounts shall be presented to the
Division
[
Board
] at the next scheduled annual review of all rates.
commission
] shall pay for medical services using
amounts contained in the agency's Maximum Affordable Payment Schedule (MAPS).
The MAPS shall continue to be maintained in its present form for public inspection
at the
division's
[
commission's
] main office at 4800
North Lamar, Austin, Texas, 78756, until superseded.)
Commission
] shall
pay for medical services according to the following:
Commission
] shall pay
for eye-medical and related services according to the Health Care Financing
Administration's (HCFA) Relative Value Units (RVU) base rate adjusted by the
Medicare conversion factor if a rate for the service has been established.
Commission
] shall pay
the rates established by Medicare for durable medical equipment, prosthetics,
orthotics, and supplies, if a rate for the service has been established.
Commission
] shall pay the rates established by Medicaid for durable medical equipment,
prosthetics, orthotics, and supplies, if a rate for the service has been established.
Commission
]
shall purchase these from national suppliers either at the supplier's published
price or a lesser negotiated price.
Commission
] shall pay
for noneye-medical and related services that are not unique to persons with
visual disabilities according to the
Division for Rehabilitation Service's
[
Texas Rehabilitation Commission's
] medical payment rates.
Commission
]
shall pay according to the following:
executive director
] or [
the executive director's
]
designee may establish procedures for and may negotiate payments for medical
services under the following conditions:
Subchapter H. PURCHASE OF GOODS AND SERVICES FOR REHABILITATION SERVICES