Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353.
MEDICAID MANAGED CARE
The Health and Human Services Commission (HHSC) adopts amendments
to Chapter 353, Subchapter A, §353.2 and §353.3 and Subchapter E, §§353.403,
353.405, 353.407, 353.409, 353.411, 353.413, 353.415, 353.417 and 353.419.
Chapter 353 describes standards for the Medicaid Managed Care program. The
amendments are adopted without changes to the proposed text as published in
the May 19, 2006, issue of the
Texas Register
(31
TexReg 4125) and will not be republished.
HHSC amends the following rules: §353.2, Definitions; §353.3,
Experience Rebate in the Managed Care Program; §353.403, Enrollment; §353.405,
Marketing; §353.407, Requirements of Health Maintenance Organizations; §353.409,
Scope of Services; §353.411, Accessibility of Services; §353.413,
Managed Care Benefits and Services for Children Under 21 Years of Age; §353.415,
Member Complaint Procedures; §353.417, Quality Assessment and Performance
Improvement; and §353.419, Financial Standards.
The amendments to the rules are necessary to comply with changes in statute
and regulation, to enhance Medicaid managed care efficiency, and to improve
services to Members and providers.
Section 6 of Senate Bill 1188, 79th Legislature, Regular Session (2005)
(codified at §533.005(a)(14) of the Government Code), requires a modification
to the way in which Medicaid Managed Care Organizations (MCOs) may reimburse
Federally Qualified Health Centers and Rural Health Clinics for after hours
care under some circumstances. In implementing this provision, it is necessary
that new definitions be added to §353.2, and that the reimbursement framework
be described. The reimbursement standard is contained in §353.407.
In addition, a new definition of Managed Care Organization is required
to bring Medicaid regulations into conformity with Texas Department of Insurance
regulations, which provide for an additional Medicaid managed care delivery
model, the Exclusive Provider Benefit Plan (EPBP). Adding these new definitions
requires corresponding changes to §§353.403, 353.405, 353.407, 353.409,
353.411 and 353.417.
The amendment to §353.3 is necessary in order to align the Medicaid
experience rebate process with that of the Children's Health Insurance Program.
The amendment to §353.411 is necessary to provide HHSC with more detailed
information regarding MCO compliance with Medicaid Member access to services
requirements. The amendment to §353.415 is necessary to clarify MCO Member
appeal rights. It is necessary to amend §353.419 to change a definition
required by §353.2, as amended, and to broaden MCO solvency requirements.
HHSC received a comment regarding the proposed amendments during the comment
period, which included a public hearing on May 30, 2006, from UniCare Health
Plans of Texas, Inc. A summary of the comment and HHSC's response follows.
Comment: HHSC received a comment from UniCare Health Plans of Texas, Inc.,
expressing support for the elimination of the six-month time limit for a default
enrollment period in §353.403(i). The commenter suggests that the "existing
rule sets an arbitrary time limit that may not apply in all markets."
Response: HHSC acknowledges the comment received from UniCare Health Plans
of Texas, Inc., in support of the proposed elimination of the six-month time
limit for a default enrollment period. No change to the rules was requested
by the commenter.
Subchapter A. GENERAL PROVISIONS
1 TAC §353.2, §353.3
The amendments are adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604175
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: May 19, 2006
For further information, please call: (512) 424-6900
1 TAC §§353.403, 353.405, 353.407, 353.409, 353.411, 353.413, 353.415, 353.417, 353.419
The amendments are adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on August 10, 2006.
TRD-200604176
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: May 19, 2006
For further information, please call: (512) 424-6900
Subchapter A. PURCHASED HEALTH SERVICES
6.
HOSPITAL SERVICES
1 TAC §354.1077
The Health and Human Services Commission (HHSC) adopts amendments
to §354.1077, relating to provider participation requirements, with changes
to the proposed text as published in the June 23, 2006, issue of the
The proposed amendments will require hospitals in eight urban service areas
to comply with the reimbursement provisions and rate reductions of 1 TAC §355.8064
in order to participate in the Texas Medicaid program. The amendments to §355.8064
are being adopted simultaneously in this issue of the
Texas Register
.
The 2006-2007 General Appropriations Act (Article II, Special Provisions,
Section 49, Senate Bill 1, 79th Legislature, Regular Session, 2005) (Act)
directs HHSC to achieve savings for services provided to Medicaid aged, blind
and disabled clients in the following service areas: Bexar, Dallas, El Paso,
Harris, Lubbock, Nueces, Tarrant and Travis. The purpose of this rule is to
implement the Section 49 mandate and to achieve the directed savings.
Section 49 of the Act further requires HHSC to utilize cost-effective models
to better manage the care of these clients and, at the same time, achieve
the identified savings. HHSC plans to meet this requirement by implementing
a non-capitated Integrated Care Management (ICM) model in the Dallas and Tarrant
service areas, and a partially capitated model with inpatient hospital services
carved out in other urban service areas. The goal of both models is to promote
proper utilization and integration of acute care and long-term care services,
while achieving the savings directed by the Legislature.
During the comment period, which included a public hearing on July 26,
2006, HHSC received written comments regarding the proposed amendments from
the partnership One Voice and the Network of Behavioral Health Providers,
the Texas Association of Public and Nonprofit Hospitals, El Paso County Hospital
District, Seton Hospital, the Texas Hospital Association, Medical City Hospital,
Christus Healthcare Network, Tenet Healthcare, HCA, and Methodist Hospital
of Dallas.
Comment: HHSC received a comment from the Texas Hospital Association concerning §354.1077,
stating that the proposed rule lacks statutory or legislative authority.
Response: HHSC has the authority to adopt §354.1077 under §531.033,
Government Code, which provides the Executive Commissioner of HHSC with broad
rulemaking authority; §531.021, Government Code, which provides HHSC
with the authority to administer Medicaid funds and adopt rules governing
the determination of Medicaid reimbursements; and §32.021, Human Resources
Code, which provides HHSC with the authority to administer the Medicaid program
and adopt rules for the proper and efficient operation of the program.
Comment: In their written comments, the partnership of One Voice and the
Network of Behavioral Health Providers, the Texas Association of Public and
Nonprofit Hospitals, El Paso County Hospital District, Seton Hospital, the
Texas Hospital Association, and Medical City Hospital stated that the proposed
rate reductions will significantly impact current reimbursement rates, which
have already been cut by five percent, resulting in hospitals receiving only
80% of their costs to provide Medicaid services.
Response: Senate Bill 1, General Appropriations Act (Article II, Special
Provisions, Section 49), 79th Legislature, Regular Session, 2005, directs
HHSC, to the extent necessary, to adjust provider payments in the designated
service areas to ensure that the Section 49 savings target is achieved.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals, the Texas Hospital Association, and Medical City Hospital
stated that the $109.5 million in savings targeted for the 2006-2007 biennium
was unrealistically high.
Response: HHSC understands the concern; however, Senate Bill 1, General
Appropriations Act (Article II, Special Provisions, Section 49), 79th Legislature,
Regular Session, 2005, directs a savings target of $109,500,000 in general
revenue.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals, the Texas Hospital Association, and Medical City Hospital
stated the hospital industry supported implementation of an Integrated Care
Management (ICM) model in all expansion service areas. The commenters expressed
the opinion that this would give all provider types an opportunity to make
the system work in a collaborative manner but that ICM is now being implemented
only in the Dallas and Tarrant service areas.
Response: The proposed rule change addresses only provider participation
requirements and not where the ICM model will be implemented.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals, Seton Hospital, the Texas Hospital Association, and Medical
City Hospital stated the proposed rule will be harmful to local taxpayers
and businesses as costs not covered by Medicaid are passed on to taxpayers
and commercial health plans.
Response: HHSC acknowledges that the proposed rule may result in a net
loss in revenue to publicly owned hospitals, not to exceed $59.3 million over
the five-year period. The negative fiscal impact on revenues of local governments
is based on an 8% reduction in fiscal year 2007 rates. Publicly owned hospitals
receiving UPL funding will be able to offset loss in federal funding resulting
from the 8% rate reduction by claiming increased federal funding from UPL
payments. However, Senate Bill 1, General Appropriations Act (Article II,
Special Provisions, Section 49), 79th Legislature, Regular Session, 2005,
directs HHSC, to the extent necessary, to adjust provider payments in the
designated service areas to ensure that the savings target is achieved.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals and the Texas Hospital Association stated the proposed
rule is arbitrary in that it does not specify the amount that the inpatient
rates will be reduced nor does it identify which hospitals in each market
will be subject to the rate reduction.
Response: HHSC acknowledges that a final determination as to which hospitals
in each market will be subject to the rate reduction or the amount of the
reductions has not yet been made, but HHSC disagrees that the rule is arbitrary.
The scope of the rule includes all hospitals within the designated service
areas, and HHSC will notify each affected hospital of any applicable rate
reduction once a final determination has been made. HHSC values each hospital's
participation in the Medicaid program, but continued participation in the
program is voluntary.
Comment: HHSC received a comment from the Texas Association of Public and
Nonprofit Hospitals stating the proposed provider participation rule is inappropriate
for a program that is voluntary.
Response: HHSC values each hospital's participation in the Medicaid program.
However, Section 49 of the 2006-2007 General Appropriations Act requires that
HHSC achieve targeted savings in the identified service areas.
Comment: In their written comments, the partnership of One Voice and the
Network of Behavioral Health Providers, the Texas Association of Public and
Nonprofit Hospitals, El Paso County Hospital District, and the Texas Hospital
Association stated the proposed rule change will force some hospitals to terminate
their Medicaid contracts, which may adversely impact access to hospital care.
Response: Senate Bill 1, General Appropriations Act (Article II, Special
Provisions, Section 49), 79th Legislature, Regular Session, 2005, directs
HHSC, to the extent necessary, to adjust provider payments in the designated
service areas to ensure that the savings target is achieved.
The amendments are adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas, to administer Medicaid funds, and to adopt rules
necessary for the proper and efficient operation of the Medicaid program;
and the Texas Government Code, §531.021(b), which provides HHSC with
the authority to propose and adopt rules governing the determination of Medicaid
reimbursements.
§354.1077.Provider Participation Requirements.
(a)
A hospital must comply with each of the following requirements
to qualify for participation as a hospital in the Texas Medical Assistance
(Medicaid) Program. A hospital must:
(1)
be licensed by the Department of State Health Services
(department) as a general or special hospital, unless exempt from licensure
by the appropriate licensing authority. This requirement does not apply to
military hospitals providing inpatient emergency hospital services;
(2)
be enrolled and participating in the Medicare Program as
a hospital;
(3)
sign a written provider agreement with the department or
its designee to participate in the Medicaid program. The provider agreement
requires the hospital to comply with the terms of the agreement and all requirements
of the Medicaid program, including regulations, rules, handbooks, standards,
and guidelines published by the department or its designee; and
(4)
comply with the utilization review plan approved by the
department or its designee.
(b)
Effective December 1, 1991, the hospital must maintain
policies and procedures regarding the following policies with respect to all
adult individuals receiving inpatient services provided by the hospital:
(1)
provide all adult individuals the following information
regarding advance directives at the time of the individual's admission as
an inpatient:
(A)
the individual's rights under Texas law, whether statutory
or as recognized by the courts of the state, to make decisions concerning
medical care, including the right to accept or refuse medical or surgical
treatment and the right to formulate advance directives (directive to physicians/living
will or durable power of attorney for health care); and
(B)
the hospital's policies respecting the implementation of
such rights;
(2)
document in the individual's medical record whether or
not the individual has executed an advance directive;
(3)
not condition the provision of care or otherwise discriminate
against an individual based on whether or not the individual has executed
an advance directive;
(4)
ensure compliance with the requirements of Texas law, whether
statutory or as recognized by the courts of Texas, respecting advance directives
at facilities of the provider or organization; and
(5)
provide for education for staff and the community on issues
concerning advance directives.
(c)
Notwithstanding subsections (a) and (b) of this section,
effective September 1, 2006, a hospital in the Bexar, Dallas, El Paso, Harris,
Lubbock, Nueces, Tarrant or Travis Service Areas will not be permitted to
participate in the Texas Medical Assistance (Medicaid) Program unless the
hospital agrees in writing to comply with the provisions of §355.8064
of this title (relating to Reimbursement Adjustment for Hospitals Providing
Inpatient Services to SSI and SSI-Related Clients).
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604177
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: June 23, 2006
For further information, please call: (512) 424-6900
1 TAC §354.1430, §354.1432
The Health and Human Services Commission (HHSC) adopts amendments
to §354.1430, Definitions, and §354.1432, Benefits and Limitations,
which relate to Texas Medicaid telemedicine services, with changes to the
proposed text as published in the April 21, 2006, issue of the
Texas Register
(31 TexReg 3335). The text of the rules will be republished.
The proposed amendments to the telemedicine services rules are to satisfy
the requirements of Senate Bill 1340, 79th Legislature, Regular Session, 2005,
which requires HHSC to develop, by rule, a pilot program under which Medicaid
recipients in need of mental health services are provided those services through
telemedicine. The Texas Department of State Health Services (DSHS) is responsible
for implementing the program. The pilot will be evaluated by the state to
determine whether extension of the use of telemedicine improves access to
mental health services and quality of care.
HHSC received comments regarding the proposed amendments during the comment
period, which included a public hearing on May 16, 2006. Comments were received
from the Texas Council of Community Mental Health and Mental Retardation (MHMR)
Centers, Inc. (Texas Council), Bluebonnet Trails Community MHMR Center, MHMR
of Tarrant County, MHMR Authority of Harris County and staff from DSHS. The
rules were modified in response to some of the comments. In addition, advanced
practice nurse is defined to correspond with the definition included in the
Medicaid Telemedicine Reimbursement Rule. A summary of the comments and HHSC's
responses follows.
Comment: HHSC received a comment from the Texas Council of Community MHMR
Centers, Inc., concerning §354.1430, which defines provider types eligible
to perform services at the remote site. The Texas Council requested that Registered
Nurses (RNs) and Licensed Vocational Nurses (LVNs) be included as allowable
remote site providers.
Response: HHSC acknowledges the comment from the Texas Council of Community
MHMR Centers, Inc. The amendments to §354.1430 allow qualified mental
health professionals (QMHPs) as defined in the Texas Administrative Code,
Title 25, §412.303(31) employed by or contracted with local mental health
authorities to serve as remote site providers. RNs are already included in
the definition of QMHPs. The intent of Senate Bill 1340 is to allow the use
of QMHPs, which does not include LVNs. No change was made to the rule in response
to the comment.
Comment: HHSC received comments from the Texas Council of Community MHMR
Centers, Inc., Bluebonnet Trails Community MHMR Center, MHMR of Tarrant County,
and MHMR Authority of Harris County, concerning the definition of the remote
site, which must be in a "rural or medically underserved area." The concern
is that limiting the pilot to rural and medically underserved areas will perpetuate
the restriction of access to services in some parts of the State, particularly
those urban areas not designated as "medically underserved areas." The community
centers contend that the homeless population in urban areas could benefit
from this pilot, and that the project could greatly impact mental health authorities'
ability or work with the homeless population, which benefits communities and
has an impact on the Statewide Jail Diversion initiative as well. Another
concern is that Texas has many urban areas that do not have readily available
public transportation, further complicating the intended population's access
to service. In cities that do have accessible public transportation, persons
with disabilities and families with children in need of service may not feel
safe using public transportation due to high crime rates in these areas.
Response: HHSC acknowledges the comments. HHSC's Medicaid telemedicine
program is limited to recipients in rural and medically underserved areas
as defined by the Department of Health and Human Services. HHSC may consider
future changes to the rule based on the evaluation of the pilot. No change
was made to the rule in response to the comment.
Comment: HHSC received comments from the Texas Council of Community MHMR
Centers, Inc., concerning the definition of a rural area, which is defined
as a "county with a population of 50,000 or less." The Texas Council reports
that there are several counties in Texas that would not meet this definition
simply because of the number of inmates incarcerated in some of Texas' state
prisons. The Texas Council indicates that is another example of access being
denied to mentally ill persons who could significantly benefit from telemedicine
services.
Response: HHSC acknowledges the comment from the Texas Council of Community
MHMR Centers, Inc., concerning the definition of a rural area. The mental
health telemedicine pilot has been designed to offer and evaluate the impact
of increased availability of these services in rural and medically underserved
areas of the state consistent with HHSC's current telemedicine program. HHSC
may consider future changes to the rule based on the evaluation of the pilot.
No change was made to the rule in response to the comment.
Comment: HHSC received a comment from the Texas Council of Community MHMR
Centers, Inc., concerning local mental health authorities and the costs associated
with both the hub and remote sites. The Texas Council understands that reimbursement
would apply only to the Medicaid service being provided at the hub site. The
Texas Council recommends that HHSC consider the total costs of providing telemedicine
services and adjust the reimbursement rates accordingly.
Response: HHSC acknowledges the comment from the Texas Council of Community
MHMR Centers, Inc., concerning payment rates. This rule affects program policy,
which is separate from the Medicaid rate-setting processes. No change was
made to the rule in response to the comment.
Comment: HHSC received comments from Bluebonnet Trails Community MHMR Center,
concerning the current limitations of telemedicine and that there are mental
health services other than those provided by a physician that could be provided
via telemedicine that would benefit Texas Medicaid citizens. Rehabilitative
services, such as skills training, and case management services may also be
performed via telemedicine, thus enhancing the accessibility of services.
Response: HHSC acknowledges the comment from the Bluebonnet Trails Community
MHMR Center. Current Texas Medicaid telemedicine policy requires that the
hub site provider be a physician. This pilot, by design, is narrow in scope
with a focus on physician services. HHSC may consider future changes to the
rule based on the evaluation of the pilot. No change was made to the rule
in response to the comment.
Comment: HHSC received a comment from DSHS staff to include language in
the rule that makes it clear that community mental health and mental retardation
centers (CMHMRCs) contracted with DSHS are qualified to be hub site providers.
Response: HHSC acknowledges the comment from DSHS staff. At this time,
HHSC has opted to include providers affiliated with local mental health authorities
instead of CMHMRCs to the list of hub site providers.
Comment: HHSC Medicaid/CHIP Division staff suggested that the definition
of advanced practice nurse in §354.1430, Definitions, correspond to the
definition of advanced practice nurse in the Medicaid Telemedicine Reimbursement
Rule, 1 TAC §355.7001.
Response: HHSC acknowledges the comment from HHSC Medicaid/CHIP Division
staff. HHSC has clarified the definition by listing the provider types that
are included within the scope of practice of an advanced practice nurse.
The amendments are adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas.
§354.1430.Definitions.
Definitions. The following words and terms, when used in this chapter,
have the following meanings.
(1)
Hub Site--A hub site is the location where the consulting
physician is physically located.
(2)
Hub Site Provider--A hub site provider must be a:
(A)
Physician at a rural health facility or an accredited medical
or osteopathic school located in Texas, or a physician at one of the following
entities affiliated through a written contract or agreement with a government
agency, accredited medical, or osteopathic school located in Texas:
(B)
Hospital;
(C)
Teaching hospital;
(D)
Tertiary center;
(E)
Health clinic; or
(F)
Local Mental Health Authority as defined in Health and
Safety Code §533.035.
(3)
Remote Site-- A remote site is where the Medicaid client
is physically located.
(4)
Remote Site Provider--A remote site provider is located
in rural or medically underserved areas and is limited to the following provider
types:
(A)
Physician;
(B)
Advanced practice nurse (APN), including nurse practitioners
(NPs) and clinical nurse specialists (CNSs), 1 TAC §355.8281; certified
nurse midwives (CNMs), 1 TAC §355.8161; and certified registered nurse
anesthetists (CRNAs), 1 TAC §355.8221;
(C)
Hospital;
(D)
Federally qualified health center (FQHC);
(E)
Rural health clinic (RHC);
(F)
Physician assistant (PA); or
(G)
One of the following qualified professionals contracted
with or employed by a local mental health authority:
(i)
Licensed psychologist;
(ii)
Licensed professional counselor (LPC);
(iii)
Licensed clinical social worker (LCSW);
(iv)
Licensed marriage and family therapist (LMFT); or
(v)
Qualified mental health professional (QMHP) as defined
in 25 TAC §412.303(31).
(5)
Rural area--A rural area is defined as a county with a
population of 50,000 or less or a county that was not designated as a metropolitan
area by the United States Bureau of the Census according to the most current
federal census and does not have within the boundaries of the county a hospital,
licensed under Chapter 241, Health and Safety Code, with more than 100 beds.
(6)
Rural Health Facility--A rural health facility is located
in a rural county and is affiliated with an accredited medical school, teaching
hospital, or government agency through a written contract or agreement.
(7)
Telemedicine--Telemedicine is a method of health care service
delivery used to facilitate medical consultations by a physician to health
care providers in rural or underserved areas for purposes of patient diagnosis
or treatment that requires advanced telecommunications technologies.
(8)
Telepathology--Telepathology is the practice of pathology
(consultation, education and research) using telecommunications to transmit
data and images between two or more sites remotely located from each other.
(9)
Teleradiology--Teleradiology is a means of electronically
transmitting radiographic patient images and consultative text from one location
to another.
(10)
Underserved--An underserved area that meets the definition
of Medically Underserved Area (MUA) or Medically Underserved Population (MUP)
by the U.S. Department of Health and Human Services.
§354.1432.Benefits and Limitations.
(a)
Telemedicine services are a health care benefit of the
Texas Medicaid Program. Telemedicine services are described below.
(1)
Telemedicine services are direct "face-to-face" interactive
video communications with the client. Teleradiology and telepathology are
exceptions to the direct face-to-face requirement.
(2)
Telemedicine hub site providers may be reimbursed only
for consultation or interpretation using interactive video as defined by Medicaid
telemedicine medical policy and as currently reimbursed under the Texas Medicaid
Program.
(3)
Telemedicine remote sites may be reimbursed for services
when any one of the following places of service are utilized and billed:
(A)
Practitioner's office;
(B)
Rural Health Clinic;
(C)
Federally Qualified Health Clinic;
(D)
Inpatient hospital;
(E)
Outpatient hospital;
(F)
Emergency room;
(G)
ICF-MR facility; or
(H)
A local mental health authority clinic as defined in Health
and Safety Code §533.035 or outreach site associated with a local mental
health authority.
(4)
Telephone conversations, chart reviews, electronic mail
messages and facsimile transmissions do not constitute a telemedicine interactive
video consultation, and will not be reimbursed as telemedicine service.
(5)
Texas Health Steps (THSteps), also known as Early and Periodic
Screening, Diagnosis and Treatment, preventive health visits are not reimbursed
if performed via telemedicine. Health care or treatment provided for conditions
identified during these preventive health visits may be reimbursed if the
health care is provided via telemedicine.
(6)
Nursing facilities, skilled nursing facilities, and client
homes are not approved places of service as remote sites for telemedicine
services.
(b)
Reimbursement for Services Performed Using Telemedicine.
(1)
Providers seeking reimbursement for telemedicine services
must provide and bill for the service in the manner prescribed by the Texas
Medicaid Program.
(2)
Telemedicine services are reimbursed in accordance with
the existing Medicaid reimbursement methodology as defined in §355.7001
of this title (relating to Telemedicine Services Reimbursement).
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604178
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: April 21, 2006
For further information, please call: (512) 424-6900
Subchapter G. TELEMEDICINE SERVICES AND OTHER COMMUNITY-BASED SERVICES
1 TAC §355.7001
The Health and Human Services Commission (HHSC) adopts an
amendment to §355.7001, Telemedicine Services Reimbursement, with minor
changes to the proposed text as published in the April 21, 2006, issue of
the
Texas Register
(31 TexReg 3337). The text
of the rule will be republished.
Section 355.7001, addresses the reimbursement methodology rule references
for telemedicine services in Chapter 355, Reimbursement Rates.
The purpose of the amendment is to revise the reimbursement methodology
for telemedicine services to add provider types delivering mental health services
through telemedicine under the pilot program required by Senate Bill (SB)
1340, 79th Legislature, Regular Session, 2005. SB 1340 requires that HHSC
develop, by rule, and the Department of State Health Services (DSHS) implement,
a pilot program under which Medicaid recipients in need of mental health services
will be provided those services through telemedicine. The pilot is intended
to enable the state to determine whether extension of the use of telemedicine
would improve the delivery of mental health services and be cost-effective.
The proposed rule has been revised for adoption to include the correct
reference to the reimbursement methodology for physician assistants (PAs)
at 1 TAC §355.8093 rather than the incorrect reference of 1 TAC §355.8091.
The rule is further revised to identify all four types of advanced practice
nurses (APNs), i.e., nurse practitioners (NPs), clinical nurse specialists
(CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse
midwives (CNMs), along with the applicable references to the specific reimbursement
methodology rules for each provider type. The proposed version identified
only NPs, CNSs, and CNMs.
HHSC received comments during the 30-day comment period. Written comments
were received from the Coalition of Nurses in Advanced Practice (CNAP) and
the Texas Academy of Nurse Anesthetists (TANA). The rule was modified in response
to the comments. A summary of the comments and HHSC's response follows:
Comment: CNAP and TANA stated that the proposed rule only included three
types of advanced practice nurses (APNs) and did not properly include CRNAs.
Response: The rule has been revised to include all four types of APNs.
The amendment is adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas; and the Texas Government Code, §531.021(b),
which provides HHSC with the authority to propose and adopt rules governing
the determination of Medicaid reimbursements.
§355.7001.Telemedicine Services Reimbursement.
Telemedicine services are reimbursed in accordance with the existing
Medicaid reimbursement methodology for the applicable provider type as follows:
(1)
physicians, 1 TAC §355.8085;
(2)
physician assistants (PAs), 1 TAC §355.8093;
(3)
advanced practice nurses (APNs), including nurse practitioners
(NPs) and clinical nurse specialists (CNSs), 1 TAC §355.8281, certified
nurse midwives (CNMs), 1 TAC §355.8161, and certified registered nurse
anesthetists (CRNAs), 1 TAC §355.8221;
(4)
hospitals, 1 TAC §355.8061 and 1 TAC §355.8063;
(5)
federally qualified health centers (FQHCs), 1 TAC §355.8261;
(6)
rural health clinics (RHCs), 1 TAC §355.8101; and
(7)
the following qualified professionals contracted with or
employed by a local mental health authority:
(A)
psychologists, 1 TAC §355.8081 and 1 TAC §355.8085;
and
(B)
licensed professional counselors (LPCs), licensed clinical
social workers (LCSWs), and licensed marriage and family therapists (LMFTs),
1 TAC §355.8091.
This agency hereby certifies that the adoption
has been reviewed by legal counsel and found to be a valid exercise of the
agency's legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604179
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: April 21, 2006
For further information, please call: (512) 424-6900
4.
MEDICAID HOSPITAL SERVICES
1 TAC §355.8063
The Health and Human Services Commission (HHSC) adopts an
amendment to §355.8063 in Chapter 355, without changes to the proposed
text as published in the June 23, 2006, issue of the
Texas Register
(31 TexReg 4974) and will not be republished. Chapter
355 describes Medicaid reimbursement methodology generally. Section 355.8063
describes the reimbursement methodology for inpatient hospital services.
The proposed amendment modifies §355.8063(o) to add freestanding psychiatric
facilities to those facilities that are reimbursed under the Tax Equity and
Fiscal Responsibility Act (TEFRA) cost principles. This change is estimated
to result in annual savings to the Medicaid program.
The amendment to §355.8063 is the result of the expiration of the
Lone STAR Select II waiver program. The Lone STAR Select II waiver program
offered participating freestanding psychiatric facilities a negotiated per
diem reimbursement in lieu of cost-based reimbursement; non-participating
psychiatric facilities were reimbursed on a cost basis. With the expiration
of the waiver, the rule is being revised to convert previously participating
freestanding psychiatric facilities from per diem reimbursement to cost-based
reimbursement, effective September 1, 2006. Converting the methodology for
freestanding psychiatric facilities from a negotiated per diem rate to TEFRA
reimbursement will allow HHSC to reimburse providers based on their actual
costs instead of a negotiated rate that does not accurately represent the
providers' true costs.
During the comment period, which included a public hearing on July 26,
2006, HHSC received written comments regarding the proposed rule from Cypress
Creek Hospital, Millwood Hospital, Texas West Oaks Hospital, Laurel Ridge
Treatment Center, the Texas Hospital Association, and the partnership One
Voice and The Network of Behavioral Health Providers. A summary of comments
and HHSC's responses follows.
Comment: In their written comments, Cypress Creek Hospital, Millwood Hospital,
Texas West Oaks Hospital, and Laurel Ridge Treatment Center stated that TEFRA
reimbursement would result in the reduction of psychiatric bed capacity for
Medicaid patients.
Response: The amendment does not require freestanding psychiatric providers
to adjust their Medicaid licensed bed capacity. A return to TEFRA cost-based
reimbursement is necessary because of the expiration of the Lone STAR Select
II waiver program, which was the basis for the negotiated per diem rate. HHSC
will consider the commenters' proposal of a prospective payment system as
a possible alternative to the TEFRA cost-based reimbursement methodology.
Comment: In their written comments, Cypress Creek Hospital, Millwood Hospital,
Texas West Oaks Hospital, Laurel Ridge Treatment Center and the Texas Hospital
Association stated that TEFRA reimbursement is inadequate for freestanding
psychiatric hospitals because the hospitals incur numerous operational costs
that are not reimbursed under TEFRA.
Response: Providers that are paid under TEFRA principles are reimbursed
based on a percentage of their allowable charges. The proposed amendment does
not alter the services that are currently covered under Medicaid or the definition
of an allowable cost. If costs incurred by the hospital are an allowable covered
cost under Medicaid, the provider will receive reimbursement for these costs.
A return to TEFRA cost-based reimbursement is necessary because of the expiration
of the Lone STAR Select II waiver program, which was the basis for the negotiated
per diem rate. HHSC will consider the commenters' proposal of a prospective
payment system as a possible alternative to the TEFRA cost-based reimbursement
methodology.
Comment: In their written comments, Cypress Creek Hospital, Millwood Hospital,
Texas West Oaks Hospital and Laurel Ridge Treatment Center stated that TEFRA
reimbursement eliminates any incentives for hospitals to continue treating
children enrolled in the Department of Family and Protective Services' Child
Protective Services (CPS) foster care program because the proposed rule shifts
the cost of HHSC's inability to place children who are Medicaid beneficiaries
in non-hospital settings onto the hospitals.
Response: The amendment changes the methodology used to reimburse providers
but does not place limitations on the Medicaid population for which freestanding
psychiatric hospitals provide medical services. Moreover, a return to TEFRA
cost-based reimbursement is necessary because of the expiration of the Lone
STAR Select II waiver program, which was the basis for the negotiated per
diem rate. HHSC will consider the commenters' proposal of a prospective payment
system as a possible alternative to the TEFRA reimbursement methodology.
Comment: In their written comments, Cypress Creek Hospital, Millwood Hospital,
Texas West Oaks Hospital, Laurel Ridge Treatment Center, and the Texas Hospital
Association stated that under Texas law, freestanding psychiatric hospitals
are required to obtain a face-to-face physician evaluation prior to each inpatient
admission for which the hospitals do not receive reimbursement.
Response: The proposed rule change pertains to the reimbursement methodology
for freestanding psychiatric hospitals, not to allowable Medicaid covered
charges.
Comment: In their written comments, Cypress Creek Hospital, Millwood Hospital,
Texas West Oaks Hospital, Laurel Ridge Treatment Center, the partnership of
One Voice and The Network of Behavioral Health Providers, and the Texas Hospital
Association recommended that HHSC implement a per diem-based prospective payment
system (PPS) reimbursement methodology effective September 1, 2006. The providers
proposed that HHSC continue to reimburse hospitals based on the current selective
contracting per diem rates until a new PPS rate methodology is implemented.
Response: Psychiatric hospitals are required to convert back to cost-based
reimbursement since the waiver program was not renewed and contracts between
HHSC and the participating freestanding psychiatric facilities have expired.
Due to time constraints, HHSC cannot implement a reimbursement change from
cost-based reimbursement to a PPS methodology by September 1, 2006. However,
HHSC will consider the commenters' proposal of a prospective payment system
as a possible alternative to the TEFRA reimbursement methodology.
The amendment is adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas, to administer Medicaid funds, and to adopt rules
necessary for the proper and efficient operation of the Medicaid program;
and the Texas Government Code, §531.021(b), which provides HHSC with
the authority to adopt rules governing the determination of Medicaid reimbursements.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604180
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: June 23, 2006
For further information, please call: (512) 424-6900
1 TAC §355.8064
The Health and Human Services Commission (HHSC) adopts new §355.8064,
Reimbursement Adjustment for Hospitals Providing Inpatient Services to SSI
and SSI-Related Clients. The new rule is adopted with changes to the proposed
text as published in the June 23, 2006, issue of the
Texas Register
(31 TexReg 4976). The text of the rule will be republished.
The new rule is being adopted without proposed subsection (c), and the succeeding
paragraphs have been renumbered accordingly.
New §355.8064 will modify Medicaid reimbursement to hospitals in eight
urban service areas for inpatient services to Supplemental Security Income
(SSI) and SSI-related clients. The 2006-07 General Appropriations Act (Article
II, Special Provisions, Section 49, S.B.1, 79th Legislature, Regular Session,
2005) (Act) directs HHSC to achieve savings for services provided to Medicaid
aged, blind and disabled clients in the following service areas: Bexar, Dallas,
El Paso, Harris, Lubbock, Nueces, Tarrant and Travis. The purpose of this
rule is to achieve the directed savings.
Section 49 of the Act further requires HHSC to utilize cost-effective models
to better manage the care of these clients and, at the same time, achieve
the identified savings. HHSC plans to meet this requirement by implementing
a non-capitated Integrated Care Management (ICM) model in the Dallas and Tarrant
service areas, and a partially capitated ICM model with inpatient hospital
services carved out in the other urban service areas. The goal of both models
is to promote proper utilization and integration of acute care and long-term
care services, while achieving the savings directed by the Legislature.
HHSC received comments regarding the proposed rule during the comment period,
which included a public hearing on July 26, 2006, from One Voice and the Network
of Behavioral Health Providers, Texas Association of Public and Nonprofit
Hospitals, El Paso County Hospital District, Seton Hospital, Texas Hospital
Association, Medical City Hospital, Christus Healthcare Network, Tenet Healthcare,
HCA, and Methodist Hospital of Dallas. The hospitals and hospital associations
shared the general consensus that the proposed rate reductions will significantly
impact current reimbursement rates, which have already been cut by 5%, resulting
in hospitals receiving only 80% of their costs associated with providing Medicaid
services. In addition, the hospitals and hospital associations stated that
the proposed rule will be harmful to local taxpayers and businesses, as costs
not covered by Medicaid are passed on to taxpayers and commercial health plans,
and that access to hospital care may be adversely impacted.
Comment: HHSC received a comment from the Texas Hospital Association concerning §355.8064,
stating that the proposed rule lacks statutory or legislative authority.
Response: HHSC has the authority to adopt §355.8064 under §531.033,
Government Code, which provides the Executive Commissioner of HHSC with broad
rulemaking authority; §531.021, Government Code, which provides HHSC
with the authority to administer Medicaid funds and adopt rules governing
the determination of Medicaid reimbursements; and §32.021, Human Resources
Code, which provides HHSC with the authority to administer the Medicaid program
and adopt rules for the proper and efficient operation of the program.
Comment: In their written comments, the partnership of One Voice and the
Network of Behavioral Health Providers, the Texas Association of Public and
Nonprofit Hospitals, El Paso County Hospital District, Seton Hospital, the
Texas Hospital Association, and Medical City Hospital stated that the proposed
rate reductions will significantly impact current reimbursement rates, which
have already been cut by 5 percent, resulting in hospitals receiving only
80% of their costs to provide Medicaid services.
Response: Senate Bill 1, General Appropriations Act (Article II, Special
Provisions, Section 49), 79th Legislature, Regular Session, 2005, directs
HHSC, to the extent necessary, to adjust provider payments in the designated
service areas to ensure that the Section 49 savings target is achieved. However,
HHSC's decision to delete proposed subsection (c) will lessen the impact of
the rule on the affected hospitals' reimbursement rates.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals, the Texas Hospital Association, and Medical City Hospital
stated that the $109.5 million in savings targeted for the 2006-07 biennium
was unrealistically high.
Response: HHSC understands the concern about the amount of the savings
target; however, Senate Bill 1, General Appropriations Act (Article II, Special
Provisions, Section 49), 79th Legislature, Regular Session, 2005, directs
a savings target of $109,500,000 in general revenue.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals, the Texas Hospital Association, and Medical City Hospital
stated the hospital industry supported implementation of an Integrated Care
Management (ICM) model in all expansion service areas. The commenters expressed
the opinion that this would give all provider types an opportunity to make
the system work in a collaborative manner but that ICM is now being implemented
only in the Dallas and Tarrant service areas.
Response: The proposed rule change addresses only provider participation
requirements and not where the ICM model will be implemented.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals, Seton Hospital, the Texas Hospital Association, and Medical
City Hospital stated the proposed rule will be harmful to local taxpayers
and businesses as costs not covered by Medicaid are passed on to taxpayers
and commercial health plans.
Response: HHSC acknowledges that the proposed rule may result in a net
loss in revenue to publicly owned hospitals. The negative fiscal impact on
revenues of local governments is based on an 8% reduction in fiscal year 06
rates. Publicly owned hospitals receiving UPL funding will be able to offset
loss in federal funding resulting from the 8% rate reduction by claiming increase
federal funding from UPL payments. However, Senate Bill 1, General Appropriations
Act (Article II, Special Provisions, Section 49), 79th Legislature, Regular
Session, 2005, directs HHSC, to the extent necessary, to adjust provider payments
in the designated service areas to ensure that the savings target is achieved.
Comment: In their written comments, the Texas Association of Public and
Nonprofit Hospitals and the Texas Hospital Association stated the proposed
rule is arbitrary in that it does not specify the amount that the inpatient
rates will be reduced nor does it identify which hospitals in each market
will be subject to the rate reduction.
Response: Subsection (b) specifies the amount of the rate reduction. Subsection
(a) identifies which hospitals will be subject to the rate reduction: all
hospitals, other than hospitals described in new subsection (c), in the identified
service areas. HHSC will notify each affected hospital of the rate reduction.
Comment: HHSC received a comment from the Texas Association of Public and
Nonprofit Hospitals stating the proposed provider participation rule is inappropriate
for a program that is voluntary.
Response: HHSC values each hospital's participation in the Medicaid program.
However, Section 49 of the 2006-07 General Appropriations Act requires that
HHSC achieve the targeted savings in the identified service areas.
Comment: In their written comments, the partnership of One Voice and the
Network of Behavioral Health Providers, the Texas Association of Public and
Nonprofit Hospitals, El Paso County Hospital District, and the Texas Hospital
Association stated the proposed rule change will force some hospitals to terminate
their Medicaid contracts, which may adversely impact access to hospital care.
Response: Senate Bill 1, General Appropriations Act (Article II, Special
Provisions, Section 49), 79th Legislature, Regular Session, 2005, directs
HHSC, to the extent necessary, to adjust provider payments in the designated
service areas to ensure that the savings target is achieved. However, HHSC's
decision to delete proposed subsection (c) will lessen the impact of the rule
on the affected hospitals' reimbursement rates.
The new rule is adopted under Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
Human Resources Code, §32.021, and Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas, to administer Medicaid funds, and to adopt rules
necessary for the proper and efficient operation of the program; and Government
Code, §531.021(b), which provides HHSC with the authority to adopt rules
governing the determination of Medicaid reimbursements.
§355.8064.Reimbursement Adjustment for Hospitals Providing Inpatient Services to SSI and SSI-Related Clients.
(a)
Effective September 1, 2006, reimbursement to hospitals
in Bexar, Dallas, El Paso, Harris, Lubbock, Nueces, Tarrant and Travis service
areas for inpatient services will be determined according to the methodology
described in §355.8063 of this title (relating to Reimbursement Methodology
for Inpatient Hospital Services) and shall be reduced by the percent discount
in subsection (b) of this section. The percent discounts are necessary to
achieve budgetary savings as permitted under §355.201 of this title (relating
to Establishment and Adjustment of Reimbursement Rates by the Health and Human
Services Commission).
(b)
Up to an eight percent discount may be applied to the reimbursement
rates of all hospitals for inpatient services provided to Supplemental Security
Income (SSI) and SSI-related clients in service areas as determined by the
Health and Human Services Commission (HHSC).
(c)
In-state children's hospitals that are cost reimbursed
in accordance with §355.8063 of this title (relating to Reimbursement
Methodology for Inpatient Hospital Services) are exempt from the percent discount
in subsection (b) of this section.
(d)
Definitions.
(1)
Bexar Service Area means Atascosa, Bexar, Comal, Guadalupe,
Kendall, Medina and Wilson counties.
(2)
Dallas Service Area means Collin, Dallas, Ellis, Hunt,
Kaufman, Navarro and Rockwall counties.
(3)
El Paso Service Area means El Paso County.
(4)
Harris Service Area means Brazoria, Fort Bend, Galveston,
Harris, Montgomery and Waller counties.
(5)
Lubbock Service Area means Crosby, Floyd, Garza, Hale,
Hockley, Lamb, Lubbock, Lynn and Terry counties.
(6)
Nueces Service Area means Aransas, Bee, Calhoun, Jim Wells,
Kleberg, Nueces, Refugio, San Patricio and Victoria counties.
(7)
Tarrant Service Area means Denton, Hood, Johnson, Parker,
Tarrant and Wise counties.
(8)
Travis Service Area means Bastrop, Burnet, Caldwell, Hays,
Lee, Travis and Williamson counties.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604181
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: June 23, 2006
For further information, please call: (512) 424-6900
1 TAC §355.8071
The Health and Human Services Commission (HHSC) adopts new §355.8071
to establish the methodology HHSC will use to distribute supplemental (Upper
Payment Limit or UPL) payments to in-state children's hospitals. The new rule
is adopted without changes to the proposed text as published in the June 23,
2006, issue of the
Texas Register
(31 TexReg
4977) and will not be republished.
New §355.8071 allows HHSC to make UPL payments to specific in-state
children's hospitals and establish the methodology HHSC will use to calculate
these supplemental payments. The 2006-07 General Appropriations Act (Article
II, Health and Human Services Commission, Rider 73, S.B. 1, 79th Legislature,
Regular Session, 2005) appropriates $12.5 million in General Revenue for each
year of the biennium to provide Medicaid UPL reimbursement to in-state children's
hospitals. The rider directs HHSC to implement Medicaid UPL reimbursement
to cover the cost incurred by Medicare designated children's hospitals in
providing inpatient services. The rider also directs HHSC to develop a methodology
to prioritize the UPL payments to reduce Medicaid losses in any children's
hospital with a Medicaid patient load that exceeds 60 percent of the hospital
total inpatient days.
HHSC did not receive comments regarding the proposed rule during the comment
period, which included a public hearing on July 26, 2006.
The new rule is adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas; and the Texas Government Code, §531.021(b),
which provides HHSC with the authority to propose and adopt rules governing
the determination of Medicaid reimbursements.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on August 10, 2006.
TRD-200604182
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: September 1, 2006
Proposal publication date: June 23, 2006
For further information, please call: (512) 424-6900
Subchapter E. PROVIDER REQUIREMENTS
Subchapter E. STANDARDS FOR MEDICAID MANAGED CARE
Chapter 354.
MEDICAID HEALTH SERVICES
33.
TELEMEDICINE SERVICES
Chapter 355.
REIMBURSEMENT RATES
Subchapter J. PURCHASED HEALTH SERVICES
Chapter 370.
STATE CHILDREN'S HEALTH INSURANCE PROGRAM