SECTION 354.1322. Provider Participation Requirements

(a) Participation requirements. To participate in the Texas Medicaid Program, a federally qualified health center (FQHC) must:

(1) be receiving a grant under the Public Health Service Act §§329, 330, or 340, or be designated by the secretary of the Department of Health and Human Services as meeting the requirements to be receiving such a grant;

(2) comply with all federal, state, and local laws and regulations applicable to the services provided;

(3) be enrolled and approved for participation in the Texas Medicaid Program;

(4) sign a written provider agreement with the Health and Human Services Commission (HHSC) or its designee;

(5) comply with the terms of the provider agreement and all requirements of the Texas Medicaid Program, including regulations, rules, handbooks, standards, and guidelines published by HHSC; and

(6) bill for covered services in the manner and format prescribed by HHSC.

(b) Affiliation agreements. Notwithstanding any other provision, HHSC will not reimburse an FQHC for services performed on behalf of the FQHC by a health-care provider under an affiliation agreement with the FQHC unless the FQHC has submitted to HHSC an attestation justifying the affiliation as required by paragraphs (3) and (4) of this subsection and HHSC has deemed the affiliation justified.

(1) For purposes of this subsection, the term "affiliation agreement" means an agreement that establishes a relationship between an FQHC and a health-care provider ("affiliate") under which the affiliate agrees to provide health-care services within the FQHC's scope of services on behalf of the FQHC and to be reimbursed by the FQHC for such services. The term does not include an employment agreement or an agreement formalizing an arrangement in which an individual physician either temporarily substitutes for a member of the FQHC's staff of physicians or temporarily fills a vacancy in the FQHC's staff of physicians.

(2) For purposes of this subsection, the term "health-care provider" means a physician, physician assistant, advanced practice registered nurse (except certified registered nurse anesthetist), visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist.

(3) The FQHC must justify the need for the affiliate to perform services on the FQHC's behalf because the affiliation increases access to care, expands the types of services offered by the FQHC, or costs less than the employment of a physician.

(4) The FQHC must submit to HHSC an attestation, signed by an individual with authority to sign documents on the FQHC's behalf, explaining the need for the affiliation. The attestation must answer and must explain the answers to the following questions:

(A) Does the affiliation governed by the agreement increase access to care?

(B) Does the affiliation governed by the agreement:

(i) add services to the FQHC's scope of services; or

(ii) enable the FQHC to maintain access to care or the services currently within the FQHC's scope of services?

(C) Would a health-care provider employed by the FQHC be less expensive than the affiliation governed by the agreement?

(5) Once HHSC receives an attestation, it has 30 business days to review the attestation and determine that the affiliation is justified. If the FQHC does not receive information to the contrary from HHSC within 35 business days after HHSC receives the attestation, the affiliation is deemed justified.

(6) The FQHC may submit claims to HHSC for services provided by the affiliate whose attestation is under review, but HHSC will not pay the claims until HHSC deems the affiliation to be justified.

Source Note: The provisions of this §354.1322 adopted to be effective August 1, 1990, 15 TexReg 4120; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective October 17, 2013, 38 TexReg 7111