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Texas Administrative Code (Last Updated: March 27,2024) |
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TITLE 1. ADMINISTRATION |
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PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION |
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CHAPTER 355. REIMBURSEMENT RATES |
| SUBCHAPTER A. COST DETERMINATION PROCESS |
| § 355.101. Introduction |
| § 355.102. General Principles of Allowable and Unallowable Costs |
| § 355.103. Specifications for Allowable and Unallowable Costs |
| § 355.104. Revenues |
| § 355.105. General Reporting and Documentation Requirements, Methods, and Procedures |
| § 355.106. Basic Objectives and Criteria for Audit and Desk Review of Cost Reports |
| § 355.107. Notification of Exclusions and Adjustments |
| § 355.108. Determination of Inflation Indices |
| § 355.109. Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs |
| § 355.110. Informal Reviews and Formal Appeals |
| § 355.111. Administrative Contract Violations |
| § 355.112. Attendant Compensation Rate Enhancement |
| § 355.114. Consumer Directed Services Payment Option |
| SUBCHAPTER B. ESTABLISHMENT AND ADJUSTMENT OF REIMBURSEMENT RATES FOR MEDICAID |
| § 355.201. Establishment and Adjustment of Reimbursement Rates for Medicaid |
| § 355.205. Rule for Emergency Temporary Reimbursement Rate Increases and Limitations on Use of Emergency Temporary Funds for Medicaid in Response to Novel Coronavirus (COVID-19) |
| § 355.207. American Rescue Plan Act Home and Community-Based Services Provider Retention Payments |
| SUBCHAPTER C. REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES |
| § 355.304. Direct Care Staff Spending Requirement on or after September 1, 2023 |
| § 355.306. Cost Finding Methodology |
| § 355.307. Reimbursement Setting Methodology |
| § 355.308. Direct Care Staff Rate Component |
| § 355.309. Performance-based Add-on Payment Methodology |
| § 355.310. Reimbursement Methodology for Customized Equipment |
| § 355.311. Medicaid Reimbursement Rates for State Veterans Homes |
| § 355.312. Reimbursement Setting Methodology--Liability Insurance Costs |
| § 355.313. Reimbursement Methodology for Rehabilitative and Specialized Services |
| § 355.314. Supplemental Payments to Non-State Government-Owned Nursing Facilities |
| § 355.315. Reimbursement Methodology for Preadmission Screening and Resident Review (PASRR) Specialized Services |
| § 355.316. Reimbursement Methodology for Pediatric Care Facilities |
| § 355.403. Vendor Hold |
| SUBCHAPTER D. REIMBURSEMENT METHODOLOGY FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) |
| § 355.455. Payments to Non-State Operated Facilities |
| § 355.456. Reimbursement Methodology |
| § 355.457. Cost Finding Methodology |
| § 355.458. Supplemental Payments to Non-State Government-Owned Facilities |
| SUBCHAPTER E. COMMUNITY CARE FOR AGED AND DISABLED |
| § 355.501. Reimbursement Methodology for Program for All-Inclusive Care for the Elderly (PACE) |
| § 355.502. Reimbursement Methodology for Common Services in Home and Community-Based Services Waivers |
| § 355.505. Reimbursement Methodology for the Community Living Assistance and Support Services Waiver Program |
| § 355.507. Reimbursement Methodology for the Medically Dependent Children Program |
| § 355.509. Reimbursement Methodology for Residential Care |
| § 355.510. Reimbursement Methodology for Emergency Response Services (ERS) |
| § 355.511. Reimbursement Methodology for Home-Delivered Meals |
| § 355.513. Reimbursement Methodology for the Deaf-Blind with Multiple Disabilities Waiver Program |
| SUBCHAPTER F. REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY |
| § 355.722. Reporting Costs by Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Providers |
| § 355.723. Reimbursement Methodology for Home and Community-Based Services and Texas Home Living Programs |
| § 355.725. Reimbursement Methodology for Common Waiver Services in Home and Community-based Services (HCS) and Texas Home Living (TxHmL) |
| § 355.743. Reimbursement Methodology for Mental Health Case Management |
| § 355.746. Reimbursement Methodology for Mental Retardation Service Coordination |
| § 355.748. Reimbursement Methodology for Preadmission Screening and Resident Review (PASRR) Level II Evaluations |
| § 355.761. Reimbursement Methodology for Institutions for Mental Diseases (IMD) |
| § 355.781. Rehabilitative Services Reimbursement Methodology |
| SUBCHAPTER G. ADVANCED TELECOMMUNICATIONS SERVICES AND OTHER COMMUNITY-BASED SERVICES |
| § 355.5902. Reimbursement Methodology for Primary Home Care |
| § 355.6907. Reimbursement Methodology for Day Activity and Health Services |
| § 355.7001. Reimbursement Methodology for Telemedicine, Telehealth, and Home Telemonitoring Services |
| SUBCHAPTER H. BASE WAGE REQUIREMENTS FOR PERSONAL ATTENDANTS |
| § 355.7051. Base Wage for a Personal Attendant |
| SUBCHAPTER I. REPORTING |
| § 355.7201. Novel Coronavirus (COVID-19) Fund Reporting |
| SUBCHAPTER J. PURCHASED HEALTH SERVICES |
| DIVISION 1. MEDICAID VISION CARE PROGRAM |
| § 355.8001. Reimbursement for Vision Care Services |
| DIVISION 2. MEDICAID HOME HEALTH PROGRAM |
| § 355.8021. Reimbursement Methodology for Home Health Services |
| § 355.8023. Reimbursement Methodology for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) |
| DIVISION 3. PHYSICIAN SERVICES |
| § 355.8041. Recipient-Initiated Second Opinions |
| DIVISION 4. MEDICAID HOSPITAL SERVICES |
| § 355.8052. Inpatient Hospital Reimbursement |
| § 355.8056. State-Owned Teaching Hospital Reimbursement Methodology |
| § 355.8058. Inpatient Direct Graduate Medical Education (GME) Reimbursement |
| § 355.8060. Reimbursement Methodology for Freestanding Psychiatric Facilities |
| § 355.8061. Outpatient Hospital Reimbursement |
| § 355.8065. Disproportionate Share Hospital Reimbursement Methodology |
| § 355.8066. State Payment Cap and Hospital-Specific Limit Methodology |
| § 355.8070. Hospital Augmented Reimbursement Program |
| DIVISION 5. GENERAL ADMINISTRATION |
| § 355.8085. Reimbursement Methodology for Physicians and Other Practitioners |
| § 355.8087. In-Home Total Parenteral Hyperalimentation Services |
| § 355.8089. In-home Respiratory Therapy Services for Ventilator-Dependent Persons |
| § 355.8091. Reimbursement to Licensed Professional Counselors, Licensed Clinical Social Workers, and Licensed Marriage and Family Therapists |
| § 355.8093. Reimbursement Methodology for Physician Assistants |
| § 355.8095. Medicaid Administrative Claiming Program |
| § 355.8097. Reimbursement Methodology for Physical, Occupational, and Speech Therapy Services |
| DIVISION 6. RURAL HEALTH CLINICS |
| § 355.8101. Rural Health Clinics Reimbursement |
| DIVISION 7. AMBULATORY SURGICAL CENTERS |
| § 355.8121. Reimbursement to Ambulatory Surgical Centers |
| DIVISION 8. HEARING AID SERVICES |
| § 355.8141. Reimbursement for Hearing Aid Services |
| DIVISION 9. MIDWIVES |
| § 355.8161. Reimbursement Methodology for Midwife Services |
| DIVISION 10. BIRTHING CENTER SERVICES |
| § 355.8181. Birthing Center Reimbursement |
| DIVISION 11. TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT |
| § 355.8200. Retained Funds for the Uncompensated Care Program |
| § 355.8201. Waiver Payments to Hospitals for Uncompensated Care |
| § 355.8202. Waiver Payments to Physician Group Practices for Uncompensated Care |
| § 355.8203. Delivery System Reform Incentive Payments |
| § 355.8204. Funding for DSRIP Monitoring Program |
| § 355.8205. Delivery System Reform Incentive Payments for Demonstration Years 7-8 |
| § 355.8206. Funding for DSRIP Monitoring Program for Demonstration Years 7-8 |
| § 355.8208. Waiver Payments to Publicly-Owned Dental Providers for Uncompensated Charity Care |
| § 355.8210. Waiver Payments to Governmental Ambulance Providers for Uncompensated Charity Care |
| § 355.8212. Waiver Payments to Hospitals for Uncompensated Charity Care |
| § 355.8214. Waiver Payments to Physician Group Practices for Uncompensated Charity Care |
| § 355.8215. Public Health Provider - Charity Care Program (PHP-CCP) |
| § 355.8216. Delivery System Reform Incentive Payments for Demonstration Years 9-10 |
| § 355.8217. Payments to Public Health Providers for Charity Care |
| § 355.8218. Funding for DSRIP Monitoring Program for Demonstration Years 9-10 |
| DIVISION 12. CERTIFIED REGISTERED NURSE ANESTHETISTS AND ANESTHESIOLOGIST ASSISTANTS |
| § 355.8221. Reimbursement Methodology |
| DIVISION 13. CHEMICAL DEPENDENCY TREATMENT FACILITY SERVICES |
| § 355.8241. Reimbursement Methodology for Chemical Dependency Treatment Facilities |
| DIVISION 14. FEDERALLY QUALIFIED HEALTH CENTER SERVICES |
| § 355.8261. Federally Qualified Health Center Services Reimbursement |
| DIVISION 15. NURSE PRACTITIONERS AND CLINICAL NURSE SPECIALISTS |
| § 355.8281. Reimbursement Methodology for Nurse Practitioners and Clinical Nurse Specialists |
| DIVISION 17. LONESTAR SELECT CONTRACTING PROGRAM |
| § 355.8321. LoneSTAR Select Contracting Process for Inpatient Hospital Services |
| DIVISION 19. MEDICAID MANAGED CARE: STANDARDS FOR THE STATE OF TEXAS ACCESS REFORM (STAR) |
| § 355.8361. Rates and Payment Structures |
| DIVISION 20. CASE MANAGEMENT FOR CHILDREN WHO ARE BLIND AND VISUALLY IMPAIRED |
| DIVISION 21. CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN |
| § 355.8401. Reimbursement Methodology for Case Management for Children and Pregnant Women |
| DIVISION 22. REIMBURSEMENT METHODOLOGY FOR THE EARLY CHILDHOOD INTERVENTION PROGRAM |
| § 355.8421. Reimbursement for Case Management Services for Infants and Toddlers with Developmental Disabilities |
| § 355.8422. Reimbursement for Specialized Rehabilitation Services for Infants and Toddlers with Developmental Disabilities |
| DIVISION 23. EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) |
| § 355.8441. Reimbursement Methodologies for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services |
| § 355.8443. Reimbursement Methodology for School Health and Related Services (SHARS) |
| § 355.8445. Reimbursement for Environmental Lead Investigations |
| DIVISION 24. EPSDT: EYEGLASS PROGRAM |
| § 355.8461. Reimbursement |
| DIVISION 28. PHARMACY SERVICES: REIMBURSEMENT |
| § 355.8541. Legend and Nonlegend Medications |
| § 355.8542. Drug Price Effective Date |
| § 355.8543. Nonlegend Drug Restrictions |
| § 355.8544. Usual and Customary Prices |
| § 355.8546. Brand-Name Drugs |
| § 355.8547. Reimbursement for Compound Prescriptions |
| § 355.8548. 340B Covered Entities |
| § 355.8549. Reimbursement to Hospitals and Physicians Who Dispense Drugs |
| § 355.8550. Third-Party Resources |
| § 355.8551. Professional Dispensing Fee |
| DIVISION 29. MEDICAL TRANSPORTATION |
| § 355.8561. Billing |
| DIVISION 30. FAMILY PLANNING |
| § 355.8581. Reimbursement Methodology for Family Planning Services |
| DIVISION 31. AMBULANCE SERVICES |
| § 355.8600. Reimbursement Methodology for Ambulance Services |
| DIVISION 32. CLINICAL LABORATORY SERVICES |
| § 355.8610. Reimbursement for Clinical Laboratory Services |
| DIVISION 33. INDIAN HEALTH SERVICES |
| § 355.8620. Reimbursement Methodology for Services Provided in Indian Health Service and Tribal Facilities |
| DIVISION 34. WOMEN'S HEALTH PROGRAM |
| § 355.8641. Reimbursement Methodology for the Women's Health Program |
| DIVISION 35. RENAL DIALYSIS SERVICES |
| § 355.8660. Renal Dialysis Reimbursement |
| SUBCHAPTER L. LOCAL FUNDS MONITORING |
| § 355.8701. Purpose |
| § 355.8702. Definitions |
| § 355.8703. Applicability |
| § 355.8704. Reporting and Monitoring |
| § 355.8705. Post-Determination Review |
| § 355.8706. State and Federal Reporting |
| § 355.8707. Notification Requirements for the Creation of a Local Provider Participation Fund (LPPF) |
| SUBCHAPTER M. MISCELLANEOUS PROGRAMS |
| DIVISION 3. COMPREHENSIVE REHABILITATION SERVICES FOR INDIVIDUALS WITH A TRAUMATIC BRAIN INJURY OR TRAUMATIC SPINAL CORD INJURY |
| § 355.9040. Reimbursement Methodology for Comprehensive Rehabilitation Services Program |
| DIVISION 4. YOUTH EMPOWERMENT SERVICES WAIVER PROGRAM |
| § 355.9060. Reimbursement Methodology for the Youth Empowerment Services Waiver Program |
| DIVISION 5. DEPARTMENT OF STATE HEALTH SERVICES HOME AND COMMUNITY-BASED SERVICES - ADULT MENTAL HEALTH |
| § 355.9070. Reimbursement Methodology for Home and Community-Based Services - Adult Mental Health Program |
| DIVISION 6. PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS |
| § 355.9080. Reimbursement Methodology for Prescribed Pediatric Extended Care Centers |
| DIVISION 7. COMMUNITY FIRST CHOICE |
| § 355.9090. Reimbursement Methodology for Community First Choice |