SECTION 355.8023. Reimbursement Methodology for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

(a) Authorized items provided to eligible Medicaid recipients are reimbursed the lesser of the billed amount or the Medicaid reimbursement rate established by HHSC.

(b) HHSC reviews the fees for individual items at least every two years as follows.

(1) If Medicare reimburses for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item, the Medicaid reimbursement rate is equal to, or a percentage of, the Medicare reimbursement rate for the procedure code. If HHSC determines that the Medicare reimbursement rate is insufficient, the methodologies in paragraphs (2) or (3) of this subsection apply.

(2) If Medicare does not reimburse for a DMEPOS item, other sources are used to determine the Medicaid payment rate as follows:

(A) analysis of Medicaid fees for the same or similar items in other states;

(B) eighty-two percent of the manufacturer's suggested retail price (MSRP);

(C) cost shown on a manufacturer's invoice submitted by the provider to HHSC; or

(D) analysis of fees paid under commercial insurance for the same or similar item or service.

(3) HHSC may use data sources or methodologies other than those listed in paragraph (2) of this subsection to establish Medicaid fees for DMEPOS when HHSC determines that those methodologies are unreasonable or insufficient.

(c) Fees for DMEPOS items are adjusted within available funding as described in §355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).

Source Note: The provisions of this §355.8023 adopted to be effective December 1, 2017, 42 TexReg 5431