SECTION 355.8401. Reimbursement Methodology for Case Management for Children and Pregnant Women

(a) Qualified providers. Payments are made to qualified providers delivering case management services to Medicaid-eligible individuals who are eligible for Case Management for Children and Pregnant Women according to Department of State Health Services (DSHS) rules at 25 TAC Chapter 27 (relating to Case Management for Children and Pregnant Women).

(b) Unit of service. Case Management for Children and Pregnant Women services are limited to one contact per day per client. Qualified providers are reimbursed based on a prospective and uniform statewide rate for the following types of services:

(1) comprehensive visit;

(2) face-to-face case management visit; and

(3) telephone case management visit.

(c) Rate methodology.

(1) The Health and Human Services Commission determines Case Management for Children and Pregnant Women rates by modeling a rate for similar case management activities and using relevant cost and fees that provide information related to case management services for children and high risk pregnant women. HHSC will utilize the cost and fee survey data compiled as a basis for updating the reimbursement rate. Total reported costs are projected from the historical reporting period to the prospective rate period.

(2) The reimbursement methodology for Case Management for Children and Pregnant Women services is also governed by §355.108 of this chapter (relating to Determination of Inflation Indices) and §355.109 of this chapter (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs).

Source Note: The provisions of this §355.8401 adopted to be effective February 1, 1991, 16 TexReg 231; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660; amended to be effective September 1, 2003, 28 TexReg 5653; amended to be effective September 1, 2013, 38 TexReg 4888