SECTION 355.8660. Renal Dialysis Reimbursement

(a) For services provided on or after the date that the modernized Medicaid Management Information System (MMIS) becomes operational, the reimbursement methodology for in-facility renal dialysis treatment services and home renal dialysis treatment services is an outpatient prospective payment system (OPPS). The OPPS used for reimbursement is the 3M™ Enhanced Ambulatory Patient Grouping (EAPG) payment methodology. EAPGs are a visit-based classification system intended to reflect the type of resources utilized in outpatient encounters for patients with similar clinical characteristics.

(b) For services prior to the date that the modernized MMIS becomes operational, payment for in-facility renal dialysis treatment services and home renal dialysis treatment services is based upon the composite rate reimbursement methodology previously used by Medicare. The composite rates reflect all changes enacted by the Balanced Budget Refinement Act of 1999 (BBRA). Rates are based on available funds and are subject to legislative appropriations.

(c) All required items and services included under the composite rate must be made available by the facility, either directly or under arrangements, for each dialysis patient. If the facility fails to make available (either directly or under arrangements) any item or service listed in this subsection, or any part of an item or service listed in this subsection, then the facility cannot be reimbursed any amount for items and services that the facility provides. Required items and services include:

(1) medically necessary dialysis equipment and dialysis support equipment;

(2) home dialysis support services including the delivery, installation, maintenance, repair, and testing of home dialysis equipment, and home support equipment;

(3) purchase and delivery of all necessary dialysis supplies, except blood which is separately reimbursable under this chapter;

(4) routine end-stage renal dialysis (ESRD) related laboratory tests; and

(5) all dialysis services furnished by the facility's staff.

(d) The following items and services also are included in the composite rate and may not be billed separately when provided by a dialysis facility:

(1) cardiac monitoring;

(2) catheter changes;

(3) crash cart usage for cardiac arrest;

(4) declotting of shunts by facility staff and any supplies used to declot shunts;

(5) dialysate used during treatment;

(6) oxygen and administration of oxygen;

(7) staff time used to administer blood, inject separately billable drugs, blood collection, and nonroutine peritoneal items;

(8) suture removal and dressing changes; and

(9) other items and services related to dialysis treatment, as determined by HHSC.

Source Note: The provisions of this §355.8660 adopted to be effective September 1, 2010, 35 TexReg 5522; amended to be effective November 26, 2023, 48 TexReg 6735