SECTION 392.605. Kidney Health Care Provider Requirements and Effective Dates

(a) Definitions. The terms in this section have the same meaning as those defined in Title 25, Part 1, §61.2 (relating to Definitions).

(b) Requirements. To qualify as a provider for the Kidney Health Care (KHC) program, as described in Title 25, Part 1, Chapter 61, Subchapter A (related to Kidney Health Care), a provider must do as follows.

(1) Outpatient dialysis facilities must:

(A) execute an agreement with the program;

(B) have Medicare certification and a Medicare End-Stage Renal Disease (ESRD) provider number;

(C) be a current Texas Medicaid provider;

(D) be licensed by the department as an ESRD facility;

(E) reimburse the program for any overpayments upon request; and

(F) not be on suspension as a KHC provider, as a Texas Medicaid provider, as a Medicare certified ESRD facility, or as a licensed Texas ESRD facility.

(2) An out-of-state outpatient dialysis facility must:

(A) meet all the requirements in paragraph (1)(A) - (C) and (E) of this subsection;

(B) be licensed by its state, if applicable;

(C) be a Medicaid provider in its state; and

(D) not be on suspension as a KHC provider, as a Texas Medicaid provider, as a Medicaid provider in its state, as a Medicare-certified ESRD facility, or by the ESRD licensing authority of its state.

(3) Any outpatient dialysis facility may be given interim approval according to the following:

(A) client applications for KHC benefits may be submitted by the facility during the period of interim approval.

(B) interim approval extends no longer than six months from the date the program mails the agreement to the facility.

(C) if interim approval lapses, the unexecuted agreement is nullified and a new agreement with term dates and the period of interim approval may be initiated by the program.

(D) claims for outpatient dialysis services shall not be considered for payment by the program until the program has a fully executed agreement with the facility.

(E) claim filing deadlines apply, as contained in Title 25, Part 1 §61.8 (relating to Claim Filing Deadlines).

(4) A pharmacy, including a mail order pharmacy, must execute an agreement as a KHC provider through the Health and Human Services Commission Pharmacy Contracts and Rebates unit or designated contractor.

(5) A physician or certified registered nurse anesthetist (CRNA) must:

(A) execute an agreement with the program;

(B) be licensed to practice medicine in the State of Texas, if a physician;

(C) be certified to practice within the scope of his or her certification in the State of Texas, if a CRNA;

(D) be a Texas Medicaid provider;

(E) not be on suspension as a KHC provider, as a physician licensed to practice medicine in the State of Texas, as a CRNA certified to practice within the scope of the certification in the State of Texas, or as a Texas Medicaid provider; and

(F) reimburse the program for any overpayments upon request.

(6) An out-of-state physician and a CRNA must:

(A) meet all the requirements in paragraph (5)(A), (D) and (F) of this subsection;

(B) be licensed to practice medicine in the state in which services are provided, if a physician; or

(C) be certified to practice within the scope of his or her certification in the state in which services are provided, if a CRNA; and

(D) not be on suspension as a KHC provider, as a Texas Medicaid provider, as a physician licensed to practice medicine in the state in which services are provided, as a CRNA certified to practice within the scope of the certification in the state in which services are provided.

(7) A hospital or ambulatory surgical center (ASC) must:

(A) execute an agreement with the program;

(B) be in compliance with all applicable laws to provide hospital or ASC services in the State of Texas;

(C) be a current Texas Medicaid provider;

(D) have Medicare certification;

(E) not be on suspension as a KHC provider, as a hospital authorized under applicable law to provide hospital services in the State of Texas, as an ASC licensed to provide ASC services in the State of Texas, as a Texas Medicaid provider, or as a Medicare certified hospital or ASC; and

(F) reimburse the program for any overpayments upon request.

(8) An out-of-state hospital or ASC must:

(A) meet all the requirements in paragraph (7)(A), (C), (D) and (F) of this subsection;

(B) be licensed to provide hospital or ASC services in the state in which services are provided;

(C) not be on suspension as a KHC provider, as a Texas Medicaid provider, as a Medicaid provider in its state, as a hospital licensed to provide hospital services in the state in which services are provided, as an ASC licensed to provide ASC services in the state in which services are to be provided, or as a Medicare certified hospital or ASC;

(9) A Medicare Prescription Drug Plan (PDP) must:

(A) execute an agreement with the program;

(B) be Medicare approved as a PDP and maintain approval;

(C) share and exchange data in an acceptable format with the program for the coordination of drug benefits under the Medicare PDP (Part D);

(D) accept a program payment for premiums; and

(E) reimburse the program for any overpayments upon request.

(c) Effective dates.

(1) The effective date of all outpatient dialysis facility agreements shall be on or after the Medicare ESRD certification date.

(2) The effective date of all pharmacy agreements shall be determined by the Health and Human Services Commission Pharmacy Contracts and Rebates unit or its designated contractor.

(3) The effective date of all other provider agreements, listed in subsection (a)(5) - (9) of this section, shall be the first day of the sixth month prior to the program's receipt of the completed and signed provider agreement.

Source Note: The provisions of this §392.605 adopted to be effective June 17, 2015, 40 TexReg 3638