DIVISION 4. MEDICAID HOSPITAL SERVICES

1 TAC §355.8052, §355.8061

The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §355.8052, concerning Inpatient Hospital Reimbursement, and §355.8061, concerning Outpatient Hospital Reimbursement.

The amendments to §355.8052 and §355.8061 are adopted without changes to the proposed text as published in the November 22, 2024, issue of the Texas Register (49 TexReg 9425). These rules will not be republished.

BACKGROUND AND JUSTIFICATION

The amendments specify that High-Cost Clinician Administered Drugs and Biologics (HCCADs), Long-Acting Reversible Contraceptive (LARC) devices, and Donor Human Milk Services will be reimbursed outside the all-patient refined diagnosis-related group (APR-DRG) inpatient reimbursement and filed on a separate outpatient claim. The non-risk payment will be paid at the lesser of billed charges or the fee-for-service reimbursement amount with the fee schedule acting as the upper-payment limit. A hospital administering these services will be reimbursed separately from the Inpatient Hospital APR-DRG reimbursement methodology. The amendments increase efficiency in the delivery of HCCADs, LARCs, and Human Breast milk.

COMMENTS

The 31-day comment period ended on December 23, 2024.

During this period, HHSC received comments regarding the proposed rules from one commenter. The comments were from the Children's Hospital Association of Texas (CHAT). A summary of the comments relating to the rules and HHSC's responses follow.

Comment: Reimbursement Methodology Clarity: The proposed rule lacks a clear methodology for non-risk payments for physician-administered drugs, which CHAT recommends explicitly including in the rule to ensure consistency.

Response: HHSC thanks the commenter for their recommendations. The methodology is included in §355.8085. Additional information will be added in the Texas Medicaid Provider Procedure Manual (TMPPM). No changes were made in response to this comment.

Comment: Protection Against Recoupment: CHAT seeks assurance from HHSC that providers following the proposed rule before its effective date (March 1, 2025) won't face recoupment actions by the Texas Health and Human Services (HHS) OIG (Office of Inspector General).

Response: HHS OIG actions are outside the scope of this rule amendment. HHSC Provider Finance Department does not direct HHS OIG actions or audits. No changes were made in response to this comment.

Comment: 340B and Medicaid Alignment: CHAT requests clarification on compliance and billing issues arising from discrepancies between Centers for Medicare and Medicaid Services (CMS)and Health Resources and Services Administration definitions of "Covered Outpatient Drug" and their impact on the 340B program.

Response: HHSC will ensure that drugs administered in an inpatient hospital setting, when directly reimbursed, are considered covered outpatient drugs, aligning with recent CMS guidance. No changes were made in response to this comment.

Comment: Adequate Reimbursement: CHAT urges HHSC to ensure type of bill 111 payments cover the costs of administering high-cost curative therapies, including professional time, supplies, and equipment.

Response: The rate adoption process is outside the scope of this rule amendment. HHSC performs research and pricing reviews that are presented for public comment prior to implementation of rates. No changes were made in response to this comment.

STATUTORY AUTHORITY

The amendments are adopted under Texas Government Code §531.0055, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the executive commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on March 5, 2025.

TRD-202500795

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Effective date: March 25, 2025

Proposal publication date: November 22, 2024

For further information, please call: (737) 867-7813

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