Texas Register Table of Contents
- 1 Texas Health and Human Services Commission
- 1.0.1 Proposed Rules Re:
- 1.0.1.1 Amending 1 TAC §355.8061, to implement an updated reimbursement methodology for outpatient hospitals.
- 1.0.1.2 Amending 1 TAC §355.8121, to revise the name of the section from “Reimbursement” to “Reimbursement to Ambulatory Surgical Centers.”
- 1.0.1.3 Amending 1 TAC §355.8610, to provide clarity on rules related to outpatient payment methodology by modifying and replacing certain terms concerning hospital laboratories for outpatients.
- 1.0.1.4 Amending 1 TAC §355.8660, to define the reimbursement process for outpatient renal dialysis centers.
- 1.0.2 In Addition Re:
- 1.0.1 Proposed Rules Re:
- 2 Texas Department of Insurance, Division of Workers’ Compensation
Texas Health and Human Services Commission
Proposed Rules Re:
Amending 1 TAC §355.8061, to implement an updated reimbursement methodology for outpatient hospitals.
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER J. PURCHASED HEALTH SERVICES
1 TAC §355.8061
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §355.8061, concerning Outpatient Hospital Reimbursement, §355.8121, concerning Reimbursement, §355.8610, concerning Reimbursement for Clinical Laboratory Services, and §355.8660, concerning Renal Dialysis Reimbursement.
BACKGROUND AND JUSTIFICATION
The purpose of the proposal is to implement the outpatient prospective payment system (OPPS) reimbursement as required by Texas Government Code §536.005, (enacted in the 82nd Texas Legislature, 1st Called Session, 2011) which requires that HHSC “convert outpatient hospital reimbursement systems to an appropriate prospective payment system.” In addition, the 2014-15 General Appropriations Act, 83rd Legislature, Regular Session, 2013 (Article II, HHSC, Rider 38) stated that “in order to ensure that access to emergency and outpatient services remain in rural parts of Texas, it is the intent of the Legislature that when HHSC changes its outpatient reimbursement methodology to a 3M™ Enhanced Ambulatory Patient Groups or similar methodology, HHSC shall promulgate a separate or modified payment level for the above defined providers.” HHSC has been unable to implement EAPGs in the current Medicaid Management Information System (MMIS) without significant technology costs. Now that the agency is moving to a modernized MMIS, EAPGs are being implemented on the same timeframe. The contracts related to the modernized MMIS anticipated the new system would become operational on September 1, 2023. However, the date may be amended to a later date if necessary for system readiness.
The OPPS that HHSC is proposing to implement is the EAPG grouper 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. EAPGs are used in outpatient prospective payment systems for a variety of outpatient settings, including hospital emergency rooms, outpatient clinics and same day surgery. EAPGs are proprietary to 3M Health Information Systems and 3M initially developed Ambulatory Patient Groups prior to 2000. In 2007, 3M made significant changes to its earlier variant of the grouper to reflect current clinical practice including coding and billing practices and to describe a broader, non-Medicare population which resulted in what we now call EAPGs. EAPGs group procedures and medical visits that share similar clinical characteristics, resource utilization patterns and cost so that payment is based on the relative intensity of the entire visit. The EAPG grouping system is designed to recognize clinical and resource variations in severity, which results in higher payments for higher intensity services and lower payments for less intensive services. While each claim may receive multiple EAPGS, each procedure is assigned to only one EAPG.
HHSC is working through the evaluation of the potential impacts in payments to hospitals and other impacted providers and expects to share those impacts in May as the evaluation is completed. The rule amendments update the reimbursement methodology in each of the four rules to clarify the transition to EAPGs.
SECTION-BY-SECTION SUMMARY
- The proposed amendment to §355.8061(a) adds new paragraph (1) to define how outpatient hospitals will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. New paragraph (2) is added to specify certain services that are excluded from the OPPS reimbursement as described in subsection (a)(1). Language from subsection (a) is used to create new paragraph (3) to specify that the paragraph applies to services provided prior to the date that the modernized MMIS becomes operational.
- The proposed amendment to §355.8061(b) deletes two references for formatting purposes and deletes paragraph (1)(C) as it describes outdated legislation that was previously approved. Section 355.8061(b)(1)(D) is changed to (C) and the subparagraph is amended to provide clarification on exemption of emergency department (ED) services from OPPS reimbursement described in subsection (a) of this section. It also corrects references to paragraphs within the rule.
- The proposed amendment to §355.8061(d) adds paragraph (1) to define how outpatient hospital imaging will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. The paragraphs are renumbered and subsection (d)(2) is updated to specify that it applies to services provided prior to the date that the modernized MMIS becomes operational. Subsection (d)(3) is updated to specify that it applies to services provided prior to the date that the modernized MMIS becomes operational.
Amending 1 TAC §355.8121, to revise the name of the section from “Reimbursement” to “Reimbursement to Ambulatory Surgical Centers.”
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER J. PURCHASED HEALTH SERVICES
1 TAC §355.8121
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §355.8061, concerning Outpatient Hospital Reimbursement, §355.8121, concerning Reimbursement, §355.8610, concerning Reimbursement for Clinical Laboratory Services, and §355.8660, concerning Renal Dialysis Reimbursement.
BACKGROUND AND JUSTIFICATION
The purpose of the proposal is to implement the outpatient prospective payment system (OPPS) reimbursement as required by Texas Government Code §536.005, (enacted in the 82nd Texas Legislature, 1st Called Session, 2011) which requires that HHSC “convert outpatient hospital reimbursement systems to an appropriate prospective payment system.” In addition, the 2014-15 General Appropriations Act, 83rd Legislature, Regular Session, 2013 (Article II, HHSC, Rider 38) stated that “in order to ensure that access to emergency and outpatient services remain in rural parts of Texas, it is the intent of the Legislature that when HHSC changes its outpatient reimbursement methodology to a 3M™ Enhanced Ambulatory Patient Groups or similar methodology, HHSC shall promulgate a separate or modified payment level for the above defined providers.” HHSC has been unable to implement EAPGs in the current Medicaid Management Information System (MMIS) without significant technology costs. Now that the agency is moving to a modernized MMIS, EAPGs are being implemented on the same timeframe. The contracts related to the modernized MMIS anticipated the new system would become operational on September 1, 2023. However, the date may be amended to a later date if necessary for system readiness.
The OPPS that HHSC is proposing to implement is the EAPG grouper 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. EAPGs are used in outpatient prospective payment systems for a variety of outpatient settings, including hospital emergency rooms, outpatient clinics and same day surgery. EAPGs are proprietary to 3M Health Information Systems and 3M initially developed Ambulatory Patient Groups prior to 2000. In 2007, 3M made significant changes to its earlier variant of the grouper to reflect current clinical practice including coding and billing practices and to describe a broader, non-Medicare population which resulted in what we now call EAPGs. EAPGs group procedures and medical visits that share similar clinical characteristics, resource utilization patterns and cost so that payment is based on the relative intensity of the entire visit. The EAPG grouping system is designed to recognize clinical and resource variations in severity, which results in higher payments for higher intensity services and lower payments for less intensive services. While each claim may receive multiple EAPGS, each procedure is assigned to only one EAPG.
HHSC is working through the evaluation of the potential impacts in payments to hospitals and other impacted providers and expects to share those impacts in May as the evaluation is completed. The rule amendments update the reimbursement methodology in each of the four rules to clarify the transition to EAPGs.
SECTION-BY-SECTION SUMMARY
The proposed amendment to §355.8121 revises the name of the section from “Reimbursement” to “Reimbursement to Ambulatory Surgical Centers” and adds (a)(1) and (a)(2) to define how ambulatory surgical centers will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. The subsections are relabeled and new subsection (b) is updated to specify that it applies to services provided prior to the date that the modernized MMIS becomes operational.
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER J. PURCHASED HEALTH SERVICES
1 TAC §355.8610
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §355.8061, concerning Outpatient Hospital Reimbursement, §355.8121, concerning Reimbursement, §355.8610, concerning Reimbursement for Clinical Laboratory Services, and §355.8660, concerning Renal Dialysis Reimbursement.
BACKGROUND AND JUSTIFICATION
The purpose of the proposal is to implement the outpatient prospective payment system (OPPS) reimbursement as required by Texas Government Code §536.005, (enacted in the 82nd Texas Legislature, 1st Called Session, 2011) which requires that HHSC “convert outpatient hospital reimbursement systems to an appropriate prospective payment system.” In addition, the 2014-15 General Appropriations Act, 83rd Legislature, Regular Session, 2013 (Article II, HHSC, Rider 38) stated that “in order to ensure that access to emergency and outpatient services remain in rural parts of Texas, it is the intent of the Legislature that when HHSC changes its outpatient reimbursement methodology to a 3M™ Enhanced Ambulatory Patient Groups or similar methodology, HHSC shall promulgate a separate or modified payment level for the above defined providers.” HHSC has been unable to implement EAPGs in the current Medicaid Management Information System (MMIS) without significant technology costs. Now that the agency is moving to a modernized MMIS, EAPGs are being implemented on the same timeframe. The contracts related to the modernized MMIS anticipated the new system would become operational on September 1, 2023. However, the date may be amended to a later date if necessary for system readiness.
The OPPS that HHSC is proposing to implement is the EAPG grouper 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. EAPGs are used in outpatient prospective payment systems for a variety of outpatient settings, including hospital emergency rooms, outpatient clinics and same day surgery. EAPGs are proprietary to 3M Health Information Systems and 3M initially developed Ambulatory Patient Groups prior to 2000. In 2007, 3M made significant changes to its earlier variant of the grouper to reflect current clinical practice including coding and billing practices and to describe a broader, non-Medicare population which resulted in what we now call EAPGs. EAPGs group procedures and medical visits that share similar clinical characteristics, resource utilization patterns and cost so that payment is based on the relative intensity of the entire visit. The EAPG grouping system is designed to recognize clinical and resource variations in severity, which results in higher payments for higher intensity services and lower payments for less intensive services. While each claim may receive multiple EAPGS, each procedure is assigned to only one EAPG.
HHSC is working through the evaluation of the potential impacts in payments to hospitals and other impacted providers and expects to share those impacts in May as the evaluation is completed. The rule amendments update the reimbursement methodology in each of the four rules to clarify the transition to EAPGs.
SECTION-BY-SECTION SUMMARY
The proposed amendment to §355.8610(a) removes the reference to services provided “by a hospital laboratory for its outpatients” and the language regarding HHSC or its designee reviewing maximum fees at least every two years from subsection (a). A slight modification is made to the name of the section by making “services” singular. Subsection (a) is reorganized for clarification and to align it with the subsequent subsection. New subsection (b)(1) defines how clinical diagnostic laboratory services will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs. New subsection (b)(2) specifies that it applies to services provided prior to the date that the modernized MMIS becomes operational, and fees for services during that time were established at a percentage of the Medicaid fee schedule.
Amending 1 TAC §355.8660, to define the reimbursement process for outpatient renal dialysis centers.
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER J. PURCHASED HEALTH SERVICES
1 TAC §355.8660
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §355.8061, concerning Outpatient Hospital Reimbursement, §355.8121, concerning Reimbursement, §355.8610, concerning Reimbursement for Clinical Laboratory Services, and §355.8660, concerning Renal Dialysis Reimbursement.
BACKGROUND AND JUSTIFICATION
The purpose of the proposal is to implement the outpatient prospective payment system (OPPS) reimbursement as required by Texas Government Code §536.005, (enacted in the 82nd Texas Legislature, 1st Called Session, 2011) which requires that HHSC “convert outpatient hospital reimbursement systems to an appropriate prospective payment system.” In addition, the 2014-15 General Appropriations Act, 83rd Legislature, Regular Session, 2013 (Article II, HHSC, Rider 38) stated that “in order to ensure that access to emergency and outpatient services remain in rural parts of Texas, it is the intent of the Legislature that when HHSC changes its outpatient reimbursement methodology to a 3M™ Enhanced Ambulatory Patient Groups or similar methodology, HHSC shall promulgate a separate or modified payment level for the above defined providers.” HHSC has been unable to implement EAPGs in the current Medicaid Management Information System (MMIS) without significant technology costs. Now that the agency is moving to a modernized MMIS, EAPGs are being implemented on the same timeframe. The contracts related to the modernized MMIS anticipated the new system would become operational on September 1, 2023. However, the date may be amended to a later date if necessary for system readiness.
The OPPS that HHSC is proposing to implement is the EAPG grouper 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. EAPGs are used in outpatient prospective payment systems for a variety of outpatient settings, including hospital emergency rooms, outpatient clinics and same day surgery. EAPGs are proprietary to 3M Health Information Systems and 3M initially developed Ambulatory Patient Groups prior to 2000. In 2007, 3M made significant changes to its earlier variant of the grouper to reflect current clinical practice including coding and billing practices and to describe a broader, non-Medicare population which resulted in what we now call EAPGs. EAPGs group procedures and medical visits that share similar clinical characteristics, resource utilization patterns and cost so that payment is based on the relative intensity of the entire visit. The EAPG grouping system is designed to recognize clinical and resource variations in severity, which results in higher payments for higher intensity services and lower payments for less intensive services. While each claim may receive multiple EAPGS, each procedure is assigned to only one EAPG.
HHSC is working through the evaluation of the potential impacts in payments to hospitals and other impacted providers and expects to share those impacts in May as the evaluation is completed. The rule amendments update the reimbursement methodology in each of the four rules to clarify the transition to EAPGs.
SECTION-BY-SECTION SUMMARY
The proposed amendment to §355.8660 adds new paragraph (a) to define how outpatient renal dialysis centers will be reimbursed based on OPPS beginning on the date that the modernized MMIS becomes operational. It specifies that the OPPS used for payments will be EAPGs.
In Addition Re:
Notice of Public Hearing on Proposed Updates to Medicaid Payment Rates
OVERVIEW
Hearing. The Texas Health and Human Services Commission (HHSC) will conduct a public hearing on July 11, 2023, at 9:00 a.m., to receive public comments on proposed updates to Medicaid payment rates for Ambulance, Birth and Woman’s Health Services, Evaluation and Management, Private Duty Nursing, Personal Care Services, Rural Hospital Inpatient and Outpatient Services. The proposed rate actions are based on direction provided by the 2024-25 General Appropriations Act (GAA), House Bill 1, 88th Legislature, Regular Session, 2023 (Article II, Special Provisions Relating to all Health and Human Services Agencies).
Public Notice – Texas State Plan for Medical Assistance Amendment
OVERVIEW
The Texas Health and Human Services Commission (HHSC) announces its intent to submit amendments to the Texas State Plan for Medical Assistance under Title XIX of the Social Security Act. The proposed amendments are effective July 1, 2023.
The purpose of the proposed amendments is to update the current State Plan to denote that certain family planning services are reimbursed to the Federal Qualified Health Clinic (FQHC) and Rural Health Clinic (RHC) as an alternative payment methodology for services provided to a Medicaid recipient at an RHC or a FQHC. This alternative payment methodology will pay the higher of the provider PPS rate or the current amount listed on the Physicians Fee Schedule.
Public Notice – Texas State Plan for Medical Assistance Amendment
OVERVIEW
The Texas Health and Human Services Commission (HHSC) announces its intent to submit amendments to the Texas State Plan for Medical Assistance under Title XIX of the Social Security Act. The proposed amendment is effective July 1, 2023.
The purpose of the amendment is to clarify the coverage of certain services like durable medical equipment and drugs for renal dialysis services as payable outside of the current composite rate due to new and/or expensive technology and high cost drugs.
Texas Department of Insurance, Division of Workers’ Compensation
Proposed Rules Re:
Amending 28 TAC §133.30, to clarify health care reimbursement policies and guidelines for telemedicine and telehealth services.
CHAPTER 133. GENERAL MEDICAL PROVISIONS
SUBCHAPTER B. HEALTH CARE PROVIDER BILLING PROCEDURES
28 TAC §133.30
OVERVIEW
The Texas Department of Insurance, Division of Workers’ Compensation (DWC) proposes to amend 28 TAC §133.30, concerning Telemedicine and Telehealth Services. Section 133.30 implements Texas Labor Code §413.011, which requires DWC to adopt health care reimbursement policies and guidelines that reflect the standardized reimbursement structures found in other health care delivery systems with minimal modifications.
BACKGROUND AND JUSTIFICATION
Amending §133.30 is necessary to conform the section to Texas Occupations Code Chapter 111, which was amended to define “teledentistry dental service” by House Bill (HB) 2056, 87th Legislature, Regular Session (2021). Section 133.30 sets billing requirements when a health care provider provides telemedicine and telehealth services.
Currently, §133.30 has definitions for “telemedicine services” and “telehealth services” but does not define “teledentistry dental service.” Section 133.30 requires health care providers to bill for “telemedicine services” and “telehealth services” using the applicable Medicare payment policies and requirements of Chapter 133 of this title. DWC proposes to add a definition for “teledentistry services” and to add Medicaid payment policies to the list of applicable payment policies that health care providers must use to bill for telemedicine, telehealth, and teledentistry services.