1 Tex. Admin. Code § 355.201 - Establishment and Adjustment of Reimbursement Rates for Medicaid
(a) Definitions. Unless the context clearly
indicates otherwise, the following words and terms when used in this section
are defined as follows:
(1) Centers for
Medicare & Medicaid Services (CMS)--The federal agency within the United
States Department of Health and Human Services responsible for overseeing and
directing Medicare and Medicaid.
(2) HHSC--The Texas Health and Human Services
Commission or its designee.
(3)
Medical assistance--A medical or health care related service, item, or supply
that is delivered to a Medicaid recipient and is approved and authorized for
payment or reimbursement by HHSC or CMS pursuant to state and federal
law.
(4) Program--A specific
component of the Medicaid program for which HHSC establishes either a
methodology to reimburse a provider or a specific fee, payment rate, or charge
that is paid to a provider for medical assistance in accordance with state and
federal law.
(5) Provider--A health
care practitioner, institution, or other entity that is enrolled in the medical
assistance program and is authorized to submit claims for payment or
reimbursement of medical assistance.
(b) Purpose. This section implements Texas
Government Code §
532.0057, and applies
to all programs that provide medical assistance and to all reimbursement
methodologies related to medical assistance prescribed under this
chapter.
(c) Establishment of fees,
rates, and charges. HHSC establishes fees, rates, and charges to be paid for
medical assistance in accordance with:
(1) the
formulas, procedures, or methodologies prescribed in this chapter;
(2) applicable state or federal law,
policies, rules, regulations, or guidelines;
(3) economic conditions that, in HHSC's
determination, substantially and materially affect provider participation;
or
(4) available levels of
appropriated state and federal funds.
(d) Adjustment of fees, rates, and charges.
Notwithstanding any other provision of this chapter, HHSC may adjust fees,
rates, and charges paid for medical assistance as necessary to achieve the
objectives of Medicaid in a manner consistent with the considerations described
in subsection (c) of this section.
(e) Notice. If HHSC establishes or adjusts
fees, rates, or charges under this section, HHSC will hold a public hearing and
provide notice of the hearing in accordance with §
355.105(g) of
this title (relating to General Reporting and Documentation Requirements,
Methods, and Procedures).
Notes
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