CSHCN 2009 > Renal Dialysis > Reimbursement

31.5 Reimbursement

The CSHCN Services Program may reimburse dialysis services using one of the following methods as defined by the Centers for Medicare & Medicaid Services (CMS):

•Method I: Composite Rate. The composite rate is paid to the dialysis facility as a comprehensive payment for all in-facility and Method I home dialysis. The cost of an item or service is included in this rate unless specifically excluded, such as the physician's professional services, lab work that is designated as separately billable, and drugs that are designated as separately billable.

Refer to: Section 31.3.1, "In-Facility Services and Method I Home Dialysis Services" for benefits and limitations concerning Method I billing.

•Method II: Direct Dealing. With direct dealing, the client works with a single supplier such as a durable medical equipment (DME) or other medical supplier (not a dialysis facility) to obtain supplies and equipment to dialyze at home. The supplier will bill the CSHCN Services Program for the services provided.

Refer to: Section 31.3.2, "Method II Home Dialysis (Dealing Direct)" for benefits and limitations concerning Method II billing.

Physicians, laboratories, and medical suppliers may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

Outpatient hospitals may be reimbursed at 80 percent of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) rate, which is equivalent to the hospital's Medicaid interim rate.

Advanced practice nurses (APNs) may be reimbursed the lower of the billed amount or 92 percent of the amount allowed by Texas Medicaid for the same service provided by a physician.