|
2.2.1 Fee Schedules
The Texas Medicaid Program reimburses certain providers based on rates published in fee schedules. These rates are uniform statewide and by provider type. According to this type of reimbursement methodology, the provider is paid the lower of its billed charges or the Medicaid rate published in the applicable fee schedule available at www.tmhp.com.
The following provider types are reimbursed based on rates published in fee schedules, with the rates calculated in accordance with the referenced reimbursement methodology as published in the Texas Administrative Code (TAC), Part 1 Administration, Part 15 Texas Health and Human Services Commission, and Chapter 355 Reimbursement Rates.
• Ambulance. The Medicaid rates for ambulance services are calculated in accordance with 1 TAC §355.8600 and are listed in Section 8 of this manual.
•Ambulatory Surgical Center (ASC). The Medicaid rates for ASCs are calculated in accordance with 1 TAC §355.8121. The current ASC/hospital-based ambulatory surgical center (HASC) fee schedule is available on the TMHP website. There is also an insert to the fee schedule available on the TMHP website. (See also Section 9 of this manual.)
•Birthing Center. The Medicaid rates for birthing centers are calculated in accordance with 1 TAC §355.8181 and are listed in Section 10 of this manual.
•Blind Children's Vocational Discovery and Development Program. The Medicaid rate for this service is calculated in accordance with 1 TAC §355.8381 and is listed in Section 11 of this manual.
•Case Management for Children and Pregnant Women (CPW). The Medicaid rates for this service are calculated in accordance with 1 TAC §355.8401 and are listed in Section 12 of this manual.
•Targeted Case Management for Early Childhood Intervention (ECI). The Medicaid rate for this service is calculated in accordance with 1 TAC §§355.8421 and 355.8423 and is listed in Section 13 of this manual.
•Certified Nurse-Midwife (CNM). The Medicaid rates for CNMs are calculated in accordance with 1 TAC §355.8161. The current CNM fee schedule is available on the TMHP website. (See also Section 14 of this manual.)
•Certified Registered Nurse Anesthetist (CRNA). According to 1 TAC §355.8221, the Medicaid rate for CRNAs is 92 percent of the rate reimbursed to a physician anesthesiologist for the same service. The current CRNA fee schedule is available on the TMHP website. (See also Section 15 of this manual.)
•Certified Respiratory Care Practitioner (CRCP) Services. The Medicaid rate per daily visit for 1-99503 is calculated in accordance with 1 TAC §355.8089. (See also Section 16 of this manual.)
•Chemical Dependency Treatment Facility (CDTF). The Medicaid rates for CDTF services are calculated in accordance with 1 TAC §355.8241 and are listed in Section 17 of this manual.
•Chiropractic Services. The Medicaid rates for chiropractic services are calculated in accordance with 1 TAC §355.8081 and 1 TAC §355.8085 and are listed in Section 18 of this manual.
•Dental. The Medicaid rates for dentists are calculated as access-based fees in accordance with 1 TAC §355.8085, 1 TAC §355.8441(11), and 1 TAC §355.455(b). The current fee schedule is available on the TMHP website. (See also Section 19 of this manual.)
•Durable Medical Equipment (DME). The current DME fee schedule is available on the TMHP website at www.tmhp.com. Home health agencies (HHAs) are reimbursed for DME and expendable supplies in accordance with 1 TAC §355-8021 (b)-(c). Texas Health Steps (THSteps) is reimbursed for DME and expendable supplies in accordance with 1 TAC §355-8441 (4)-(5). (See also Sections 24 and 43 of this manual.)
•Family Planning Services. The Medicaid rates for family planning services are calculated in accordance with 1 TAC §355.8584 and are listed in Section 20 of this manual.
•Genetic Services. The procedure codes and Medicaid rates for genetic services are listed in Section 22 of this manual.
•Hearing Aid and Audiometric Evaluations. Newborn hearing screenings are provided at the birthing facility before hospital discharge and, as such, are reimbursed in accordance with the reimbursement methodology for the specific type of birthing facility. Outpatient hearing screening and diagnostic testing services for children are provided by physicians and are reimbursed in accordance with the reimbursement methodology for physician services at 1 TAC §355.8085 and 1 TAC §355.8141. (See also Section 23 of this manual.)
•Texas Medicaid (Title XIX) Home Health Services. The reimbursement methodology for professional services delivered by HHAs are statewide visit rates calculated in accordance with 1 TAC §355.8021(a). (See also Section 24 of this manual.)
•Independent Laboratory. The Medicaid rates for independent laboratories are calculated in accordance with 1 TAC §355.8081 and §355.8610, and the Deficit Reduction Act of 1984 (DEFRA). By federal law, Medicaid payments for a clinical laboratory service cannot exceed the Medicare payment for that service. Early Periodic Screening, Diagnosis, and Treatment (EPSDT)/THSteps medical and newborn screening laboratory services provided by the Department of State Health Services (DSHS) Laboratory are reimbursed based on actual costs in accordance with 1 TAC §355.8610. (See also Sections 26 and 43 of this manual.)
•Indian Health Services. The reimbursement methodology for outpatient services provided in Indian Health Services Facilities operating under the authority of Public Law 93-638 is located at 1 TAC §355.8620. The procedure code for reimbursing these services is 1-T1015, and the current encounter rate is $256.
•In-Home Total Parenteral Nutrition (TPN)/Hyperalimentation Supplier. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8087. The procedure codes reimbursable to these providers are listed in Section 27 of this manual.
•Licensed Marriage and Family Therapist (LMFT). According to 1 TAC §355.8091, the Medicaid rate for LMFTs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085. (See also Section 29 of this manual.)
•Licensed Clinical Social Worker (LCSW). According to 1 TAC §355.8091, the Medicaid rate for LCSWs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085. (See also Section 28 of this manual.)
•Licensed Professional Counselor (LPC). According to 1 TAC §355.8091, the Medicaid rate for LPCs is 70 percent of the rate paid to a psychiatrist or psychologist for a similar service per 1 TAC §355.8085. (See also Section 30 of this manual.)
•Maternity Service Clinic (MSC). The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8201. The procedure codes reimbursable to these providers are listed in Section 31 of this manual, and the Medicaid rates are listed in the current fee schedule, which is available on the TMHP website.
•Mental Health (MH) Mental Retardation (MR). The Medicaid rates for MH case management are calculated in accordance with 1 TAC §355.743 and those for MR service coordination are calculated in accordance with 1 TAC §355.746. The Medicaid rates for MH rehabilitative services are calculated in accordance with 1 TAC §355.781. The procedure codes covered by these services are listed in Section 32 of this manual.
•Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS). According to Title 1 TAC §355.8281, the Medicaid rate for NPs and CNSs is 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. The current NP and CNS fee schedule is available on the TMHP website. (See also Section 34 of this manual.)
•Physical Therapists/Independent Practitioners. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081 and §355.8085. The procedure codes reimbursable to these providers are listed in Section 35 of this manual, and the Medicaid rates are listed in the current fee schedule, which is available on the TMHP website.
•Physician. The Medicaid rates for physicians and certain other practitioners are calculated in accordance with 1 TAC §355.8085. The current fee schedule is available on the TMHP website. For more information about physician services, see Section 2.2.1.1, "Physician Services in Outpatient Hospital Setting" and Section 36, "Physician" .
•Physician Assistant (PA). According to 1 TAC §355.8093, the Medicaid rate for PAs is 92 percent of the rate paid to a physician (MD or DO) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. The current fee schedule for PAs is available on the TMHP website. (See also Section 37 of this manual.)
•Psychologist. The Medicaid rates for psychologists are calculated in accordance with 1 TAC §355.8081 and §355.8085. The procedure codes reimbursable to psychologists are listed in Section 38 of this manual, and the Medicaid rates are listed in the current fee schedule, which is available on the TMHP website.
•Radiological and Physiological Laboratory and Portable X-Ray Supplier. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081 and §355.8085. The procedure codes reimbursable to these providers are listed in Section 39 of this manual, and the Medicaid rates are listed in the current fee schedule, which is available on the TMHP website.
•Renal Dialysis Facility. The Medicaid rates for these providers are composite rates based on calculations specified by the Centers for Medicare & Medicaid Services (CMS). The procedure codes reimbursable to these providers are listed in Section 40 of this manual, and the Medicaid rates are listed in the current fee schedule, which is available on the TMHP website.
•School Health and Related Services (SHARS). The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8443. The procedure codes reimbursable to these providers are listed in Section 42 of this manual and the district-specific interim rates are posted on the HHSC Rate Analysis website for Acute Care Services.
•Texas Health Steps (THSteps). THSteps reimburses by provider type in accordance with 1 TAC §355.8441. Approved providers enrolled in the Texas Medicaid Program are reimbursed for THSteps services in the same manner as they are reimbursed for other Medicaid services. Some of the procedure codes reimbursable under THSteps are listed in Section 43 of this manual. THSteps-Comprehensive Care Program (CCP) reimburses for DME and expendable supplies in accordance with 1 TAC §355.8441(4)-(5).
•Tuberculosis (TB) Clinics. The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8341. Procedure codes and applicable rates for these providers are listed in Section 44 of this manual.
•Vision Care (Optometrists, Opticians). The Medicaid rates for these providers are calculated in accordance with 1 TAC §355.8081 and §355.8085. The current fee schedule for optometrists is available on the TMHP website. (See also Section 45 of this manual.)
Call the TMHP Contact Center at 1-800-925-9126 to request one of the referenced fee schedules or visit the TMHP website at www.tmhp.com.
|
