TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Reimbursement

24.3 Reimbursement

The reimbursement methodology for professional services delivered by home health agencies are statewide visit rates calculated in accordance with 1 TAC §355.8021(a).

Fee schedules for all services in this chapter are available on the TMHP website at www.tmhp.com/file library/file library/fee schedules.

A skilled nurse (SN) and/or home health aide (HHA) visit may be provided up to a maximum of 2.5 hours per visit. A combined total of three SN and/or HHA visits may be reimbursed per day.

When services are provided to more than one client in the same setting, only the units directly provided to each client at distinct, separate time periods will be reimbursed. Provider documentation must support the services were delivered at distinct, separate time periods. Total home health services billed for all clients cannot exceed the individual provider's total number of hours spent at the place of service (POS).

One as needed (PRN) SN visit may be reimbursed every 30 days outside of the prior authorized visits when SN visits have been authorized for the particular client.

For reimbursement purposes, Home Health SN and/or HHA services are always billed as POS 2 (home) regardless of the setting in which the services are actually provided. SN and/or HHA services provided in the day care or school setting will not be reimbursed.

All unique procedure codes must be billed according to the description of the procedure code. The quantity billed must be identified and each procedure code must be listed as separate line items on the claim. SN, HHA, physical therapy (PT), and occupational therapy (OT) visits must be billed in 15 minute increments.

Procedural modifiers are required when billing SN, HHA, PT, and OT visits.

Home health agencies are reimbursed for DME and expendable supplies in accordance with 1 TAC §355.8021. The current DME fee schedule is available on the TMHP website at www.tmhp.com. Providers may also request a hard copy of the fee schedule by contacting the TMHP Contact Center at 1-800-925-9126.

TMHP manually prices DME and expendable supplies that have no established fee, other than nutritional products, based on the manufacturer's suggested retail price (MSRP) less 18 percent, with documentation of the MSRP submitted by the provider. If there is no MSRP available, reimbursement is at an established percentage of the provider's invoice cost. Nutritional products that require manual pricing are priced at 89.5 percent of the average wholesale price (AWP). The Texas Medicaid Program does not reimburse separately for associated DME charges, including but not limited to, battery disposal fees or state taxes. Reimbursement for any associated charges is included in the reimbursement for a specific piece of equipment.

Refer to: "Texas Medicaid Reimbursement" for more information about reimbursement.