TITLE 1. ADMINISTRATION

PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 355. REIMBURSEMENT RATES

SUBCHAPTER J. PURCHASED HEALTH SERVICES

The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §355.8085, concerning Reimbursement Methodology for Physicians and Other Practitioners; and §355.8441, concerning Reimbursement Methodologies for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services.

Sections 355.8085 and 355.8441 are adopted without changes to the proposed text as published in the January 31, 2025, issue of the Texas Register (50 TexReg 595). These rules will not be republished.

BACKGROUND AND JUSTIFICATION

The amendments are necessary to clarify the current structure of reimbursement methodologies for certain services and programs administered by HHSC. The amendments add details to describe the methodology HHSC uses to determine reimbursement amounts to Licensed Behavior Analysts (LBAs) and Licensed Assistant Behavior Analysts (LaBAs) for Applied Behavior Analysis (ABA) professional services. The amendments also add to the types of analyses that can be utilized for reimbursement methodology for Physicians and Other Practitioners.

In addition, following a Centers for Medicare & Medicaid Services (CMS) revision of their reimbursement methodologies, references to the Medicare reimbursement methodology are updated to comply with the CMS changes. The intent is to remove outdated reimbursement percentages and references to the Medicare average sales price and replace them with simpler references to the Medicare fee schedules where applicable. Where §355.8085 currently specifies its applicability to the Texas Medicaid program, the language has been revised to include "and other programs administered by Texas HHSC," in order to add clarity that the rule can apply to other programs in addition to Medicaid. This update provides clarification regarding the scope of the reimbursement methods.

COMMENTS

The 31-day comment period ended on March 3, 2025.

During this period, HHSC received comments regarding the proposed rules from one commenter. HHSC received comments from the Texas Association for Behavior Analysis, Public Policy Group. A summary of comments relating to the rules and HHSC's responses follow.

Comment: The commenter requested that "HHSC include a provider type (20) Behavior Technicians (Registered Behavior Technician (RBT), Board Certified AutismTechnician, or Applied Behavior Analysis Technician) to the proposed list of providers…and the same rate setting process should apply to the services rendered by this provider type."

Response: HHSC appreciates this request but declines to make an update at this time because the cost of adding a new provider type would be an added cost in the existing claims system that is not required to implement the existing rate methodology. Amending provider types without additional funding available is not economic and efficient at this time.

Comment: The commenter requests that "HHSC adopt a differential rate strategy that attracts providers to underserved communities and improves access to medically necessary care across the state."

Response: HHSC declines to revise the rule in response to this comment because it is a broad request that would require extensive research on differential rate strategy as well as time to receive public comment on such a strategy. HHSC will take this comment into consideration in future rule updates related to this topic.

Comment: The commenter requests that HHSC specify the reimbursement methodology for Adaptive Behavior Service Current Procedure Terminology codes, since "there is no Medicare fee schedule for [these codes]" and "HHSC cannot base the Relative Value Unit (RVUs) in the HHSC reimbursement methodology on the RVUs of the individual services as specified within the Medicare Fee Schedule." The request was made for LBA, LaBA, and RBT provider types.

Response: HHSC declines to revise the rules in response to this comment. Section 355.8085 outlines different reimbursement methodologies utilized to reimburse providers, including when Medicare rates do not exist. Reimbursement methodologies applicable to services administered by LBAs and LaBAs are outlined in Section 355.8441.