Opportunity for Public Comment on the Medicaid Fee-For-Service Access … · 2020-02-12 · Opportunity for Public Comment on the Medicaid Fee-For-Service Access Monitoring Review

Opportunity for Public Comment on the Medicaid Fee-For-Service Access Monitoring Review Plan

Title 42 Code of Federal Regulations §§447.203-204 require states to submit a fee-for-service Access Monitoring Review Plan (AMRP) every three years. The

intent is for states to have methods and procedures to assure payments to fee-for-service providers are sufficient to enlist enough providers to ensure that

care and services are available to Medicaid recipients the same as the general population for the geographic area. The AMRP is specific to the fee-for-service

population, so managed care data is not included in the fee-for-service AMRP. Access monitoring for managed care services are handled through a separate

process.

The draft fee-for-service AMRP will be posted to the HHSC website for a 30-day comment period. HHSC invites public comment on the draft AMRP and will

accept public comments until 5:00 p.m. (CST) on March 11, 2020. Interested stakeholders can email comments to [email protected].

Thank you for your time and consideration.

Should you require additional assistance, please, contact Cynthia Henderson at

[email protected].

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DRAFT

01/13/20

2019 TEXAS MEDICAID FEE-FOR-SERVICE ACCESS MONITORING

REVIEW PLAN

42 Code of Federal Regulations §447.203(b)

March 1, 2020

Texas Health and Human Services Commission

Medicaid and CHIP Services

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DRAFT

Contents Overview ............................................................................................... 4

Texas Fee-for-Service AMRP .................................................................. 5

Population Analysis ................................................................................. 6

2017 Recipient Counts by SDA and Population ...................................... 7

Data to Assess Access: Public Input........................................................... 9

Complaint Monitoring Processes ............................................................. 9

TMHP Appeals, Complaints, and Resolution Division ............................. 10

HHSC Medicaid and CHIP Services ..................................................... 10

HHSC Office of the Ombudsman ........................................................ 11

HHSC Rate Hearing Comment and Resolution Process ............................. 11

Data to Assess Access: Service-Specific Analyses ...................................... 13

Common Elements of Analyses ............................................................ 13

1. Service Delivery Area ................................................................ 13

2. Provider Categories .................................................................. 13

3. Recipient Categories ................................................................. 14

Primary Care Services ......................................................................... 14

PC1 - MEDICAL PCPs. ....................................................................... 16

PC2 - DENTAL PCPs. ........................................................................ 19

Physician Specialist Services ................................................................ 22

PS1 - CARDIOVASCULAR DISEASE. ................................................... 23

PS2 - EAR, NOSE, & THROAT. ........................................................... 26

PS3 - ORTHOPEDIC SURGERY. .......................................................... 29

PS4 - UROLOGY. ............................................................................. 32

PS5 - OPHTHALMOLOGIST. ............................................................... 35

Behavioral Health Services .................................................................. 38

BH1 - SERVICES BY BEHAVIORAL HEALTH PROVIDERS. ....................... 39

BH2 - SERVICES BY NON-BEHAVIORAL HEALTH PROVIDERS. ............... 42

BH3 - MENTAL HEALTH DELIVERED BY PSYCHIATRISTS. ...................... 45

BH4 - SERVICES DELIVERED BY ALL PROVIDERS. ............................... 48

BH5 - SUBSTANCE USE DISORDER SERVICES BY ALL PROVIDERS. ....... 51

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DRAFT

BH6 - SUBSTANCE USE DISORDER SERVICES BY CHEMICAL DEPENDENCY TREATMENT FACILITIES. .................................................................. 54

Pre- and Post-Natal Obstetric Services .................................................. 57

OB1 - OBSTETRICS HEALTH PROVIDERS. ........................................... 58

Home Health Services ......................................................................... 61

HH1 - HHA SKILLED NURSING. ......................................................... 62

HH2 - HOME HEALTH AGENCY AIDES. ................................................ 65

HH 3 - DURABLE MEDICAL EQUIPMENT. ............................................. 68

HH4 - PHYSICAL, OCCUPATIONAL, OR SPEECH LANGUAGE THERAPY BY HOME HEALTH AGENCY. ................................................................... 71

Process for Rate Restructuring and Reductions .......................................... 74

2016 Physical, Occupational, and Speech Language Therapy Rate Reduction 75

Public Input on the Draft Report .............................................................. 78

Conclusion ........................................................................................... 79

APPENDIX A: Complaints Contact Information ......................................... 81

APPENDIX B: Rate Comparison Tables ..................................................... 83

PC1-Rate: Medical PCPs ...................................................................... 84

PC2-Rate: Dental PCPs........................................................................ 86

PS1-Rate: Cardiovascular Disease ........................................................ 88

PS2-Rate: Ears, Nose and Throat (ENT) ................................................ 90

PS3-Rate: Orthopedic Surgery ............................................................. 92

PS4-Rate: Urology .............................................................................. 94

PS5-Rate: Ophthalmology ................................................................... 96

BH1-Rate: Behavioral health services by behavioral health providers ........ 98

BH2-Rate: Behavioral health services by non-behavioral health providers 100

BH3-Rate: Mental health services by a psychiatrist ............................... 102

BH4-Rate: Mental health services by all providers ................................ 104

BH5-Rate: Substance use disorder services by all providers ................... 106

BH6-Rate: Substance use disorder services by chemical dependency treatment facility.............................................................................. 108

OB1-Rate: Obstetrics services by an obstetrics provider ........................ 110

HH-1 Rate: Services by home health agencies ..................................... 112

HH3-Rate: Durable medical equipment services ................................... 114

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DRAFT

Overview Section 1902(a)(30)(A) of the Social Security Act (the Act) requires states to have methods and procedures to assure payments to providers are “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.”1 Title 42 of the Code of Federal Regulations (CFR) §§447.203-204 establishes a standardized, transparent, data-driven process for states to document that their fee-for-service provider payment rates are consistent with §1902 of the Act.

Major provisions of the rule: • State Medicaid programs must submit an initial fee-for-service

Access Monitoring Review Plan (AMRP) by October 1, 20162, and every three years thereafter.

• The plan must analyze certain services for sufficient access under a state-established methodology.

• When states submit state plan amendments reducing or restructuring rates, they must include an analysis of the current level of access, expected effect the amendment will have on access and information, and concerns shared by stakeholders.

• States must establish or maintain ongoing means for provider and beneficiary access-to-care input.

• For identified access issues, states must establish corrective action plans within 90 days intended to remediate identified access to care issues within 12 months.

The Texas Health and Human Services Commission (HHSC) submitted its first AMRP on October 1, 2016 (using state fiscal year (SFY) 2015 data). On December 1, 2017, HHSC submitted an addendum to include additional elements related to children with disabilities, rate comparisons, and geo- access maps (using SFY 2016 data).

1 42 U.S.C. §1396a(a)(30)(A). 2 42 C.F.R. §447.203(b)95). HHSC submitted the initial plan on October 1, 2016.

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Texas Fee-for-Service AMRP Consistent with 42 CFR §447.203(b), the Texas AMRP includes:

• analysis of a minimum set of defined fee-for-service categories,

including primary care, specialty care, home health, behavioral health, and obstetrics, with possible analysis of other services, as determined by complaint volume or other factors of the state's choosing3;

• prescribed data elements, such as provider availability and utilization by geographic area, which support analysis of whether recipients have sufficient access to care;

• consideration of input from providers and recipients; • comparative rate review of state fee-for-service Medicaid rates to other

payer rates, such as Medicare; • description of standards and methodologies used to monitor access

and how the state measures against these standards; • procedures to periodically monitor access, for at least three years after

certain rate reductions or restructuring, including an analysis establishing access to care for the specific service at the time of state plan amendment and periodic reviews (at least annually) over three years demonstrating sustained service access; and

• determination of sufficiency of access to care based on findings.

3 42 CFR §447.203(b) also indicates that an AMRP may include an analysis of other services as determined by complaint volume or other factors. Texas’ AMRP does not include any of this “possible analysis” because there was not a significantly higher than usual volume of beneficiary, provider or other stakeholder access complaints for a geographic area.

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Population Analysis The plan and monitoring analysis must consider the characteristics of the beneficiary population, in accordance with 42 CFR §447.203(b)(1)(iv). In Texas, the fee-for-service population has diminished significantly over the last decade as Texas has established managed care models for most populations and expanded those models throughout the state. State Fiscal Year 2016: 12.1 percent fee-for-service State Fiscal Year 2017: 8.5 percent fee-for-service State Fiscal Year 2018: 6.1 percent fee-for-service. Most individuals in the small fee-for-service population are awaiting managed care enrollment, which takes up to 45 days. At least 77 percent of the remaining 6.1 percent of the fee-for-service recipients are eventually enrolled in managed care. The following table represents the total number of people receiving fee-for-service Medicaid by Service Delivery Area (SDA) and analysis categories for SFY 2017 fee-for-service data. The total number of people receiving fee-for-service Medicaid includes both those not required to enroll in managed care during the reporting period and those required to temporarily enroll in fee-for-service Medicaid while awaiting managed care enrollment. The table includes three Medicaid Rural Service Areas (MRSA), which are rural counties that do not include significant urban centers.

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2017 Recipient Counts by SDA and Population

SDA Adult without a disability

Adult with a disability

Child without a disability

Child with a disability All Recipients

Bexar 17,632 18,872 45,198 11,874 92,672

Dallas 28,542 27,507 74,773 15,396 145,302

El Paso 6,994 8,824 17,648 4,370 37,514

Harris 55,986 38,869 121,445 26,635 241,377

Hidalgo 25,091 23,139 53,267 18,127 118,354

Jefferson 5,588 7,184 12,762 3,700 29,030

Lubbock 4,962 7,817 14,509 2,770 29,830

MRSA Central 8,971 14,454 23,863 6,592 53,438

MRSA Northeast 10,989 20,277 28,643 8,758 68,140

MRSA West 10,955 19,659 29,655 6,617 66,410

Nueces 5,857 7,699 14,374 4,613 32,239

Tarrant 18,649 19,584 51,424 10,714 99,678

Travis 11,337 12,073 30,752 6,103 59,908

Unknown 10,853 702 2,163 949 14,627

Texas Total 220,922 224,466 517,681 126,418 1,070,7664 Baseline from SFY

2016 226,274 218,868 554,452 161,519 1,161,113

4 At least 77% of the 1,070,776 fee-for-service recipients were enrolled in managed care.

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Data to Assess Access: Public Input HHSC uses multiple forms of public input to inform access-to-care analysis and meet requirements of 42 CFR §447.203(b)(7). Two of the most important input mechanisms are:

• complaint data, to inform ongoing access review; and • comments provided during the rate-hearing process, to inform decision-

making prior to rate changes. Complaint Monitoring Processes

HHSC uses existing mechanisms for ongoing beneficiary and provider access to care input during a quarterly review process that aggregates complaints to HHSC internal and contractor sources. HHSC reviews complaint data more frequently if the volume of stakeholder input dictates or if more frequent review is appropriate given a rate reduction or restructuring subject to the requirements of 42 CFR §447.203(b)(6).

HHSC’s Compact with Texans outlines5 the agency’s customer service principles and standards, including a complaint process. As part of that process, Medicaid recipients are directed to first contact the HHSC program for which they have an inquiry or complaint. If the concern is not resolved to their satisfaction, HHSC directs recipients to contact the Texas Health and Human Services (HHS) Office of the Ombudsman. This process is applicable to both recipients and providers participating in Medicaid fee-for-service. In both cases, HHSC contracts with its claims administrator, the Texas Medicaid and Healthcare Partnership (TMHP), to receive initial contact regarding complaints and inquiries related to fee-for-service Medicaid.

Descriptions of various entities that monitor complaints and accept public input on an ongoing basis follow. Appendix A contains contact information for the various fee-for-service recipient and provider complaint channels.

5 The Compact with Texans can be found here: https://hhs.texas.gov/about-hhs/your-rights/compact-texans

https://hhs.texas.gov/about-hhs/your-rights/compact-texans

https://hhs.texas.gov/about-hhs/your-rights/compact-texans

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TMHP Appeals, Complaints, and Resolution Division The TMHP Appeals, Complaints, and Resolution division receives issues and complaints via escalations from the TMHP contact center, HHSC referral, and an email address for complaints.

TMHP Appeals, Complaints, and Resolution staff capture detail on the complainant, provider, complaint classification, complaint description, and complaint resolution. Complaint data is reported weekly and monthly to HHSC by the TMHP Project Management team.

Section 7.3.4 of the Texas Medicaid Provider Procedures Manual6

(TMPPM), which is a resource for all Medicaid providers, describes the provider-complaint process, and provides contact information. The complaint contact information is also listed on the TMHP website and on the provider Remittance and Status reports.

Recipients receive TMHP contact information, in addition to other contact information, in the Your Health Care Guide for Medicaid7. The number for the Medicaid Recipient hotline is listed in various places on the HHSC website8 and on the back of fee-for-service Medicaid Your Texas Benefits cards. The hotline tells recipients how to address their Medicaid needs, including how to file complaints. The TMHP website also includes ways recipients can contact TMHP.9

HHSC Medicaid and CHIP Services

Medicaid and CHIP Services (MCS) staff receive issues and complaints that escalate from TMHP or other areas of HHSC, such as the Office of the Ombudsman. MCS staff confirm the complaint pertains to services for a fee-for-service recipient, engage the resources necessary to resolve the

6 The TMPPM can be found here: http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx

7 Your Health Care Guide http://www.tmhp.com/TMHP_File_Library/Medicaid/Client/2018%20FFS%20Handbook_English.pdf 8 HHSC Contacts: https://hhs.texas.gov/services/health/medicaid-chip/about-medicaid-chip/medicaid-chip-contact-us 9 TMHP Contacts: http://www.tmhp.com/pages/tmhp/tmhp_contacts.aspx

http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx

http://www.tmhp.com/TMHP_File_Library/Medicaid/Client/2018%20FFS%20Handbook_English.pdf


https://hhs.texas.gov/services/health/medicaid-chip/about-medicaid-chip/medicaid-chip-contact-us

https://hhs.texas.gov/services/health/medicaid-chip/about-medicaid-chip/medicaid-chip-contact-us

http://www.tmhp.com/pages/tmhp/tmhp_contacts.aspx

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issue, then record the outcome. Information is tracked via the Customer Relationship Management tool.

HHSC Office of the Ombudsman

The HHSC Office of the Ombudsman is a team of professionals committed to a high-level of customer service. The Office of the Ombudsman receives, responds to, and refers calls and correspondence from the public, while working closely with HHS system leadership, management, and program staff.

The Office of the Ombudsman's services include: • conducting independent reviews of complaints concerning agency

policies or practices; • ensuring policies and practices are consistent with the goals of HHSC; • ensuring people are treated fairly, respectfully, and with dignity; and • making referrals to other agencies, as appropriate.

Ombudsman staff attempt to resolve complaints within 10 business days, provide regular ongoing updates to the complainant, and follow up with the person making the complaint upon resolution.

A tracking database captures all contacts the Office of the Ombudsman receives. The office collects key data points, including the subject matter of complaints or inquiries and resolution descriptions. The office produces monthly reports and can run specific reports relevant to areas within HHSC.

People who are enrolled in Medicaid services receive a welcome packet that contains their Medicaid ID card and information about ways to contact the Office of the Ombudsman. Contact information is also listed in the Your Health Care Guide posted on the TMHP10 website. Additionally, the Office of the Ombudsman produces outreach materials for recipients and community partner organizations.

HHSC Rate Hearing Comment and Resolution Process

10 http://www.tmhp.com/TMHP_File_Library/Medicaid/Client/2017%20FFS%20Handbook_English.pdf



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The HHSC Rate Analysis Division (RAD) holds quarterly and, if required, special rate hearings to obtain public comment on proposed rate reimbursement adjustments. The Texas Register and HHS websites publish notices announcing the rate hearings with instructions for accessing the rate hearing packets and public comment procedures. Before the rate hearing, information packets are posted on the RAD website and HHS sends an email notice to stakeholders indicating packets are posted. HHS broadcasts rate hearings live and archives them on the HHS website for public viewing.

Commenters have the chance to document and discuss their support for or concerns with the proposed rate actions through: • written comments submitted until 5 p.m. the day of the rate hearing

via email, fax, or postal mail; and • verbal testimony recorded at the rate hearing.

After the rate hearing and before making a final recommendation, RAD staff analyze all submitted comments and documentation. Staff consult with clinical, policy, and other appropriate HHSC staff regarding the merits of access to care issues raised through the rate hearing comment process. After consultation, staff may develop alternative rate adjustment recommendations.

HHSC RAD staff present summarized comments, analysis, and final RAD recommendations to HHSC leadership for review, discussion, and final decision. Once a decision is finalized, RAD staff directs the HHSC claims administrator to implement the new rates and publish provider notifications regarding the adopted rates and their effective date. The claims administrator publishes this information on its website.

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Data to Assess Access: Service-Specific Analyses In accordance with 42 CFR §447.203(b)(5)(ii)(A)-(E), the AMRP must address the following service categories: • Primary care • Physician specialist • Behavioral health • Pre- and post-natal obstetrics • Home health services

The state did not identify additional categories of service to be included in this AMRP pursuant to 42 CFR §447.203(b)(5)(ii)(F). In assessing the five service categories listed in 42 CFR §447.203(b)(5)(ii)(A)-(E), HHSC used state fiscal year 2017 enrollment and utilization data to verify fee-for-service utilization in all reported service categories in all SDAs of the state.

In addition, this AMRP includes Medicare rate comparisons for the top 20 procedure codes for each service category, as applicable. Texas Medicaid does not currently have a resource for private-payer rate data. HHSC continues to explore options for obtaining commercial payer data.

Common Elements of Analyses

The following assumptions in this section apply to all service-specific analyses, unless otherwise noted in the service-specific section. Data was drawn from fee-for-service claims from the 2017 state fiscal year.

1. Service Delivery Area

All analyses reflect the actual number of fee-for-service recipients broken down by the SDAs used in Medicaid managed care. This structure facilitates comparative analyses between fee-for-service and managed care populations, as appropriate. Enrolled and active provider counts are stratified by Medicaid SDAs using the county of the provider's physical address. Stratification of recipient counts by SDA are based on a recipient's county of residence.

2. Provider Categories

Each analysis reflects unduplicated data for one or more of the following

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provider categories: • Enrolled providers - includes providers who are enrolled in the

Medicaid program, regardless of whether they actively provided services, and meet the criteria defined for each service category.

• Active providers - includes the providers, identified by HHSC, who provided services to Medicaid recipients in fee-for-service specific to each service category within the 2017 state fiscal year.

• Providers with new recipients - includes primary care and physician specialty care providers who saw fee-for-service recipients and submitted claims with procedure codes or modifiers indicating a new recipient.

3. Recipient Categories

Each analysis reflects unduplicated data for each of the following categories of recipients:

• Adults 21 or older with a disability and without one. • Children 20 or younger with a disability and without one.

Primary Care Services

Data for primary care services addresses medical and dental providers separately. The primary care medical providers' data includes:

• Physicians (M.D. or D.O.) and physician group practices with specialties in family practice, internal medicine, pediatrics, or obstetrics/gynecology;

• Federally qualified health centers; • Rural health clinics; • Comprehensive health centers; • Physician assistants; • Advanced practice registered nurses; and • Texas Health Steps medical providers11.

The primary care dental providers' data includes:

• Dentists (D.D.S. or D.M.D.);

11 Provider categories are not mutually exclusive, as providers may enroll as Texas Health Steps medical providers in addition to the other provider types above.

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• Dentistry groups; and • Providers enrolled as Texas Health Steps dental or Texas Health

Steps dental groups12. The tables below reflect services received by fee-for-service recipients from Medicaid enrolled providers during state fiscal year 2017.

12 Provider categories are not mutually exclusive, as providers may enroll as Texas Health Steps dental providers in addition to the other provider types above.

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PC1 - MEDICAL PCPs. Number of enrolled and active medical PCPs, PCPs who saw new clients, and number of clients receiving services from a medical primary care provider by SDA and client group during state fiscal year 2017

Medicaid SDA

Enrolled PCPs

Active PCPs

PCPs with New Clients

Adult without a disability

Adult with a

disability

Child without

a disability

Child with a disability

Bexar SDA 5,405 247 181 2,879 2,007 20,329 2,965

Dallas SDA 10,604 376 274 4,506 2,305 33,884 3,950

El Paso SDA 1,856 116 93 437 1,089 8,106 1,314

Harris SDA 14,046 667 516 5,602 4,281 58,875 7,528

Hidalgo SDA 2,833 347 297 2,909 5,786 27,946 7,400

Jefferson SDA 1,757 101 79 944 1,464 5,725 1,041

Lubbock SDA 2,111 100 66 450 1,353 5,269 625

MRSA Central 4,290 162 123 1,433 2,889 9,681 1,800

MRSA Northeast 4,148 222 156 1,805 4,005 11,323 2,114

MRSA West 3,889 294 183 1,706 4,322 11,696 1,865

Nueces SDA 1,792 128 88 579 1,278 6,108 1,345

Tarrant SDA 6,106 233 153 841 1,712 19,595 2,061

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Travis SDA 4,783 171 124 1,969 2,772 14,662 1,463

Out-of-State - 11 5 - - - -

Unknown - 3 1 5 72 179 220

Texas Totals 48,777 3,158 2,323 26,040 35,196 233,057 35,636

Baseline from SFY 2016

58,822 4,578 3,170 36,034 48,032 265,422 100,461

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PC2 - DENTAL PCPs. Number of enrolled and active dental PCPs, dental PCPs who saw new clients, and number of clients receiving services from a dental PCP by SDA and client group during state fiscal year 2017

Medicaid SDA Enrolled Dental PCPs

Active Dental PCPs

Dental PCPs with

New Clients


Adult with a

disability


Child with a

disability

Bexar SDA 1,441 253 219 3 461 10,227 130

Dallas SDA 2,757 562 493 5 283 21,723 235

El Paso SDA 451 71 61 - 22 5,671 53

Harris SDA 3,316 782 687 - 312 30,505 279

Hidalgo SDA 1,034 239 215 4 75 15,360 105

Jefferson SDA 350 51 48 - 105 2,628 30

Lubbock SDA 391 42 37 - 88 2,879 37

MRSA Central 619 80 63 - 74 4,512 72

MRSA Northeast 683 98 82 - 210 5,815 101

MRSA West 583 89 75 - 231 6,270 100

Nueces SDA 404 63 54 2 59 2,859 24

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Tarrant SDA 2,090 336 306 3 384 13,161 157

Travis SDA 928 181 149 - 274 6,487 74

Out-of-State - 5 2 - - - -

Unknown - 1 1 - 2 67 13

Texas Total 10,334 2,827 2,472 17 2,567 128,135 1,408


13,845 2,780 2,464 15 2,724 140,548 1,650

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Physician Specialist Services To address priority specialty physician services identified by the state, Texas has aligned the fee-for-service physician specialty analysis with analysis of physician specialists in Medicaid managed care. Therefore, data was collected on the following specialties:

• Cardiovascular Disease • Ear, Nose, and Throat (ENT) • Orthopedic Surgery • Urology • Ophthalmologists

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PS1 - CARDIOVASCULAR DISEASE. TX Medicaid FFS Access to Care: Number of enrolled and active specialists, specialists who saw new clients, and number of clients receiving services from a specialist by SDA and client group during SFY 2017

Medicaid SDA Enrolled Specialists

Active Specialis

ts

Specialists with New

Clients


Adult

with a disability


Child

with a disability

Bexar SDA 197 1 1 2 66 - -

Dallas SDA 379 3 2 13 119 9 3

El Paso SDA 59 4 2 1 63 13 11

Harris SDA 581 17 10 37 587 6 6

Hidalgo SDA 71 3 2 5 243 - -

Jefferson SDA 43 1 1 3 78 2 1

Lubbock SDA 66 3 1 1 16 6 3

MRSA Central 103 - - - 6 - 1

MRSA Northeast 155 3 2 5 125 3 6

MRSA West 108 5 4 3 124 7 1

Nueces SDA 62 2 2 3 32 1 -

Tarrant SDA 249 7 4 6 46 1 1

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Travis SDA 137 1 - - 6 - -

Unknown - - - - 1 - -

Texas Total 1,934 50 31 79 1,508 48 33

Baseline from SFY 2016 2,319 190 127 361 5,240 79 178

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PS2 - EAR, NOSE, & THROAT. Number enrolled and active ENT specialists, ENT specialists who saw new clients, and clients receiving services from an ENT specialist during state fiscal year 2017

Medicaid SDA Enrolled Active Specialist with New

Clients


Adult with a

disability


Child with a

disability

Bexar SDA 75 1 1 1 26 15 4

Dallas SDA 102 3 3 - 43 10 2

El Paso SDA 18 1 1 - 1 1 2

Harris SDA 220 10 10 27 112 92 39

Hidalgo SDA 28 2 2 8 85 9 6

Jefferson SDA 9 1 1 - 21 1 -

Lubbock SDA 19 - - - 2 - -

MRSA Central 42 2 2 1 23 5 -

MRSA Northeast 40 6 6 9 196 91 35

MRSA West 37 5 5 5 92 43 9

Nueces SDA 20 2 2 2 51 8 2

Tarrant SDA 57 2 1 1 8 4 -

Travis SDA 45 1 1 1 1 3 5

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Unknown - - - - 1 - 2

Texas Total 681 35 34 55 662 281 105


778 108 89 125 1,315 524 859

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PS3 - ORTHOPEDIC SURGERY. Number of enrolled and active orthopedic surgeons, surgeons who saw new clients, and number of clients receiving services from an orthopedic surgeon during state fiscal year 2017

Medicaid SDA

Enrolled

Active

Specialist with New

Clients


Adult with a

disability


Child with a

disability

Bexar SDA 176 6 4 8 56 7 1

Dallas SDA 286 12 6 2 66 2 -

El Paso SDA 68 1 1 1 64 - -

Harris SDA 399 9 6 6 80 14 1

Hidalgo SDA 59 6 6 30 188 28 14

Jefferson SDA 29 - - - 2 - -

Lubbock SDA 57 1 1 - 6 - -

MRSA Central 116 1 - - 16 3 -

MRSA Northeast 114 2 2 - 13 - -

MRSA West 87 4 3 4 103 22 1

Nueces SDA 43 1 1 1 7 - 1

Tarrant SDA 219 6 5 17 48 4 2

Travis SDA 146 1 1 1 4 5 1

30

Unknown - - - - 1 - -

Texas Total 1,636 50 36 70 653 85 21

Baseline from SFY 2016 1,911 183 141 190 2,062 445 760

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PS4 - UROLOGY. Number of enrolled and active urologists, urologists who saw new clients, and number of clients receiving services from a urologist during state fiscal year 2017

Medicaid SDA

Enrolled

Active


Clients


Adult with a

disability


Child with a

disability

Bexar SDA 58 - - - 13 - -

Dallas SDA 169 - - - 3 - -

El Paso SDA 30 1 1 1 27 - -

Harris SDA 198 6 6 9 42 - 1

Hidalgo SDA 35 3 1 22 86 5 3

Jefferson SDA 10 - - 1 - - -

Lubbock SDA 31 2 2 1 30 4 2

MRSA Central 47 3 2 3 11 1 -

MRSA Northeast 55 1 1 - 2 1 2

MRSA West 39 3 3 3 114 2 -

Nueces SDA 17 - - - - - -

Tarrant SDA 102 1 1 - 9 - -

Travis SDA 46 1 1 - 15 - -

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Out-of-State - 1 1 - - - -

Texas Total 697 22 19 39 352 13 8

Baseline from SFY 2016 889 78 57 94 1,128 54 33

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PS5 - OPHTHALMOLOGIST. Number of enrolled and active ophthalmologists, ophthalmologists who saw new clients, and number of clients receiving services from an ophthalmologist during state fiscal year 2017

Medicaid SDA

Enrolled

Active


Clients


Adult with a

disability


Child with a

disability

Bexar SDA 147 15 3 11 217 326 159

Dallas SDA 246 12 6 21 221 18 3

El Paso SDA 34 3 - 7 78 140 140

Harris SDA 352 7 1 56 223 174 103

Hidalgo SDA 62 8 4 59 747 165 116

Jefferson SDA 42 - - - 6 1 4

Lubbock SDA 55 2 - - 34 3 3

MRSA Central 76 3 1 5 166 9 13

MRSA Northeast 92 2 - - 66 2 3

MRSA West 54 7 3 4 194 20 22

Nueces SDA 38 2 - 1 200 80 82

Tarrant SDA 160 8 2 11 161 6 5

Travis SDA 113 3 - 3 93 17 6

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Unknown - - - - 2 2 3

Texas Total 1,223 72 20 178 2,408 963 659

Baseline from SFY 2016 1,593 234 29 520 6,284 1,711 3,770

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Behavioral Health Services Behavioral health services are any services for which a mental health or substance use disorder is listed as the recipient’s primary diagnosis on mental health and substance use disorder-related claims or procedure codes.

The tables below reflect behavioral services received by fee-for-service recipients from Medicaid enrolled providers in SFY 2017.

The analysis first looks at all behavioral health service codes—either mental health or substance use disorder—and documents services provided to recipients with the specified diagnosis by providers classified as behavioral health providers versus other provider types. Behavioral health providers are psychiatrists, psychologists, social workers, counselors, mental health rehabilitation and case management service providers, psychiatric hospitals, and chemical dependency treatment facilities. Behavioral health services may be provided by non-behavioral health provider types, such as a non- psychiatrist physician who prescribes a recipient anti-depressant medication.

The remaining analyses in the behavioral health section address either mental health or substance use disorder services rather than behavioral health services collectively. The analysis in table BH3 specifically identifies mental health services provided by a psychiatrist. Psychiatrists may provide services not within the scope of practice of other mental health provider types.

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BH1 - SERVICES BY BEHAVIORAL HEALTH PROVIDERS. Number of enrolled and active behavioral health providers and number of clients receiving behavioral health services from behavioral health providers during state fiscal year 2017

Medicaid SDA

Enrolled providers

Active providers


Adult with a disability


Child with a disability

Bexar SDA 1,711 333 559 1,469 2,305 1,492

Dallas SDA 1,372 186 146 1,254 994 177

El Paso SDA 402 98 177 501 525 560

Harris SDA 2,565 418 599 2,521 2,714 2,089

Hidalgo SDA 491 208 486 1,081 1,695 4,239

Jefferson SDA 271 71 206 494 717 956

Lubbock SDA 359 156 123 620 635 256

MRSA Central 748 179 310 877 968 731

MRSA Northeast 779 213 369 1,440 1,366 1,326

MRSA West 670 202 348 1,345 1,304 936

Nueces SDA 297 95 248 567 585 640

Tarrant SDA 1,182 251 344 1,296 1,606 1,160

Travis SDA 1,470 233 301 1,383 1,477 643

40

Out-of-State - 7 - - - -

Unknown - 1 2 45 16 97

Texas Total 10,832 2,644 4,201 14,769 16,798 15,248

Baseline from state fiscal year 2016 11,746 2,880 4,248 16,553 16,297 26,635

41

42

BH2 - SERVICES BY NON-BEHAVIORAL HEALTH PROVIDERS. Number of active non-behavioral health providers delivering services and number of clients with specified diagnosis receiving services from non-behavioral health providers during state fiscal year 2017

Medicaid SDA Active

providers

Adult without a

disability

Adult with a

disability


Child with a

disability

Bexar SDA 544 1,081 5,156 4,208 3,207

Dallas SDA 843 671 6,530 2,473 1,266

El Paso SDA 251 244 1,263 828 1,036

Harris SDA 1,322 2,150 9,779 6,155 6,412

Hidalgo SDA 866 848 3,558 2,091 5,259

Jefferson SDA 220 416 1,937 1,095 1,069

Lubbock SDA 203 278 1,544 999 499

MRSA Central 364 692 3,588 2,063 1,891

MRSA Northeast 559 793 4,868 1,905 2,008

MRSA West 589 677 4,320 2,072 1,592

Nueces SDA 286 403 1,868 1,324 1,442

Tarrant SDA 542 955 5,398 2,742 2,114

Travis SDA 390 629 3,596 2,405 1,236

43

Out-of-State 84 - - - -

Unknown 28 2 100 35 177

Totals 7,028 9,814 53,096 30,275 29,100

Baseline from SFY 2016 7,921 9,515 50,675 28,098 58,310

44

45

BH3 - MENTAL HEALTH DELIVERED BY PSYCHIATRISTS. Enrolled and active psychiatrists and clients receiving services from a psychiatrist for a mental health disorder during state fiscal year 2017

Medicaid SDA Enrolled Psychiatrists

Active Psychiatrists


Adult with a

disability


Child with a

disability

Bexar SDA 313 31 9 294 423 472

Dallas SDA 352 22 7 381 180 24

El Paso SDA 117 4 1 83 6 22

Harris SDA 584 24 28 587 230 225

Hidalgo SDA 59 8 26 333 343 1,575

Jefferson SDA 65 5 56 94 136 468

Lubbock SDA 51 8 17 327 53 22

MRSA Central 212 8 4 138 50 46

MRSA Northeast 175 9 1 319 208 214

MRSA West 160 5 5 166 85 58

Nueces SDA 38 3 23 162 45 68

Tarrant SDA 197 19 15 506 404 362

Travis SDA 293 9 1 156 77 18

46


Unknown - - - 6 3 25

Texas Total 1,828 159 193 3,525 2,237 3,594

Baseline from SFY 2016 2,545 247 268 5,808 3,107 8,897

47

48

BH4 - SERVICES DELIVERED BY ALL PROVIDERS. Number of active providers providing services and number of clients with specified diagnosis receiving services by SDA during state fiscal year 2017

Medicaid SDA Active Adult

without a disability

Adult with a

disability


Child with a

disability

Bexar SDA 838 1,120 5,308 5,241 3,990

Dallas SDA 991 639 6,563 2,867 1,330

El Paso SDA 334 292 1,362 1,082 1,286

Harris SDA 1,671 2,133 9,968 7,201 7,020

Hidalgo SDA 1,040 1,002 3,752 3,035 7,539

Jefferson SDA 278 476 2,012 1,404 1,563

Lubbock SDA 345 307 1,736 1,357 654

MRSA Central 519 772 3,690 2,471 2,185

MRSA Northeast 733 853 5,069 2,633 2,652

MRSA West 761 768 4,626 2,694 1,941

Nueces SDA 359 471 2,034 1,528 1,718

Tarrant SDA 757 981 5,597 3,487 2,634

Travis SDA 593 672 3,816 2,990 1,473

49


Unknown 26 3 113 37 222

Texas Total 9,258 10,450 55,154 37,810 36,062

Baseline from SFY 2016 10,381 10,216 53,548 35,740 65,027

50

51

BH5 - SUBSTANCE USE DISORDER SERVICES BY ALL PROVIDERS. Number of active providers providing substance use disorder treatment and number of clients with specified diagnosis receiving these services by SDA during state fiscal year 2017

Medicaid SDA Active Adult

without a disability

Adult with a

disability


Child with a Disability

Bexar SDA 142 274 583 103 34

Dallas SDA 232 132 751 74 20

El Paso SDA 66 72 140 44 20

Harris SDA 317 316 982 140 70

Hidalgo SDA 160 139 341 152 119

Jefferson SDA 51 56 181 47 18

Lubbock SDA 74 60 198 26 5

MRSA Central 115 109 389 25 15

MRSA Northeast 173 129 535 35 25

MRSA West 167 91 411 46 8

Nueces SDA 79 119 169 76 26

Tarrant SDA 132 188 601 71 28

Travis SDA 141 114 398 86 19

52


Unknown 7 1 10 3 3

Texas Total 1,871 1,800 5,672 926 409

Baseline from SFY 2016 1,894 1,731 5,385 1,009

1,364

53

54

BH6 - SUBSTANCE USE DISORDER SERVICES BY CHEMICAL DEPENDENCY TREATMENT FACILITIES.13

Number of enrolled and active chemical dependency treatment providers providing services for treatment of a substance use disorder and number of clients receiving these services during state fiscal year 2017

Medicaid SDA Enrolled

CDTFs Active CDTFs


Adult with a

disability


Child with a

disability

Bexar SDA 20 10 165 54 15 5

Dallas SDA 27 4 21 10 21 -

El Paso SDA 11 5 46 13 22 12

Harris SDA 50 18 57 25 22 13

Hidalgo SDA 23 16 53 10 59 62

Jefferson SDA 10 4 13 6 33 6

Lubbock SDA 9 2 5 8 4 1

MRSA Central 10 8 46 15 7 6

MRSA Northeast 16 10 50 16 8 9

MRSA West 21 3 8 9 15 5

Nueces SDA 12 7 63 17 31 9

13 A Chemical Dependency Treatment Facility is licensed by the Health and Human Services Commission to offer treatment for persons with chemical dependency.

55

Tarrant SDA 14 5 73 30 30 10

Travis SDA 15 6 37 27 29 3

Unknown - - 1 - 1 -

Texas Total 233 96 638 239 295 141

Baseline from SFY 2016 202 86 537 174 277 363

56

33

57

Pre- and Post-Natal Obstetric Services The analysis of pre- and post-natal obstetric services must address related services, including labor and delivery. For this analysis, the term "obstetric health services" refers to any services received to recipients with:

• primary diagnosis related to pregnancy, childbirth, or the postnatal

period; • primary diagnosis for certain conditions originating in the perinatal

period; or • diagnosis-related group codes for child birth-related procedures.

Obstetrics health providers include obstetricians, nurse midwives, maternity service clinics, or birthing centers.

The tables below reflect pre- and post-natal obstetric services received by fee-for-service recipients from Medicaid-enrolled providers during state fiscal year 2017.

58

OB1 - OBSTETRICS HEALTH PROVIDERS. Number of enrolled and active obstetrics providers, obstetrics providers who saw new clients, and number of clients receiving obstetrics services from an obstetric service provider during state fiscal year 2017

Medicaid SDA Enrolled Active Provider with New

Clients

Adult without a Disability

Adult with a

Disability

Child without

a Disability

Child with a

Disability

Bexar SDA 328 24 7 814 5 191 15

Dallas SDA 730 27 11 381 2 84 6

El Paso SDA 146 7 5 133 1 27 1

Harris SDA 1,169 59 24 1,206 15 287 29

Hidalgo SDA 237 18 7 658 3 171 12

Jefferson SDA 60 10 6 251 2 72 6

Lubbock SDA 117 - - 2 - 2 -

MRSA Central 177 4 2 121 1 34 2

MRSA Northeast 231 13 5 270 5 78 5

MRSA West 211 17 3 234 2 58 5

Nueces SDA 95 2 - 94 2 29 2

Tarrant SDA 64 27 12 340 6 67 3

59

Travis SDA 346 7 1 38 - 15 -

Out-of-State - - - - - - -

Unknown - - - 2 - - 1

Texas Total 3,850 215 83 4,540 44 1,113 86

Baseline from SFY 2016 4,566 511 200 9,651 149 2,432 496

60

36

61

Home Health Services The analysis of home health services must address services meeting criteria at 42 CFR §440.70. Services meeting that criteria include services delivered at the beneficiary's place of residence, or in any setting in which normal life activities take place (with limited exceptions),14 and: • Home health skilled nursing • Home health aide services • Medical supplies, equipment, and appliances • Physical, occupational, and speech language therapy services delivered

by a home health agency15

In accordance with the regulatory description of home health services as services meeting criteria at 42 CFR §440.70, the below charts include data on home health services and do not include data on services, such as private duty nursing or personal care services, authorized in other sections of federal law and regulation that may be delivered in the home.

14 Per 42 CFR §440.70(c), home health services do not include services delivered in a hospital, nursing facility, or certain intermediate care facilities for people with intellectual disabilities or any facility for which payment could be made under Medicaid for inpatient services that include room and board. 15 Physical and occupational therapy are optional home health services Texas has opted to cover. Speech language therapy is not a home health benefit in Texas. However, speech language therapy in the home is a benefit for children, and speech language therapy services may be provided by home health agencies; thus, speech language therapy services are included in this section of the analysis.

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HH1 - HHA SKILLED NURSING. Enrolled and active providers of skilled nursing and number of clients receiving these services during state fiscal year 201716


HHAs Active HHAs


Adult with a

Disability

Child without a Disability

Child with a

Disability

Bexar SDA 169 86 19 1,090 29 21

Dallas SDA 444 227 13 1,802 5 12

El Paso SDA 73 48 12 596 3 11

Harris SDA 645 287 26 2,126 8 15

Hidalgo SDA 330 154 25 1,963 17 21

Jefferson SDA 58 39 5 500 - 3

Lubbock SDA 38 27 9 494 4 8

MRSA Central 58 32 7 754 1 3

MRSA Northeast 117 75 7 1,267 3 2

MRSA West 90 63 5 1,007 2 6

Nueces SDA 65 50 9 784 2 10

Tarrant SDA 167 83 7 800 12 26 16 Data do not include private duty nursing services available to clients 20 and younger. Private duty nursing services are not among the home health services meeting criteria at 42 CFR §440.70; private duty nursing services are authorized in other sections of federal law and regulation.

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Travis SDA 70 33 5 653 - 3

Unknown - 6 - 11 - 4

Texas Total 2,282 1,191 149 13,788 86 145

Baseline from SFY 2016 2,248 1,345 218 16,505 140 452

64

65

HH2 - HOME HEALTH AGENCY AIDES. Enrolled and active home health agencies providing aides and number of clients receiving home health agency aide services during state fiscal year 201717


HHAs Active HHAs


Adult with a

Disability


Child with a

Disability

Bexar SDA 169 34 - 68 - -

Dallas SDA 444 101 1 215 - -

El Paso SDA 73 31 - 70 - -

Harris SDA 645 83 1 161 - -

Hidalgo SDA 330 24 - 32 - -

Jefferson SDA 58 21 - 46 - -

Lubbock SDA 38 20 - 56 - -

MRSA Central 58 17 - 50 - -

MRSA Northeast 117 40 - 97 - -

MRSA West 90 40 - 136 - -

Nueces SDA 65 21 - 38 - -

17 Data do not include attendant care services delivered to children and young adults, known as personal care services. These services are not among the home health services meeting criteria at 42 CFR §440.70; personal care services are authorized in other sections of federal law and regulation.

66

Tarrant SDA 167 39 - 137 - -

Travis SDA 70 15 - 43 - -

Unknown - 1 - 1 - -

Texas Total 2,282 476 2 1,146 - - Baseline from SFY 2016 2,248 586 6 1,653 1 1

67

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HH 3 - DURABLE MEDICAL EQUIPMENT. Enrolled and active durable medical equipment providers and number of clients receiving durable medical equipment from a durable medical equipment service provider during state fiscal year 2017

Medicaid SDA

Enrolled DME

Providers

Active DME

Providers


Adult with a

Disability


Child with a

Disability

Bexar SDA 258 143 122 2,827 1,145 2,261

Dallas SDA 432 267 145 5,004 1,672 3,348

El Paso SDA 112 76 57 1,537 444 846

Harris SDA 628 395 184 5,944 2,469 4,786

Hidalgo SDA 285 225 321 5,545 1,891 4,107

Jefferson SDA 106 57 46 1,253 345 467

Lubbock SDA 113 71 43 1,488 307 544

MRSA Central 150 95 56 2,636 420 970

MRSA Northeast 233 155 104 4,115 637 1,477

MRSA West 178 127 98 3,931 588 1,132

Nueces SDA 95 71 45 1,330 344 702

Tarrant SDA 302 162 91 3,086 1,192 2,287

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Travis SDA 209 114 71 1,943 556 1,123


Unknown - 5 1 78 19 173 Texas Total 2,941 2,002 1,383 40,540 12,005 24,144


3,159 2,043 1,450 42,593 13,519 34,309

70

71

HH4 - PHYSICAL, OCCUPATIONAL, OR SPEECH LANGUAGE THERAPY BY HOME HEALTH AGENCY.

Enrolled and active home health agencies and number of clients receiving physical, occupational or speech language therapy from a home health agency during state fiscal year 2017


HHAs Active HHAs


Adult with a

Disability


Child with a

Disability

Bexar SDA 169 107 8 761 800 2,176

Dallas SDA 444 200 2 1,036 577 2,582

El Paso SDA 73 52 9 380 58 501

Harris SDA 645 284 9 1,454 631 2,786

Hidalgo SDA 330 170 9 918 215 2,176

Jefferson SDA 58 35 - 293 50 163

Lubbock SDA 38 29 5 438 172 212

MRSA Central 58 39 7 617 127 394

MRSA Northeast 117 73 5 972 195 761

MRSA West 90 59 6 716 82 260

Nueces SDA 65 48 4 396 52 317

Tarrant SDA 167 85 5 627 394 1,318

72

Travis SDA 70 40 1 564 281 890

Unknown - 4 - 7 6 97

Texas Total 2,282 1,203 70 9,146 3,628 14,618

Baseline from SFY 2016 2,248 1,359 83 11,056 3,918 19,364

73

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Process for Rate Restructuring and Reductions Texas Medicaid will continue to comply with requirements at 42 CFR §447.203(b)(6) and 42 CFR §447.204 to monitor the impact of state plan amendments reducing or restructuring provider payment rates when the changes could result in diminished access.18 HHSC will monitor provider availability and access to care for at least three years after the effective date of proposed rate restructuring or reductions meeting the criteria for such monitoring under 42 CFR §447.203(b)(6). Monitoring will occur at least annually. The associated state plan submission will include the monitoring plan.

HHSC will develop specific monitoring plans as appropriate for any affected service. Key factors in such monitoring approaches will likely include monitoring: • recipient complaints, including analysis of reported versus

substantiated complaints; and • utilization patterns of recipients that affected providers serve,

including discrete provider types and patterns across different recipient groups.

Complaint monitoring includes complaints received by the Medicaid and CHIP Services, the TMHP Appeals, Complaints, and Resolution division, and from the HHS Office of the Ombudsman.

If an access to care issue is identified, HHSC will comply with requirements at 42 CFR §447.203(b)(8) to submit a corrective action plan within 90 days of discovery, with action steps and timelines to remediate the access deficiency within 12 months.

18 During a technical assistance call between CMS and HHSC on July 7, 2016, CMS indicated that when rate changes are tied to a methodology approved in the Texas Medicaid state plan, the monitoring requirements at 42 CFR 447.203(b)(6) and 42 CFR 447.204 do not apply

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2016 Physical, Occupational, and Speech Language Therapy Rate Reduction

On December 15, 2016, Texas implemented rate adjustments to physical, occupational, and speech language therapy provided by comprehensive outpatient rehabilitation facilities, home health agencies, and independent therapists. HHSC has continued to monitor complaints and provider availability. There have been no recent complaints related to access to FFS therapy services. The number of Medicaid enrolled therapy providers was relatively stable until the deadline for the Affordable Care Act (ACA) reenrollment requirement in February 2017. In that month, the number of enrolled therapy providers decreased from 6,913 to 5,999, or 13 percent. The overall number of enrolled therapy providers has gradually and partially rebounded to 6,401 by March 2019. The trend in enrollment after the ACA deadline varies by therapy provider type. After a 21 percent decrease following the ACA reenrollment deadline, home health agency enrollment has remained relatively flat. In contrast, independent therapists have not only rebounded but have surpassed their pre-February 2017 numbers. The chart below shows the speech language, occupational, and physical therapy utilization rates per 1,000 members per month for fee-for-service recipients from September 2015 through August 2018 (SFYs 2016-2018). Multiple, consecutive changes which directly and indirectly relate to therapy care make it challenging to distinguish how each event may or may not have impacted the provision of therapy services. Some of the events are described below.

• Service utilization decreased in May 2016, after HHSC instituted policy

changes related to required documentation and prior authorization for therapies.

• A noteworthy decrease in therapy utilization among fee-for-service

recipients occurred in November 2016, due to the transition of around 170,000 children with disabilities from fee-for-service to a managed care program. These children are high utilizers of therapy services so the change in the fee-for-service population reduced overall utilization rates for that program. Since the therapy reimbursement rate changes occurred a month later (December 2016), it is difficult to parse any direct additional impact from that event.

• The deadline for provider reenrollment pursuant to the ACA occurred in

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February 2017, resulting in at least a temporary decline across all provider types in the Medicaid network.

• In September 2017, an additional approximately 50,000 children in

Adoption Assistance or Permanency Care Assistance Managed Care Expansion were transitioned from fee-for-service to managed care programs, which again changed the composition of the remaining fee-for-service program population.

77

78

Public Input on the Draft Report Notice of the opportunity to provide public comment on the draft Texas Medicaid Access Monitoring Review Plan was:

• posted on the Medicaid/CHIP Medical Policy webpage; and • emailed to the Medical Care Advisory Committee and to subscribers of

the HHS GovDelivery service (a subscription service that allows users to receive email notices on particular topics.) The GovDelivery notice was sent to subscribers who selected the topics: Medicaid Providers and Medicaid Medical Policy Review.

The notice included a link to the draft plan, the 30-day time period for providing public comment, and the email address for submitting comments

79

Conclusion The 2016 AMRP and 2017 AMRP Addendum provided baseline analysis for traditional fee-for-service access to care. This analysis uses the baselines provided in 2016 as compared to 2017 to trend fee-for-service data by managed care service delivery area (SDA). HHSC considers multiple data sources when analyzing access to care for fee -for-service Medicaid recipients. The number of fee-for-service recipients were compared with the number of providers by SDA and total numbers for the state. Complaint data were also analyzed for each provider category. Service rates were compared to Medicare rates. Complaints and provider availability were monitored, in particular, following the across the board therapy rate reduction which occurred in 2016. Regarding the number of providers, the number of active FFS providers has generally decreased as the recipient enrollment in managed care has increased. Texas Medicaid has a very high beneficiary enrollment in managed care with only a limited number of recipients receiving care through a fee-for-service delivery system. In 2014, 19.6 percent of the Texas Medicaid population was served in traditional fee-for-service Medicaid. In 2018, only 6.1 percent of the Medicaid population was served in traditional fee-for-service Medicaid, and at least 77 percent were transitioned to managed care within 45 days. The number and percent of Texas Medicaid recipients served in traditional fee-for-service Medicaid continues to shrink as Texas expands populations served in managed care. As the number of recipients enrolled in fee-for-service care decreased, so did the number of active fee-for service providers. For example, cardiologists active in fee-for-service decreased by 74% from FY 2016 to FY 2017; however, individuals in fee-for-service billing for cardiac care decreased by 72%. Active Ear, Nose and Throat providers decreased by 68% between 2016 and 2017; however, recipients utilizing fee-for-service ENT dropped by 61% for the same timeframe. Similar trends are seen across all provider categories except substance use disorder chemical dependency treatment facilities, dental PCPs, and home health providers which saw a slight increase in active providers and a decrease in recipients billing for services.

Additionally, the deadline for provider reenrollment pursuant to the Affordable Care Act (ACA)19 occurred in February 2017 during the reporting period. As a

19 The ACA is a federal law that required state Medicaid agencies to revalidate the enrollment of all providers in state Medicaid programs.

80

result, Texas experienced at least a temporary decline across all provider types. The number of enrolled providers was relatively stable until the deadline for the ACA reenrollment requirement in February 2017. All SDAs have enrolled fee-for-service providers in all categories. Active medical and dental primary care providers are available in all SDAs, but not all SDAs have certain specialty providers active or accepting new recipients. Some SDAs did not have active specialist for cardiovascular disease; ear, nose, and throat; orthopedic surgery; urology, ophthalmologist, or obstetric health. In those SDAs, recipients in need of the services would have to travel outside of their home service area; thus, potentially creating an access to care issue. Additionally, HHSC analyzed access to care complaint data. Fee-for-service complaint monitoring did not reveal any substantiated complaints related to provider access in SFY 2017 or SFY 2018. Inquires related to locating a provider were quickly resolved through coordination with HHSC and TMHP. Currently, HHSC is reviewing the current fee-for-service complaint process and identifying opportunities to streamline the process and data tracking. HHSC works with TMHP to identify provider types needing additional recruitment activities given a low number of providers in certain areas of the state. The following provider specialties --cardiovascular disease; ear, nose, and throat; orthopedic surgery; and urology are on the list for potential recruitment activities. HHSC works with TMHP to monitor progress in recruiting new providers in areas where there are shortages. Texas like many states is challenged with ensuring access to care for acute medical services for the general population. A 2017 State Physician Workforce Report20 ranks Texas 47th out of 50 states when comparing the number of active (licensed and working at least 20 hours per week) primary care physicians per 100,000 population. In 2017, there were 1,399 cardiovascular disease specialists and based on population, the number of people per physician was 19,916. There were 675 urologists in Texas which based on population size is 41,278 people per physician. There were 1,290 orthopedic surgeons and based on population size, 21,599 people per physician. Considering the challenges Texas faces in serving the needs of the general population, Medicaid fee-for-service access to care data does not indicate individuals receiving Medicaid are facing greater challenges.

20 American Medical Colleges 2017 Texas Physician Workforce Data Report (AMA Physician Masterfile December 31, 2016) https://www.aamc.org/download/484596/data/texasprofile.pdf

https://www.aamc.org/download/484596/data/texasprofile.pdf

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APPENDIX A: Complaints Contact Information 1. Texas Medicaid Call Transfer Line:

1-800-252-8263 (Press 5 for complaints or get help with programs)

2. HHSC Office of the Ombudsman Office Mailing address: HHSC Ombudsman Office Texas Health and Human Services Commission Office of the Ombudsman, MC H-700 P O Box 13247 Austin, TX 78711-3247

Phone: 1-877-787-8999 (toll-free)

Texas Relay: 7-1-1 or 1-800-735-2989 (toll-free) for the deaf or hearing impaired

Fax: 1-888-780-8099 (toll-free)

Website: https://hhs.texas.gov/about-hhs/your-rights/office-ombudsman

3. Texas Medicaid & Healthcare Partnership (TMHP) Email for provider and recipient complaints: [email protected]

Provider information:

• Texas Medicaid Provider Procedures Manual details processes: http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx

• Provider Contact Center: 1-800-925-9126 • Provider Mailing Address:

TMHP Complaints Resolution Department PO Box 204270 Austin, TX 78720-4270

4. HHSC Claims Administrator Operations Management Texas Medicaid providers may file complaints to HHSC Claims Administrator Operations Management if they do not believe they

https://hhs.texas.gov/about-hhs/your-rights/office-ombudsman

https://hhs.texas.gov/about-hhs/your-rights/office-ombudsman

mailto:[email protected]

http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_m

http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_m

http://www.tmhp.com/Pages/Medicaid/Medicaid_Publications_Provider_manual.aspx

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received the full due process from TMHP in the management of an appeal for a fee-for-service claim. Texas Medicaid providers must exhaust the appeals and grievance process with TMHP before filing a complaint with the HHSC Claims Administrator Operations Management. Mailing Address: Texas Health and Human Services Commission HHSC Claims Administrator Operations Management Mail Code 91X PO Box 204077 Austin, TX 78720-4077

5. Recipient information: Recipient hotline for Medicaid program benefits: 1-800-335-8957

Recipient line for questions on service requests: 1-800-414-3406

6. Rate Hearing Information Rate hearing packets: http://www.hhsc.state.tx.us/rad/rate- packets.shtml

Telephone: (512) 730-7401

Fax: (512) 730-7475

E-mail: [email protected]

Mailing Address: Texas Health and Human Services Commission Attention: Rate Analysis, Mail Code H-400 P.O. Box 149030 Austin, TX 78714-9030

Overnight mail, special delivery mail, or hand delivery: Texas Health and Human Services Commission Attention: Rate Analysis, Mail Code H-400 Brown-Heatly Building 4900 North Lamar Austin, TX 78751

http://www.hhsc.state.tx.us/rad/rate-packets.shtml



mailto:[email protected]

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APPENDIX B: Rate Comparison Tables Medicare rates as of August 2019 are compared to Texas Medicaid rates as of August 2019 for the 20 procedure codes appearing most frequently on a fee-for-service claim for the provider types included in the utilization analysis.

In Texas Medicaid, Medicare crossover claims (including coinsurance and deductibles) are carved out of all managed care models (except the Dual Demo) and are billed through the fee-for-service claims system. These Medicare codes are included in the tables below and might not have an associated rate in Texas Medicaid, such codes may not be a benefit. Please note some codes included on fee-for-service claims are informational only and do not have either a Medicare or Medicaid rate. Texas Medicaid does not currently have a resource for private payer rate data.

The five-character numerical codes included in the tables below are obtained from the Current Procedural Terminology (CPT®), copyright 2017 by the American Medical Association (AMA). The AMA developed CPT is a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures performed by physicians.

The responsibility for the content of this notice is with HHSC and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse, or interpretation of information contained in this notice. Fee schedules and related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained.

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PC1-Rate: Medical PCPs Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

` Procedure Code

Medicare Non-Facility

Medicare Facility

Texas Medicaid

Age Range

Texas Medicaid Non-

Facility

Texas Medicaid Facility

1 92507 $ 80.37 $ 80.37 0-20 $ 107.78 $ 107.78

2 97530 $ 40.72 $ 40.72 0-20 $ 33.75 $ 33.75

3 99213 $ 75.32 $ 51.90 0-20 $ 37.64 $ 37.64

4 97110 $ 31.35 $ 31.35 0-20 $ 33.75 $ 33.75

5 99214 $ 110.28 $ 80.01 0-20 $ 52.86 $ 52.86

6 99232 $ 73.88 $ 73.88 21-999 $ 45.48

7 95004 $ 4.32 $ 4.32 0-20 $ 5.33

8 99444 21-999 $ 57.20 $ 39.03

9 99214 $ 110.28 $ 80.01 21-999 $ 47.68 $ 47.68

10 99283 $ 63.07 $ 63.07 0-20 $ 61.56

11 99213 $ 75.32 $ 51.90 21-999 $ 33.95 $ 33.95

12 99233 $ 105.59 $ 105.59 21-999 $ 61.17

13 99285 $ 176.23 $ 176.23 21-999 $ 101.00

14 95165 $ 14.42 $ 3.24 0-20 $ 10.38

15 99284 $ 119.65 $ 119.65 0-20 $ 90.07

85

16 99284 $ 119.65 $ 119.65 21-999 $ 81.24

17 97112 $ 35.68 $ 35.68 0-20 $ 33.75 $ 33.75

18 92015 $ 20.18 $ 19.82 21-999 $ 15.50 $ 14.97

19 99203 $ 109.92 $ 77.48 0-20 $ 61.56 $ 61.56

20 99212 $ 45.77 $ 25.95 0-20 $ 25.04 $ 25.04

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PC2-Rate: Dental PCPs Texas Medicaid21 rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code Non-Facility Facility

1 D2392 $105.30 $105.30

2 D2391 $ 80.34 $ 80.34

3 D1351 $ 28.24 $ 28.24

4 D2930 $149.12 $149.12

5 D0150 $ 35.32 $ 35.32

6 D0120 $ 28.85 $ 28.85

7 D3220 $ 84.05 $ 84.05

8 D7140 $ 64.06 $ 64.06

9 D2330 $ 75.81 $ 75.81

10 D2331 $100.46 $100.46

11 D2934 $149.12 $149.12

12 D2150 $ 83.57 $ 83.57

13 D0140 $ 18.78 $ 18.78

14 D2140 $ 62.80 $ 62.80

15 D2933 $149.12 $149.12

16 D7111 $ 11.47 $ 11.47

21 Medicare does not establish rates for dental services.

87

17 D0240 $ 9.80 $ 9.80

18 D2940 $ 34.95 $ 34.95

19 D0350 $ 18.38 $ 18.38

20 D2390 $143.33 $143.33

88

PS1-Rate: Cardiovascular Disease Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid

Non-Facility


1 93010 $8.65 $8.65 21-999 $6.42 $6.42

2 93000 $17.30 $17.30 0-20 $13.47 $13.47

3 93306 $210.47 $210.47 21-999 $156.11

4 93000 $17.30 $17.30 21-999 $12.83 $12.83

5 93303 $239.66 $239.66 0-20 $186.65

6 93320 $54.42 $54.42 0-20 $42.38

7 93325 $25.59 $25.59 0-20 $19.93

8 99213 $75.32 $51.90 21-999 $33.27 $33.27

9 99232 $73.88 $73.88 21-999 $44.57

10 99214 $110.28 $80.01 21-999 $46.73 $46.73

11 99213 $75.32 $51.90 0-20 $36.89 $36.89

12 93010 $8.65 $8.65 0-20 $6.74 $6.74

13 99214 $110.28 $80.01 0-20 $51.80 $51.80

14 93306 $210.47 $210.47 0-20 $163.91

15 99204 $166.86 $131.18 21-999 $79.62 $79.62

89

16 99205 $209.75 $171.19 0-20 $109.74 $109.74

17 99215 $147.76 $112.80 0-20 $79.75 $79.75

18 76700 $123.61 $123.61 21-999 $93.29

19 93015 $72.44 $72.44 21-999 $53.73

20 99212 $45.77 $25.95 21-999 $22.14 $22.14

90

PS2-Rate: Ears, Nose and Throat (ENT) Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid Non-

Facility


1 95115 $9.37 $9.37 0-20 $7.02

2 95165 $14.42 $3.24 0-20 $10.38

3 99213 $75.32 $51.90 0-20 $36.89 $36.89

4 99213 $75.32 $51.90 21-999 $33.27 $33.27

5 69210 $48.29 $33.88 0-20 $39.01 $26.38

6 95117 $10.81 $10.81 0-20 $8.14

7 95004 $4.32 $4.32 0-20 $5.33

8 31575 $119.29 $68.83 21-999 $86.34 $51.86

9 92567 $15.50 $11.17 0-20 $11.51

10 92557 $38.92 $33.52 0-20 $30.03

11 31231 $205.06 $67.03 0-20 $166.16 $52.20

12 99212 $45.77 $25.95 0-20 $24.54 $24.54

13 99212 $45.77 $25.95 21-999 $22.14 $22.14

14 99214 $110.28 $80.01 0-20 $51.80 $51.80

15 69436 $162.54 $162.54 0-20 $128.55

16 92552 $32.07 $32.07 0-20 $25.26

17 92555 $24.51 $24.51 0-20 $19.09

91

18 10021 $100.19 $58.02 21-999 $92.75 $53.19

19 31536 $217.68 $217.68 21-999 $162.52

20 43191 $161.09 $161.09 21-999 $118.95 $118.95

92

PS3-Rate: Orthopedic Surgery Compares Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code Medicare Non-Facility

Medicare Facility

Texas Medicaid Age Range

Texas Medicaid Non-Facility


1 99203 $109.92 $77.48 0-20 $60.33 $60.33

2 99213 $75.32 $51.90 21-999 $33.27 $33.27

3 99213 $75.32 $51.90 0-20 $36.89 $36.89

4 99204 $166.86 $131.18 21-999 $79.62 $79.62

5 99214 $110.28 $80.01 0-20 $51.80 $51.80

6 73100 $32.44 $32.44 0-20 $24.98

7 99214 $110.28 $80.01 21-999 $46.73 $46.73

8 99203 $109.92 $77.48 21-999 $54.41 $54.41

9 99204 $166.86 $131.18 0-20 $88.27 $88.27

10 73030 $30.63 $30.63 21-999 $22.19

11 29075 $88.66 $63.79 0-20 $69.61 $50.24

12 73070 $27.39 $27.39 0-20 $21.61

13 73090 $28.47 $28.47 0-20 $20.49

14 73560 $32.80 $32.80 21-999 $23.52

15 29065 $98.03 $69.92 0-20 $76.90 $55.01

93

16 73610 $33.88 $33.88 0-20 $24.98

17 99283 $63.07 $63.07 0-20 $60.33

18 73120 $29.55 $29.55 0-20 $22.45

19 73560 $32.80 $32.80 0-20 $24.70

20 99284 $119.65 $119.65 0-20 $88.27

94

PS4-Rate: Urology Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid Non-

Facility


1 99221 $103.07 $103.07 21-999 $58.72

2 99213 $75.32 $51.90 21-999 $33.27 $33.27

3 52332 $487.61 $162.18 21-999 $377.17 $120.82

4 99232 $73.88 $73.88 21-999 $44.57

5 99203 $109.92 $77.48 0-20 $60.33 $60.33

6 99214 $110.28 $80.01 21-999 $46.73 $46.73

7 99231 $40.00 $40.00 21-999 $31.05

8 50590 $756.82 $592.84 21-999 $440.25

9 52310 $276.78 $157.85 21-999 $187.92 $117.35

10 99203 $109.92 $77.48 21-999 $54.41 $54.41

11 99204 $166.86 $131.18 21-999 $79.62 $79.62

12 52000 $194.25 $84.33 21-999 $126.44 $63.62

13 99223 $205.42 $205.42 21-999 $117.74

14 52281 $307.41 $158.57 21-999 $210.10 $117.88

15 52352 $369.76 $369.76 21-999 $275.32

95

16 76775 $59.46 $59.46 21-999 $44.11

17 99212 $45.77 $25.95 0-20 $24.54 $24.54

18 99214 $110.28 $80.01 0-20 $51.80 $51.80

19 99244 $185.96 $156.41 21-999 $112.50 $112.50

20 99253 $117.13 $117.13 21-999 $82.08 $82.08

96

PS5-Rate: Ophthalmology Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid Non-

Facility


1 92015 $20.18 $19.82 0-20 $16.28 $15.72

2 92014 $128.66 $81.09 0-20 $104.13 $66.24

3 92015 $20.18 $19.82 21-999 $15.50 $14.97

4 92012 $89.74 $53.70 0-20 $72.13 $43.78

5 92060 $65.59 $65.59 0-20 $55.01 $55.01

6 92004 $153.53 $101.27 0-20 $124.90 $82.52

7 S0621 0-20 $72.13 $43.78

8 S0620 0-20 $68.48 $39.86

9 92004 $153.53 $101.27 21-999 $118.95 $78.59

10 92014 $128.66 $81.09 21-999 $99.17 $63.08

11 S0621 21-999 $68.70 $41.70

12 S0620 21-999 $65.22 $37.96

13 92012 $89.74 $53.70 21-999 $68.70 $41.70

14 67311 $611.22 $611.22 0-20 $666.02 $666.02

15 92225 $28.11 $21.98 0-20 $22.73 $17.96

97

16 92226 $25.95 $19.46 0-20 $20.49 $15.72

17 99213 $75.32 $51.90 0-20 $36.89 $36.89

18 92083 $65.23 $65.23 21-999 $52.39 $52.39

19 92133 $37.84 $37.84 21-999 $35.55 $35.55

20 92285 $21.98 $21.98 0-20 $17.68 $17.68

98

BH1-Rate: Behavioral health services by behavioral health providers Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Tx Medicaid Age Range

Modifier

Tx Medicaid Non-Facility

Tx Medicaid Facility

1 90837 $136.95 $127.22 0-20 $106.66 $100.78

2 90837 $136.95 $127.22 21-999 $101.58 $95.93

3 90834 $91.18 $84.69 0-20 $71.01 $68.49

4 90834 $91.18 $84.69 21-999 $67.63 $65.08

5 90837 $136.95 $127.22 0-20 $106.66 $100.78

6 90847 $114.60 $106.68 0-20 $89.25 $83.08

7 90791 $140.19 $127.58 0-20 $119.82 $119.82

8 90853 $27.39 $25.23 0-20 $24.70 $24.70

9 90834 $91.18 $84.69 0-20 $71.01 $68.49

10 90832 $68.47 $63.43 21-999 $50.79 $44.66

11 90847 $114.60 $106.68 0-20 $89.25 $83.08

12 90791 $140.19 $127.58 21-999 $113.91 $113.91

13 90791 $140.19 $127.58 0-20 $119.82 $119.82

14 90837 $136.95 $127.22 0-20 U1 $106.66 $100.78

15 90853 $27.39 $25.23 0-20 H9 $24.70 $24.70

99

16 90853 $27.39 $25.23 21-999 $23.52 $23.52

17 90837 $136.95 $127.22 0-20 59 $106.66 $100.78

18 90847 $114.60 $106.68 21-999 $85.00 $79.12

19 90834 $91.18 $84.69 0-20 U8 $71.01 $68.49

20 90837 $136.95 $127.22 0-20 AH $106.66 $100.78

100

BH2-Rate: Behavioral health services by non-behavioral health providers Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims with a behavioral health diagnosis.

Procedure Code


Medicare Facility

Tx Medicaid Age Range Modifier Tx Medicaid

Non-Facility Tx Medicaid

Facility

1 90837 $136.95 $127.22 0-20 $106.66 $100.78

2 90837 $136.95 $127.22 21-999 $101.58 $95.93

3 90834 $91.18 $84.69 0-20 $71.01 $68.49

4 90834 $91.18 $84.69 21-999 $67.63 $65.08

5 90847 $114.60 $106.68 0-20 $89.25 $83.08

6 90791 $140.19 $127.58 0-20 $119.82 $119.82

7 90853 $27.39 $25.23 0-20 $24.70 $24.70

8 90832 $68.47 $63.43 21-999 $50.79 $44.66

9 90832 $68.47 $63.43 0-20 $53.33 $49.39

10 90791 $140.19 $127.58 21-999 $113.91 $113.91

11 90837 $136.95 $127.22 0-20 U1 $106.66 $100.78

12 90853 $27.39 $25.23 0-20 H9 $24.70 $24.70

13 90853 $27.39 $25.23 21-999 $23.52 $23.52

14 90837 $136.95 $127.22 0-20 59 $106.66 $100.78

15 90847 $114.60 $106.68 21-999 $85.00 $79.12

101

16 90834 $91.18 $84.69 0-20 U8 $71.01 $68.49

17 90837 $136.95 $127.22 0-20 AH $106.66 $100.78

18 90834 $91.18 $84.69 0-20 U1 $71.01 $68.49

19 90837 $136.95 $127.22 0-20 U8 $106.66 $100.78

20 90837 $136.95 $127.22 0-20 AJ $106.66 $100.78

102

BH3-Rate: Mental health services by a psychiatrist Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid

Non-Facility


1 99213 $75.32 $51.90 0-20 $37.64 $37.64

2 99214 $110.28 $80.01 0-20 $52.86 $52.86

3 90792 $157.49 $144.52 0-20 $122.65 $119.82

4 90833 $71.00 $66.31 0-20 $55.29 $51.64

5 99215 $147.76 $112.80 0-20 $81.38 $81.38

6 99213 $75.32 $51.90 21-999 $33.95 $33.95

7 99231 $40.00 $40.00 21-999 $31.68

8 99214 $110.28 $80.01 21-999 $47.68 $47.68

9 99232 $73.88 $73.88 21-999 $45.48

10 90792 $157.49 $144.52 21-999 $116.81 $113.91

11 99233 $105.59 $105.59 21-999 $61.17

12 90791 $140.19 $127.58 0-20 $119.82 $119.82

13 99308 $69.92 $69.92 21-999 $37.02

14 90837 $136.95 $127.22 0-20 $106.66 $100.78

15 90833 $71.00 $66.31 21-999 $52.66 $49.18

103

16 90836 $89.74 $83.97 0-20 $69.89 $65.40

17 99238 $74.24 $74.24 21-999 $54.58

18 99223 $205.42 $205.42 21-999 $120.14

19 99215 $147.76 $112.80 21-999 $73.40 $73.40

20 90838 $118.57 $111.00 0-20 $92.34 $86.45

104

BH4-Rate: Mental health services by all providers Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims with a mental health related diagnosis.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid Non-

Facility


1 99213 $75.32 $51.90 0-20 $37.64 $37.64

2 99214 $110.28 $80.01 0-20 $52.86 $52.86

3 90792 $157.49 $144.52 0-20 $122.65 $119.82

4 90833 $71.00 $66.31 0-20 $55.29 $51.64

5 99215 $147.76 $112.80 0-20 $81.38 $81.38

6 99213 $75.32 $51.90 21-999 $33.95 $33.95

7 99231 $40.00 $40.00 21-999 $31.68

8 99214 $110.28 $80.01 21-999 $47.68 $47.68

9 99232 $73.88 $73.88 21-999 $45.48

10 90792 $157.49 $144.52 21-999 $116.81 $113.91

11 99233 $105.59 $105.59 21-999 $61.17

12 90791 $140.19 $127.58 0-20 $119.82 $119.82

13 99308 $69.92 $69.92 21-999 $37.02

14 90837 $136.95 $127.22 0-20 $106.66 $100.78

15 90833 $71.00 $66.31 21-999 $52.66 $49.18

105

16 90836 $89.74 $83.97 0-20 $69.89 $65.40

17 99238 $74.24 $74.24 21-999 $54.58

18 99223 $205.42 $205.42 21-999 $120.14

19 99215 $147.76 $112.80 21-999 $73.40 $73.40

20 90838 $118.57 $111.00 0-20 $92.34 $86.45

106

BH5-Rate: Substance use disorder services by all providers Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code


Medicare Facility

Texas Medicaid Age

Range

Texas Medicaid Non-

Facility


1 H0020 --

21-999 $11.00 – w/ modifier

UA $2.00 –

w/ modifier U1

2 H0004 --

21-999 $14.50

3 H0005 --

21-999 $28.00

4 H0004 --

0-20 $14.50

5 H0005 --

0-20 $28.00

6 H2035 --

0-20 $133.75

7 H0047 --

21-999 $25.39

8 H2035 --

21-999 $59.78

9 H0001 --

21-999 $41.35

10 H2010 --

21-999 $20.00 – w/ modifier

UA $17.50 –

w/ modifier U1

107

11 S9445 --

21-999 $80.87

12 H0012 --

21-999 $49.92

13 H0031 --

21-999 $26.96

14 T1007 --

21-999 $40.44

15 H0001 --

0-20 $41.35

16 H0020 --

0-20 $11.00 – w/ modifier

UA $2.00 –

w/ modifier U1

17 H0016 --

21-999 $8.42

18 H0050 --

21-999 $26.93

19 H0012 --

0-20 $49.92

20 H0031 --

0-20 $26.96

108

BH6-Rate: Substance use disorder services by chemical dependency treatment facility Compares Medicare and Texas Medicaid rates for billed services.

Procedure Code


Medicare Facility

Texas Medicaid

Age Range

Texas Medicaid

Non-Facility


1

H0020 21-999

$11.00 – w/ modifier

UA $2.00 –

w/ modifier U1

2 H0004 21-999 $14.50

3 H0005 21-999 $28.00

4 H0004 0-20 $14.50

5 H0005 0-20 $28.00

6 H2035 0-20 $133.75

7 H0047 21-999 $25.39

8 H2035 21-999 $59.78

9 H0001 21-999 $41.35

10

H2010 21-999

$20.00 – w/ modifier

UA $17.50 –

w/ modifier U1

11 S9445 21-999 $80.87

12 H0012 21-999 $49.92

109

13 H0031 21-999 $26.96

14 T1007 21-999 $40.44

15 H0001 0-20 $41.35

16

H0020 0-20

$11.00 – w/ modifier UA

$2.00 – w/ modifier U1

17 H0016 21-999 $8.42

18 H0050 21-999 $26.93

19 H0012 0-20 $49.92

20 H0031 0-20 $26.96

110

OB1-Rate: Obstetrics services by an obstetrics provider Compares 2019 Medicare and Texas Medicaid rates for the 20 procedure codes appearing most frequently on fee-for-service claims.

Procedure Code Medicare Rate Non-Facility

Medicare Rate Facility

Texas Medicaid Rate

Age Range

Texas Medicaid Rate

Non-Facility

Texas Medicaid Rate

Facility 1 99213 $75.32 $51.90 21-999 $33.27 $33.27

2 99214 $110.28 $80.01 21-999 $46.73 $46.73

3 99204 $166.86 $131.18 21-999 $79.62 $79.62

4 99213 $75.32 $51.90 0-20 $36.89 $36.89

5 99203 $109.92 $77.48 21-999 $54.41 $54.41

6 76830 $123.97 $123.97 21-999 $93.02

7 99214 $110.28 $80.01 0-20 $51.80 $51.80

8 99205 $209.75 $171.19 21-999 $98.98 $98.98

9 99204 $166.86 $131.18 0-20 $88.27 $88.27

10 99215 $147.76 $112.80 21-999 $71.93 $71.93

11 99212 $45.77 $25.95 21-999 $22.14 $22.14

12 99203 $109.92 $77.48 0-20 $60.33 $60.33

13 90472 $12.97 $12.97 0-20 $7.84

14 99232 $73.88 $73.88 21-999 $44.57

15 90471 $16.94 $16.94 0-20 $7.84

16 99211 $23.07 $9.37 21-999 $13.22 $13.22

17 36410 $17.66 $9.73 21-999 $12.83 $7.22

111

18 76830 $123.97 $123.97 0-20 $97.67

19 76856 $111.36 $111.36 21-999 $83.93

20 99212 $45.77 $25.95 0-20 $24.54 $24.54

112

HH-1 Rate: Services by home health agencies Compares 2019 Medicare22 and Texas Medicaid rates for the 20 most frequently billed services by home health agencies.

Procedure Code Medicare Non-Facility Medicare Facility Texas Medicaid

Age Range Texas Medicaid

Non-Facility Texas Medicaid

Facility 1 92507 $80.37 $80.37 0-20 $107.78 $107.78

2 97530 $40.72 $40.72 0-20 $33.75 $33.75

3 97110 $31.35 $31.35 0-20 $33.75 $33.75

4 97168 $63.79 $63.79 0-20 $104.57 $104.57

5 92526 $87.94 $87.94 0-20 $129.34 $129.34

6 97164 $58.74 $58.74 0-20 $104.57 $104.57

7 97112 $35.68 $35.68 0-20 $33.75 $33.75

8 S9152 0-20 $118.87 $118.87

9 97166 $92.98 $92.98 0-20 $116.19 $116.19

10 97116 $30.99 $30.99 0-20 $31.22 $31.22

11 92523 $199.66 $199.66 0-20 $169.81 $169.81

12 97162 $86.49 $86.49 0-20 $116.19 $116.19

13 97167 $92.98 $92.98 0-20 $116.19 $116.19

14 97163 $86.49 $86.49 0-20 $116.19 $116.19

15 97165 $92.98 $92.98 0-20 $116.19 $116.19

22 Home health agencies receive a predetermined amount for Medicare home health services and do not receive a fee-for-service payment. The rate comparison presented reflects the Texas Medicaid fee-for-service rate and the Medicare physician fee schedule because the rate

113

16 97161 $86.49 $86.49 0-20 $116.19 $116.19

17 97110 $31.35 $31.35 21-999 $33.75 $33.75

18 92610 $88.30 $74.24 0-20 $205.12 $205.12

19 97535 $34.96 $34.96 0-20 $33.75 $33.75

20 97140 $28.47 $28.47 0-20 $31.80 $31.80

114

HH3-Rate: Durable medical equipment services Compares 2019 Medicare and Texas Medicaid rates for the 20 most frequently billed services.

Procedure Code Medicare Rural Medicare Non-rural

Texas Medicaid Age Range

Texas Medicaid New Purchase

(J)

Texas Medicaid Rent (L)

1 E0431 0-20 NF

2 E0570 157.95 0-20 $129.63

3 K0108 NF 0-20 $0.00

4 E0465 $1,074.31 0-20 $0.00 $1,059.64

5 E1390 $121.46 $68.78 0-20 $0.00 $148.76

6 E0776 $136.96 $14.00 0-20 $96.85 $9.69

7 E0445 NF NF 0-20 $2,036.88 $203.69

8 E1028 NF NF 0-20 $165.23

9 E0482 $484.00 0-20 $0.00 $314.60

10 E0240 NF 21-999

$1,434.28 – w/ mod

TF $1,935.82 –

w/ mod TG

$86.42 – w/no mod

11 E0971 $40.29 $27.33 0-20 $38.51

12 E0562 $220.52 $22.04 0-20 $220.52 $22.05

13 E0973 $75.45 $48.59 0-20 $68.33

14 B9002 NF 0-20 $1,225.78 $122.58

115

15 E0601 $936.39 $93.64 0-20 $811.38 $81.14

16 E0466 $1,074.31 0-20 $0.00 $1,059.64

17 E1399 NF NF 0-20 $0.00 $0.00

18 E0978 $32.95 $21.64 0-20 $35.40

19 E0960 $82.21 $69.66 0-20 $88.72

20 E0955 NF NF 0-20 $182.29

Documents

Opportunity for Public Comment on the Medicaid Fee-For-Service Access … · 2020-02-12 · Opportunity for Public Comment on the Medicaid Fee-For-Service Access Monitoring Review