The Texas Health and Human Services Commission (HHSC) Provider Finance Department (PFD) conducted a provider engagement meeting on September 25, 2025, to receive comments on Medicaid payment rates that may be addressed at the November 2025 rate hearings.
The topics for the Provider Engagement Meeting are listed below. Please note that the topics listed in this notice comprise a provisional list of topics to be presented at the November 2025 rate hearing. However, HHSC will determine the final list of topics to be presented at the November 2025 rate hearing.
Acute Care Services:
- Calendar Fee Review
- Allergy Tests
- Auditory System Surgery
- Blood Products
- Clinical Lab
- Durable Medical Equipment
- Ear, Nose, and Throat
- Female Genital System Surgery
- Hearing Aids
- Intravenous Treatment including Chemotherapy
- “K” Codes
- Male Genital System Surgery
- Musculoskeletal System Surgery
- Nuclear Medicine
- Orthotics and Prosthetics
- Outpatient Behavioral Health Services
- Physician Administered Drugs – Non-Oncology
- Physician Administered Drugs – Oncology
- Physician Administered Drugs – Vaccines & Toxoids
- Physician Administered Drugs – NDCX
- Pulmonary Services
- PT/OT/ST Independent Therapist, Home Health Agency (HHA), and CORF/ORF
- Radiation Oncology
- Radiopharmaceuticals
- Substance Use Disorder Services
- “Q” Codes
- Medical Policy Review
- Family Planning (Syphilis Testing)
- Non-Policy Q Codes – Skin Substitutes
- Title V – Vaccine Codes
- Healthcare Common Procedure Coding System (HCPCS)
- Quarterly HCPCS Updates:
- Q1 HCPCS Drugs
- Q1 HCPCS Non-Drugs
- Q2 HCPCS Drugs
- Q2 HCPCS Non-Drugs
- Non-Quarterly HCPCS Drugs
- Quarterly HCPCS Updates:
Public Comment Summary
Pediatric Therapy and Private Duty Nursing Challenges
- Numerous speakers detailed severe access issues due to stagnating or reduced Medicaid reimbursement rates for pediatric therapy, PDN, and home health services.
- Data was shared on dwindling provider numbers, rising waitlists (notably a 7,700 child therapy waitlist), and workforce shortages.
- Many cited that reimbursement rates have not kept up with inflation or the true costs of care/practice, with some rates reportedly 20-27% lower than a decade ago.
- Both therapy and PDN stakeholders emphasized cost savings and improved outcomes from early and home-based intervention but warned of unsustainable business models and increasing care deserts if rates are not increased.
- Private duty nursing for medically fragile children was highlighted as a cost containment measure that faces underfunding, leading to unnecessary hospitalizations and system strain.
Durable Medical Equipment (DME), Supplies, and Market Disruptions
- DME providers (including specialty and respiratory providers) reported more than a decade of stagnant rates despite sharp increases in costs for equipment, labor, fuel, shipping, and compliance.
- Comparisons showed Texas Medicaid rates for DME lag behind Medicare and market costs, with some reimbursements up to 40% less than Medicare.
- Significant recent disruptions—especially after the implementation of “Rider 32″—have seen more claims processed by MCOs, who often pay even lower rates than the state fee schedule, threatening provider sustainability.
- Providers reported difficulty recruiting and retaining staff due to uncompetitive wages, with many small/local businesses exiting the Medicaid market, particularly impacting rural and vulnerable populations.
- Patients and providers described a real risk of “access deserts” for essential medical equipment and supplies.
- Calls were made for at least a 20% rate increase and policy changes to ensure MCOs pay no less than the state Medicaid rate.
- Complaints about MCOs denying contracts to DME providers were raised
Enteral Nutrition and Specialty Formula Access
- Multiple testimonies described growing access barriers for medically fragile patients to essential enteral nutrition formulas due to rapidly rising costs (over 20% increases) and stagnant reimbursements.
- Broader market disruptions, including recalls and supply chain problems, were cited as driving up costs.
- Providers reported being forced to limit or discontinue products, risking negative health outcomes and higher healthcare costs due to preventable ER visits and hospitalizations.
- Requests included treating nutritional formula as an essential food, increasing rates, and reducing administrative burdens (e.g., Title 19 form).
- Additional forms bring administrative burden
Clinical Lab and Biomarker Rate Considerations
- Stakeholders in clinical laboratory and genetic/biomarker testing (e.g., for cancer and SB989) requested that HHSC align Medicaid reimbursement rates with Medicare fee schedules, especially for advanced or proprietary tests (PLA codes).
- The importance of precision diagnostics for vulnerable populations (e.g., pediatric cancer patients) was underlined, with emphasis on clinical utility and modest budget impact.
- Requests included specific attention to the use of correct and current CPT/HCPCS/PLA codes and rate establishment.
Patient and Provider Perspectives
- Patients and clinicians shared personal stories emphasizing the life-changing value of access to home-based therapy, PDN, and specialized equipment, such as powered wheelchairs and mobility aids.
- Providers described operational struggles, increased regulatory/administrative burdens, and the erosion of personal financial stability due to rate stagnation and increased requirements (e.g., electronic visit verification).
- There were strong appeals for rate adjustments tied to inflation and cost of living, support for workforce retention, and prioritization of vulnerable populations.
Testifying.
Jessica Boston, Texas Association for Home Care and Hospice. Home – TAHCH.org
Gabriel Dinn, Home – Kids Developmental Clinic
Jonathan Willman, Consolidated Home Health Home | Chomehealth
Katherine Ohrston, Maxim Healthcare | Elevating Care to Empower Lives
Benny Abward, Date Healthcare Services LLC – Developmental Disability Care – Flower Mound, Texas
Adam Cole, Cole Health Home – Cole Health: Leading Pediatric Therapy Excellence
Tim Howe, National Seating Mobility NSM — National Seating & Mobility
Michael McCormack, Winter Pediatric Therapy
Paige Trayhan, Sentido Health https://www.medicarelist.com/supplier/sentido-health-27905-commercial-park-tomball-tx/
Victoria Pederson, Texas Medical Equipment Provider Association TexMEP – Home
Mark Dowan, TexMEP
Benjamin Echard, Adaptive Biotechnologies Powering the Age of Immune Medicine – Adaptive Biotech
Kelly Seager, Coloplast Ostomy, Continence, Interventional Urology, Wound & Skin Care Products | Coloplast
Dave Richard, CareASSIST Sanofi CareASSIST
Carmen Gutierras Apple Homecare Medical Supply Inc – DME Supplier – Customized Equipment in Richardson, TX
Martha Garcia, Representing herself (Supporting National Seating and Mobility as a client)
Emelda Flores, Reliable DME Accredited Experts Meeting Your Medical Equipment Needs | Reliable Medical
Jose Emmanual Friday, Santa Fe Durable Medical Equipment, https://npino.com/medical-supplies/1619345535-santa-fe-durable-medical-equipment-corp/
Martha Myers, Representing herself as a therapist
Diana Gonzales, (inaudible) DME provider
David Chandler, American Association for Homecare Empowering HME Providers | AAHomecare – The Voice of Home Medical Equipment
Gene McWise, Myriad Genetics Advancing health insights through genetic testing | Myriad Genetics
Laura Freeman, Therapy 2000 Pediatric Home Health Care & Therapy Services In Texas
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