Hearing. The Texas Health and Human Services Commission (HHSC) conducted a public hearing to receive public comments on proposed updates to:
- Medicaid payment rates for proposed Medicaid payment SHARS reimbursement methodology, 10-1-2025-adj-medicaid-reimbursement-rates.pdf
- Non-Medicaid payment rates to Kidney Health Care Program – Hospital, and Non-Hospital, and 9-1-2025-non-med-kidney-health-care.pdf
- proposed updates to Medical Policy Review for Physician Administered Drugs.
9-1-2025-fee-review-physician-administered-drug.pdf
Proposal. The rate actions for the following services are proposed to be effective September 1, 2025 (the proposed rule packet specifies that the effective date is October 1 for the SHARS item) :
Non-Medicaid Review
(1) Kidney Health Care Program – Non-Hospital Rates
(2) Kidney Health Care Program – Hospital Rates
Medical Policy Review
(1) Medical Policy Review – Physician Administered Drugs
SHARS Rate Methodology
- Update procedure codes for auditory rehabilitation associated with prelingual and postlingual hearing loss
- expand SHARS coverage to include pure tone audiometry, speech audiometry, tympanometry, acoustic reflect testing, and conditioning play audiometry, all existing Texas Medicaid benefits
Methodology and Justification. The proposed payment rates were calculated in accordance with Title 1 of the Texas Administrative Code:
Section 355.8052 – Inpatient Hospital Reimbursement;
Section 355.8061 – Outpatient Hospital Reimbursement;
Section 355.8085 – Reimbursement Methodology for Physicians and Other Practitioners;
Section 355.8660 – Renal Dialysis Reimbursement; and
Section 355.8443 – Reimbursement Methodology for School Health and Related Services (SHARS).
SHARS.
Background HHSC is responsible for determining reimbursement for the Texas SHARS program. HHSC calculates proposed rates using established methodologies that conform to all applicable state statutes, rules, and other requirements. HHSC must ensure compliance with all regulations as outlined in the Centers for Medicare and Medicaid Services (CMS), the Texas Medicaid Provider Procedures Manual (TMPPM), and the Texas Administrative Code (TAC).
Methodology The proposed payment rates were calculated in accordance with 1 TAC Section 355.8443, Reimbursement Methodology for School and Related Services (SHARS).
Proposed Rate Adjustments
- Remove procedure codes 92507 and 92508 from the list of reimbursable audiology services under SHARS while continuing to allow them to be reimbursed under the SHARS speech and language services benefit.
- Replace codes 92507 and 92508 on the list of reimbursable audiology services under SHARS with codes 92630 and 92633, indicated for prelingual and post-lingual hearing loss, respectively.
- Expand SHARS coverage to include procedure codes 92552, 92555, 92567, 92568, and 92582, which are existing benefits of Texas Medicaid.
Kidney Health Care
Background. The Sunset Advisory Commission (SAC) recommended that rate-setting functions for the various HHSC-administered non-Medicaid programs, including Kidney Health Care, be consolidated and that rates for the same services should be uniform across programs. HHSC reviewed the Kidney Health Care program rates to comply with this requirement. HHSC calculates proposed rates using established methodologies that conform to the Social Security Act and related federal regulations, the federally approved Texas Medicaid State Plan, all applicable state statutes and rules, and other requirements.
Methodology The Kidney Health Care program follows the Texas Administrative Code (TAC), Title 26, Part 1, Chapter 365, Kidney Health Care. This TAC specifies the requirements and policies for accessing and delivering the Kidney Health Care program, as well as payment guidelines. The specific administrative rules that govern the establishment of the fees in this proposal include the following TAC rules:
- 1 TAC Section 355.8061 – Outpatient Hospital Reimbursement;
- 1 TAC Section 355.8085 – Reimbursement methodology for physicians and other practitioners; and
- 1 TAC Section 355.8660 – Renal Dialysis Reimbursement
Proposed Rate Adjustments Specific proposed payment rates are listed in the following: 9-1-2025-non-med-kidney-health-care.pdf
Physician Administered Drugs
Background. HHSC is responsible for the reimbursement determination functions for the Texas Medicaid Program. Proposed rates are calculated utilizing established methodologies that conform to the Social Security Act and related federal regulations, the federally approved Texas Medicaid State Plan, all applicable state statutes and rules, and other requirements. HHSC reviewed the Medical Policy Review – Physician Administered Drugs Medicaid reimbursement rates to follow these requirements.
Methodology The specific administrative rules that govern the establishment of the fees in this proposal include in the following Texas Administrative Code (TAC) rules: • §355.8085, which addresses the reimbursement methodology for physicians and other practitioners.
Proposed Rate Adjustments Specific proposed payment rate adjustments are listed in the following: 9-1-2025-fee-review-physician-administered-drug.pdf
For Rate detail, please follow the links above.
Public Comment. No public comment was offered.
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