Section 306.327 - Medicaid Reimbursement(a) Billable and non-billable activities. (1) A Medicaid provider may only bill for medically necessary MH rehabilitative services that are provided face-to-face to: (A) a Medicaid-eligible individual;(B) the LAR of a Medicaid-eligible adult (on behalf of the adult); or(C) the LAR or primary caregiver of a Medicaid-eligible child or adolescent (on behalf of the child or adolescent).(2) The cost of the following activities are included in the Medicaid MH rehabilitative services reimbursement rate(s) and may not be directly billed by the Medicaid provider: (A) developing and revising the recovery plan and interventions that are appropriate to an individual's needs;(B) staffing and team meetings to discuss the provision of MH rehabilitative services to a specific individual;(C) monitoring and evaluating outcomes of interventions, including contacts with a person other than the individual;(D) documenting the provision of MH rehabilitative services;(E) a staff member traveling to and from a location to provide MH rehabilitative services;(F) all services provided within a day program for acute needs that are delivered by a staff member, including services delivered in response to a crisis or an episode of acute psychiatric symptoms; and(G) administering the uniform assessment to individuals who are receiving psychosocial rehabilitative services.(b) Non-reimbursable activities. (1) The department will not reimburse a Medicaid provider for any MH rehabilitative services provided to an individual who is: (A) a resident of an intermediate care facility for persons with an intellectual or developmental disability as described in 42 CFR § 440.150;(B) a resident in an IMD;(C) an inmate of a public institution as defined in 42 CFR § 435.1009;(D) a resident in a Medicaid-certified nursing facility unless the individual has been determined through a pre-admission screening and annual resident review assessment to be eligible for the specialized service of MH rehabilitative services;(E) a patient in a general medical hospital; or(F) not Medicaid-eligible.(2) With the exception of crisis intervention services and psychosocial rehabilitative services that are being provided to resolve a crisis situation, the department will not reimburse a Medicaid provider for any combination of MH rehabilitative services delivered in excess of eight hours per individual per day. In addition, the department will not reimburse a Medicaid provider for more than:(A) two hours per individual per day of medication training and support services;(B) four hours per individual per day of psychosocial rehabilitative services when the psychosocial rehabilitative services are being provided in non-crisis situations;(C) four hours per individual per day of skills training and development services; and(D) six hours per individual per day of day programs for acute needs.(3) The department will not reimburse a Medicaid provider for: (A) an MH rehabilitative service that is not included in the individual's recovery plan (except for crisis intervention services documented in accordance with § 306.311(b) of this title (relating to Service Authorization and Recovery Plan)) and psychosocial rehabilitative services provided in a crisis situation;(B) an MH rehabilitative service that is not authorized in accordance with § 306.311 of this title (except for crisis intervention services documented in accordance with § 306.311(b) of this title);(C) an MH rehabilitative service provided in excess of the amount authorized in accordance with § 306.311(a)(1) of this title;(D) an MH rehabilitative service provided outside of the duration authorized in accordance with § 306.311(b) of this title;(E) a psychosocial rehabilitative service provided to an individual receiving MH case management services in accordance with Chapter 412, Subchapter I of this title (relating to MH Case Management);(F) an MH rehabilitative service that is not documented in accordance with § 306.323 of this title (relating to Documentation Requirements);(G) an MH rehabilitative service provided to an individual who does not meet the eligibility criteria as described in § 306.309 of this title (relating to Eligibility);(H) an MH rehabilitative service provided to an individual who does not have a current uniform assessment (except for crisis intervention services documented in accordance with § 306.311(b) of this title);(I) an MH rehabilitative service provided to an individual who is not present, awake, and participating during such service;(J) an MH rehabilitative service that is provided via electronic media;(K) a crisis service provided to an individual who does not have a serious mental illness; and(L) any other activity or service identified as non-reimbursable in the department's MH Rehabilitative Services Billing Guidelines, referenced in § 306.333 of this title (relating to Guidelines).(c) Services provided same time and same day. (1) If a Medicaid provider provides more than one MH rehabilitative service to an individual at the same time and on the same day, the Medicaid provider may bill for only one of the services provided.(2) A Medicaid provider may bill for a MH rehabilitative service provided to a child or adolescent's LAR or primary caregiver at the same time and on the same day the child or adolescent is receiving another MH rehabilitative service only if the staff member providing the service to the LAR or primary caregiver is different from the staff member providing the service to the child or adolescent.(d) Services provided before a fair hearing. If the provision of a MH rehabilitative service is continued prior to a fair hearing decision being rendered, as required by 1 TAC § 357.7(relating to Agency and Designee Responsibilities), the Medicaid provider may bill for such service.26 Tex. Admin. Code § 306.327
Adopted to be effective January 22, 2014, 39 TexReg 299; Transferred from Title 25, § 416.14 by Texas Register, Volume 45, Number 08, February 21, 2020, TexReg 1239, eff. 3/15/2020