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Texas Board of Veterinary Medical Examiners Adopted Rules

Texas Board of Veterinary Medical Examiners Adopted Rules

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Texas Board of Veterinary Medical Examiners Adopted Rules
Texas Board of Veterinary Medical Examiners Adopted Rules

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10/16/2014

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TITLE
1.
ADMINISTRATION
PART
15.
TEXAS
HEALTH
AND
HUMAN
SERVICES
COMMISSION
CHAPTER 
352.
MEDICAID
AND
CHILDREN'S
HEALTH
INSURANCE
PROGRAM
PROVIDER 
ENROLLMENT
1
TAC
§352.17
The
Texas
Health
and
Human
Service
Commission
(HHSC)
adopts
amended
§352.17,
concerning
Out-of-State
Medicaid
Provider 
Eligibility,
with
changes
to
the
proposed
text
as
pub-lished
in
the
June
28,
2013,
issue
of 
the
Texas
Register 
(38
TexReg
4067).
The
text
of 
the
rule
will
be
republished.
Background
and
Justication
Senate
Bill
1401,
83rd
Texas
Legislature,
Regular 
Session,
2013,
amended
Subchapter 
B,
Chapter 
531,
Government
Code,
by
adding
§531.066
to
authorize
enrollment
of 
laboratories
as
in-state
providers
in
the
Texas
Medicaid
program,
regardless
of 
where
the
facility
is
located
and
under 
certain
conditions.
The
provisions
of 
this
amendment
contemplate
that
the
overwhelm-ing
majority
of 
the
requests
for 
reimbursement
from
out-of-state
laboratories
will
be
for 
the
analysis
of 
samples
taken
in-state
and
shipped
to
an
out-of-state
facility
for 
analysis.
The
amendment
does
not
contemplate
reimbursement
for 
laboratory
tests
taken
at
laboratories
located
outside
of 
Texas.
The
amendment
to
§352.17
as
adopted
will
implement
§531.066
of 
the
Government
Code.
Comments
The
30-day
comment
period
ended
July
28,
2013.
During
this
period,
HHSC
received
comments
regarding
the
amended
rule
from
Brown
McCarroll,
LLP,
Sequenom,
Inc.,
and
State
Repre-sentative
Eddie
Rodriguez.
 A
summary
of 
comments
related
to
the
proposed
amended
rule
and
HHSC's
responses
follow.
Comment:
Two
commenters
requested
that
proposed
language
in
§352.17(h)(2)
reading
"employs
at
least
1,000
people
working
at
a
site
located
within
the
state
of 
Texas"
be
revised
to
align
with
the
legislative
intent
of 
S.B.
1401.
The
revised
language
should
read
"employ
at
least
1,000
persons
at
places
of 
employment
located
in
this
state".
Response:
HHSC
agrees
with
the
recommendation
and
modi-ed
subsection
(h)(2)
to
reect
the
recommended
language.
Comment:
One
commenter 
recommended
that
the
rule
further 
dene
the
term
"afliate"
for 
the
purposes
of 
this
rule
to
include
a
relationship
between
an
out-of-state
and
an
in-state
laboratory
governed
by
a
written
agreement.
Response:
HHSC
acknowledges
the
comment,
but
no
changes
were
made
to
the
rule
as
the
proposed
denition
of 
"afliate"
is
inconsistent
with
the
legislative
intent.
Comment:
One
commenter 
recommended
that
HHSC
reduce
the
number 
of 
employees
located
in
places
of 
employment
in
the
state
required
by
the
rule
Response:
HHSC
acknowledges
the
comment,
but
no
changes
were
made
to
the
rule,
as
the
1,000-employee
limit
is
mandated
in
Government
Code
§531.066.
Statutory
 Authority
The
amendment
is
adopted
under 
Texas
Government
Code
§531.033,
which
provides
the
Executive
Commissioner 
of 
HHSC
with
broad
rulemaking
authority;
and
Texas
Human
Resources
Code
§32.021
and
Texas
Government
Code
§531.021(a),
which
provide
HHSC
with
the
authority
to
administer 
the
federal
medical
assistance
(Medicaid)
program
in
Texas.
 §352.17.
Out-of-State
 Medicaid 
 Provider 
 Eligibility.
(a)
This
section
applies
only
to
an
out-of-state
Medicaid
appli-cant
or 
re-enrolling
 provider.
An
applicant
or 
re-enrolling
 provider 
is
considered
out-of-state
if:
(1)
the
 physical
address
where
services
are
or 
will
 be
ren-dered
is
located
outside
the
Texas
state
 border 
and
within
the
United
States;
(2)
the
 physical
address
where
the
services
or 
 products
originate
or 
will
originate
is
located
outside
the
Texas
state
 border 
and
within
the
United
States
when
 providing
services,
 products,
equipment,
or 
supplies
to
a
Medicaid
recipient
in
the
state
of 
Texas;
or 
(3)
the
 physical
address
where
services
are
or 
will
 be
ren-dered
is
located
within
the
Texas
state
 border,
 but:
(A)
the
applicant
or 
re-enrolling
 provider 
maintains
all
 patient
records,
 billing
records,
or 
 both,
outside
the
Texas
state
 border;
and
(B)
the
applicant
or 
re-enrolling
 provider 
is
unable
to
 produce
the
originals
or 
exact
copies
of 
the
 patient
records
or 
 billing
records,
or 
 both,
from
the
location
within
the
Texas
state
 border 
where
services
are
rendered.
(b)
An
applicant
or 
re-enrolling
 provider 
that
is
considered
out-of-state
under 
subsection
(a)
of 
this
section
is
ineligible
to
 partici- pate
in
Medicaid
unless
HHSC
or 
its
designee
approves
the
applicant
or 
re-enrolling
 provider 
for 
enrollment
on
the
 basis
of 
a
determination
that
the
applicant
or 
re-enrolling
 provider 
has
 provided,
is
 providing,
or 
will
 provide
services
under 
one
or 
more
of 
the
following
criteria:
(1)
The
services
are
medically
necessary
emergency
ser-vices
 provided
to
a
recipient
who
is
located
outside
the
Texas
state
 bor-der,
in
which
case
the
enrollment
will
 be
time-limited
for 
an
appropriate
 period
as
determined
 by
HHSC
or 
its
designee,
not
to
exceed
one
year.
 ADOPTED
 RULES 
 August 
23,
2013
38
TexReg 
5427 
 
(2)
The
services
are
medically
necessary
services
 provided
to
a
recipient
who
is
located
outside
the
Texas
state
 border,
and
in
the
expert
opinion
of 
the
recipient's
attending
 physician
or 
other 
 provider,
the
recipient's
health
would
 be
or 
would
have
 been
endangered
if 
the
recipient
were
required
to
travel
to
Texas,
in
which
case
the
enrollment
will
 be
time-limited
for 
an
appropriate
 period
as
determined
 by
HHSC
or 
its
designee,
not
to
exceed
one
year.
(3)
The
services
are
medically
necessary
services
that
are
more
readily
available
to
a
recipient
in
the
state
where
the
recipient
is
located,
in
which
case
the
enrollment
will
 be
time-limited
for 
an
appropriate
 period
as
determined
 by
HHSC
or 
its
designee.
(4)
The
services
are
medically
necessary
to
a
recipient
who
is
eligible
on
the
 basis
of 
 participation
in
an
adoption
assistance
or 
foster 
care
 program
administered
 by
the
Texas
Department
of 
Family
and
Protective
Services
under 
Title
IV-E
of 
the
Social
Security
Act,
in
which
case
the
enrollment
may
 be
time-limited
for 
an
appropriate
 period
as
determined
 by
HHSC
or 
its
designee.
(5)
 prior 
authorized
 by
HHSC
or 
its
designee,
and
documented
medical
 justication
indicating
the
reasons
the
recipient
must
obtain
medical
care
outside
Texas
is
furnished
to
HHSC
or 
its
designee
 before
 provid-ing
the
services
and
 before
 payment,
in
which
case
the
enrollment
may
 be
time-limited
for 
an
appropriate
 period
as
determined
 by
HHSC
or 
its
designee.
(6)
The
services
are
medically
necessary
and
it
is
the
cus-tomary
or 
general
 practice
of 
recipients
in
a
 particular 
locality
within
Texas
to
obtain
services
from
the
out-of-state
 provider,
if 
the
 provider 
is
located
in
the
United
States
and
within
50
miles
driving
distance
from
the
Texas
state
 border,
or 
as
otherwise
demonstrated
on
a
case-by-case
 basis.
(A)
Enrollment
under 
this
 paragraph
may
 be
time-lim-ited
for 
an
appropriate
 period
as
determined
 by
HHSC
or 
its
designee.
(B)
An
out-of-state
 provider 
does
not
meet
the
criterion
in
this
 paragraph
merely
on
the
 basis
of 
having
established
 business
relationships
with
one
or 
more
 providers
that
 participate
in
Medicaid.
(7)
The
services
are
medically
necessary
services
to
one
or 
more
dually
eligible
recipients
(i.e.,
recipients
who
are
enrolled
in
 both
Medicare
and
Medicaid)
and
the
out-of-state
 provider 
may
 be
consid-ered
for 
reimbursement
of 
co-payments,
deductibles,
and
co-insurance,
in
which
case
the
enrollment
may
 be
time-limited
for 
an
appropriate
 pe-riod
as
determined
 by
HHSC
or 
its
designee,
and
the
enrollment
will
 be
restricted
to
receiving
reimbursement
only
for 
the
Medicaid-covered
 portion
of 
Medicare
crossover 
claims.
(8)
The
services
are
 provided
 by
a
 pharmacy
that
is
a
dis-tributor 
of 
a
drug
that
is
classied
 by
the
U.S.
Food
and
Drug
Admin-istration
(FDA)
as
a
limited
distribution
drug.
(c)
An
out-of-state
 provider 
that
applies
for 
enrollment
in
Medicaid
must
submit
documentation
along
with
the
enrollment
application
to
demonstrate
that
the
 provider 
meets
one
or 
more
of 
the
criteria
in
subsection
(b)
of 
this
section.
The
 provider 
must
submit
any
additional
requested
information
to
HHSC
or 
its
designee
 before
enrollment
may
 be
approved.
(d)
If 
HHSC
or 
its
designee
determines
that
an
out-of-state
 provider 
meets
one
or 
more
of 
the
criteria
in
subsection
(b)
of 
this
sec-tion,
the
 provider 
must
meet
all
other 
applicable
enrollment
eligibility
requirements,
including
those
specied
in
Chapter 
371
of 
this
title
(re-lating
to
Medicaid
and
Other 
Health
and
Human
Services
Fraud
and
Abuse
Program
Integrity)
 before
enrollment
may
 be
approved.
(e)
Other 
applicable
requirements.
The services are medically necessary and have been(1)
An
out-of-state
 provider 
that
is
enrolled
 pursuant
to
subsections
(b)
- (d)
of 
this
section
must
follow
all
other 
applicable
Medicaid
 participation
requirements
identied
 by
HHSC
or 
its
de-signee
for 
each
service
 provided.
Other 
applicable
requirements
that
must
 be
followed
may
include:
(A)
service
 benets
and
limitations;
(B)
documentation
 procedures;
(C)
obtaining
 prior 
authorization
for 
the
service
when-ever 
required;
and
(D)
claims
ling
deadlines
as
specied
in
§354.1003
of 
this
title
(relating
to
Time
Limits
for 
Submitted
Claims).
(2)
Certain
out-of-state
 providers
are
not
entitled
to
utilize
the
extended
365-day
claim
ling
deadline
 provided
in
§354.1003(a)(5)(H)
of 
this
title
that
is
otherwise
available
to
out-of-state
 providers,
and
must
comply
with
the
same
claims
ling
deadlines
that
apply
to
in-state
 providers
under 
that
section.
Those
out-of-state
 providers
are:
(A)
 providers
that
are
approved
for 
enrollment
under 
the
criterion
specied
in
subsection
(b)(6)
of 
this
section,
where
the
specic
 basis
for 
approval
is
that
the
 provider 
is
located
within
50
miles
driving
distance
from
the
Texas
state
 border;
and
(B)
 providers
that
are
approved
for 
enrollment
under 
the
criterion
specied
in
subsection
(b)(7)
of 
this
section
regarding
du-ally
eligible
recipients.
(f)
An
out-of-state
 provider 
that
is
enrolled
 pursuant
to
sub-sections
(b)
- (d)
of 
this
section
must:
(1)
comply
with
the
terms
of 
the
Medicaid
 provider 
agree-ment;
(2)
 provide
services
in
compliance
with
all
applicable
fed-eral,
state,
and
local
laws
and
regulations
related
to
licensure
and
cer-tication
in
the
state
where
the
out-of-state
 provider 
is
located;
and
(3)
comply
with
all
state
and
federal
laws
and
regulations
relating
to
Medicaid.
(g)
HHSC
or 
its
designee
determines
the
 basis
and
amount
of 
reimbursement
for 
medical
services
 provided
outside
Texas
and
within
the
United
States
in
accordance
with
Chapter 
355
of 
this
title
(relating
to
Reimbursement
Rates).
(h)
A
laboratory
may
 participate
as
an
in-state
 provider 
un-der 
any
 program
administered
 by
a
health
and
human
services
agency,
including
HHSC,
that
involves
laboratory
services,
regardless
of 
the
location
where
any
specic
service
is
 performed
or 
where
the
labora-tory's
facilities
are
located
if:
(1)
the
laboratory
or 
an
entity
that
is
a
 parent,
subsidiary,
or 
other 
afliate
of 
the
laboratory
maintains
laboratory
operations
in
Texas;
(2)
the
laboratory
and
each
entity
that
is
a
 parent,
sub-sidiary,
or 
other 
afliate
of 
the
laboratory,
individually
or 
collectively,
employ
at
least
1,000
 persons
at
 places
of 
employment
located
in
this
state;
and
(3)
the
laboratory
is
otherwise
qualied
to
 provide
the
ser-vices
under 
the
 program
and
is
not
 prohibited
from
 participating
as
a
 provider 
under 
any
 benets
 programs
administered
 by
a
health
and
hu-man
services
agency,
including
HHSC,
 based
on
conduct
that
consti-tutes
fraud,
waste,
or 
abuse.
38
TexReg 
5428
 August 
23,
2013
Texas
 Register 
 
This
agency
hereby
certies
that
the
adoption
has
been
reviewed
by
legal
counsel
and
found
to
be
a
valid
exercise
of 
the
agency's
legal
authority.
Filed
with
the
Ofce
of 
the
Secretary
of 
State
on
 August
12,
2013.
TRD-201303347
Steve
 Aragon
Chief 
Counsel
Texas
Health
and
Human
Services
Commission
Effective
date:
September 
1,
2013
Proposal
publication
date:
June
28,
2013
For 
further 
information,
please
call:
(512)
424-6900
CHAPTER 
353.
MEDICAID
MANAGED
CARE
SUBCHAPTER 
J.
OUTPATIENT
PHARMACY
SERVICES
1
TAC
§§353.903,
353.905,
353.907,
353.913
The
Texas
Health
and
Human
Services
Commission
(HHSC)
adopts
amended
§§353.903,
353.905,
353.907,
and
353.913,
concerning
outpatient
pharmacy
services
in
the
Medicaid
man-aged
care
program.
Sections
353.907
and
353.913
are
adopted
without
changes
to
the
proposed
text
as
published
in
the
June
28,
2013,
issue
of 
the
Texas
Register 
(38
TexReg
4069)
and
will
not
be
republished.
Sections
353.903
and
353.905
are
adopted
with
changes
to
the
proposed
text
as
published
in
the
June
28,
2013,
issue
of 
the
Texas
Register 
(38
TexReg
4069).
The
text
of 
the
rules
will
be
republished.
Background
and
Justication
The
amendments
are
adopted
to
comply
with
legislation
passed
by
the
83rd
Legislature
that
impact
the
outpatient
pharmacy
ben-ets
requirements
for 
Medicaid
and
Children's
Health
Insurance
Program
(CHIP)
managed
care
organizations.
Senate
Bill
(S.B.)
1106,
83rd
Legislature,
Regular 
Session,
2013,
requires
Medicaid
and
CHIP
Managed
Care
Organiza-tions
(MCOs)
to
increase
the
level
of 
transparency
by
requiring
MCOs
to
disclose
to
its
network
pharmacy
providers
the
sources
used
in
calculating
the
maximum
allowable
cost
(MAC)
list
for 
that
provider.
It
also
allows
pharmacies
to
challenge
a
MAC
price,
update
MAC
prices
every
seven
days,
and
provides
a
process
for 
a
pharmacy
to
readily
access
its
MAC
prices.
S.B.
644,
83rd
Legislature,
Regular 
Session,
2013,
requires
Medicaid
and
CHIP
MCOs
to
accept
standard
prior 
authorization
(PA)
forms
developed
by
the
Texas
Department
of 
Insurance
(TDI)
when
submitted
by
prescribing
providers
for 
pharmacy
services.
 Additionally,
the
adopted
rules
clarify
the
denition
of 
covered
outpatient
drugs;
update
references;
clarify
that
the
MCO's
sub-contractors
are
also
required
to
comply
with
Subchapter 
J
of 
Chapter 
353;
and
make
technical
corrections.
Comments
During
the
public
comment
period,
HHSC
received
comments
from
the
Texas
Pharmacy
Business
Council,
the
Texas
 Associa-tion
of 
Health
Plans,
and
H-E-B
Grocery
Company.
 A
summary
of 
the
comments
and
responses
follow.
Comment:
One
commenter 
noted
that
the
proposed
preamble
included
a
description
of 
S.B.
1106
that
incorrectly
indicated
that
MCOs
are
required
to
notify
pharmacies
of 
MAC
price
changes
weekly.
The
commenter 
stated
that
the
bill
requires
MCOs
to
review
and
update
MAC
prices
every
seven
days.
Response:
HHSC
agrees
that
SB
1106
requires
MCOs
to
review
and
update
MAC
prices
every
seven
days.
No
change
was
made
to
the
rules
in
response
to
this
comment.
Comment:
One
commenter 
noted
that
the
"Statutory
 Author-ity"
section
of 
the
proposed
preamble
included
references
to
Government
Code
§533.005(a)(23)(K)
and
stated
that
it
requires
pharmacies
to
disclose
how
they
set
their 
MAC
prices.
The
commenter 
stated
that
the
Government
Code
reference
requires
MCOs
to
disclose
how
they
set
their 
MAC
prices.
Response:
HHSC
agrees
in
part
as
S.B.
1106
requires
the
MCO
to
disclose
the
sources
used
to
determine
the
MAC
pricing
for 
the
maximum
allowable
cost
list
specic
to
each
provider.
HHSC
updated
the
description
of 
the
Government
Code
provision
in
the
preamble
to
accurately
describe
the
bill's
requirement
for 
MCOs.
No
change
was
made
to
the
rules
in
response
to
this
comment.
Comment:
 A
commenter 
indicated
that
the
denition
of 
"maximum
allowable
cost"
in
§353.903
states
that
a
MAC
reim-bursement
limit
is
set
by
a
MCO
when
Medicaid
and
CHIP
MAC
unit
prices
will
actually
be
set
by
the
pharmacy
benet
manager 
(PBM)
subcontracted
with
the
MCO.
The
commenter 
provided
suggested
changes
to
the
denition
of 
MAC.
Response:
HHSC
agrees
in
part
and
has
amended
the
deni-tion
in
§353.903
to
specify
that
the
unit
price
is
set
by
a
MCO,
or 
its
subcontractor,
and
to
clarify
that
the
prices
are
meant
for 
reimbursement
of 
therapeutically
equivalent
multi-source
drugs.
Comment:
One
commenter 
noted
that
§353.905
requires
MCOs
to
comply
with
§533.005(a)(23)(K)
and
(a-2)
of 
the
Government
Code
"with
respect
to
MAC
lists."
This
section
of 
law
includes
MAC
requirements
that
are
not
specic
to
a
list.
The
commenter 
recommended
that
"with
respect
to
MAC
lists"
be
deleted.
Response:
The
section
of 
the
Government
Code
being
refer-enced,
per 
S.B.
1106,
is
specic
to
maximum
allowable
costs.
HHSC
updated
§353.905
to
reference
the
broader 
state
law
that
covers
pharmacy
benets
in
Medicaid
managed
care,
which
in-clude
the
MAC
requirements.
Comment:
One
commenter 
recommended
that
HHSC
explicitly
state
in
§353.905(j)
that
subcontractors
include
PBMs.
Response:
HHSC
appreciates
the
comment,
but
respectfully
disagrees.
MCOs
are
contractually
required
to
ensure
all
of 
their 
subcontractors
follow
the
HHSC
contract
and
Texas
 Administra-tive
Code
Medicaid
and
CHIP
rule
requirements.
In
§353.903,
HHSC
denes
PBMs
to
mean
the
entity
administering
pharmacy
benets
on
behalf 
of 
a
MCOs.
Therefore,
it
is
not
necessary
to
specically
reference
PBMs
in
§353.905.
No
change
was
made
to
the
rules
in
response
to
this
comment.
Comment:
One
commenter 
noted
that
S.B.
1106
requires
MCOs/PBMs
to
provide
a
process
for 
pharmacies
to
readily
access
the
MAC
list
and
recommended
that
additional
language
be
added
to
the
preamble
to
express
legislative
intent
that
MCOs/PBMs
use
internet
portals
or 
other 
on-demand
processes
to
allow
pharmacies
access
to
the
MAC
list.
Response:
HHSC
agrees,
but
intends
to
enforce
this
require-ment
contractually
by
requiring
MCOs
to
use
a
website
or 
other 
internet
process
to
provide
pharmacies
easy
access
to
MAC
lists.
No
change
was
made
to
the
rules
in
response
to
this
com-ment.
 ADOPTED
 RULES 
 August 
23,
2013
38
TexReg 
5429

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