AI-assisted research summary: The executive commissioner must adopt reasonable rules and standards for Medicaid payment fees, charges, and rates, and the commissioner may set them using specified factors and methods.
Sec. 532.0057. FEES, CHARGES, AND RATES. (a) The executive commissioner shall adopt reasonable rules and standards governing the determination of fees, charges, and rates for Medicaid payments. (b) In adopting rules and standards required by Subsection (a), the executive commissioner: (1) may provide for payment of fees, charges, and rates in accordance with: (A) formulas, procedures, or methodologies commission rules prescribe; (B) state or federal law, policies, rules, regulations, or guidelines; (C) economic conditions that substantially and materially affect provider participation in Medicaid, as the executive commissioner determines; or (D) available levels of appropriated state and federal funds; and (2) shall include financial performance standards that, in the event of a proposed rate reduction, provide private ICF-IID facilities and home and community-based services providers with flexibility in determining how to use Medicaid payments to provide services in the most cost-effective manner while continuing to meet state and federal Medicaid requirements. (c) Notwithstanding any other provision of Chapter 32, Human Resources Code, Chapter 531 or revised provisions of Chapter 531, as that chapter existed on March 31, 2025, or Chapter 540 or 540A, the commission may adjust the fees, charges, and rates paid to Medicaid providers as necessary to achieve the objectives of Medicaid in a manner consistent with the considerations described by Subsection (b)(1). (d) In adopting rates for Medicaid payments under Subsection (a), the executive commissioner may adopt reimbursement rates for appropriate nursing services provided to recipients with certain health conditions if those services are determined to provide a cost-effective alternative to hospitalization. A physician must certify that the nursing services are medically appropriate for the recipient for those services to qualify for reimbursement under this subsection. (e) In adopting rates for Medicaid payments under Subsection (a), the executive commissioner may adopt cost-effective reimbursement rates for group appointments with Medicaid providers for certain diseases and medical conditions commission rules specify. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.