Committee on Article II: Overview of Medicaid Cost Reporting for Long Term Services and Supports Programs
Medicaid Rate Setting Methodologies •
Methodologies vary based on type of service, whether service has a Medicare equivalent, federal law, and available data.
• Acute Care (physicians, CORF/ORF, HHA, DME, medical supplies, SHARS, MAC)
• Resource-based Fees: equal to Medicare Relative Value Unit (RVU) for the service multiplied by applicable Medicaid conversion factor.
• Access-based Fees:
• Healthcare Common Procedure Coding System Fee Analyzer
• Average or percentage of Wholesale Price (AWP)
• Medispan – online database of AWP and Average Sales Price for drugs and biologicals
• Mean or median of the Medicaid fees for 10 most populous states plus four states bordering Texas
• Current Texas Medicaid fee for similar service
• Manufacturer Suggested Retail Price
• Cost reports and time study-based fees (SHARS and MAC)
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