Medicaid

• All general acute care hospitals except for children's hospitals will be reimbursed for NBHS services according to the Texas Medicaid prospective payment methodology based on the Diagnosis Related Group (DRG). The cost of providing this service is factored into the calculation of the DRG relative weights. The Texas Department of State Health Services recognizes that it is necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, the Department of State Health Services makes adjustments to the DRG classifications and relative weights at least every three years. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.
• Hospitals with 100 or fewer licensed beds are reimbursed the greater of the amount the hospital received under the DRG system or the amount the hospital would have received under TEFRA principles of reimbursement. If the reimbursement under TEFRA principles is greater than the amount of reimbursement received under the DRG system, the difference will be reimbursed to the hospital. This determination is made with a tentative settlement and subsequent adjustments, if applicable, at final cost settlement. The 100 or fewer licensed bed exemption applies to hospital fiscal years beginning on or after September 1, 1989. Hospitals with 100 or fewer licensed beds that are participating in the LoneSTAR Select I Contracting Program, as a contracted hospital, are not eligible for retrospective cost settlements during the period the contract with the LoneSTAR Select I Contracting Program is in effect.
• The NBHS is considered a screening test and may not be billed as a separate and unique service.
  • Only those newborns who fail the NBHS will be referred for diagnostic testing. These diagnostic tests may be billed as an outpatient using existing codes and fee structures.

Commercial Insurance

• The State Board of Insurance has enacted required policy changes to mandate that NBHS be reimbursed by insurers.

CHIP

• NBHS is a covered service through CHIP. The birth admission hearing screen is covered as part of the DRG.

Uninsured

• As with other uninsured services, the hospital will be at risk for loss of reimbursement for services provided to unfunded clients. However, the law still requires that the hospital provide the service.
• The monitoring process must ensure that there is a match between BVS reported births at an individual hospital and NBHS.