CurrentCommunity Health ChoicePolicy N/A

Separate Reimbursement of Certain Inpatient High-Cost Drug and Biologics (HCCADs)

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This policy explains when certain high-cost drugs and biologics administered during inpatient care may be carved out of the APR-DRG payment and billed separately on an outpatient claim. It applies to Community Health Choice fee-for-service and managed care providers.

Policy Summary

PayerCommunity Health Choice

PolicySeparate Reimbursement of Certain Inpatient High-Cost Drug and Biologics (HCCADs)

Policy CodePolicy N/A

Change TypeRevised policy

Effective DateJune 2, 2025

Next Review DateN/A

Key ActionSubmit a listed HCCAD on an outpatient claim for separate reimbursement instead of treating it as included in the APR-DRG payment.

SourceLink

POLICY UPDATE CHANGES

Certain HHSC-approved inpatient high-cost drugs and biologics are being carved out of the APR-DRG and made eligible for separate reimbursement.

14High-cost drugs and biologics listed for separate reimbursement

2Delivery/payment programs covered

$3M+Potential cost per dose

APR-DRG carve-out

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CurrentCommunity Health ChoicePolicy N/A

Separate Reimbursement of Certain Inpatient High-Cost Drug and Biologics (HCCADs)

Customize your policy alerts

Sign up for all communityhealthchoice policy alerts

Know when communityhealthchoice releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerCommunity Health Choice

PolicySeparate Reimbursement of Certain Inpatient High-Cost Drug and Biologics (HCCADs)

Policy CodePolicy N/A

Change TypeRevised policy

Effective DateJune 2, 2025

Next Review DateN/A

Key ActionSubmit a listed HCCAD on an outpatient claim for separate reimbursement instead of treating it as included in the APR-DRG payment.

SourceLink

POLICY UPDATE CHANGES

Certain HHSC-approved inpatient high-cost drugs and biologics are being carved out of the APR-DRG and made eligible for separate reimbursement.

14High-cost drugs and biologics listed for separate reimbursement

2Delivery/payment programs covered

$3M+Potential cost per dose

APR-DRG carve-out

Eligibility for Separate HCCAD Reimbursement

Separate reimbursement is available only when the inpatient high-cost drug or biologic meets all of the following criteria.

ALL of the following

The drug or biologic is approved by the Texas Health and Human Services Commission (HHSC) to be carved out of the All-Patient Refined Diagnosis Related Group (APR-DRG).
The drug or biologic appears on the designated HCCAD list: HEMGENIX, ELEVIDYS, SKYSONA, LYFGENIA, ZYNTEGLO, ROCTAVIAN, ZOLGENSMA, CASGEVY, KYMRIAH, CARVYKTI, ABECMA, BREYANZI, TECARTUS, or YESCARTA.
Eligible HCCADs may be billed on an outpatient claim for separate reimbursement.

Designated HCCAD List

HCCAD Listmixed

HEMGENIX	Listed HCCAD drug or biologic
ELEVIDYS	Listed HCCAD drug or biologic
SKYSONA	Listed HCCAD drug or biologic
LYFGENIA	Listed HCCAD drug or biologic
ZYNTEGLO	Listed HCCAD drug or biologic
ROCTAVIAN	Listed HCCAD drug or biologic
ZOLGENSMA	Listed HCCAD drug or biologic
CASGEVY	Listed HCCAD drug or biologic
KYMRIAH	Listed HCCAD drug or biologic
CARVYKTI	Listed HCCAD drug or biologic

1–10 of 14

1/2

Separate Billing Requirement

Billing Rule

Bill designated inpatient high-cost drugs separately

For an HHSC-approved HCCAD that appears on the designated list, submit the drug or biologic on an outpatient claim for separate reimbursement. Do not treat the eligible item as included in the APR-DRG inpatient payment.

Applies to eligible HCCADs administered during inpatient care.
Separate reimbursement is available through an outpatient claim.
The policy applies to both fee-for-service and managed care.
Effective June 2, 2025.

Key Terms

HCCAD

TermHCCAD

DefinitionA drug or biologic that HHSC has approved to be carved out of the All-Patient Refined Diagnosis Related Group (APR-DRG).

Billing treatmentAn approved HCCAD may be billed on an outpatient claim for separate reimbursement.

Diagnosis Related Group (DRG)

TermDiagnosis Related Group (DRG)

DefinitionA payment grouping that reflects all average hospital costs associated with providing care for a patient's primary diagnosis and complications.

Inpatient drugs and biologics

Policy Summary

PayerCommunity Health Choice

PolicySeparate Reimbursement of Certain Inpatient High-Cost Drug and Biologics (HCCADs)

Policy CodePolicy N/A

Change TypeRevised policy

Effective DateJune 2, 2025

Next Review DateN/A

Key ActionSubmit a listed HCCAD on an outpatient claim for separate reimbursement instead of treating it as included in the APR-DRG payment.

SourceLink

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