Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter G - STAR+PLUS › Section 353.608 - Minimum Payment Amounts to Qualified Nursing Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. This section establishes
				  minimum payment amounts for certain non-state government-owned nursing facility
				  providers participating in the STAR+PLUS Program, or other Medicaid managed
				  care programs offering nursing facility services, and the conditions for
				  receipt of these amounts.
(b)
				  Definitions.
(1) Calculation Period--A month
				  used to calculate the Minimum Payment Amount. There are six calculation periods
				  in Eligibility Period One, twelve calculation periods in Eligibility Period
				  Two, nine calculation periods in Eligibility Period Two-A, and five calculation
				  periods in Eligibility Period Three.
(2) CHOW Application--An application filed
				  with the Department of Aging and Disability Services for a nursing facility
				  change of ownership.
(3) Clean
				  Claim--A claim submitted by a provider for health care services rendered to an
				  enrollee with the data necessary for the managed care organization to
				  adjudicate and accurately report the claim. Claims for Nursing Facility Unit
				  Rate services that meet the Department of Aging and Disability Services'
				  criteria for clean claims submission are considered Clean Claims. Additional
				  information regarding Department of Aging and Disability Services' criteria for
				  clean claims submission is included in HHSC's Uniform Managed Care Manual,
				  which is available on HHSC's website.
(4) DADS--The Texas Department of Aging and
				  Disability Services, or its successor agency.
(5) Eligibility Period--A period of time for
				  which a Qualified Nursing Facility may receive the Minimum Payment Amounts
				  described in this section.
(6)
				  Eligibility Period One--The first period of time for which a Qualified Nursing
				  Facility may receive the Minimum Payment Amounts described in this section,
				  covering dates of service from the later of March 1, 2015, or the date on which
				  nursing facility services become managed care services, to August 31,
				  2015.
(7) Eligibility Period
				  Two--The second period of time for which a Qualified Nursing Facility may
				  receive the Minimum Payment Amounts described in this section, covering dates
				  of service from September 1, 2015, to August 31, 2016.
(8) Eligibility Period Two-A--The third
				  period of time for which a Qualified Nursing Facility may receive the Minimum
				  Payment Amounts described in this section, covering dates of service from
				  December 1, 2015, to August 31, 2016.
(9) Eligibility Period Three--The fourth
				  period of time for which a Qualified Nursing Facility may receive the Minimum
				  Payment Amounts described in this section, covering dates of service from April
				  1, 2017, to August 31, 2017. Centers for Medicare & Medicaid Services (CMS)
				  approval is required for any payments to be made under this section for
				  Eligibility Period Three.
(10)
				  First Payment--The payment made in the ordinary course of business by MCOs to
				  Qualified Nursing Facilities for the provision of covered services to Medicaid
				  recipients.
(11) HHSC--The Texas
				  Health and Human Services Commission or its designee.
(12) Intergovernmental transfer (IGT)--A
				  transfer of public funds from a non-state governmental entity to
				  HHSC.
(13) IGT Responsibility--The
				  IGT owed by a non-state governmental entity, as determined by HHSC, for funding
				  the non-federal share of the increase in the payments to the MCOs due to the
				  Minimum Payment Amount program.
(14) MCO--A Medicaid managed care
				  organization contracted with HHSC to provide nursing facility services to
				  Medicaid recipients.
(15) Minimum
				  Payment Amount--The minimum payment amount for a Qualified Nursing Facility, as
				  calculated under subsection (d) of this section.
(16) Network Nursing Facility--A nursing
				  facility that has a contract with an MCO for the delivery of Medicaid covered
				  benefits to the MCO's enrollees.
(17) Non-state Governmental Entity--A
				  hospital authority, hospital district, health district, city or
				  county.
(18) Non-state
				  Government-owned Nursing Facility--A network nursing facility where a non-state
				  governmental entity holds the license and is a party to the nursing facility's
				  Medicaid provider enrollment agreement with the state.
(19) Nursing Facility Add-on Services--The
				  types of services that are provided in the nursing facility setting by a
				  provider, but are not included in the Nursing Facility Unit Rate, including but
				  not limited to emergency dental services, physician-ordered rehabilitative
				  services, customized power wheel chairs, and augmentative communication
				  devices.
(20) Nursing Facility Unit
				  Rate--The types of services included in the DADS daily rate for nursing
				  facility providers, such as room and board, medical supplies and equipment,
				  personal needs items, social services, and over-the-counter drugs. The Nursing
				  Facility Unit Rate also includes applicable nursing facility rate enhancements
				  as described in §
											RSA
				  355.308 of this title (relating to Direct
				  Care Staff Rate Component), and professional and general liability insurance.
				  Nursing Facility Unit Rates exclude Nursing Facility Add-on Services.
(21) Qualified Nursing Facility--A Non-state
				  Government-Owned Network Nursing Facility that meets the eligibility
				  requirements described in subsection (e) of this section.
(22) Public Funds--Funds derived from taxes,
				  assessments, levies, investments, and other public revenues within the sole and
				  unrestricted control of a non-state governmental entity that holds the license
				  and is party to the Medicaid provider enrollment agreement with the state.
				  Public funds do not include gifts, grants, trusts, or donations, the use of
				  which is conditioned on supplying a benefit solely to the donor or grantor of
				  the funds.
(23) Regional Healthcare
				  Partnership (RHP)--A collaboration of interested participants that work
				  collectively to develop and submit to the state a regional plan for health care
				  delivery system reform as defined and established under Chapter 354, Subchapter
				  D of this title (relating to Texas Healthcare Transformation and Quality
				  Improvement Program).
(24) RUG--For
				  the purpose of calculations described in subsection (d)(1) of this section, a
				  resource utilization group under Medicare Part A as established by the Centers
				  for Medicare & Medicaid Services (CMS). For the purpose of calculations
				  described in subsection (d)(2) of this section, a resource utilization group
				  under the RUG-III 34 group classification system, Version 5.20, index
				  maximizing, as established by the state and CMS.
(25) Second Payment--The amount a Qualified
				  Nursing Facility can receive that is equal to the Minimum Payment Amount less
				  adjustments to that amount, as described in subsection (d) of this
				  section.