reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter X - REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES › Section 554.2316 - Collection of Applied Income

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Nursing facilities may collect from the recipient only the applied income that
				  is specified on the recipient's payment plan forms, except when that amount
				  exceeds the monthly vendor rate. In this event, the facility may collect only
				  an applied-income amount equal to the maximum monthly Medicaid vendor
				  rate.
(b) If a payment plan appears
				  incorrect, the facility administrator should contact the local Texas Department
				  of Human Services (DHS) worker to correct the plan. Even if a recipient's
				  income increases, the administrator must not collect an increased payment until
				  the plan is changed. The administrator should not collect an increased payment
				  in anticipation of a payment plan increase.
(c) If an admitted recipient does not have a
				  payment plan, the administrator should contact the local worker for help in
				  determining how much applied income is owed. If the forthcoming forms indicate
				  a lesser payment, the administrator should refund the excess immediately and
				  notify the worker.
(d) Facilities
				  that collect payments (part applied income, part Medicaid) in excess of the
				  vendor rate are in violation of DHS regulations and of Public Law 95-142 which
				  makes "solicitation of supplementation" a felony.
(e) Regional DHS staff must report any
				  violations. If an investigation shows that the facility has violated this
				  standard, a recommendation for withholding vendor payments, contract
				  termination, referral to the courts, or other contract action may be
				  made.
(f) The nursing facility must
				  refund the recipient's prorated applied income money when the recipient has
				  paid in advance for the full month and is discharged from the facility any time
				  during the month. The facility must make the refund within 30 calendar days
				  from and including the date of discharge, even when vendor payment has not been
				  received from DHS.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter X - REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES › Section 554.2318 - Computation of Daily Reimbursement Rate for Recipients with Applied Income

Current through Reg. 49, No. 28; July 12, 2024
(a) Reimbursement
				  is computed by multiplying the established daily rate by the number of days in
				  the month. The recipient's applied income is then subtracted and the result is
				  divided by the number of days in the month.
(b) A facility may not collect more than the
				  applied income reported on the payment plan form in a 31-day month.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter X - REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES › Section 554.2326 - Medicaid Swing Bed Program for Rural Hospitals

Current through Reg. 49, No. 28; July 12, 2024
(a) Program
				  description. HHSC operates the Medicaid Swing Bed Program for rural hospitals
				  located in counties with populations of 100,000 or less. The Medicaid Swing Bed
				  Program is modeled on Medicare's Swing Bed Program. The Medicaid Swing Bed
				  Program permits participating rural hospitals to use their beds interchangeably
				  to furnish both acute hospital care and nursing facility care to Medicaid
				  recipients, when no care beds are available in nursing facilities (NFs) in the
				  area. When a participating rural hospital furnishes NF nursing care to Medicaid
				  recipients, HHSC makes payment to the hospital using the same procedures and
				  the same Resource Utilization Group daily rates that the Texas Health and Human
				  Services Commission authorizes for reimbursing NFs participating in the Texas
				  Medicaid Nursing Home Program.
(b)
				  Application to participate. Rural hospitals apply to HHSC to participate in the
				  Medicaid Swing Bed Program. Each applicant must be located in a county with a
				  population of 100,000 or less and must meet the qualifying requirements of the
				  Medicare Swing Bed Program. Hospitals approved for participation enter into
				  swing bed provider agreements with HHSC.
(c) Parallel participation in Medicare. A
				  rural hospital participating in the Medicaid Swing Bed Program must:
(1) have a Medicare hospital provider
				  agreement; and
(2) be
				  Medicare-certified as a swing bed hospital in the Medicare Swing Bed Program.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter Y - MEDICAL NECESSITY DETERMINATIONS › Section 554.2401 - General Qualifications for Medical Necessity Determinations

Current through Reg. 49, No. 28; July 12, 2024
Medical necessity is the prerequisite for participation in
					 the Medicaid (Title XIX) Long-term Care program. This section contains the
					 general qualifications for a medical necessity determination. To verify that
					 medical necessity exists, an individual must meet the conditions described in
					 paragraphs (1) and (2) of this section.
(1) The individual must demonstrate a medical
				  condition that:
(A) is of sufficient
				  seriousness that the individual's needs exceed the routine care which may be
				  given by an untrained person; and
(B) requires licensed nurses' supervision,
				  assessment, planning, and intervention that are available only in an
				  institution.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter Y - MEDICAL NECESSITY DETERMINATIONS › Section 554.2403 - Medical Necessity Determination

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. A recipient must have a
				  determination of medical necessity for nursing facility care to participate in
				  the Texas Medicaid Nursing Facility Program.
(1) The state Medicaid claims administrator
				  makes a medical necessity determination by evaluating a recipient's medical and
				  nursing needs based on the MDS assessment required by DADS.
(2) A recipient must have a determination of
				  medical necessity for nursing facility care before the nursing facility can be
				  paid for services, except as provided in § 554.2413 of this subchapter
				  (relating to Determination of Payment Rate Based on the MDS Assessment
				  Submission) and § 554.2611 of this chapter (relating to Retroactive Vendor
				  Payment).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter Y - MEDICAL NECESSITY DETERMINATIONS › Section 554.2405 - Physicians' Certifications and Recertifications

Current through Reg. 49, No. 28; July 12, 2024
The recipient's physician is required at intervals
					 specified in § 554.1210(b) of Title 40 (relating to Certification and
					 Recertification Requirements in Medicaid-Certified Facilities) to certify or
					 recertify the necessity for continued nursing facility care.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter Y - MEDICAL NECESSITY DETERMINATIONS › Section 554.2407 - Denied Medical Necessity

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  If the state Medicaid claims administrator determines that a Medicaid applicant
				  or a recipient does not meet the criteria for medical necessity described in
				  § 554.2401 of this subchapter (relating to General Qualifications for
				  Medical Necessity Determinations), the state Medicaid claims administrator
				  notifies the attending physician and the nursing facility in writing and
				  provides them an opportunity to present additional information about the
				  applicant's or recipient's medical need for nursing facility care.
(1) If the attending physician or a nursing
				  facility physician does not respond or contest the findings of the state
				  Medicaid claims administrator within 10 working days after receipt of the
				  written notice about the decision, the findings are final.
(2) If the attending physician or a nursing
				  facility physician contests the findings of the state Medicaid claims
				  administrator, at least one physician with the state Medicaid claims
				  administrator must review the case. If the state Medicaid claims
				  administrator's physician determines that the applicant's or recipient's
				  admission or stay is not medically necessary, the determination becomes
				  final.
(3) The state Medicaid
				  claims administrator sends written notification of the final determination of
				  denied medical necessity to the attending physician, the nursing facility, and
				  the applicant or recipient (or responsible party).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter Y - MEDICAL NECESSITY DETERMINATIONS › Section 554.2413 - Determination of Payment Rate Based on the MDS Assessment Submission

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. In
				  this section, the following words and terms have the following meanings unless
				  the context clearly indicates otherwise.
(1)
				  All conditions of eligibility--A recipient meets all conditions of eligibility
				  when the state Medicaid claims administrator approves the recipient for medical
				  necessity and the recipient meets financial eligibility for Medicaid.
(2) On-time MDS assessment--An MDS assessment
				  that is submitted in accordance with the federal MDS submission schedule and is
				  received by the state Medicaid claims administrator within 31 days after the
				  completion date.
(3) Missed MDS
				  assessment--An MDS assessment that is received by the state Medicaid claims
				  administrator outside the time period that the MDS assessment covers.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2602 - Additional Charges (Items and Services Excluded from Vendor Payment)

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				  Department of Human Services (DHS) does not make vendor payments when a Title
				  XIX recipient is absent from the facility because of:
(1) therapeutic home visits that extend
				  beyond three days; or
(2) hospital
				  inpatient services. However, DHS makes vendor payments for periods when a
				  recipient is a hospital outpatient subject to the following limitations.
(A) DHS makes vendor payments when a Title
				  XIX recipient is absent from the nursing facility past midnight for outpatient
				  hospital services, including services resulting from hospital outpatient
				  observation. In these cases the facility must document in the clinical record
				  that the recipient was not admitted as an inpatient in the hospital.
(B) If the recipient is admitted to the
				  hospital for inpatient services anytime during a hospital outpatient
				  observation period, a patient transaction notice showing discharge must be
				  submitted effective the date the recipient left the nursing facility.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2603 - Therapeutic Home Visits Away from the Facility

Current through Reg. 49, No. 28; July 12, 2024
(a) The facility must have written policies
				  and procedures governing recipient therapeutic home visits away from the
				  facility for the purpose of visiting with relatives and friends.
(b) The following conditions must be met for
				  the facility to receive vendor payment:
(1)
				  the recipient's plan of care provides for physician-authorized therapeutic
				  visits;
(2) the facility must
				  provide equipment and supplies necessary to meet the needs of the recipient,
				  including, but not limited to, medication and oxygen and supplies for its
				  administration;
(3) if a visit
				  exceeds three days, the facility submits a discharge form effective the first
				  day. Days are defined as 24-hour periods extending from midnight to midnight.
				  In determining days of absence from a facility, the first day is the first
				  24-hour period beginning at midnight after the recipient's departure.
				  Situations that require a discharge form effective the first day include:
(A) alternate care living arrangements,
				  including at home;
(B) transfer or
				  discharge to other medical care or living arrangements covered under Title XIX;
				  and
(C) therapeutic visits that are
				  over three days (one night must be spent in the facility between therapeutic
				  home visits if vendor payment is to be made);
(4) the facility must maintain a record of
				  each therapeutic visit away from the facility. Verification that therapeutic
				  visits took place and were documented is a part of the audit procedures during
				  the DHS audit of the facility. DHS does not pay for therapeutic visits which
				  were not documented.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2604 - Vendor Payment Information

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Vendor payment will be made based upon the nursing facility administrator's or
				  the administrative designee's approval of the Nursing Care Statement.
(b) Vendor payment will be made at periodic
				  intervals but not less than once per month for services rendered during the
				  previous billing period.
(c) The
				  vendor payment for an entire month will be in accordance with the number of
				  calendar days in the month.
(d)
				  Vendor payment for time periods of less than an entire calendar month shall be
				  made in accordance with the number of days care was provided beginning with the
				  effective date on the Notification of Recipient Medical Necessity Determination
				  and/or Vendor Payment Plan.
(e)
				  Days are defined as 24-hour periods extending from midnight to midnight.
				  Payment is computed in terms of whole days, even though the recipient may have
				  been in a nursing facility only a fractional part of the day of entrance. (See
				  § 554.2601(e) of Title 40 (relating to Vendor Payment (Items and Services
				  Included)).
(f) Vendor payment will
				  be made in terms of daily rates.
(g) The recipient must have the status of a
				  certified recipient, must have been determined to be in need of nursing
				  facility care, and must be physically located in a Medicaid-certified bed of a
				  facility at the time the service is rendered in order for the facility to
				  receive payment for the service.
(h) The Texas Department of Human Services
				  (DHS) will owe the facility no interest on payments not made within the time
				  limits provided in these rules, the provider contract, or Chapter 2251 of the
				  Government Code when the delay is the result of a bona fide dispute between DHS
				  and the facility over compliance with the terms and conditions of the Medicaid
				  program or is the result of other rules, laws or contract terms authorizing the
				  withholding or nonpayment.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2605 - Effective Date of Vendor Coverage

Current through Reg. 49, No. 28; July 12, 2024
If an applicant is determined to be eligible and in need of
					 nursing facility care, the effective date of vendor coverage is either the date
					 the individual entered the facility, the date of application, or the date the
					 need for nursing facility care was established, whichever date is the
					 latest.
(1) Once the effective date is
				  established, the Texas Department of Human Services (DHS), through the contract
				  agreement with the facility, sets the acceptable rates for services.
(2) If the facility charges the applicant an
				  amount over the recognized monthly rate set by DHS, the difference must be
				  refunded to the recipient or the responsible party.
(3) Private pay individuals living in
				  Medicaid certified nursing facilities, or distinct parts, who do not receive
				  SSI cash benefits may be eligible for "Three months prior" vendor payments.
				  (See § 554.2408 of Title 40 (relating to Retroactive Medical Necessity
				  Determinations)).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2606 - Supplementation of Vendor Payments

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Facilities must abide by Public Law 95-142 related to Medicare/Medicaid
				  antifraud and abuse amendments.
(b)
				  Participation will be limited to providers of services who accept, as payment
				  in full, the amounts paid in accordance with the fee structure approved by the
				  Texas Department of Human Services (DHS).
(c) Providers who have a contract with DHS
				  and who solicit contributions, donations, or gifts from Medicaid recipients or
				  family members will be in noncompliance with federal requirements.
(d) The facility must inform Medicaid
				  recipients and their families that their right to nursing facility services is
				  not contingent upon contributions. The facility must give copies of this notice
				  to the recipient, and either the responsible party or family
				  representative.
(e) If a recipient,
				  family member, guardian, or other interested party does make a free-will
				  contribution, the nursing facility administrator executes a statement for
				  signature by both the contributor and the administrator. It will state that the
				  services provided to any Medicaid recipient in the nursing facility are not
				  predicated upon contributions and that the gifts are free-will
				  contributions.
(f) When a provider
				  accepts federal and/or state funds for items or services delivered which are
				  not reimbursed within the per diem, the facility must document:
(1) that the type of item or service is
				  ordered by the physician;
(2) that
				  the item or service has not been billed to more than one payor source;
				  and
(3) that the recipient actually
				  received the item or service.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2607 - Penalties for Supplementation

Current through Reg. 49, No. 28; July 12, 2024
A felony conviction with a fine of not more than $25,000 or
					 imprisonment for not more than five years or both can be imposed on anyone in
					 the facility who knowingly and willfully:
(1) accepts, from the recipient, money or
				  other considerations in excess of rates established by the state for services
				  provided under a state plan approved under Title XIX;
(2) charges, solicits, accepts, or receives
				  any gifts, money, donation, or other consideration in addition to amounts
				  required to be paid under a state plan approved under Title XIX (other than
				  charitable donations from an organization or a person unrelated to the
				  recipient) as a precondition for admitting or keeping a recipient in the
				  nursing facility; or
(3) accepts
				  reimbursement from more than one source (including per diem reimbursement) for
				  the same item or service.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2608 - Limitations on Provider Charges

Current through Reg. 49, No. 28; July 12, 2024
A provider of Medicaid (Title XIX) services may neither
					 charge nor take other recourse against Medicaid applicants or recipients, their
					 family members, or their representatives for any claim denied or reduced by the
					 Texas Department of Human Services (DHS) because of the provider's failure to
					 comply with any DHS rule, regulation, or procedure.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2609 - Payment of Claims

Current through Reg. 49, No. 28; July 12, 2024
To receive payment for a service, a nursing facility must
					 submit a complete and accurate claim to the state Medicaid claims administrator
					 so that it is received within 12 months after the date of service. In this
					 section, the date of service is the last day of the month in which the service
					 was provided.
(1) All payments are
				  subject to availability of funds as provided by law.
(2) For purposes of this section, third party
				  means an individual, entity, or program other than DADS or the program provider
				  that is or may be liable to pay all or part of the expenditures for nursing
				  facility services, including:
(A) A
				  commercial insurance company offering health or casualty insurance to
				  individuals or groups (including both experience-rated insurance contracts and
				  indemnity contracts);
(B) A profit
				  or nonprofit prepaid plan offering either medical services or full or partial
				  payment for services; and
(C) An
				  organization administering health or casualty insurance plans for professional
				  associations, unions, fraternal groups, employer-employee benefit plans, and
				  any similar organization offering these payments or services, including
				  self-insured and self-funded plans.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2610 - Medicare Part A Skilled Nursing Facility Deductible and Coinsurance Payment

Current through Reg. 49, No. 28; July 12, 2024
When the Texas Department of Human Services (DHS) receives
					 valid Medicare claims, DHS pays a portion of the Medicare Part A skilled
					 nursing facility (SNF) deductible and coinsurance. When Medicare changes its
					 daily interim payment, DHS adjusts the Medicaid payment on the Part A SNF
					 coinsurance amount if necessary. The adjustment is effective on the first day
					 of the month following the Medicare change.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2611 - Retroactive Vendor Payment

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  In this section, retroactive vendor payment is payment DADS makes retroactively
				  to a nursing facility for services the nursing facility provided to an
				  individual who was eligible for, but had not yet applied for, Medicaid. A
				  nursing facility is eligible for up to three months retroactive vendor payment
				  for services it provided, if:
(1) the
				  individual resided in a Medicaid-certified nursing facility, or a distinct
				  part, during the time services were provided;
(2) the individual did not receive
				  Supplemental Security Income cash benefits;
(3) the individual met Medicaid financial
				  eligibility requirements;
(4) the
				  state Medicaid claims administrator has a current MDS assessment for the
				  individual that the facility submitted in compliance with the federal MDS
				  submission requirements; and
(5)
				  the nursing facility met physician certification and plan of care requirements
				  during the time services were provided.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2612 - Quality Incentive Payment

Current through Reg. 49, No. 28; July 12, 2024
For services delivered after September 1, 1999, the Texas
					 Department of Human Services (DHS) may make Quality Incentive payments to
					 facilities according to reimbursement rules developed by the Health and Human
					 Services Commission. DHS will determine the qualifying facilities.
(1) The Texas Board of Human Services will
				  review the adopted plan at least biennially.
(2) Incentive payments will be based on:
(A) specific resident care domains selected
				  from the Center for Health Systems Research and Analysis (CHSRA) Quality
				  Indicators; and
(B) regulatory
				  compliance.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2613 - Augmentative Communication Device Systems

Current through Reg. 49, No. 28; July 12, 2024
(a) A specialized augmentative communication
				  device system (ACD), also referred to as a speech-generating device system, is
				  reimbursable if purchased by a facility for a Medicaid recipient and all
				  criteria defined in this section are met. A physician and a licensed speech
				  therapist must determine a recipient needs the ACD, and the facility must
				  obtain DADS' approval of the request for reimbursement.
(b) A facility must request and receive prior
				  authorization from DADS before purchasing the ACD. The request for prior
				  authorization must include:
(1) an evaluation
				  and recommendation from a licensed speech therapist to purchase the
				  ACD;
(2) an attestation from the
				  recipient's attending physician that the ACD is medically necessary for the
				  recipient to maximize his functional communication within the facility's
				  environment; and
(3) a minimum of
				  two bids for the ACD or a request for an exception to the two-bid minimum if
				  the recommended ACD is only available through one vendor.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2614 - Customized Power Wheelchairs

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Customized power wheelchairs (CPWCs) are a service in the nursing facility
				  Medicaid program for Medicaid-eligible nursing facility residents when
				  medically necessary and prior authorized by the Health and Human Services
				  Commission (HHSC) or its designee.
(b) A CPWC is a wheelchair that consists of a
				  power mobility base and customized seating system.
(1) The power mobility base may include
				  programmable electronics and may utilize alternate input devices.
(2) The wheelchair must be medically
				  necessary, adapted, and fabricated to meet the individualized needs of the
				  resident, and intended for the exclusive and ongoing use of the
				  resident.
(3) Components of the
				  customized seating system must be in part or entirely usable only by the
				  resident for whom the power wheelchair is adapted and fabricated.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter AA - VENDOR PAYMENT › Section 554.2615 - Resident Transaction Notices

Current through Reg. 49, No. 28; July 12, 2024
A nursing facility must electronically submit to the state
					 Medicaid claims administrator a resident transaction notice within 72 hours
					 after a recipient's admission or discharge from the Medicaid nursing facility
					 vendor payment system. The nursing facility administrator must sign the
					 resident transaction notice.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 1 - GENERAL PROVISIONS › Section 554.2701 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to:
(1) describe the requirements of a nursing
					 facility related to preadmission screening and resident review (PASRR), which
					 is a federal requirement in Code of Federal Regulations, Title 42, Part 483,
					 Subpart C to ensure that:
(A) an individual
					 seeking admission to a nursing facility or a resident of a nursing facility
					 receives a PASRR Level I screening (PL 1) to identify whether the
					 individual or resident is suspected of having mental illness (MI), an
					 intellectual disability (ID), or a developmental disability (DD); and
(B) an individual or resident suspected of
					 having MI, ID, or DD receives a PASRR Level II evaluation (PE) to confirm MI,
					 ID, or DD and, if confirmed, to evaluate whether the individual or resident
					 needs nursing facility care and specialized services;
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 1 - GENERAL PROVISIONS › Section 554.2702 - Limitation on Charges for Nursing Facility Services

Current through Reg. 49, No. 28; July 12, 2024
A nursing facility must comply with this subchapter to
						receive payment for services provided to a Medicaid-eligible
						resident.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 1 - GENERAL PROVISIONS › Section 554.2703 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						subchapter, have the following meanings unless the context clearly indicates
						otherwise:
(1) Alternate placement
					 assistance--Assistance provided to a resident to locate and secure services
					 chosen by the resident or LAR that meet the resident's basic needs in a setting
					 other than a nursing facility. Assistance includes the identification of
					 specific services and supports available through alternate resources for which
					 the resident may be eligible and an explanation of the possible benefits and
					 consequences of selecting a setting other than a nursing facility.
(2) Coma--A state of unconsciousness
					 characterized by the inability to respond to sensory stimuli as documented by a
					 physician.
(3) Comprehensive care
					 plan--A plan, defined in § 554.101 of this chapter (relating to
					 Definitions), that includes, for a designated resident, nursing facility
					 specialized services and nursing facility PASRR support activities.
(4) Convalescent care--A type of care
					 provided after an individual's release from an acute care hospital that is part
					 of a medically prescribed period of recovery.
(5) CMWC--Customized manual wheelchair. A
					 wheelchair that consists of a manual mobility base and customized seating
					 system and is adapted and fabricated to meet the individualized needs of a
					 designated resident.
(6)
					 DADS--Department of Aging and Disability Services or HHSC, as its successor
					 agency. For purposes of the PASRR process, HHSC is the state authority for
					 intellectual and developmental disabilities.
(7) DD--Developmental disability. A
					 disability that meets the criteria described in the definition of "persons with
					 related conditions" in Code of Federal Regulations (CFR) Title 42,
					 §435.1010.
(8) Delirium--A
					 serious disturbance in an individual's mental abilities that results in a
					 decreased awareness of the individual's environment and confused
					 thinking.
(9) Designated
					 resident--A Medicaid recipient with ID or DD who is 21 years of age or older
					 and who is a resident.
(10)
					 DME--Durable medical equipment. The following items, including any accessories
					 and adaptations needed to operate or access the item:
(A) a gait trainer;
(B) a standing board;
(C) a special needs car seat or travel
					 restraint;
(D) a specialized or
					 treated pressure-reducing support surface mattress;
(E) a positioning wedge;
(F) a prosthetic device; and
(G) an orthotic device.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 2 - NURSING FACILITY RESPONSIBILITIES › Section 554.2704 - Nursing Facility Responsibilities Related to PASRR

Current through Reg. 49, No. 28; July 12, 2024
(a) If an individual seeks admission to a
					 nursing facility, the nursing facility:
(1)
					 must coordinate with the referring entity to ensure the referring entity
					 conducts a PL 1; and
(2) may
					 provide assistance in completing the PL 1, if the referring entity is a family
					 member, LAR, other personal representative selected by the individual, or a
					 representative from an emergency placement source and requests assistance in
					 completing the PL 1.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 2 - NURSING FACILITY RESPONSIBILITIES › Section 554.2705 - Nursing Facility Responsibilities Related to the Fair Hearing Process

Current through Reg. 49, No. 28; July 12, 2024
An individual or the individual's LAR or responsible
						party who is not in agreement with a PASRR determination that the individual
						does or does not require a nursing facility level of care may request a fair
						hearing to appeal the determination in accordance with 1 TAC Chapter 357,
						Subchapter A (relating to Uniform Fair Hearing Rules).
(1) If the hearing officer finds that the
					 individual requires a nursing facility level of care, a nursing facility may
					 admit the individual immediately. The individual must meet other eligibility
					 requirements for the facility to receive payment for services provided to the
					 individual.
(2) If the hearing
					 officer finds that the individual does not require a nursing facility level of
					 care, the nursing facility must not admit the individual.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 2 - NURSING FACILITY RESPONSIBILITIES › Section 554.2706 - Nursing Facility Responsibilities Related to a Designated Resident

Current through Reg. 49, No. 28; July 12, 2024
(a) A nursing
					 facility employee, nursing facility contractor, or nursing facility specialized
					 services provider must report to the LIDDA the identity of any designated
					 resident who expresses an interest in transitioning to the community.
(b) For a designated resident, a nursing
					 facility must designate staff and necessary contractors to be members of the
					 resident's SPT.
(c) A nursing
					 facility must ensure its staff and contractors who are members of a designated
					 resident's SPT:
(1) attend and participate in
					 the designated resident's SPT meetings as scheduled and convened by the service
					 coordinator;
(2) contribute to the
					 development of the designated resident's ISP; and
(3) assist the SPT by:
(A) monitoring all nursing facility
					 specialized services, LIDDA specialized services and LMHA specialized services,
					 if applicable, provided to the designated resident to ensure the designated
					 resident's needs are being met;
(B)
					 making timely referrals, service changes, and amendments to the ISP as
					 needed;
(C) ensuring that the
					 designated resident's ISP, including nursing facility specialized services,
					 nursing facility PASRR support activities, and LIDDA specialized services, is
					 coordinated with the nursing facility's comprehensive care plan;
(D) if the designated resident has expressed
					 interest in community living:
(i) developing
					 a transition plan for the designated resident to live in the community; or
(ii) identifying the action the
					 SPT will take to address concerns and remove barriers to the designated
					 resident living in the community; and
(E) reviewing and discussing the information
					 included in the ISP and transition plan with key nursing facility staff who
					 work with the resident.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 2 - NURSING FACILITY RESPONSIBILITIES › Section 554.2707 - Transition Activities Related to Designated Residents

Current through Reg. 49, No. 28; July 12, 2024
(a) A nursing facility must participate in
					 implementing the transition plan developed by an SPT for a designated
					 resident.
(b) A nursing facility
					 must document in the comprehensive care plan for a designated resident any
					 nursing facility responsibilities to support the implementation of the
					 resident's transition plan.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 2 - NURSING FACILITY RESPONSIBILITIES › Section 554.2708 - Educational and Informational Activities for Residents

Current through Reg. 49, No. 28; July 12, 2024
A nursing facility must:
(1) allow access to residents by the State
					 Ombudsman, a certified ombudsman, an ombudsman intern, and representatives of
					 the protection and advocacy system in the state for individuals with mental
					 illness or individuals with intellectual or developmental disabilities to
					 educate and inform them of their rights and options related to PASRR;
(2) allow access to designated residents to
					 support educational activities about community living options arranged by the
					 LIDDA; and
(3) provide a designated
					 resident with adequate notice and assistance to be prepared for and participate
					 in scheduled community visits.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 2 - NURSING FACILITY RESPONSIBILITIES › Section 554.2709 - Incident and Complaint Reporting

Current through Reg. 49, No. 28; July 12, 2024
In addition to reporting incidents and complaints,
						including abuse and neglect, to DADS as required by § 554.602 of this
						chapter (relating to Incidents of Abuse and Neglect Reportable to the Texas
						Department of Aging and Disability Services (DADS) and Law Enforcement Agencies
						by Facilities) and § 554.2006 of this chapter (relating to Reporting
						Incidents and Complaints), a nursing facility must report the information by
						making a telephone report immediately after learning of the incident or
						complaint:
(1) to the service
					 coordinator, if it involves a designated resident; and
(2) to the LMHA representative, if it
					 involves a designated resident with MI receiving LMHA specialized
					 services.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 3 - NURSING FACILITY SPECIALIZED SERVICES FOR DESIGNATED RESIDENTS › Section 554.2750 - Nursing Facility Specialized Services for Designated Residents

Current through Reg. 49, No. 28; July 12, 2024
(a) A nursing
					 facility must request authorization from HHSC to provide a nursing facility
					 specialized service to a designated resident if the service is agreed to by the
					 designated resident's IDT in accordance with § 554.2704 of this subchapter
					 (relating to Nursing Facility Responsibilities Related to PASRR) or the
					 designated resident's SPT in accordance with §
											17.502(2)
					 of Title 40 (relating to Service Planning Team (SPT) Responsibilities for a
					 Designated Resident).
(b) Before
					 providing a nursing facility specialized service, a nursing facility must
					 request and receive authorization from HHSC through the LTC Online Portal to
					 provide the service.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 3 - NURSING FACILITY SPECIALIZED SERVICES FOR DESIGNATED RESIDENTS › Section 554.2751 - Requesting Authorization to Provide Therapy Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Before requesting authorization to
					 provide a therapy service to a designated resident, a nursing facility must
					 ensure that:
(1) the therapy service is
					 required by the designated resident's comprehensive care plan;
(2) the designated resident has a diagnosis
					 relevant to the need for the therapy service;
(3) the therapy service is ordered by the
					 designated resident's attending physician; and
(4) a therapy provider who meets the
					 qualifications in §554.2752 of this division (relating to Qualifications
					 of a Provider of Therapy Services) completes an assessment within 30 days
					 before the nursing facility request for authorization to provide the therapy
					 service.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 3 - NURSING FACILITY SPECIALIZED SERVICES FOR DESIGNATED RESIDENTS › Section 554.2752 - Qualifications of a Provider of Therapy Services

Current through Reg. 49, No. 28; July 12, 2024
A nursing facility must ensure that therapy services are
						provided to a designated resident by:
(1) a person who:
(A) is a speech-language pathologist licensed
					 by the Texas Department of Licensing and Regulation; or
(B) meets the educational requirements and
					 has accumulated, or is in the process of accumulating, the supervised
					 professional experience required to be licensed as a speech-language
					 pathologist;
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION › Subchapter BB - NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) › Division 3 - NURSING FACILITY SPECIALIZED SERVICES FOR DESIGNATED RESIDENTS › Section 554.2753 - Payment for Therapy Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 HHSC pays a nursing facility for therapy services provided to a designated
					 resident based on fees determined in accordance with 1 TAC §
											355.313(relating
					 to Reimbursement Methodology for Rehabilitative and Specialized Services).
(b) A therapy session is one hour
					 of therapy provided to one resident.
(c) An assessment is reimbursed at the same
					 rate as a therapy session.
(d) An
					 occupational therapist or physical therapist may assess a designated resident
					 at any time to evaluate the needs of the designated resident for a therapy
					 service, but HHSC does not pay for an assessment of a designated resident
					 conducted within 180 days after the previous assessment of the designated
					 resident.
(e) A nursing facility
					 must submit a complete and accurate claim for a therapy service within 12
					 months after the last day of an authorization from HHSC to provide the
					 service.