Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter M - MISCELLANEOUS PROGRAMS › Division 3 - COMPREHENSIVE REHABILITATION SERVICES FOR INDIVIDUALS WITH A TRAUMATIC BRAIN INJURY OR TRAUMATIC SPINAL CORD INJURY › Section 355.9040 - Reimbursement Methodology for Comprehensive Rehabilitation Services Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Payment rate determination. Payment rates
					 are determined based on the methodology described for each service array.
(1) Traumatic Brain Injury (TBI) and Spinal
					 Cord Injury (SCI) Inpatient Comprehensive Medical Rehabilitation Services
					 Array. The Texas Department of Assistive and Rehabilitative Services or its
					 successor agency (DARS) negotiates contracts with inpatient facilities to
					 provide services based on data from the Centers for Medicare & Medicaid
					 Services (CMS) Healthcare Cost Report Information System (HCRIS).
(2) TBI and SCI Outpatient Services Array.
(A) For services and purchases for which a
					 specific rate can be established without regard to the individual receiving the
					 service or item, the Texas Health and Human Services Commission (HHSC) will
					 establish Comprehensive Rehabilitation Services (CRS) fee-for-service rates
					 based on a review of rates for similar services as presented in one or more of
					 the following data sources: HHSC fee schedules, previous DARS fee schedules,
					 Medicare fee schedules, other states' Medicaid fee schedules, and/or commercial
					 insurance fee schedules.
(i) Where information
					 on comparable rates is not available, HHSC will establish rates representing
					 best value based on the factors listed in §
														391.103(2) of this
					 title (relating to Definitions).
(ii) To ensure adequate access to services,
					 DARS medical director, or optometric consultant may approve exceptions to
					 established rates, with review by the HHSC Provider Finance Department
					 (PFD).
(B) For services
					 and purchases for which a specific rate can be established without regard to
					 the individual receiving the service or item, but for which a CRS rate has not
					 yet been set at the time an individual's program planning team determines that
					 the service is required, HHSC will establish an interim CRS rate.
(i) DARS will contact HHSC PFD to request an
					 interim CRS rate.
(ii) HHSC PFD
					 will determine the interim CRS rate based on the process in subparagraph (A) of
					 this paragraph.
(iii) Claims paid
					 at an interim rate established under this subparagraph will not be adjusted
					 once a rate is formally adopted for that service.
(C) For services and purchases for which the
					 cost of the service or item purchased is specific to the individual receiving
					 the service or item, HHSC will establish a CRS rate at the time of purchase,
					 based on best value, as defined by the reasonable and customary industry
					 standards for each specific service or item purchased.
(3) Post-Acute Brain Injury (PABI)
					 Residential Services Array. DARS will pay providers a per diem rate for each
					 allowable day of PABI Residential Service. DARS will also pay providers for
					 such ancillary services as have been approved in the individual's program plan
					 and received by the individual.
(A) The
					 initial per diem rate is the sum of a base component, which covers room and
					 board, administration, personal assistance, and facility and operations costs;
					 a core service component, which covers core therapy services; and an additional
					 amount for periodic required evaluations.
(i)
					 HHSC determines the base component as follows:
(I) determine the rates for the small and
					 medium classes of facilities in the Intermediate Care Facilities for
					 Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
					 program as specified in §
															355.456 of this chapter (relating
					 to Reimbursement Methodology);
(II)
					 adjust the ICF/IID rates to account for the specific needs of the CRS
					 population; and
(III) average the
					 adjusted rates for individuals with limited, extensive, pervasive, and
					 pervasive plus levels of need, weighting by the days of service for those
					 individuals from the most recently reviewed and accepted ICF/IID cost
					 reports.
(ii) HHSC
					 determines the core service component by reviewing the rates or contracted
					 payment amounts for similar services, including the five common core therapy
					 services (Physical Therapy, Occupational Therapy, Speech/Language Therapy,
					 Cognitive Rehabilitation Therapy, and Neuropsychological Therapy) paid by the
					 following payers: HHSC, the Texas Department of Aging and Disability Services
					 (DADS), DARS, Medicare, other states' Medicaid programs, and commercial
					 insurance companies. Based on this review, HHSC determines an appropriate rate
					 per hour that is multiplied by the hours in the tier structure below to
					 determine the rate for each tier. Determination of the applicable tier for a
					 day of service is governed by DARS program standards.
(I) Base - 0 hours.
(II) Base Plus - 0.5 hours.
(III) Tier 1 - 1.5 hours.
(IV) Tier 2 - 2.5 hours.
(V) Tier 3 - 3.5 hours.
(VI) Tier 4 - 4.5 hours.
(VII) Tier 5 - 5.5 hours.
(VIII) Tier 6 - 6.5 hours.
(IX) Tier 7 - 7.5 hours.
(X) Tier 8 - 8.5 hours.
(iii) HHSC determines the additional amount
					 for periodic required evaluations by averaging the common core therapy
					 evaluation rates, multiplying the average by 12, and dividing the product by
					 the number of days in the rate year.
(B) If HHSC determines that adequate cost and
					 services delivery data is available, HHSC may rebase the per diem rate
					 components.
(i) For the base component, if
					 HHSC deems it appropriate to require contracted providers to submit a cost
					 report, HHSC will determine if cost data collected as described in subsection
					 (c) of this section is reliable and sufficient to support development of a cost
					 report-based rate. If such reliable and sufficient data is available, HHSC may
					 develop a reimbursement rate using that data to replace the initial base
					 component.
(ii) For the core
					 service component, HHSC will collect and evaluate detailed service delivery
					 data. HHSC may rebase the core service component based on the detailed service
					 delivery data.
(C) HHSC
					 determines the ancillary services rates as described in paragraph (2) of this
					 subsection.
(4) PABI and
					 Post-Acute SCI Non-Residential Services Array. HHSC will set separate base
					 rates for facility-based and community-based services, as described in
					 subparagraph (A) of this paragraph. DARS will pay for each allowable billing
					 increment, as defined by program standards. DARS will also pay for such core
					 and ancillary services as have been approved in the individual's program plan
					 and received by the individual.
(A) Initial
					 rates will consist of an hourly base rate which covers administration, personal
					 assistance, and facility and operations costs.
(i) For providers offering Non-Residential
					 Services in a setting that is also a residential facility or shares space with
					 a residential facility, HHSC determines the initial hourly base rate as
					 follows:
(I) determine the rates for the small
					 and medium classes of facilities in the ICF/IID program as specified in §
															355.456 of this chapter;
(II) adjust the ICF/IID rates to account for
					 the specific needs of the CRS population and the base services to be provided
					 in a Non-Residential facility-based setting;
(III) average the adjusted rates for
					 individuals with limited, extensive, pervasive and pervasive plus levels of
					 need, weighting by the days of service for those individuals from the most
					 recently reviewed and accepted ICF/IID cost reports; and
(IV) divide the average by
					 eight.
(ii) For providers
					 offering Non-Residential Services in the home of the individual receiving the
					 service or in a community setting not connected or affiliated with a
					 residential setting, HHSC determines the initial hourly base rate as follows:
(I) determine the case management and the
					 other attendant care cost components (also known as the administration and
					 facility cost area) of the habilitation base rate under the Community Living
					 Assistance and Support Services (CLASS) program, as described in §
															355.505 of this chapter (relating
					 to Reimbursement Methodology for the Community Living Assistance and Support
					 Services Waiver Program); and
(II)
					 adjust the rate to account for specific needs of the CRS population and the
					 base services to be provided in a non-residential home or community
					 setting.
(B) If
					 HHSC deems it appropriate to require contracted providers to submit a cost
					 report, HHSC will determine if cost data collected as described in subsection
					 (c) of this section is reliable and sufficient to support development of a
					 cost-report-based rate. If such reliable and sufficient data is available, HHSC
					 may develop cost-report-based rates to replace the initial hourly base
					 rates.
(C) HHSC will determine the
					 rates for core services as described in paragraph (2)(A) of this
					 subsection.
(D) HHSC will determine
					 the rates for ancillary services as described in paragraph (2) of this
					 subsection.