reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 7 - CERTIFICATION ENTITIES › Section 354.3251 - Certification Entity Minimum Requirements

Current through Reg. 49, No. 28; July 12, 2024
A certification entity must have:
(1) experience licensing or certifying a
					 professional or paraprofessional group;
(2) documented application procedures for
					 each certification type;
(3)
					 documented procedures for certification renewal of peer specialists and peer
					 specialist supervisors;
(4)
					 documented procedures for investigating complaints and taking action against a
					 certified person or training entity, as needed;
(5) documented procedures for processing
					 appeals or grievances;
(6)
					 documented procedures for determining reciprocity with another state's peer
					 specialist or peer specialist supervisor certification;
(7) a documented fee policy;
(8) documented procedures for taking each
					 possible action on a certification, including late renewal, expiration,
					 inactive status, suspension, revocation, and voluntary
					 relinquishment;
(9) documented
					 procedures for initial certification and renewal criminal history and registry
					 checks, per § 354.3201 of this subchapter (relating to Criminal History
					 and Registry Checks);
(10)
					 documented policy and procedures for an exception process for background
					 checks, per § 354.3201(l) of this subchapter, if the certification entity
					 plans to offer an exception process;
(11) documented procedures for monitoring
					 approved training entities; and
(12) a plan for professional translation of
					 application and certification renewal documents into prevalent
					 languages.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 7 - CERTIFICATION ENTITIES › Section 354.3253 - Certification Entity Application Process

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant to be a certification entity
					 submits an application and all required documentation to HHSC, in a format
					 specified by HHSC.
(b) Within 90
					 calendar days, HHSC sends the applicant a notice of disapproval, a notice of
					 approval, or a notice of required additional materials or revisions to the
					 application.
(c) If HHSC sends a
					 notice of required additional materials or revisions to the application, the
					 applicant must submit the requested materials within 90 calendar days. HHSC may
					 require a new application if additional materials or revisions are not
					 submitted to HHSC within 90 calendar days.
(d) HHSC approves an application which is in
					 compliance with this subchapter and which properly documents applicant
					 eligibility.
(e) HHSC disapproves
					 an application if the applicant:
(1) does not
					 meet the eligibility and application requirements set out in this
					 subchapter;
(2) fails or refuses to
					 properly complete or submit required information; or
(3) knowingly presents false or misleading
					 information in the application process.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 7 - CERTIFICATION ENTITIES › Section 354.3255 - Certification Entity Ongoing Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) An approved certification entity must
					 operate according to the:
(1) requirements of
					 this subchapter; and
(2)
					 application materials that the certification entity submitted to and approved
					 by HHSC.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 8 - COMPLAINTS, APPEALS, AND HEARINGS › Section 354.3301 - Recipient Complaints

Current through Reg. 49, No. 28; July 12, 2024
Recipient complaints are addressed per Subchapter I of
						this chapter (relating to Medicaid Program Appeals
						Procedures).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 8 - COMPLAINTS, APPEALS, AND HEARINGS › Section 354.3303 - Peer Specialist or Peer Specialist Supervisor

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant for training under §
					 354.3157 of this subchapter (relating to Application for Training) may appeal a
					 denial of the application for training to the certification entity that
					 approved the training entity that is the subject of the complaint.
(b) An applicant for certification, a
					 certified peer specialist, or a certified peer specialist supervisor may appeal
					 the denial, suspension, or revocation of a certification or a denial of a
					 certification renewal to the certification entity. The certification entity
					 must have a process for addressing such appeals.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 8 - COMPLAINTS, APPEALS, AND HEARINGS › Section 354.3305 - Training Entity

Current through Reg. 49, No. 28; July 12, 2024
A training entity may appeal the denial, suspension, or
						revocation of a certification to the certification entity. The certification
						entity must have a process for addressing such appeals.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter N - PEER SPECIALIST SERVICES › Division 8 - COMPLAINTS, APPEALS, AND HEARINGS › Section 354.3307 - Certification Entity

Current through Reg. 49, No. 28; July 12, 2024
In the event of denial, suspension, or revocation of its
						approval as a certification entity by HHSC under this subchapter, a
						certification entity may request a hearing before an administrative law judge
						of the HHSC Appeals Division.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4001 - Purpose and Authority

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to describe requirements
					 related to electronic visit verification authorized by:
(1) Title XIX, Section 1903(l) of the Social
				  Security Act (42 U.S.C.
				  §
											1396b(l));
(2) Texas Government Code §
										531.024172;
				  and
(3) Texas Human Resources Code
				  §
										161.086.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4003 - 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) CDS employer--Consumer
				  directed services employer. A member or the member's legally authorized
				  representative who participates in the CDS option and whose financial
				  management services agency (FMSA) uses an electronic visit verification (EVV)
				  vendor system or an EVV proprietary system. A CDS employer is responsible for
				  hiring and retaining a service provider who delivers a service described in
				  §
										354.4005 of this subchapter
				  (relating to Personal Care Services that Require the Use of EVV) or §
										354.4006 of this subchapter
				  (relating to Home Health Care Services that Require the Use of EVV).
(2) CDS option--Consumer directed services
				  option. A service delivery option in which a CDS employer employs and retains a
				  service provider and directs the delivery of a service described in §
										354.4005 or §
										354.4006 of this
				  subchapter.
(3) CFC--Community
				  First Choice. A Medicaid state plan option governed by Code of Federal
				  Regulations, Title 42, Part 441, Subpart K, Home and Community-Based Attendant
				  Services and Supports State Plan Option (Community First Choice). CFC services
				  include the following.
(A) CFC HAB--CFC
				  habilitation. A Medicaid state plan service that provides habilitation through
				  CFC as described in §
											354.1361 of this chapter (relating
				  to Definitions).
(B) CFC PAS--CFC
				  personal assistance services. A Medicaid state plan service that provides
				  personal assistance services through CFC as described in §
											354.1361 of this chapter.
(C) CFC PAS/HAB--CFC personal assistance
				  services/habilitation. A Medicaid state plan service provided through CFC that
				  provides both personal assistance services and habilitation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4005 - Personal Care Services that Require the Use of EVV

Current through Reg. 49, No. 28; July 12, 2024
(a) A program
				  provider must ensure a service provider uses EVV to document the provision of
				  the following personal care services by the program provider:
(1) in the traditional Medicaid service model
				  also referred to as fee-for-service, including for members enrolled in STAR who
				  receive PCS through fee-for-service:
(A) CFC
				  PAS;
(B) CFC HAB;
(C) PCS provided under Texas Health Steps
				  CCP, including SRO; and
(D)
				  PCS-Behavioral Health provided under Texas Health Steps CCP, including
				  SRO;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4006 - Home Health Care Services that Require the Use of EVV

Current through Reg. 49, No. 28; July 12, 2024
(a) A program
				  provider must ensure a service provider uses EVV to document the provision of
				  the following home health care services by the program provider on or after
				  January 1, 2024:
(1) in the traditional
				  Medicaid service model also referred to as fee-for-service, for a member who
				  does not reside in a nursing facility, an ICF/IID, or an IMD, the following
				  services when provided in the residence of the member:
(A) any nursing service, other than
				  PDN;
(B) occupational therapy;
				  and
(C) physical therapy;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4007 - EVV System

Current through Reg. 49, No. 28; July 12, 2024
(a) A program
				  provider or FMSA must use one of the following EVV systems to electronically
				  document the provision of a service described in §
										354.4005 or §
										354.4006 of this subchapter
				  (relating to Personal Care Services that Require the Use of EVV and Home Health
				  Care Services that Require the use of EVV):
(1) an EVV vendor system; or
(2) an EVV proprietary system.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4009 - EVV Visit Transaction and EVV Claim

Current through Reg. 49, No. 28; July 12, 2024
(a) A program
				  provider and an FMSA must:
(1) ensure that an
				  EVV visit transaction contains the data elements required by the EVV system,
				  including:
(A) the first and last name of the
				  member who received the service;
(B) the type of service provided;
(C) the date the service was
				  provided;
(D) the time the service
				  began and the time the service ended;
(E) the first and last name of the service
				  provider who provided the service;
(F) the location, including the address or
				  geolocation, where the service was provided; and
(G) other information HHSC determines
				  necessary to ensure the accurate payment of a claim for services, as described
				  in the EVV Policy Handbook; and
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4011 - Visit Maintenance

Current through Reg. 49, No. 28; July 12, 2024
(a) A program
				  provider and an FMSA must complete visit maintenance, including the visit
				  maintenance described in §
										354.4007(d) of
				  this subchapter (relating to EVV System):
(1)
				  in accordance with the EVV Policy Handbook; and
(2) within the visit maintenance time frame
				  after the date a service was provided as described in the EVV Policy
				  Handbook.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4013 - HHSC and MCO Compliance Reviews and Enforcement Actions

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC and an MCO
				  conduct the following compliance reviews in accordance with the EVV Policy
				  Handbook:
(1) an EVV Usage Review;
(2) an EVV Landline Phone Verification
				  Review; and
(3) an EVV Required
				  Free Text Review.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4015 - EVV Training Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A program
				  provider that uses an EVV vendor system, an FMSA that uses a vendor system, and
				  a CDS employer whose FMSA uses an EVV vendor system must ensure that an EVV
				  system user completes EVV System Training described in the EVV Policy Handbook
				  and provided by the EVV vendor:
(1) before the
				  EVV system user begins using the EVV system; and
(2) yearly thereafter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4017 - Process to Request Approval of a Proposed EVV Proprietary System and Additional Requirements for a PSO

Current through Reg. 49, No. 28; July 12, 2024
(a) This section
				  applies to a program provider or FMSA seeking HHSC's approval of a proposed EVV
				  proprietary system. To request HHSC's approval of a proposed EVV proprietary
				  system, a program provider or FMSA must comply with the onboarding process
				  described in the EVV Policy Handbook, which includes:
(1) completing and submitting the EVV
				  Proprietary System Request Form; and
(2) participating in an operational readiness
				  review session.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4019 - Access to EVV System and EVV Documentation

Current through Reg. 49, No. 28; July 12, 2024
A program provider and an FMSA must:
(1) allow HHSC and the MCO with which the
				  program provider or FMSA has a contract immediate, direct, and on-site access
				  to the EVV system the program provider or FMSA uses;
(2) at HHSC's request, allow HHSC to review
				  EVV system documentation or obtain a copy of that documentation at no charge to
				  HHSC; and
(3) at the request of an
				  MCO with which an EVV claim is filed, allow the MCO to review EVV system
				  documentation related to the EVV claim or obtain a copy of that documentation
				  at no charge to the MCO.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4021 - Additional Requirements

Current through Reg. 49, No. 28; July 12, 2024
A program provider, an FMSA, a CDS employer, a service
					 provider, a member, and an MCO must comply with:
(1) applicable state and federal laws, rules,
				  regulations, including the Health Insurance Portability Accountability Act of
				  1966 at 42 U.S.C. §
											1320d, et. seq., and regulations adopted
				  under that act at 45 CFR Parts 160 and 164; and
(2) the EVV Policy Handbook.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4023 - Sanctions

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC or an MCO
				  may propose to recoup funds paid to a program provider or FMSA as described in:
(1)
											§
											354.4009(d) of
				  this subchapter (relating to EVV Visit Transaction and EVV Claim);
				  and
(2)
											§
											354.4013(h) of
				  this subchapter (relating to HHSC and MCO Compliance Reviews and Enforcement
				  Actions.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter O - ELECTRONIC VISIT VERIFICATION › Section 354.4025 - Administrative Hearing

Current through Reg. 49, No. 28; July 12, 2024
(a) If, as
				  described in this subchapter, HHSC proposes to terminate the contract of a
				  program provider or FMSA, proposes to recoup funds paid to a program provider
				  or FMSA, or imposes a vendor hold on a program provider or FMSA, the program
				  provider or FMSA may request an administrative hearing in accordance with
				  §
										357.484 of this title (relating to
				  Request for a Hearing).
(b) If, as
				  described in this subchapter, an MCO proposes to terminate the contract of a
				  program provider or FMSA, proposes to recoup funds paid to a program provider
				  or FMSA, or imposes a vendor hold on a program provider or FMSA, the program
				  provider or FMSA may appeal the proposed action in accordance with the MCO's
				  policy.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter P - AUTISM SERVICES › Division 1 - GENERAL PROVISIONS › Section 354.5001 - Purpose and Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Applied behavior
					 analysis (ABA) services for autism are covered through the Texas Health
					 Steps-Comprehensive Care Program (THSteps-CCP) for Medicaid enrolled children:
(1) who are under 21 years of age;
(2) who have a diagnosis of autism spectrum
					 disorder (ASD); and
(3) for whom
					 ABA services are medically necessary and clinically appropriate and
					 effective.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter P - AUTISM SERVICES › Division 1 - GENERAL PROVISIONS › Section 354.5003 - 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) ABA--Applied behavior
					 analysis. The practice of applying the principles of learning and behavior,
					 specifically about how behavior affects, and is affected by, past and current
					 environmental events in conjunction with biological variables to improve the
					 human condition through behavior change that is based on current,
					 evidence-based, specialized principles, and delivered by a qualified
					 professional under this subchapter.
(2) APRN--Advanced practice registered nurse.
					 A person who:
(A) is currently licensed
					 without restriction as an advanced practice registered nurse by the Texas Board
					 of Nursing under Texas Occupations Code (TOC), Chapter 301 (relating to
					 Nurses); and
(B) practices under a
					 current, executed prescriptive authority agreement with a qualified physician
					 in accordance with TOC, Chapter 157, Subchapter B (relating to Delegation to
					 Advanced Practice Registered Nurses and Physician
					 Assistants).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter P - AUTISM SERVICES › Division 2 - SERVICE PROVIDERS › Section 354.5011 - Providers of Applied Behavior Analysis (ABA) Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Providers of ABA
					 services include:
(1) LBAs who:
(A) practice within the LBA's state scope of
					 practice and licensure requirements, meet all relevant provider qualifications,
					 and comply with all applicable law, rules, and requirements under this
					 subchapter;
(B) are currently
					 enrolled in Texas Medicaid through TMHP;
(C) for claims submission purposes, serve as
					 the Medicaid enrolled rendering provider for all ABA evaluation, treatment, and
					 supervision services, including those ABA services rendered under the LBA's
					 supervision by an LaBA or a BT, as applicable, where the rendering provider for
					 the specific service, which may be the LBA, LaBA, or BT, may or must, as
					 applicable, be indicated on the claim with an appropriate Medicaid modifier;
					 and
(D) may provide the following
					 Medicaid reimbursable ABA services when authorized:
(i) ABA evaluation and treatment services to
					 the child;
(ii) education and
					 training services to the LAR, parent, or caregiver, as applicable;
(iii) supervision services for the LaBA or
					 BT, as applicable, to whom the LBA has delegated service delivery;
					 and
(iv) required participation in
					 ABA-related interdisciplinary team meetings, if
					 utilized.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter P - AUTISM SERVICES › Division 3 - PARAMETERS FOR SERVICE PROVISION › Section 354.5021 - Service Description, Requirements, and Limitations for Providing Applied Behavior Analysis (ABA) Services

Current through Reg. 49, No. 28; July 12, 2024
(a) This subsection
					 describes ABA services and Requirements for providing ABA services.
(1) ABA services under this subchapter may be
					 available only when the documentation of the diagnosis of ASD, or re-evaluation
					 of the diagnosis:
(A) identifies current ASD
					 symptoms and symptom severity level using the DSM, as determined by a qualified
					 medical or health care professional under the Autism Section of the TMPPM,
					 including a member of an interdisciplinary diagnostic team who is authorized by
					 licensure to use the DSM;
(B)
					 includes data from use and interpretation of an additional ASD diagnostic tool
					 or tools, as clinically and age appropriate, as determined by a qualified
					 medical or health care professional under the Autism Section of the TMPPM,
					 including a member of an interdisciplinary diagnostic team who is authorized by
					 licensure to use the ASD diagnostic tool or tools;
(C) includes a determination that the
					 diagnosis of ASD is clinically appropriate, made by a qualified medical or
					 health care professional, or a PCP or other physician working in collaboration
					 with an authorized interdisciplinary diagnostic team under this subchapter and
					 the Autism Section of the TMPPM, and confirms that the analysis of all elements
					 of a comprehensive diagnostic evaluation at a minimum is the basis for the
					 determination;
(D) is current
					 (within three years of the request for ABA services) to provide timely age- and
					 developmentally-appropriate information;
(E) includes all additional required items
					 for the documentation of the diagnosis in the Autism Section in the TMPPM;
					 and
(F) may facilitate delivery of
					 holistic health care services for the child.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter P - AUTISM SERVICES › Division 3 - PARAMETERS FOR SERVICE PROVISION › Section 354.5023 - Additional Medicaid Reimbursement Limitations and Exclusions Specific to Applied Behavior Analysis (ABA) Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Texas Medicaid
					 will not reimburse ABA services when ABA services:
(1) address academic goals;
(2) address goals only related to
					 performative social norms that do not significantly impact health, safety, or
					 independence;
(3) are not expected
					 to result in improvements in the child's level of functioning, other than
					 medically necessary services at the maintenance or consultative
					 level;
(4) do not require the
					 specific skills and judgment of an LBA to perform or supervise;
(5) do not meet evidence-based standards of
					 practice for ABA for effective treatment of ASD;
(6) use any experimental or investigational
					 treatment methods even with legally effective consent;
(7) are not generally accepted as clinically
					 effective or appropriate, or not within the normal course and duration of
					 treatment for medically necessary ABA services;
(8) are for the convenience of those who are
					 closest to the child or the provider (e.g., as respite care, or limiting
					 treatment to a setting chosen by provider for convenience);
(9) do not include the child age- and
					 developmentally-appropriately engaging in a clinical ABA therapeutic
					 relationship;
(10) are provided by
					 a clinic or agency owned or partially owned by the child (if the child is
					 legally authorized to represent his/herself)) or the child's LAR;
(11) are provided directly by the child's
					 LAR;
(12) are delivered by a BT in
					 the school setting as a shadow or an aide or to provide general support to the
					 child; and
(13) include separate
					 billing for:
(A) indirect ABA service time
					 related to ABA treatment; parent or caregiver education and training;
					 ABA-related interdisciplinary team meetings; or supervision of an LaBA or BT;
					 for example, pre- and post-work for a session are not reimbursed separately,
					 other than the pre- and post-work that is allowable for ABA evaluation
					 services; or
(B) any indirect
					 supervision, or direct supervision which does not otherwise meet all
					 requirements in this subchapter, the Autism Section of the TMPPM, and the
					 relevant Current Procedural Terminology code.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.101 - Introduction

Current through Reg. 49, No. 28; July 12, 2024
(a) The information in §
										RSA
				  355.102 of this chapter (relating to General
				  Principles of Allowable and Unallowable Costs), §
										RSA
				  355.103 of this chapter (relating to
				  Specifications for Allowable and Unallowable Costs), §
										RSA 355.104 of this
				  chapter (relating to Revenues), and §
										RSA
				  355.105 of this chapter (relating to General
				  Reporting and Documentation Requirements, Methods, and Procedures) applies to
				  Intermediate Care Facilities for Persons with Mental Retardation, Home and
				  Community-based Services, Service Coordination/Targeted Case Management,
				  Rehabilitative Services, School Health and Related Services, and Texas Home
				  Living programs cost reports pertaining to providers' fiscal years ending in
				  calendar year 2004 and subsequent years. For all other programs these sections
				  apply to cost reports pertaining to the providers' fiscal years ending in
				  calendar year 1997 and subsequent years.
(b) The following terms, when used in this
				  subchapter, have the following meanings:
(1)
				  DADS--The Texas Department of Aging and Disability Services, its successor
				  agency, or designee.
(2) DARS--The
				  Texas Department of Assistive and Rehabilitative Services, its successor
				  agency, or designee.
(3) DSHS--The
				  Texas Department of State Health Services, its successor agency, or
				  designee.
(4) HHSC--The Health and
				  Human Services Commission, its successor agency, or designee.
(5) Line item--A specific informational,
				  statistical, revenue, or expense data element in a cost report.
(6) TEA--The Texas Education Agency, its
				  successor agency, or designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.104 - Revenues

Current through Reg. 49, No. 28; July 12, 2024
A provider must report in the format specified by the Texas
					 Health and Human Services Commission (HHSC) revenues that reflect the activity
					 of the provider and that are directly related to the provision of contracted
					 client care or services. A provider may not report revenues from other programs
					 or activities in which the contracted provider may be engaged.
(1) Revenues should be reported net of
				  charity allowances and courtesy allowances, and bad debt expense.
(2) Any revenues received directly by the
				  provider through a voucher or from other direct payment systems as described in
				  §
										RSA
				  355.103(b)(20)(K) of this
				  title (relating to Specifications for Allowable and Unallowable Costs) must not
				  be reported on the cost report unless specifically requested by the
				  program-specific reimbursement methodology rules, HHSC procedures, or cost
				  report instructions.
(3) For
				  guidelines in reporting revenue received as a federal grant, refer to §
										RSA
				  355.103(b)(18) of this title
				  and to program-specific reimbursement methodology rules.
(4) For guidelines in offsetting revenues
				  against certain expenses, refer to §
										RSA
				  355.103(b)(18)(D) of this
				  title.
(5) For reporting interest
				  income:
(A) report as interest income, with
				  no offset to interest expense, any interest earned on funded depreciation
				  accounts, qualified pension funds, and debt service reserve funds required by
				  non-related party lenders; and
(B)
				  report as interest income, interest earned from all other sources, after first
				  netting this income against interest expenses in the following sequence:
(i) interest incurred on working capital
				  loans; and
(ii) interest incurred
				  on all other loans except mortgage loans. Mortgage loans are not to be
				  offset.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.106 - Basic Objectives and Criteria for Audit and Desk Review of Cost Reports

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				  Health and Human Services Commission (HHSC) conducts desk reviews and field
				  audits of provider cost reports in order to ensure that all financial and
				  statistical information reported in the cost reports conforms to all applicable
				  rules and instructions. Cost reports must be completed according to
				  instructions and rules in accordance with §
										RSA
				  355.105(b)(4) of this title
				  (relating to General Reporting and Documentation Requirements, Methods, and
				  Procedures). HHSC may require supporting documentation other than that
				  contained in the cost report to substantiate reported information.
(1) For nursing facilities, failure to
				  complete cost reports according to instructions and rules in accordance with
				  §
											RSA
				  355.105(b)(4) of this title
				  may result in vendor hold as specified in §
											RSA 355.403 of this
				  title (relating to Vendor Hold).
(2) For Intermediate Care Facilities for
				  Persons with Mental Retardation, Home and Community-based Services, Service
				  Coordination/Targeted Case Management, Rehabilitative Services, and Texas Home
				  Living programs, failure to complete cost reports according to instructions and
				  rules constitutes an administrative contract violation. In the case of an
				  administrative contract violation, procedural guidelines and informal
				  reconsideration and/or appeal processes are specified in §
											RSA
				  355.111 of this title (relating to
				  Administrative Contract Violations).
(3) For School and Health Related Services
				  (SHARS), failure to complete cost reports according to instructions and rules
				  described in §
											RSA
				  355.105(b)(4) of this title
				  may result in an administrative contract violation as specified in §
											RSA
				  355.8443 of this title (relating to
				  Reimbursement Methodology for School Health and Related Services
				  (SHARS)).
(4) For all other
				  programs, failure to complete cost reports according to instructions and rules
				  in accordance with §
											RSA
				  355.105(b)(4) of this title
				  constitutes an administrative contract violation. In the case of an
				  administrative contract violation, procedural guidelines and informal
				  reconsideration and/or appeal processes are specified in §
											RSA
				  355.111 of this title.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.107 - Notification of Exclusions and Adjustments

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas Health and Human Services
				  Commission (HHSC) notifies providers of exclusions and adjustments to reported
				  expenses made during HHSC's desk reviews and field audits of cost reports. HHSC
				  mails notices of desk-review exclusions and adjustments within 15 working days
				  after finalization of the desk review by HHSC. The notice consists of a letter
				  to the provider and desk-review adjustment sheet(s), or an e-mail notification
				  to the provider and online access to view the cost report adjustments, that
				  specifies:
(1) the line items on the cost
				  report that have been adjusted or excluded;
(2) the amount of each adjustment or
				  exclusion; and
(3) the principal
				  reason for each adjustment or exclusion.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.109 - Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs

Current through Reg. 49, No. 28; July 12, 2024
(a) In conducting
				  reimbursement reviews for adjustments, the Texas Health and Human Services
				  Commission (HHSC) takes into consideration changes in laws, rules, regulations,
				  policies, guidelines, or economic factors which will have a demonstrable
				  material impact on most contracted providers' costs of providing services
				  meeting federal and state standards.
(1) HHSC
				  may recommend adjustments to reimbursement when federal or state laws, rules,
				  regulations, policies, or guidelines are adopted, promulgated, judicially
				  interpreted, or otherwise changed in ways that affect allowable costs. The law,
				  rule, regulation, policy, or guideline change must result in necessary changes
				  in allowable costs that:
(A) affect most, if
				  not all, contracted providers; and
(B) require contracted providers to take
				  definitive action to incur additional allowable costs not included in the cost
				  database used to determine reimbursements and which would not otherwise be
				  covered in reimbursements.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.110 - Informal Reviews and Formal Appeals

Current through Reg. 49, No. 28; July 12, 2024
(a) General provisions.
(1) Definitions. The following words or
				  terms, when used in this section, have the following meanings, unless the
				  context clearly indicates otherwise.
(A)
				  Formal appeal--An administrative hearing requested by an interested party under
				  subsection (d) of this section and conducted in accordance with procedures
				  described at §§
												RSA
				  357.481-
				  RSA
				  357.498 of this title (relating to Hearings
				  Under the Administrative Procedure Act).
(B) Informal review--The informal
				  reexamination of an action or determination by the Texas Health and Human
				  Services Commission (HHSC) under this chapter requested by an interested party
				  and conducted in accordance with subsection (c) of this section.
(C) Interested party--An HHSC Enterprise
				  contracted or enrolled provider.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.111 - Administrative Contract Violations

Current through Reg. 49, No. 28; July 12, 2024
The Texas Health and Human Services Commission (HHSC) may
					 take the following actions for administrative contract violations.
(1) HHSC grants the following compliance
				  periods for administrative contract violations:
(A) For failure to submit a cost report by
				  the due date, HHSC grants the provider a compliance period of no more than 15
				  calendar days.
(B) For all other
				  administrative contract violations, HHSC grants the provider a compliance
				  period of no more than 15 calendar days to correct a contract violation. At the
				  end of the compliance period, if HHSC determines that a contract violation is
				  not corrected, but determines that the provider has made substantial progress
				  toward correcting the contract violation, HHSC may grant an additional one-time
				  extension period of up to 15 calendar days.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.112 - Attendant Compensation Rate Enhancement

Current through Reg. 49, No. 28; July 12, 2024
(a) Eligible
				  programs. Providers contracted in the following programs are eligible to
				  participate in the attendant compensation rate enhancement:
(1) Community Living Assistance and Support
				  Services (CLASS)--Direct Service Agency (DSA);
(2) Day Activity and Health Services
				  (DAHS);
(3) Deaf-Blind with
				  Multiple Disabilities Waiver (DBMD);
(4) Home and Community-based Services
				  (HCS);
(5) Intermediate Care
				  Facilities for Individuals with Intellectual Disability or Related Conditions
				  (ICF/IID) ("Related Conditions" has the same meaning as in 26 TAC §
											261.203(relating to
				  Definitions));
(6) Primary Home
				  Care (PHC);
(7) Residential Care
				  (RC); and
(8) Texas Home Living
				  (TxHmL).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter A - COST DETERMINATION PROCESS › Section 355.114 - Consumer Directed Services Payment Option

Current through Reg. 49, No. 28; July 12, 2024
(a) For all programs providing consumer
				  directed services (CDS) except the Home and Community-based Services (HCS)
				  program:
(1) The monthly payment to the
				  contracted CDS agency is determined by modeling the estimated cost to carry out
				  the responsibilities of the CDS agency.
(2) The rates for CDS that provide the funds
				  available to the consumers participating in CDS are modeled and are based on
				  the payment rates paid to contracted agencies for providing services to
				  consumers who do not participate in CDS, and then removing from those rates
				  amounts needed to fund CDS agencies responsibilities.
(3) The sum of the payments to the contracted
				  CDS agencies for a 12-month period and the funds available to the consumers
				  participating in CDS for the same 12-month period will not exceed, in the
				  aggregate, the amount that would have been paid to agencies for the same 12
				  month period if the consumers were not participating in CDS.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter B - ESTABLISHMENT AND ADJUSTMENT OF REIMBURSEMENT RATES FOR MEDICAID › Section 355.201 - Establishment and Adjustment of Reimbursement Rates for Medicaid

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. Unless the context clearly
				  indicates otherwise, the following words and terms when used in this section
				  are defined as follows:
(1) Centers for
				  Medicare & Medicaid Services (CMS)--The federal agency within the United
				  States Department of Health and Human Services responsible for overseeing and
				  directing Medicare and Medicaid.
(2) HHSC--The Texas Health and Human Services
				  Commission or its designee.
(3)
				  Medical assistance--A medical or health care related service, item, or supply
				  that is delivered to a Medicaid recipient and is approved and authorized for
				  payment or reimbursement by HHSC or CMS pursuant to state and federal
				  law.
(4) Program--A specific
				  component of the Medicaid program for which HHSC establishes either a
				  methodology to reimburse a provider or a specific fee, payment rate, or charge
				  that is paid to a provider for medical assistance in accordance with state and
				  federal law.
(5) Provider--A health
				  care practitioner, institution, or other entity that is enrolled in the medical
				  assistance program and is authorized to submit claims for payment or
				  reimbursement of medical assistance.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter B - ESTABLISHMENT AND ADJUSTMENT OF REIMBURSEMENT RATES FOR MEDICAID › Section 355.205 - Rule for Emergency Temporary Reimbursement Rate Increases and Limitations on Use of Emergency Temporary Funds for Medicaid in Response to Novel Coronavirus (COVID-19)

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  The Texas Health and Human Services Commission (HHSC) uses the methodology
				  described in this section to establish emergency temporary reimbursement rate
				  increases while limiting use of the funds received by the provider through the
				  increases. This section also describes the circumstances in which recoupments
				  will be necessary for certain provider types or services during the COVID-19
				  federal public health emergency period. Provider types and services that are
				  eligible for increased reimbursement rates under this section include:
(1) all provider types and services for which
				  a reimbursement rate methodology is described in this chapter; and
(2) any other provider or service that is
				  established in response to COVID-19.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter B - ESTABLISHMENT AND ADJUSTMENT OF REIMBURSEMENT RATES FOR MEDICAID › Section 355.207 - American Rescue Plan Act Home and Community-Based Services Provider Retention Payments

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  The Texas Health and Human Services Commission (HHSC) uses the methodology
				  described in this section to establish retention payments for Home and
				  Community-Based Services (HCBS) under HHSC's spending plan pursuant to section
				  9817 of the American Rescue Plan Act.
(b) Definitions. The following words and
				  terms, when used in this section, have the following meanings, unless the
				  context clearly indicates otherwise:
(1)
				  Direct Care staff--
(A) A provider, or an
				  employer in the consumer directed services (CDS) option, who provides the
				  following services, as described in Title 40 Texas Administrative Code (TAC)
				  §49.101 (relating to Application):
(i)
				  Community Attendant Services program services;
(ii) Primary Home Care program
				  services;
(iii) day activity and
				  health services;
(iv) in the
				  Community Living Assistance and Support Services Program:
(I) community first choice personal
				  assistance services/habilitation (CFC PAS/HAB);
(II) habilitation (transportation);
(III) supported employment;
(IV) in-home respite;
(V) nursing services; or
(VI) specialized nursing services;
(v) in the Deaf-Blind Multiple
				  Disabilities Program:
(I) CFC
				  PAS/HAB;
(II) residential
				  habilitation (transportation);
(III) in-home respite;
(IV) licensed assisted living;
(V) licensed home health assisted
				  living;
(VI) supported
				  employment;
(VII) day
				  habilitation;
(VIII) nursing
				  services; or
(IX) specialized
				  nursing services;
(vi)
				  in the Home and Community-Based Services Program:
(I) CFC PAS/ HAB;
(II) supported home living
				  (transportation);
(III) supervised
				  living;
(IV) residential support
				  services;
(V) day
				  habilitation;
(VI) supported
				  employment;
(VII) in-home
				  respite;
(VIII) nursing services;
				  or
(IX) specialized nursing
				  services; and
(vii) in
				  the Texas Home Living Program:
(I) CFC
				  PAS/HAB;
(II) community support
				  services (transportation);
(III)
				  day habilitation;
(IV) supported
				  employment;
(V) in-home
				  respite;
(VI) nursing services;
				  or
(VII) specialized nursing
				  services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter C - REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES › Section 355.304 - Direct Care Staff Spending Requirement on or after September 1, 2023

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction.
				  The Texas Health and Human Services Commission (HHSC) uses the methodology
				  described in this section to establish rate increases to the direct care staff
				  component base rate for nursing facility services while limiting the use of
				  funds received by the provider through these increases. This section describes
				  the spending requirements associated with receiving the rate increases and
				  circumstances in which recoupments will be necessary for a provider's failure
				  to meet those requirements.
(b)
				  Definitions. The following words and terms, when used in this section, have the
				  following meanings, unless the context clearly indicates otherwise.
(1) Direct care staff base rate--The direct
				  care staff base rate is calculated in accordance with §
											355.308(k) of this
				  chapter (relating to Direct Care Staff Rate Component.
(2) Direct care staff cost center--This cost
				  center will include compensation for employee and contract labor Registered
				  Nurses (RNs), including Directors of Nursing (DONs) and Assistant Directors of
				  Nursing (ADONs); Licensed Vocational Nurses (LVNs), including DONs and ADONs;
				  medication aides; and nurse aides performing nursing-related duties for
				  Medicaid contracted beds.
(3) Rate
				  year--The standard rate year begins on the first day of September and ends on
				  the last day of August of the following year.
(4) Responsible entity--The contracted
				  provider, owner, or legal entity that received the revenue to be recouped is
				  responsible for the repayment of any recoupment amount.