reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter B - RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO › Section 265.14 - Service Back-up Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) At the initial
				  meeting with the SRO provider, the individual or LAR presents the service
				  back-up plan to the SRO provider that includes:
(1) specific back-up plan
				  strategies;
(2) the specific steps
				  to implement each strategy, including contact with the SRO provider;
				  and
(3) the contact information for
				  each person or entity listed in the service back-up plan.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter B - RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO › Section 265.15 - Management Agreement

Current through Reg. 49, No. 28; July 12, 2024
(a) At the initial
				  meeting with an SRO provider, an individual or LAR and the SRO provider must
				  negotiate a management agreement that establishes:
(1) the responsibilities of the individual
				  and the SRO provider;
(2) how often
				  quality assurance visits will occur; and
(3) how often quality assurance phone
				  contacts will occur.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter B - RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO › Section 265.16 - Service Provider Selection

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  potential service provider must pass the pre-employment screenings, including
				  criminal history and registry checks, conducted by an SRO provider in order to
				  be eligible to be selected as a service provider.
(b) An individual, LAR, or representative
				  interviews and selects service providers who:
(1) have been recommended by the individual;
				  or
(2) are currently employed by
				  the SRO provider and match the skills and traits identified by the individual
				  during the SRO orientation.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter B - RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO › Section 265.17 - Service Provider Orientation Training

Current through Reg. 49, No. 28; July 12, 2024
(a) At or before the time a service provider
				  starts delivering services, an individual, LAR or representative must train the
				  selected service provider on the specific manner in which the individual
				  prefers the approved tasks in the service plan to be delivered.
(b) If negotiated with an individual, an SRO
				  provider may assist with the service provider orientation in the individual's
				  home.
(c) An individual must
				  document the service provider orientation, including:
(1) the tasks to be performed;
(2) the training aspects specific to the
				  needs of the individual;
(3) the
				  date on which orientation was completed;
(4) any scheduled follow-up training to be
				  conducted; and
(5) an evaluation of
				  the orientation.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter B - RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO › Section 265.18 - Individual Responsibilities in the SRO

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An individual, LAR, or representative who chooses to participate in the SRO
				  serves as the daily manager of service delivery, including scheduling and
				  managing a service provider.
(b)
				  The individual who chooses to participate in the SRO must ensure the service
				  provider is following the service plan, including:
(1) ensuring and verifying that the service
				  provider does only the tasks listed in the service plan and works only the
				  number of hours listed in the service plan;
(2) complying with SRO provider policies,
				  including payroll policies;
(3)
				  reviewing, approving, and signing service provider time sheets; and
(4) ensuring that the service provider
				  submits time sheets to the SRO provider within the required time
				  frames.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter B - RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO › Section 265.19 - Supervision and Evaluation

Current through Reg. 49, No. 28; July 12, 2024
An individual, LAR, or representative must:
(1) evaluate a service provider's job
				  performance at the time designated by the SRO provider; and
(2) document and submit each performance
				  evaluation to the SRO provider.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter C - RESPONSIBILITIES OF AN SRO PROVIDER › Section 265.21 - Contracting as an SRO Provider

Current through Reg. 49, No. 28; July 12, 2024
To become an SRO provider, a provider must:
(1) have a current program contract with
				  DADS;
(2) request a contract
				  amendment to the program contract that allows an individual receiving one or
				  more services from the provider to have a service delivered through SRO;
				  and
(3) have at least one person
				  employed by the provider attend and complete the SRO training authorized by
				  DADS.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter C - RESPONSIBILITIES OF AN SRO PROVIDER › Section 265.22 - SRO Provider Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  At the initial meeting with an individual, an SRO provider must:
(1) negotiate a management agreement with the
				  individual;
(2) discuss and approve
				  a service back-up plan with the individual;
(3) provide SRO provider time sheets to the
				  individual and explain the submission process, including how frequently time
				  sheets must be completed and submitted; and
(4) orient the individual to the SRO
				  provider's evaluation process, including forms and the schedule for evaluating
				  service providers.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter D - TERMINATION OF THE SRO › Section 265.31 - Voluntary Termination of Participation in the SRO

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual may request voluntary
				  termination of participation in the SRO at any time.
(b) A case manager or service coordinator
				  must terminate support consultation in the individual's service plan when
				  participation in the SRO is terminated.
(c) The termination must last at least 90
				  calendar days before the individual may be considered for re-enrollment in the
				  SRO.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter D - TERMINATION OF THE SRO › Section 265.32 - Involuntary Termination of Participation in the SRO

Current through Reg. 49, No. 28; July 12, 2024
(a) A case manager or service coordinator may
				  involuntarily terminate an individual from participation in the SRO, in
				  accordance with the requirements of the individual's program, in any of the
				  following situations:
(1) non-delivery of
				  services or extended breaks in services;
(2) noncompliance with SRO management
				  responsibilities;
(3) noncompliance
				  with a service back-up plan; or
(4)
				  over- or under-utilization of services or funds allocated in the individual's
				  service plan for delivery of services to the individual through the SRO and in
				  accordance with the requirements of the individual's program.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter D - TERMINATION OF THE SRO › Section 265.33 - Immediate Jeopardy and Involuntary Termination of Participation in the SRO

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual's
				  case manager or service coordinator must immediately convene the individual's
				  service planning team concerning issues that may warrant immediate termination
				  of the individual's participation in the SRO, including:
(1) allegations of abuse, neglect,
				  exploitation, or fraud; and
(2)
				  concerns about the individual's health, safety, or welfare.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter E - SUPPORT CONSULTATION › Section 265.41 - Support Consultation Services

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Support consultation is provided by a person who meets the qualifications of a
				  support advisor as described in Chapter 41 of this title (relating to Consumer
				  Directed Services Option). A support advisor may be an employee or contractor
				  of:
(1) An FMSA; or
(2) another entity.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter E - SUPPORT CONSULTATION › Section 265.42 - Support Advisor Responsibilities

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  support advisor must conduct the initial SRO orientation. The support advisor
				  must document and notify the SRO provider and case manager or service
				  coordinator that the individual has completed the orientation before SRO
				  services can begin.
(b) A support
				  advisor must assist an individual, in accordance with the individual's service
				  plan, with:
(1) completing forms,
				  assessments, and other documents required by the individual's program that
				  require individual or LAR input or completion;
(2) complying with requirements of the
				  individual's program as related to services delivered through the
				  SRO;
(3) interviewing potential
				  service providers, preparing job descriptions, and training service
				  providers;
(4) managing service
				  providers for authorized program services delivered through the SRO;
(5) helping an individual to use effective
				  communication, decision-making, and problem-solving skills;
(6) developing, revising, and implementing
				  service back-up plans;
(7)
				  developing, revising, and implementing corrective action plans;
(8) complying with the requirements of the
				  individual's program and this chapter;
(9) contacting appropriate persons or
				  entities based on their roles, responsibilities, and eligibility, including:
(A) a case manager or service coordinator;
				  and
(B) government agencies,
				  including DADS and the Department of Family and Protective Services;
				  and
(10) teaching ongoing
				  supervisory-related skills.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter F - BUDGET › Section 265.51 - Service Provider Payment in the SRO

Current through Reg. 49, No. 28; July 12, 2024
Payment rates for the SRO are the same rates determined for
					 the program when services are delivered through a program
					 provider.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter G - REPORTING ALLEGATIONS › Section 265.61 - Reporting Allegations

Current through Reg. 49, No. 28; July 12, 2024
A person to whom this chapter applies must report any
					 suspicion or knowledge of abuse, neglect, or exploitation of an individual in
					 accordance with existing state laws and DADS rules.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 265 - SERVICE RESPONSIBILITY OPTION › Subchapter H - OVERSIGHT › Section 265.71 - Oversight

Current through Reg. 49, No. 28; July 12, 2024
DADS oversees roles and responsibilities of the
					 following:
(1) an individual or LAR
				  who chooses to participate in the SRO;
(2) a representative;
(3) an FMSA;
(4) a support advisor;
(5) an SRO provider;
(6) a case manager; and
(7) a service coordinator.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter A - INTRODUCTION › Section 266.101 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this chapter,
					 shall have the following meanings, unless the context clearly indicates
					 otherwise. Individual subchapters may have definitions that are specific to the
					 subchapter.
(1) APRN--Advanced
				  practice registered nurse. A registered nurse licensed under Texas Occupations
				  Code Chapter 301 to practice as an advanced practice registered
				  nurse.
(2) Attending physician--A
				  person who:
(A) is any of the following:
(i) a doctor of medicine or osteopathy
				  legally authorized to practice medicine and surgery by the State in which he or
				  she performs that function or action;
(ii) an APRN who meets the training,
				  education, and experience requirements as described in
				  42 CFR §
													410.75(b); or
(iii) a physician assistant who meets the
				  requirements in
				  42 CFR §
													410.74(c);
				  and
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter A - INTRODUCTION › Section 266.103 - Submitting Written Information to HHSC

Current through Reg. 49, No. 28; July 12, 2024
A hospice must submit written information to HHSC in
					 accordance with the instructions on the HHSC website.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.201 - Duration of Hospice Care Coverage: Election Periods

Current through Reg. 49, No. 28; July 12, 2024
(a) An individual who is eligible may elect
				  to receive hospice care during one or more of the following election periods:
(1) an initial 90-day period;
(2) a subsequent 90-day period; or
(3) an unlimited number of subsequent 60-day
				  periods.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.203 - Certification of Terminal Illness

Current through Reg. 49, No. 28; July 12, 2024
(a) Written
				  certification.
(1) For the initial election
				  period, a hospice must obtain a signed and dated Physician Certification of
				  Terminal Illness Form that meets the requirements of this section before the
				  hospice submits an initial request for payment, but no more than 15 days before
				  the election period begins.
(2) For
				  an election period after the initial election period, a hospice must obtain a
				  signed and dated Physician Certification of Terminal Illness Form that meets
				  the requirements of this section before the previous period expires, but no
				  more than 15 days before the next election period begins.
(3) The hospice must submit the Physician
				  Certification of Terminal Illness Form to the TMHP Long Term Care Online
				  Portal.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.205 - Election of Hospice Care

Current through Reg. 49, No. 28; July 12, 2024
(a) Filing an
				  election statement. An individual who meets the eligibility requirements for
				  hospice care may elect hospice by filing the Individual
				  Election/Cancellation/Update Form with a particular hospice. If the individual
				  is physically or mentally incapacitated, the individual's representative may
				  file the form. If the individual is dually eligible for Medicaid and Medicare,
				  the individual must elect the Medicaid and Medicare hospice benefit at the same
				  time.
(b) Content of election
				  statement. The election statement must include the following:
(1) identification of the particular hospice
				  that will provide care to the individual;
(2) the individual's or representative's
				  acknowledgment that the individual or representative has been given a full
				  explanation of the palliative rather than curative nature of hospice care as it
				  relates to the individual's terminal illness;
(3) acknowledgment that certain Medicaid
				  services, as set forth in subsection (d) of this section, are waived by the
				  election;
(4) the effective date of
				  the election, which may be the first day of hospice care or a later date, but
				  must be no earlier than the date of the election statement; and
(5) the signature of the individual or
				  representative.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.207 - Revoking the Election of Hospice Care

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  An individual or representative may revoke the individual's election of hospice
				  care at any time during an election period. If the individual is dually
				  eligible for Medicaid and Medicare, the individual must revoke the Medicaid and
				  Medicare hospice election at the same time.
(b) To revoke the election of hospice care,
				  the individual or representative must file the Individual
				  Election/Cancellation/Update Form with the hospice.
(c) The revocation effective date may not be
				  earlier than the date the revocation is made.
(d) An individual, upon revoking the election
				  of hospice care for a particular election period:
(1) is no longer covered under Medicaid for
				  hospice care;
(2) resumes Medicaid
				  coverage of the benefits waived under § 266.205(d) of this subchapter
				  (relating to Election of Hospice Care); and
(3) may at any time elect to receive hospice
				  coverage as long as the individual meets eligibility requirements.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.209 - Requirements for Payments

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for Medicaid hospice payment, the hospice
					 must document that services provided meet the following requirements.
(1) The hospice providing the services must
				  have a Medicaid hospice contract with HHSC on the date it provides
				  services.
(2) The services must be
				  reasonable and necessary for the palliation or management of the terminal
				  illness, as well as conditions related to the terminal illness.
(3) The hospice must deliver the services on
				  or after the date the individual elects hospice care in accordance with §
				  266.205 of this subchapter (relating to Election of Hospice Care) but before
				  the date the individual revokes the election of hospice care in accordance with
				  § 266.207 of this subchapter (relating to Revoking the Election of Hospice
				  Care).
(4) The hospice election
				  statement must identify the hospice requesting payment as the individual's
				  hospice provider.
(5) A physician
				  must certify that the individual receiving hospice services is terminally ill
				  in accordance with § 266.203 of this subchapter (relating to Certification
				  of Terminal Illness).
(6) The
				  individual receiving services must be eligible for Medicaid.
(7) The hospice must establish an
				  individualized plan of care prior to initiating services.
(8) The services the hospice provides must be
				  consistent with the plan of care.
(9) If the individual receiving services
				  lives in a nursing facility or ICF/IID, the hospice must have a contract with
				  that nursing facility or ICF/IID.
(10) If the individual receiving services is
				  dually eligible for Medicare and Medicaid, the hospice service must not be
				  covered by the Medicare hospice benefit.
(11) The hospice must submit both the
				  Individual Election/Cancellation/Update Form and the Physician Certification of
				  Terminal Illness Form to the TMHP Long Term Care Online Portal.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.211 - Continuous Home Care

Current through Reg. 49, No. 28; July 12, 2024
CHC is provided only during a period of crisis for a
					 maximum of five consecutive days to maintain an individual at the individual's
					 place of residence.
(1) A minimum of
				  eight hours of CHC must be provided during a 24-hour day that begins and ends
				  at midnight. The care need not be continuous. For example, four hours could be
				  provided in the morning and another four hours in the evening of that
				  day.
(2) Skilled nursing care must
				  be provided for the identified crisis for more than half of the CHC period and
				  must be provided by either an RN or licensed vocational nurse. The RN or
				  licensed vocational nurse must be an employee of the hospice providing
				  services. For an individual residing in a nursing facility, the skilled nursing
				  care requirement is not met when facility staff provided skilled nursing care
				  for the crisis. For the purpose of CHC, skilled nursing care includes at least
				  one of the following:
(A) administration of
				  intravenous or intramuscular medications;
(B) insertion, sterile irrigation, and
				  replacement of catheters;
(C)
				  initial clinical assessment for specific therapeutic responses; or
(D) application of dressings involving
				  prescription medications.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.213 - Extension of Continuous Home Care

Current through Reg. 49, No. 28; July 12, 2024
(a) If
				  the hospice believes that the period of crisis will extend beyond five
				  consecutive days, the IDT must discuss the temporary alternate placement
				  available to meet the needs of the individual during the period of crisis, such
				  as a hospital or nursing facility. This discussion must occur and be documented
				  before the fifth day of the crisis. If, after this discussion, the hospice
				  believes that an extension of CHC is necessary instead of alternate placement,
				  the hospice must fax a Request for CHC Extension Form to HHSC.
(1) The extension request must be faxed to
				  HHSC by the fourth day of the CHC period.
(2) The extension request must include:
(A) a description of the specific crisis and
				  how the hospice plans to resolve the crisis;
(B) documentation of all CHC provided during
				  the period of crisis for which the hospice is seeking the extension;
(C) physician's orders;
(D) documentation of daily physician plan of
				  care oversight;
(E) documentation
				  that skilled nursing care was provided as more than half of the care given in a
				  24-hour period for each of the three days of CHC;
(F) documentation of the IDT's discussion
				  regarding alternate placement prior to the initiation of CHC; and
(G) documentation of the reasons the CHC
				  period must be extended, including the reasons the originally documented
				  alternate placement is no longer appropriate or desired.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.215 - Respite Care

Current through Reg. 49, No. 28; July 12, 2024
(a) Respite care is
				  short-term inpatient care provided to an individual only when necessary to
				  relieve the family members or other persons caring for the individual at
				  home.
(b) Respite care can be
				  provided by:
(1) a hospice that meets the
				  condition of participation for providing inpatient care directly; or
(2) a hospital or nursing facility that also
				  meets the Medicare standards regarding 24-hour nursing service and patient
				  areas.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.217 - Medicaid Hospice Payments and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Medicaid hospice per diem and hourly
				  rates. For each day that an individual is under the care of a hospice, the
				  hospice is paid an amount applicable to the type and intensity of the services
				  furnished to the individual. HHSC pays a daily rate for routine home care,
				  in-patient respite care, and general inpatient care. For CHC and the SIA, the
				  amount of payment is based on the number of hours of care furnished to the
				  individual on that day.
(1) Routine home care.
				  The hospice is paid the routine home care rate for each day the individual is
				  at home, under the care of the hospice, and not receiving CHC. The appropriate
				  routine home care rate is determined as follows.
(A) For routine home care delivered during
				  the first 60 days an individual is receiving hospice care, the routine home
				  care rate is the higher base payment rate.
(B) For routine home care delivered after the
				  first 60 days an individual is receiving hospice care, the routine home care
				  rate is the reduced base payment rate.
(C) If an individual receiving hospice
				  services is discharged and readmitted to hospice not more than 60 days after
				  the discharge, HHSC will count all days the individual received hospice
				  services since the original hospice admission in determining the proper base
				  payment rate.
(D) If an individual
				  receiving hospice services is discharged and readmitted to hospice more than 60
				  days after the discharge, HHSC disregards the previous hospice admission in
				  determining the proper base payment rate.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.219 - Utilization Review and Control Activities Performed by HHSC

Current through Reg. 49, No. 28; July 12, 2024
(a) Hospice staff must cooperate with HHSC
				  staff during utilization review of hospice services and the review of hospice
				  clinical records.
(b) The hospice
				  must respond within 30 calendar days after HHSC makes a request for
				  information.
(c) HHSC staff review
				  most claims for payment after they are paid and recoup any overpayments,
				  pursuant to § 266.225 and § 266.227 of this subchapter (relating to
				  Informal Review and Review Decision and Notice).
(d) HHSC staff review claims for the SIA
				  before paying the SIA.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.221 - Hospice Documentation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Types of Documentation Required. A hospice must maintain the following
				  information on each individual receiving Medicaid hospice services.
(1) Signed hospice election and discharge
				  forms.
(2) Signed Physician's
				  Certification of Terminal Illness.
(3) Physician narratives.
(4) Documentation of each face-to-face
				  assessment.
(5) Patient history and
				  physical exams before and during the provision of hospice services, including
				  previous and new diagnoses, emergency room visits, and ability to perform
				  activities of daily living.
(6)
				  Physician consultation reports, orders, and progress notes.
(7) Hospital admission and discharge
				  reports.
(8) Plans of care covering
				  all periods during which the hospice provides services to the
				  individual.
(9) Nursing assessments
				  and nursing notes.
(10) IDT meeting
				  notes.
(11) Medication
				  administration records, including doses, frequency, and routes.
(12) Signs and symptoms, anthropometric
				  measurements, weights, oral intake, and laboratory and diagnostic testing
				  results supporting the conclusion that the individual's condition is
				  terminal.
(13) Other documentation
				  supporting the plan of care, service delivery, and outcome of
				  services.
(14) Summary of
				  circumstances surrounding the death, including date, time, family in
				  attendance, and hospice staff in attendance.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.223 - Recoupment

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC recoups from a hospice under 40 TAC
				  §
										49.533(relating to
				  Recoupment) amounts paid to the hospice for a service if the hospice has not
				  complied with the requirements described in this chapter.
(b) Recoupment amounts for hospice
				  eligibility and level of service utilization reviews.
(1) HHSC recoups 100 percent of the hospice
				  claim amount for the dates of service reviewed when the hospice fails to
				  provide HHSC the following:
(A) the Individual
				  Election/Cancellation/Update Form completed in accordance with § 266.205
				  of this subchapter (relating to Election of Hospice Care);
(B) the Physician Certification of Terminal
				  Illness Form completed in accordance with § 266.203 of this subchapter
				  (relating to Certification of Terminal Illness);
(C) a physician narrative that meets the
				  minimum criteria in § 266.203(c)(2) of this subchapter; or
(D) if the individual receiving hospice
				  services is in an election period after the subsequent 90-day election period,
				  documentation of the face-to-face assessment required by § 266.203(d) of
				  this subchapter.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.225 - Informal Review

Current through Reg. 49, No. 28; July 12, 2024
(a) Before HHSC
				  issues a notice of proposed recoupment amount under 40 TAC §
										49.533(c)
				  (relating to Recoupment), HHSC gives a hospice:
(1) a description of the alleged rule
				  violation warranting the proposed recoupment;
(2) the amount of the proposed recoupment;
				  and
(3) the option to:
(A) request an informal review to demonstrate
				  that the hospice did not commit the alleged violation; or
(B) accept the proposed recoupment.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter B - UTILIZATION REVIEW › Section 266.227 - Review Decision and Notice

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC
				  issues a notice of proposed recoupment under 40 TAC §
										49.533(c)
				  (relating to Recoupment), if HHSC upholds or modifies a proposed recoupment
				  after the informal review.
(b) The
				  notice of proposed recoupment includes:
(1) a
				  description of the alleged rule violations warranting the proposed
				  recoupment;
(2) the amount of the
				  proposed recoupment;
(3) HHSC's
				  decision to uphold or modify the proposed recoupment issued after an informal
				  review; and
(4) the option for the
				  hospice to:
(A) accept the proposed
				  recoupment; or
(B) appeal the
				  proposed recoupment as provided in 40 TAC §
												49.541(relating
				  to Contractor's Right to Appeal).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter C - CONTRACTING REQUIREMENTS › Section 266.301 - Eligibility Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) To be eligible
				  to elect hospice care under Medicaid, an individual must:
(1) be certified as Medicaid eligible by HHSC
				  or the Social Security Administration; and
(2) be certified as being terminally ill in
				  accordance with § 266.203 of this chapter (relating to Certification of
				  Terminal Illness).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter C - CONTRACTING REQUIREMENTS › Section 266.303 - Change of the Designated Hospice

Current through Reg. 49, No. 28; July 12, 2024
(a) An
				  individual or representative may change the particular hospice from which the
				  individual receives hospice care once in each election period. If the recipient
				  is dually eligible for Medicaid and Medicare, the individual must change the
				  Medicaid and Medicare hospice providers at the same time.
(b) The change of the designated hospice is
				  not a revocation of the election for the period in which it is made.
(c) To change the designated hospice, the
				  individual or representative must file, with both the hospice from which care
				  has been received and with the newly designated hospice, a statement that
				  includes the following information:
(1) the
				  name of the hospice from which the individual has received care and the name of
				  the hospice from which the individual plans to receive care; and
(2) the date the change is to be
				  effective.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter C - CONTRACTING REQUIREMENTS › Section 266.305 - General Contracting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A
				  hospice participating in the Medicaid Hospice Program must comply with this
				  chapter and applicable federal regulations and state rules, including 42 CFR
				  Part 418; 26 TAC Chapter 558 (relating to Licensing Standards for Home and
				  Community Support Services Agencies); and 40 TAC Chapter 49 (relating to
				  Contracting for Community Services).
(b) A hospice participating in the Medicaid
				  Hospice Program must not have restrictive policies or practices, including:
(1) requiring an individual to execute a will
				  with the hospice named as legatee or devisee;
(2) assigning an individual's life insurance
				  to the hospice;
(3) transferring an
				  individual's property to the hospice;
(4) requiring an individual to pay a lump sum
				  or make any other payment or concession to the hospice beyond the recognized
				  Medicaid rate;
(5) controlling or
				  restricting an individual or legal representative in using the individual's
				  personal needs allowance while in a nursing facility or an ICF/IID;
(6) restricting an individual from
				  transferring or withdrawing from the Medicaid Hospice Program at will, except
				  as provided by state law;
(7)
				  denying appropriate hospice care to an individual on the basis of the
				  individual's race, religion, color, national origin, sex, age, disability,
				  marital status, or source of payment; and
(8) preventing or requiring the execution of
				  written or unwritten directives to reject life-sustaining procedures by an
				  adult individual.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter C - CONTRACTING REQUIREMENTS › Section 266.307 - Voluntary Termination of Hospice Contract

Current through Reg. 49, No. 28; July 12, 2024
(a) At least 10 days before a hospice
				  terminates its contract with HHSC, the hospice must:
(1) for each individual receiving Medicaid
				  hospice services, submit an Individual Election/Cancellation/Update Form to the
				  TMHP Long Term Care Online Portal indicating the individual has changed his
				  designated hospice or revoked his election of hospice care; and
(2) for each individual receiving Medicaid
				  hospice services who is changing his designated hospice, ensure that a copy of
				  the individual's active record is sent to the receiving hospice in order to
				  ensure continuity of care and services to the individual.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter C - CONTRACTING REQUIREMENTS › Section 266.309 - Condition of Participation-Physical Therapy, Occupational Therapy, and Speech-language Pathology

Current through Reg. 49, No. 28; July 12, 2024
(a) Physical
				  therapy services, occupational therapy services, and speech-language pathology
				  services must be available and, when provided, offered in a manner consistent
				  with accepted standards of practice.
(b) Lab services must be provided under the
				  following conditions.
(1) If the hospice
				  engages in laboratory testing outside of the context of assisting an individual
				  in self-administering a test with an appliance that has been cleared for that
				  purpose by the FDA, such testing must be in compliance with all applicable
				  requirements of 42 CFR Part 493 .
(2) If the hospice chooses to refer specimens
				  for laboratory testing to another laboratory, the referral laboratory must be
				  certified in the appropriate specialties and sub-specialties of services in
				  accordance with the applicable requirements of 42 CFR Part 493 .
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 266 - MEDICAID HOSPICE PROGRAM › Subchapter C - CONTRACTING REQUIREMENTS › Section 266.311 - Waiver Requirements for Nursing Services or Occupational, Physical, and Speech Therapies

Current through Reg. 49, No. 28; July 12, 2024
(a) CMS may approve
				  a waiver for nursing services or occupational, physical, and speech therapies
				  provided by a hospice which is located in a non-urbanized area. The location of
				  a hospice that operates in several areas is considered to be the location of
				  its central office. The hospice must provide evidence that it was operational
				  on or before January 1, 1983, and that it made a good faith effort to hire a
				  sufficient number of nurses or therapists to provide services directly. CMS
				  bases its decision on whether to approve a waiver application on the following:
(1) the current Bureau of the Census
				  designations for determining non-urbanized areas;
(2) evidence that a hospice was operational
				  on or before January 1, 1983, including:
(A)
				  proof that the organization was established to provide hospice services on or
				  before January 1, 1983;
(B)
				  evidence that hospice-type services were furnished to patients on or before
				  January 1, 1983; and
(C) evidence
				  that the hospice care was a discrete activity rather than an aspect of another
				  type of provider's patient care program on or before January 1, 1983;
				  and
(3) evidence that a
				  hospice made a good faith effort to hire nurses or therapists, including:
(A) copies of advertisements in local
				  newspapers that demonstrate recruitment efforts;
(B) job descriptions for nurse employees or
				  therapists;
(C) evidence that
				  salary and benefits are competitive for the area; and
(D) evidence of any other recruiting
				  activities, such as recruiting efforts at health fairs and contacts with nurses
				  or therapists at other providers in the area.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.2 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
This chapter establishes the requirements for agencies
				  contracting to provide services to eligible elderly clients through the Texas
				  Department of Human Services' Programs of All-Inclusive Care for the Elderly
				  (PACE).
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.4 - Introduction

Current through Reg. 49, No. 28; July 12, 2024
(a) Programs of All-Inclusive Care for the
				Elderly (PACE) provide community-based acute and long-term care services to
				persons who meet the medical requirements for nursing facility care and can be
				served safely in the community. PACE is jointly funded and administered by the
				Centers for Medicare and Medicaid Services and the state of Texas. The PACE
				provider agency receives a monthly capitation payment and is at full risk for
				the delivery of all services needed by the client.
(b) Rules governing the operation of the PACE
				program are contained in 42 Code of Federal Regulations, Part 460. These
				regulations, as currently written or amended in the future, are incorporated by
				reference as the rule base for operating the PACE program in Texas.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.6 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The words and terms used in this chapter have the following
				  meanings, unless the context clearly indicates otherwise.
(1) Capitation--The uniform per client
				monthly amount that DADS pays to a provider agency.
(2) CFR--The Code of Federal
				Regulations.
(3) CMS--The Centers
				for Medicare and Medicaid Services.
(4) DADS--The Department of Aging and
				Disability Services or its successor agency.
(5) Former military member--A person who
				served in the United States Army, Navy, Air Force, Marine Corps, or Coast
				Guard:
(A) who declared and maintained Texas
				as the person's state of legal residence in the manner provided by the
				applicable military branch while on active duty; and
(B) who was killed in action or died while in
				service, or whose active duty otherwise ended.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.8 - Contracting Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) To become
				a provider agency, an applicant must:
(1) be
				selected by DADS, through a request for proposals process, to submit an
				application to CMS to become a provider agency;
(2) be approved by CMS as described in 42
				CFR, Part 460, Subpart B to be a provider agency;
(3) enter into a program agreement with CMS
				and DADS as described in 42 CFR, Part 460, Subpart C; and
(4) be licensed as an adult daycare
				center.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.10 - Interest List

Current through Reg. 49, No. 28; July 12, 2024
(a) A provider agency
				must maintain an up-to-date interest list of individuals who are interested in
				receiving PACE services and reside in the provider agency's service area.
(b) A person may request an
				individual's name be added to the PACE interest list maintained by the provider
				agency serving the service area in which the individual resides by submitting a
				request in person, by phone, or in writing, and providing the following
				information:
(1) the name of the individual;
(2) the date of the request for
				PACE services;
(3) the individual's
				physical and mailing addresses;
(4)
				the individual's birth date;
(5)
				the individual's contact phone number;
(6) the name and phone number of the LAR, if
				applicable; and
(7) the name and
				phone number of the person requesting services on behalf of the individual, if
				different from the LAR.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.12 - Client Eligibility Criteria

Current through Reg. 49, No. 28; July 12, 2024
(a) To be
				eligible for participation the applicant must:
(1) be 55 years old or older;
(2) meet the medical necessity criteria for
				nursing facility care in accordance with §
										19.2401
				of this title (relating to General Qualifications for Medical Necessity
				Determinations);
(3) live in a
				Programs of All-Inclusive Care for the Elderly (PACE) service area;
				and
(4) be determined by the PACE
				Interdisciplinary Team (IDT) as able to be safely served in the
				community.
Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 270 - CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 270.14 - Living Arrangements

Current through Reg. 49, No. 28; July 12, 2024
Programs of All-Inclusive Care for the Elderly (PACE) clients
				  must reside in:
(1) their own
				home;
(2) a relative's
				home;
(3) a licensed assisted
				living facility;
(4) a licensed
				nursing facility; or
(5) an adult
				foster care home that contracts with the Texas Department of Human
				Services.