Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter E - COMMUNITY CARE FOR AGED AND DISABLED › Section 355.501 - Reimbursement Methodology for Program for All-Inclusive Care for the Elderly (PACE)

Current through Reg. 49, No. 28; July 12, 2024
(a) General
				  specifications. The Texas Health and Human Services Commission (HHSC)
				  determines the upper payment limits and reimbursement rates for each PACE
				  contractor. HHSC applies the general principles of cost determination as
				  specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(b) Frequency of reimbursement determination.
				  The upper payment limits and reimbursement rates are determined coincident with
				  the state's biennium.
(c) Upper
				  payment limit determination. There are three upper payment limits calculated
				  for each PACE contract: one for clients eligible only for Medicaid services
				  (Medicaid-only clients), one for clients eligible for both Medicare and
				  Medicaid services (dual-eligible clients), and one for clients eligible for
				  only Medicare services as Qualified Medicare Beneficiaries (QMBs). An average
				  monthly historical cost per client receiving nursing facility services and Home
				  and Community Based Services (HCBS) under either the fee-for-service payment
				  system or the managed care program is calculated for the counties served by
				  each PACE contract for the upper payment limits for Medicaid-only clients and
				  for dual-eligible clients.
(1) The upper
				  payment limits for Medicaid-only and for dual-eligible clients for the biennium
				  are calculated for the base period using historical claims and encounter data
				  and member-month data from the most recent state fiscal year of complete claims
				  available prior to the state's biennium.
(2) The historical costs are derived from
				  claims data for clients age 55 and older receiving nursing facility services or
				  HCBS in the counties served by each PACE contract.
(3) The historical costs include:
(A) acute care services, including inpatient,
				  outpatient, professional, and other acute care services;
(B) prescriptions;
(C) medical transportation;
(D) nursing facility services;
(E) hospice services;
(F) long-term care specialized services, such
				  as physical therapy, occupational therapy, and speech therapy;
(G) HCBS;
(H) Primary Home Care (including Family Care)
				  services; and
(I) Day Activity and
				  Health Services.
(4)
				  Effective on and after January 1, 2006, the historical prescription costs from
				  paragraph (3)(B) of this subsection that are used in the calculation of the
				  upper payment limit, and as such the associated payment rate, for dual-eligible
				  clients for each PACE contract will exclude the costs of any drug that is in a
				  category covered by Medicare Part D.
(5) To determine an average monthly
				  historical cost for the counties served by each PACE contract, the total
				  historical claims data for the counties served by each PACE contract are
				  divided by the number of member months for the counties served by each PACE
				  contract.
(6) An adjustment for
				  administrative costs is added to the average monthly historical cost per
				  client. The per member month amount is added for:
(A) processing claims, based on the state's
				  cost to process claims under the managed care payment system; and
(B) case management, based on the state's
				  cost to provide case management under the managed care payment system for HCBS
				  clients.
(7) The sum of
				  the average monthly historical cost per client for each PACE contract and the
				  amounts from paragraph (5) of this subsection are projected from the claims
				  data base period identified in paragraph (1) of this subsection to the rate
				  period to account for anticipated changes in costs for each PACE contract. The
				  methodology used for trending historical costs for calculating PACE Upper
				  Payment Limits (UPLs) and rates is comparable to that used for trending costs
				  in the managed care program.
(8)
				  The PACE Upper Payment Limit (UPL) method may be adjusted to account for
				  statistical outliers, small populations, programmatic changes, catastrophic
				  events, or other economic changes, as determined by HHSC to be actuarially
				  appropriate. Data from sources other than those described in paragraphs (1) and
				  (2) of this subsection may be used, if deemed by HHSC necessary to calculate an
				  appropriate UPL. For example, HHSC may consider comparable data from other time
				  periods.