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 355.513 - Reimbursement Methodology for the Deaf-Blind with Multiple Disabilities Waiver Program

Current through Reg. 49, No. 28; July 12, 2024
(a) General
				  information. The Texas Health and Human Services Commission (HHSC) applies the
				  general principles of cost determination as specified in §
										355.101 of this title (relating to
				  Introduction). Providers are reimbursed for waiver services provided to
				  individuals who are deaf-blind with multiple disabilities.
(b) Other sources of cost information. If
				  HHSC has determined that there is not sufficient reliable cost report data from
				  which to set reimbursements and reimbursement ceilings for waiver services,
				  reimbursements and reimbursement ceilings will be developed by using rates for
				  similar services from other Medicaid programs; data from surveys; cost report
				  data from other similar programs; consultation with other service providers or
				  professionals experienced in delivering contracted services; and other
				  sources.
(c) Waiver rate
				  determination methodology. If HHSC deems it appropriate to require contracted
				  providers to submit a cost report, recommended reimbursements for waiver
				  services will be determined on a fee-for-service basis in the following manner
				  for each of the services provided:
(1) Total
				  allowable costs for each provider will be determined by analyzing the allowable
				  historical costs reported on the cost report.
(2) Each provider's total reported allowable
				  costs, excluding depreciation and mortgage interest, are projected from the
				  historical cost-reporting period to the prospective reimbursement period as
				  described in §
											355.108 of this title (relating to
				  Determination of Inflation Indices). The prospective reimbursement period is
				  the period of time that the reimbursement is expected to be in
				  effect.
(3) Payroll taxes and
				  employee benefits are allocated to each salary line item on the cost report on
				  a pro rata basis based on the portion of that salary line item to the amount of
				  total salary expense for the appropriate group of staff. Employee benefits will
				  be charged to a specific salary line item if the benefits are reported
				  separately. The allocated payroll taxes are Federal Insurance Contributions Act
				  (FICA) or Social Security, Medicare Contributions, Workers' Compensation
				  Insurance (WCI), the Federal Unemployment Tax Act (FUTA), and the Texas
				  Unemployment Compensation Act (TUCA).
(4) Allowable administrative and overall
				  facility/operations costs are allocated or spread to each waiver service cost
				  component on a pro rata basis based on the portion of each waiver service's
				  service units reported to the amount of total waiver service units reported.
				  Service-specific facility and operations costs for out-of-home respite, and
				  individualized skills and socialization services will be directly charged to
				  the specific waiver service.
(5)
				  For nursing services provided by a registered nurse (RN), nursing services
				  provided by a licensed vocational nurse (LVN), physical therapy, occupational
				  therapy, speech/language therapy, behavioral support services, audiology
				  services, dietary services, employment assistance, and supported employment, an
				  allowable cost per unit of service is calculated for each contracted provider
				  cost report in accordance with paragraphs (1) - (4) of this subsection. The
				  allowable costs per unit of service for each contracted provider cost report is
				  multiplied by 1.044. This adjusted allowable costs per unit of service may be
				  combined into an array with the allowable cost per unit of service of similar
				  services provided by other programs in determining rates for these services in
				  accordance with §
											355.502 of this title (relating to
				  Reimbursement Methodology for Common Services in Home and Community-Based
				  Services Waivers).
(6) Requisition
				  fees are reimbursements paid to the Deaf-Blind with Multiple Disabilities
				  (DBMD) Waiver contracted providers for their efforts in acquiring adaptive
				  aids, medical supplies, dental services, and minor home modifications for DBMD
				  participants. Reimbursement for adaptive aids, medical supplies, dental
				  services, and minor home modifications will vary based on the actual cost of
				  the adaptive aid, medical supply, dental service, and minor home modification.
				  Reimbursements are determined using a method based on modeled projected
				  expenses which are developed by using data from surveys, cost report data from
				  similar programs, consultation with other service providers or professionals
				  experienced in delivering contracted services, or other sources.
(7) For residential habilitation
				  transportation, chore, and intervener (excluding Interveners I, II, and III),
				  services, two cost areas are created:
(A) The
				  attendant cost area, which includes salaries, wages, benefits, and mileage
				  reimbursement calculated as specified in §
												355.112 of this title (relating to
				  Attendant Compensation Rate Enhancement).
(B) An administration and facility cost area,
				  which includes costs for services not included in subparagraph (A) of this
				  paragraph as determined in paragraphs (1) - (4) of this subsection. An
				  allowable cost per unit of service is determined for each contracted provider
				  cost report for the administration and facility cost area. The allowable costs
				  per unit of service for each contracted provider cost report are arrayed. The
				  units of service for each contracted provider cost report in the array are
				  summed until the median unit of service is reached. The corresponding expense
				  to the median unit of service is determined and is multiplied by
				  1.044.
(C) The attendant cost area,
				  and the administration and facility cost area are summed to determine the cost
				  per unit of service.
(8)
				  For Interveners I, II, and III, payment rates are developed based on rates
				  determined for other programs that provide similar services. If payment rates
				  are not available from other programs that provide similar services, payment
				  rates are determined using a pro forma approach in accordance with §
											355.105(h) of this
				  title (relating to General Reporting and Documentation Requirements, Methods,
				  and Procedures). Interveners I, II, and III are not considered attendants for
				  purposes of the Attendant Compensation Rate Enhancement described in §
											355.112 of this title, and
				  providers are not eligible to receive direct care add-ons to the Intervener I,
				  II, or III rates.
(9) Assisted
				  living services payment rates are determined using a pro forma approach in
				  accordance with §
											355.105(h) of this
				  title. The rates are adjusted periodically for inflation. The room and board
				  payments for waiver clients receiving assisted living services are covered in
				  the reimbursement for these services and will be paid to providers from the
				  client's Supplemental Security Income, less a personal needs
				  allowance.
(10) Pre-enrollment
				  assessment services and case management services payment rates are determined
				  by modeling the salary for a Case Manager staff position. This rate is
				  periodically updated for inflation.
(11) The orientation and mobility services
				  payment rate is determined by modeling the salary for an Orientation and
				  Mobility Specialist staff position. This rate is updated periodically for
				  inflation.
(12) HHSC may adjust
				  reimbursement if new legislation, regulations, or economic factors affect
				  costs, according to §
											355.109 of this title (relating to
				  Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors
				  Affect Costs).