reglab/statecodes huggingface dataset:
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 355.306 - Cost Finding Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) Cost
				  reports. Cost reporting requirements vary depending on whether the provider
				  participates in the Direct Care Staff Rate enhancement program. All providers
				  who participate in the rate enhancement program must file a cost report, as
				  described in §
										RSA
				  355.308 of this title (relating to Direct
				  Care Staff Rate Component). A provider that is not participating in the rate
				  enhancement program must file a cost report unless:
(1) the provider meets one or more of the
				  conditions in §
											RSA
				  355.105(b)(4)(D) of this
				  title (relating to General Reporting and Documentation Requirements, Methods,
				  and Procedures); or
(2) the cost
				  report would represent costs accrued during a time period immediately preceding
				  a period of decertification, if the decertification period was greater than
				  either 30 calendar days or one entire calendar month.
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 355.310 - Reimbursement Methodology for Customized Equipment

Current through Reg. 49, No. 28; July 12, 2024
(a) Reimbursement rates for customized power
				  wheelchairs (CPWCs) and associated physical or occupational therapy evaluations
				  provided under 40 TAC §
										RSA
				  19.2614(relating to Customized Power
				  Wheelchairs) are determined as follows:
(1)
				  For CPWCs, rates are determined in accordance with § 355.8023 of this
				  title (relating to Reimbursement Methodology for Durable Medical Equipment,
				  Prosthetics, Orthotics and Supplies (DMEPOS)).
(2) For evaluations required for CPWCs under
				  40 TAC §
											RSA
				  19.2614(c), rates are
				  determined in accordance with §
											RSA
				  355.313 of this title (relating to
				  Reimbursement Methodology for Rehabilitative and Specialized
				  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 355.311 - Medicaid Reimbursement Rates for State Veterans Homes

Current through Reg. 49, No. 28; July 12, 2024
(a) The following definitions apply to this
				  section:
(1) Health and Human Services
				  Commission (HHSC)--The state administrative agency authorized to adopt
				  standards and rules to govern reimbursement rates and methodologies for
				  Medicaid nursing facility services pursuant to Government Code §
											RSA
				  531.021.
(2) Rate period--The state fiscal
				  year.
(3) State veterans home--A
				  nursing facility as defined in Title 40, Texas Administrative Code (TAC)
				  §176.1 (relating to Definitions) that is contracted with the Department of
				  Aging and Disability Services (DADS) under 40 TAC §
											RSA
				  19.2322(relating to Medicaid Bed Allocation
				  Requirements) to provide nursing facility services to eligible Medicaid
				  recipients who reside in a state veterans home.
(4) Department of Aging and Disability
				  Service (DADS)--The state administrative agency authorized to contract for
				  nursing facility services to Medicaid recipients pursuant to Chapter 32, Human
				  Resources Code.
(5) Veterans Land
				  Board (VLB)--The state administrative agency authorized under Chapter 164,
				  Natural Resources Code, to establish and operate state veterans
				  homes.
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 355.312 - Reimbursement Setting Methodology-Liability Insurance Costs

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 Nursing Facility (NF) Liability Insurance Coverage Rate
				  Add-ons.
(b) Definitions.
(1) Provider--A person who has a written
				  agreement with HHSC to provide Medicaid NF services to an individual or a
				  person who is contracted with a managed care organization as defined in §
											RSA 353.2 of this
				  title (relating to Definitions) to provide Medicaid NF services.
(2) Independently procured insurance--An
				  insurance transaction involving an insurance contract independently procured
				  from an insurance company not licensed in Texas through negotiations occurring
				  entirely outside the state of Texas that is reported and on which premium tax
				  is paid.
(3) Open enrollment
				  period--Open enrollment period begins on the first day of July and ends on the
				  last day of that same July preceding the rate year for which payments are being
				  determined.
(4) Purchased captive
				  insurance--General or professional liability insurance purchased from a
				  non-admitted captive insurance company that insures solely directors and
				  officer's liability insurance for the directors and officers of the company's
				  parent and affiliated companies and the risks of the company's parent and
				  affiliated companies, if applicable.
(5) Purchased commercial liability
				  insurance--Either general or professional liability insurance from a commercial
				  carrier or a non-profit service corporation in an arm's-length transaction that
				  provides for the shifting of risk to the unrelated party. The commercial
				  carrier or non-profit service corporation must meet the requirements as set by
				  the Texas Department of Insurance (TDI) for authorized insurance.
(6) Rate year--The rate year begins on the
				  first day of September and ends on the last day of August of the following
				  year.
(7)
				  Self-insurance--Self-insurance is a means whereby a provider undertakes the
				  risk to protect itself against anticipated liabilities by providing funds
				  equivalent to liquidate those liabilities. If a provider enters into an
				  arrangement with an unrelated party that does not provide for the shifting of
				  risk to the unrelated party, such an agreement shall be considered
				  self-insurance. Self-insurance is not purchased liability insurance.
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 355.313 - Reimbursement Methodology for Rehabilitative and Specialized Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Providers other than nursing facilities
				  delivering Medicaid specialized and rehabilitative services, defined in 40 TAC
				  §
										RSA
				  19.1306, (relating to Payment for Specialized
				  and Rehabilitative Services), are reimbursed for physical therapy evaluations,
				  occupational therapy evaluations, speech therapy evaluations, physical therapy
				  sessions, occupational therapy sessions, and speech therapy sessions in
				  accordance with statewide fees determined by the Texas Health and Human
				  Services Commission (HHSC).
(1) The hourly
				  fees for physical therapy and occupational therapy sessions are based on the
				  current Medicare nonfacility Relative Value Units (RVUs) times the current
				  Medicaid conversion factor times four, since the Medicare RVUs for these
				  sessions are based on 15-minute increments.
(2) The hourly fee for a speech therapy
				  session is based on the current Medicare nonfacility RVU times the current
				  Medicaid conversion factor times two, since the Medicare RVUs for a speech
				  therapy session is based on 30-minute increments.
(3) The fees for physical therapy
				  evaluations, occupational therapy evaluations, and speech therapy evaluations
				  are the same as the hourly fees for each type of therapy session, as provided
				  in paragraphs (1) and (2) of this subsection.
(4) The fees for specialized and
				  rehabilitative services delivered by providers other than nursing facilities
				  are reviewed coincident with the biennium, with any fee adjustments made within
				  available funds.
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 355.314 - Supplemental Payments to Non-State Government-Owned Nursing Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Notwithstanding other
				  provisions of this subchapter and subject to the availability of funds,
				  supplemental payments are available under this section for nursing facility
				  services provided by eligible non-state government-owned nursing
				  facilities.
(b) Definitions. When
				  used in this section, the following definitions apply:
(1) Adjudicated claim--A claim for a covered
				  Medicaid nursing facility service that has been paid by HHSC.
(2) HHSC--The Texas Health and Human Services
				  Commission or its designee.
(3)
				  Intergovernmental transfer (IGT)--A transfer of public funds from a non-state
				  governmental entity to HHSC.
(4)
				  Medicaid supplemental payment limit--The maximum supplemental payment available
				  to a participating non-state government-owned nursing facility for a specific
				  quarterly calculation period as calculated in subsection (f) of this
				  section.
(5) Medicaid supplemental
				  payment limit calculation period--The federal fiscal quarter determined by HHSC
				  for which supplemental payment amounts are calculated based on adjudicated
				  claims for days of service provided in the same quarter in the prior federal
				  fiscal year.
(6) Non-state
				  governmental entity--A hospital authority, hospital district, healthcare
				  district, city, or county.
(7)
				  Non-state government-owned nursing facility--A nursing facility where a
				  non-state governmental entity holds the license and is party to the facility's
				  Medicaid contract.
(8) Public
				  funds--Funds derived from taxes, assessments, levies, investments, and other
				  public revenues within the sole and unrestricted control of a non-state
				  governmental entity that holds the license and is party to the Medicaid
				  contract of the nursing facility identified in subsection (c) of this section.
				  Public funds do not include gifts, grants, trusts, or donations, the use of
				  which is conditioned on supplying a benefit solely to the donor or grantor of
				  the funds.
(9) Upper payment
				  limit--A reasonable estimate of the amount that would be paid for the services
				  furnished by a non-state government-owned nursing facility under Medicare
				  payment principles, as calculated in subsection (f) of this section.
(10) Upper payment limit calculation
				  period--The federal fiscal quarter one year prior to the Medicaid supplemental
				  payment limit calculation period. For example, October 1 - December 31, 2011,
				  is the upper payment limit calculation period for the October 1 - December 31,
				  2012, Medicaid supplemental payment limit calculation period.
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 355.315 - Reimbursement Methodology for Preadmission Screening and Resident Review (PASRR) Specialized Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Payment rate
				  determination. HHSC develops payment rates for Employment Assistance services,
				  Supported Employment services, Independent Living Skills Training services,
				  Behavioral Support services, Habilitation Coordination services, and Day
				  Habilitation services based on rates HHSC has determined for other programs
				  that provide similar services. If payment rates for other programs that provide
				  similar services are not available, HHSC determines payment rates using a pro
				  forma approach in accordance with §
										RSA
				  355.105(h) of this title
				  (relating to General Reporting and Documentation Requirements, Methods, and
				  Procedures).
(b) Related
				  information. Section
				  RSA 355.101 of this
				  title (relating to Introduction) and §
										RSA
				  355.105(g) of this title
				  also apply.
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 355.316 - Reimbursement Methodology for Pediatric Care Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Pediatric Care Facility Class. The
				  purpose of this special class is to recognize, through the adoption of a
				  special payment rate, the cost differences that exist in a pediatric nursing
				  facility or distinct unit of a nursing facility that serves predominantly
				  children.
(b) Definitions. The
				  following terms, when used in this section, have the following meanings, unless
				  otherwise stated.
(1) Children--For the
				  purposes of this pediatric care facility class, children are defined as being
				  at or below 22 years of age.
(A) Only a
				  pediatric care facility that is designated in its entirety as a pediatric care
				  facility may count as children a limited number of adults who were admitted to
				  the facility as children, but who are no longer children (i.e., individuals who
				  have "aged in place"), for purposes of determining if the facility meets the
				  requirements for remaining a pediatric care facility described in paragraph (3)
				  of this subsection. The number of such individuals who may be counted as
				  children for purposes of determining if the facility continues to meet the
				  requirements for remaining a pediatric care facility is limited to 33 percent
				  of the average daily census of the facility.
(B) Individuals who have "aged in place" as
				  described in subparagraph (A) of this paragraph may not be counted toward
				  meeting the requirements for a facility to initially become a pediatric care
				  facility, nor can they be counted toward meeting the requirements for a
				  distinct unit to remain a pediatric care facility.
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 355.403 - Vendor Hold

Current through Reg. 49, No. 28; July 12, 2024
The Texas Health and Human Services Commission (HHSC) or
					 its designee may delay or withhold vendor payment to a provider in order to
					 investigate or correct financial or accounting irregularities or to obtain
					 required documentation.
(1) Vendor
				  payments will be held until the circumstances resulting in vendor hold are
				  corrected.
(2) A provider has the
				  right to appeal a vendor hold as specified in 1 TAC §§
										RSA
				  357.481-
				  RSA
				  357.490 (Right to a Hearing).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter D - REIMBURSEMENT METHODOLOGY FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) › Section 355.455 - Payments to Non-State Operated Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC or its designee will pay to
				  non-state-operated facilities modeled rates that will vary by class of facility
				  and a resident's level-of-need.
(b)
				  The non-state operated facility modeled rates include payment for both
				  residential and day program services. Residents receive medical and dental
				  services through the Medicaid identification card. Any medical expenses other
				  than Medicaid-covered services are the responsibility of the ICF/MR
				  provider.
(c) With a limit of
				  $5,000 per resident per year, HHSC or its designee will pay a provider for the
				  actual cost of a resident's durable medical equipment, excluding augmentative
				  communication devices, if:
(1) the cost of
				  the equipment exceeds $1,000;
(2)
				  the facility receives approval from HHSC or its designee to purchase the
				  equipment;
(3) the provider submits
				  a voucher to HHSC or its designee for the cost of the equipment; and
(4) the resident is eligible for Medicare
				  benefits and the provider has submitted a Medicare claim and received a
				  response to the claim prior to requesting payment from HHSC or its
				  designee.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter D - REIMBURSEMENT METHODOLOGY FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) › Section 355.456 - Reimbursement Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) Types of
				  facilities. There are two types of facilities for purposes of rate setting:
				  state-operated and non-state operated. Facilities are further divided into
				  classes that are determined by the size of the facility.
(b) Classes of non-state operated facilities.
				  There is a separate set of reimbursement rates for each class of non-state
				  operated facilities, which are as follows.
(1) Large facility--A facility with a
				  Medicaid certified capacity of 14 or more as of the first day of the full month
				  immediately preceding a rate's effective date or, if certified for the first
				  time after a rate's effective date, as of the date of initial
				  certification.
(2) Medium
				  facility--A facility with a Medicaid certified capacity of nine through 13 as
				  of the first day of the full month immediately preceding a rate's effective
				  date or, if certified for the first time after a rate's effective date, as of
				  the date of initial certification.
(3) Small facility--A facility with a
				  Medicaid certified capacity of eight or fewer as of the first day of the full
				  month immediately preceding a rate's effective date or, if certified for the
				  first time after a rate's effective date, as of the date of initial
				  certification.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter D - REIMBURSEMENT METHODOLOGY FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) › Section 355.458 - Supplemental Payments to Non-State Government-Owned Facilities

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Notwithstanding other
				  provisions of this subchapter and subject to the availability of funds,
				  supplemental payments are available under this section for intermediate care
				  facility for individuals with an intellectual disability or related conditions
				  (ICF/IID) services provided by eligible non-state government-owned
				  ICFs/IID.
(b) Definitions. When
				  used in this section, the following definitions apply:
(1) Aggregate upper payment limit--A
				  reasonable estimate of the amount that would be paid for the services furnished
				  by non-state government-owned ICFs/IID under Medicare payment principles, as
				  calculated in subsection (f) of this section.
(2) HHSC--The Texas Health and Human Services
				  Commission or its designee.
(3)
				  Intergovernmental transfer (IGT)--A transfer of public funds from a
				  governmental entity to HHSC.
(4)
				  Medicaid supplemental payment limit--The maximum supplemental payment available
				  to a participating non-state government-owned ICF/IID for a specific Medicaid
				  supplemental payment limit calculation period as calculated in subsection (f)
				  of this section.
(5) Medicaid
				  supplemental payment limit calculation period--The federal fiscal quarter
				  determined by HHSC for which supplemental payment amounts are
				  calculated.
(6) Non-state
				  government-owned ICF/IID--An ICF/IID where a non-state governmental entity is
				  party to the facility's Medicaid contract.
(7) Non-state governmental entity--A
				  community center established under Chapter 534, Subchapter A of the Texas
				  Health and Safety Code or a hospital authority, hospital district, healthcare
				  district, city, or county.
(8)
				  Public funds--Funds derived from taxes, assessments, levies, investments, and
				  other public revenues within the sole and unrestricted control of the
				  governmental entity that is party to the Medicaid contract of the ICF/IID
				  identified in subsection (c) of this section. Public funds do not include
				  gifts, grants, trusts, or donations, the use of which is conditioned on
				  supplying a benefit solely to the donor or grantor of the funds.
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 355.502 - Reimbursement Methodology for Common Services in Home and Community-Based Services Waivers

Current through Reg. 49, No. 28; July 12, 2024
(a) General
				  requirements. The Texas Health and Human Services Commission (HHSC) applies the
				  general principles of cost determination as specified in §
										RSA 355.101 of this
				  title (relating to Introduction). Common services are those services that are
				  available in multiple home and community-based services (HCBS)
				  waivers.
(b) Professional services.
				  Professional services include nursing services provided by a registered nurse
				  (RN) or a licensed vocational nurse (LVN) (including Adjunct Support and
				  Respite in the Medically Dependent Children Program), physical therapy,
				  occupational therapy, speech/language therapy, cognitive rehabilitative
				  therapy, nutrition/dietary services, audiology services, and behavioral support
				  services.
(c) Employment services.
				  Employment services include employment assistance and supported
				  employment.
(d) Rates for
				  professional services, employment services, and in-home respite. The rates for
				  these services are calculated in the following manner:
(1) If there is sufficient reliable cost
				  report data from which to determine reimbursements, rates are calculated in the
				  following manner.
(A) An allowable cost per
				  unit of service for each cost report is calculated in accordance with the
				  specific methodology for each HCBS waiver.
(B) The allowable cost per unit of service
				  for each cost report for all HCBS waivers is combined into an array.
(C) The array of allowable costs per unit of
				  service for all HCBS waivers is weighted by the number of units of service, and
				  the median cost per unit of service is calculated.
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 355.509 - Reimbursement Methodology for Residential Care

Current through Reg. 49, No. 28; July 12, 2024
(a) General requirements. The Texas Health
				  and Human Services Commission (HHSC), or its designee, applies the general
				  principles of cost determination as specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(b) Cost reporting.
(1) Providers must follow the cost-reporting
				  guidelines as specified in §
											RSA
				  355.105 of this title (relating to General
				  Reporting and Documentation Requirements, Methods, and Procedures).
(2) Excused from submission of cost reports.
				  If required by HHSC, a contracted provider must submit a cost report unless the
				  provider meets one or more of the conditions in §
											RSA
				  355.105(b)(4)(D) of this
				  title.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.722 - Reporting Costs by Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) Submittal of
				  cost reports. On a biennial basis, providers must submit cost reports to Texas
				  Health and Human Services Commission (HHSC) Provider Finance Department only in
				  even years, beginning with providers' 2018 cost reports. HHSC applies the
				  general principles of cost determination as specified in §
										355.101 of this title (relating to
				  Introduction).
(1) Attendant service costs.
				  Attendant service costs are defined in §
											355.112 of this title (relating to
				  Attendant Compensation Rate Enhancement).
(2) Staff who provide both attendant and
				  non-attendant services. For staff whose duties include work other than the
				  provision of attendant services for the provider, time spent providing
				  attendant services and associated expenses may be reported as attendant service
				  costs if properly documented in accordance with §
											355.105 of this title (relating to
				  General Reporting and Documentation Requirements, Methods, and
				  Procedures).
(3) Providers must
				  report the following costs:
(A) Staff wages
				  related to the delivery of attendant services.
(B) These costs may be either the provider's
				  actual expense or contracted expenditures.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.723 - Reimbursement Methodology for Home and Community-Based Services and Texas Home Living Programs

Current through Reg. 49, No. 28; July 12, 2024
(a) Prospective
				  payment rates. The Texas Health and Human Services Commission (HHSC) sets
				  payment rates to be paid prospectively to Home and Community-based Services
				  (HCS) and Texas Home Living (TxHmL) providers.
(b) Levels of need.
(1) Variable rates. Rates vary by level of
				  need (LON) for the following services:
(A)
				  host home/companion care (HH/CC);
(B) individualized skills and
				  socialization;
(C) residential
				  support services (RSS); and
(D)
				  supervised living (SL).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.725 - Reimbursement Methodology for Common Waiver Services in Home and Community-Based Services (HCS) and Texas Home Living (TxHmL)

Current through Reg. 49, No. 28; July 12, 2024
(a) Common waiver services. 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 in
				  accordance with §
										RSA
				  355.723 of this title (relating to
				  Reimbursement Methodology for Home and Community-Based Services (HCS) and Texas
				  Home Living (TxHmL) Programs). This adjusted allowable cost 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 §
										RSA
				  355.502 of this title (relating to
				  Reimbursement Methodology for Common Services in Home and Community-Based
				  Services Waivers).
(b) Requisition
				  fees. Requisition fees are reimbursements paid to the HCS and TxHmL contracted
				  providers for their efforts in acquiring adaptive aids, medical supplies,
				  dental services, and minor home modifications for HCS and TxHmL participants.
				  Requisition fee 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 and/or
				  professionals experienced in delivering contracted services; and/or other
				  sources.
(c) Requisition fees
				  unallowable costs. The actual cost of adaptive aids, medical supplies, dental
				  services, and home modifications is not allowable for cost reporting purposes.
				  Allowable labor costs associated with acquiring adaptive aids, medical
				  supplies, dental services, and home modifications should be reported in the
				  cost report. Any item purchased for participants in this program and reimbursed
				  through a voucher payment system is unallowable. Refer to §
										RSA
				  355.103(b)(20)(K) of this
				  title (relating to Specifications for Allowable and Unallowable
				  Costs).
(d) Transition assistance
				  services. The reimbursement for transition assistance services will be
				  determined in accordance with §
										RSA
				  355.502(e) of this
				  title.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.727

Current through Reg. 49, No. 28; July 12, 2024
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.743 - Reimbursement Methodology for Mental Health Case Management

Current through Reg. 49, No. 28; July 12, 2024
(a) Authority. Payments are made to qualified
				  providers delivering Mental Health Case Management (CM) to Medicaid-enrolled
				  individuals who are eligible for CM according to program rules established by
				  the Department of State Health Services (DSHS). The reimbursement determination
				  authority is specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(b) Reimbursement rates. Separate rates are
				  set for services based on the following:
(1)
				  Site-based setting. Routine CM is a face-to-face contact with the client at the
				  provider's place of business (e.g., clinic, outpatient office).
(2) Community-based setting. Intensive CM is
				  a face-to-face contact with the client at the client's home, work place,
				  school, or other location that best meets the need of the client.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.746 - Reimbursement Methodology for Mental Retardation Service Coordination

Current through Reg. 49, No. 28; July 12, 2024
(a) Definitions. The following words and
				  terms, when used in this section have the following meanings, unless the
				  context clearly indicates otherwise.
(1)
				  Allowable costs--Those expenses that are reasonable and necessary costs in the
				  normal conduct of operations relating to case management services as defined in
				  §
											RSA
				  355.102(f)(1) and (2) of
				  this title (relating to General Principles of Allowable and Unallowable
				  Costs).
(2) Provider--An entity
				  delivering service coordination to Medicaid-enrolled individuals according to
				  program rules established by Department of Aging and Disability Services
				  (DADS).
(3) Collateral--An actively
				  involved person as defined in 40 TAC §
											RSA
				  2.553(1) (relating to
				  Definitions).
(4) Unit of
				  Service--Two statewide encounter rates are established for Mental Retardation
				  Service Coordination services. The encounter unit of service is established as
				  follows:
(A) Comprehensive encounter
				  (Encounter Type A) is a face-to-face contact with the client based on an
				  average time of 45 minutes per contact. The comprehensive encounter is limited
				  to one billable encounter per client per calendar month.
(B) Follow-up encounter (Encounter Type B) is
				  a face-to-face, telephone, or telemedicine contact that involves interface with
				  the client or collateral and is based on an average time of 15 minutes per
				  contact. The follow-up encounter is limited to three follow-up encounters per
				  provider per calendar month for each comprehensive encounter that has occurred
				  within the calendar month. The follow-up encounter does not have to be provided
				  to the client for whom the comprehensive encounter was provided.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.748 - Reimbursement Methodology for Preadmission Screening and Resident Review (PASRR) Level II Evaluations

Current through Reg. 49, No. 28; July 12, 2024
(a) Qualified
				  providers. Payments are made to qualified providers delivering a Level II
				  evaluation to determine if a person believed to have a mental illness (MI) or
				  an intellectual or developmental disability (IDD) requires the level of care
				  provided by a nursing facility (NF) and, if so, whether the person needs
				  specialized services for their MI or IDD according to the program rules as
				  defined in 40 TAC Chapter 17 (relating to Preadmission Screening and Resident
				  Review).
(b) Unit of service.
				  Qualified providers are reimbursed based on a 15-minute unit of service for a
				  PASRR Level II evaluation.
(c)
				  Reimbursement methodology.
(1) The Health and
				  Human Services Commission determines the PASRR Level II evaluation rate based
				  on the salary cost for a qualified provider and other statistical data on
				  providers delivering similar services.
(2) The reimbursement methodology for a PASRR
				  Level II evaluation is also governed by: §
											RSA
				  355.108 of this chapter (relating to
				  Determination of Inflation Indices); §
											RSA
				  355.109 of this chapter (relating to
				  Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors
				  Affect Costs); and §
											RSA
				  355.110 of this chapter (relating to Informal
				  Reviews and Formal Appeals).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY › Section 355.781 - Rehabilitative Services Reimbursement Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) Authority. Payments are made to qualified
				  providers delivering rehabilitative services to Medicaid-eligible individuals
				  who are eligible for rehabilitative services according to the program rules
				  established by the Department of State Health Services (DSHS). The
				  reimbursement determination authority is specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(b) Reimbursement rates. Prospective and
				  uniform statewide rates for rehabilitative services are determined for
				  rehabilitative services specified in the Mental Health Services program rules
				  in 25 TAC Chapter 419, Subchapter L (relating to Mental Health Rehabilitative
				  Services) for the following:
(1) Day programs
				  for acute needs--adult;
(2) Crisis
				  intervention services--individual-child/adolescent and adult;
(3) Medication training and
				  support--individual-child/adolescent and adult;
(4) Medication training and
				  support--group-adult;
(5)
				  Medication training and support--group-child/adolescent;
(6) Psychosocial rehabilitative
				  services--individual-adult;
(7)
				  Psychosocial rehabilitative services--group-adult;
(8) Skills training and
				  development--individual-child/adolescent and adult;
(9) Skills training and
				  development--group-adult; and
(10)
				  Skills training and development-group-child/adolescent.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter G - ADVANCED TELECOMMUNICATIONS SERVICES AND OTHER COMMUNITY-BASED SERVICES › Section 355.5902 - Reimbursement Methodology for Primary Home Care

Current through Reg. 49, No. 28; July 12, 2024
(a) General requirements. The Texas Health
				  and Human Services Commission (HHSC) applies the general principles of cost
				  determination as specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(b) Cost reporting. Provider agencies must
				  follow the cost-reporting guidelines as specified in §
										RSA
				  355.105 of this title (relating to General
				  Reporting and Documentation Requirements, Methods and Procedures).
(1) Number of cost reports to be submitted.
				  Every legal entity must submit a cost report unless the entity meets one or
				  more of the conditions in §
											RSA
				  355.105(b)(4)(D) of this
				  title.
(A) Contracted providers participating
				  in the attendant compensation rate enhancement.
(i) At the same level of enhancement. If all
				  the contracts under the legal entity participate in the enhancement at the same
				  level of enhancement, the contracted provider must submit one cost report for
				  the legal entity.
(ii) At different
				  levels of enhancement. If all the contracts under the legal entity participate
				  in the enhancement but they participate at more than one enhancement level, the
				  contracted provider must submit one cost report for each level of
				  enhancement.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter G - ADVANCED TELECOMMUNICATIONS SERVICES AND OTHER COMMUNITY-BASED SERVICES › Section 355.6907 - Reimbursement Methodology for Day Activity and Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Day Activity and Health Care Services.
				  Day activity and health care facilities provide noninstitutional care to
				  clients residing in the community through rehabilitative nursing and social
				  services. The Texas Department of Aging and Disability Services (DADS)
				  reimburses Day Activity and Health Services (DAHS) provider agencies for the
				  services they provide to clients.
(b) General requirements. For the completion
				  and submittal of cost reports pertaining to providers' fiscal years ending in
				  calendar year 1997 and subsequent years, providers must apply the information
				  in this section. The Texas Health and Human Services Commission (HHSC) applies
				  the general principles of cost determination as specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(c) Cost-reporting guidelines. Providers must
				  follow the cost-reporting guidelines as specified in §
										RSA
				  355.105 of this title (relating to General
				  Reporting and Documentation Requirements, Methods, and Procedures).
(d) Exclusion of cost reports.
(1) Providers are responsible for reporting
				  only allowable costs on the cost report, except where cost report instructions
				  indicate that other costs are to be reported in specific lines or sections.
				  Only allowable cost information is used to determine recommended reimbursement.
				  HHSC excludes from reimbursement determination any unallowable expenses
				  included in the cost report and makes the appropriate adjustments to expenses
				  and other information reported by providers. The purpose is to ensure that the
				  database reflects costs and other information which are necessary for the
				  provision of services and are consistent with federal and state
				  regulations.
(2) Individual cost
				  reports may not be included in the database used for reimbursement
				  determination if:
(A) there is reasonable
				  doubt as to the accuracy or allowability of a significant part of the
				  information reported; or
(B) an
				  auditor determines that reported costs are not verifiable.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter G - ADVANCED TELECOMMUNICATIONS SERVICES AND OTHER COMMUNITY-BASED SERVICES › Section 355.7001 - Reimbursement Methodology for Telemedicine, Telehealth, and Home Telemonitoring Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Eligible
				  providers performing telemedicine medical, telehealth, or home telemonitoring
				  services are defined in §
										RSA 354.1430 of this
				  title (relating to Definitions), §
										RSA
				  354.1432 of this title (relating to
				  Telemedicine and Telehealth Benefits and Limitations), and §
										RSA
				  354.1434 of this title (relating to Home
				  Telemonitoring Benefits and Limitations).
(b) The Health and Human Services Commission
				  (HHSC) reimburses eligible distant site professionals providing telemedicine
				  medical services as follows:
(1) Physicians
				  are reimbursed for their Medicaid telemedicine medical services in the same
				  manner as their other professional services in accordance with §
											RSA
				  355.8085 of this title (relating to
				  Reimbursement Methodology for Physicians and Other Practitioners).
(2) Physician assistants are reimbursed for
				  their Medicaid telemedicine medical services in the same manner as their other
				  professional services in accordance with §
											RSA
				  355.8093 of this title (relating to
				  Reimbursement Methodology for Physician Assistants).
(3) Advanced Practice Registered Nurses
				  (APRNs) are reimbursed for their Medicaid telemedicine medical services in the
				  same manner as their other professional services in accordance with §
											RSA
				  355.8281 of this title (relating to
				  Reimbursement Methodology for Nurse Practitioners and Clinical Nurse
				  Specialists).
(4) Certified nurse
				  midwives are reimbursed for their Medicaid telemedicine medical services in the
				  same manner as their other professional services in accordance with §
											RSA
				  355.8161 of this title (relating to
				  Reimbursement Methodology for Midwife Services).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter I - REPORTING › Section 355.7201 - Novel Coronavirus (COVID-19) Fund Reporting

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. The Texas Health and Human
				  Services Commission (HHSC) collects semi-annual reports from hospitals and
				  nursing facilities to compile legislatively-mandated reports. This section
				  outlines the reporting requirements related to novel coronavirus (COVID-19)
				  federal fund reporting. This section also describes the circumstances in which
				  penalties and recoupments will be necessary for certain provider types for
				  failure to submit required semi-annual reports.
(b) Definitions. Unless the context clearly
				  indicates otherwise, the following words and terms, when used in this section,
				  are defined as follows.
(1) Authorized
				  representative--An organization or person authorized to report on behalf of a
				  hospital or nursing facility.
(2)
				  HHSC--The Texas Health and Human Services Commission, or its
				  designee.
(3) Hospital--A licensed
				  public or private institution as defined in Chapter
				  241 of the
				  Texas Health and Safety Code or licensed under Chapter
				  577 of the
				  Texas Health and Safety Code.
(4)
				  Nursing facility--A licensed public or private institution to which Chapter
				  242, Texas
				  Health and Safety Code, applies.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 1 - MEDICAID VISION CARE PROGRAM › Section 355.8001 - Reimbursement for Vision Care Services

Current through Reg. 49, No. 28; July 12, 2024
The Texas Health and Human Services Commission (HHSC)
						determines and may adjust the reimbursement rate or methodologies for vision
						care services according to the provisions described in §
											RSA
						355.8085 of this title (relating to
						Reimbursement Methodology for Physicians and Other Practitioners).
(1) Examination. Reimbursement for eye
					 examinations by refraction is determined in accordance with §
											RSA
					 355.8085 of this title.
(2) Eyewear. Reimbursement for prosthetic
					 eyewear is determined in accordance with §
											RSA
					 355.8085 of this title and includes fitting
					 services. Reimbursement for nonprosthetic eyewear is based on:
(A) the unit cost for each pair of eyeglasses
					 rather than costs for components; or
(B)a fixed-unit price determined by
					 competitive procurement, as authorized in §
												RSA
					 354.1025 of this title (relating to
					 Competitive Procurement of Vision Care Services). If nonprosthetic eyewear is
					 competitively procured, a dispensing fee may be paid to the dispensing provider
					 in accordance with §
												RSA
					 355.8085 of this title.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 2 - MEDICAID HOME HEALTH PROGRAM › Section 355.8021 - Reimbursement Methodology for Home Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Authorized home health nursing and aide
					 services provided to eligible Medicaid recipients are reimbursed the lesser of
					 the billed amount or the Medicaid reimbursement rate established by
					 HHSC.
(b) HHSC reviews the fees for
					 nursing and aide services at least once every two years based upon:
(1) analysis of the Centers for Medicare
					 & Medicaid Services fees for the same or similar services;
(2) analysis of Medicaid fees for the same or
					 similar services in other states; and
(3) analysis of fees paid under commercial
					 insurance for the same or similar services.