Texas Register
(22 TexReg 12369-12372), is the proposal
of rules by the Health and Human Services Commission to describe cost reimbursement
methodology requirements for the pilot program. Responsibility for adopting
rules governing the determination of fees, charges, and rates for Medicaid
payments under Chapter 32, Texas Human Resource Code, transferred to the
Health and Human Services Commission on September 1, 1997, pursuant to §531.021
of the Texas Government Code.
Don Green, chief financial officer, has determined that for each year of
the first five-year period the rule, as proposed, is in effect there will
be no fiscal implications for state or local government as a result of enforcing
or administering the proposed sections.
Ernest McKenney, director, Medicaid Administration, has determined that
for each year of the first five years the new sections are in effect the
public benefit anticipated will be that data from the pilot on the role of
the local authority will be used to improve service delivery systems prior
to state wide implementation For each year of the first five years the new
sections are in effect there is no anticipated economic cost to persons who
are required to comply with the proposed sections. There will be no effect
on small business.
A public hearing will be held at 8:30 a.m., Monday, February 23, 1998,
in Room 240 of the main TDMHMR Central Office building (Building 2) at TDMHMR
Central Office, 909 West 45th Street, Austin, Texas, to accept oral and written
testimony concerning the proposal. Persons requiring an interpreter for the
deaf or hearing impaired should notify Sheila Wilkins, Office of Policy Development,
at least 72 hours prior to the hearing by calling (512) 206-4516.
Questions about the content of the proposal may be directed to Mr. McKenney.
Comments on the proposed sections should be submitted to Linda Logan, director,
Policy Development, Texas Department Mental Health and Mental Retardation,
P.O. Box 12668, Austin, TX 78711-2668, within 30 days of publication.
The amended sections are proposed under the Texas Health and
Safety Code, §532.015(a), which provides TDMHMR with broad rulemaking
authority; Human Resource Code, Chapter 32, §32.021, and Government Code,
Chapter 531, §531.021, which provide the Texas Health and Human Services
Commission (THHSC) with the authority to administer federal medical assistance
funds and administer the state's medical assistance program. Senate Bill 509
of the 74th Texas Legislature clarifies THHSC's authority to delegate the
operation of all or part of a Medicaid program to a health and human service
agency.
The section affects Human Resources Code, Chapter 32, and Government Code,
Chapter 531, §531.021.
§409.517.Rejected Claims.
If the Texas Department of Mental Health and Mental Retardation (TDMHMR)
rejects a claim because of errors, the provider must research the errors,
initiate appropriate corrective action, and resubmit a corrected claim to
TDMHMR with supporting documentation within 180 calendar days from the end
of the month of service or within 30 days of notification of a rejected claim
by TDMHMR, whichever is later.
§409.519.Calculation of Consumer Co-payment.
(a)
Consumers who are determined to be financially eligible
based on the special institutional income limit are required to share in the
cost of waiver services. The method for determining the consumer's co-payment
is described in subsection (b) of this section and documented on the Texas
Department of Human Services Medical Assistance Only Worksheet. When calculating
the co-payment amount for consumers with incomes that exceed the supplemental
security income (SSI) federal benefit rate (FBR), deduct the following:
(1)
the cost of the consumer's maintenance needs which must
be equivalent to the special institutional income limit for eligibility under
the Texas Medicaid program.
(2)
the cost of the maintenance needs of the consumer's
dependent children. This amount is equivalent to the Temporary Assistance
to Needy Families (TANF) basic monthly grant for children or a spouse with
children, using the recognizable needs amounts in the TANF Budgetary Allowances
Chart; and
(3)
the costs incurred for medical or remedial care which
are necessary but are not subject to payment by Medicare, Medicaid, or any
other third party. These include the cost of health insurance premiums, deductibles,
and co-insurance.
(b)
The co-payment amount is the consumer's remaining income
after all allowable expenses have been deducted. The co-payment amount is
applied only to the cost of home and community-based services which are funded
through the MRLA Pilot Program and specified on the consumer's IPC. The co-payment
must not exceed the cost of services actually delivered.
(c)
Consumers must pay the cost sharing amount to the provider
contracted to deliver authorized waiver services.
§409.521.Spousal Impoverishment Provisions.
(a)
For program consumers with spouses who live in the community,
the income and resource eligibility requirements are determined according
to the spousal impoverishment provisions in the Social Security Act, §1924,
and as specified in the Medicaid State Plan and in §409.505(a)(1) of
this title (relating to Client Eligibility Criteria.)
(b)
After the consumer is determined to be eligible for Medicaid,
the Texas Department of Human Services (TDHS) determines the amount of the
consumer's income applicable to payment.
(c)
To determine the amount of the consumer's income applicable
to payment, TDHS uses the same methodology as if the consumer were residing
in an institution, except that the personal needs allowance is equal to the
institutional income cap. The spousal diversion is equal to the SSI income
limit.
§409.523.Maintenance of MRLA Pilot Program Referral List.
(a)
The local MRA will maintain an up-to-date list of individuals
living in and waiting for MRLA Pilot Program services in the MRA's local
service area.
(1)
The MRA will assign the individual's placement on the
referral list, chronologically by date of application.
(2)
The MRA will notify MRLA Pilot Program providers
in its local service area of the process providers should use to refer applicants
who wish to be placed on the referral list.
(3)
The MRA may disregard an applicant on the referral
list only when the following documentation exists:
(A)
written permission of the applicant or the applicant's
legal representative to remove the applicant's name from the referral list;
(B)
the applicant is deceased;
(C)
the applicant moved out of the local service area; or
(D)
TDMHMR has denied the applicant's enrollment and the applicant
or the applicant's legal representative has had an opportunity to exercise
the applicant's right to appeal the decision according to §409.505 of
this title (relating to Client Eligibility Criteria).
(4)
At the written request of an applicant or the
legal representative of an applicant who moves to the local service area
of a different MRA, the original MRA will assist in transferring the applicant's
name and current application date to the MRA having jurisdiction in the local
service area where the applicant has moved. The MRA receiving the referral
transfer will add the individual's name to its referral list maintaining
the current application date assigned by the transferring MRA.
§409.525.Process for Applicant Referral and Enrollment.
(a)
The MRA designated by TDMHMR for the geographic area in
which the applicant resides will receive all requests from applicants seeking
enrollment into the MRLA Pilot Program.
(1)
The MRA will register the applicant on the MRA's referral
list as specified in §409.523 of this title (relating to Maintenance
of MRLA Pilot Program Referral List).
(2)
The MRA will notify the first applicant on the referral
list when a placement vacancy occurs in the MRA's local service area and
begin the referral/enrollment process by informing the applicant and/or the
applicant's legal representative of his/her choice between participation
in the ICF-MR Program or the MRLA Pilot Program and documenting the applicant's
or the representative's choice of services.
(3)
If the applicant or representative chooses participation
in the MRLA Pilot Program, the MRA will assign a Service Coordinator who
will develop a Person-Directed Plan (PDP). At minimum, the PDP will include
the following:
(A)
a description of the services and supports the individual
requires to continue living in the community;
(B)
a description of the individual's current services and
supports, identifying those that would continue to be available if the individual
enrolled in the MRLA Pilot Program (e.g., services not covered under the
approved waiver);
(C)
individual outcomes to be achieved through MRLA Pilot
Program service components and justification for each service component to
be included in the applicant's IPC;
(D)
identification of all determinations needed to establish
the applicant's eligibility for SSI or Medicaid benefits and for an ICF-MR
Level of Care (LOC); and
(E)
actions and methods to be used to reach identified service
outcomes, projected completion dates, and person(s) responsible for completion.
(4)
The service coordinator prepares an application
for the individual's enrollment into the MRLA Pilot Program.
(A)
If the applicant's financial eligibility for the MRLA
Pilot Program must be established, the MRA will initiate, monitor, and support
the individual's application processes necessary to obtain a financial eligibility
determination.
(B)
The MRA will complete an LOC assessment form. The MRA
will determine or validate a determination that the applicant has mental retardation
in accordance with Chapter 405, Subchapter D of this title (relating to Determination
of Mental Retardation and Appropriateness for Admission to Mental Retardation
Services) or verify that the individual has been diagnosed by a licensed physician
as having a related condition as defined in §406.202 of this title (relating
to Definitions for Level-of-Care and Level-of-Need Criteria). The MRA will
administer the Inventory for Client and Agency Planning (ICAP) and recommend
a level-of-need assignment to TDMHMR in accordance with §409.507 of this
title (related to Payment Category Assignment and Provider Claims Payment).
(C)
Develop a proposed IPC with the applicant based on the
PDP and §409.503(b) of this title (relating to Service Components of
the MRLA Program).
(5)
The Service Coordinator will inform the applicant
or the applicant's legal representative of all available MRLA Pilot Program
providers in the local service area. The Service Coordinator will:
(A)
assist the applicant or the applicant's legal representative
in selecting potential providers within the local service area;
(B)
review the proposed IPC with potential provider agencies
as selected by the applicant or the applicant's legal representative;
(C)
arrange for meetings/visits with potential providers as
desired by the applicant or the applicant's legal representative;
(D)
assure that the applicant's or representative's choice
of a specific provider is documented, is signed by the applicant or the applicant's
representative and is retained by the MRA in the individual's record; and
(E)
negotiate/finalize the proposed IPC to be delivered by
the selected provider.
(b)
When the selected provider has agreed to deliver the services
delineated on the IPC, the MRA will submit the application for enrollment
to TDMHMR. TDMHMR will send notification of the applicant's approval or denial
of MRLA Pilot Program enrollment to the applicant, the selected provider,
and the responsible MRA.
(c)
The selected provider will initiate services in accordance
with the approved IPC upon receipt of TDMHMR's enrollment approval.
§409.527.Revisions and Renewals of IPCs, LOCs and LONs for Enrolled Individuals.
(a)
At least annually, but prior to the expiration of an individual's
IPC, the service coordinator, the individual, the individual's legal representative,
and the provider must review the PDP to assure individual outcomes previously
identified are relevant. The IPC is reviewed by the service planning team,
updated to reflect any changes to the PDP, and is submitted to TDMHMR for
approval.
(b)
The service coordinator, in collaboration with the service
planning team, will initiate revisions to the IPC in response to changes in
the individual's needs as documented in the current PDP.
§409.529.Coordination of Transfers and Permanent Discharges.
(a)
Individuals who are currently receiving services from
an HCS or HCS-O Program provider and who are moving to a geographic area covered
by the MRLA Pilot Program may request to transfer their services to an MRLA
Pilot Program provider. The service coordinator from the receiving MRA will:
(1)
coordinate with the individual and their current HCS or
HCS-O provider to facilitate selection of a provider and enrollment in the
MRLA Pilot Program.
(2)
determine in conjunction with the current HCS or
HCS-O provider and the receiving MRLA provider, an effective date for enrollment.
(3)
review the current IPC with the individual and the
receiving MRLA provider and will negotiate and finalize the initial MRLA Pilot
Program IPC. The effective date of the individual's IPC as established in
the HCS or HCS-O Program will not be changed upon enrollment with an MRLA
provider.
(b)
Individuals currently receiving services within the MRLA
Pilot Program may request to transfer their services to another MRLA provider
in any of the local service areas specified in §409.501(a) of this title
(relating to Geographic Area of the MRLA Pilot Program).
(1)
If an individual is transferring to a provider within
the same MRA, the service coordinator will coordinate with the individual,
the current provider, and the receiving provider to facilitate the transfer.
(2)
If the transfer will be to another MRA in the MRLA
Pilot Program, the sending and receiving MRAs will coordinate the transfer.
The receiving service coordinator will review the current IPC with the individual
and the receiving MRLA provider and will initiate any changes if needed. The
effective date of the individual's IPC will not be changed upon transfer to
another provider.
(3)
The MRAs will determine in conjunction with the current
provider and the receiving MRLA provider, an effective date for transfer.
(c)
Individuals who are moving outside the geographic area
of the MRLA Pilot Program and who are currently receiving services from an
MRLA provider may request to transfer their services to an HCS or HCS-O Program
provider in the area to which they are moving.
(1)
If the individual is seeking HCS-O Program services, the
service coordinator will confirm the individual's eligibility with TDMHMR.
(2)
The receiving MRA will assist the individual or the
individual's representative to facilitate selection of an HCS or HCS-O provider.
(3)
The current and the receiving MRAs will determine
in conjunction with the current MRLA provider and the receiving HCS or HCS-O
provider an effective date for enrollment.
(4)
The effective date of the individual's IPC as established
in the MRLA Pilot Program will not be changed upon enrollment into the HCS
or HCS-O Program.
(d)
TDMHMR must approve all discharges from program services.
(1)
The service coordinator must submit the request to TDMHMR
to discharge an individual from program services.
(2)
TDMHMR will send a written discharge notification
to the participant or the participant's representative, the provider, and
the MRA indicating the effective date of the discharge and the participant's
right to a fair hearing in accordance with §409.505 of this title (relating
to Client Eligibility Criteria).
§409.531.Certification Status.
(a)
Program providers contracted with TDMHMR for participation
in the MRLA Pilot Program must be in continuous compliance with the MRLA
Pilot Program Principles for Program Providers as described in Each program
provider participating in the MRLA Pilot Program will receive a certification
review conducted by TDMHMR or its designee at least annually in order to
maintain certification status.
Figure 1: 25 TAC §409.531(a).
(1)
TDMHMR personnel will conduct all certification reviews
of program providers operated by the local Mental Retardation Authority.
(2)
TDMHMR or its designee will conduct all certification
reviews of non-MRA operated program providers.
(b)
Certification review corrective action plans required from
the program provider as determined by prior reviews under the HCS or HCS-O
Consumer Principles for Evidentiary Certification and related timelines remain
in effect until the first certification review as a program provider participating
in the MRLA Pilot Program.
§409.533.Hazards to Health, Safety, and Welfare.
A hazard to health, safety, and welfare is any condition that the
review team determines may result in imminent death, or serious or permanent
harm to an individual. A hazard is designated as such in the MRLA Pilot Program
certification review report. If the hazard is corrected during the review
visit, the corrections will also be designated in the report.
(1)
Immediate Corrective Action. Findings determined to be
a hazard to health, safety and welfare must be corrected by the program provider
before the exit conference of the respective review.
(2)
Sanctions. If the program provider does not correct
the hazard to health, safety, and welfare before the exit conference,
(A)
the program provider will be denied certification, and
(B)
the MRA with permission of the Texas Department of Mental
Health and Mental Retardation (TDMHMR) will immediately coordinate development
of alternative services for people enrolled in the provider's program, as
appropriate.
§409.535.Compliance.
If any item of noncompliance with the MRLA Pilot Program Evidentiary
Principles for Program Providers remains uncorrected at the time of the exit
conference, the program provider must complete corrective action within 30
calendar days following the exit conference. TDMHMR or its designee must complete
a follow-up review within 15 calendar days following the 30th day. The follow-up
review may be either a desk review of documentation or an on-site review at
the review team's discretion.
§409.537. Sanctions.
(a)
If the program provider does not correct all remaining
items of noncompliance by the completion of the first follow-up review, a
vendor hold may be implemented and will continue until corrective action is
confirmed by TDMHMR.
(1)
TDMHMR or its designee will complete a second follow-up
review between 30 and 60 calendar days from the date the vendor hold was implemented.
(2)
If the program provider corrects all items of noncompliance
by the completion of the second follow-up review, the vendor hold is removed
effective the date the review is completed.
(b)
TDMHMR denies certification and initiates contract cancellation
if the program provider does not correct all items of noncompliance by the
completion of the second follow-up review.
§409.539.Unannounced or Intermittent Review Visits.
(a)
TDMHMR or its designee may conduct unannounced or intermittent
review visits at any time, with or without prior notice to the program provider.
(b)
Items of noncompliance noted in unannounced or intermittent
review visits may result in certification action described in §409.533
and §409.537 of this title (relating to Hazards to Health, Safety, and
Welfare; Compliance; and Sanctions).
§409.541.Compliance with MRLA Pilot Program Principles for Mental Retardation Authorities.
(a)
Mental Retardation Authorities participating in the MRLA
Pilot Program must be in continuous compliance with the MRLA Pilot Program
Principles for Authorities as described in
Figure 2:25 TAC §409.541(a).
(b)
Each Mental Retardation Authority participating in the
MRLA Pilot Program will receive a compliance review conducted by TDMHMR at
least annually.
(c)
If any item of noncompliance remains uncorrected by the
Mental Retardation Authority at the time of the review exit conference, the
Mental Retardation Authority will develop a plan of correction with timelines
to be implemented after approval by TDMHMR. TDMHMR may take action as specified
in the performance contract between the local Mental Retardation Authority
and TDMHMR if the MRA fails to develop or implement an approved plan of correction.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
February 2, 1998.
TRD-9801449
Ann Utley
Chairman, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 15, 1998
For further information, please call: (512) 206-4516