Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 352.
QUALITY ASSURANCE FEE FOR LONG-TERM CARE FACILITIES
1 TAC §§352.1 - 352.9
The Health and Human Services Commission (the Commission)
proposes new chapter 352, Quality Assurance Fee for Long-term Care Facilities, §352.1
(concerning the Purpose and Duration of chapter 352), §352.2 (concerning
Definitions), §352.3 (concerning quality assurance fee), §352.4
(concerning required reports), §352.5 (concerning review and Determination
of the Quality Assurance Fee), §352.6 (concerning Payment and Collection
of Quality Assurance Fee), §352.7 (concerning Enforcement), §352.8
(concerning Penalty), §352.9 (concerning Informal Reviews), and §352.10
(concerning Formal Appeals), to implement the requirements of chapter 252,
subchapter H, Health and Safety Code (effective September 1, 2001).
The proposed chapter establishes a methodology for the determination of
the quality assurance fee, the reporting of data by regulated facilities,
the collection of the quality assurance fee, the assessment of a penalty for
certain types of noncompliance, and the conduct of informal reviews and formal
appeals by the Commission or its designee.
Background and Summary of Factual Basis for the Rules
The 77th Texas Legislature enacted Senate Bill number 1839, which included
a new subchapter H to chapter 252, Health and Safety Code. Subchapter H authorizes
the establishment, collection, and enforcement of a quality assurance fee
for intermediate care facilities for persons with mental retardation (ICFs/MR)
and facilities operated according to the requirements of chapter 252, Health
and Safety Code, and owned by community mental health mental retardation centers,
as described in chapter 534, Health and Safety Code.
Section 252.202 (as added by S.B. 1839), authorizes the Commission or the
Texas Department of Human Services to set a quality assurance fee in an amount
that generates annual revenues not to exceed 6 percent of a facility's gross
annual receipts in the state. The statute requires the fee to be based on
the number of patient days and gross receipts reported by a facility. Section
252.205 requires HHSC to adopt rules to implement Subchapter H and authorizes
the Commission to assess an administrative penalty. The rules may not grant
exceptions to the quality assurance fee, and the administrative penalty may
not exceed the greater of one-half the amount of any outstanding quality assurance
fee or $20,000. Section 252.207 directs the Commission's disposition of the
proceeds of collected quality assurance fees. Section 252.209 provides for
the expiration of subchapter H on September 1, 2005, if the 79th Texas Legislature
fails to reauthorize the subchapter.
Section 9.02 of S.B. 1839 provides that for the first month following the
effective date of S.B. 1839, the quality assurance fee is equal to $5.25 multiplied
by the number of patient days as determined under subchapter H. The quality
assurance fee established under §9.02 remains in effect until the Commission
or the Texas Department of Human Services at the direction of the Commission,
obtains the information necessary to set the fee under §252.202, Health
and Safety Code.
The proposed rules were developed in conjunction with the Texas Department
of Human Services and the Texas Department of Mental Health and Mental Retardation.
Section-by-Section Explanation
Section 352.1 describes the purpose of the proposed rules and establishes
an expiration date of September 1, 2005, if the Texas Legislature fails to
extend Chapter 252, Health and Safety Code. Section 352.2 provides definitions
for critical terms in the proposed rules. Section 352.3 describes the methodology
by which the quality assurance fee is established. Section 352.4 prescribes
reporting requirements for facilities subject to the quality assurance fee.
Section 352.5 requires the Commission or its designee to review reported data
and to set a quality assurance fee in accordance with §352.4. Section
352.6 describes a facility's responsibility to pay the quality assurance fee
and the methods by which the fee may be collected. Section 352.7 describes
the (concerning Enforcement), §352.8 (concerning Penalty), §352.9
(concerning Informal Reviews), and §352.10 (concerning Formal Appeals)
Public Benefit
Don Green, Chief Financial Officer, has determined that during the first
five years that the proposed rules are in effect, the public will benefit
from the changes in the reimbursement of facilities required under chapter
252, subchapter H, Health and Safety Code. The principal benefit will be the
greater emphasis that will be placed on direct care staffing, wages, and benefits
under the reimbursement instructions provided in the statute. The public also
will benefit from increases in reimbursement that result from the collection
of quality assurance fees, either to facilities that pay the quality assurance
fee or to the Medicaid waiver programs identified in §252.206(d), Health
and Safety Code. Finally, the public will benefit from the increased federal
funding that the state may receive from the application of some of the quality
assurance fee collections.
Fiscal Note
Don Green, Chief Financial Officer, has determined that for the first five
years that the proposed rules are in effect, there will be no fiscal impact
to the state resulting from the collection of quality assurance fees under
this chapter. There will be an increase in state revenues resulting from the
enhanced federal matching funds that will be available for rate increases.
This increase will result in an estimated $41.3 million in additional federal
funds for the biennium to support increased reimbursement rates paid to ICFs/MR
that participate in the state Medicaid program.
No additional costs will be borne by local governments as a result of the
rules.
Small and Micro-business Impact Analysis
The proposed rules will not result in additional costs to persons required
to comply with the rules, nor do the rules have any anticipated adverse effect
on small or micro-businesses. The rules will not affect local employment.
Regulatory Analysis
The Health and Human Services Commission has determined that none of the
proposed rules is a "major environmental rule" as defined by §2001.0225,
Government Code. "Major environmental rule" is defined to mean a rule the
specific intent of which is to protect the environment or reduce risks to
human health from environmental exposure and that may adversely affect in
a material way the economy, a sector of the economy, productivity, competition,
jobs, the environment, or the public health and safety of the state or a sector
of the state. None of the proposed rules is specifically intended to protect
the environment or reduce risks to human health from environmental exposure.
Takings Impact Assessment
The Health and Human Services Commission has determined that the proposed
rules do not restrict or limit an owner's right to their property that would
otherwise exist in the absence of governmental action and therefore do not
constitute a taking under Texas Government Code, §2007.043. The following
is a summary of that assessment. The proposed rules are reasonably taken to
fulfill requirements of state law.
Public Comment
A hearing to accept oral and written testimony from members of the public
concerning the proposal has been scheduled for 2:00 PM, Tuesday, September
18, 2001, in the Texas Health and Human Services Commission Conference Room
5501 of the Brown-Heatly State office building at 4900 North Lamar Boulevard,
in Austin, Texas. Persons requiring accommodations for a disability should
notify Jeff Phelps, at least 72 hours prior to the hearing at (512) 424-6657.
Public comment may be submitted in writing to Steve Lorenzen, Director,
Medicaid Rate Setting, Health and Human Services Commission, by mail addressed
to P.O. Box 13247, Austin, Texas 78711, or by facsimile to (512) 424-6586.
Comments must be submitted by 5:00 p.m., September 24, 2001. Further information
may be obtained by calling Mr. Lorenzen at (512) 424-6633.
Statutory Authority
The amendments are proposed under §531.021(b), Government Code, which
requires HHSC to adopt reasonable rules and standards to govern the determination
of fees, charges, and rates for medical assistance payments under Chapter
32, Human Resources Code, in consultation with the agencies that operate the
Medicaid program; and §531.033, Government Code, which provides the commissioner
of health and human services with authority to adopt rules necessary to carry
the duties of HHSC under Chapter 531, Government Code.
The proposed amended rules implement §531.021(b), Government Code,
concerning the adoption of rules and standards to govern the determination
of fees, charges, and rates for medical assistance payments under Chapter
32, Human Resources Code, and §32.0281, Human Resources Code, concerning
the adoption of rules regarding Medicaid reimbursement rates.
§352.1. Purpose and Duration of Chapter.
(a)
This chapter implements the determination, assessment,
collection, and enforcement of the quality assurance fee authorized under
chapter 252, Health and Safety Code, subchapter H.
(b)
The purpose of the quality assurance fee established under
this chapter is to improve the quality of care provided to persons with mental
retardation as follows:
(1)
The quality assurance fee is intended to support and/or
maintain an increase in reimbursement to licensed intermediate care facilities
for the mentally retarded and facilities operated according to the requirements
of chapter 252, Health and Safety Code and owned by a community mental health
and mental retardation center as described in chapter 534, subchapter A, Health
and Safety Code, that participate in Medicaid program, subject to legislative
appropriation for this purpose; and
(2)
If funds generated from the collection of quality assurance
fees under this chapter are available following fulfillment of the purpose
described in subsection (b)(1) of this section, such funds may be allocated
to the Home and Community Based waiver program and the Mental Retardation
Local Authority waiver program established pursuant to 42 U.S.C. § 1396n(c).
(3)
The Commission or its designee may also offset allowable
expenses to administer the quality assurance fee program against revenues
generated by the collection of the quality assurance fee.
(c)
This chapter will expire on September 1, 2005, unless chapter
252, subchapter H, Health and Safety Code, is extended by the 79th Texas Legislature.
§352.2.Definitions.
As used in this chapter, the following terms shall have the meanings
prescribed below, unless the context clearly indicates otherwise:
(1)
"Facility" means:
(A)
An intermediate care facility for the mentally retarded
or the corporate parent of an intermediate care facility for the mentally
retarded licensed under chapter 252, Health and Safety Code; or
(B)
A facility operated according to the requirements of chapter
252, Health and Safety Code, and owned by a community mental health and mental
retardation center as described in chapter 534, subchapter A, Health and Safety
Code.
(2)
"Gross receipts" means money paid to a facility as compensation
for services provided to patients, including client participation, but does
not include charitable contributions to a facility.
(3)
"Total patient days" means the sum, computed on a monthly
basis, of the following:
(A)
The total number of patients occupying a facility bed immediately
before midnight on each day of the month;
(B)
The total number of facility beds that are on hold on each
day of the month and that have been placed on hold for a period not to exceed
three consecutive calendar days during which a patient is in a hospital during
the month; and
(C)
The total number of beds that are on hold on each day of
the month and that have been placed on hold for a period not to exceed three
consecutive calendar days during which a patient is on therapeutic home leave
during the month.
(D)
The total number of days a patient is discharged from a
facility are not counted in the calculation of the total patient days under
this chapter.
§352.3.Quality Assurance Fee Determination Methodology.
(a)
Interim quality assurance fee. As provided in section 9.02
of the Act of May 28, 2001, 77th Leg. R.S., (Senate Bill 1839), the quality
assurance fee for the month September 2001, and for each month thereafter
until implementation of a final quality assurance fee under subsection (b)
of this section is the total number of patient days reported by a facility
under §352.4 of this chapter multiplied by $5.25.
(b)
Quality assurance fee. Beginning November 1, 2001 the quality
assurance fee for a facility is in the amount of 5.5 percent of each reimbursement
or payment rate received, including those received from the resident, for
each resident in the facility during a calendar month, provided the amount
of all such quality assurance fees assessed for the facility during the 12-month
period following assessment of the quality assurance fee do not exceed six
percent of the facility's total annual gross receipts in Texas.
(c)
Not later than July 31, 2002, and every six months thereafter,
the commission or its designee will review each individual facility's quality
assurance fee calculation. A facility's liability for the quality assurance
fee may be adjusted following this review to ensure that the quality assurance
fee does not exceed six percent of annual revenue.
§352.4.Required reports.
(a)
The following reports must be filed by a facility in accordance
with the instructions of the Commission or its designee:
(1)
The monthly patient day report required under subsection
(c) of this section; and
(2)
The semi-annual report of gross receipts required under
subsection (d) of this section.
(b)
Amended reports.
(1)
A facility may amend a report required under subsections
(c) or (d) of this section;
(2)
An amended monthly patient day report must be filed no
later than 10 calendar days following the filing of the report required under
subsection (c) of this section.
(3)
An amended report of gross receipts must be filed no later
than 10 calendar days following the filing of the report required under subsection
(d) of this section.
(c)
Monthly patient day report.
(1)
A facility must report, not later than the 10th calendar
day after the last day of a month, the total number of patient days for the
facility during the preceding month.
(2)
A facility must file the report required by this subsection
on forms or in the format and according to the instructions prescribed by
the commission or its designee.
(3)
The first report required under this subsection is not
due until the 10th day after the end of the first full month following the
effective date of this chapter. This report will cover the months September
1, 2001 through the end of the first full month following the effective date
of this chapter.
(d)
Reporting of gross receipts.
(1)
A facility must report, not later than the 10th calendar
day following the last day of the sixth month following the effective date
of this chapter, the total gross receipts the facility received during the
preceding 6-month period.
(2)
A facility must file the report required by this subsection
on forms or in the format and according to the instructions prescribed by
the commission or its designee.
§352.5.Payment and Collection of Quality Assurance Fee.
A facility must:
(1)
Pay the amount of the quality assurance fee in accordance
with the instructions of the commission or its designee not later than the
30th day of the month; or
(2)
Pay the amount of the quality assurance fee in accordance
with the instructions of the commission or its designee and request an informal
review of the calculation of the quality assurance fee in accordance with §352.8
of this chapter.
(3)
The first payment required under this section is not due
until the 30th day after the end of the first full month following the effective
date of this chapter. That payment will cover all the months beginning September
1, 2001 through the end of the first full month following the effective date
of this chapter.
(4)
The commission or its designee may review the calculation
of the quality assurance fee to ensure its accuracy and instruct the facility
to correct its calculation and payment.
§352.6.Enforcement.
(a)
The commission or its designee may audit a facility's records
or the record of any corporate parent or affiliate of a facility for the purpose
of determining the total patient days or gross receipts of the facility.
(b)
The commission may not grant any exceptions from the quality
assurance fee or the provision of any data necessary for the Commission or
its designee to calculate the fee.
§352.7.Penalty.
(a)
The commission or its designee will assess a financial
penalty against a facility that:
(1)
Fails to timely file the monthly facility report required
under §352.4 of this chapter;
(2)
Files a false, erroneous, or fraudulent monthly facility
report that the commission or its designee concludes resulted in the assessment
of a quality assurance fee that is less than the facility should have been
assessed; or
(3)
Fails to timely pay a quality assurance fee assessed under §352.5
of this chapter.
(4)
A penalty assessed under this section is in an amount equal
to one-half the amount of the outstanding quality assurance fee or fees, not
to exceed $20,000.
(b)
The commission or its designee will notify a facility in
writing of the assessment of a penalty under this section and the amount of
the penalty.
(c)
The commission or its designee may make a referral to an
appropriate authority in cases where the commission or its designee makes
a good faith determination that a facility has:
(1)
Committed fraud in the submission of information to the
commission or its designee;
(2)
Willfully submitted erroneous information to the commission
or its designee; or
(3)
Violated a requirement of its license or Medicaid certification.
(d)
The commission or its designee may report a facility that
fails to pay the quality assurance fee to the Comptroller of Public Accounts
or other appropriate authority for purposes of implementing a suspension of
payments to the provider.
(e)
The assessment of a penalty under this section does not
relieve a facility from:
(1)
Providing services to patients in accordance with its obligations
under contract or the law;
(2)
Paying additional quality assurance fees that may be assessed
to the facility; or
(3)
Otherwise complying with licensure and certification requirements.
§352.8.Informal review.
(a)
A facility that believes the commission or its designee
incorrectly calculated the amount of a quality assurance fee as defined in
this chapter, may request an informal review from the commission or its designee
in accordance with this section.
(b)
The purpose of an informal review is to provide for the
informal and efficient resolution of the matters in dispute. An informal review
is not a formal administrative hearing, but is a prerequisite to obtaining
a formal administrative hearing and is conducted according to the following
procedures:
(1)
The facility must request an informal review in writing
to the commission or its designee, delivered by United States mail or special
mail delivery within 20 calendar days of the date on the written notification
of any of the actions described in subsection (a) of this section.
(2)
A facility's written request for an informal review must
include:
(A)
A concise statement of the specific actions or determinations
the facility disputes;
(B)
The facility's recommended resolution; and
(C)
Any supporting documentation the facility deems relevant
to the dispute. It is the responsibility of facility to submit all pertinent
information at the time of its request for an informal review.
(c)
On receipt of a request for informal review, the commission
or its designee assigns the review to appropriate staff.
(1)
The lead staff member coordinates a review by appropriate
staff of the information submitted by the interested party.
(2)
Staff may request additional information from the facility,
which the facility must submit in writing to the lead staff member within
14 calendar days of the request for additional information. Information received
after 14 days may not be used in the panel's written decision unless the interested
party receives approval of the lead staff member to submit the information
after 14 days.
(d)
Within 30 days of the date the request for informal review
is received by the commission or its designee or the date additional requested
information is received by the commission or its designee, the lead staff
member must send the interested party its written decision by certified mail,
return receipt requested.
§352.9.Formal Appeal of Penalty.
A facility that wishes to appeal the assessment of a penalty under §352.8
of this chapter may request a formal appeal from the Texas Department of Human
Services in accordance with 40 T.A.C. §90.236.
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 August 20, 2001.
TRD-200104886
Marina S. Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Earliest possible date of adoption: September 30, 2001
For further information, please call: (512) 424-6576
Subchapter A. COST DETERMINATION PROCESS
1 TAC §355.114
The Texas Health and Human Services Commission (HHSC) proposes
new §355.114, concerning vendor fiscal intermediary payment option, in
its Medicaid Reimbursement Rates chapter. The purpose of the new section is
to create a vendor fiscal intermediary (VFI) payment model for programs that
offer personal attendant services.
This proposal establishes the payment rate methodology used to determine
the consumer payment rate. The consumer can use the methodology to pay a personal
attendant, and use the VFI payment rate to pay for contracted VFI services.
The sum of these two payment rates cannot exceed the payment rate for contracted
providers who deliver services to clients who do not participate in the VFI
option. This option will be made available in the Consumer-Managed Personal
Attendant Services, Community Based Alternatives (CBA), Community Living Assistance
and Support Services (CLASS), Deaf- Blind with Multiple Disabilities, In-home
and Family Support, Medically Dependent Children, Primary Home Care, and Family
Care Services programs within the Texas Department of Human Services (DHS).
The VFI model was piloted in DHS's Client Managed Attendant Services program
and the Personal Attendant Services program of the Texas Rehabilitation Commission
(TRC) under House Bill 2084 of the 75th Legislature. The pilot has been expanded
to other Community Care for the Aged and Disabled (CCAD) programs under Senate
Bill 1586 of the 76th Legislature, which directs HHSC to expand this model
to other HHSC community programs.
Don Green, chief financial officer, has determined that for the first five-year
period the section is in effect, there will be no fiscal implications for
state or local governments as a result of enforcing or administering the section.
Commissioner Don Gilbert has determined that for the first five years the
section is in effect, the public benefit anticipated as a result of adoption
of the proposed rule will be that consumers enrolled in these programs will
be able to determine the compensation of their attendants within an approved
service plan budget that is based on the consumer payment rate. There will
be no effect on small or micro businesses as a result of enforcing or administering
the section, because a limited number of consumers will take advantage of
the VFI payment option. A contracted provider who currently serves a consumer
who decides to participate in the option can choose to continue providing
some of the employer-related responsibilities, such as processing payroll
and maintaining records for business tax filings at the VFI payment rate.
There is no anticipated economic cost to persons who are required to comply
with the proposed section.
Questions about the content of this proposal may be directed to Carolyn
Pratt at (512) 438-4057 in DHS's Rate Analysis Department. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-202,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
The proposal is available for public review at local offices of DHS. For
further information, contact Carolyn Pratt in DHS's Rate Analysis Department
at (512) 438-4057.
Under §2007.003(b) of the Texas Government Code, the department
has determined that Chapter 2007 of the Government Code does not apply to
these rules. Accordingly, the department is not required to complete a takings
impact assessment regarding these rules.
The new section is proposed under Texas Government Code §531.033,
which authorizes the commissioner of HHSC to adopt the rules necessary to
carry out the commission's duties, and §531.021(b), which establishes
the commission as the agency responsible for adopting reasonable rules governing
the determination of fees, charges, and rates for medical assistance payments
under Chapter 32, Human Resources Code.
The section implements the Government Code, §531.033 and §531.021(b).
§355.114.Vendor Fiscal Intermediary Payment Option.
(a)
The vendor fiscal intermediary (VFI) payment option is
made available to eligible consumers in the Community Based Alternatives (CBA),
Community Living Assistance and Support Services (CLASS), Deaf-Blind Multiple
Disabilities, Medically Dependent Children, and Primary Home Care (PHC) programs.
(b)
The sum of the payment rate for the contracted VFI and
the payment rate for the consumer must not exceed the hourly attendant compensation
enhancement participant payment rate made to contracted providers in these
programs. The payment rate for the contracted VFI is determined by modeling
the estimated administrative cost to carry out the responsibilities of the
VFI. The payment rate for the consumer is determined by subtracting the contracted
VFI payment rate from the attendant compensation enhancement participation
payment rate made to contracted providers in these programs.
(c)
The VFI payment rate is paid to the VFI as a percentage
of the amount expended and claimed to the Texas Department of Human Services
(DHS).
(d)
Consumers must expend on the average hourly compensation
of attendants, an amount equal to the calculated consumer payment rate per
hour of service divided by 1.07. Compensation includes salaries and wages,
payroll taxes, workers' compensation, employee benefits/insurance, and mileage
reimbursement.
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 August 17, 2001.
TRD-200104829
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Earliest possible date of adoption: September 30, 2001
For further information, please call: (512) 438-3734
1 TAC §355.311
The Texas Health and Human Services Commission (HHSC) proposes
new §355.311, concerning Medicaid reimbursement rates for state veterans
homes, in its Medicaid Reimbursement Rates chapter. The purpose of the amendment
is to implement appropriations rider 56 passed by the 77th Legislature. Rider
56 directs HHSC to work in consultation with the Texas Veterans Land Board
to develop reimbursement rates for state veterans homes.
The proposed rule creates the reimbursement methodology for state veterans
homes that defines how payment rates will be determined for these homes. Medicaid
payment rates for these homes will be based on actual cost to the state for
Medicaid services delivered in the homes.
Don Green, chief financial officer, has determined that for the first five-year
period the section is in effect, there will be fiscal implications for state
government as a result of enforcing or administering the section. The effect
on state government for the first five- year period the sections will be in
effect is an estimated additional cost of $146,042 in fiscal year (FY) 2002;
$146,042 in FY 2003; $146,042 in FY 2004; $146,042 in FY 2005; and $146,042
in FY 2006. There will be no fiscal implications for local governments as
a result of enforcing or administering the section.
Commissioner Don Gilbert has determined that for the first five years the
section is in effect, the public benefit anticipated as a result of adoption
of the proposed rule will be that Medicaid-eligible veterans and qualified
family members will be able to receive services in a state veterans home.
There will be no effect on small or micro businesses as a result of enforcing
or administering the section, because the section allows Medicaid funds to
be used for the care of Medicaid-eligible veterans and their family members.
It is anticipated that most veterans and their family members served in these
homes will transfer from veterans hospitals. There is no anticipated economic
cost to persons who are required to comply with the proposed section.
Questions about the content of this proposal may be directed to Carolyn
Pratt at (512) 438-4057 in DHS's Rate Analysis Department. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-193,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
The proposal is available for public review at local offices of DHS. For
further information, contact Carolyn Pratt in DHS's Rate Analysis Department
at (512) 438-4057.
Under §2007.003(b) of the Texas Government Code, the department has
determined that Chapter 2007 of the Government Code does not apply to these
rules. Accordingly, the department is not required to complete a takings impact
assessment regarding these rules.
The amendment is proposed under Texas Government Code §531.033,
which authorizes the commissioner of HHSC to adopt the rules necessary to
carry out the commission's duties, and §531.021(b), which establishes
the commission as the agency responsible for adopting reasonable rules governing
the determination of fees, charges, and rates for medical assistance payments
under Chapter 32, Human Resources Code.
The new section implements the Government Code, §§531.033 and
531.021(b).
§355.311.Medicaid Reimbursement Rates for State Veterans Homes
(a)
The following definitions apply to this section:
(1)
Debt service on revenue bonds--The principal and interest
payments on Veterans Home Revenue Bonds sold under authorization of Chapter
164, Texas Natural Resources Code, and issued for the purpose of acquisition,
construction, operation, and maintenance of a state veterans home or homes.
(2)
Deposits to the operating reserve--The monthly deposits
by the Veterans Land Board (VLB) to a facility's operating reserve as required
by the trust indenture(s) related to State of Texas Veterans Home Revenue
Bonds as authorized under 40 TAC §176.3 (relating to Sale of Bonds).
(3)
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 §531.021.
(4)
Management agreement--The management and operations agreement
between the Veterans Land Board (VLB) of the State of Texas and the operator
of a state veterans home in effect during the rate period.
(5)
Rate period--The state fiscal year.
(6)
State veterans home--A nursing facility as defined in Title
40, Texas Administrative Code (TAC) §176.1 (relating to Veterans Homes
Definitions) that is contracted with DHS under 40 TAC §19.2322 (relating
to Allocation, Reallocation, and Decertification Requirements) to provide
nursing facility services to eligible Medicaid recipients who reside in a
state veterans home.
(7)
Texas Department of Human Services (DHS)--The state administrative
agency authorized to contract for nursing facility services to Medicaid recipients
pursuant to Chapter 32, Human Resources Code.
(8)
Transportation agreement--The agreement between the VLB
and the operator of the facility in effect during the rate period. Not all
operators may have a transportation agreement.
(9)
Veterans Land Board (VLB)--The state administrative agency
authorized under Chapter 164, Natural Resources Code, to establish and operate
state veterans homes.
(10)
VLB administrative expenses--VLB expenses related to oversight
of the state veterans home program.
(b)
DHS reimburses the VLB for nursing facility services provided
by the VLB to Medicaid clients in state veterans homes.
(c)
HHSC determines reimbursement rates for state veterans
homes to provide nursing facility services.
(d)
Reimbursement rates for state veterans homes are determined
prospectively for each home based on the lower of an estimate of per diem
cost for the rate period as calculated in subsection (e) of this section or
the state veterans home semi-private room basic daily rate. Rates are reconciled
retrospectively based on actual cost in accordance with subsection (k) of
this section.
(e)
For each home, the estimated per diem costs are calculated
as follows:
(1)
For the rate period, sum the following:
(A)
the monthly fixed-fee component of the management and operation
fee as described in the management agreement for each month in the rate period,
(B)
the variable-fee component of the management and operation
fee per patient day in effect during the rate period times estimated patient
days during the rate period,
(C)
vehicle payments, if any, as defined in the transportation
agreement,
(D)
deposits to the operating reserve,
(E)
debt service on the revenue bonds, and
(F)
VLB administrative expenses.
(2)
Divide the sum, as determined in paragraph (1) of this
subsection, by the estimated patient days for the rate period to determine
the interim prospective per diem rate. Estimated patient days for the rate
period are determined based on the most recently available, reliable utilization
data for the facility.
(f)
The facility-specific payment rate as, determined in subsection
(d) of this section, will be paid for all Medicaid eligible residents of a
state veterans home regardless of the Texas Index for Level of Effort (TILE)
level of the resident.
(g)
Veterans Administration (VA) per diem payments to the State
of Texas VLB for nursing home care as defined in 38 Code of Federal Regulations
(CFR) §51.40 (relating to monthly payment) are considered third-party
resources (TPRs) under 40 TAC §15.215 (relating to Third-Party Resources).
These payments are offset against per diem payment rates for Medicaid-eligible
residents of a state veterans home.
(h)
Residents of a state veterans home are not eligible to
receive the supplemental reimbursements authorized under §§355.307(b)(3)(E)
and (F) of this title (relating to Qualifying Ventilator-Dependent Residents
and Qualifying Children with tracheostomies).
(i)
State veterans homes are not eligible to participate in §355.308
of this title (relating to Enhanced Direct Care Staff Rate).
(j)
The VLB submits financial and statistical information in
a format designated by HHSC. This information may be reviewed or audited in
accordance with §355.106 of this title (relating to Basic Objectives
and Criteria for Audit and Desk Review of Cost Reports). Financial and statistical
information submitted by the VLB is not included in the cost report databases
used in the reimbursement determination process for the Texas Medicaid Nursing
Facility program.
(k)
For each state veterans home, the prospective per diem
rate is adjusted retrospectively based on actual costs accrued during the
rate period, with capital equipment and capital improvement costs accrued
by the VLB for the facility substituted for deposits to the operating reserve
in the cost calculation, and actual patient days provided substituted for
estimated patient days.
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 August 17, 2001.
TRD-200104813
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Earliest possible date of adoption: September 30, 2001
For further information, please call: (512) 438-3734
Chapter 355.
MEDICAID REIMBURSEMENT RATES
Subchapter C. REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES
Subchapter J. PURCHASED HEALTH SERVICES