Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353.
MEDICAID MANAGED CARE
Subchapter A. GENERAL PROVISIONS
1 TAC §353.4
The Health and Human Services Commission (HHSC) adopts new §353.4,
Requirements of STAR and STAR+PLUS Programs Concerning Out-of-Network Providers,
with changes to the proposed text as published in the August 5, 2005, issue
of the
Texas Register
(30 TexReg 4396). The
text of the rule will be republished.
HHSC amended Chapter 353, Medicaid Managed Care, by adding new rule §353.4
to Subchapter A. Subsection (a) of the rule identifies HHSC as the state agency
with oversight for the Medicaid managed care program and confirms the responsibility
of the participating managed care organizations (MCOs) to offer a provider
network that meets the needs of their members. Subsection (b) outlines the
steps for an appropriate referral to an out-of-network provider, use of out-of-network
emergency services, and member access to other out-of-network services that
may be necessary in other circumstances.
Subsection (c) describes the methodology used to determine the amount of
reimbursement paid by an MCO for out-of-network services. Subsection (d) describes
the timing and content of quarterly reports to HHSC from MCOs concerning out-of-network
use. Subsection (e) concerns MCO member utilization of out-of-network services,
including the standards by which excessive utilization will be determined
and the special circumstances taken into consideration by HHSC in calculating
an MCO's out-of-network utilization.
The provider complaint process is covered in subsection (f), including
the timeframes for HHSC's response and for any action required from the MCO
if HHSC determines that the complaint is valid. Subsection (g) describes when
a corrective action plan will be required for an MCO, what the plan will require,
and what actions must be taken either by HHSC or the MCO as a result of the
need for a corrective action plan.
After further internal review, HHSC is making a technical correction to
subsection (d), Reporting Requirements, to clarify that the report required
by the rule and by the Medicaid Managed Care Organization contracts is the
Out-Of-Network report in the Uniform Managed Care Manual and not the financial
statistical report (FSR), another quarterly report provided by the Medicaid
MCOs. HHSC also is adding subsection (h) to clarify that the requirements
of this rule apply to MCO contracts in effect on or after September 1, 2006.
HHSC received comments regarding the proposed rule during the comment period
from the Texas Hospital Association and Texas Health Resources. A summary
of the comments and HHSC's responses follow.
Comment:
HHSC received a comment from the Texas Hospital Association (THA) regarding
the proposed July 1, 2006, effective date of the rule. Citing a high number
of complaints and litigation associated with this issue since 1998, THA strongly
recommends that HHSC implement the rule within 30 days of adoption. In addition,
THA urges HHSC to amend existing or new Medicaid managed care contracts to
require the MCOs to comply with the out-of-network reimbursement rules. Texas
Health Resources (THR) supported this recommendation.
Response:
HHSC acknowledges the comment received from THA and THR, but disagrees.
This rule requires contract changes and new tracking, reporting, and monitoring
systems for both HHSC and the MCOs. Those changes, along with the time required
for implementation of new policies and procedures, affect the timeline for
the rule's implementation. While the rule will be adopted effective January
22, 2006, it will apply to contracts in effect on or after September 1, 2006,
to coincide with the start date of the new Medicaid MCO contracts. Subsection
(h) has been added to reflect that applicability.
Comment:
HHSC received a comment from both THA and THR concerning Subsection (c)(1),
Reasonable Reimbursement Methodology, related to the reimbursement rate for
an out-of-network, in service area provider. Both recommend that the rate
be set at 100% of the Medicaid fee schedule, rather than no less than the
prevailing fee-for-service (FFS) rate, less 3%.
Response:
HHSC acknowledges the comments, but disagrees. Section 2.203 of House Bill
2292, codified in relevant part at Government Code §533.007(g) and (h),
provides for HHSC's determination of a reasonable reimbursement methodology
for use by the MCOs when reimbursing out-of-network providers. That section
also provides for HHSC's imposing a corrective action plan on an MCO found
to be in violation of that reasonable reimbursement methodology. One statutory
element of such a corrective action plan is a requirement that the affected
MCO pay the out-of-network provider the prevailing Medicaid FFS rate rather
than paying according to the reasonable reimbursement methodology. HHSC has
interpreted House Bill 2292 as directing the reasonable reimbursement methodology
to be something less than the prevailing Medicaid FFS rate. The rule as proposed
includes a reasonable reimbursement methodology in accordance with HHSC's
interpretation of the statute.
Comment:
HHSC received a comment from THA in support of the language in subsection
(c)(2) Reasonable Reimbursement Methodology, related to out-of-network, out-of-service
area providers.
Response:
HHSC agrees with the comment and appreciates the support of THA for the
proposed language related to reimbursement for out-of-network, out-of-service
area providers.
Comment:
HHSC received a comment concerning subsection (d), Reporting Requirements,
from THA expressing concern that two reporting requirements found in a previous
draft version of the rules have been eliminated. THA requests that these reporting
requirements be re-instated into the final adoption of the rules.
Response:
HHSC acknowledges the comment received from THA, but disagrees. HHSC felt,
after considering stakeholder input, the additional reporting requirements
in the earlier draft version of the proposed rule would yield little useful
information and be an unnecessary burden to the reporters. HHSC eliminated
those requirements from the proposed rule as published.
Comment:
HHSC received a comment from both THA and THR concerning subsection (e)(2)(B),
Out-Of-Network Usage Standards - Emergency Room Visits. Both believe that
the allowance of no more than 30% of the Managed Care Organization's (MCO)
emergency room (ER) visits at an out-of-network facility is too generous.
They recommend that HHSC use 25% in keeping with the 25% benchmark for inpatient
services found at subsection (e)(2)(A).
Response:
HHSC acknowledges THA and THR's comment, but disagrees. Out-of-network
usage standards were established based upon a review of recent Medicaid MCO
utilization of services. Emergency room usage is typically higher than that
of the other service categories. The MCO member may not be near a network
provider when the need for emergency care arises. Therefore, the standard
allowance for out-of-network emergency room care was set at a greater percentage
than the allowance for out-of-network inpatient services or other outpatient
services.
Comment:
HHSC received comments concerning subsection (e)(2)(C), Out-Of-Network
Usage Standards - Other Outpatient Services. Both THA and THR recommend that
the MCO be limited to no more than 25% for "other outpatient services." They
also recommend that the calculation be based on 25% of "what the MCO would
have paid to the provider for 'other outpatient services' based on the Medicaid
fee schedule for specialty, pediatric subspecialty and ancillary provider
services."
Response:
HHSC acknowledges the comments, but disagrees. HHSC is reserving the right
to establish the out-of-network usage limit as proposed because of the variety
of services that are under the umbrella of "other outpatient services". The
utilization benchmarks were established based upon dollars billed.
Comment:
HHSC received a comment from THA concerning subsection (e)(3)(A) and (B),
Special Considerations in Calculating Out-of-Network Usage. THA expressed
appreciation for the degree of thoroughness HHSC will undertake to determine
out-of-network usage and network adequacy. However, they suggest in order
for HHSC to reliably determine the effort the MCO made to contract, that HHSC
consider information from both the MCO and facility, and not just the MCO.
Response:
HHSC appreciates the recognition of the thoroughness with which HHSC intends
to examine out-of-network usage. HHSC acknowledges the comment concerning
HHSC's consideration of information from the provider involved, but disagrees
that any change in the proposed rule is necessary. The rule does not preclude
HHSC from seeking information from sources other than the MCO to determine
if the MCO has met the applicable usage standards. HHSC assures the commenter
that efforts to include all relevant information will be made.
Comment:
HHSC received two comments related to subsection (f)(5)(A) related to Provider
Complaints. Both THA and THR expressed appreciation for HHSC's willingness
to impose a payment deadline on the MCO when it has been determined that additional
reimbursement by the MCO is owed to the out-of-network provider. However,
they claim that the inclusion of the language allowing the MCO 30 days from
the date the claim is considered a "clean claim" is unnecessary, and recommend
that it be removed.
Response:
HHSC recognizes the commencer's concerns, but disagrees. The language in
the rule meets statutory requirements set out in Government Code 533.007(j)
and Section 2.203 of House Bill 2292.
Comment:
HHSC received the same comment from THA and THR related to subsection (g)(2),
Corrective Action Plan. They state that the Lewin Report suggested the withholding
of 5 percent of all capitation funds from the MCO until the out-of-network
volumes are compliant within the required standard. They also claim that a
March 16, 2005, letter from Medical Care Advisory Committee Chairman Linda
Ponder also asked HHSC to reconsider this corrective action and include it
in the proposed rule when published. THA suggests the following language:
"(E) Initiate a 5 percent withhold of all capitation funds from the MCO until
such time the out-of-network volumes become compliant within the required
standard for three consecutive months. Once maintained, all withheld funds
will be paid to the MCO without interest." THR suggests the following language:
"(E) Initiate a 5 percent withhold of all capitation funds from the MCO for
that period of time the out-of-network volumes are not compliant within the
required standard."
Response:
HHSC acknowledges the comment, but disagrees. The recommended change is
more restrictive than the statute requires. HHSC has determined that the rule
and applicable contract language contain sufficient protection for affected
providers.
The new rule is adopted under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas.
§353.4.Requirements of STAR and STAR+PLUS Programs Concerning Out-of-Network Providers.
(a)
Network adequacy. The Health and Human Services Commission
(HHSC) is the state agency responsible for overseeing and monitoring the Medicaid
managed care program. The managed care organizations (MCOs) participating
in the Medicaid managed care program must offer a network of providers that
is sufficient to meet the needs of the Medicaid population who are MCO members.
HHSC will monitor MCO members' access to an adequate provider network through
reports from the MCOs and complaints received from providers and members.
The reporting requirements are discussed in paragraph (d) of this section.
(b)
MCO requirements concerning treatment of members by out-of-network
providers.
(1)
The MCO shall allow referral of its member(s) to an out-of-network
provider, shall timely issue the proper authorization for such referral, and
shall timely reimburse the out-of-network provider for authorized services
provided when:
(A)
Medicaid covered services are medically necessary and these
services are not available through an in-network provider;
(B)
A provider currently providing authorized services to the
member requests authorization for such services to be provided to the member
by an out-of-network provider; and
(C)
The authorized services are provided within the time period
specified in the MCO's authorization. If the services are not provided within
the required time period, a new request for referral from the requesting provider
must be submitted to the MCO prior to the provision of services.
(2)
An MCO may not refuse to reimburse an out-of-network provider
for emergency or post-stabilization services provided as a result of the MCO's
failure to arrange for and authorize a timely transfer of a member.
(3)
MCO requirements concerning emergency services.
(A)
The MCO shall allow its members to be treated by any emergency
services provider for emergency services and/or for services to determine
if an emergency condition exists.
(B)
The MCO is prohibited from requiring an authorization for
emergency services or for services to determine if an emergency condition
exists.
(4)
MCOs may be required by contract with HHSC to allow members
to obtain services from out-of-network providers in circumstances other than
those described above.
(c)
Reasonable Reimbursement Methodology
(1)
The MCO shall reimburse an out-of-network, in area service
provider no less than the prevailing Medicaid Fee-For-Service (FFS) rate less
3 percent. The Medicaid Fee-For-Service rates are defined as those rates for
providers of services in the Texas Medicaid Program for which reimbursement
methodologies are specified in the Texas Administrative Code (TAC) at Title
1, Part 15, Chapter 355, exclusive of the rates and payment structures in
Medicaid Managed Care.
(2)
The MCO shall reimburse an out-of-network, out-of-area
service provider at no less than 100 percent of the Medicaid Fee-For-Service
rate.
(3)
In accordance with Subsections 533.005 (a)(12) and (b)
of the Government Code, all post stabilization services provided to a member
by an out-of-network provider must be reimbursed by the MCO at the rates for
providers of services in the Texas Medicaid Program for which reimbursement
methodologies are specified in the Texas Administrative Code (TAC) at Title
1, Part 15, Chapter 355 until the MCO arranges for the timely transfer of
the member, as determined by the member's attending physician, to a provider
in the MCO's network.
(d)
Reporting requirements
(1)
Each MCO that contracts with HHSC to provide health care
services to members in a health care service region must submit quarterly
information in its Out-of-Network quarterly report to HHSC.
(2)
Each report submitted by an MCO must contain information
about members enrolled in each HHSC Medicaid managed care program provided
by the MCO. The report shall include the following information:
(A)
The types of services provided by out-of-network providers
for members of the MCO's Medicaid managed care plan.
(B)
The scope of services provided by out-of-network providers
to members of the MCO's Medicaid managed care plan.
(C)
Total number of hospital admissions, as well as number
of admissions that occur at each out-of-network hospital. Each out-of-network
hospital must be identified.
(D)
Total number of emergency room visits, as well as total
number of emergency room visits that occur at each out-of-network hospital.
Each out-of-network hospital must be identified.
(E)
Total dollars billed for other outpatient services, as
well as total dollars billed by out-of-network providers for other outpatient
services.
(F)
Any additional information required by HHSC.
(3)
HHSC will determine the specific form of the report described
above and will include the report form as part of the Medicaid managed care
contract between HHSC and the MCOs.
(e)
Utilization
(1)
Upon review of the reports described in paragraph (d) of
this section that are submitted to HHSC by the MCOs, HHSC may determine that
an MCO exceeded maximum Out-of-Network usage standards set by HHSC for out-of-network
access to health care services during the reporting period.
(2)
Out-of-Network Usage Standards
(A)
Inpatient Admissions: No more than 25 percent of an MCO's
total hospital admissions, by service delivery area, may occur in out-of-network
facilities.
(B)
Emergency Room Visits: No more than 30 percent of an MCO's
total emergency room visits, by service delivery area, may occur in out-of-network
facilities.
(C)
Other Outpatient Services: No more than 30 percent of total
dollars billed to an MCO for "other outpatient services" may be billed by
out-of-network providers.
(3)
Special Considerations in Calculating MCO Out-of-Network
Usage of Inpatient Admissions and Emergency Room Visits.
(A)
In the event that an MCO exceeds the maximum Out-of-Network
usage standard set by HHSC for Inpatient Admissions or Emergency Room Visits,
HHSC may modify the calculation of that MCO's Out-of-Network usage for that
standard if:
(i)
The admissions or visits to a single out-of-network facility
account for 25% or more of the MCO's admissions or visits in a reporting period;
and
(ii)
HHSC determines that the MCO has made all reasonable efforts
to contract with that out-of-network facility as a network provider without
success.
(B)
In determining whether the MCO has made all reasonable
efforts to contract with the single out-of-network facility described above
in Subparagraph (A) of this paragraph, HHSC will consider at least the following
information:
(i)
How long the MCO has been trying to negotiate a contract
with the out-of-network facility;
(ii)
The in-network payment rates the MCO has offered to the
out-of-network facility;
(iii)
The other, non-financial contractual terms the MCO has
offered to the out-of-network facility, particularly those relating to prior
authorization and other utilization management policies and procedures;
(iv)
The MCO's history with respect to claims payment timeliness,
overturned claims denials, and provider complaints;
(v)
The MCO's solvency status; and
(vi)
The out-of-network facility's reasons for not contracting
with the MCO.
(C)
If the conditions described in subparagraph (A) of this
paragraph are met, HHSC may modify the calculation of the MCO's Out-of-Network
usage for the relevant reporting period and standard by excluding from the
calculation the Inpatient Admissions or Emergency Room Visits to that single
out-of-network facility.
(f)
Provider Complaints.
(1)
HHSC will accept provider complaints regarding reimbursement
for or overuse of out-of-network providers and will conduct investigations
into any such complaints.
(2)
When a provider files a complaint regarding out-of-network
payment, HHSC will require the relevant MCO to submit data to support its
position on the adequacy of the payment to the provider. The data will include
at a minimum a copy of the claim for services rendered and an explanation
of the amount paid and of any amounts denied.
(3)
Not later than the 60th day after HHSC receives a provider
complaint, HHSC shall notify the provider who initiated the complaint of the
conclusions of HHSC's investigation regarding the complaint. The notification
to the complaining provider will include:
(A)
A description of the corrective actions, if any, required
of the MCO in order to resolve the complaint; and
(B)
If applicable, a conclusion regarding the amount of reimbursement
owed to an out-of-network provider.
(4)
If HHSC determines through investigation that an MCO did
not reimburse an out-of-network provider based on a reasonable reimbursement
methodology as described within subsection (c) of this section, HHSC shall
initiate a corrective action plan. Refer to subsection (g) of this section
for information about the contents of the corrective action plan.
(5)
If, after an investigation, HHSC determines that additional
reimbursement is owed to an out-of-network provider, the MCO must:
(A)
Pay the additional reimbursement owed to the out-of-network
provider within 90 days from the date the complaint was received by HHSC or
30 days from the date the clean claim, or information required that makes
the claim clean, is received by the MCO, whichever comes first; or,
(B)
Submit a reimbursement payment plan to the out-of-network
provider within 90 days from the date the complaint was received by HHSC.
The reimbursement payment plan provided by the MCO must provide for the entire
amount of the additional reimbursement to be paid within 120 days from the
date the complaint was received by HHSC.
(6)
If the MCO does not pay the entire amount of the additional
reimbursement within 90 days from the date the complaint was received by HHSC,
HHSC may require the MCO to pay interest on the unpaid amount. If required
by HHSC, interest accrues at a rate of 18 percent simple interest per year
on the unpaid amount from the 90th day after the date the complaint was received
by HHSC, until the date the entire amount of the additional reimbursement
is paid.
(7)
HHSC will pursue any appropriate remedy authorized in the
contract between the MCO and HHSC if the MCO fails to comply with a corrective
action plan under subsection (g) of this section.
(g)
Corrective Action Plan.
(1)
A corrective action plan is required by HHSC in the following
situations:
(A)
The MCO exceeds a maximum standard established by HHSC
for out-of-network access to health care services described in subsection
(e) of this section; or
(B)
The MCO does not reimburse an out-of-network provider based
on a reasonable reimbursement methodology as described within subsection (c)
of this section.
(2)
A corrective action plan imposed by HHSC will require one
of the following:
(A)
Reimbursements by the MCO to out-of-network providers at
rates that equal the allowable rates for the health care services as determined
under Sections 32.028 and 32.0281, Human Resources Code, for all health care
services provided during the period:
(i)
the MCO is not in compliance with a utilization standard
established by HHSC; or
(ii)
the MCO is not reimbursing out-of-network providers based
on a reasonable reimbursement methodology, as described in subsection (c)
of this section.
(B)
Initiation of an immediate freeze by HHSC on the enrollment
of additional recipients in the MCO's managed care plan until HHSC determines
that the provider network under the managed care plan can adequately meet
the needs of the additional recipients;
(C)
Education by the MCO of recipients enrolled in the managed
care plan regarding the proper use of the provider network under the health
care plan; or
(D)
Any other actions HHSC determines are necessary to ensure
that Medicaid recipients enrolled in managed care plans provided by the MCO
have access to appropriate health care services and that providers are properly
reimbursed by the MCO for providing medically necessary health care services
to those recipients.
(h)
The requirements of this rule apply to an MCO contract
that is in effect on or after September 1, 2006.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on January 2, 2006.
TRD-200600007
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: January 22, 2006
Proposal publication date: August 5, 2005
For further information, please call: (512) 424-6900
Subchapter A. COST DETERMINATION PROCESS
1 TAC §355.112
The Texas Health and Human Services Commission (HHSC) adopts
the amendment to §355.112, concerning attendant compensation rate enhancement,
in its Reimbursement Rates chapter, without changes to the proposed text as
published in the October 21, 2005, issue of the
Texas Register
(30 TexReg 6848) and will not be republished.
The amended §355.112 makes several changes to the Attendant Compensation
Rate Enhancement program. The amendment mandates that providers that fail
to meet their enhancement requirements in a prior period have their enrollment
in the attendant compensation rate enhancement program limited to the level
they achieved in the prior period. However, a provider is permitted to present
documentation supporting a higher level of enrollment if the provider believes
that his or her prior period achievement does not represent his or her current
attendant compensation levels. The amendment prohibits granting newly requested
enhancements to providers owing funds identified for recoupment. The amendment
deletes existing enrollment limitation rules.
The amendment changes the spending requirement from accrued attendant compensation
revenue per unit of service divided by 1.10 to accrued attendant compensation
revenue per unit of service times 0.90. The amendment eliminates the base
rate for participants in all Attendant Compensation Rate Enhancement programs,
except Community Based Alternatives Assisted Living/Residential Care (CBA
AL/RC), and modifies the enrollment process to accommodate this change.
The amendment mandates that if a report is not received within a year of
its due date, any recoupments due to nonsubmittal of the report are made permanent
and the vendor hold relating to the report is released. Under the amendment,
for a contract to qualify for reinvestment, HHSC Rate Analysis must have received
an acceptable Attendant Compensation Report at least 30 days prior to, and
the contract must be ongoing at, the time reinvestment is determined. If the
provider fails to repay the amount due or fails to submit an acceptable payment
plan within 60 days of notification of the recoupment, the amendment allows
HHSC or its designee to collect recoupments owed by a provider from other
Texas Department of Aging and Disability Services (DADS) contracts controlled
by the provider.
Under the amended rule, amended Attendant Compensation Reports must be
received by HHSC Rate Analysis prior to the date the provider is notified
of compliance with spending requirements for the report in question. In addition,
the amendment clarifies attendant compensation reporting requirements; training
requirements for Attendant Compensation Report preparers; the process for
calculating enhancement level add-ons; and the process for calculating reinvestment.
The amendment explains that if the granting of newly requested enhancements
to ongoing providers is limited during enrollment, the granting of enhancements
to new providers is limited to that same level. Under the amendment, informal
reviews and formal appeals relating to Attendant Compensation Reports are
governed by §355.110 of this title (relating to Informal Reviews and
Formal Appeals). The amendment also clarifies resulting enrollment levels
and grouping statuses for contracts after contract assignments and explains
that Attendant Compensation Rate Enhancement rules do not prohibit providers
from compensating attendants at a level above that funded by the enhanced
attendant compensation rate.
Finally, the amendment replaces references to the Texas Department of Human
Services with references to DADS or HHSC or its designee, as appropriate;
replaces references to Primary Home Care/Family Care with references to Primary
Home Care; and replaces references to Priority 1 with references to Priority.
The amendments will increase consistency between the community care Attendant
Compensation Rate Enhancement and the nursing facility Direct Care Staff Rate
Enhancement. As well, the amendment pertaining to limiting providers' enrollment
in the enhancement program to the level they achieved in a prior period will,
in years in which no new funds are appropriated for enhanced attendant compensation
rates, allow providers at the lowest enhancement levels to increase their
levels and nonparticipants to become participants using funds that are made
available by this limitation while allowing providers at the highest enhancement
levels to keep their levels when they have met their spending requirements.
The spending requirement calculation amendment will make the calculation
of the spending requirement more straightforward and give providers more flexibility
in allocating limited funding between attendant compensation and other operating
expenses. The amendment eliminating the participant base rate with no enhancement
levels for all Attendant Compensation Rate Enhancement programs except for
CBA AL/RC is adopted because participants (other than CBA AL/RC participants)
are not currently paid a different base rate than nonparticipants, rather
participants receive the same base rate as nonparticipants plus enhancements.
The amendments pertaining to reinvestment will ensure that reinvested funds
are distributed to ongoing contracts rather than to entities no longer contracted
to provide care to clients. As well, these changes will ensure that reinvestment
can be calculated in a timely fashion. The amendment pertaining to recouping
funds owed by a provider from other DADS contracts controlled by the provider
if the provider fails to repay the amount due will simplify the collection
process for delinquent recoupments. The remaining amendments will clarify
and simplify the administration of the attendant compensation rate enhancement.
HHSC received positive comments regarding the proposed amendment from the
Texas Association for Home Care during the comment period. As well, the Texas
Association for Home Care suggested an additional rule change that was not
part of the rule proposal and, therefore, not considered for purposes of this
rulemaking action.
Comment: The Texas Association for Home Care proposed that the minimum
level of participation for providers that wish to begin participating in the
attendant compensation rate enhancement be entered at or above the level set
for the Consumer Directed Services option.
Response: HHSC acknowledges receipt of this comment but will not be making
changes in response to a comment on a portion of a rule to which no amendment
was proposed. Any such change would violate the notice requirement of the
Administrative Procedures Act.
The amendment is adopted under the Texas Government Code, §531.033,
which authorizes the Executive Commissioner of HHSC to adopt rules necessary
to carry out the Commission's duties; Texas Government Code §531.0055,
which authorizes the Executive Commissioner to adopt rules for the operation
and provision of health and human services by the health and human services
agencies and to adopt or approve rates of payment required by law to be adopted
or approved by a health and human services agency.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on December 30, 2005.
TRD-200506137
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: January 19, 2006
Proposal publication date: October 21, 2005
For further information, please call: (512) 424-6900
1 TAC §355.503
The Texas Health and Human Services Commission (HHSC) adopts
the amendment to §355.503, concerning the reimbursement methodology for
the Community-Based Alternatives Waiver Program, in its Reimbursement Rates
chapter, without changes to the proposed text as published in the October
21, 2005, issue of the
Texas Register
(30
TexReg 6860) and will not be republished.
The amended §355.503 includes the process of annually adjusting provider
payment rates for the Community Based Alternatives Assisted Living/Residential
Care Waiver in the reimbursement methodology for this program. The reimbursement
methodology for this program states that clients will use the increase in
their Supplemental Security Income (SSI) Federal Benefit Rate, which they
receive January 1 each year, to increase their room-and-board payment and
cover a greater share of the rate, thereby reducing the Department of Aging
and Disability Services (DADS) share of the rate. In addition, the amendment
states that the direct care rate component for the Community Based Alternatives
Assisted Living/Residential Care Waiver is calculated into the six levels
of care for clients in this program. Finally, references and citations relating
to cost reporting for the Community Based Alternatives Assisted Living/Residential
Care Waiver have been updated from former Department of Human Services (DHS)
rules to HHSC and/or DADS rules as applicable.
HHSC did not receive any comments regarding the proposed amendment during
the comment period.
The amendment is adopted under the Texas Government Code, §531.033,
which authorizes the Executive Commissioner of HHSC to adopt rules necessary
to carry out the Commission's duties; Texas Government Code §531.0055,
which authorizes the Executive Commissioner to adopt rules for the operation
and provision of health and human services by the health and human services
agencies and to adopt or approve rates of payment required by law to be adopted
or approved by a health and human services agency.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on December 30, 2005.
TRD-200506138
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: January 19, 2006
Proposal publication date: October 21, 2005
For further information, please call: (512) 424-6900
1 TAC §355.509
The Texas Health and Human Services Commission (HHSC) adopts
the amendments to §355.509, concerning the reimbursement methodology
for Residential Care, in its Reimbursement Rates chapter, without changes
to the proposed text as published in the October 21, 2005, issue of the
The amended §355.509 includes the process of annually adjusting provider
payment rates for the Residential Care Program in the reimbursement methodology
for this program. The reimbursement methodology for this program states that
clients will use the increase in their Supplemental Security Income (SSI)
Federal Benefit Rate, which they receive January 1 each year, to increase
their room-and-board payment and cover a greater share of the rate, thereby
reducing the Department of Aging and Disability Services (DADS) share of the
rate. In addition, references and citations relating to cost reporting for
the Community Based Alternatives Assisted Living/Residential Care Waiver have
been updated from former Department of Human Services (DHS) rules to HHSC
and/or DADS rules as applicable.
HHSC did not receive any comments regarding the proposed amendments during
the comment period.
The amendments are adopted under the Texas Government Code, §531.033,
which authorizes the Executive Commissioner of HHSC to adopt rules necessary
to carry out the Commission's duties; Texas Government Code §531.0055,
which authorizes the Executive Commissioner to adopt rules for the operation
and provision of health and human services by the health and human services
agencies and to adopt or approve rates of payment required by law to be adopted
or approved by a health and human services agency.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on December 30, 2005.
TRD-200506139
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: January 19, 2006
Proposal publication date: October 21, 2005
For further information, please call: (512) 424-6900
Chapter 355.
REIMBURSEMENT RATES
Subchapter E. COMMUNITY CARE FOR AGED AND DISABLED
Chapter 394.
MEDIATION AND NEGOTIATED RULEMAKING