Part 2. TEXAS ETHICS COMMISSION
Chapter 20. REPORTING POLITICAL CONTRIBUTIONS AND EXPENDITURES
Subchapter B. GENERAL REPORTING RULES
The Texas Ethics Commission proposes new §20.56, relating to the reporting of a political contribution in the form of a pledge.
The proposed new §20.56 would clarify the method for reporting pledges of political contributions. The rule would require a pledge of a contribution that is actually received in the reporting period in which it was accepted to be reported on the "political contributions" schedule. The rule also would require that the "date of the contribution" is the date the pledge was accepted.
David A. Reisman, Executive Director, has determined that for each year of the first five years that the rule is in effect there will be no fiscal implication for the state and no fiscal implication for local government as a result of enforcing or administering the rule as proposed. Mr. Reisman has also determined that the rule will have no local employment impact.
Mr. Reisman has also determined that for each year of the first five years the rule is in effect, the anticipated public benefit will be clarity in what is required by the law.
Mr. Reisman has also determined there will be no direct adverse effect on small businesses or micro-businesses because the rule does not apply to single businesses.
Mr. Reisman has further determined that there are no economic costs to persons required to comply with the rule.
The Texas Ethics Commission invites comments on the proposed rule from any member of the public. A written statement should be mailed or delivered to Natalia Luna Ashley, Texas Ethics Commission, P.O. Box 12070, Austin, Texas 78711-2070, or by facsimile (FAX) to (512) 463-5777. A person who wants to offer spoken comments to the commission concerning the proposed rule may do so at any commission meeting during the agenda item "Communication to the Commission from the Public" and during the public comment period at a commission meeting when the commission considers final adoption of the proposed rule. Information concerning the date, time, and location of commission meetings is available by telephoning (512) 463-5800 or, toll free, (800) 325-8506.
The proposed new §20.56 is proposed under Government Code, Chapter 571, Section 571.062, which authorizes the commission to adopt rules concerning the laws administered and enforced by the commission.
The proposed new §20.56 affects section 254.031 of the Election Code.
§20.56.Reporting a Pledge of a Contribution.
(a) The date of a pledge of a contribution is the date the pledge was accepted, regardless of when the pledge is actually received.
(b) Except as provided by subsection (c), a pledge of a contribution shall be reported on the pledge schedule for the reporting period in which the pledge was accepted.
(c) A pledge of a contribution that is actually received in the reporting period in which the pledge was accepted, shall be reported on the contribution schedule or the loan schedule, as applicable, and in accordance with subsection (a).
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 April 17, 2007.
TRD-200701441
Natalia Luna Ashley
General Counsel
Texas Ethics Commission
Earliest possible date of adoption: June 3, 2007
For further information, please call: (512) 463-5800
Chapter 251. REGIONAL PLANS--STANDARDS
The Commission on State Emergency Communications (CSEC) proposes an amendment to §251.6, concerning guidelines for strategic plans, amendments, and allocation of funds.
The proposed changes are intended to align the rule with CSEC's biennial appropriation from the Texas Legislature, more clearly identify sections of Health and Safety Code, Chapter 771, governing CSEC's authority to allocate appropriated funds, and to shorten the rule by moving procedural requirements into a CSEC Program Policy Statement (PPS).
Paul Mallett, CSEC executive director, has determined that, for each year of the first five years that the rule is in effect, enforcing or administering the rule will result in: (1) No additional costs or reduction in costs to the state and local governments; (2) No loss or increase in revenue to the state; and (3) Possible changes from the historical percentages of appropriated funds allocated to each Regional Planning Commission (RPC). Whether an RPC's biennial allocation percentage increases or decreases will be determined by various factors including, but not limited to, the amount of 9-1-1 Fees and Surcharge CSEC is appropriated in each of its legislative strategies and the financial needs of the RPC in order to implement these strategies.
Mr. Mallett has also determined that, for each year of the first five years the rule is in effect, the public benefit expected as a result of enforcing the rule will be an overall enhancement of the effectiveness of 9-1-1 service in the RPC program area by aligning the allocating of funds to the RPCs with CSEC's legislative appropriation strategies. The anticipated economic costs to persons who are required to comply with the rule will be borne solely by the RPCs and will depend upon the financial needs of each RPC to implement the legislative appropriation strategies. Mr. Mallett has determined that, although no historical data is available, there appears to be no direct effect on small or micro-businesses.
Comments on the amendment may be submitted in writing to Paul Mallett, Executive Director, Commission on State Emergency Communications, 333 Guadalupe Street, Suite 2-212, Austin, Texas 78701-3942 within 30 days after publication of the proposal in the May 4, 2007, issue of the Texas Register.
The amendment is proposed under the Texas General Appropriations Act appropriation of 9-1-1 Fees and Equalization Surcharge to CSEC; and Texas Health and Safety Code, §§771.051, 771.056, 771.071, 771.0711, 771.072, 771.075, 771.0751, 771.077, 771.078, and 771.079 which authorize CSEC to plan, develop, fund, administer, approve, and enhance the provisioning and effectiveness of 9-1-1 service. The proposed amendment is proposed in accordance with the process for rulemaking as prescribed by Texas Government Code, Chapter 2001, Subchapter B.
No other statutes, articles, or codes are affected by the proposed amendment.
§251.6.Guidelines for Strategic Plans, Amendments, and [ Revenue ] Allocation of Funds .
(a) Purpose. This [The Commission on State
Emergency Communications (Commission) establishes this] rule
provides [to provide
] guidelines for a regional planning commission
(RPC) to follow in developing and [or] amending its
regional plan and for [in describing] how
appropriated
funds are
[
money
] allocated by the Commission
on State
Emergency Communications (Commission) to the RPCs
[
is to be allocated
in the region
].
(b) (No change.)
(c) Regional
Plans
[
Plan Budgets
] . Regional
plans shall be
developed
consistent with
Health and Safety
Code §771.055, the Items of Appropriation in the Texas Legislature's
biennial appropriation to the Commission, and Commission rules and policies.
Regional plans shall be submitted to the Commission for consideration in accordance
with Health and Safety Code §771.056 and Commission rules and policies.
[
the Administration, Equipment, and Program Budgets approved by
the Commission. The Program Budget includes the following four major strategic
plan levels (in order of priority):
]
[
(1)
Level I: The equipment, network,
and database equipment and/or services that provide the essential elements
of 9-1-1 service, including the maintenance and replacement of equipment.]
[
(A)
Network;]
[
(B)
Wireless;]
[
(C)
Database;]
[
(D)
Equipment Lease;]
[
(E)
Language Line; and]
[
(F)
Equipment Maintenance.]
[
(2)
Level II: The activities,
equipment, and/or services that directly support and enhance 9-1-1 call delivery
and data maintenance for the level of service provided to the region.]
[
(A)
Database Maintenance;]
[
(B)
MIS;]
[
(C)
Mapped ALI;]
[
(D)
PSAP Room Prep;]
[
(E)
PSAP Training; and]
[
(F)
Public Education.]
[
(3)
Level III: The activities,
equipment, and/or services that provide auxiliary enhancements to the delivery
of 9-1-1 calls and the level of service provided to the region.]
[
(A)
Network Diversity;]
[
(B)
PSAP Supplies; and]
[
(C)
Ancillary Maintenance &
Repair]
[
(4)
Level IV: Use of Revenue in
Certain Counties. The activities, equipment, and/or services that provide
necessary auxiliary enhancements to the 9-1-1 system of a county eligible
under Health and Safety Code section 771.0751 because it has a population
over 700,000 or is the county that has the highest population within an RPC
participating in the Commission program.]
[
(d)
Regional Plans. Regional plans
developed in compliance with Chapter 771 and Commission Rule 251.1 shall include
projected financial operating information for at least the two state fiscal
years following submission of the plan; and strategic planning information
for at least the five state fiscal years following submission of the plan.]
[
(1)
The Commission shall establish
the format of regional plans for the sake of identifying overall statewide
requirements in its implementation.]
[
(2)
Regional plans shall be consistent
with the four major implementation priority levels identified above and with
all applicable Commission policies and rules.]
[
(3)
An RPC shall submit financial
reports at least quarterly on a schedule to be established by the Commission.
The financial report shall identify actual implementation costs by county,
regional plan priority level and component.]
[
(4)
An RPC shall submit performance
reports at least quarterly on a schedule to be established by the Commission.
The performance report shall reflect the progress of implementing the RPC's
regional plan, including the status of equipment, services and program deliverables,
in a format to be determined by the Commission.]
(d)
[
(e)
] Amendments to Regional Plans.
Requests for amendments to regional plans shall be submitted to the Commission
for consideration in accordance with Health and Safety Code §771.056
and Commission rules and policies, approval. The Commission shall take action
on amendment requests at least four times per fiscal year.
[
(1)
An RPC may make changes to
its approved regional plan to accommodate unanticipated requirements and/or
to prevent disruption of its implementation schedule, contingent upon compliance
with all Commission policies and procedures.]
[
(2)
Requests for amendments to
the regional plan shall be submitted in writing to the Commission. The documentation
required for changes will be submitted according to Commission policy. The
Commission shall take action, no fewer than four times annually, on any regional
plan amendment request submitted for approval.]
[
(3)
Emergency situations requiring
amendments to regional plans that require additional funding may be presented
to the Commission for review and consideration contingent upon the availability
of such funds within the Program Budget level priorities in subsection (c)
of this section.]
(e)
[
(f)
] Allocation of
Appropriated
Funds to an RPC
[
Revenue
].
(1)
Service Fee
:
[
allocation--
]Consistent
with Health and Safety Code §§771.056(d)
, 771.071(f), 771.0711(c),
771.075, 771.0751, 771.077(e), 771.078(b) and (d), and 771.079(c), and the
Commission's biennial appropriation from the Texas Legislature,
[
and 771.078
] the Commission shall allocate, by contract, service fee
funds
[
revenue
] to an RPC contingent on the availability
of appropriated funds.
(2)
Equalization Surcharge
: Consistent with Health and
Safety Code §§771.0711(j), 771.072(d) and (f), 771.075, 771.0751
and 771.078(e), and the Commission's biennial appropriation from the Texas
Legislature, the Commission shall allocate, by contract, equalization surcharge
funds to an RPC contingent on the availability of appropriated funds.
[
Funds
]
[
(A)
Within the context of Health
and Safety Code section 771.056(d), the Commission shall consider any revenue
insufficiencies to represent need for equalization surcharge funding support]
[
(B)
Consistent with this rule,
the Commission shall allocate, by agreement, equalization surcharge funds
and service fees to RPCs based upon the Commission's statewide strategic plan
and contingent upon the availability of appropriated funds over a two year
period.]
[
(C)
The Commission may allocate
equalization surcharge to an emergency communication district (District) based
on District requests and availability of appropriated funds.]
[
(D)
Equalization surcharge funds
shall be allocated first to recipients requiring such funds for administrative
budgetary purposes, followed by the Program Budget level priorities in subsection
(c) of this section.]
[
(E)
If sufficient equalization
surcharge funds are not available to fund all RPC regional plan and District
requests, funds shall be allocated to provide a consistent level of 91-1 service
throughout the State of Texas in accordance with the Program Budget level
priorities in subsection (c) of this section. Allocation methods may include,
but are not limited to, the following:]
[
(i)
In reverse order of priority,
reducing the number of priority level components supported with equalization
surcharge funds; and/or]
[
(ii)
In order of priority, proportionally
allocating available funds among requesting agencies.]
[
(F)
The Commission may elect to
hold a balance of equalization surcharge funds in reserve for emergencies
and other contingencies.]
[
(g)
Funding Parameters for Ancillary
Equipment. Ancillary Equipment includes the following when the equipment supports
9-1-1 call delivery: surge protection devices, emergency power equipment,
voice recorders, and paging systems. An RPC shall refer to the strategic planning
guidelines for instructions as to the appropriate budget line item to which
the costs for purchase and maintenance of these items should be assigned.]
[
(1)
Paging Systems. Funding for
the paging systems may be approved when such systems are the most effective
means of 911 call delivery. Funding for pagers (receivers) will be limited
to necessary core responders. The Commission will fund the actual cost of
the pagers not to exceed $450 per pager.]
[
(2)
Voice Recording Equipment.
Voice loggers may be approved when the primary use of the equipment is in
support of the 9-1-1 call-taking and calldelivery function. Extra capacity
on such systems may be used for other public safety functions (such as dispatch).]
[
(A)
The Commission will normally
fund voice recording capability in a PSAP to record the conversation on 9-1-1
lines and administrative or 10-digit emergency lines in order to also accommodate
wireless, telematics, and Voice over IP 9-1-1 emergency calls.]
[
(B)
The Commission will normally
fund recording capability to record the transfer of an emergency call from
the PSAP first answering the call to the agency that is responsible for providing
the required emergency services.]
[
(C)
The funding of recording devices
to transfer information from another recorder will be approved only upon specific
justification of need.]
[
(D)
The following guidelines will
apply to determine the amount to be funded by the Commission:]
[
(i)
For a 2 position PSAP, the
Commission will fund the actual cost of the recording system not to exceed
$15,000; or]
[
(ii)
For PSAPs with 3 positions
or more, the Commission will fund the actual cost of the recording system
not to exceed $25,000.]
[
(E)
The Commission will consider
funding of recording capabilities greater than those suggested by the guidelines
when sufficient justification is provided as part of a regional plan.]
[
(3)
Emergency Power Equipment.
Each PSAP location should be evaluated by the RPC to determine if the emergency
power system needs to be updated to insure the ability to answer 9-1-1 calls
in the event that commercial power is interrupted. Emergency power equipment
should be evaluated and tested on a regular schedule. Other considerations
include:]
[
(A)
An uninterrupted power source
(UPS) should be considered as basic emergency power equipment. A UPS should
provide continuous power to keep essential 9-1-1 system components functioning
for a short period of time until generator or other emergency power equipment
become operable, if necessary. A UPS primarily functions continuously to maintain
a clean source of commercial power.]
[
(B)
Generators should be considered
as auxiliary emergency power equipment and should directly support an existing
(or planned) 9-1-1 system. A generator should provide continuous power to
keep 9-1-1 equipment specific to the PSAP functioning.]
[
(C)
The following guidelines will
apply to determine the amount of generator costs to be funded by the Commission:]
[
(i)
For a 2 position PSAP, the
Commission will fund the actual cost of the generator not to exceed $25,000.]
[
(ii)
For PSAPs with 3 positions
or more, the Commission will fund the actual cost of the generator not to
exceed $40,000.]
[
(4)
Funding may be approved by
the Commission for surge protection devices when they are used for protection
of 9-1-1 specific electronic equipment. A complete evaluation of grounding
at 9-1-1 PSAPs may be funded by the Commission.]
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 April 23, 2007.
TRD-200701514
Paul Mallett
Executive Director
Commission on State Emergency Communications
Earliest possible date of adoption: June 3, 2007
For further information, please call: (512) 305-6930
Chapter 354. MEDICAID HEALTH SERVICES
Subchapter A. PURCHASED HEALTH SERVICES
Division 9. AMBULANCE SERVICES
1 TAC §§354.1111, 354.1113, 354.1115
The Texas Health and Human Services Commission (HHSC or Commission) proposes amendments to the following rules related to Medicaid ambulance services: §354.1111, Definitions; §354.1113, Additional Claim Information Requirements; and §354.1115, Authorized Ambulance Services.
Background and Justification
The proposed amendments align Medicaid rules with the statutory requirement to obtain prior authorization for non-emergency ambulance transport (Human Resources Code, §32.024(t)). Other changes to the rule include updating terminology and reorganizing the rule content.
Section-by-Section Summary
Changes to §354.1111, Definitions, reflect the reorganization of the Health and Human Services agencies pursuant to House Bill 2292, 78th Legislature, Regular Session, 2003. The proposal also amends the definition of "emergency medical condition" to include psychiatric disturbances, or symptoms of substance abuse and to track the definitions of "emergency medical condition" found in 42 Code of Federal Regulations 438.114(a) and 489.24(b). Other definitions are updated or removed from the rule as a result of revisions to the corresponding sections 354.1113, Additional Claim Information Requirements, and 354.1115, Authorized Ambulance Services.
Section 354.1113, Additional Claim Information Requirements, is revised to specify what must be included to document medical necessity on ambulance claims, including the requirement that transport documentation substantiate the level of service and mode of transportation. The rule also requires that a prior authorization number for nonemergency services be obtained before an ambulance is used to transport a recipient. The rule additionally clarifies the types of supporting documentation that the ambulance provider and requesting provider must maintain and make available if requested by the Office of the Inspector General or the Commission or its designee; examples of supporting documentation were deleted from this rule, and will be included instead in policy.
Section 354.1115, Authorized Ambulance Services, is amended to specifically reflect the requirements found in §32.024(t) of the Human Resources Code concerning prior authorization for nonemergency ambulance transportation. Physicians, nursing facilities, health care providers, or other responsible parties will be required to obtain authorization from the Commission or its designee before an ambulance can be used to transport a recipient in a non-emergency situation. The Commission has 48 hours to respond to the request once it is received. The rule also outlines the circumstances under which the Commission will grant immediate authorization for transport and the process an ambulance provider should follow to receive payment in cases where the requesting provider did not receive a required prior authorization.
Non-substantive terminology changes are made throughout the chapter, including replacing references to the Texas Department of Health with the Health and Human Services Commission.
Fiscal Note
Thomas M. Suehs, Deputy Executive Commissioner for Financial Services, has determined that during the first five years the amended rules are in effect there will be no fiscal impact to state government. The proposed rules will not result in any fiscal implications for local health and human services agencies. Local governments will not incur additional costs.
Small and Micro-Business Impact Analysis
Mr. Suehs has also determined that there will not be an effect on small businesses or micro businesses to comply with the proposed amendments, as they will not be required to alter their business practices as a result of the rules. There are no anticipated economic costs to persons who are required to comply with the proposed rules. There is no anticipated negative impact on local employment.
Public Benefit
Chris Traylor, Associate Commissioner for Medicaid and CHIP, has determined that for each of the first five years the proposed rules are in effect, the public will benefit from the adoption of the rules. The anticipated public benefit, as a result of enforcing the proposed amendments, is consistency in availability of ambulance services.
Regulatory Analysis
HHSC has determined that this proposal is not a "major environmental rule" as defined by the Government Code, §2001.0225. A "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. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under the Government Code, §2007.043.
Public Comment
Written comments on the proposal may be submitted to Garry Walsh, Senior Policy Analyst, Medicaid/CHIP Division, Texas Health and Human Services Commission, P.O. Box 85200, Austin, TX 78708-5200, Mail Code H-390 91X; by fax to (512) 506-7808; or by e-mail to Garry.Walsh@hhsc.state.tx.us within 30 days of the publication of this proposal in the Texas Register.
Public Hearing
A public hearing is scheduled for May 24, 2007 from 9:00 a.m. to 10:00 a.m. in the HHSC Lone Star Conference Room at 11209 Metric Boulevard, Austin, Texas 78758. Persons requiring further information, special assistance, or accommodations should contact Meisha Spencer at (512) 491-1453.
Statutory Authority
The amendments are proposed 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.
The proposed amendments affect the Human Resources Code, Chapter 32, and the Texas Government Code, Chapters 531 and 533. No other statutes, articles, or codes are affected by this proposal.
§354.1111.Definitions.
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
(1) Ambulance provider--A provider of ambulance services who:
(A) is enrolled as an ambulance provider
in
[
with
] the
Texas Medicaid Program
[
department or its
designee
] to provide ambulance services for Medicaid
recipients
[
clients
];
(B) is licensed with the
Department of State Health Services
[
Texas Department of Health
], Emergency Medical Services
Division;
(C) is enrolled in Medicare;
(D) agrees to accept assignment on all Medicare/Medicaid claims; and
(E) agrees to provide these services according to state and local laws, regulations, and guidelines governing ambulance services.
(2) Appropriate facility--The nearest [
Medicaid-enrolled
] medical facility that is equipped to provide medical care for the
illness or injury of the Medicaid
recipient
[
client
]
involved. It is the institution, equipment, personnel,
and
capability
to provide the services necessary to support the required medical care [
, and the distance to the facility
] that determine whether a facility
is appropriate.
(3)
Commission--Health and Human Services Commission
[
Department--Texas Department of Health (department)
].
(4) Designee--The [
department's
] contractor responsible
for reimbursing Medicaid providers
of
[
for
] ambulance
transport services for Medicaid
recipients
[
clients
].
(5) Emergency medical condition--A medical condition (including
emergency labor and delivery) manifesting itself by acute symptoms of sufficient
severity (including severe pain
, psychiatric disturbances, or symptoms
of substance abuse
) such that
a prudent layperson with an average
knowledge of health and medicine, could reasonably expect
the absence
of immediate medical attention [
could reasonably be expected
] to
result in one of the following:
(A) placing the
recipient's
[
client's
]
health
(or, with respect to a pregnant woman, the health of the woman
or her unborn child)
in serious jeopardy;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(6) Emergency transport--
Transport
[Ambulance transport service] provided by a [
Medicaid-enrolled
] ambulance
provider for a Medicaid
recipient
[
client
] whose condition
meets the definition of an emergency medical condition. [
Examples of
conditions appropriate for emergency transports include, but are not limited
to, acute and severe illnesses, untreated fractures, loss of consciousness,
semiconsciousness, seizing during transport, acute or severe injuries from
auto accidents, and extensive burns. Conditions requiring CPR in transit or
the use of above-routine restraints for the safety of the client or crew may
also be considered emergencies
]. Facility-to-facility transports
are
[
may be
] appropriate as emergencies if the required [
emergency
] treatment
for the emergency medical condition
is
not available at the first facility.
(7) Non
-
emergency transport--
Transport provided
by a ambulance provider for a Medicaid recipient to or from a scheduled medical
appointment, to or from another licensed facility for treatment, or to the
recipient's home after discharge from a hospital. Non-emergency transport
is appropriate when the Medicaid recipient's medical condition is such that
the use of an ambulance is the only appropriate means of transport, e.g.,
alternate means of transport are medically contraindicated.
[
Ambulance
transport service, to or from a medical appointment, for a Medicaid client
who requires treatment in another location and who is so severely disabled
that the use of an ambulance is the only appropriate means of transfer.
]
(8) Medically necessary--
When the condition of the Medicaid
recipient meets the definition of emergency medical condition or meets the
requirements for non-emergency transport.
[
The condition of the
Medicaid client is such that the use of any other method of transportation
is contraindicated and, in the case of a client who is severely disabled,
there is no other suitable transportation.
]
[
(9)
Severely disabled--A Medicaid client whose
physical condition limits his mobility and requires the client to be bed-confined
at all times, unable to sit unassisted at all times, or requires continuous
life-support systems (including oxygen or intravenous infusion).
]
§354.1113.Additional Claim Information Requirements.
(a) In addition to the general requirements in §354.1001 of this title (relating to Claim Information Requirements), the following information is required on claims for ambulance services:
(1) Documentation of medical necessity in accordance with codes representing medical conditions as designated by the Commission:
(A) The transport documentation must substantiate the level of service and mode of transport provided;
(B) Reimbursement is recouped when the documentation does not substantiate that the level of service and mode of transport provided accurately matches the level of service and mode of transport claimed; and
(C) The level of service and mode of transport provided must be medically necessary based on the clinical situation and needs of the recipient;
(2)
[
(1)
]
Type
[
type
] of ambulance service provided (
e.g,
air, ground, or boat);
(3)
[
(2)
]
Origin
[
origin
] and destination of each separate trip;
(4)
[
(3)
]
Charges
[
charges
] for ambulance services, including [
both
] base rates and mileage rates
; and
[
, and written justification of the number of miles traveled; and]
[
(4)
appropriate supporting documentation requested
by the Texas Health and Human Services Commission or its designee to support
the determination of the medical necessity and appropriateness of the ambulance
transport. Examples of supporting documentation include, but are not limited
to, transferring records (medical; emergency room records from transferring
hospital); ambulance run sheets; time of transport; acuity of client; distance
of transport; traffic patterns; and actual distance to nearest appropriate
facility.
]
(5) Prior authorization number (PAN).
(b) Obtaining a prior authorization number.
(1) A PAN for non-emergency transports must be obtained before an ambulance is used to transport a recipient.
(2) A PAN for out-of-state ambulance transports must be obtained before an ambulance is used to transport a recipient.
(c) Supporting documentation is required to be maintained by both the ambulance provider and the requesting provider including a physician, nursing facility, health care provider or other responsible party. Supporting documentation is to be made available if requested by the Office of Inspector General (OIG) or the Commission or its designee.
(1) An ambulance provider is required to maintain documentation that represents the recipient's medical conditions and other clinical information to substantiate medical necessity and the level of service and mode of transportation requested. This supporting documentation is limited to documents developed or maintained by the ambulance provider.
(2) Physicians, nursing facilities, health care providers or other responsible parties are required to maintain physician orders related to requests for prior authorization of non-emergency and out-of-state ambulance services. These providers must also maintain documentation of medical necessity for the ambulance transport.
§354.1115.Authorized Ambulance Services.
In
[
These requirements are in
] addition to the
requirements [
as
] stated in
this section, a provider must
comply with §354.1001
[
§29.1
] of this title (relating
to Claim Information Requirements), and
§354.1113
[
§29.902
] of this title (relating to Additional Claim Information Requirements).
(1) Emergency Ambulance Transportation. The
Commission
[
department
] or its designee
will reimburse
[
reimburses
] a Medicaid-enrolled provider for the emergency
transport
[
transportation
] of a Medicaid recipient
with
[
whose condition conforms with the definition of
] an emergency medical
condition
in accordance with the following criteria
[
as stated
in §29.901 of this title (relating to Definitions) and
]:
(A)
Transport
[
the transportation
] must
be to
an appropriate facility
[
the nearest facility capable
of providing the appropriate level of care for the recipient's condition
]. If the
transport
[
transportation
] is made to a facility
other than
an appropriate facility
[
the nearest facility
],
payment is limited to the amount that would be payable to
an appropriate
facility
[
the nearest facility
]; or
(B)
Transport
[
transportation
] by air
or boat ambulance is reimbursable if the time and distance required to
reach an appropriate facility
[
the nearest facility capable of
providing the appropriate level of care for the recipient's condition
]
make the
transport
[
transportation
] by ground ambulance
[
unreasonable,
] impractical[
,
] or would endanger the
life or safety of the recipient. If the recipient's medical condition does
not meet the emergency air or boat criteria, but does meet the emergency ground
transportation criteria, the payment to the provider is limited to the amount
that would be payable at the emergency ground transportation rate.
(2) Non
-
emergency Ambulance Transportation. The
Commission
[
department
] or its designee
may reimburse
[
reimburses
] a Medicaid-enrolled
ambulance
provider
for [
the
] non
-
emergency
transport
[
transportation of a Medicaid recipient. under the following conditions:
]
when the following requirements are met:
(A)
A physician, nursing facility, health care
provider, or other responsible party, shall obtain authorization from the
Commission or its designee before an ambulance is used to transport a recipient
in circumstances not involving an emergency.
[
the recipient is severely disabled as defined in §29.901 of this title;
]
(i) Except as provided by clause (iii) of this subparagraph, a request for authorization must be evaluated by the Commission or its designee based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition.
(ii) Except as provided by clause (iii) of this subparagraph, a response to a request for authorization must be made by the Commission or its designee not later than 48 hours after receipt of the request.
(iii) A request for authorization must be granted immediately by the Commission or its designee and must be effective for a period of 180 days from the date of issuance if the request includes a written statement from a physician that:
(I) States that alternative means of transporting the recipient are contraindicated; and
(II) Is dated not earlier than the 60th day before the date on which the request for authorization is made.
[
(B)
the severely disabled recipient can not
be transported by any means other than an ambulance without endangering the
health or safety of the recipient; and
]
[
(C)
the nonemergency ambulance transportation
of the severely disabled Medicaid recipient is to or from a scheduled medical
appointment and authorization has been received from the department or its
designee.]
[
(i)
The prior authorization for nonemergency
ambulance transportation will be based upon the following:
]
[
(I)
the recipient's medical needs and disability;
and
]
[
(II)
duration of time if regular transportation
will be required as a result of the recipient's medical needs and disability.
]
[
(ii)
The prior authorization request must
be approved or denied by the department or its designee not later than 48
hours after receipt of a request unless clause (iii) of this subparagraph
applies.
]
[
(iii)
A request for authorization must be
immediately granted and must be effective for a period of 180 days from the
date of issuance if the request includes a written statement from a physician
that:
]
[
(I)
states that alternative means of transporting
the recipient are contraindicated;
]
[
(II)
is dated not earlier than the 60th day
before the date on which the request for authorization is made; and
]
[
(III)
is submitted on the Texas Department
of Health approved Physician Certification Form.
]
(B) A person denied payment for ambulance services rendered is entitled to payment from the nursing facility, healthcare provider, or other responsible party that requested the services if:
(i) Payment under the Medicaid program is denied because of lack of prior authorization; and
(ii) The person provides the nursing facility, healthcare provider, or other responsible party with a copy of the bill for which payment was denied.
(3)
Hearings. For information about recipient fair hearings,
refer to the Commission's fair hearing rules, Chapter 357 of this title (relating
to Hearings).
[
Recipient Fair Hearing. A denial, delay, reduction,
or modification of ambulance transportation services may be appealed by the
recipient under the department's fair hearing rules as stated in Chapter 36
of this title (relating to Medicaid Program Appeals Procedures).
]
(4) Provider Appeal.
An ambulance provider denied payment
for services rendered because of failure to obtain prior authorization, or
because a request for prior authorization was denied, is entitled to appeal
the denial of payment to the Commission or its designee.
A denial of a [
transportation
] claim may be appealed by a provider under the
Commission's
[
department's
] appeals procedures contained
in the Texas Medicaid Provider Procedures Manual
and §354.1003 of
this title (relating to Time Limits for Submitted Claims)
.
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 April 20, 2007.
TRD-200701511
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 3, 2007
For further information, please call: (512) 424-6900
Subchapter J. PURCHASED HEALTH SERVICES
Division 3. PHYSICIAN SERVICES
The Health and Human Services Commission (HHSC) proposes to add new §355.8043 to Chapter 355 of Title 1 of the Texas Administrative Code. Section 355.8043 establishes the methodology HHSC will use to distribute supplemental Medicaid Upper Payment Limit (UPL) payments to certain physicians.
Background and Purpose
HHSC requested approval from the Centers for Medicare and Medicaid Services (CMS) to implement a supplemental payment program to state-affiliated physician group practices through the submission of a State Plan Amendment (SPA) on June 30, 2004. The change in reimbursement practice recognizes the unique role state-affiliated physician group practices play in providing services to Medicaid recipients. As a result of this change in methodology, the State will obtain additional federal revenue for state-owned medical schools that bill Medicaid. The state matching funds required to draw down federal dollars will be provided by the state-owned medical schools. The effective date of this SPA is May 1, 2004.
Fiscal Note
Thomas M. Suehs, Deputy Executive Commissioner for Financial Services, has determined that the proposed new rule is not expected to increase state expenditures, but will increase the amount of federal matching funds to the State. During State Fiscal Year 2007, HHSC estimates that the proposed new rule will result in increased federal matching funds of $231,923,879; this figure includes retroactive payments for state Fiscal Years 2004 - 2006. HHSC estimates that the state will receive an estimated increase in federal matching funds of $68,000,000, per fiscal year, in subsequent years.
Small Business and Micro-business Impact Analysis
HHSC has determined that there is no adverse economic effect on small businesses or micro-businesses, or on businesses of any size, as a result of enforcing or administering the proposed new rule.
Cost to Persons and Effect on Local Economies
HHSC does not anticipate that there will be any economic cost to persons who are required to comply with this proposed new rule. The new rule will not affect a local economy.
Public Benefit
Mr. Suehs, Deputy Executive Commissioner for Financial Services, determined that, for the first five years the rule is in effect, the public benefit expected as a result of enforcing the proposed new rule is that state-owned physician group practices in the State of Texas will recover more of their cost of treating Medicaid patients.
Regulatory Analysis
HHSC has determined that this proposal is not a "major environmental rule" as defined by §2001.0225 of the Texas Government Code. A "major environmental rule" is defined to mean a rule, the specific intent of which is, to protect the environment or reduce risk 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 a state or a sector of the state. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code, §2007.043.
Public Comment
Questions about the content of this proposal may be directed to Lupita Villarreal (512) 491-1178 in HHSC Rate Analysis-Hospital Services. Written comments on the proposal may be submitted to Mrs. Villarreal by facsimile (512) 491-1998; e-mail to Lupita.Villarreal@hhsc.state.tx.us; or by mail to HHSC Rate Analysis-Hospital Services, Mail Code H-400, P.O. Box 85200, Austin, TX 78708-5200, within 30 days of publication in the Texas Register.
Statutory Authority
The new rule is proposed 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; and the Texas Government Code, §531.021(b), which provides HHSC with the authority to propose and adopt rules governing the determination of Medicaid reimbursements.
The proposed new rule affects Chapter 531 of the Texas Government Code and Chapter 32 of the Human Resources Code. No other statutes, articles, or codes are affected by this proposal.
§355.8043.Supplemental Payments to Certain Physicians.
Supplemental payments to certain physicians.
(1) Notwithstanding other provisions of this section, supplemental payments are available under this paragraph to physicians who are recognized as essential to the Texas State Medicaid program. To be identified as an essential physician and qualify for a supplemental payment, the physician must be:
(A) A Texas licensed physician;
(B) Enrolled as a Texas Medicaid provider; and
(C) Employed by an eligible physician group practice that is state-owned or operated. Employees under contract with a physician group practice are not included in supplemental payment calculations nor are they eligible for this supplemental payment. Eligible physician group practices consist of those affiliated with:
(i) UT--Southwestern--Effective: 5/1/2004
(ii) UT--San Antonio--Effective: 5/1/2004
(iii) UT--Tyler--Effective: 5/1/2004
(iv) UT--Houston--Effective: 5/1/2004
(v) UTMB--Effective: 5/1/2004
(vi) MD Anderson--Effective: 5/1/2004
(vii) University of North Texas--Effective: 5/1/2004
(viii) Texas Tech--Amarillo--Effective: 5/1/2004
(ix) Texas Tech--El Paso--Effective: 5/1/2004
(x) Texas Tech--Lubbock--Effective: 5/1/2004
(xi) Texas Tech--Odessa--Effective: 5/1/2004
(2) For services rendered by physicians employed by the practices at paragraph (1) of this section, a supplemental payment will be made that is equal to the difference between the Medicaid payments otherwise made and payments at the Medicare Equivalent (specifically the Medicare non facility rate equivalent) of the Average Commercial Rate Payment. This supplemental payment will, for the same dates of service, be reduced by any other supplemental payment found elsewhere in the state plan. Payment will be made quarterly and will not be made prior to the delivery of services.
(3) The Base Period Medicare Equivalent of the Average Commercial Rate to be paid to practitioners affiliated with physician group practices eligible under paragraph (1)(C) of this section, will be determined as follows. The following calculation will be performed separately for each of the practices that employ eligible practitioners. Supplemental payment to each practice will be based on this per practice calculation:
(A) Compute Average Commercial Fee Schedule: For the base period, compute the average commercial allowed amount per Current Procedural Terminology (CPT) Code, including patient share amounts, for the top five payers for procedure codes with payment rates. The top five commercial third-party payers will be determined by total billed charges reported by practice plans as defined in paragraph (1)(C) of this section.
(B) Calculate the Base Period Average Commercial Payment Ceiling: Multiply the Average Commercial Fee Schedule, as determined in paragraph (3)(A) of this section, by the number of times each procedure code was rendered in the base period and paid to eligible plans on behalf of Medicaid beneficiaries, as reported from the Medicaid Management Information System (MMIS). The sum of the product for all procedure codes shall determine the Base Period Average Commercial Payment Ceiling.
(C) Determine the Base Period Medicare Payment Ceiling: For each of the procedure codes used to determine the Average Commercial Payment Ceiling in paragraph (3)(B) of this section, multiply the base period, non-facility Medicare allowed rate from the April release Relative Base Relative Value System (RBRVS) by the number of times each procedure code was rendered in the base period and paid to eligible plans on behalf of Medicaid beneficiaries as reported from the MMIS. The sum of the product for all procedure codes will represent the Base Period Medicare-equivalent Payment Ceiling.
(D) Determine the Base Period Medicare Equivalent of the Average Commercial Rate: Divide the Base Period Average Commercial Payment Ceiling computed in paragraph (3)(B) by the Base Period Medicare Payment Ceiling determined in paragraph (3)(C) of this section.
(E) Periodic Updates to the Base Period Medicare Equivalent of the Average Commercial Rate: The State will update this ratio at least every three years.
(4) Determination of Supplemental Payment.
(A) The supplemental payment ceiling for each physician practice eligible under paragraph (1)(C) of this section, will be determined as follows: The Medicare Equivalent of the Average Commercial Rate is multiplied by the Medicare payment at the non-facility rate per CPT Code, then multiplied by the Medicaid volume by CPT Code for the same period, as reported through the MMIS.
(i) (Medicare Equivalent of the Average Commercial Rate) X (Medicare Payment per CPT Code) X (Medicaid Volume per CPT Code) = Payment Ceiling.
(ii) Medicare payment at the non-facility rate and Medicaid volume for those services are derived from the same period of time.
(B) Determine the Medicaid Supplemental Payment Ceiling: The Medicaid Supplemental Payment for each plan, as described in paragraph (1)(C) of this section, will equal the current period payment ceiling at the Medicare Equivalent of the Average Commercial Rate less all Medicaid payments, including enhanced payments, for procedure codes rendered in the current period and paid to eligible physician group practices on behalf of Medicaid beneficiaries as reported from the MMIS. Medicaid volume and payments will include all available payments and adjustments.
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 April 20, 2007.
TRD-200701512
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 3, 2007
For further information, please call: (512) 424-6900
The Texas Health and Human Services Commission (HHSC) proposes to amend Title 1 of the Texas Administrative Code (TAC), §355.8441, by adding paragraph (12) covering the reimbursement methodology for personal care services delivered to Medicaid-eligible clients under age 21.
Background and Justification
Alberto N. v. Hawkins was filed in 1999, in the U.S. District Court for the Eastern District of Texas. Plaintiffs were children who alleged they had been denied access to certain medically necessary in-home Medicaid service, including personal care services (PCS). To meet plaintiffs' needs, and the needs of those similarly situated, HHSC is establishing a personal care services benefit designed especially for THSteps beneficiaries. Currently personal care services for THSteps-eligible beneficiaries are available through the Primary Home Care program operated by the Department of Aging and Disability Services. The proposed new PCS benefit is expected to be operational by September 1, 2007. The personal care services benefit will be available to any THSteps-eligible beneficiary who requires assistance with activities of daily living, instrumental activities of daily living, and health-related functions due to a physical, cognitive, or behavioral limitation related to his or her disability or chronic health condition, regardless of diagnosis, type of illness, or condition. This proposed reimbursement methodology rule accompanies new personal care services program rules at 1 TAC §§363.601, 363.603, 363.605, and 363.607, which were previously proposed in the April 16, 2007, issue of the Texas Register. In conjuction with this rule, HHSC is proposing new §355.8443 of this title (relating to Reimbursement Methodology for School Health and Related Services (SHARS)) to be published in the May 11, 2007, issue of the Texas Register.
Section-by-Section Summary
Proposed §355.8441(12)(A) provides that the reimbursement methodology for personal care services delivered by school districts is located at §355.8443, relating to the Reimbursement Methodology for School Health and Related Services (SHARS).
Proposed §355.8441(12)(B) describes the reimbursement methodology for personal care services delivered by providers other than school districts as fees determined by HHSC or its designee using at least one of the following methods: a review of rates paid to providers delivering similar services; modeling using an analysis of other data available to HHSC; or a combination of the two. Personal care services delivered under the Consumer Directed Services (CDS) payment option will be reimbursed in accordance with §355.114, relating to the Consumer Directed Services Payment Option.
Fiscal Note
Thomas M. Suehs, Deputy Executive Commissioner for Financial Services, has determined that during the first five-year period the proposed rules are in effect there will be a fiscal impact to state government of $53.6 million for state fiscal year (SFY) 2008, $55.6 million for SFY 2009, $57.0 million for SFY 2010, $58.3 million for SFY 2011, and $59.7 million for SFY 2012. The proposed rules will not result in any fiscal implications for local health and human services agencies. Local governments will not incur additional costs.
Small and Micro-business Impact Analysis
Mr. Suehs has also determined that there will be no effect on small businesses or micro businesses to comply with the proposal, as they will not be required to alter their business practices as a result of the rule. There are no anticipated economic costs to persons who are required to comply with the proposed rule. There is no anticipated negative impact on local employment.
Public Benefit
Carolyn Pratt, Director of Rate Analysis, has determined that for each year of the first five years the proposed rules are in effect, the public will benefit from the adoption of the amendment. The anticipated public benefit, as a result of enforcing the amendment, will be to provide additional personal care services to the Medicaid population under 21 years of age.
Regulatory Analysis
HHSC has determined that this proposal is not a "major environmental rule" as defined by §2001.0225 of the Texas Government Code. A "major environmental rule" is defined to mean a rule the specific intent of which is to protect the environment or reduce risk 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 a state or a sector of the state. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under §2007.043 of the Government Code.
Public Comment
Written comments on the proposal may be submitted to Nancy Kimble, Senior Rate Analyst in the Rate Analysis Division, Texas Health and Human Services Commission, P.O. Box 85200, MC-H400, Austin, Texas 78708-5200; by fax (512) 491-1983 or by e-mail at Nancy.Kimble@hhsc.state.tx.us within 30 days of publication of this proposal in the Texas Register.
Statutory Authority
The amendment is proposed 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; and the Texas Government Code, §531.021(b), which provides HHSC with the authority to propose and adopt rules governing the determination of Medicaid reimbursements.
The proposed amendment affects the Human Resources Code, Chapter 32, and the Texas Government Code, Chapter 531. No other statutes, articles, or codes are affected by this proposal.
§355.8441.Reimbursement Methodologies for Early and Periodic Screening, Diagnosis and Treatment[ -Comprehensive Care Program ] (EPSDT[ -CCP ]) Services.
The following are reimbursement methodologies for services provided
under the Early and Periodic Screening, Diagnosis and Treatment[
-Comprehensive
Care Program
] (EPSDT[
-CCP
])
program, delivered only to Medicaid clients under age 21
, also known as
the
Texas
Health Steps [
CCP
] (THSteps[
-CCP
])[
, only to client
under age 21
]. Reimbursement methodologies for services provided to
all Medicaid clients, including clients under age 21, are located elsewhere
in this chapter.
(1)
THSteps[
-CCP
] counseling and psychotherapy services
are reimbursed to freestanding psychiatric hospitals and facilities in accordance
with §355.8063 of this title (relating to Reimbursement Methodology for
Inpatient Hospital Services). The reimbursement methodologies for counseling
and psychotherapy services provided to all Medicaid clients are located elsewhere
in this chapter.
(2) - (11) (No change.)
(12) Personal care services (PCS) are reimbursed in accordance with the following Medicaid reimbursement methodologies for the applicable provider type:
(A) School districts delivering PCS under School Health and Related Services (SHARS) are reimbursed in accordance with §355.8443 of this title (relating to Reimbursement Methodology for School Health and Related Services (SHARS)); and
(B) Providers other than school districts delivering PCS are reimbursed as follows:
(i) PCS and PCS delivered in conjunction with delegated nursing services are reimbursed fees determined by HHSC or its designee. The fees are determined using at least one of the following methods: a review of rates paid to providers delivering similar services; modeling using an analysis of other data available to HHSC; or a combination thereof, as determined appropriate by HHSC.
(ii) PCS delivered through the Consumer Directed Services (CDS) payment option are reimbursed in accordance with §355.114 of this title (relating to Consumer Directed Services Payment Option).
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 April 20, 2007.
TRD-200701513
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 3, 2007
For further information, please call: (512) 424-6900