Part II.
Texas Department of Mental Health and Mental Retardation
Chapter 406.
ICF/MR Programs
Subchapter B. Contracting Requirements
25 TAC §406.53
The Texas Department of Mental Health and Mental Retardation
(department) proposes amendments to §406.53, concerning provider application
requirements specific to ICF/MR, of Chapter 406, Subchapter B, concerning
contracting requirements.
The amendments allow the department to manage the capacity of individual
state schools and state centers by transferring beds between facilities while
ensuring that the capacity of all state schools and state centers does not
exceed the number authorized in The Long Term Care Plan for People with Mental
Retardation and Related Conditions required by Texas Health and Safety Code,
§533.062. Additionally, the amendments permit a residential facility
seeking initial certification in the Intermediate Care Facilities for Persons
with Mental Retardation (ICF/MR) program to have a capacity of more than six
beds if that facility has been funded solely with state funds previously,
and is approved by the department to apply to participate in the ICF/MR program
as part of the refinancing initiative authorized by the General Appropriations
Act, 75th Legislature, Article II, Page 68, Paragraph 9 (1997). The amendments
also delete an extraneous "shall" in subsection (a); replace commas with semicolors
in subsection (a)(1)(A) and (B); delete an extraneous "the" before "TDMHMR"
in subsection (b); substitute "person" for "individual" in subsection (b)(1)(B)
to be consistent with terminology used elsewhere in the section; and replace
"catchment area" with "local service area" consistent with current department
usage. In addition, a reference in subsection (e) to the statutorily required
long term care plan is updated with the plan's present title, which is "The
Long Term Care Plan for People with Mental Retardation and Related Conditions."
In that same subsection, the term "current" is added before the title of the
plan to clarify that new ICF/MR applications may not exceed the total ICF/MR
program capacity established by the plan in effective at the time of the application.
Also in subsection (e), the statutory reference requiring the development
of the plan has been added for the convenience of persons complying with the
rule and the term "service capacity" is replaced with "authorized bed capacity"
to be consistent with terminology used in the plan.
Stephen Zeeck, acting chief financial officer, has determined that for
each year of the first five years the proposed amendments are in effect enforcing
or administering the amendments does not have forseeable implications relating
to costs or revenues of state and local government.
Barry Waller, director, Long Term Services and Supports, has determined
that for each year of the first five-year period the amendments as proposed
are in effect, the expected public benefit is ability of the department to
more efficiently manage the residential capacity of the state schools and
state centers, and to draw down additional federal funds for those programs
currently funded solely through general revenue. There is no economic cost
to persons required to comply with the amendments. There is no adverse economic
effect on small businesses required to comply with the amendments because
the rules will not impact small businesses. It is not anticipated that the
proposed amendments will affect a local economy.
Written comments concerning the proposal may be mailed to Linda Logan,
director, Policy Development, Texas Department of Mental Health and Mental
Retardation, P.O. 12668, Austin, Texas 78711, or faxed to 512/206-4750, within
30 days of publication of these proposed amendments.
A hearing to accept oral and written testimony from members of the public
concerning the proposal has been scheduled for 1:30 p.m., Friday, February
19, 1999, in the department's Central Office Auditorium, Building 2 (main
building), 909 West 45th Street, Austin. Persons requiring an interpreter
for the deaf or hearing impaired should contact the TDMHMR Central Office
operator at least 72 hours prior to the hearing at TDD (512) 206-5330. Persons
requiring any other accommodation for a disability should notify Sheila Wilkins,
Office of Policy Development, at least 72 hours prior to the hearing at (512)
206-4516 or at the TDY phone number of Texas Relay, 1-800-735-2988.
The amendment is proposed under the Texas Health and Safety Code,
§532.015(a), which provides the Texas Board of Mental Health and Mental
Retardation with broad rulemaking authority; the Texas Government Code, §531.021(a),
and the Texas Human Resources Code, §32.021(a), which provide the Texas
Health and Human Services Commission (THHSC) with the authority to administer
the federal medical assistance (Medicaid) program in Texas; Acts 1995, 74th
Texas Legislature, Chapter 6, §1, (Senate Bill 509), which clarifies
the authority of THHSC to delegate the operation of all or part of a Medicaid
program to a health and human services agency; and the Human Resources Code,
§32.021(c), which provides an agency operating part of the Medicaid program
with the authority to adopt necessary rules for the proper and efficient operation
of the program. THHSC has delegated to the department the authority to operate
the ICF/MR program.
Texas Government Code, §531.021(a), and the Texas Human Resources
Code, §32.021(a) and (c), are affected by the proposed amendment.
§406.53.Provider Application Requirements Specific to ICF/MR.
(a)
The words and terms in paragraphs (1)-(3) of this subsection,
when used in this section, [
(1)
Applicant -- The individual(s) and/or entities specified
on TDMHMR's or its designated agent facility ownership information form who:
(A)
operate a for-profit organization
;
[
(B)
serve as the authorizing entity for a nonprofit organization
;
[
(C)
(No change.)
(2)-(3)
(No change.)
(b)
All applicants for participation in the ICF/MR program
must submit an application to [
(1)
The documentation submitted must indicate that the following
persons will have completed the ICF/MR preapplication training course prior
to approval of the application:
(A)
(No change.)
(B)
the
person
[
(C)
(No change.)
(2)
(No change.)
(c)
All applications must meet the requirements specified in
paragraphs (1)-(3) of this subsection.
(1)
The certified capacity of a
new facility seeking initial certification or a certified facility seeking
to increase its certified capacity may not exceed six beds except for:
(A)
a state school or state center seeking to increase
its certified capacity, if the total capacity of all state schools and state
centers does not exceed the authorized bed capacity for "campus facilities"
as set forth in The Long Term Care Plan for People with Mental Retardation
and Related Conditions required by Texas Health and Safety Code, §533.062;
and
(B)
a new facility seeking initial certification
that has been funded solely with state funds and has been approved by TDMHMR
to apply to be refinanced under the ICF/MR program, in accordance with the
General Appropriations Act, 75th Legislature, Article II, Page 68, Paragraph
9 (1997).
[
Requested certification
is limited to a maximum of six beds per facility. This includes new facilities
seeking initial certification and currently certified facilities seeking to
increase the certified bed capacity.]
(2)
(No change.)
(3)
The proposed facility must submit documentation to
verify that the mental retardation authority (MRA) in whose
local service
[
(d)
(No change.)
(e)
TDMHMR will approve applications that meet all requirements
set forth in this section and are within the
authorized bed
[
(1)-(3)
(No change.)
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 January
26, 1999.
TRD-9900539
Charles Cooper
Chair, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 206-4516
25 TAC §406.101
The Texas Department of Mental Health and Mental Retardation
(TDMHMR) proposes amendments to §406.101 concerning vendor payments,
of Chapter 406, Subchapter C, concerning vendor payments.
The amendments stipulate that when an individual's Medicaid eligibility
is established after the provision of services in the Intermediate Care Facilities
for Persons with Mental Retardation (ICF/MR) Program in Texas, a claim for
those services must be received by National Heritage Insurance Company (NHIC)
no later than 180 calendar days from the date Medicaid eligibility is established.
The current rule allows these claims to be received 30 days after the provider
is notified of Medicaid eligibility or 180 calendar days after the end of
the service month, whichever is later. The amendment will make the ICF/MR
claims submission requirements consistent with those of other Texas human
services programs.
Stephen Zeeck, acting chief financial officer, has determined that for
each year of the first five years the proposed amendments are in effect enforcing
or administering the amendments does not have significant foreseeable implications
relating to costs or revenues of state or local government.
Ernest McKenney, director, Medicaid Administration, has determined that
for each year of the first five years that the proposed amendments are in
effect, the public benefit is to make the claims submission requirements consistent
across Texas human services programs. There is no economic cost to persons
required to comply with the proposed amendments. There is no adverse economic
effect on small businesses required to comply with the amendments. It is not
anticipated that the proposed amendments will affect a local economy.
Written comments concerning the proposal may be mailed to Linda Logan,
director, Policy Development, Texas Department of Mental Health and Mental
Retardation, P.O. 12668, Austin, Texas 78711, or faxed to 512/206-4750, within
30 days of publication of these proposed amendments.
The amendment is proposed under the Texas Health and Safety Code,
§532.015(a), which provides the Texas Board of Mental Health and Mental
Retardation with broad rulemaking authority; the Texas Government Code, §531.021(a),
and the Texas Human Resources Code, §32.021(a), which provide the Texas
Health and Human Services Commission (THHSC) with the authority to administer
the federal medical assistance (Medicaid) program in Texas; Acts 1995, 74th
Texas Legislature, Chapter 6, §1, (Senate Bill 509), which clarifies
the authority of THHSC to delegate the operation of all or part of a Medicaid
program to a health and human services agency; and the Human Resources Code,
§32.021(c), which provides an agency operating part of the Medicaid program
with the authority to adopt necessary rules for the proper and efficient operation
of the program. THHSC has delegated to the department the authority to operate
the ICF/MR program.
Texas Government Code, §531.021(a), and the Texas Human Resources
Code, §32.021(a) and (c), are affected by the proposed amendment.
§406.101.Vendor Payments.
(a)-(b)
(No change.)
(c)
An Intermediate Care Facility for the Mentally Retarded
(ICF/MR) is not entitled to payment if the monthly claim or adjustment for
services is not received by the National Heritage Insurance Company (NHIC)
within 180 calendar days from the end of the service month [
(1)
In the event that an individual's
Medicaid eligibility is established after the provision of services, the 180
calendar day time period will start on the date eligibility is established.
(2)
All claims and adjustments for months
prior to January 1, 1999, must be submitted by March 31, 1999. A claim for
services regarding an individual without a valid LOC determination must be
received by NHIC within 90 calendar days from the date
an individual's
Medicaid eligibility is re-established or the date a valid determination
of LOC is made, whichever is later.
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 January
26, 1999.
TRD-9900540
Charles Cooper
Chair, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 206-4516
Subchapter D. Home and Community-Based Services (HCS)
25 TAC §409.103, §409.109
The Texas Department of Mental Health and Mental Retardation
(department) proposes amendments to §409.103, concerning payment category
assignment and provider claims payment, and §409.109, concerning corrective
action and provider sanctions, of Chapter 409, Subchapter D, concerning home
and community-based services (HCS).
The amendments to §409.103 clarify the criteria for increasing the
level-of-need of an individual who exhibits dangerous behavior and for assigning
the "pervasive plus" level-of-need (LON 9) to an individual who exhibits extremely
dangerous behavior. The amendments also replace all references to the Level-of-Care
Assessment Form (TDHS Form 3650) with references to the department's new MR/RC
Assessment Form, which has replaced Form 3650 for purposes of reporting an
individual's level-of-care and level-of-need. In addition, an incorrect reference
in §409.103(c)(1) is revised from "§406.203 of this title (relating
to Eligibility and Review)" to "§406.203 of this title (relating to Eligibility
for Level-of-care Determination)."
The amendments to §409.109 modify Principles 18 and 62 of the HCS
Consumer Principles for Evidentiary Certification (Figure 1: 25 TAC §409.109).
Principle 18 is revised to clarify that a family member of an individual enrolled
in the HCS program can be a qualified provider of Foster/Companion Care. Principle
62 is revised to allow for the provision of out-of-home respite services for
up to six individuals at a time in a respite facility which is not the residence
of any individual.
Stephen Zeeck, acting chief financial officer, has determined that for
each year of the first five years the proposed amendments are in effect enforcing
or administering the amendments does not have foreseeable implications relating
to costs or revenues of state and local government.
Barry Waller, director, Long Term Services and Supports, has determined
that for each year of the first five-year period the amendments to §409.103
as proposed are in effect, the public benefit is expected to be a better understanding
by HCS providers of the criteria for increasing an individual's LON when the
individual exhibits dangerous behavior and for assigning a "pervasive plus"
LON. In addition, use by HCS providers of the new assessment form, which already
is being used in the Intermediate Care Facilities for Individuals with Mental
Retardation (ICF/MR) program, will assure consistency across the Medicaid
programs operated by the department. For each year of the first five-year
period that the amendments to §409.109 as proposed are in effect, the
public benefit is expected to be the potential for providers to offer out-of-home
respite services in a respite facility which is not the residence of any individual
receiving HCS program services. There is no economic cost to persons required
to comply with the amendments. It is not anticipated that the proposed amendments
will have an adverse economic effect on small businesses because the amendments
impose no additional requirements on HCS providers and the new MR/RC Assessment
Form is not more difficult or time-consuming to complete than the TDHS Form
3650 currently in use. It is not anticipated that the proposed amendments
will affect a local economy.
A hearing to accept oral and written testimony from members of the public
concerning the proposed amendments is scheduled for 1:30 p.m., Tuesday, March
9, 1999, in the auditorium of the department's Central Office, Building 2,
909 West 45 Street, Austin. Persons requiring an interpreter for the deaf
or hearing impaired should contact the TDMHMR Central Office operator at least
72 hours prior to the hearing at TDD (512) 206-5330. Persons requiring other
accommodations for a disability should notify Sheila Wilkins, Office of Policy
Development, at least 72 hours prior to the hearing at (512) 206-4516 or at
the TDY phone number of Texas Relay, 1/800-735-2988.
Comments concerning this proposal must be submitted in writing to Linda
Logan, Director, Policy Development, Texas Department of Mental Health and
Mental Retardation, by mail to P.O. 12668, Austin, Texas, 78711, or by fax
to 512/206-4750, within 30 days of publication of this notice.
The amendments are proposed under the Texas Health and Safety
Code, §532.015(a), which provides the Texas Board of Mental Health and
Mental Retardation with broad rulemaking authority; the Texas Government Code,
§531.021(a), and the Texas Human Resources Code, §32.021(a), which
provide the Texas Health and Human Services Commission (THHSC) with the authority
to administer the federal medical assistance (Medicaid) program in Texas;
Acts 1995, 74th Texas Legislature, Chapter 6, §1, (Senate Bill 509),
which clarifies the authority of THHSC to delegate the operation of all or
part of a Medicaid program to a health and human services agency; and the
Human Resources Code, §32.021(c), which provides an agency operating
part of the Medicaid program with the authority to adopt necessary rules for
the proper and efficient operation of the program. THHSC has delegated to
the department the authority to operate the HCS program.
Texas Health and Safety Code, §532.015, Texas Government Code, §531.021(a),
and the Texas Human Resources Code, §32.021(a) and (c), are affected
by the proposed amendments.
§409.103.Payment Category Assignment and Provider Claims Payment.
(a)-(b)
(No change.)
(c)
Reimbursement for HCS foster care, residential supports,
and day habilitation is based upon the program participant's payment category
assignment and the reimbursement rate for the specific service component provided.
(1)
The payment category for a program participant is based
upon a level-of-need (LON) assignment completed by TDMHMR or its designee
as part of the level-of-care determination according to §406.203 of this
title (relating to
Eligibility for Level-of-care Determination
[
(A)
An HCS Program applicant or participant is assigned one
of the following five levels of need:
(i)
An intermittent LON (LON 1) is assigned if the
individual's
ICAP service level score equals 7, 8, or 9;
(ii)
A limited LON (LON 5) is assigned if the
individual's
ICAP service level score equals 4, 5, or 6;
(iii)
An extensive LON (LON 8) is assigned if the
individual's
ICAP service level score equals 2 or 3;
(iv)
A pervasive LON (LON 6) is assigned if the
individual's
ICAP service level score equals 1;
(v)
Regardless of an individual's ICAP service level score,
a pervasive plus LON (LON 9) is assigned if the individual meets the criteria
set forth in subparagraph (C) of this paragraph.
[
(B)
LON assignments 1, 5, and 8, made in accordance
with subparagraph (A) of this paragraph may be increased to the next LON if:
(i)
the individual exhibits dangerous behavior that could cause
serious physical injury to the individual or others;
(ii)
a written behavior intervention plan has been implemented
that is based on ongoing written data, targets the dangerous behavior with
individualized objectives, and specifies intervention procedures to be followed
when the dangerous behavior occurs;
(iii)
additional staff are constantly prepared to physically
prevent the dangerous behavior or intervene when the behavior occurs; and
(iv)
the MR/RC Assessment Form is correctly scored with a "1"
in the "Behavior" section.
[(B)
The LON assignment may be modified to
take into account extraordinary service needs that result from unusual behavioral
challenges. The LON for these individuals combines ICAP service level scores
and needs identified on selected items on the TDHS Form 3650. A LON that does
not directly correspond to the ICAP service level score will be subject to
utilization review by TDMHMR or its designee.]
[(i)
Individuals who have very challenging behaviors that require
a behavior intervention program that includes constant preventive actions
by additional provider staff will be assigned the next higher LON from the
original level. Additional staff may assist in the supervision of other individuals.
Individuals originally assigned a pervasive LON will retain that assignment.
Very challenging behaviors have the following characteristics:]
[(I)
The behavior presents a danger to the individual or to
others;]
[(II)
The behavior warrants individualized objectives which
include written intervention procedures;]
[(III)
The frequency of the behavior is reduced only with constant
staffing and a highly structured environment,]
[(IV)
The behavior is difficult or impossible for a single
staff person to control when it occurs;]
[(V)
The behavior precludes some activities and an environment
that cannot be structured. The interventions used to control the behavior
require regular documentation, monitoring, and revisions as needed to meet
the needs of the individual; and]
[(VI)
TDHS Form 3650 indicates an intervention code of 1 on
at least one of Items 70-73.]
(C)
An individual who exhibits
extremely dangerous behavior and whose MR/RC Assessment Form is correctly
scored with a "2" in the "Behavior" section is assigned a pervasive plus LON
(LON 9). Extremely dangerous behavior:
(i)
could be life threatening to the individual
or to others;
(ii)
must be targeted with individualized
objectives in a written behavior intervention plan that is based on ongoing
written data and specifies intervention procedures to be followed when the
behavior occurs; and
(iii)
is managed by provider staff whose duty
is to exclusively and constantly supervise the individual during the individual's
waking hours, which must be at least 16 hours per day.
[(ii)
Individuals who have extremely challenging
behaviors which pose a risk of harm to themselves or others and who require
constant one-to-one staff supervision, 16 hours per day, will be assigned
a pervasive plus LON. Extremely challenging behaviors have the following characteristics:]
[(I)
The behavior may be life-threatening;]
[(II)
The behavior warrants the highest priority of individualized
objectives which include a written record of every occurrence of the behavior;]
[(III)
The frequency of the behavior is difficult to reduce;]
[(IV)
The consequences of the behavior are difficult to minimize;
and]
[(V)
TDHS Form 3650 indicates an intervention code of 2 on
at least one of the Items 70-73.]
(2)
The provider completes the ICAP, enters
the resulting service level score on the
MR/RC Assessment Form
[
(3)
(No Change.)
(4)
TDMHMR
may
perform [
(A)-(B)
(No Change.)
(5)
Providers requesting a change to a higher LON
at times other than the annual reevaluation must submit
an MR/RC Assessment
Form
[
(d)-(g)
(No change.)
§409.109.Corrective Action and Provider Sanction.
The HCS provider must be in continuous compliance with the HCS Consumer
Principles for Evidentiary Certification. Each HCS provider will receive a
certification review at least annually in order to maintain certification
status. The guidelines specified in §§409.110-409.115 of this title
(relating to Hazards to Health, Safety, and Welfare; Level I Action; Level
II Action; Level III Action; Unannounced or Intermittent Review Visits; and
Discretionary Certification Sanctions) are used by TDMHMR to determine the
need for provider sanctions and/or provider onsite follow up review visits
that occur before those required concurrently with the recertification review.
Current certification review corrective action plans required from the provider
and related timelines remain in effect.
Figure 1: 25 TAC §409.109
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
February 1, 1999.
TRD-9900627
Charles Cooper
Chair, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 206-4516
25 TAC §409.167
The Texas Department of Mental Health and Mental Retardation
(department) proposes amendments to §409.167, concerning corrective action
and provider sanction, of Chapter 409, Subchapter E, concerning home and community-based
waiver services-OBRA (HCS-O).
The amendments to §409.167 modify Principles 22 and 102 of the HCS-O
Consumer Principles for Evidentiary Certification (Figure 1: 25 TAC §409.167).
Principle 22 is revised to clarify that a family member of an individual enrolled
in the HCS-O program can be a qualified provider of Foster/Companion Care.
Principle 102 is revised to allow for the provision of out-of-home respite
services for up to six individuals at a time in a respite facility which is
not the residence of any individual.
Stephen Zeeck, acting chief financial officer, has determined that for
each year of the first five years the proposed amendments are in effect enforcing
or adminstering the amendments does not have forseeable implications relating
to costs or revenues of state and local government.
Barry Waller, director, Long Term Services and Supports, has determined
that for each year of the first five-year period the amendments to §409.167
as proposed are in effect, the public benefit is expected to be the potential
for providers to offer out-of-home respite services in a respite facility
which is not the residence of any individual receiving HCS-O program services.
There is no economic cost to persons required to comply with the amendments.
It is not anticipated that the proposed amendments will have an adverse economic
effect on small businesses because the amendments impose no additional requirements
on HCS-O. It is not anticipated that the proposed amendments will affect a
local economy.
A hearing to accept oral and written testimony from members of the public
concerning the proposed amendments is scheduled for 1:30 p.m., Tuesday, March
9, 1999, in the auditorium of the department's Central Office, Building 2,
909 West 45 Street, Austin. Persons requiring an interpreter for the deaf
or hearing impaired or other accommodations for a disability should notify
Sheila Wilkins, Office of Policy Development, at least 72 hours prior to the
hearing at (512) 206-4516 or at the TTY phone number of Texas Relay, 1 (800)
735-2988.
Comments concerning this proposal must be submitted in writing to Linda
Logan, Director, Policy Development, Texas Department of Mental Health and
Mental Retardation, by mail to P.O. 12668, Austin, Texas, 78711, or by fax
to 512/206-4750, within 30 days of publication of this notice.
The amendments are proposed under the Texas Health and Safety
Code, §532.015(a), which provides the Texas Board of Mental Health and
Mental Retardation with broad rulemaking authority; the Texas Government Code,
§531.021(a), and the Texas Human Resources Code, §32.021(a), which
provide the Texas Health and Human Services Commission (THHSC) with the authority
to administer the federal medical assistance (Medicaid) program in Texas;
Acts 1995, 74th Texas Legislature, Chapter 6, §1, (Senate Bill 509),
which clarifies the authority of THHSC to delegate the operation of all or
part of a Medicaid program to a health and human services agency; and the
Human Resources Code, §32.021(c), which provides an agency operating
part of the Medicaid program with the authority to adopt necessary rules for
the proper and efficient operation of the program. THHSC has delegated to
the department the authority to operate the HCS-O program.
Texas Health and Safety Code, §532.015, Texas Government Code, §531.021(a),
and the Texas Human Resources Code, §32.021(a) and (c), are affected
by the proposed amendments.
§409.167.Corrective Action and Provider Sanction.
The HCS-O provider must be in continuous compliance with the HCS-O
Consumer Principles for Evidentiary Certification as described in this section.
Each HCS-O provider will receive a certification review at least annually
in order to maintain certification status. The guidelines specified in §§409.168-409.173
of this title (relating to Hazards to Health, Safety and Welfare; Level I
Action; Level II Action; Level III Action; Unannounced or Intermittent Review
Visits; and Discretionary Certification Sanctions) are used by TDMHMR to determine
the need for provider sanctions and/or provider on-site follow-up review visits
that occur before those required concurrently with the recertification review.
Current certification review corrective action plans required from the provider
and related timelines that are referenced in the HCS-O Program Provider Manual
remain in effect, if applicable.
Figure 1: 25 TAC §409.167
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
February 1, 1999.
TRD-9900626
Charles Cooper
Chair, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 206-4516
25 TAC §409.531
The Texas Department of Mental Health and Mental Retardation
(department) proposes amendments to §409.531, concerning certification
status, of Chapter 409, Subchapter L, concerning mental retardation local
authority (MRLA) program.
The amendments to §409.531 modify Principle P14 and add new Principle
P16 of MRLA Program Principles for Program Providers (Figure 1: 25 TAC §409.531).
Principle P14 is revised to clarify that a family member of an individual
enrolled in the MRLA program can be a qualified provider of Foster/Companion
Care. Principle P16 allows for the provision of out-of-home respite services
for up to six individuals at a time in a respite facility which is not the
residence of any individual.
Stephen Zeeck, acting chief financial officer, has determined that for
each year of the first five years the proposed amendments are in effect enforcing
or adminstering the amendments does not have forseeable implications relating
to costs or revenues of state and local government.
Barry Waller, director, Long Term Services and Supports, has determined
that for each year of the first five-year period the amendments to §409.531
as proposed are in effect, the public benefit is expected to be the potential
for providers to offer out-of-home respite services in a respite facility
which is not the residence of any individual receiving MRLA program services.
There is no economic cost to persons required to comply with the amendments.
It is not anticipated that the proposed amendments will have an adverse economic
effect on small businesses because the amendments impose no additional requirements
on MRLA. It is not anticipated that the proposed amendments will affect a
local economy.
A hearing to accept oral and written testimony from members of the public
concerning the proposed amendments is scheduled for 1:30 p.m., Tuesday, March
9, 1999, in the auditorium of the department's Central Office, Building 2,
909 West 45 Street, Austin. Persons requiring an interpreter for the deaf
or hearing impaired or other accommodations for a disability should notify
Sheila Wilkins, Office of Policy Development, at least 72 hours prior to the
hearing at (512) 206-4516 or at the TTY phone number of Texas Relay, 1 (800)
735-2988.
Comments concerning this proposal must be submitted in writing to Linda
Logan, director, Policy Development, Texas Department of Mental Health and
Mental Retardation, by mail to P.O. 12668, Austin, Texas, 78711, or by fax
to 512/206-4750, within 30 days of publication of this notice.
The amendments are proposed under the Texas Health and Safety
Code, §532.015(a), which provides the Texas Board of Mental Health and
Mental Retardation with broad rulemaking authority; the Texas Government Code,
§531.021(a), and the Texas Human Resources Code, §32.021(a), which
provide the Texas Health and Human Services Commission (THHSC) with the authority
to administer the federal medical assistance (Medicaid) program in Texas;
Acts 1995, 74th Texas Legislature, Chapter 6, §1, (Senate Bill 509),
which clarifies the authority of THHSC to delegate the operation of all or
part of a Medicaid program to a health and human services agency; and the
Human Resources Code, §32.021(c), which provides an agency operating
part of the Medicaid program with the authority to adopt necessary rules for
the proper and efficient operation of the program. THHSC has delegated to
the department the authority to operate the MRLA program.
Texas Health and Safety Code, §532.015, Texas Government Code, §531.021(a),
and the Texas Human Resources Code, §32.021(a) and (c), are affected
by the proposed amendments.
§409.531.Certification Status.
(a)
MRLA program providers contracting with TDMHMR for participation
in the MRLA Program must be in continuous compliance with the MRLA Program
Principles for Program Providers as described in Mental Retardation Local
Authority Program Principles for Program Providers. Each MRLA program provider
participating in the MRLA Program will receive a certification review conducted
by TDMHMR or its designee at least annually in order to maintain certification
status.
Figure 1: 25 TAC §409.531(a)
(1)-(2)
(No change.)
(b)
(No change.)
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
February 1, 1999.
TRD-9900625
Charles Cooper
Chair, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 206-4516
Subchapter O. Enrollment of Medicaid Waiver Program Providers
25 TAC §§419.701-419.710
The Texas Department of Mental Health and Mental Retardation
(TDMHMR) proposes new §§419.701-419.710 of Chapter 419, Subchapter
O, governing Enrollment of Medicaid Waiver Program Providers, which concerns
enrollment of providers in a Medicaid waiver program.
The new sections establish the process and conditions under which TDMHMR
enrolls providers of home and community-based services waiver programs including
Home and Community-based Services (HCS), Home and Community-based - OBRA Services
(HCS-O), and Mental Retardation Local Authority (MRLA) Programs, operated
by TDMHMR as authorized by the Health Care Financing Administration in accordance
with §1915(c) of the Social Security Act.
Stephen Zeeck, acting chief financial officer of the department, has determined
that for each of the first five years the proposed sections are in effect
enforcing or administering the sections does not have foreseeable implications
relating to costs or revenues for state or local government.
Ernest McKenney, director, Medicaid Administration, has determined that
for each year of the first five years the sections are in effect, the public
benefit expected as a result of adopting the proposed sections is consistency
in minimum qualifications and preparation of providers at the time of enrollment
in waiver programs. The probable economic cost to persons required to comply
with these sections is the expense necessary for one or two applicant representatives
to attend a one to two-day pre-application orientation held in Austin, Texas.
It is not anticipated that these sections will have an adverse economic effect
on small businesses because the travel expenses are minimal. It is not anticipated
that the rule will affect a local economy.
A public hearing will be held at 1:30 p.m. on February 19, 1999, in the
auditorium of the main TDMHMR Central Office building (Building 2), 909 West
45th Street, Austin, Texas, to accept oral and written testimony concerning
the proposal. Persons needing an accommodation to attend the hearing and persons
with special needs requiring assistance should contact Sheila Wilkins, Office
of Policy Development, at least 72 hours prior to the hearing by calling (512)
206-4516. Persons with hearing impairments may also call
TTY-Message - Texas Relay
toll-free at (800) 735-2988.
Comments on the proposal may be submitted to Linda Logan, director, Policy
Development, Texas Department Mental Health and Mental Retardation, P.O. Box
12668, Austin, TX 78711-2668, within 30 days of publication of this notice.
The new sections are proposed under the Texas Health and Safety
Code, §532.015(a), which provides TDMHMR with broad rulemaking authority;
the Texas Government Code, §531.021(a), and the Texas Human Resources
Code §32.021(a), which provide the Texas Health and Human Services Commission
(THHSC) with the authority to administer the federal medical assistance (Medicaid)
program in Texas; Acts 1995, 74th Texas Legislature, Chapter 6, §1, (Senate
Bill 509), which clarifies the authority of THHSC to delegate the operation
of all or part of a Medicaid program to a health and human services agency;
and the Human Resources Code, §32.021(c), which provides an agency operating
part of the Medicaid program with the authority to adopt necessary rules for
the proper and efficient operation of the program. THHSC has designated TDMHMR
as the operating agency for selected Medicaid programs.
The sections affect the Health and Safety Code, §532.015, Human Resources
Code, §32.021, and Government Code, §531.021.
§419.701.Purpose.
The purpose of this subchapter is to establish the process and conditions
under which the Texas Department of Mental Health and Mental Retardation (TDMHMR)
enrolls providers of home and community-based services waiver programs operated
by TDMHMR including the Home and Community-based Services (HCS), Home and
Community-based Services - OBRA (HCS-O), and the Mental Retardation Local
Authority (MRLA) Programs as authorized by the Health Care Financing Administration
in accordance with §1915(c) of the Social Security Act.
§419.702.Application.
This subchapter applies to any person seeking to participate as a waiver
program provider.
§419.703.Definitions.
The following words and terms, when used in this subchapter, have the
following meanings, unless the context clearly indicates otherwise:
(1)
Affiliate - An employee or independent contractor of an
applicant or a person with a significant financial interest in an applicant
including, but not limited, to the following:
(A)
if the applicant is a corporation, then each officer, director,
stockholder with an ownership of at least 5%, subsidiary, and parent company;
(B)
if the applicant is a limited liability company, then each
officer, member, subsidiary, and parent company;
(C)
if the applicant is an individual, then the individual's
spouse, each partnership and each partner thereof of which the individual
is a partner and each corporation in which the individual is an officer, director,
or stockholder with an ownership of at least 5%;
(D)
if the applicant is a partnership, then each partner and
parent company; or
(E)
if the applicant is a group of co-owners under any other
business arrangement, then each owner, officer, director, or the equivalent
thereof under the specific business arrangement, and each parent company.
(2)
Applicant - A person seeking to participate as
a program provider in the Home and Community-based Services, Home and Community-based
Services - OBRA, or Mental Retardation Local Authority Programs.
(3)
Assignment of a waiver program provider agreement
- The transfer of rights, interests, and obligations of the waiver program
provider agreement from the program provider to another person.
(4)
Debarred - Termination of rights to continue an existing
Medicaid provider agreement, to receive a new Medicaid provider agreement,
to participate as a provider or manager of a provider agency, or to make a
bid, offer, application or proposal for a TDMHMR Medicaid provider agreement
or contract in accordance with §406.63(b)(2) of this title (relating
to Debarment and Suspension of Current and Potential Contractor's Rights)
of Chapter 406, Subchapter B of this title (relating to ICF/MR Programs Contracting
Requirements).
(5)
Excluded - The temporary or permanent exclusion by
a state or federal authority of a person from participating as a provider
in a federal health care program as defined in Section 1128(f) of the Social
Security Act. Exclusion includes refusal to reimburse the person for items
and services furnished by that person and refusal to enter into or renew a
provider agreement or the termination of the provider agreement with the person.
(6)
HCSSA license - A Home and Community Support Services
Agencies license issued by the Texas Department of Health in accordance with
Chapter 115 of this title (relating to Home and Community Support Services
Agencies).
(7)
LAR (legally authorized representative) - The parent
or guardian of an individual who is a minor or the guardian of an individual
who is an adult.
(8)
Person - A corporation, organization, government or
governmental subdivision or agency, business trust, estate, trust, partnership,
association, individual, or any other legal entity.
(9)
Program provider - A person who delivers waiver program
services under a waiver program provider agreement with TDMHMR.
(10)
Self-assessment - The document an applicant completes
to describe the procedures that are used and the evidence that is presented
to demonstrate the applicant's compliance with the program provider principles.
(11)
Title XVIII - Title XVIII (Medicare) of the Social
Security Act.
(12)
Title XIX - Title XIX (Medicaid) of the Social Security
Act.
(13)
Title XX - Social Services Block Grant of the Social
Security Act.
(14)
Waiver program - A home and community-based program
serving people with mental retardation and/or related conditions which is
operated by TDMHMR, including the HCS, HCS-O, and MRLA programs, as authorized
by the Health Care Financing Administration in accordance with Section 1915(c)
of the Social Security Act.
(15)
Waiver program provider agreement - A written agreement
between TDMHMR and a program provider that describes the conditions for participating
as a program provider, a program provider's obligations in providing waiver
program services, and the obligations of TDMHMR.
§419.704.Pre-application Orientation.
An applicant must attend the waiver program provider pre-application
orientation (PAO) prior to receiving a program provider application packet
for enrollment as a program provider.
(1)
TDMHMR conducts a PAO at least twice a year. The date of
the PAO and registration process are published in the Texas Register at least
90 calendar days prior to the PAO.
(2)
Upon an applicant's written request, TDMHMR provides
the applicant with information regarding the provider application and enrollment
processes and a registration form for the PAO.
(3)
To attend the PAO, an applicant must submit a completed
registration form to TDMHMR no later than 30 calendar days prior to the PAO.
The registration is valid only for the PAO announced most recently in the
Texas Register. All portions of the registration form must be completed including,
but not limited to:
(A)
the name of the waiver program(s) in which the applicant
seeks to participate;
(B)
a list of the counties in which the applicant proposes
to operate as a program provider;
(C)
the legal name of the applicant and the name of the individual
authorized to sign a provider agreement with TDMHMR; and
(D)
the name, title/function, address, and telephone number
of not more than two representatives of the applicant who attend the PAO.
Each registered applicant representative must be an individual who is responsible
for the direct management of the program.
(4)
Admittance to the PAO is limited to the two applicant
representatives named on the applicant's registration.
(5)
A person may attend the PAO on behalf of only one
applicant.
§419.705.Application Process.
(a)
Upon request, TDMHMR provides a program provider application
packet to an applicant representative on the day the applicant representative
completes the PAO.
(b)
The completed program provider application packet must
be received by TDMHMR no later than 45 calendar days following the PAO. If
the last day of this 45-day time period is a Saturday, Sunday, or day on which
TDMHMR Central Office is closed, then the period extends through the end of
the next day which is not a Saturday, Sunday, or day on which TDMHMR Central
Office is closed. Application packets must be delivered in accordance with
the application instructions.
(1)
An applicant must complete all portions of the application
according to the application instructions including, but not limited to:
(A)
the applicant's operational or organizational plan to ensure
sufficient staff resources are available to provide each required waiver service
component; and
(B)
the resume or curriculum vita of the applicant's employee
or contractor who manages and oversees the direct provision of all services
to people who are enrolled in the program that:
(i)
demonstrates the employee or contractor has a minimum of
three years' verifiable work experience in planning and providing direct services
to people with mental retardation or other developmental disabilities; and
(ii)
contains three verifiable professional references;
(C)
documents necessary to complete and execute a waiver program
provider agreement;
(D)
self-assessment; and
(E)
documentation that a representative of the applicant attended
the last scheduled PAO.
(2)
TDMHMR may reject a program provider application
packet that:
(A)
is incomplete in any aspect;
(B)
contains a self-assessment that demonstrates less than
90% compliance with the program provider principles;
(C)
is received by TDMHMR after the date specified in subsection
(b) of this section or is not delivered according to the application instructions;
(D)
is submitted by an applicant whose representative did not
complete the most recent PAO;
(E)
contains false information; or
(F)
does not contain original signatures and dates.
(3)
TDMHMR may reject an application packet for good
cause which includes, but is not limited to:
(A)
TDMHMR has previously terminated a Medicaid provider agreement
or other contract with the applicant or its affiliate within the last three
years prior to the application;
(B)
the applicant or its affiliate has been excluded or debarred;
(C)
another state or federal agency has terminated a contract,
licensure, or certification of the applicant or its affiliate within the last
three years prior to the application date;
(D)
the applicant or its affiliate has an outstanding Medicaid
program audit exception or other unresolved financial liability owed to the
State of Texas;
(E)
the applicant or its affiliate is ineligible to enroll
as a Medicaid provider for reasons relating to criminal history records as
set forth in TDMHMR rules; or
(F)
the applicant or its affiliate has terminated a provider
agreement in a federal health care program as defined in §1128(f) of
the Social Security Act while an adverse action or sanction was in effect.
(4)
After the application due date, TDMHMR reviews
all application packets and provides written notification to each applicant
advising whether its application is approved or rejected. If an application
is approved, the applicant is also informed of the date and time of the next
orientation for waiver program providers.
§419.706.Provisional Certification.
(a)
An applicant whose application packet is approved by TDMHMR
must attend the orientation for waiver program providers conducted by TDMHMR
prior to being provisionally certified.
(b)
Admittance to the orientation for waiver program providers
is limited to three representatives for each applicant.
(1)
At least one representative must be the individual who
is directly responsible for the administration of the program.
(2)
At least one representative must be the applicant's
employee or contractor who manages and oversees the provision of direct services
to consumers who are enrolled in the program and who has provided TDMHMR with
a resume or curriculum vita meeting the requirements described in §419.705(b)(1)(B)
of this title (relating to Application Process).
(3)
A representative may attend on behalf of only one
applicant.
(c)
TDMHMR provisionally certifies only those applicants that:
(1)
demonstrate 100% compliance with the program provider principles
on the self-assessment by the end of the orientation for waiver program providers
and complete the entire orientation for waiver program providers; and
(2)
comply with all requirements of §419.704 of this
title (relating to Pre-application Orientation), §419.705 of this title,
and this section.
(d)
TDMHMR revokes the provisional certification of a provider
that does not submit a copy of its HCSSA license in accordance with §419.707(a)
of this title (relating to Provider Agreement).
(e)
An applicant that is not provisionally certified in accordance
with subsection (c) of this section or a program provider whose provisional
certification has been revoked must re-apply to enroll as a program provider
in accordance with this subchapter.
§419.707.Provider Agreement.
(a)
TDMHMR enters into a provider agreement only with a provisionally
certified provider who has submitted a copy of its current HCSSA license to
TDMHMR no later than 270 calendar days following the provisional certification
date. The license must be valid for a minimum of licensed home health services
and personal assistance services. If the last day of the 270-day time period
is a Saturday, Sunday, or day on which TDMHMR Central Office is closed, then
the period extends through the end of the next day which is not a Saturday,
Sunday, or day on which TDMHMR Central Office is closed.
(b)
TDMHMR approves a consumer's enrollment in a program of
a provisionally certified provider only after the effective date of the waiver
program provider agreement as determined by TDMHMR.
§419.708.Provider Certification.
(a)
No later than 120 days following TDMHMR's approval of the
enrollment of the first consumer in a provisionally certified provider's program,
TDMHMR or its designee conducts a certification review in accordance with
Chapter 409, Subchapter D of this title (relating to Home and Community-based
Services), Chapter 409, Subchapter E of this title (relating to Home and Community-based
Services - OBRA), or Chapter 409, Subchapter L of this title (relating to
Mental Retardation Local Authority Program), as applicable.
(b)
TDMHMR may terminate the waiver program provider agreement
of a provisionally certified provider that is not certified within 540 calendar
days following the effective date of the waiver program provider agreement.
(c)
TDMHMR may terminate the waiver program provider agreement
of a provisionally certified provider that was provisionally certified prior
to the effective date of this subchapter but is not certified within 365 calendar
days following the effective date of this subchapter.
(d)
A program provider whose waiver program provider agreement
has been terminated in accordance with subsection (b) or (c) of this section
must re-apply to enroll as a program provider in accordance with this subchapter.
§419.709.Deemed Provider Certification.
(a)
Upon request of an HCS-O provider certified in accordance
with Chapter 409, Subchapter E of this title (relating to Home and Community-based
Waiver Services - OBRA), TDMHMR may, at its discretion, deem the program provider
provisionally certified as an HCS provider.
(b)
Upon request of an HCS provider certified in accordance
with Chapter 409, Subchapter D of this title (relating to Home and Community-based
Services), TDMHMR may, at its discretion, deem the program provider provisionally
certified as an HCS-O provider.
§419.710.Waiver Program Provider Agreement Assignment.
(a)
No assignment of a waiver program provider agreement is
effective until it is approved in writing by TDMHMR. The effective date of
the assignment may not precede the date of TDMHMR's approval of the assignment.
(b)
A program provider must notify TDMHMR Medicaid Administration
in writing at least 60 days prior to the proposed assignment of its waiver
program provider agreement. This notification must include the legal name
of the proposed assignee, proposed date of the assignment, and the provider
vendor number. If the program provider fails to provide this notification
in a timely manner, approval of the assignment may be delayed.
(c)
Upon approval of the assignment, the program provider (hereafter
referred to as the assignor) and the assignee, as indicated, are subject to
the following provisions.
(1)
The assignee must keep, perform and fulfill all of the
terms, conditions and obligations that must be performed by the assignor under
the provider agreement and this subchapter.
(2)
The assignee is subject to all pending conditions
which exist against the assignor, including but not limited to, any plan of
correction, audit exception, vendor hold, or proposed contract termination.
(3)
The assignor and the assignee are jointly and severally
liable to TDMHMR for any liabilities or obligations that arise from any act,
event, or condition which occurred or existed prior to the effective date
of the assignment and which is identified in any survey, review, or audit
conducted by TDMHMR.
(4)
The assignor must complete and submit billing claims
to TDMHMR for services provided prior to the approval date of the assignment
in accordance with state rules.
(5)
The assignee must complete the enrollment/transfer
process within 95 days of the effective date of the assignment if any consumer
requests to transfer into or from the assignor's program or any initial enrollments
into the assignor's program are pending as of the effective date of the assignment;
(6)
The assignor must give written notification to each
consumer or the consumer's LAR in the assignor's program of the proposed assignment,
the proposed effective date of the assignment and of the consumer's option
to transfer to another program provider.
(7)
The assignee must retain written documentation signed
by each consumer or the consumer's LAR verifying that the notification was
received and indicates the consumer's or LAR's choice whether to receive services
from the assignee after the assignment is effective or to transfer to another
program provider.
(d)
TDMHMR does not approve an assignment unless:
(1)
the proposed assignee holds a current waiver program provider
agreement with TDMHMR or is eligible to enter into a provider agreement with
TDMHMR as specified in §419.707(a) of this title (relating to Provider
Agreement);
(2)
consumers are enrolled and receiving services or individuals
are pending enrollment (as indicated by the TDMHMR Automated Enrollment and
Billing System) in the assignor's program; and
(3)
the assignor and the proposed assignee submit an assignment
agreement to TDMHMR that includes:
(A)
a statement that the assignor and assignee agree to the
provisions set forth in subsection (c) of this section;
(B)
the effective date of the assignment, the name and address
of the assignor and assignee and the provider vendor number to be assigned;
(C)
a statement that the assignment is subject to and contingent
upon TDMHMR's written approval of the assignment or the assignment is void;
(D)
the signatures of the authorized representatives of the
assignor and the assignee acknowledged before a notary public;
(E)
a blank space for TDMHMR's representative to sign indicating
approval of the assignment agreement; and
(F)
any other provision required by law to make the assignment
agreement legally enforceable.
(e)
TDMHMR may disapprove an assignment for good cause including,
but not limited to:
(1)
a vendor hold on Medicaid payments is currently in effect
for a program operated by the proposed assignee; or
(2)
a proposed contract/provider agreement termination
is in effect for a program operated by the proposed assignee.
(f)
If TDMHMR approves an assignment, TDMHMR may place a vendor
hold on Medicaid payments to the assignor until all findings made from a survey,
billing and payment review or audit which has been or is being conducted by
TDMHMR are resolved.
(1)
At its discretion, TDMHMR may allow an assignor to obtain
a surety bond or an irrevocable letter of credit in order to release the vendor
hold prior to completing a survey, billing and payment review, or audit.
(2)
The surety bond or irrevocable letter of credit must
be for a period of three years. The three-year period begins with the effective
date of the assignment. TDMHMR specifies the amount of the surety bond or
letter of credit.
(3)
The surety bond or irrevocable letter of credit must
be in a format acceptable to TDMHMR and must not include requirements for
TDMHMR to:
(A)
return the original bond or irrevocable letter of credit
prior to receipt of payment; or
(B)
submit a sight draft or any other draft or demand requirement
other than TDMHMR's letter demanding payment.
(4)
If the assignor submits an acceptable surety
bond or irrevocable letter of credit to TDMHMR, TDMHMR releases the vendor
hold.
(g)
TDMHMR may recoup Medicaid payments from the assignor or
assignee for liabilities or obligations arising from any act, event, or condition
which occurred or existed prior to the effective date of the assignment and
which is identified in a survey, review, or audit conducted by TDMHMR.
(h)
If TDMHMR approves an assignment, TDMHMR or its designee
conducts an on-site certification review within 120 days of the effective
date of the assignment in accordance with Chapter 409, Subchapter D of this
title (relating to Home and Community-based Services), Chapter 409, Subchapter
E of this title (relating to Home and Community-based Waiver Services - OBRA),
or Chapter 409, Subchapter L of this title (relating to Mental Retardation
Local Authority Program), as applicable.
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 January
26, 1999.
TRD-9900538
Charles Cooper
Chair, Texas MHMR Board
Texas Department of Mental Health and Mental Retardation
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 206-4516
Chapter 1301.
Health Care Information
Subchapter B. Collection and Reporting of Health Plan Employer Data and Information Set (HEDIS) from Health Maintenance Organizations (HMO)
25 TAC §§1301.32-1301.34
The Texas Health Care Information Council (the Council) proposes
amendments to §§1301.32-1301.34, concerning the collection and reporting
of Health Plan Employer Data and Information Set (HEDIS) from health maintenance
organizations (HMOs). The amendments are proposed to provide Texas citizens
and consumers relevant regional information upon which to make decisions regarding
HMOs; to incorporate HMO reporting division definitions as reported to the
Texas Department of Insurance (TDI) under 28 TAC §11.304; and to comply
with Texas Health and Safety Code, Title 2, Subtitle E Chapter 108.006 (a)(4)
relating to building on and not duplicating other state data. The proposed
amendment to §1301.32 includes the new terms "Service Area Division"
and "HEDIS Guidelines" and adds new language to the terms "HEDIS", "Reporting
set measures", "Service Area" and "Testing set measures" to clarify the HEDIS
Reporting Manual to be used in this chapter. Section 1301.32 also has numbers
assigned to the definitions as required by 1 TAC §91.23. The proposed
amendments to §1301.33 remove language requiring this rule to be amended
annually. Language is added to §1301.33 (b) that requires HMOs to report
HEDIS data from the same division that is currently required by the Texas
Department of Insurance. The proposed amendment to §1301.33(c) changes
the deadline for data to be received by the Council. The proposed amendments
§1301.33(e) and §1301.34 clarify and provide consistency of language
in this subchapter. These amendments apply beginning with the 1998 data to
be reported in 1999.
Jim Loyd, Executive Director, Texas Health Care Information Council, has
determined that for the first five-year period the amended rules are in effect
there will be no additional cost to local governments. There are no fiscal
implications relating to costs or revenues of the local governments as a result
of the amendments to 25 TAC §§1301.32 - 1301.33, because the local
governments (Bexar County Hospital District, Harris County Hospital District
and Dallas County Hospital District) affected by these amendments maintain,
at a minimum, partial ownership of an HMO corporation and do not have multiple
service area divisions.
Mr. Loyd estimates that for the first year of the first five-year period
no more than $600 will be required by the state as a result of enforcing or
administering the amendments. The cost is attributable to receiving and processing
an estimated six additional HEDIS data sets at a cost of $100 each per the
Council's contract with NCQA. For each of the following years Mr. Loyd estimates
the costs to the state will be approximately $1000. This value is based on
the $100 per HEDIS data set submitted times the average increase of licensed
HMOs in Texas (10) for the last four years. This average increase is high
due the 26 new HMOs licensed in 1996.
Mr. Loyd also has determined that for each year of the first five-year
period the rules are in effect the public benefit will be a more accurate
reflection of HMO operations which may be relied upon by Texas consumers in
making informed choices regarding HMO selection.
For the first five years there will be an estimated economic cost of $90,000
annually per data set for the affected HMOs to comply with the proposed amendments.
This estimate was calculated from averages of costs reported by seven HMOs
on a Survey of Texas HMOs, Costs of HEDIS Data Collection, Verification and
Submission to the THCIC (1998), conducted by the Texas Association of Health
Plans. The estimate includes $40,000 for data audits, $21,000 for contracting
out for the Consumer Assessment of Health Plans Study (CAHPS) and $29,000
for chart review.
A public hearing on the proposed rules has been scheduled for Wednesday,
February 24, 1999, at 9:00 a.m. at 4900 North Lamar, Room 1430, Austin, Texas.
Comments on the proposed amendments may be submitted to Jim Loyd, Executive
Director, Texas Health Care Information Council, Brown-Heatly Building, 4900
North Lamar OOL-3407, Austin, Texas 78751-2399 no later than 30 days from
the date that these proposed rules are published in the
Texas Register
.
The amendments are proposed under the Health and Safety Code,
§108.006, and §108.009. The Council interprets §108.006 as
authorizing it to adopt rules necessary to carry out Chapter 108, including
rules concerning data collection requirements and rules prescribing a process
for providers to submit data. The Council interprets §108.009 as authorizing
it to collect data using methods of the health benefit plans industry.
The Texas Health and Safety Code, Chapter 108, §108.006, §108.009,
1 TAC §91.23 and 28 TAC §11.304 are affected by these proposed amendments.
§1301.32. Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the context clearly indicates otherwise.
(1)
Council--The Texas Health Care Information
Council.
(2)
Executive director--The chief administrative
officer of the Council, or, in the event the Council is without an executive
director, the person designated by the chairperson of the Council to perform
the functions and exercise the authority of the executive director.
(3)
HEDIS--An acronym for the Health Plan
Employer Data and Information Set, [
(4)
HEDIS data--The information the health
maintenance organization collects and reports to the Council in accordance
with the provisions of this chapter.
Data are collected from January
1st through December 31st annually.
(5)
HEDIS Guidelines - The
version of the HEDIS reporting guidelines as specified by the Council.
(6)
HMO--A health maintenance organization
as defined in Texas Health Maintenance Organization Act, Texas Insurance Code,
Article 20A.02(j), Texas Civil Statutes.
(7)
NCQA--The National Committee for Quality
Assurance
, 2000 L Street, N.W., Suite 500, Washington, D.C. 20036
.
(8)
Reporting set measures--Those measures
specified as "Reporting Set Measures" in the HEDIS
Guidelines
[
(9)
Service area-
as defined in 28 TAC,
Part 1, Chapter 11 Subchapter A §11.2(b)
[
(10)
Service area division - An operation
of a HMO corporation that meets one of the following conditions:
(A)
a distinct and separate operation
of a HMO corporation as opposed to other operations of the corporation serving
other distinct and separate geographical service areas;
(B)
a separate geographical area
whereby the geographical location of an enrollee or a group contract holder
is used in determining charges or rates; or
(C)
a service area that crosses
state lines or international boundaries is considered to have a separate divisional
operation in each state or country and requires separate cost centers and
reports.
(11)
Single Service HMO--An HMO offering
a single health care service as defined in Texas Health Maintenance Organization
Act, Texas Insurance Code, Article 20A.02(r), Texas Civil Statutes.
(12)
Testing set measures--Those measures
specified as "Testing Set Measures" in the HEDIS
Guidelines
[
§1301.33. Collection and Reporting of Health Plan Employer Data and Information Set (HEDIS) Data by Health Maintenance Organizations (HMOs).
(a)
Any health maintenance organization (HMO) operating in
the State of Texas on December 1, 1996, and on that date each year thereafter,
shall have a system in place to collect the full HEDIS data set, and shall
be required to report HEDIS data, collected during the next calendar year.
[
(b)
HMOs shall report HEDIS data,
by Service area division
[
(c)
The
HMO shall report HEDIS data to the Council by
the reporting deadline as specified
[
(d)
(No change.)
(e)
Any HMO which judges that it cannot meet required performance
measure specifications due to either low enrollment (such that sample size
requirements are not met) or short time of existence (such that length of
time requirements are not met) shall provide the Council with a narrative
that documents the reason for not reporting the data for that performance
measure. Single service HMOs shall notify the Council to address which measures
are applicable to the services they provide. All requests for exemptions from
reporting data for any performance area(s) required by this chapter shall
be submitted by the HMO on an annual basis, prior to November 15th of the
year
for
[
(1)-(4)
(No change.)
§1301.34. Verification of Data.
(a)
The entire subset of HEDIS data specified by the Council
on November 15th of the year
for
[
(b)
(No change.)
(c)
Verification of HEDIS data shall be by an independent auditor
using guidelines as developed by the National Committee for Quality Assurance
(NCQA) in effect on November 15th of the year
for
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State on February
1, 1999.
TRD-9900676
Jim Loyd
Executive Director
Texas Health Care Information Council
Earliest possible date of adoption: March 14, 1999
For further information, please call: (512) 424-6490
shall
] have the following meanings[
,
] unless the context clearly indicates otherwise:
,
]
,
] or
the
] TDMHMR or its designated agent
for review and approval. The application must include documentation to verify
the applicant's ability to ensure the delivery of quality care and services.
individual
] who will
be responsible for the direct management of the facility; or
(1)
catchment
] area the proposed facility is located has been
notified of the development of the proposed facility and the proposed facility's
admission criteria.
service
] capacity set forth in
the current "The Long Term Care
Plan for People with Mental Retardation and Related Conditions" required by
Texas Health and Safety Code, §533.062
[
The Plan on Long-Term
Care for People with Mental Retardation or Related Conditions
]. Applications
that have not received approval from TDMHMR or its designated agent within
a 90-calendar-day period from the date submitted will be withdrawn from the
review process and returned to the applicant.
Subchapter C. Vendor Payments
or within
30 calendar days of notification of the Medicaid eligibility determination,
whichever is later
].
Chapter 409.
Medicaid Programs
Eligibility and Review
]). LON assignments are derived from the
service level score obtained from the administration of the Inventory for
Client and Agency Planning (ICAP) to the program applicant/participant and
from selected items on the
MR/RC Assessment Form
[
Level of
Care Assessment Form (TDHS Form 3650)
].
A "pervasive plus"
LON (LON 9) is assigned when the TDHS Form 3650 documents an intervention
code of 2 on at least one of Items 70-73.
]
TDHS Form 3650
], and completes the remainder of
the form
[
Form 3650
]. Information entered on the
MR/RC Assessment
Form
[
Form 3650
] must represent the applicant's/participant's
current status.
A
completed
MR/RC Assessment Form
[
Form 3650
] is submitted to TDMHMR for initial program enrollment or
[
to TDMHMR
] for annual eligibility reevaluation.
performs
]
annual reevaluations of LON assignments in conjunction with annual reevaluations
of ICF-MR LOC.
TDHS Form 3650
] with supporting documentation describing
the changes in the individual's needs to TDMHMR in accordance with §409.120
(relating to Utilization Review). A provider in disagreement with TDMHMR's
denial to increase an individual's LON assignment may request reconsideration
by TDMHMR or its designee. The provider must submit a written request for
reconsideration of the denial in accordance with §409.120 of this title
(relating to Utilization Review) to TDMHMR within 10 calendar days of notification
of the denial.
Subchapter E. Home and Community-based Waiver Services-OBRA (HCS-O)
Subchapter L. Mental Retardation Local Authority (MRLA) Program
Chapter 419.
Medicaid State Operating Agency Responsibilities
Part XVI.
Texas Health Care Information Council
Version 3.0,
] published by
the National Committee for Quality Assurance. HEDIS is a set of standardized
performance measures, designed to allow for the reliable comparison of the
performance of managed care health plans. HEDIS covers a broad range of areas:
effectiveness of care, accessibility/availability of care, satisfaction with
the experience of care, cost of care, stability of the health plan, informed
health care choices, use of services, and plan descriptive information. HEDIS
is a registered trademark of NCQA. [
A copy is on file and available for
review during normal working hours at the Texas Health Care Information Council,
4900 North Lamar, OOL-3407, Austin, Texas 78751. Copies may be purchased from
the National Committee for Quality Assurance, 2000 L Street, N.W., Suite 500,
Washington, D.C. 20036.
]
3.0 Manual and specified as such during the year in which the HEDIS data is
collected
].
The area in which
the HMO is licensed to serve its population
].
3.0 Manual and specified as such during the year in which the HEDIS data is
collected
].
The Council shall update this rule as necessary by November 15th of
each year, to reflect changes in legislation, the current version of HEDIS,
and other appropriate mandates.
] Single service HMOs which contract
as secondary providers with other HMOs to provide services to covered lives
which are the same lives covered by the primary HMO, shall report data as
necessary to fulfill data reporting requirements under this rule to the primary
HMO, which will report HEDIS data to the Council. Single service HMOs, which
contract directly with employers to provide specific services, shall report
HEDIS data directly to the Council. Basic HMOs which contract as secondary
providers with other basic HMOs to provide a range of health care services
normally considered to be full health coverage on a specified group of covered
lives, e.g., ages 0 to 18 year olds, shall report complete HEDIS data to primary
HMOs, with which the secondary HMOs have contracted to provide services, which,
in turn, shall report directly to the Council.
at a minimum, by service areas in which they are licensed
].
Data to be reported shall be a subset of the "Reporting Set Measures" (i.e.,
this excludes data specified as "Testing Set Measures"), as specified by the
Council by November 15th of the year
for
[
in
] which
the data
are
[
is
] collected. Reporting by any specific
subpopulation (e.g., Medicare, Medicaid) will be specified by the Council
by November 15th of the year
for
[
in
] which the data
are
[
is
] collected.
HEDIS data specified by the
Council on November 15th of the year in which the data is collected shall
be reported by the HMO to the Council
] by
NCQA or as specified
by the executive director (should the date be incompatible with the Council's
goals) in the current year
[
July 1st of the following year, and
shall include HEDIS data collected from January 1st through December 31st
].
in
] which the data
are
[
is
] collected, and processed by the executive director using the following
procedures.
in
] which the data
are
[
is
] collected, and reported by the HMO to the Council
[
by July 1st of the following year,
] shall be verified.
in
]
which the data
are
[
is
] collected. If no guidelines
have been released by NCQA, the data will be verified in accordance with auditing
procedures as specified by the Council. These auditing procedures shall be
specified by the Council by November 15th of the year
for
[
in
] which the data
are
[
is
] collected.
Subchapter D. Rules and Procedures for Council Officers, Council Employees, Donors and Donations