Part 7.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
Chapter 155.
RULES OF PROCEDURES
1 TAC §155.19, §155.29
The State Office of Administrative Hearings (SOAH) proposes
amendments to §155.19, Computation of Time, and §155.29, Pleadings.
The rules are being amended to correct the references in them from the previous
rule related to dismissal for failure to prosecute, former §155.57(b),
which was renumbered as §155.56(a) (relating to Dismissal Proceedings)
in the adopted rules published in the February 27, 2004, issue of the
Cathleen Parsley, General Counsel, has determined that for the first five-year
period the amended rules are in effect there will be no fiscal implications
for state or local government as a result of enforcing or administering them.
Cathleen Parsley, General Counsel, also has determined that for the first
five-year period the amended rules are in effect the public benefit anticipated
as a result of the rules will be to ensure more efficient and fair procedures
for participants in contested case hearings. There will be no effect on small
businesses as a result of enforcing the rules. There is no anticipated economic
cost to individuals who are required to comply with the proposed rules.
Written comments must be submitted within 30 days after publication of
the proposed amendments in the
Texas Register
to
Debra Anderson, Legal Assistant, State Office of Administrative Hearings,
P.O. Box 13025, Austin, Texas 78711-3025, or by facsimile to (512) 463-1576.
The amended rules are proposed under Government Code, Chapter
2003, §2003.050, which authorizes the State Office of Administrative
Hearings to conduct contested case hearings and requires adoption of hearings
procedural rules, and Government Code, Chapter 2001, §2001.004, which
requires agencies to adopt rules of practice setting forth the nature and
requirements of formal and informal procedures.
The proposed amendments affect Government Code, Chapters 2001 and 2003.
§155.19.Computation of Time.
(a) - (b)
(No change.)
(c)
When by these rules or judge order an act is required or
allowed to be done at or within a specified time, the judge may, for cause
shown, order the period enlarged if application therefore is made before the
expiration of the specified period. In addition, where good cause is shown
for the failure to act within the specified period, the judge may permit the
act to be done after the expiration of the specified period. The judge may
not enlarge the period for taking any action under the rules relating to
reopening the record, §155.15(a)(4) of this title (relating to Powers
and Duties of Judges), to
default, §155.55 of this title (relating
to Failure to Attend Hearing and Default), and to the failure to prosecute,
§155.56(a) of this title (relating to Dismissal Proceedings)
[
§155.29.Pleadings.
(a) - (h)
(No change.)
(i)
Motions to
reopen the record under §155.15(a)(4)
of this title (relating to Powers and Duties of Judges), to
set aside
a default under §155.55(e) (relating to Failure to Attend Hearing and
Default), [
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 March 12, 2004.
TRD-200401862
Cathleen Parsley
General Counsel
State Office of Administrative Hearings
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 475-4931
Chapter 354.
MEDICAID HEALTH SERVICES
Subchapter A. PURCHASED HEALTH SERVICES
25.
SCHOOL HEALTH AND RELATED SERVICES
1 TAC §354.1341
The Texas Health and Human Services Commission (HHSC) proposes
to amend §354.1341, concerning the delivery of School Health and Related
Services (SHARS). As a result of a SHARS review conducted by Centers for Medicare
and Medicaid Services (CMS), a recommendation was made to encourage the State
to establish group procedure codes and set reimbursement rates for services
provided in a group setting. HHSC proposes to amend the existing SHARS rule
to allow for the delivery of group services. Additionally, the amendment allows
for Registered Nurse (RN) and Licensed Vocational Nurse (LVN) services, medication
administration, nursing services delegated by an RN to unlicensed personnel,
personal care services, and transportation aides activities.
Tracy Henderson, Chief Financial Officer, has determined that during the
first five years the proposed rule is in effect there will be no fiscal implications
for state or local government as a result of enforcing or administering the
section.
Ed White, Director of Rate Setting and Forecasting, has determined that
during the first five years the proposed rule is in effect, it will benefit
the public by providing a clear description of the SHARS program. Small businesses
and micro-businesses will not be required to alter their business practices
to comply with the proposed rule, so it will not affect these businesses.
There are no anticipated economic costs to persons required to comply with
the proposed rule, nor any impact on local employment.
HHSC has determined that this proposed rule is not a "major environmental
rule" as defined by §2001.0225 of the Texas Government Code. "Major environmental
rule" is defined to mean a rule the specified 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. The proposed rule is not specifically
intended to protect the environment or reduce risks to human health from environmental
exposure.
HHSC has determined that these amendments do not restrict or limit owners'
rights to their property that would otherwise exist in the absence of governmental
action and therefore, do not constitute a taking under §2007.043, Government
Code.
Written comments on the proposed rule may be submitted to Arnulfo Gomez,
Program Specialist, Medicaid/CHIP Benefits, Texas Health and Human Services
Commission, 1100 W. 49th Street, Austin, Texas 78756, within 30 days of publication
of this proposal in the
Texas Register
.
A public hearing concerning the proposed rule will be held on April 14,
2004, from 1:30 to 2:30 p.m. The hearing will be held in the HHSC Davis Mountains
Conference Room, 11209 Metric Blvd., Braker Center Bldg. H, Austin, Texas.
The amendment is proposed under the Texas Government Code, §531.033,
which provides the Commissioner of HHSC with broad rulemaking authority; 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 Texas Government Code, Chapter 531,
and Chapter 32 of the Human Resources Code. No other statutes, articles, or
codes are affected by the proposed rule.
§354.1341.Benefits and Limitations.
(a)
Subject to the specifications, conditions, limitations,
and requirements established by the Texas
Health and Human Service Commission
(HHSC)
[
(b)
School health and related services must be prescribed in
the student's approved individual education program (IEP) as required by the
Texas Education Code, §21.501(7), and implemented through State Board
of Education regulations (Texas Administrative Code, Title 19, Part II, Chapter
89, §§89.221-89.224).
(c)
School health and related services are to be delivered
in the least restrictive environment consistent with the nature of the specific
service(s) and the physical and mental condition of the student.
(d)
School health and related services may include, but are
not necessarily limited to:
(1)
audiology
, individual and group delivered by licensed/certified
therapist or licensed/ certified assistant
;
(2)
counseling
, individual and group delivered by licensed/certified
therapist
;
(3)
medical services;
(4)
occupational therapy
, individual and group delivered
by licensed/certified therapist or licensed/ certified assistant
;
(5)
physical therapy
, individual and group delivered by
licensed/certified therapist or licensed/ certified assistant
;
(6)
psychological services;
(7)
speech therapy
, individual and group delivered by
licensed/certified therapist or licensed/ certified assistant
;
(8)
assessment;
(9)
school health services
, including Registered Nurse
(RN) services, medication administration, nursing services delegated by an
RN (in compliance with RN delegated nursing tasks criteria as determined by
the Board of Nurse Examiners) to an employee or health aide;
[
(10)
special transportation services (effective for services
provided on or after August 1, 1993)
, including transportation aides;
and
[
(11)
personal care services including transportation
aides.
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 March 15, 2004.
TRD-200401910
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 424-6576
Subchapter C. REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES
1 TAC §355.308
The Texas Health and Human Services Commission (HHSC) proposes
to amend §355.308, concerning direct care staff rate component, in its
Medicaid Reimbursement Rates chapter.
The purpose of the amendment is to eliminate the requirement that a nursing
facility must have met its minimum staffing requirement prior to "purchasing"
credit for additional direct care staff minutes, and to mandate that each
facility's enrollment in the enhanced direct care staff rate be limited to
the lower of its current level of enrollment plus three levels or the level
it achieved in a prior period. The amendment also clarifies that, in cases
where a facility's Medicaid contract is cancelled before open enrollment for
the enhancement program and the facility is not granted a new contract until
after the end of the open enrollment period, the facility's enhancement level
under the new contract will be limited to the lower of the facility's enhancement
level under the prior contract plus three levels or the level the facility
achieved in a prior period. In either case, the facility's enhancement level
is contingent upon the availability of funds. The amendment also clarifies
that: (1) facilities participating in the enhancement program are required
to staff at least one level higher than the facility's minimum staffing requirement
as determined by HHSC; (2) only facilities participating in the enhancement
program can be included in any aggregate calculations for determining compliance
with spending requirements; (3) requests from controlling entities to aggregate
their contracts for purposes of determining compliance with spending requirements
must be submitted at the time each Staffing and Compensation Report is submitted;
and (4) swing beds are reimbursed at the direct care staff base rate with
no enhancement levels.
In addition, new rule language is added in §355.308(a)(9) to clarify
that paid feeding assistants may not be counted toward staffing requirements
under the state's direct care staff rate enhancement program. This will maintain
consistency with federal regulations at 42 Code of Federal Regulations (CFR) §483.30
and 42 CFR §483.75(e), which prohibit feeding assistants from being counted
toward minimum staffing requirements.
Tom Suehs, Deputy Executive Commissioner for Financial Services, has determined
that for the first five-year period the proposed section is in effect, there
are no fiscal implications for state government or local government as a result
of enforcing or administering the section.
Ed White, Director, Rate Setting and Forecasting, has determined that for
each year of the first five years the section is in effect, the public benefit
anticipated as a result of eliminating the requirement that a nursing facility
must have met its minimum staffing requirement prior to "purchasing" credit
for additional direct care staff minutes is that nursing facility providers
will be given greater flexibility to meet their staffing requirements with
staff time or increased staff wages and/or benefits. The public benefit of
regulating each facility's enrollment in the enhanced direct care staff rate
to the lower of its current level of enrollment plus three levels or the level
it achieved in a prior period is that the distribution of enhancement levels
will be more equitable. The distribution will be more equitable because facilities
that failed to meet their self- selected staffing requirements in a prior
period will be prevented from enrolling at levels not supported by their previous
performance, which will make funds available to increase the enrollment levels
of other facilities and allow nonparticipants to become participants. The
public benefit of the numbered clarifications is that nursing facility providers
will find it easier to understand and participate in the enhanced direct care
staff rate program.
The public benefit anticipated as a result of enforcing the new language
in §355.308(a)(9) is that nursing facility providers will have clear
direction that paid feeding assistants are not to be reported as direct care
staff. This will reduce confusion when providers are completing nursing facility
cost and staff and compensation reports.
There is no anticipated adverse economic effect on small or micro businesses
as a result of enforcing or administering the section because the rule imposes
no specific costs or charges on a facility that must comply with the rule.
However, under both current and proposed language, facilities' enrollment
in the enhancement program may be limited prospectively based upon past performance.
The current language requires that a facility's enrollment be limited prospectively
to the level it achieved in a prior period plus two additional levels if the
facility failed to meet its self-selected staffing requirement by four or
more levels. The proposed language requires that a facility's enrollment be
limited prospectively to the level it achieved plus zero additional levels
if the facility failed to meet its self-selected staffing requirement by any
number of levels. This more stringent requirement will lead to limits on enrollments
of more facilities and those limits will be of a greater amount than under
the current rule. Under current rates, the impact of this limitation for those
facilities subject to a limitation will be 29.5 cents per level per Medicaid
resident day. This impact will be the same for small and large businesses
that fail to meet self- imposed staffing requirements.
There is no anticipated economic cost to persons who are required to comply
with the proposed section. There is no anticipated effect on local employment
in geographic areas affected by this section.
Questions about the content of this proposal may be directed to Pam McDonald
by telephone at (512) 491-1373, or by fax at (512) 491-1998, in HHSC Rate
Analysis. Written comments on the proposal may be submitted to Ms. McDonald
by fax at (512) 491-1998 or by mail at HHSC Rate Analysis, Mail Code H-400,
1100 West 49th Street, Austin, TX 78756-3101, within 30 days of publication
in the
Texas Register
. For further information
regarding the proposal or to make the proposal available for public review,
contact local offices of the Texas Department of Human Services or Pam McDonald
at (512) 491-1373 in HHSC Rate Analysis.
Under §2007.003(b) of the Government Code, HHSC has determined that
Chapter 2007 of the Government Code does not apply to this rule. Accordingly,
HHSC is not required to complete a takings impact assessment regarding this
rule.
The amendment is proposed under the Government Code, §531.033,
which authorizes the commissioner of HHSC to adopt rules necessary to carry
out the commission's duties, and §531.021(b), which establishes HHSC
as the agency responsible for adopting reasonable rules governing the determination
of fees, charges, and rates for medical assistance payments under the Human
Resources Code, Chapter 32.
The amendment affects the Government Code, §§531.033 and 531.021(b).
§355.308.Direct Care Staff Rate Component.
(a)
Direct care staff cost center. This cost center will include
compensation for employee and contract labor Registered Nurses (RNs), including
Directors of Nursing (DONs) and Assistant Directors of Nursing (ADONs); Licensed
Vocational Nurses (LVNs), including DONs and ADONs; medication aides; and
nurse aides performing nursing-related duties for Medicaid contracted beds.
(1)-(8)
(No change.)
(9)
Paid feeding assistants are
not included in the direct care staff cost center and are not to be counted
toward the staffing requirements described in subsection (j) of this section.
Paid feeding assistants are intended to supplement certified nurse aides,
not to be a substitute for certified or licensed nursing staff.
(b)-(c)
(No change.)
(d)
Enrollment contract amendment. An initial enrollment contract
amendment is required from each facility choosing to participate in the enhanced
direct care staff rate. Participating and nonparticipating facilities may
request to modify their enrollment status (i.e., a nonparticipant can request
to become a participant, a participant can request to become a nonparticipant,
a participant can request to change its enhancement level) during any open
enrollment period.
Nonparticipants and participants requesting to increase
their enrollment levels will be limited to requesting increases of three or
fewer enhancement levels during any single open enrollment period unless such
limits are waived by HHSC.
Requests to modify a facility's enrollment
status during an open enrollment period must be received by HHSC Rate Analysis
by the last day of the open enrollment period as per subsection (c) of this
section. If the last day of the open enrollment period falls on a weekend,
a national holiday, or a state holiday, then the first business day following
the last day of the open enrollment period is the final day the receipt of
the enrollment contract amendment will be accepted. An enrollment contract
amendment that is not received by the stated deadline will not be accepted.
A facility
[
(e)-(h)
(No change.)
(i)
Enrollment limitations. A facility will not be enrolled
in the enhanced direct care staff rate at a level higher than the level it
achieved on its most recently available, audited Staffing and Compensation
Report. HHSC will issue a notification letter that informs a facility in writing
of its enrollment limitations (if any) prior to the first day of the open
enrollment period.
(1)
Requests for revision. A facility may request
a revision of its enrollment limitation if the facility's most recently available,
audited Staffing and Compensation Report does not represent its current staffing
levels.
(A)
A request for revision of enrollment limitation
must include the documentation specified in subparagraph (B) of this paragraph
and must be received by HHSC Rate Analysis by hand delivery, United States
mail, or special delivery mail no later than 30 calendar days from the date
on the notification letter. If the 30th calendar day is a weekend day, national
holiday, or state holiday, then the first business day following the 30th
calendar day is the final day the receipt of the written request will be accepted.
A request for revision that is not received by the stated deadline and that
is not submitted on the form specified by HHSC will not be accepted and the
enrollment limitation specified in the notification letter will apply.
(B)
A facility that requests a revision of
its enrollment limitation must submit documentation, in the form specified
by HHSC in the notification letter, which shows that, for the period beginning
September 1 of the current rate year and ending April 30 of the current rate
year, the facility met a higher staffing level than the notification letter
indicates. In such cases, the facility's enrollment limitation will be established
at the level supported by its request for revision documentation. It is the
responsibility of the facility to render all required documentation at the
time of its request for revision. Requests not in the form specified by HHSC
in the notification letter and requests that fail to support a staffing level
different than indicated in the notification letter will result in a rejection
of the request and the enrollment limitation specified in the notification
letter will apply.
(C)
A request for revision must be signed by
an individual legally responsible for the conduct of the facility or legally
authorized to bind the facility, such as the sole proprietor, a partner, a
corporate officer, an association officer, a governmental official, a limited
liability company member, a person authorized by the applicable DHS Form 2031
for the interested party on file at the time of the request, or a legal representative
for the interested party. A request for revision that is not signed by an
individual legally responsible for the conduct of the interested party will
not be accepted and the enrollment limitation specified in the notification
letter will apply.
(D)
If the facility's Staffing and Compensation
Report for the rate year that included the open enrollment period described
in subsection (d) of this section shows the facility staffed below the level
it presented in its request for revision, HHSC will immediately recoup all
enhancement payments associated with the request for revision documents and
the facility will be limited to the level supported by the report for the
remainder of the rate year.
(E)
At no time will a facility be allowed to
enroll in the enhancement program at a level higher than its current level
of enrollment plus three additional levels unless otherwise instructed by
HHSC Rate Analysis.
(2)
New owners after a change of ownership.
Enhancement levels for a new owner after a change of ownership will be determined
in accordance with subsection (y) of this section. A new owner will not be
subject to enrollment limitations based upon the prior owner's performance.
This exemption from enrollment limitations does not apply in cases where DHS
has approved a successor-liability-agreement that transfers responsibility
from the former owner to the new owner.
(3)
New facilities. A new facility's enrollment
will be determined in accordance with subsection (e) of this section.
[
(j)
Determination of staffing requirements for participants.
Facilities choosing to participate in the enhanced direct care staff rate
agree to maintain certain direct care staffing levels
above the minimum
staffing levels described in paragraph (1) of this subsection
. In order
to permit facilities the flexibility to substitute RN, LVN and aide (Medication
Aide and nurse aide) staff resources and, at the same time, comply with an
overall nursing staff requirement, total nursing staff requirements are expressed
in terms of LVN equivalent minutes. Conversion factors to convert RN and aide
minutes into LVN equivalent minutes are based upon most recently available,
reliable relative compensation levels for the different staff types.
(1)
(No change.)
(2)
Enhanced staffing levels.
Facilities
[
(3)
Granting of staffing enhancements. HHSC divides all requested
enhancements
, after applying any enrollment limitations from subsection
(i) of this section,
into two groups: pre-existing enhancements that
facilities request to carry over from the prior year and newly-requested enhancements.
Newly-requested enhancements may be enhancements requested by facilities that
were nonparticipants in the prior year or by facilities that were participants
in the prior year desiring to be granted additional enhancements. [
(A)-(B)
(No change.)
(4)
(No change.)
(k)-(l)
(No change.)
(m)
Staffing requirements for participating facilities. Each
participating facility will be required to maintain adjusted LVN-equivalent
minutes equal to those determined in subsection (j) of this section. Each
participating facility's adjusted LVN-equivalent minutes maintained during
the reporting period will be determined as follows.
(1)
(No change.)
(2)
Determine adjusted LVN-equivalent minutes maintained. Compare
the unadjusted LVN- equivalent minutes maintained by the facility during the
reporting period from paragraph (1) of this subsection to the LVN-equivalent
minutes required of the facility as determined in subsection (j) of this section.
The adjusted LVN-equivalent minutes are determined as follows:
(A)-(B)
(No change.)
(C)
For adjusted LVN-equivalent
minutes calculated on or after March 1, 2004, requirements relating to the
minimum LVN-equivalent minutes required for participation in subparagraphs
(A) and (B) of this paragraph do not apply.
(n)
Staffing accountability. Participating facilities will
be responsible for maintaining the staffing levels determined in subsection
(j) of this section. HHSC will determine the adjusted LVN- equivalent minutes
maintained by each facility during the reporting period by the method described
in subsection (m) of this section.
[
[
(o)-(q)
(No change.)
(r)
Voluntary withdrawal. Facilities wishing to withdraw from
participation must notify HHSC in writing by certified mail. Facilities voluntarily
withdrawing must remain nonparticipants for the remainder of the rate year.
Facilities that voluntarily withdraw from participation will have their participation
end effective on the date of the withdrawal, as determined by HHSC.
(s)-(y)
(No change.)
(z)
Contract cancellations. If a facility's Medicaid contract
is cancelled before the first day of an open enrollment period as defined
in subsection (c) of this section and the facility is not granted a new contract
until after the last day of the open enrollment period, participation in the
enhanced direct care staff rate as it existed prior to the date when the facility's
contract was cancelled will be reinstated when the facility is granted a new
contract, if it remains under the same ownership
, subject to the availability
of funding. Any enrollment limitations from subsection (i) of this section
that would have applied to the cancelled contract will apply to the new contract
.
(aa)
In cases where a parent company, sole member, or governmental
body controls more than one nursing facility (NF) contract
participating
in the enhanced direct care staff rate
, the parent company, sole member,
or governmental body
has the option
[
(bb)
Medicaid Swing Bed Program for Rural Hospitals. When a
rural hospital participating in the Medicaid swing bed program furnishes NF
nursing care to a Medicaid recipient under 40 TAC §19.2326 (relating
to Medicaid Swing Bed Program for Rural Hospitals), DHS makes payment to the
hospital using the same procedures, the same case-mix methodology, and the
same TILE rates that HHSC authorizes for reimbursing NFs
receiving the
direct care staff base rate with no enhancement levels
[
(cc)-(dd)
(No change.)
(ee)
Notification of lack of available funds. If HHSC determines
that funds are not available to continue participation for facilities from
which it has not received an acceptable request to modify their enrollment
by the last day of an enrollment period as per subsection (d) of this section
[
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 March 12, 2004.
TRD-200401872
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 438-3734
1 TAC §355.311
The Texas Health and Human Services Commission (HHSC) proposes
to amend §355.311, concerning Medicaid reimbursement rates for state
veterans homes, in its Medicaid Reimbursement Rates chapter. The purpose of
the amendment is to remove the requirement that the lower of the estimated
per diem cost or the semi-private basic daily rate be used as the interim
rate of reimbursement for state veterans homes and to require the use of the
semi-private basic daily rate as the interim rate. The amendment also (1)
deletes definitions for "debt service on revenue bonds," "deposits to the
operating reserve," "management agreement," "transportation agreement," and
"VLB administrative expenses;" (2) corrects several cross- referenced section
titles; and (3) provides specific references to rules within this chapter
that the Veterans Land Board (VLB) should follow when preparing its financial
and statistical information.
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
for the first five-year period the proposed section is in effect, there are
no fiscal implications for state government or local government as a result
of enforcing or administering the section.
Ed White, Director, Rate Setting and Forecasting, has determined that for
each year of the first five years the section is in effect, the public benefits
anticipated as a result of enforcing the section are that: (1) VLB staff will
no longer need to calculate the estimated per diem cost for the interim rate
determination and, as a result, the savings in VLB staff time can be directed
to other projects and services to veterans; (2) the rules will clearly specify
that the veterans home semi- private basic daily rate is the interim rate;
and (3) the public will have accurate section titles for rule cross-references
within HHSC's rule base. There is no adverse economic effect on small or micro
businesses as a result of enforcing or administering the section, because
the amendment applies only to the Veterans Land Board, which is a state agency
participating in the Medicaid nursing facility program and does not meet the
definition of a small or micro business. There is no anticipated economic
cost to persons who are required to comply with the proposed section. There
is no anticipated effect on local employment in geographic areas affected
by this section.
Questions about the content of this proposal may be directed to Giannina
Zishka in HHSC's Rate Analysis Department (telephone: (512) 491-1371 or fax:
(512) 491-1998). Written comments on the proposal may be submitted to Giannina
Zishka via fax or mail to HHSC Rate Analysis, Mail Code H-400, 1100 West 49th
Street, Austin, TX 78756-3101, within 30 days of publication in the
Under §2007.003(b) of the Government Code, HHSC has determined that
Chapter 2007 of the Government Code does not apply to this rule. Accordingly,
HHSC is not required to complete a takings impact assessment regarding this
rule.
The amendment is proposed under the Government Code, §531.033,
which authorizes the commissioner of HHSC to adopt rules necessary to carry
out the commission's duties, and §531.021(b), which establishes HHSC
as the agency responsible for adopting reasonable rules governing the determination
of fees, charges, and rates for medical assistance payments under the Human
Resources Code, Chapter 32.
The amendment affects the Government Code, §531.033 and §531.021(b).
§355.311.Medicaid Reimbursement Rates for State Veterans Homes.
(a)
The following definitions apply to this section:
[
[
(1)
[
[
(2)
[
(3)
[
(4)
[
[
(5)
[
[
(b)
DHS reimburses the VLB for nursing facility services provided
by the VLB to Medicaid clients in state veterans homes.
(c)
HHSC determines reimbursement rates for state veterans
homes to provide nursing facility services.
(d)
Interim reimbursement
[
[
[
[
[
[
[
[
[
[
(e)
[
(f)
[
(g)
[
(h)
[
(i)
[
(j)
[
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 March 12, 2004.
TRD-200401874
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 438-3734
The Texas Health and Human Services Commission (HHSC) proposes the
repeal of Chapter 355, Subchapter F, governing General Reimbursement Methodology
for all Medical Assistance Programs §§355.732, 355.733, 355.744,
355.745, and 355.775 and an amendment to §355.742 to delete the reference
of HCS-OBRA because the program no longer exists.
The rules describe the reimbursement methodology of the Mental Retardation
Local Authority (MRLA) Program and the Home and Community Based Services -
OBRA (HCS-O) Program and are proposed for repeal because the programs are
no longer in operation. The Texas Health and Safety Code, §533.0355,
added by House Bill 2292 of the 78th Legislature, redefined the responsibilities
of mental retardation authorities (MRAs), program providers, and the Department
of Mental Health and Mental Retardation (MHMR) under the Mental Retardation
Local Authority (MRLA) Program. The redefined responsibilities describe a
program model that more closely resembles that of the Home and Community-Based
Services (HCS) Program than the MRLA Program. MHMR determined that the most
efficacious manner to implement the redefined waiver program responsibilities
required by §533.0355 was to provide all waiver services and supports
through the HCS Program. Effective September 1, 2003, MHMR has provided all
Medicaid waiver services through the HCS Program.
Tom Suehs, Deputy Executive Commissioner for Financial Services, has determined
that, for each year of the first five-year period that the proposed repeals
and amendment are in effect, there are no foreseeable fiscal implications
relating to costs or revenues of state or local government.
David Palmer, Director, Rate Analysis, has determined that, for each year
of the first five-year period the proposed repeals and amendment are in effect,
the public benefit expected is that HHSC reimbursement rules will be consistent
with the description of available Medicaid waiver services and supports. There
is no anticipated impact on small or micro-businesses to comply with the proposed
repeals and amendment, as they will not be required to alter their business
practices as a result of the repeals. There are no anticipated economic costs
to persons required to comply with the proposed repeals. There is no anticipated
impact on a local economy.
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
governmental action and therefore does not constitute a taking under §2007.043,
Government Code.
Comments concerning the proposed repeals and amendment may be submitted
in writing to Lupita Villarreal, Rate Analysis, by mail to 1100 West 49th
Street, Mail Code H-400, Austin, Texas 78756-3101, by fax to 512/491-1998,
or by e-mail to lupita.villarreal@hhsc.state.tx.us within 30 days of publication
of this proposal in the
Texas Register
.
Subchapter F. GENERAL REIMBURSEMENT METHODOLOGY FOR ALL MEDICAL ASSISTANCE PROGRAMS
1 TAC §§355.732, 355.733, 355.744, 355.745, 355.775
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Health and Human Services Commission or in the Texas Register
office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Texas Government
Code, §531.033, which provides the commissioner of HHSC with broad rulemaking
authority; the Texas Government Code, §531.021(a), and the Texas Human
Resources Code, §32.021(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 repeals affect the Texas Government Code, Chapter 531, and
the Texas Human Resources Code, Chapter 32.
§355.732.Cost Report.
§355.733.Reimbursement Methodology.
§355.744.Service Coordination Definitions for Mental Retardation Local Authority (MRLA) Program.
§355.745.Service Limitations for Service Coordination through MRLA.
§355.775.Reimbursement Methodology for the MRLA Program.
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 March 15, 2004.
TRD-200401911
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 424-6576
1 TAC §355.742
The amendment is proposed under the Texas Government Code, §531.033,
which provides the commissioner of HHSC with broad rulemaking authority; the
Texas Government Code, §531.021(a), and the Texas Human Resources Code, §32.021(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 Texas Government Code, Chapter 531,
and the Texas Human Resources Code, Chapter 32.
§355.742.Service Limitations for MR Service Coordination and Targeted Case Management .
(a)
Case management services will not be reimbursable as a
Medicaid service for which another payor is liable. Case management activities
associated with the following are not reimbursable as an optional targeted
case management service:
(1)
Medicaid eligibility determinations and redeterminations;
(2)
Medicaid eligibility intake processing;
(3)
Medicaid preadmission screening;
(4)
prior authorization for Medicaid services;
(5)
required Medicaid utilization review;
(6)
Texas Health Steps administration; and
(7)
Medicaid "lock-in" provided for under §1915(a) of
the Omnibus Reconciliation Act of 1987.
(b)
Specifically, reimbursement will not be made for the following:
(1)
outreach activities that are designed to locate individuals
who are potentially Medicaid eligible. This exclusion does not include Medicaid
eligible persons requiring services outlined in TDMHMR rules;
(2)
any medical evaluation, examination or treatment billable
as a distinct Medicaid covered benefit. However, referral arrangements and
staff consultation for such services are reimbursable as a case management
service;
(3)
services provided under the home and community-based services
waiver for persons with mental retardation (HCS);
[(4)
services provided under the home and
community-based services waiver for persons with mental retardation or related
conditions (HCS-OBRA); or ]
(4)
[
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 March 15, 2004.
TRD-200401912
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 424-6576
1 TAC §355.761
The Texas Health and Human Services Commission (HHSC) proposes
to amend §355.761, concerning reimbursement methodology for Institutions
for Mental Diseases (IMD), in its Medicaid Reimbursement Rates chapter to
specify that reimbursement is determined bi-annually and that the reimbursement
period is based on state fiscal year and that the prospective reimbursement
rate is compared to the Support, Maintenance and Treatment (SMT) rate.
Tom Suehs, Deputy Executive Commissioner for Financial Services, has determined
that for each year of the first five-year period the proposed section is in
effect, there will be no foreseeable implications relating to costs or revenues
of state or local government.
David Palmer, Director, Rate Analysis, has determined that for each year
of the first five years the section is in effect, the public benefit expected
as a result of enforcing the section is that the reimbursement methodology
for Institutions for Mental Diseases (IMD) will appropriately reflect policy.
There is no anticipated impact on small or micro-businesses to comply with
the proposed amendment as they will not be required to alter their business
practices as a result of the amendment. There are no anticipated economic
costs to persons required to comply with the proposed amendment. There is
no anticipated impact on a local economy.
HHSC has determined that this proposal does not restrict or limit an owner's
right to their property that would otherwise exist in the absence of governmental
action and therefore does not constitute a taking under §2007.043, Government
Code.
Comments concerning the proposed amendment may be submitted in writing
to Lupita Villarreal, Rate Analysis, by mail to 1100 West 49th Street, Mail
Code H-400, Austin, Texas, 78756-3101, by fax to 512/491-1178, or by e-mail
to lupita.villarreal@hhsc.state.tx.us within 30 days of publication of this
proposal in the
Texas Register
. For further
information regarding the proposal or to make the proposal available for public
review, contact local offices of the Department of Human Services (DHS) or
Lupita Villarreal at (512) 491-1178 in HHSC's Rate Analysis Department.
The amendment is proposed under the Texas Government Code, §531.033,
which provides the executive commissioner of HHSC with broad rulemaking authority;
the Texas Government Code, §531.021(a), and the Texas Human Resources
Code, §§32.021(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 Texas Government Code, Chapter 531,
and the Texas Human Resources Code, Chapter 32.
§355.761.Reimbursement Methodology for Institutions for Mental Diseases (IMD).
(a)
The Health and Human Services Commission (HHSC) determines
IMD reimbursement
bi-
annually. A statewide prospective reimbursement
will be available to all eligible IMD providers for reimbursable IMD services.
This reimbursement is inclusive of all costs allowable under Medicare payment
principles.
(b)
Initial reimbursement period. The initial reimbursement
period is defined as November 16, 1994-April 30, 1996. The reimbursement for
this period is determined from Medicare cost reports for state-operated hospitals,
which provided IMD services between September 1, 1993, and August 31, 1994.
The Medicare cost reports are reviewed by HHSC to assure that the costs used
for calculating each hospital's average per diem cost for IMD services are
allowable under Medicare payment principles and are only those costs incurred
by the hospital for care and treatment provided to persons 65 years and older
and occupying a Medicare-certified bed. Using these Medicare cost reports,
each hospital's average per diem cost for IMD services is calculated. HHSC
adjusts each hospital's average per diem cost for IMD services to the initial
reimbursement period by applying a cost-of-living index. The cost-of-living
index used is the
Centers for Medicare and Medicaid Services (CMS)
[
(c)
The reimbursement period begins on
September
[
(1)
Annually, each IMD provider is required to submit to HHSC
a copy of its Medicare cost report for its most recent fiscal year ending
prior to September 1. Cost reports must be received by HHSC no later than
90 days following the end of the IMD provider's fiscal year. Each IMD provider
is required to identify in its cost report as a subunit (IMD unit) those Medicare-certified
units on which reimbursable IMD services were provided. The Medicare cost
reports are reviewed by HHSC to assure that the costs to be used for calculating
each IMD provider's average per diem cost for IMD services are allowable under
Medicare payment principles and are only those costs incurred for care and
treatment provided to persons 65 years of age and older and occupying a Medicare-certified
bed.
(2)
Upon completion of the reviews of cost reports, and prior
to calculating average per diem costs for each IMD provider, cost reports
and prior payment histories are reviewed. To ensure the integrity of the data
and avoid bias in the resulting reimbursement due to low volume and other
inefficiencies, cost reports of IMD providers will be eliminated from the
database for any one of the following reasons:
(A)
being in operation fewer than 90 calendar days during the
previous cost reporting period;
(B)
having an occupancy rate on its IMD units of less than
90% for 50% or more of the days covered during the previous cost reporting
period; or
(C)
individually accounting for fewer than 5.0% of the total
days of care reimbursed by Medicaid as IMD services during the previous cost
reporting period.
(3)
Using the Medicare cost reports in the database, HHSC calculates
for each IMD provider an average per diem cost for IMD services. Each IMD
provider's average per diem cost is adjusted to the future reimbursement period
by applying a cost-of-living index. The cost-of-living index used is the
Centers for Medicare and Medicaid Services (CMS)
[
(4)
After adjusting the average per diem cost for each IMD
provider, the average per diem costs of all IMD providers remaining in the
database are arrayed from high to low. The median (50th percentile) average
per diem cost is selected as the prospective reimbursement for the future
reimbursement period. If the 50th percentile falls between IMD providers,
then the immediately higher average per diem cost will be selected as the
reimbursement.
The prospective reimbursement rate is compared to the
Support, Maintenance and Treatment (SMT) rate.
All IMD providers will
be paid
the lower of the prospective rate or SMT rate
[
(d)
Financial Audits. Financial audits are performed periodically
on all IMD providers. IMD providers have the right to appeal exclusions and
adjustments to cost reports according to TDMHMR's informal reviews and administrative
hearings process [
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 March 15, 2004.
TRD-200401913
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 424-6576
6.
RURAL HEALTH CLINICS
1 TAC §355.8101
The Texas Health and Human Services Commission (HHSC) proposes
amendments to §355.8101, concerning Reimbursement Methodology for Rural
Health Clinics (RHCs). The purpose of this revision is to allow a Prospective
Payment System (PPS) rate to be calculated for an RHC that does not have an
audited cost report from its Medicare Intermediary for its 1999 and/or 2000
fiscal years.
Tom Suehs, Deputy Executive Commissioner for Financial Services, has determined
that, for the first five-year period the amendment is in effect, there are
no fiscal implications for state government as a result of enforcing or administering
the section. There are no fiscal implications for local governments as a result
of enforcing or administering the section.
David Palmer, Director of Rate Setting and Actuarial Services, has determined
that during the first five years the proposed section is in effect, the public
benefit anticipated as a result of enforcing the section is increased provider
understanding of the reimbursement methodology. There is no adverse economic
effect on small or micro-businesses as a result of enforcing or administering
the proposed amendment. There is no anticipated economic cost to persons who
are required to comply with the proposed amendment. There is no anticipated
effect on local employment in geographic areas affected by this section.
Questions about the content of this proposal may be directed to Nancy Kimble
(telephone: 512-491-1363; FAX: 512-491-1983) in HHSC Rate Setting for Acute
Care Services. Written comments on the proposal may be submitted to Ms. Kimble
via facsimile or mail to HHSC Rate Setting for Acute Care Services, Mail Code
H-410, 1100 West 49th Street, Austin, TX 78756-3101, within 30 days of publication
in the
Texas Register
. Copies of the proposal
will also be made available for public review at the local offices of the
Texas Department of Human Services.
A public hearing is scheduled for Wednesday, April 14, 2004, from 10:30
am until 11:30 am. The hearing will be held in the Davis Mountains Conference
Room of the Braker Center, Building H, 11209 Metric Boulevard, Austin, Texas
78758-4021.
Under §2007.003(b) of the Government Code, HHSC has determined that
Chapter 2007 of the Government Code does not apply to this rule. Accordingly,
HHSC is not required to complete a takings impact assessment regarding this
rule.
The amendment is proposed under the Texas Government Code, §531.033,
which authorizes the commissioner of HHSC to adopt rules necessary to carry
out the commission's duties, and §531.021(b), which established HHSC
as the agency responsible for adopting reasonable rules governing the determination
of fees, charges, and rates for medical assistance payments under the Human
Resources Code, Chapter 32.
The amendment implements the Government Code, §§531.033 and 531.021(b).
§355.8101.Reimbursement.
(a)
Prospective Payment System. Rural health clinics (RHCs)
employing the Prospective Payment System (PPS) methodology, in accordance
with section 1902(aa) of the Social Security Act as amended by the Benefits
Improvement and Protection Act (BIPA) of 2000 (42 U.S.C. §1396a(aa))
effective for the RHC's fiscal year that includes dates of service occurring
January 1, 2001, and after, RHCs will be reimbursed a PPS per visit rate for
Medicaid-covered services. There will no longer be a cost settlement for RHCs
for dates of service on or after January 1, 2001.
(1)
The PPS per visit rate for both hospital-based and freestanding
RHCs will be calculated based on one hundred percent (100%) of the average
of the RHC's reasonable costs for providing Medicaid-covered services as determined
from audited cost reports for the RHC's 1999 and 2000 fiscal years. The PPS
per visit rates will be calculated by adding the total audited reimbursable
costs as determined from the 1999 and 2000 cost reports and dividing by the
total audited visits for these same two periods.
In the event an audited
cost report will not be received from the Medicare Intermediary, the PPS per
visit rate for both hospital-based and freestanding RHCs will be calculated
based on one hundred percent (100%) of the average of the RHC's reasonable
costs for providing Medicaid-covered services as determined from audited or
unaudited cost reports for the RHC's 1999 and 2000 fiscal years.
(2)
For hospital-based RHCs, an interim PPS per visit rate
for each RHC will be calculated based upon the encounter rate from the latest
finalized cost report settlement, adjusted as provided for in paragraph (7)
of this subsection . For freestanding RHCs, the interim PPS per visit rate
for each RHC will be based upon the per visit rate in the Medicaid payment
system as of December 31, 2000, adjusted as provided for in paragraph (7)
of this subsection. When HHSC has determined a final PPS rate, interim payments
will be reconciled back to January 1, 2001.
(3)
Reasonable costs, as used in setting the interim PPS rate,
the PPS rate or any subsequent effective rate, is defined as those costs that
are allowable under Medicare Cost Principles as outlined in 42 CFR part 413.
The cost limits that were in place on December 31, 2000, shall be maintained
in determining reasonable costs. Reasonable costs shall not include unallowable
costs.
(4)
Unallowable costs are expenses that are incurred by an
RHC and that are not directly or indirectly related to the provision of covered
services according to applicable laws, rules, and standards. An RHC may expend
funds on unallowable cost items, but those costs must not be included in the
cost report/survey, and they are not used in calculating a rate determination.
Unallowable costs include, but are not necessarily limited to, the following:
(A)
compensation in the form of salaries, benefits, or any
form of compensation given to individuals who are not directly or indirectly
related to the provision of covered services;
(B)
personal expenses not directly related to the provision
of covered services;
(C)
management fees or indirect costs that are not derived
from the actual cost of materials, supplies, or services necessary for the
delivery of covered services, unless the operational need and cost effectiveness
can be demonstrated;
(D)
advertising expenses other than those for advertising in
the telephone directory yellow pages, for employee or contract labor recruitment,
and for meeting any statutory or regulatory requirement;
(E)
business expenses not directly related to the provision
of covered services. For example, expenses associated with the sale or purchase
of a business or expenses associated with the sale or purchase of investments;
(F)
political contributions;
(G)
depreciation and amortization of unallowable costs, including
amounts in excess of those resulting from the straight line depreciation method;
capitalized lease expenses, less any maintenance expenses, in excess of the
actual lease payment; and goodwill or any excess above the actual value of
the physical assets at the time of purchase. Regarding the purchase of a business,
the depreciable basis will be the lesser of the historical but not depreciated
cost to the previous owner or the purchase price of the assets. Any depreciation
in excess of this amount is unallowable;
(H)
trade discounts and allowances of all types, including
returns, allowances, and refunds received on purchases of goods or services.
These are reductions of costs to which they relate and thus, by reference,
are unallowable;
(I)
donated facilities, materials, supplies, and services including
the values assigned to the services of unpaid workers and volunteers whether
directly or indirectly related to covered services, except as permitted in
42 C.F.R. Part 413;
(J)
dues to all types of political and social organizations,
and to professional associations whose functions and purpose are not reasonably
related to the development and operation of patient care facilities and programs,
or the rendering of patient care services;
(K)
entertainment expenses except those incurred for entertainment
provided to the staff of the RHC as an employee benefit. An example of entertainment
expenses is lunch during the provision of continuing medical education on-site;
(L)
board of director's fees, including travel costs and meals
provided for these directors;
(M)
fines and penalties for violations of statutes, regulations,
and ordinances of all types;
(N)
fund raising and promotional expenses except as noted in
subparagraph (D) of this subsection;
(O)
interest expenses on loans pertaining to unallowable items,
such as investments. Also the interest expense on that portion of interest
paid that is reduced or offset by interest income;
(P)
insurance premiums pertaining to items of unallowable cost;
(Q)
any accrued expenses that are not a legal obligation of
the provider or are not clearly enumerated as to dollar amount;
(R)
mileage expense exceeding the current reimbursement rate
set by the federal government for its employee travel;
(S)
cost for goods or services that are purchased from a related
party and which exceed the original cost to the related party;
(T)
out-of-state travel expenses not related to the provision
of covered services, except out-of-state travel expenses for training courses
that increase the quality of medical care and/or the operating efficiency
of the RHC;
(U)
over-funding contributions to self-insurance funds that
do not represent payments based on current liabilities;
(5)
A visit is a face-to-face encounter between an RHC patient
and a physician, physician assistant, advanced nurse practitioner, certified
nurse-midwife, visiting nurse, or clinical nurse practitioner. Encounters
with more than one health professional and multiple encounters with the same
health professional that take place on the same day and at a single location
constitute a single visit, except where one of the following conditions exists:
(A)
after the first encounter, the patient suffers illness
or injury requiring additional diagnosis or treatment; or
(B)
the RHC patient has a medical visit and an "other" health
visit.
(6)
A visit is a face-to-face encounter between an RHC patient
and a physician, physician assistant, advanced nurse practitioner, certified
nurse mid-wife, visiting nurse, or clinical nurse practitioner. An "other"
health visit includes, but is not limited to, a face-to-face encounter between
an RHC patient and a clinical social worker.
(7)
Effective for each RHC's fiscal year that includes dates
of services occurring on or after October 1, 2001, subsequent increases in
an RHC's PPS per visit rate or the effective rate shall be the rate of change
in the Medicare Economic Index (MEI) for Primary Care.
(8)
The effective rate is the rate paid to the RHC for the
current fiscal year. The effective rate equals the base rate plus the MEI
for each of the RHC's fiscal years since the setting of its PPS rate. The
effective rate shall be calculated at the start of each RHC's fiscal year
and shall be applied prospectively for that fiscal year.
(9)
An adjustment shall be made to the effective rate if change
is due to a change in scope. An RHC or HHSC may request an adjustment of the
effective rate equal to one hundred percent (100%) of reasonable costs by
the filing of a cost report and the necessary documentation to support a claim
that the RHC has undergone a change in scope. A cost report, filed to request
an adjustment in the effective rate, may be filed at any time during an RHC's
fiscal year but no later than five (5) calendar months after the end of the
RHC's fiscal year. All requests for adjustment in the RHC's effective rate
must include at least 6 months of financial data. Any effective rate adjustment
granted as a result of such a filing must be completed within sixty (60) days
of receipt of a workable cost report and documentation supporting the RHC's
claim that it has undergone a change in scope. Within sixty (60) days of submitting
a workable cost report, HHSC or its designee shall make a determination regarding
a new effective rate. The new effective rate shall become effective the first
day of the month immediately following its determination. All subsequent increases
shall be calculated using the adjusted effective rate.
(10)
Any request to adjust an effective rate must be accompanied
by documentation showing that the RHC has had a change in scope.
(11)
A change in scope of services provided by an RHC includes
the addition or deletion of a service or a change in the magnitude, intensity,
or character of services currently offered by an RHC or one of the RHC's sites.
A change in scope includes:
(A)
an increase in service intensity attributable to changes
in the types of patients served, including but not limited to, HIV/AIDS, the
homeless, elderly, migrant, other chronic diseases or special populations;
(B)
any changes in services or provider mix provided by an
RHC or one of its sites;
(C)
changes in operating costs that have occurred during the
fiscal year and that are attributable to capital expenditures, including new
service facilities or regulatory compliance;
(D)
Changes in operating costs attributable to changes in technology
or medical practices at the RHC;
(E)
indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing teaching services
to interns and residents; or
(F)
any changes in scope approved by the Health Resources and
Service Administration (HRSA).
(12)
A workable cost report includes the following:
(A)
for a hospital-based RHC, complete HCFA Form 2552 and HCFA
Form 339 with certification by an officer or administrator including:
(i)
M-1 (analysis of provider-based RHC costs);
(ii)
M-2 (allocation of overhead to RHC services);
(iii)
M-3 (calculation of reimbursement settlement for RHC
services);
(iv)
M-5 (analysis of payments to hospital-based RHC services
rendered to program beneficiaries);
(v)
S-8 (statistical data/information purposes);
(vi)
RHC net expenses for allocation of costs for services
rendered on or after January 1, 1998, reported on the hospital's worksheet
A, column 7 traced properly to the RHC's total facility costs on line 32,
column 7 on M-1 worksheet; and
(vii)
hospital's overhead worksheet expenses allocated to each
of the hospital-based RHC cost centers on worksheet B, Part I (column 27 minus
column 0) traced properly to line 15, column 5 on M-2 worksheet for each hospital-based
RHC.
(B)
for a freestanding RHC, a complete HCFA 222 Form and HCFA
339 Form with certification by an officer of administrator.
(13)
Once the base rate for an RHC has been calculated, the
RHC will be paid its effective rate without the need to file a cost report.
Except as specified in paragraph (14) of this subsection, a cost report will
be required only if the RHC is seeking to adjust its effective rate as an
RHC.
(14)
New RHCs will file a projected cost report within 90 days
of their designation to establish an initial payment rate. The cost report
will contain the RHC's reasonable costs anticipated to be incurred during
the RHC's initial fiscal year. The RHC will file a cost report within five
(5) months of the end of the RHC's initial fiscal year. The cost settlement
must be completed within six (6) months of receipt of a cost report. The cost
per visit rate established by the cost settlement process shall be the base
rate. Any subsequent increases will be calculated as provided herein. A new
RHC location established by an existing RHC participating in the Medicaid
program will receive the same effective rate as the RHC establishing the new
location. An RHC establishing a new location may request an adjustment to
its effective rate as provided herein if its costs have increased as a result
of establishing a new location.
(15)
In the event that the total amount paid to an RHC by a
managed care organization is less than the amount the RHC would receive under
PPS, the state will reimburse the difference on a quarterly basis. The state's
quarterly supplemental payment obligation will be determined by subtracting
the baseline payment under the contract for services being provided from the
effective rate without regard to the effects of financial incentives that
are linked to utilization outcomes, reductions in patient cost, or bonuses.
(16)
An RHC shall submit a copy of its audited Medicare cost
report to HHSC within 15 days of receipt.
(b)
Alternative Payment System. RHCs employing the alternative
to the PPS methodology in accordance with section 1902(aa) of the Social Security
Act as amended by the Benefits Improvement and Protection Act (BIPA) of 2000
(42 U.S.C. §1396a(aa)) effective for the RHC fiscal year that includes
dates of service occurring January 1, 2001, and after, will be reimbursed
a per visit rate for Medicaid-covered services. There will no longer be a
cost settlement for RHCs for dates of service on or after January 1, 2001.
(1)
Written and signed agreements will be obtained from all
RHC providers agreeing to the alternative methodology.
(2)
The alternative PPS per visit rate for both hospital-based
and freestanding RHCs will be calculated based on one hundred percent (100%)
of the average of the RHC's reasonable costs for providing Medicaid
-
covered services as determined from audited cost reports for the RHC's
1999 and 2000 fiscal years. The alternative PPS per visit rates will be calculated
by adding the total audited reimbursable costs as determined from the 1999
and 2000 cost reports and dividing the total audited visits for these same
two periods.
In the event an audited cost report will not be received
from the Medicare Intermediary, the alternative PPS per visit rate for both
hospital-based and freestanding RHCs will be calculated based on one hundred
percent (100%) of the average of the RHC's reasonable costs for providing
Medicaid-covered services as determined from audited or unaudited cost reports
for the RHC's 1999 and 2000 fiscal years.
The per visit rate using this
alternative methodology will provide reimbursement equal to or greater than
what would have occurred under PPS.
(3)
For hospital-based RHCs, an interim alternative PPS per
visit rate for each RHC will be calculated based upon the encounter rate from
the latest cost report settlement, adjusted as provided for in paragraph (8)
of this subsection. For freestanding RHCs, the interim alternative PPS per
visit rate for each RHC will be based upon the per visit rate in the Medicaid
payment system as of December 31, 2000, adjusted as provided for in paragraph
(8) of this subsection. When HHSC has determined a final alternative PPS rate,
interim payments will be reconciled back to January 1, 2001. Adjustments will
be made only if the interim payments are less than what would have occurred
under PPS.
(4)
Reasonable costs, as used in setting the interim alternative
PPS rate, the alternative PPS rate or any subsequent effective rate, is defined
as those costs that are allowable under Medicare Cost Principles as outlined
in 42 C.F.R. part 413. The cost limits that were in place on December 31,
2000, shall be maintained in determining reasonable costs. Reasonable costs
shall not include unallowable costs.
(5)
Unallowable costs are expenses that are incurred by an
RHC and that are not directly or indirectly related to the provision of covered
services according to applicable laws, rules, and standards. An RHC may expend
funds on unallowable cost items, but those costs must not be included in the
cost report/survey, and they are not used in calculating a rate determination.
Unallowable costs include, but are not necessarily limited to, the following:
(A)
compensation in the form of salaries, benefits, or any
form of compensation given to individuals who are not directly or indirectly
related to the provision of covered services;
(B)
personal expenses not directly related to the provision
of covered services;
(C)
management fees or indirect costs that are not derived
from the actual cost of materials, supplies, or services necessary for the
delivery of covered services, unless the operational need and cost effectiveness
can be demonstrated;
(D)
advertising expenses other than those for advertising in
the telephone directory yellow pages, for employee or contract labor recruitment,
and for meeting any statutory or regulatory requirement;
(E)
business expenses not directly related to the provision
of covered services. For example, expenses associated with the sale or purchase
of a business or expenses associated with the sale or purchase of investments;
(F)
political contributions;
(G)
depreciation and amortization of unallowable costs, including
amounts in excess of those resulting from the straight line depreciation method;
capitalized lease expenses, less any maintenance expenses, in excess of the
actual lease payment; and goodwill or any excess above the actual value of
the physical assets at the time of purchase. Regarding the purchase of a business,
the depreciable basis will be the lesser of the historical but not depreciated
cost to the previous owner or the purchase price of the assets. Any depreciation
in excess of this amount is unallowable;
(H)
trade discounts and allowances of all types, including
returns, allowances, and refunds received on purchases of goods or services.
These are reductions of costs to which they relate and thus, by reference,
are unallowable;
(I)
donated facilities, materials, supplies, and services including
the values assigned to the services of unpaid workers and volunteers whether
directly or indirectly related to covered services, except as permitted in
42 C.F.R. part 413;
(J)
dues to all types of political and social organizations,
and to professional associations whose functions and purpose are not reasonably
related to the development and operation of patient care facilities and programs,
or the rendering of patient care services;
(K)
entertainment expenses except those incurred for entertainment
provided to the staff of the RHC as an employee benefit. An example of entertainment
expenses is lunch during the provision of continuing medical education on-site;
(L)
board of director's fees, including travel costs and meals
provided for these directors;
(M)
fines and penalties for violations of statutes, regulations,
and ordinances of all types;
(N)
fund raising and promotional expenses except as noted in
subparagraph (D) of this subsection;
(O)
interest expenses on loans pertaining to unallowable items,
such as investments. Also the interest expense on that portion of interest
paid that is reduced or offset by interest income;
(P)
insurance premiums pertaining to items of unallowable cost;
(Q)
any accrued expenses that are not a legal obligation of
the provider or are not clearly enumerated as to dollar amount;
(R)
mileage expense exceeding the current reimbursement rate
set by the federal government for its employee travel;
(S)
cost for goods or services that are purchased from a related
party and which exceed the original cost to the related party;
(T)
out-of-state travel expenses not related to the provision
of covered services, except out-of-state travel expenses for training courses
that increase the quality of medical care and/or the operating efficiency
of the RHC;
(U)
over-funding contributions to self-insurance funds that
do not represent payments based on current liabilities;
(6)
A visit is a face-to-face encounter between an RHC patient
and a physician, physician assistant, advanced nurse practitioner, certified
nurse-midwife, visiting nurse, or clinical nurse practitioner. Encounters
with more than one health professional and multiple encounters with the same
health professional that take place on the same day and at a single location
constitute a single visit, except where one of the following conditions exists:
(A)
after the first encounter, the RHC patient suffers illness
or injury requiring additional diagnosis or treatment; or
(B)
the RHC patient has a medical visit and an "other" health
visit.
(7)
A visit is a face-to-face encounter between an RHC patient
and a physician, physician assistant, advanced nurse practitioner, certified
nurse mid-wife, visiting nurse, or clinical nurse practitioner. An "other"
health visit includes, but is not limited to, a face-to-face encounter between
an RHC patient and a clinical social worker.
(8)
Effective for each RHC's fiscal year that includes dates
of services occurring on or after October 1, 2001, subsequent increases in
an RHC's alternative PPS per visit rate or the effective rate shall be the
rate of change in the MEI for Primary Care.
(9)
The effective rate is the rate paid to the RHC for the
current fiscal year. The effective rate equals the base rate plus the MEI
for each of the RHC's fiscal years since the setting of its alternative PPS
rate. The effective rate shall be calculated at the start of each RHC's fiscal
year and shall be applied prospectively for that fiscal year.
(10)
An adjustment shall be made to the effective rate if change
is due to a change in scope. An RHC or HHSC may request an adjustment of the
effective rate equal to one hundred percent (100%) of reasonable costs by
the filing of a cost report and the necessary documentation to support a claim
that the RHC has undergone a change in scope. A cost report, filed to request
an adjustment in the effective rate, may be filed at any time during an RHC's
fiscal year but no later than five (5) calendar months after the end of the
RHC's fiscal year. All requests for adjustment in the RHC's effective rate
must include at least 6 months of financial data. Any effective rate adjustment
granted as a result of such a filing must be completed within sixty (60) days
of receipt of a workable cost report and documentation supporting the RHC's
claim that it has undergone a change in scope. Within sixty (60) days of submitting
a workable cost report, HHSC or its designee shall make a determination regarding
a new effective rate. The new effective rate shall become effective the first
day of the month immediately following its determination. All subsequent increases
shall be calculated using the adjusted effective rate.
(11)
Any request to adjust an effective rate must be accompanied
by documentation showing that the RHC has had a change in scope.
(12)
A change in scope of services provided by an RHC includes
the addition or deletion of a service or a change in the magnitude, intensity,
or character of services currently offered by an RHC or one of the RHC's sites.
A change in scope includes:
(A)
an increase in service intensity attributable to changes
in the types of patients served, including but not limited to, HIV/AIDS, the
homeless, elderly, migrant, other chronic diseases or special populations;
(B)
any changes in services or provider mix provided by an
RHC or one of its sites;
(C)
changes in operating costs that have occurred during the
fiscal year and that are attributable to capital expenditures including new
service facilities or regulatory compliance;
(D)
changes in operating costs attributable to changes in technology
or medical practices at the RHC;
(E)
indirect medical education adjustments and a direct graduate
medical education payment that reflects the costs of providing teaching services
to interns and residents; or
(F)
any changes in scope approved by the Health Resources and
Service Administration (HRSA).
(13)
A workable cost report includes the following:
(A)
for a hospital-based RHC, complete HCFA Form 2552 and HCFA
Form 339 with certification by an officer or administrator including:
(i)
M-1 (analysis of provider-based RHC costs);
(ii)
M-2 (allocation of overhead to RHC services);
(iii)
M-3 (calculation of reimbursement settlement for RHC
services);
(iv)
M-5 (analysis of payments to hospital-based RHC services
rendered to program beneficiaries);
(v)
S-8 (statistical data/information purposes);
(vi)
RHC net expenses for allocation of costs for services
rendered on or after January 1, 1998, reported on the hospital's worksheet
A, column 7 traced properly to the RHC's total facility costs on line 32,
column 7 on M-1 worksheet; and
(vii)
hospital's overhead worksheet expenses allocated to each
of the hospital-based RHC cost centers on worksheet B, Part I (column 27 minus
column 0) traced properly to line 15, column 5 on M-2 worksheet for each hospital-based
RHC.
(B)
for a freestanding RHC, a complete HCFA 222 Form and HCFA
339 Form with certification by an officer of administrator.
(14)
Once the base rate for an RHC has been calculated, the
RHC will be paid its effective rate without the need to file a cost report.
Except as specified in paragraph (15) of this subsection, a cost report will
be required only if the RHC is seeking to adjust its effective rate as an
RHC.
(15)
New RHCs must file a projected cost report within 90 days
of their designation to establish an initial payment rate. The cost report
will contain the RHC's reasonable costs anticipated to be incurred during
the RHC's initial fiscal year. The RHC will file a cost report within five
(5) months of the end of the RHC's initial fiscal year. The cost settlement
must be completed within six (6) months of receipt of a cost report. The cost
per visit rate established by the cost settlement process will be the base
rate. Any subsequent increases will be calculated as provided herein. A new
RHC location established by an existing RHC participating in the Medicaid
program will receive the same effective rate as the RHC establishing the new
location. An RHC establishing a new location may request an adjustment to
its effective rate as provided herein if its costs have increased as a result
of establishing a new location.
(16)
In the event that the total amount paid to an RHC by a
managed care organization is less than the amount that the RHC would receive
under the alternative PPS, the state will reimburse the difference on a quarterly
basis. The state's quarterly supplemental payment obligation will be determined
by subtracting the baseline payment under the contract for services being
provided from the effective rate without regard to the effects of financial
incentives that are linked to utilization outcomes, reductions in patient
cost, or bonuses.
(17)
An RHC shall submit a copy of its audited Medicare cost
report to HHSC within 15 days of receipt.
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 March 15, 2004.
TRD-200401914
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 424-6576
1 TAC §355.8301
The Texas Health and Human Services Commission (HHSC) proposes
amendments to §355.8301, concerning Reimbursement Methodology for School
Health and Related Services (SHARS). One purpose of these amendments is to
provide a reimbursement methodology for services provided in group settings
(e.g., counseling, physical therapy, occupational therapy, and school health
services). A second purpose is to provide a reimbursement methodology for
services provided by licensed/certified assistants (e.g., Licensed Physical
Therapist Assistants and Certified Occupational Therapist Assistants). Another
purpose is to provide a reimbursement methodology for school health services
provided by a Licensed Vocational Nurse (LVN) or Licensed Practical Nurse
(LPN), as well as school health services provided by an unlicensed person
through proper delegation from a Registered Nurse (RN). Additionally, the
amendments add a reimbursement methodology for personal care services, including
transportation aide services.
Tom Suehs, Deputy Executive Commissioner for Financial Services, has determined
that, for the first five-year period the amendment is in effect, there are
no fiscal implications for state government, but there are fiscal implications
for federal government as a result of enforcing or administering the section
since SHARS providers are school districts and charter schools which certify
the expenditure of the state portion of the reimbursement for these services.
There are fiscal implications for local governments as a result of enforcing
or administering the section since SHARS providers are school districts and
charter schools that are considered local governments.
The effect on federal government for the first five-year period the sections
are in effect is an estimated increase in expenditures of $22,316,893 for
each fiscal year (FY) from FY2005 through FY2009.
David Palmer, Director of Rate Setting and Actuarial Services, has determined
that during the first five years the proposed section is in effect, the public
benefit anticipated as a result of enforcing the sections is increased provider
understanding of the reimbursement methodology. There is no adverse economic
effect on small or micro-businesses as a result of enforcing or administering
the proposed amendment. There is no anticipated economic cost to persons who
are required to comply with the proposed amendment. There is no anticipated
effect on local employment in geographic areas affected by this section.
Questions about the content of this proposal may be directed to Nancy Kimble
(telephone: 512-491-1363; FAX: 512-491-1983) in HHSC Rate Setting for Acute
Care Services. Written comments on the proposal may be submitted to Ms. Kimble
via facsimile or mail to HHSC Rate Setting for Acute Care Services, Mail Code
H-410, 1100 West 49th Street, Austin, TX 78756-3101, within 30 days of publication
in the
Texas Register
. Copies of the proposal
will also be made available for public review at the local offices of the
Texas Department of Human Services.
A public hearing is scheduled for Wednesday, April 14, 2004, from 1:30
pm until 2:30 pm. The hearing will be held in the Davis Mountains Conference
Room of the Braker Center, Building H, 11209 Metric Boulevard, Austin, Texas
78758-4021.
Under §2007.003(b) of the Government Code, HHSC has determined that
Chapter 2007 of the Government Code does not apply to this rule. Accordingly,
HHSC is not required to complete a takings impact assessment regarding this
rule.
The amendment is proposed under the Texas Government Code, §531.033,
which authorizes the commissioner of HHSC to adopt rules necessary to carry
out the commission's duties, and §531.021(b), which established HHSC
as the agency responsible for adopting reasonable rules governing the determination
of fees, charges, and rates for medical assistance payments under the Human
Resources Code, Chapter 32.
The amendment implements the Government Code, §§531.033 and 531.021(b).
§355.8301.Reimbursement.
(a)
The Texas
Health and Human Services Commission (HHSC)
or its designee reimburses
[
(1)
prospective;
and
(2)
cost related
.
[
[(3)
reflect the cost of efficient service
provision.]
(b)
Basis for rate analysis.
(1)
Because the services named in
§354.1341(d)(1)-(9)
[
(2)
For subsequent periods,
HHSC or its designee
[
(3)
The costs from the historical cost-reporting
period are adjusted to the prospective rate period using reasonable and appropriate
methods for projecting costs as determined by HHSC or its designee. HHSC or
its designee may utilize a general cost inflation index obtained from a reputable
independent professional source and, where HHSC or its designee deems appropriate
and pertinent data are available, develop and/or utilize several cost-specific
and program-specific inflation indices, as follows.
(A)
HHSC or its designee utilizes the Implicit Price Deflator
(IPD) for Government Consumption Expenditures and Gross Investment for State
and Local Governments as the general cost inflation index.
(B)
HHSC or its designee may use specific indices in place
of the general cost inflation index specified in subparagraph (A) of this
paragraph when appropriate cost-specific or program-specific cost indices
are available. The specific indices that HHSC or its designee may use include,
but are not limited to, the following:
(i)
Federal Insurance Contributions Act (FICA) or Social Security
taxes, including Old Age, Survivors, and Disability Insurance (OASDI) and
Medicare taxes, are set by federal statute. The inflation rate for these taxes
is the average tax rate, or average tax per payroll dollar, during the prospective
reimbursement period divided by the average tax rate, or average tax per payroll
dollar, during each provider's reporting period.
(ii)
The unemployment tax inflation index is based on unemployment
insurance payroll taxes in accordance with the Federal Unemployment Tax Act
(FUTA) and the Texas Unemployment Compensation Act (TUCA) rates and is the
average tax rate during the prospective reimbursement period divided by the
average tax rate during each provider's reporting period.
(iii)
Inflation factors for salaries of clinicians, certified/licensed
assistants, school health aides, and personal care attendants are based on
wage survey data pertaining to specific types of staff in Texas when HHSC
or its designee has determined that reliable data of this kind are available
for specific services.
[(3)
Concomitant with the cost data collection,
a time study will be conducted to capture the distribution of service provider
staff time in delivery of each of the services covered under school health
and related services. This will include direct face-to-face contact with the
client, indirect time spent in relation to a direct service delivery, and
time spent on administrative/educational/supervisory activities. Updates of
time study will coincide with the cost report process.]
(4)
Providers participating in the MAC program
are required to provide quarterly time study information. The information
includes time information for clinicians, certified/licensed assistants, and
school health aides delivering the following SHARS: audiology, counseling,
occupational therapy, physical therapy, psychological services, speech therapy,
assessment and school health services. Costs for these services are properly
allocated to each unit of service based upon the results of the MAC program
quarterly time study information, resulting in a cost per unit of service
for each district for each of the listed services. Other personnel delivering
SHARS who are not required to provide quarterly time study information for
the MAC program (e.g., personal care attendants) will be required to provide
time study information for one quarter for the calculation of reimbursement
rates for services provided by them.
(A)
For services provided in an individual setting by the licensed
or certified clinician, the cost per unit of service for each type of clinician
is arrayed from low to high, with the median cost per unit of service selected
as the recommended rate for that service. For services provided in an individual
setting by a licensed or certified assistant, the cost per unit of service
for each type of licensed or certified assistant is arrayed from low to high,
with the median cost per unit of service selected as the recommended rate
for that service.
(B)
For services provided in a group setting by the licensed
or certified clinician, the recommended rate for the service provided by the
licensed or certified clinician in an individual setting is divided by the
average number of clients in a group, based on a study of a representative
sample of the services provided in group settings. For services provided in
a group setting by a licensed or certified assistant, the recommended rate
for the service provided by the licensed or certified assistant in an individual
setting is divided by the average number of clients in a group, based on a
study of a representative sample of the services provided in group settings.
(C)
For school health services, recommended rates are calculated
for services provided in an individual or group setting by a Registered Nurse
(RN), a Licensed Vocational Nurse (LVN) or a Licensed Practical Nurse (LPN),
and by an unlicensed person to whom the task has been properly delegated by
an RN in accordance with Subparagraphs A and B of this paragraph.
(D)
Medication administration will be reimbursed either under
school health services as a service provided by an RN, LVN or LPN, or unlicensed
person to whom the task has been properly delegated by an RN or under a separate
reimbursement rate calculated per dose as a percentage of the recommended
rate for services provided by an RN, LVN or LPN, or unlicensed person to whom
the task has been properly delegated by an RN, depending on the service requirements
of the student. The initial percentage effective September 1, 2004, is 20%,
based on a time study of the length of time required by RNs to administer
medication by dose.
[(4)
Costs will be assigned to each face-to-face
service episode to reflect the time spent in both direct service delivery
and indirect activities in relation to the direct service delivery. ]
(5)
Since time for medical services staff
is not covered by the MAC program quarterly time study information and since
most of these services are delivered by contracted staff, the recommended
rate per unit of service is based on a survey of the average cost per provider
per unit of service for these services. The average cost per provider per
unit of service is arrayed from low to high, with the median cost per unit
of service selected as the recommended rate for medical services.
[(5)
Costs will be adjusted from the cost
reporting period to the prospective period in accordance with the procedures
contained in 40 TAC §24.301 (concerning Determination of Inflation Indices).]
[(6)
Cost per service type may be analyzed
by such factors as type of staff delivering the service, environment in which
the service is delivered and geographic area to determine the need for multiple
rates for a specific service. The intent is to establish a single rate per
service type statewide unless the above analyses demonstrate compelling evidence
to do otherwise. ]
[(7)
For each category for which a rate is
to be set, the costs will be arrayed from low to high and a rate approximating
the median cost in the category will be selected as the recommended rate for
the category.]
(6)
[
(c)
Unallowable costs are defined as those expenses incurred
by a provider that are neither directly or indirectly related to the provision
of contracted services according to applicable laws, rules, and standards.
Unallowable costs are not used in calculating recommended rates.
Providers
have the right to notice of exclusions and disallowances made during the conduct
of desk
reviews
[
(d)
HHSC or its designee may adjust reimbursement
rates for SHARS when federal or state laws, rules, regulations, policies,
or guidelines are adopted, promulgated, judicially interpreted, or otherwise
changed in ways that can reasonably be expected to effect allowable costs.
HHSC or its designee may also adjust reimbursement rates when changes in economic
factors significantly affect allowable costs. Any of these adjustments may
result in increases or decreases in the reimbursement rates.
[(d)
The actions described in this section
necessary to establish rates for school health and related services will be
performed by the department or its designee.]
[(e)
In accordance with 40 TAC §24.501
(concerning Adjusting Rates When New Legislation, Regulation, or Economic
Factors Affect Costs), rates may be adjusted to reflect changes in legislation,
regulations, or economic factors.]
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 March 15, 2004.
TRD-200401915
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 25, 2004
For further information, please call: (512) 424-6576
§155.57(b) of this title (relating to Summary Disposition and Dismissal)
], except as stated in those rules.
for summary disposition and
] to set aside a dismissal
for failure to prosecute, under
§155.56(a) (relating to Dismissal
Proceedings), and §155.57 (relating to Summary Disposition)
[
§155.57 (relating to Summary Disposition and Dismissals)
], shall
be governed by the referenced sections.
Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Department of Health
] or its designee, school health
and related services are those health and related services performed on or
after January 1, 1991, that are determined to be medically necessary and reasonable
to ensure a Medicaid-eligible student with a disability under age 21 receives
the benefits accorded to him or her by federal and state legislation guaranteeing
a free and appropriate public education.
and
]
.
]
Chapter 355.
MEDICAID REIMBURSEMENT RATES
Facilities
] from which HHSC Rate Analysis has
not received an acceptable request to modify their enrollment by the last
day of the open enrollment period will continue at the level of participation
in effect during the open enrollment period within available funds
until
the facility notifies HHSC in accordance with subsection (r) of this section
that it no longer wishes to participate or until the facility's enrollment
is limited in accordance with subsection (i) of this section
. If HHSC
determines that funds are not available to continue participation at the level
of participation in effect during the open enrollment period, facilities will
be notified as per subsection (ee) of this section. To be acceptable, an enrollment
contract amendment must be completed according to instructions, signed by
an authorized signator as per the Texas Department of Human Services (DHS)
Form 2031 applicable to the provider's contract or ownership type, and be
legible.
Enrollment. Facilities choosing to participate in the enhanced direct care
staff rate must submit to HHSC a signed contract amendment as described in
subsection (d) of this section, before the end of the open enrollment period.
Participation will remain in effect, subject to availability of funds, until
the facility notifies HHSC in accordance with subsection (r) of this section
that it no longer wishes to participate or the facility is removed from participation
as described in subsection (n) of this section. If HHSC determines that funds
are not available to continue participation, facilities will be notified as
per subsection (ee) of this section. Facilities voluntarily withdrawing from
participation will have their participation end effective on the date of the
withdrawal as determined by HHSC.
]
Participating facilities
] desiring to
participate in the enhanced
direct care staff rate are required to
staff above the minimum requirements
from paragraph (1) of this subsection
. These facilities
may request
LVN-equivalent staffing enhancements from an array of LVN-equivalent enhanced
staffing options and associated add-on payments during open enrollment
under subsection (d) of this section
.
For
the granting of enhancements to be effective on or after September 1, 2001,
for an enhancement to qualify as a pre-existing enhancement a facility must
have actually met the enhancement's staffing requirements during the most
recent reporting period from which reliable data is available at the time
qualification is determined.
] Using the process described herein, HHSC
first determines the distribution of carry-over enhancements. If HHSC determines
that funds are not available to carry over some or all pre-existing enhancements,
facilities will be notified as per subsection (ee) of this section. If funds
are available after the distribution of carry-over enhancements, HHSC then
determines the distribution of newly requested enhancements. HHSC may not
distribute newly requested enhancements to facilities owing funds identified
for recoupment from subsections (n) and/or (o) of this section.
(1)
]
HHSC or its designee will recoup all direct
care staff revenues associated with unmet staffing goals from participating
facilities that fail to meet their staffing requirements during the reporting
period.
(2)
In addition, effective the
first day of the rate year immediately following the determination that a
facility failed to maintain the required weighted average LVN-equivalent minutes
for the reporting period by four or more adjusted LVN-equivalent minutes or
that a facility that was required to provide at least four LVN-equivalent
minutes above its minimum staffing requirement, as determined in subsection
(j)(1) of this section failed to meet its minimum staffing requirement for
the reporting period, the facility will have its enrollment in the enhancement
program limited to a level consistent with the highest adjusted LVN-equivalent
minutes, as defined in subsection (m) of this section, that the facility actually
attained plus two additional LVN-equivalent minutes. If the adjusted level
attained is more than two LVN- equivalent minutes below the minimum direct
care staff requirement for participation, the facility will be precluded from
enrollment in the enhancement program and will be a nonparticipant. These
enrollment limitations will remain in effect for the longer of either one
full rate year or until the first day of the rate year that begins after funds
identified for recoupment from subsections (n) and/or (o) of this section
are repaid to HHSC or its designee.]
may request at the time
each Annual Staffing and Compensation Report is submitted, in a manner prescribed
by HHSC,
] to have its
participating
contracts' compliance
with the spending requirements detailed in subsection (o) of this section
for the applicable reporting period evaluated in the aggregate
. In such
cases, compliance with the spending requirements will be evaluated in the
aggregate
for all
participating
NF contracts
that the
parent company, sole member or governmental body
[
it
] controlled
at the end of the rate year or at the effective date of the change of ownership
or termination of its last
participating
NF contract.
This
option is called grouping. To exercise the grouping option, the parent company,
sole member, or governmental body must submit a grouping request, in a manner
prescribed by HHSC, at the time each Annual Staffing and Compensation Report
is submitted.
In limited partnerships in which the same single general
partner controls all the limited partnerships, that single general partner
must
[
may
] make this request. Other such requests will be
reviewed on a case-by-case basis. A new request to have compliance with spending
requirements evaluated in the aggregate must be submitted for each reporting
period. NF contracts that change ownership or terminate effective after the
end of the applicable reporting period, but prior to the determination of
compliance with spending requirements as per subsection (o) of this section,
are excluded from all aggregate spending calculations. These contracts' compliance
with spending requirements will be determined on an individual basis and the
costs and revenues will not be included in the aggregate spending calculation.
A facility that does not participate in the enhanced direct care staff rate
is excluded from all aggregate spending calculations because it is not subject
to the spending requirements detailed in subsection (o) of this section.
participating
in the enhanced direct care staff rate at the minimum level required for participation
]. These hospitals are not subject to the staffing and spending requirements
detailed in this section.
, to maintain participation until a facility notifies it that the facility
no longer wishes to participate or is removed from participation as per subsection
(i) of this section,
] or to fund carry-over enhancements as per subsection
(j)(3) of this section, HHSC will notify providers in a manner determined
by HHSC that such funds are not available.
(1)
Debt service on revenue bonds--The
principal and interest payments on Veterans Home Revenue Bonds sold under
authorization of Chapter 164, Texas Natural Resources Code, and issued for
the purpose of acquisition, construction, operation, and maintenance of a
state veterans home or homes.]
(2)
Deposits to the operating
reserve--The monthly deposits by the Veterans Land Board (VLB) to a facility's
operating reserve as required by the trust indenture(s) related to State of
Texas Veterans Home Revenue Bonds as authorized under 40 TAC §176.3 (relating
to Sale of Bonds).]
(3)
] Health and Human Services Commission
(HHSC)--The state administrative agency authorized to adopt standards and
rules to govern reimbursement rates and methodologies for Medicaid nursing
facility services pursuant to Government Code §531.021.
(4)
Management agreement--The
management and operations agreement between the Veterans Land Board (VLB)
of the State of Texas and the operator of a state veterans home in effect
during the rate period.]
(5)
] Rate period--The state fiscal
year.
(6)
] State veterans home--A nursing
facility as defined in Title 40, Texas Administrative Code (TAC) §176.1
(relating to [
Veterans Homes
] Definitions) that is contracted with
DHS under 40 TAC §19.2322 (relating to
Medicaid Bed Allocation Requirements
[
Allocation, Reallocation, and Decertification Requirements
])
to provide nursing facility services to eligible Medicaid recipients who reside
in a state veterans home.
(7)
] Texas Department of Human Services
(DHS)--The state administrative agency authorized to contract for nursing
facility services to Medicaid recipients pursuant to Chapter 32, Human Resources
Code.
(8)
Transportation agreement--The
agreement between the VLB and the operator of the facility in effect during
the rate period. Not all operators may have a transportation agreement.]
(9)
] Veterans Land Board (VLB)--The
state administrative agency authorized under Chapter 164, Natural Resources
Code, to establish and operate state veterans homes.
(10)
VLB administrative expenses--VLB
expenses related to oversight of the state veterans home program.]
Reimbursement
]
rates for state veterans homes are determined prospectively for each home
based on the [
lower of an estimate of per diem cost for the rate period
as calculated in subsection (e) of this section or the
] state veterans
home semi- private basic daily rate in effect on the first day of the rate
period. Rates are reconciled retrospectively based on actual cost in accordance
with subsection
(j)
[
(k)
] of this section.
(e)
For each home, the estimated
per diem costs are calculated as follows:]
(1)
For the rate period, sum the following:]
(A)
the monthly fixed-fee component of the management
and operation fee as described in the management agreement for each month
in the rate period,]
(B)
the variable-fee component of the management
and operation fee per patient day in effect during the rate period times estimated
patient days during the rate period,]
(C)
vehicle payments, if any, as defined in the
transportation agreement,]
(D)
deposits to the operating reserve,]
(E)
debt service on the revenue bonds, and]
(F)
VLB administrative expenses.]
(2)
Divide the sum, as determined in paragraph
(1) of this subsection, by the estimated patient days for the rate period
to determine the interim prospective per diem rate. Estimated patient days
for the rate period are determined based on the most recently available, reliable
utilization data for the facility.]
(f)
] The facility-specific payment
rate, as determined in subsection (d) of this section, will be paid for all
Medicaid eligible residents of a state veterans home regardless of the Texas
Index for Level of Effort (TILE) level of the resident.
(g)
] Veterans Administration (VA)
per diem payments to the State of Texas VLB for nursing home care as defined
in 38 Code of Federal Regulations (CFR) §51.40 (relating to monthly payment)
are considered third-party resources [
(TPRs)
] under 40 TAC §15.215
(relating to
Third-party Resources (TPRs)
[
Third-Party Resources
]). These payments are offset against per diem payment rates for Medicaid-eligible
residents of a state veterans home.
(h)
] Residents of a state veterans
home are not eligible to receive the supplemental reimbursements authorized
under [
§
] §355.307(b)(3)(E) and (F) of this title (relating
to
Reimbursement Setting Methodology
[
Qualifying Ventilator-Dependent
Residents and Qualifying Children with tracheostomies
]).
(i)
] State veterans homes are not
eligible to participate in §355.308 of this title (relating to [
Enhanced
] Direct Care Staff Rate
Component
).
(j)
] The VLB submits financial and
statistical information in a format designated by HHSC.
The financial
and statistical information must be completed in accordance with the provisions
of §355.102 and §355.103 of this title (relating to General Principles
of Allowable and Unallowable Costs; and Specifications for Allowable and Unallowable
Costs).
This information may be reviewed or audited in accordance with §355.106
of this title (relating to Basic Objectives and Criteria for Audit and Desk
Review of Cost Reports). Financial and statistical information submitted by
the VLB is not included in the cost report databases used in the reimbursement
determination process for the Texas Medicaid Nursing Facility program.
(k)
] For each state veterans home,
the
interim reimbursement
[
prospective per diem
] rate
is adjusted retrospectively based on actual costs accrued during the rate
period[
, with capital equipment and capital improvement costs accrued
by the VLB for the facility substituted for deposits to the operating reserve
in the cost calculation, and actual patient days provided substituted for
estimated patient days
].
Chapter 355.
MEDICAID REIMBURSEMENT RATES
Subchapter F. REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS AND MENTAL RETARDATION
(5)
] case management services covered
by another Medicaid-reimbursed program or any other non-Medicaid funding source.
Subchapter F. REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS AND MENTAL RETARDATION
Health Care Financing Administration's (HCFA)
] Market Basket Forecast
Excluded Hospital Input Price Index (as reported in the Dallas Regional Medical
Services Letter Number 95-015). Due to the length of the initial reimbursement
period, the percentages by which the average per diem costs are adjusted are
prorated by taking 1/12 of the forecast for calendar year 1994 plus 12/12
of the forecast for calendar year 1995 plus 4/12 of the forecast for calendar
year 1996. After adjusting the average per diem cost for each hospital, the
average per diem costs for all of the hospitals are arrayed from high to low.
The median (50th percentile) average per diem cost is selected as the prospective
reimbursement for the initial reimbursement period. If the 50th percentile
falls between IMD providers, then the immediately higher average per diem
cost will be selected as the reimbursement.
May
] 1 and ends on
August 31
[
April 30
] of the
following year.
Health Care Financing
Administration's (HCFA)
] Market Basket Forecast Excluded Hospital Input
Price Index (as reported to the States in the Dallas Regional Medical Services
Letter for the federal fiscal quarter ending in December of the year preceding
the next reimbursement period). The percentage used for adjustments to each
IMD provider's average per diem cost is prorated, using
1/3
[
2/3
] of the forecast for the calendar year in which the reimbursement
period begins (
September
[
May
] through December) plus
2/3
[
1/3
] of the forecast for the next calendar year (January
through
August
[
April
]).
this
reimbursement
] for each day during the next reimbursement period that
IMD services are provided to an eligible individual.
contained in §355.707 of this title (relating
to Informal Reviews and Administrative Hearings
]).
Subchapter J. PURCHASED HEALTH SERVICES
16.
SCHOOL HEALTH AND RELATED SERVICES
Department of Health (department) will
reimburse
] enrolled providers
for
[
such as Texas school
districts and school district cooperatives
] providing school health
and related services to
Medicaid-eligible students
[
Medicaid
eligible children
] with disabilities.
HHSC or its designee calculates
[
The department determines
] reimbursement rates at least
once every five years for school health and related services
(SHARS),
with
[
. However,
] adjustments [
will be
] made for
inflation annually
for those years when reimbursement rates are not calculated
[
as provided in subsection (b)(5) of this section
]. These
rates are:
; and
]
§29.2601(d)(1)-(9)
] of this title (relating to Benefits
and Limitations)
were
[
are
] comparable to those included
in
§621.23(5)(C)-(E)
[
§33.503
] of
Title
25
[
this title
] (relating to
Service Delivery Requirements
for Comprehensive Services) for the Early Childhood Intervention (ECI) program
[
Reimbursable Services for the Early Childhood Intervention (ECI)
Medicaid Initiative
], initial rates
were
[
have been
] derived from data collected as a part of the ECI program rate setting
process
prior to October 1, 1994
.
the department
] will collect cost data from a representative sample
of providers
as reported to the Texas Education Agency (TEA) through
the Public Education Information Management System (PEIMS), the Foundation
School Program (FSP), the Medicaid Administration Claims (MAC) program, and/or
other auditable sources. These
[
This
] data [
will
]
contain the direct costs associated with delivery of
SHARS
[
school health and related services
], the indirect program costs associated
with service delivery, and general and administrative costs associated with
the management of the facility and program. [
These cost reports will
be subject to the general guidelines for review and edit outlined in 40 TAC §24.102
and §24.201 (concerning Methodology and Basic Objectives and Criteria
for Desk Review of Cost Reports).
]
(8)
] Reimbursement for special transportation
services
is
[
will be
] based on a rate per
student
round trip
, with student round trip being defined as one Medicaid-eligible
student requiring special transportation services, picked up at home or school,
delivered to a location where an approved Medicaid service is provided, and
delivered back to home or school. The recommended rate for special transportation
services is primarily based upon costs and statistics reported by districts
in the FSP report. The costs per district per student round trip is calculated
and arrayed from low to high, with the median cost per unit of service selected
as the recommended rate per student round trip for special transportation
services
.
audits
] or on-site audits
of the
costs, statistics, time study information and any other information used in
the calculation of reimbursement rates for school health and related services
[
as specified in 40 TAC §24.401 (concerning Notification)
]. Providers may request an informal review and, if necessary, an administrative
hearing
of any exclusion or disallowance
[
of the action
]
taken by
HHSC or its designee during the conduct of desk reviews or on-site
audits
[
the department. The procedures to be followed are set forth
in 40 TAC §24.601 (concerning Reviews and Administrative Hearings)
].
33.
INDIAN HEALTH SERVICES