1 TAC §355.307
The Texas Health and Human Services Commission (HHSC)
adopts an amendment to §355.307, Reimbursement Setting Methodology,
under Title 1 of the Texas Administrative Code (TAC), Part 15, Chapter
355, Subchapter C. The proposed rule is adopted with changes to the
proposed text as published in the February 13, 2009, issue of the
Texas Register (34 TexReg 919). The text
of the rule will be republished.
Background and Justification
This rule establishes the reimbursement methodology for the Nursing
Facility (NF) program, including Medicaid reimbursement rates for
pediatric care facilities. HHSC, under its authority and responsibility
to administer and implement rates, is updating this rule to allow
a limited number of adults who were admitted to the facility as children
but who are now over the age of 22 (i.e., individuals who have "aged
in place") to be counted as children for purposes of determining if
a facility meets the requirements for remaining a pediatric care facility.
This change applies only when the pediatric care facility is the
entire facility; it does not apply to pediatric care facilities that
are distinct units within a larger facility. In addition, the change
applies only to determining if an already existing pediatric care
facility continues to meet the pediatric care facility census requirements.
It does not apply to determining if a non-pediatric care facility
meets the requirements to become a pediatric care facility.
In this specific instance, the proposal amends current rule language
that requires a pediatric care facility to maintain an average daily
census of 80 percent children, as defined in this rule. The proposed
amendment would allow a limited number of aging-in-place adults to
be counted as children for the limited purpose of determining whether
the facility continues to meet the pediatric care facility 80 percent
census requirement. Under the proposed amendment, a pediatric care
facility could, for purposes of the 80 percent census requirement,
count as "children" aging-in-place adults up to 15 percent of the
facility's average daily census. The census count, therefore, would
include the actual number of children plus aging-in-place adults up
to 15 percent of the facility's average daily census.
Examples of facilities that would qualify as pediatric care facilities
under the rule include the following:
Facility A - A facility with an average daily census of 100 where
80 percent or more of the residents are children;
Facility B - A facility with an average daily census of 100 where
70 percent of the residents are children and 10 percent of the residents
are aging-in-place adults.
Examples of facilities that would not qualify as pediatric care
facilities include:
Facility C - A facility with an average daily census of 100 where
less than 80 percent of the residents are children and none of the
residents are aging-in-place adults.
Facility D - A facility with an average daily census of 100 where
60 percent of the residents are children and 20 percent of the residents
are aging-in-place adults.
Facility D would not qualify as a pediatric care facility under
the rule because, to meet the 80 percent requirement, it would have
to include more than 15 percent of its census as aging-in-place adults.
Facilities with an average daily census of less than 80 percent
children and no aging-in-place adults and facilities that require
more than 15 percent of their average daily census to be aging-in-place
adults in order to meet the 80 percent requirement will no longer
qualify as pediatric care facilities. At that point, the facility
will have to create a pediatric care distinct unit if it wishes to
continue receiving the pediatric reimbursement rate for its residents
who are children. The adopted rule includes new subsection (c)(4),
which describes the procedures to be followed when HHSC identifies
an existing pediatric care facility that has an average daily census
of less than 80 percent children.
Comments
The 30-day comment period ended March 13, 2009. During this period,
HHSC received comments regarding the proposed amendment to §355.307
from representatives of the one provider that currently operates a
pediatric care facility. A summary of the comments relating to the
proposed rule and HHSC's responses follow:
Comment concerning §355.307(c)(2)(C). The commenter recommended
that the limit on the number of adults that have "aged in place" and
that could be counted to meet the pediatric care facility child census
requirement be eliminated.
Response: HHSC calculates facility-specific rates for pediatric
care facilities based on each facility's actual costs for providing
care. HHSC believes that the requirement that a substantial number
of individuals residing in a pediatric care facility be children is
reasonable given the cost differences between nursing facilities that
serve a predominantly pediatric population and nursing facilities
that serve a predominantly geriatric population. HHSC did not change
the proposed rule in response to this comment.
Comment concerning §355.307(c)(3). The commenter proposed
language to delineate the processes by which: (1) HHSC would notify
a facility that it was not in compliance with the pediatric care facility
census requirement; and (2) a facility would come into compliance
with the census requirement or transition to a new facility payment
class.
Response: In response to this comment, HHSC has added paragraph
(4) to §355.307(c). This new paragraph explains that HHSC will
notify a facility that it is not in compliance with the pediatric
care facility census requirement. The notice also will explain that
the facility must either come into compliance with the requirement
or transition to a new facility payment class.
The amendment is adopted under the Texas Government Code §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking
authority; the Human Resources Code §32.021, and the Texas Government
Code §531.021(a), which provide HHSC with the authority to administer
the federal medical assistance (Medicaid) program in Texas; 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.
§355.307.Reimbursement Setting Methodology.
(a) Case mix classes. The Texas Health and Human Services
Commission (HHSC) reimbursement rates for nursing facilities (NFs)
vary according to the assessed characteristics of the recipient. Rates
are determined for 34 case mix classes of service, plus a 35th, temporary
classification assigned by default when assessment data are incomplete
or in error and a 36th classification assigned by default when an
assessment is missing.
(b) Reimbursement determination. HHSC applies the general
principles of cost determination as specified in §355.101 of
this title (relating to Introduction).
(1) Rate Components. Under the case mix methodology,
reimbursements are comprised of five cost-related components: the
direct care staff component; the other recipient care component; the
dietary component; the general/administration component; and the fixed
capital asset component. The direct care staff component is calculated
as specified in §355.308 of this title (relating to Direct Care
Staff Rate Component).
(A) The dietary rate component is constant across all
case mix classes and is calculated at the median cost (weighted by
Medicaid days of service in the rate base) in the array of projected
allowable per diem costs for all contracted nursing facilities included
in the rate base, multiplied by 1.07.
(B) The general/administration rate component is constant
across all case mix classes and is calculated at the median cost (weighted
by Medicaid days of service in the rate base) in the array of projected
allowable per diem costs for all contracted nursing facilities included
in the rate base, multiplied by 1.07.
(C) The fixed capital asset component is constant across
all case mix classes and is calculated as follows:
(i) Determine the 80th percentile in the array of allowable
appraised property values per licensed bed, including land and improvements.
Appraised values for this purpose are determined as follows:
(I) For proprietary facilities, tax exempt facilities
provided an appraisal from their local property taxing authority,
and tax exempt facilities not provided an appraisal from their local
property taxing authority because of an "exempt" status whose independent
appraisal is in the first year of its five-year interval as described
in §355.306(g)(2)(B)(ii) of this title (relating to Cost Finding
Methodology), allowable appraised values are determined as described
in §355.306(g) of this title (relating to Cost Finding Methodology).
(II) For tax exempt facilities not provided an appraisal
from their local property taxing authority because of an "exempt"
status whose independent appraisal is not in the first year of its
five-year interval as described in §355.306(g)(2)(B)(ii) of this
title (relating to Cost Finding Methodology), allowable appraised
values are determined by indexing the facility's allowable appraised
value as determined in §355.306(g) of this title (relating to
Cost Finding Methodology) to the median increase in appraised values
among contracted facilities in the state as a whole from the reporting
period coinciding with the first year of the facility's five-year
interval to the reporting period upon which reimbursements are to
be based.
(III) Those facilities that do not report an allowable
appraised value as described in §355.306(g) of this title (relating
to Cost Finding Methodology) are not included in the array for purposes
of calculating the use fee.
(ii) Project the 80th percentile of appraised property
values per bed by one-half the forecasted increase in the personal
consumption expenditures (PCE) chain-type price index from the cost
reporting year to the rate year.
(iii) Calculate an annual use fee per bed as the projected
80th percentile of appraised property values per bed times an annual
use rate of 14%.
(iv) Calculate a per diem use fee per bed by dividing
the annual use fee per bed by annual days of service per bed at the
higher of 85% occupancy, or the statewide average occupancy rate during
the cost reporting period.
(v) The use fee is limited to the lesser of the fee
as calculated in clauses (i) - (iv) of this subparagraph, or the fee
as calculated by inflating the fee from the previous rate period by
the forecasted rate of change in the PCE chain-type price index.
(2) Case mix classification system. All Medicaid recipients
are classified according to the Resource Utilization Group (RUG-III)
34 group classification system, Version 5.20, index maximizing, as
established by the state and the Centers for Medicare and Medicaid
Services (CMS). Each of the case-mix groups, including the default
groups, is assigned CMS standard nursing time measurements for Registered
Nurses (RNs), Licensed Vocational Nurses (LVNs) and aides (Medication
Aides and Certified Nurse Aides). These measurements indicate the
amount of staff time required on average to deliver care to residents
in that group.
(3) Per diem rate methodology. Staff determine per
diem rate recommendations for each of the RUG-III groups and for the
default groups according to the following procedures:
(A) For each RUG-III group, calculate a total LVN-equivalent
minute statistic by converting the CMS standard nursing time measurements
for RNs, LVNs and aides into Texas-specific LVN-equivalent minutes
as per §355.308(j) of this title (relating to Direct Care Staff
Rate Component) and summing the converted figures.
(B) Weight the total LVN-equivalent minute statistics
from subparagraph (A) of this paragraph for each RUG-III group except
the default groups as follows and determine the statewide weighted
average total adjusted minutes:
(i) For rates effective September 1, 2008, the total
LVN-equivalent minute statistics for each RUG-III group will be weighted
by the estimated statewide recipient days of service by case mix group
during the period beginning the first day of December 2007 and ending
the last day of February 2008.
(ii) For rates effective September 1, 2009, the total
LVN-equivalent minute statistics for each RUG-III group will be weighted
by the estimated statewide recipient days of service by case mix group
during the period beginning the first day of September 2008 and ending
the last day of February 2009.
(iii) For rates effective September 1, 2011 and thereafter,
for the other recipient care rate component, the total LVN-equivalent
minute statistics for each RUG-III group will be weighted by the estimated
statewide recipient days of service by case mix group during the cost
reporting period covered by the rate base. For the direct care rate
component, the total LVN-equivalent minute statistics for each RUG-III
group will be weighted by the estimated statewide recipient days of
service by case mix group during the period beginning the first day
of September, 2008 and ending the last day of February, 2009.
(C) Determine the standardized statewide case mix index
for each of the RUG-III groups by dividing each of the total LVN-equivalent
minute statistics described under subparagraph (A) of this paragraph
by the statewide weighted average total adjusted minutes described
under subparagraph (B) of this paragraph.
(D) The other recipient care rate component varies
according to case mix class of service and is calculated as follows.
Adjust the raw sum of other recipient care costs in all nursing facilities
included in the rate base in order to account for disallowed costs
and inflation, as specified in §355.306 of this title (relating
to Cost Finding Methodology). Then divide the adjusted total by the
sum of recipient days of service in all facilities in the current
rate base. Multiply the resulting weighted, average per diem cost
of other recipient care by 1.07. The result is the average other recipient
care rate component. To calculate the other recipient care per diem
rate component for each of the RUG-III case mix groups and for the
default groups, multiply each of the standardized statewide case mix
indexes from subparagraph (C) of this paragraph by the average other
recipient care rate component.
(E) Total case mix per diem rates vary according to
case mix class of service and according to participant status in Direct
Care Staff Rate enhancements described in §355.308 of this title
(relating to Direct Care Staff Rate Component).
(i) For each participating facility, for each of the
RUG-III case mix groups and for the default groups, the recommended
total per diem rate is the sum of the following five rate components:
(I) the dietary rate component from paragraph (1)(A) of this subsection;
(II) the general/administration rate component from
paragraph (1)(B) of this subsection;
(III) the fixed capital asset use fee component from
paragraph (1)(C) of this subsection;
(IV) the case mix group's other recipient care per
diem rate component by case mix group from subparagraph (D) of this
paragraph; and
(V) the case mix group's total direct care staff rate
component for that participating facility as determined in §355.308(l)
of this title (relating to Direct Care Staff Rate Component).
(ii) For nonparticipating facilities, for each of the
RUG-III case mix groups and for the default groups, the recommended
total per diem rate is the sum of the following five rate components:
(I) the dietary rate component from paragraph (1)(A) of this subsection;
(II) the general/administration rate component from
paragraph (1)(B) of this subsection;
(III) the fixed capital asset use fee component from
paragraph (1)(C) of this subsection;
(IV) the case mix group's other recipient care per
diem rate component by case mix group from subparagraph (D) of this
paragraph; and
(V) the case mix group's total direct care staff base
rate component as determined in §355.308(k) of this title (relating
to Direct Care Staff Rate Component).
(F) Qualifying ventilator-dependent residents may receive
a supplement to the per diem rate specified in subparagraph (E) of
this paragraph.
(i) To qualify for supplemental reimbursement, a resident
must require artificial ventilation for at least six consecutive hours
daily and the use must be prescribed by a licensed physician.
(ii) A ventilator-dependent resource differential case
mix index for the other recipient care rate component is calculated
by subtracting the standardized statewide case mix index for the SE1
RUG-III case mix group from subparagraph (C) of this paragraph from
3.61. A ventilator-dependent resource differential case mix index
for the direct care staff base rate component is calculated by dividing
the resource differential case mix index for the other recipient care
rate component by 0.9908.
(iii) The per diem rate supplement is calculated by
multiplying the resource differential case mix index for the other
recipient care rate component times the per diem average other recipient
care rate component, as described in subparagraph (D) of this paragraph
and multiplying the resource differential case mix index for the direct
care staff base rate component by the average direct care staff base
rate component as described in §355.308(k) of this title (relating
to Direct Care Staff Rate) and summing the products.
(iv) The supplemental reimbursement for residents requiring
continuous artificial ventilation is 100% of the per diem ventilator
rate supplement.
(v) The supplemental reimbursement for residents not
requiring continuous artificial ventilation daily but requiring artificial
ventilation for at least six consecutive hours daily is 40% of the
per diem ventilator rate supplement.
(G) Qualifying children with tracheostomies requiring
daily care may receive a supplement to the per diem rate specified
in subparagraph (E) of this paragraph.
(i) To qualify for supplemental reimbursement, a resident
must be less than 22 years of age; require daily cleansing, dressing,
and suctioning of a tracheostomy; and be unable to do self care. The
daily care of the tracheostomy must be prescribed by a licensed physician.
(ii) The supplemental reimbursement for children receiving
daily tracheostomy care is 60% of the per diem ventilator rate supplement
as specified in subparagraph (F) of this paragraph.
(H) Children with qualifying conditions as specified
in subparagraphs (F) and (G) of this paragraph may receive only one
of the supplemental reimbursements. Therefore, children with tracheostomies
who are also ventilator-dependent are not eligible to receive both
supplemental reimbursements.
(c) Special reimbursement class. HHSC may define special
reimbursement classes, including experimental reimbursement classes
of service to be used in research and demonstration projects on new
reimbursement methods and reimbursement classes of service, to address
the cost differences of a select group of recipients. Special classes
may be implemented on a statewide basis, may be limited to a specific
region of the state, or may be limited to a selected group of providers.
(1) Pediatric Care Facility Class. The purpose of this
special class is to recognize, through the adoption of a facility-specific
payment rate, the cost differences that exist in a nursing facility
or distinct unit of a nursing facility that serves predominantly children.
(2) Definitions.
(A) Pediatric care facility--Except as provided for
in subparagraph (C) of this paragraph, a pediatric care facility is
an entire facility that has maintained an average daily census of
80% or more children for the six-month period prior to its entry into
the pediatric care facility class based on the entire licensed facility.
A pediatric care facility can also be a distinct unit of a facility
that has maintained an average daily census of 85% or more children
for the six-month period prior to its entry into the pediatric care
facility class based on the distinct unit of the facility. To remain
a pediatric care facility, the pediatric care facility must maintain
an average daily census of 80% or more children if the pediatric care
facility is an entire facility and 85% or more children if the pediatric
care facility is a distinct unit of the facility. The contracted provider
must request in writing by certified mail or by special mail delivery
where the delivery can be verified to become a member of the pediatric
care facility special reimbursement class. The request must be sent
to the Texas Health and Human Services Commission.
(B) Distinct unit--A portion of a nursing facility
that is physically separate from (beds are not commingled with) other
units of the facility. The distinct unit can be an entire wing, a
separate building, an entire floor, or an entire hallway. The distinct
unit consists of all beds within the designated area. A distinct unit
must consist of 28 or more Medicaid-contracted beds.
(C) Children--For the purposes of this pediatric care
facility class, children are defined as being at or below 22 years of age.
(i) Only for a pediatric care facility that is designated
in its entirety as a pediatric care facility, a limited number of
adults who were admitted to the facility as children but who are no
longer children (i.e., individuals who have "aged in place") may be
counted as children for purposes of determining if the facility meets
the requirements for remaining a pediatric care facility described
in subparagraph (A) of this paragraph. The number of such individuals
who may be counted as children for purposes of determining if the
facility continues to meet the requirements for remaining a pediatric
care facility is limited to 15% of the average daily census of the
facility.
(ii) Individuals who have "aged in place" as described
in clause (i) of this subparagraph may not be counted toward meeting
the requirements for a facility to initially become a pediatric care
facility nor can they be counted toward meeting the requirements for
a distinct unit to remain a pediatric care facility.
(3) Payment rate determination. Payment rates will
be determined in the following manner:
(A) Cost reports and payment rate determination for
pediatric care facilities are governed by the requirements specified
in Subchapter A of this chapter (relating to Cost Determination Process)
except that payment rates are determined annually, coincident with
the state's fiscal year, within available funds. A nursing facility
that contains a pediatric care facility distinct unit must complete
two cost reports: one report for the pediatric care facility distinct
unit and one report for the remainder of the facility.
(B) Payment rates for this class of service will be
determined on a facility-specific basis for the pediatric care facility.
The total allowable costs from the most recent cost report deemed
acceptable are adjusted for inflation from the cost report period
to the rate period. The adjusted cost is divided by the greater of
total patient days of service reported on the cost report or the days
of service at 85% of contracted capacity of the pediatric care facility.
The resulting cost per day is multiplied by a factor of 1.03 to determine
the final facility-specific rate. If no acceptable cost report is
available, the provider will be required to submit a cost report covering
the time period specified by HHSC.
(C) The facility-specific payment rate from paragraph
(3)(B) of this subsection will be paid for all Medicaid residents
of a qualifying pediatric care facility regardless of the RUG level
of the resident.
(D) Residents of the pediatric care facility will not
be eligible to receive the ventilator-dependent or the children-with-tracheostomies
supplemental reimbursements.
(E) Pediatric care facilities are not eligible to participate
in §355.308 of this title (relating to Enhanced Direct Care Staff Rate).
(4) If HHSC determines that a pediatric care facility
that is designated in its entirety as a pediatric care facility no
longer qualifies as a member of such class according to paragraph
(2) of this subsection, HHSC will notify the facility in writing.
(A) Within 30 calendar days of the date on the written
notification, HHSC Rate Analysis must receive a written compliance
plan from the facility as described in subparagraph (B) of this paragraph.
If the 30th calendar day is a weekend day, national holiday, or state
holiday, the first business day following the 30th calendar day is
the final day receipt of the plan will be accepted.
(B) The compliance plan must indicate the facility's
intent to, within 180 calendar days of the date of HHSC's initial
written notification to the facility, come into compliance with paragraph
(2) of this subsection by:
(i) Managing a sufficient number of admissions and
discharges to come into compliance with the requirements of paragraphs
(2)(A) and (2)(C) of this subsection to remain a member of the pediatric
care facility special reimbursement class;
(ii) Creating a distinct unit of the facility as described
under paragraph (2)(B) of this subsection; or
(iii) Withdrawing the entire facility from the pediatric
care facility special class.
(C) HHSC will make a written determination regarding
approval or disapproval of the compliance plan. A facility that submits
a compliance plan that is subsequently disapproved will cease being
reimbursed as a member of the pediatric facility special class on
the first day of the month following HHSC's disapproval of the compliance
plan.
(D) A compliance plan that is not received by the stated
deadline will not be accepted, and the facility will be removed from
the pediatric care facility special reimbursement class retroactive
to the first day of the month following the date of HHSC's initial
written notification to the facility.
(E) A facility that obtains approval of its compliance
plan from HHSC Rate Analysis will continue to be reimbursed as a member
of the pediatric care special class until 180 calendar days of the
date of HHSC's initial written notification to the facility. If by
that time the facility has not achieved the stated goal of its compliance
plan, the facility will be removed from the pediatric care special
class effective the first day of the following month.
(F) If, at any time, HHSC determines that a facility
that has come into compliance with paragraph (2) of this subsection
by managing a sufficient number of admissions and discharges, as described
in subparagraph (B)(i) of this paragraph, no longer qualifies as a
member of such class, that facility will be excluded from the pediatric
care special class for 365 days from the date HHSC makes its determination.
The facility may apply to rejoin the class on the 366th day.
(G) A facility that is removed from or withdraws from
the pediatric care special class will be considered a new facility,
as described in §355.308(e) of this title for purposes of enrollment
in the Nursing Facility Direct Care Staff Rate enhancement.
(H) A facility that is removed or withdraws from the
pediatric care special class may not re-enter the class within one
year of its removal or withdrawal.
(d) Nurse aide training and competency evaluation costs.
(1) DADS reimburses nursing facilities for the actual
costs of training and testing nurse aides as required under the Omnibus
Budget Reconciliation Act of 1987 (OBRA '87). Payments are based on
cost reimbursement vouchers that are to be submitted quarterly. Allowable
costs are limited to those costs incurred for training provided after
October 1, 1990, for:
(A) actual training course expenses up to a set amount
determined by DADS per nurse aide;
(B) competency evaluation; or
(C) supplies and materials used in the nurse aide training
not already covered by the training course fee.
(2) Nurse aide salaries while in training are factored
into the vendor rate and are not to be included on the reimbursement
voucher.
(3) Training program costs that exceed the DADS cost
ceiling must have prior approval from DADS before costs can be reimbursed.
A written request to Provider Billing Services must include:
(A) name and vendor number of facility.
(B) description of training program for which the facility
is seeking reimbursement approval, to include:
(i) name, telephone number and address of the nurse
aide training and competency evaluation program (NATCEP);
(ii) whether the NATCEP program is facility or non-facility-based; and
(iii) name of the NATCEP program director.
(C) an explanation of why the cost for the NATCEP exceeds
the reimbursement ceiling. The explanation must include:
(i) a completed nurse aide unit cost calculation form
for a facility-based NATCEP; or
(ii) a breakdown of the nurse aide unit cost by the
instructor fees and training materials for a non-facility-based NATCEP.
(D) an explanation of why the nursing facility cannot
utilize a training program at or below the reimbursement ceiling and
what steps the facility has taken to explore more cost efficient training
courses. The explanation must include:
(i) the availability of NATCEPs, such as the location
or the frequency of training offered, in the geographic region of
the facility;
(ii) the name and address of each NATCEP that the facility
has explored as a provider of nurse aide training; and
(iii) the cost per nurse aide for each NATCEP identified
in clause (i) of this subparagraph, as specified in subparagraph (C)(i)
or (ii) of this paragraph.
(4) All prior approval requests as outlined in paragraph
(3) of this subsection must be submitted to DADS, Provider Billing
Services that:
(A) may request additional information in order to
evaluate a reimbursement request; and
(B) will make the final decision on a reimbursement request.
(5) All nurse aide training courses must be approved
by DADS before costs associated with them can be reimbursed.
(6) Nursing facilities are responsible for tracking
and documenting nurse aide training costs for each nurse aide trained.
All documentation is subject to DADS audits. If substantiating documentation
for amounts billed to DADS cannot be verified, DADS will immediately
recoup funds paid to the facility.
(7) Individuals who have successfully completed a nurse
aide training and competency evaluation program (NATCEP) may be directly
reimbursed for costs incurred in completing a NATCEP. The individual
must meet all of the conditions specified in subparagraphs (A) - (E)
of this paragraph.
(A) The individual must not have been employed at the
time of completing the NATCEP.
(B) The individual must have been employed by, or received
an offer of employment from, a nursing facility not later than 12
months after successfully completing the NATCEP.
(C) The individual must have been employed by the facility
for no less than six months.
(D) The nursing facility must not have claimed reimbursement
for training expenses for the individual.
(E) The individual must be listed on the current Nurse
Aide Registry.
(8) Individuals must submit cost reimbursement vouchers
to DADS with proof that the individual has been employed by a facility
for no less than six months.
(9) Individuals who leave nursing facility employment
before accruing the required six months of employment, as specified
in paragraph (7)(C) of this subsection, may receive 50% reimbursement
as long as the individual was employed for no less than three months.
(10) Reimbursement to individuals may not exceed the
reimbursement ceiling as detailed in paragraph (1)(A) of this subsection.
(e) Oxygen costs. Oxygen costs incurred on or after
January 1, 1995, will not be reimbursed on cost reimbursement vouchers.
Those oxygen costs must be reported as expenses on the cost report.
(f) TILE to RUG-III Hold Harmless Transition. For rates
effective September 1, 2008, payment rates for the direct care staff
component and the other recipient care component will be updated within
available funds, payment rates for the dietary, general/administration
and fixed capital asset rate components will be equal to the rates
in effect on August 31, 2008 times 1.025, payment rates for the professional
and general liability insurance add-on and the professional-only liability
insurance add-on will be equal to the rates in effect on August 31,
2008 times 1.024, and the payment rate for the general-only liability
insurance add-on will be equal to the rate in effect on August 31,
2008 times 1.018.
(1) To calculate the updated direct care staff per
diem rate component for each of the RUG-III case mix groups and for
the default groups, divide each of the standardized statewide case
mix indexes from subsection (b)(3)(C) of this section by 0.9908, which
is the weighted average TILE case mix index for the 1998 cost reporting
period, multiply each quotient by the statewide average TILE case
mix index for the period beginning the first day of December, 2007
and ending the last day of February, 2008 as represented in the Texas
Department of Aging and Disability Services (DADS) Claims Management
System (CMS) on or around June 1, 2008 and multiply each product by
the average updated direct care staff rate component.
(2) To calculate the updated other recipient care per
diem rate component for each of the RUG-III case mix groups and for
the default groups, divide each of the standardized statewide case
mix indexes from subsection (b)(3)(C) of this section by 1.0267, which
is the weighted average TILE case mix index for the 2005 cost reporting
period, multiply each quotient by the statewide average TILE case
mix index for the period beginning the first day of December, 2007
and ending the last day of February, 2008 as represented in the Texas
Department of Aging and Disability Services (DADS) Claims Management
System (CMS) on or around June 1, 2008 and multiply each product by
the average updated other recipient care rate component.
(3) For state fiscal year 2009 only, for each Medicaid-contracted
nursing facility, HHSC will:
(A) Calculate the sum of the weighted average TILE
direct care staff base rate (with no enhancements) and other recipient
care rate based on the TILE rates for these cost areas in effect on
August 31, 2008 and the facility's approved to be paid days of service
by TILE from January 1, 2008 through June 30, 2008 as represented
in the Texas Department of Aging and Disability Services (DADS) Claims
Management System (CMS) on or around November 3, 2008.
(B) Calculate the sum of the weighted average RUG-III
direct care staff base rate (with no enhancements) and other recipient
care rate based on the RUG rates for these cost areas in effect on
September 1, 2008 and the facility's approved to be paid days of service
by RUG-III for those recipients paid under RUG-III from September
1, 2008 through February 28, 2009 as represented in the DADS CMS on
or around March 31, 2009.
(C) Compare the sum from subparagraph (A) of this paragraph
to the sum from subparagraph (B) of this paragraph. If the sum from
subparagraph (A) is greater then the sum from subparagraph (B), DADS
will pay the facility 80 percent of the difference between the sum
from subparagraph (A) and the sum from subparagraph (B) times the
facility's approved to be paid days of service for those recipients
paid under RUG-III from September 1, 2008 through February 28, 2009
as represented in the DADS CMS on or around March 31, 2009.
(D) Calculate the sum of the weighted average RUG-III
direct care staff base rate (with no enhancements) and other recipient
care rate based on the RUG rates for these cost areas in effect on
September 1, 2008 and the facility's approved to be paid days of service
by RUG-III for those recipients paid under RUG-III from March 1, 2009
through August 31, 2009 as represented in the DADS CMS on or around
September 30, 2009.
(E) Compare the sum from subparagraph (A) of this paragraph
to the sum from subparagraph (D) of this paragraph. If sum from subparagraph
(A) is greater then the sum from subparagraph (D), DADS will pay the
facility 80 percent of the difference between the sum from subparagraph
(A) and the sum from subparagraph (D) times the facility's approved
to be paid days of service for those recipients paid under RUG-III
from March 1, 2009 through August 31, 2009 as represented in the DADS
CMS on or around September 30, 2009.
(F) Calculate the sum of the weighted average RUG-III
direct care staff base rate (with no enhancements) and other recipient
care rate based on the RUG rates for these cost areas in effect on
September 1, 2008, and the facility's approved to be paid days of
service by RUG-III for those recipients paid under RUG-III from September
1, 2008, through August 31, 2009, as represented in the DADS CMS on
or around January 4, 2010.
(G) Compare the sum from subparagraph (A) of this paragraph
to the sum from subparagraph (F) of this paragraph.
(i) If the sum from subparagraph (A) is greater than
the sum from subparagraph (F), determine the difference between the
sum from subparagraph (A) and the sum from subparagraph (F) times
the facility's approved to be paid days of service for those recipients
paid under RUG-III from September 1, 2008, through August 31, 2009,
as represented in the DADS CMS on or around January 4, 2010, and subtract
the hold harmless payments made under subparagraphs (C) and (E) from
the product calculated in this clause.
(I) If the result is a positive number, DADS will pay
the facility the difference.
(II) If the result is a negative number, DADS will
recoup the difference from the facility.
(ii) If the sum from subparagraph (A) is less than
the sum from subparagraph (F) and the facility received a hold harmless
payment under subparagraph (C) and/or (E), DADS will recoup from the
facility the hold harmless payments made under these subparagraphs.
(4) "On or around" as used in this subsection means
the date that the state pulls the information as described in the
subsection as close to the dates specified in subsection as feasible
and determined by the state. Once the state does the data pull, no
other pulls will be made for the purpose of calculating the values
described in this subsection. This means that once the paid days of
service for a paragraph have been determined for purposes of calculating
the TILE to RUG-III hold harmless transition, they will not be updated
for late Minimum Data Set (MDS) submissions, Utilization Review RUG-III
changes, retroactive eligibility or any other reason.
This agency hereby certifies that the adoption
has been reviewed by legal counsel and found to be a valid exercise
of the agency's legal authority.
Filed with the Office of the Secretary of State on July 9, 2009.
TRD-200902828
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Effective date: July 29, 2009
Proposal publication date: February 13, 2009
For further information, please call: (512) 424-6900