| (a) Introduction. The Texas Health and Human Services
Commission (HHSC) uses the methodology described in this section to
establish Nursing Facility (NF) Liability Insurance Coverage Rate
Add-ons.
(b) Definitions.
(1) Provider--A person who has a written agreement
with HHSC to provide Medicaid NF services to an individual or a person
who is contracted with a managed care organization as defined in §353.2
of this title (relating to Definitions) to provide Medicaid NF services.
(2) Independently procured insurance--An insurance
transaction involving an insurance contract independently procured
from an insurance company not licensed in Texas through negotiations
occurring entirely outside the state of Texas that is reported and
on which premium tax is paid.
(3) Open enrollment period--Open enrollment period
begins on the first day of July and ends on the last day of that same
July preceding the rate year for which payments are being determined.
(4) Purchased captive insurance--General or professional
liability insurance purchased from a non-admitted captive insurance
company that insures solely directors and officer's liability insurance
for the directors and officers of the company's parent and affiliated
companies and the risks of the company's parent and affiliated companies,
if applicable.
(5) Purchased commercial liability insurance--Either
general or professional liability insurance from a commercial carrier
or a non-profit service corporation in an arm's-length transaction
that provides for the shifting of risk to the unrelated party. The
commercial carrier or non-profit service corporation must meet the
requirements as set by the Texas Department of Insurance (TDI) for
authorized insurance.
(6) Rate year--The rate year begins on the first day
of September and ends on the last day of August of the following year.
(7) Self-insurance--Self-insurance is a means whereby
a provider undertakes the risk to protect itself against anticipated
liabilities by providing funds equivalent to liquidate those liabilities.
If a provider enters into an arrangement with an unrelated party that
does not provide for the shifting of risk to the unrelated party,
such an agreement shall be considered self-insurance. Self-insurance
is not purchased liability insurance.
(c) Eligibility. To be eligible to receive and retain
liability insurance coverage rate add-ons from HHSC under this section:
(1) the provider must be enrolled as a Medicaid provider;
(2) the provider must be actively providing and billing
for NF services provided to Medicaid clients; and
(3) the provider must maintain acceptable liability
insurance coverage as described in this section during the rate year
for which the liability insurance add-ons will be paid.
(d) Payment rates. Payment rates for purchased general
and professional liability insurance will be determined as follows.
(1) Determine the portion of the general and administration
rate component from §355.307 of this subchapter (relating to
Reimbursement Setting Methodology) attributable to allowable liability
insurance costs.
(2) Determine the amount of total dollars that would
be expended if the liability rate component from paragraph (1) of
this subsection were paid uniformly to all providers during the rate
effective period.
(3) Estimate the number of days of service that will
be covered by purchased liability insurance during the rate period.
(4) Divide the total dollars available for liability
insurance from paragraph (2) of this subsection by the estimated number
of days of service that will be covered by purchased liability insurance
during the rate period from paragraph (3) of this subsection. Estimate
the proportion of this per diem amount accruing from general liability
insurance and the proportion accruing from professional liability
insurance to determine the payment rate for each day of purchased
general liability insurance and the payment rate for each day of purchased
professional liability insurance.
(5) Payment rates for purchased general and professional
liability insurance may be adjusted as often as HHSC determines is
necessary to ensure that the total dollars expended during the rate
period do not exceed the amount appropriated for this purpose.
(6) Since these payment rates are determined through
an allocation of available appropriations among estimated units of
service covered by purchased liability insurance, a public rate hearing
is not required when adjustments are made to the payment rates.
(7) Providers will be notified, in a manner determined
by HHSC, of adjustments to the payment rates for purchased general
and professional liability insurance.
(8) Providers who purchase general liability insurance
without professional liability insurance are only eligible to receive
payment of the rate for purchased general liability insurance. Providers
who purchase professional liability insurance without general liability
insurance are only eligible to receive payment of the rate for purchased
professional liability insurance. Providers who purchase both general
and professional liability insurance are eligible to receive payment
of both rates.
(e) Open enrollment. Each rate year, HHSC notifies
providers of open enrollment for providers to receive the liability
insurance rate add-ons via email sent to an authorized representative
per the signature authority designation form applicable to the provider's
contract or ownership type. If open enrollment has been postponed
or canceled, HHSC will notify providers by email before the first
day of the open enrollment period. Should conditions warrant, HHSC
may conduct additional enrollment periods during a rate year. A provider
must submit an attestation in accordance with subsection (f) of this
section during an open enrollment period to receive the liability
rate add-ons for each rate year. The HHSC Provider Finance Department
must receive the attestation by the last day of the open enrollment
period. If the last day of open enrollment is on a weekend day, state
holiday, or national holiday, the HHSC Provider Finance Department
must receive the attestation by the next business day. A provider
who fails to submit an acceptable attestation of agreement in accordance
with this section will not receive the add-on rates during the rate
year.
(f) Attestation of agreement. The provider must submit
an electronic attestation of agreement to comply with subsection (c)(3)
of this section during the open enrollment period prior to the rate
year the liability insurance add-ons will be paid. The electronic
attestation will include the following.
(1) The provider must indicate that it is carrying
general liability and professional liability insurance; general liability
insurance without professional liability insurance; or professional
liability insurance only.
(2) The provider must attest that it has purchased
liability insurance issued through an entity meeting any one of the
following criteria. These entities have been determined by the TDI
to be authorized to issue liability insurance policies in the State
of Texas.
(A) An insurance company identified as an admitted,
licensed insurer authorized to write liability insurance in Texas.
This type of insurance company is designated as "active" on the TDI
website. This designation includes risk retention groups chartered
inside the State of Texas.
(B) An insurance company that is an eligible surplus
lines insurer which requires that there be a Texas licensed surplus
lines agent placing the coverage with the insurance company. This
type of insurance company is designated as "eligible" on the TDI website.
(C) The Texas Medical Liability Insurance Underwriting
Association (JUA). This insurance arrangement is designated as "active"
on the TDI website.
(D) A risk retention group chartered outside the State
of Texas that is registered with the TDI and which is designated as
"registered" on the TDI website.
(3) The provider must attest that if it purchased independently
procured insurance, the coverage was purchased through an independently
procured insurance arrangement. The provider must also attest that
taxes on the premiums of independently procured insurance were paid
to and received by the Texas Comptroller for the calendar year in
which the policy was procured, continued or renewed.
(4) The provider must agree that if it purchased insurance
through a captive insurance company that taxes on the premiums of
captive insurance were paid to and received by the Texas Comptroller
for the calendar year in which the policy was procured, continued
or renewed.
Cont'd... |
