| (a) Except as provided in subsection (b) of this section,
HHSC pays for on-site, off-site, and in-home individualized skills
and socialization provided to an individual in accordance with an
individual's LON and the reimbursement rates for on-site, off-site,
and in-home individualized skills and socialization.
(b) If approved in accordance with §263.2027 of
this subchapter (relating to Enhanced Staffing Rate) HHSC pays:
(1) a level one enhanced staffing rate for off-site
individualized skills and socialization for an individual with a LON
1 or LON 5; and
(2) a level two enhanced staffing rate for off-site
individualized skills and socialization for an individual with an
LON 1, LON 5, LON 8, or LON 6.
(c) If an individual's HCS Program services and CFC
services are suspended or terminated, a program provider must not
submit a claim for on-site, off-site, or in-home individualized skills
and socialization provided during the period of the individual's suspension
or after the termination, except that the program provider may submit
a claim for the first day of the individual's suspension or termination.
(d) HHSC does not pay a program provider for on-site,
off-site, or in-home individualized skills and socialization, or recoups
any payments made to the program provider for on-site, off-site, or
in-home individualized skills and socialization, if:
(1) the individual receiving on-site, off-site, or
in-home individualized skills and socialization was, at the time on-site,
off-site, or in-home individualized skills and socialization was provided,
ineligible for the HCS Program;
(2) on-site, off-site, or in-home individualized skills
and socialization is provided to an individual during a period of
time for which there is not a signed, dated, and authorized IPC for
the individual;
(3) on-site, off-site, or in-home individualized skills
and socialization is provided during a period of time for which there
is not a signed and dated ID/RC Assessment for the individual;
(4) on-site, off-site, or in-home individualized skills
and socialization is provided during a period of time for which the
individual did not have an LOC determination;
(5) on-site, off-site, or in-home individualized skills
and socialization is not provided in accordance with a signed, dated,
and authorized IPC that includes on-site, off-site, or in-home individualized
skills and socialization;
(6) on-site, off-site, or in-home individualized skills
and socialization is not provided in accordance with the individual's
PDP or implementation plan;
(7) on-site, off-site, or in-home individualized skills
and socialization is provided before the individual's enrollment date
into the HCS Program;
(8) on-site, off-site, or in-home individualized skills
and socialization is not provided in accordance with this subchapter;
(9) on-site or off-site individualized skills and socialization is
not provided in accordance with Chapter 559, Subchapter H of this
title (relating to Individualized Skills and Socialization Provider
Requirements);
(10) on-site, off-site, or in-home individualized skills
and socialization is not provided in accordance with the HCS Program
Billing Requirements;
(11) on-site, off-site, or in-home individualized skills
and socialization is not documented in accordance with the HCS Program
Billing Requirements;
(12) the program provider did not comply with 40 TAC §49.305
(relating to Records);
(13) the claim for on-site, off-site, or in-home individualized
skills and socialization did not meet the requirements in 40 TAC §49.311
(relating to Claims Payment) or the HCS Program Billing Requirements;
(14) HHSC determines that on-site, off-site, or in-home
individualized skills and socialization would have been paid for by
a source other than the HCS Program if the program provider had submitted
to the other source a proper, complete, and timely request for payment
for on-site, off-site, or in-home individualized skills and socialization;
(15) on-site or off-site individualized skills and
socialization is provided by a service provider who did not meet the
qualifications to provide on-site or off-site individualized skills
and socialization in accordance with §559.227(a) of this title
(relating to Program Requirements) and the HCS Program Billing Requirements;
(16) in-home individualized skills and socialization
is provided by a service provider who did not meet the qualifications
to provide in-home individualized skills and socialization as described
in §263.2023 of this subchapter (relating to Service Provider
Qualifications and Training for In-Home Individualized Skills and
Socialization) and the HCS Program Billing Requirements;
(17) on-site, off-site, or in-home individualized skills
and socialization was paid at an incorrect LON because the information
entered in the HHSC data system from a completed ID/RC Assessment
is not identical to the information on the completed ID/RC Assessment;
(18) on-site, off-site, or in-home individualized skills
and socialization was not provided;
(19) on-site or off-site individualized skills and
socialization is provided during a period of time that the individual
produced marketable goods and was paid below minimum wage for producing
the goods in accordance with Section 14(c) of the Fair Labor Standards
Act;
(20) in-home individualized skills and socialization
is not provided in the residence of the individual as required by §263.2013(a)
of this subchapter (relating to Provision of In-Home Individualized
Skills and Socialization); or
(21) in-home individualized skills and socialization
is provided to an individual without the documentation required by §263.2013(c)
of this subchapter.
(e) HHSC does not pay a program provider for day habilitation,
or recoups any payments made to the program provider for day habilitation,
if day habilitation is provided on or after March 1, 2023, even if
an individual's IPC includes day habilitation on or after March 1,
2023.
(f) HHSC conducts provider fiscal compliance reviews,
also known as billing and payment reviews, in accordance with rules
governing the HCS Program and the HCS Program Billing Requirements
to determine whether a program provider is in compliance with this
subchapter.
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