| (a) Types of facilities. There are two types of facilities
for purposes of rate setting: state-operated and non-state operated.
Facilities are further divided into classes that are determined by
the size of the facility.
(b) Classes of non-state operated facilities. There
is a separate set of reimbursement rates for each class of non-state
operated facilities, which are as follows.
(1) Large facility--A facility with a Medicaid certified
capacity of 14 or more as of the first day of the full month immediately
preceding a rate's effective date or, if certified for the first time
after a rate's effective date, as of the date of initial certification.
(2) Medium facility--A facility with a Medicaid certified
capacity of nine through 13 as of the first day of the full month
immediately preceding a rate's effective date or, if certified for
the first time after a rate's effective date, as of the date of initial
certification.
(3) Small facility--A facility with a Medicaid certified
capacity of eight or fewer as of the first day of the full month immediately
preceding a rate's effective date or, if certified for the first time
after a rate's effective date, as of the date of initial certification.
(c) Classes of state-operated facilities. There is
a separate interim rate for each class of state-operated facilities,
which are as follows:
(1) Large facility--A facility with a Medicaid certified
capacity of 17 or more as of the first day of the full month immediately
preceding a rate's effective date or, if certified for the first time
after a rate's effective date, as of the date of initial certification.
(2) Small facility--A facility with a Medicaid certified
capacity of 16 or less as of the first day of the full month immediately
preceding a rate's effective date or, if certified for the first time
after a rate's effective date, as of the date of initial certification.
(d) Reimbursement rate determination for non-state
operated facilities. HHSC will adopt the reimbursement rates for non-state
operated facilities in accordance with §355.101 of this title
(relating to Introduction) and this subchapter.
(1) Reimbursement rates combine residential and day
program services, i.e., payment for the full 24 hours of daily service.
(2) Reimbursement rates are differentiated based on
the level of need (LON) of the individual receiving the service. The
levels of need are intermittent, limited, extensive, pervasive, and
pervasive plus.
(3) The recommended modeled rates are based on cost
components deemed appropriate for economically and efficiently operated
services. The determination of these components is based on cost reports
submitted by Intermediate Care Facilities for Individuals with an
Intellectual Disability or Related Conditions (ICF/IID) providers.
(4) Direct service workers cost area. This cost area
includes direct service workers' salaries and wages, benefits, and
mileage reimbursement expenses. The reimbursement rate for this cost
area is calculated as specified in §355.112 of this title (relating
to Attendant Compensation Rate Enhancement).
(5) Direct care trainers and job coaches cost area.
This cost area includes direct care trainers' and job coaches' salaries
and wages, benefits, and mileage reimbursement expenses. The reimbursement
rate for this cost area is calculated as specified in §355.112
of this title.
(6) Add-on reimbursement rate. There is an available
add-on reimbursement rate, in addition to the daily reimbursement
rate, for certain individuals.
(A) The add-on is based on the Resource Utilization
Group (RUG-III) 34 group classification system as described in §355.307
of this title (relating to Reimbursement Setting Methodology).
(B) There are three add-on groupings based on certain
RUG-III 34 classification groups and the assessed Activities of Daily
Living (ADL) score.
(i) Group 1 includes Extensive Services 3 (SE3), Extensive
Services 2 (SE2), and Rehabilitation with ADL score of 17-18 (RAD).
(ii) Group 2 includes Rehabilitation with ADL score
of 14-16 (RAC), Rehabilitation with ADL score of 10-13 (RAB), Extensive
Services 1 (SE1), Special Care with ADL score of 17-18 (SSC), Special
Care with ADL score of 15-16 (SSB), and Special Care with ADL score
of 4-14 (SSA).
(iii) Group 3 includes Rehabilitation with ADL score
of 4-9 (RAA), Clinically Complex with Depression and ADL score of
17-18 (CC2), Clinically Complex with ADL score of 17-18 (CC1), Clinically
Complex with Depression and ADL score of 12-16 (CB2), Clinically Complex
and ADL score of 12-16 (CB1), Clinically Complex with Depression and
ADL score of 4-11 (CA2), and Clinically Complex and ADL score of 4-11
(CA1).
(C) An individual must meet the following criteria
to be eligible to receive the add-on rate:
(i) be assigned a RUG-III 34 classification in Group
1, Group 2, or Group 3;
(ii) be a resident of a large state-operated facility
for at least six months immediately prior to referral or a resident
of a Medicaid-certified nursing facility immediately prior to referral;
and
(iii) for residents of a large state-operated facility
only, have a LON which includes a medical LON increase as described
in 40 TAC §9.241 (relating to Level of Need Criteria), but not
be assessed a LON of pervasive plus.
(D) The add-on for each Group is determined based on
data and costs from the most recent nursing facility cost reports
accepted by HHSC.
(i) For each Group, compute the median direct care
staff per diem base rate component for all facilities as specified
in §355.308 of this title (relating to Direct Care Staff Rate
Component); and
(ii) Subtract the average nursing portion of the current
recommended modeled rates as specified in subsection (d)(3) of this
section.
(e) Reimbursement determination for state-operated
facilities. Except as provided in paragraph (2) of this subsection
and subsection (f) of this section, state-operated facilities are
reimbursed an interim rate with a settlement conducted in accordance
with paragraph (1)(B) of this subsection. HHSC will adopt the interim
reimbursement rates for state-operated facilities in accordance with §355.101
of this title and this subchapter.
(1) State-operated facilities certified prior to January
1, 2001, will be reimbursed using an interim reimbursement rate and
settlement process.
(A) Interim reimbursement rates for state-operated
facilities are based on the most recent cost report accepted by HHSC.
(B) Settlement is conducted each state fiscal year
by class of facility. If there is a difference between allowable costs
and the reimbursement paid under the interim rate, including applied
income, for a state fiscal year, federal funds to the state will be
adjusted based on that difference.
(2) A state-operated facility certified on or after
January 1, 2001, will be reimbursed using a pro forma rate determined
in accordance with §355.101(c)(2)(B) and §355.105(h) of
this title (relating to Introduction and General Reporting and Documentation
Requirements, Methods and Procedures). A facility will be reimbursed
under the pro forma rate methodology until HHSC receives an acceptable
cost report which includes at least 12 months of the facility's cost
data and is available to be included in the annual interim rate determination
process.
(f) HHSC may define experimental classes of service
to be used in research and demonstration projects on new reimbursement
methods. Demonstration or pilot projects based on experimental classes
may be implemented on a statewide basis or may be limited to a specific
region of the state or to a selected group of providers. Reimbursement
for an experimental class is not implemented, however, unless HHSC
and the Centers for Medicare and Medicaid Services (CMS) approve the
experimental methodology.
(g) Cost Reporting.
(1) Providers must follow the cost-reporting guidelines
as specified in §355.105 of this title.
(2) Providers must follow the guidelines in determining
whether a cost is allowable or unallowable as specified in §355.102
and §355.103 of this title (relating to General Principles of
Allowable and Unallowable Costs, and Specifications for Allowable
and Unallowable Costs).
(3) Revenues must be reported on the cost report in
accordance with §355.104 of this title (relating to Revenues).
(h) Adjusting costs. Each provider's total reported
allowable costs, excluding depreciation and mortgage interest, are
projected from the historical cost-reporting period to the prospective
reimbursement period as described in §355.108 of this title (relating
to Determination of Inflation Indices). HHSC may adjust reimbursement
if new legislation, regulations, or economic factors affect costs,
according to §355.109 of this title (relating to Adjusting Reimbursement
When New Legislation, Regulations, or Economic Cont'd... |
