| (a) Billable and non-billable activities.
(1) A Medicaid provider may only bill for medically
necessary MH rehabilitative services that are provided face-to-face
to:
(A) a Medicaid-eligible individual;
(B) the LAR of a Medicaid-eligible adult (on behalf
of the adult); or
(C) the LAR or primary caregiver of a Medicaid-eligible
child or adolescent (on behalf of the child or adolescent).
(2) The cost of the following activities are included
in the Medicaid MH rehabilitative services reimbursement rate(s) and
may not be directly billed by the Medicaid provider:
(A) developing and revising the recovery plan and
interventions that are appropriate to an individual's needs;
(B) staffing and team meetings to discuss the provision
of MH rehabilitative services to a specific individual;
(C) monitoring and evaluating outcomes of interventions,
including contacts with a person other than the individual;
(D) documenting the provision of MH rehabilitative
services;
(E) a staff member traveling to and from a location
to provide MH rehabilitative services;
(F) all services provided within a day program for
acute needs that are delivered by a staff member, including services
delivered in response to a crisis or an episode of acute psychiatric
symptoms; and
(G) administering the uniform assessment to individuals
who are receiving psychosocial rehabilitative services.
(b) Non-reimbursable activities.
(1) The department will not reimburse a Medicaid provider
for any MH rehabilitative services provided to an individual who is:
(A) a resident of an intermediate care facility for
persons with an intellectual or developmental disability as described
in 42 CFR §440.150;
(B) a resident in an IMD;
(C) an inmate of a public institution as defined in
42 CFR §435.1009;
(D) a resident in a Medicaid-certified nursing facility
unless the individual has been determined through a pre-admission
screening and annual resident review assessment to be eligible for
the specialized service of MH rehabilitative services;
(E) a patient in a general medical hospital; or
(F) not Medicaid-eligible.
(2) With the exception of crisis intervention services
and psychosocial rehabilitative services that are being provided to
resolve a crisis situation, the department will not reimburse a Medicaid
provider for any combination of MH rehabilitative services delivered
in excess of eight hours per individual per day. In addition, the
department will not reimburse a Medicaid provider for more than:
(A) two hours per individual per day of medication
training and support services;
(B) four hours per individual per day of psychosocial
rehabilitative services when the psychosocial rehabilitative services
are being provided in non-crisis situations;
(C) four hours per individual per day of skills training
and development services; and
(D) six hours per individual per day of day programs
for acute needs.
(3) The department will not reimburse a Medicaid provider
for:
(A) an MH rehabilitative service that is not included
in the individual's recovery plan (except for crisis intervention
services documented in accordance with §416.6(b) of this title
(relating to Service Authorization and Recovery Plan)) and psychosocial
rehabilitative services provided in a crisis situation;
(B) an MH rehabilitative service that is not authorized
in accordance with §416.6 of this title (except for crisis intervention
services documented in accordance with §416.6(b) of this title);
(C) an MH rehabilitative service provided in excess
of the amount authorized in accordance with §416.6(a)(1) of this
title;
(D) an MH rehabilitative service provided outside of
the duration authorized in accordance with §416.6(b) of this
title;
(E) a psychosocial rehabilitative service provided
to an individual receiving MH case management services in accordance
with Chapter 412, Subchapter I of this title (relating to MH Case
Management);
(F) an MH rehabilitative service that is not documented
in accordance with §416.12 of this title (relating to Documentation
Requirements);
(G) an MH rehabilitative service provided to an individual
who does not meet the eligibility criteria as described in §416.5
of this title (relating to Eligibility);
(H) an MH rehabilitative service provided to an individual
who does not have a current uniform assessment (except for crisis
intervention services documented in accordance with §416.6(b)
of this title);
(I) an MH rehabilitative service provided to an individual
who is not present, awake, and participating during such service;
(J) an MH rehabilitative service that is provided via
electronic media;
(K) a crisis service provided to an individual who
does not have a serious mental illness; and
(L) any other activity or service identified as non-reimbursable
in the department's MH Rehabilitative Services Billing Guidelines,
referenced in §416.17 of this title (relating to Guidelines).
(c) Services provided same time and same day.
(1) If a Medicaid provider provides more than one MH
rehabilitative service to an individual at the same time and on the
same day, the Medicaid provider may bill for only one of the services
provided.
(2) A Medicaid provider may bill for a MH rehabilitative
service provided to a child or adolescent's LAR or primary caregiver
at the same time and on the same day the child or adolescent is receiving
another MH rehabilitative service only if the staff member providing
the service to the LAR or primary caregiver is different from the
staff member providing the service to the child or adolescent.
(d) Services provided before a fair hearing. If the
provision of a MH rehabilitative service is continued prior to a fair
hearing decision being rendered, as required by 1 TAC §357.7
(relating to Agency and Designee Responsibilities), the Medicaid provider
may bill for such service.
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| Source Note: The provisions of this §307.327 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239 |
