(a) In this section, retroactive vendor payment is
payment DADS makes retroactively to a nursing facility for services
the nursing facility provided to an individual who was eligible for,
but had not yet applied for, Medicaid. A nursing facility is eligible
for up to three months retroactive vendor payment for services it
provided, if:
(1) the individual resided in a Medicaid-certified
nursing facility, or a distinct part, during the time services were
provided;
(2) the individual did not receive Supplemental Security
Income cash benefits;
(3) the individual met Medicaid financial eligibility
requirements;
(4) the state Medicaid claims administrator has a current
MDS assessment for the individual that the facility submitted in
compliance with the federal MDS submission requirements; and
(5) the nursing facility met physician certification
and plan of care requirements during the time services were provided.
(b) After receipt of an application for Medicaid, Texas
Health and Human Services Commission (HHSC) Medicaid eligibility staff
notify the applicant whether the applicant meets financial eligibility.
The state Medicaid claims administrator uses the applicant's current
MDS assessment to make the MN determination and determine the effective
date of the MN determination. For the purpose of establishing three
months prior eligibility, the effective date of the MN determination
for a new recipient is the first day of the month in which the recipient
qualified for MN.
(c) If the requirements in subsection (a) of this section
are met, DADS makes a retroactive vendor payment based on the recipient's
calculated RUG rate for the period covered by the retroactive vendor
payment.
(d) DADS or HHSC may verify that the recipient's record
includes the required physician's certification, recertification,
and plans of care, and that the plans were reviewed as required during
the applicable periods.
(e) If a recipient paid the nursing facility for services
for which the facility later receives retroactive vendor payment,
the facility must reimburse the recipient the full amount the recipient
paid, beginning with the effective date of Medicaid eligibility,
minus any applied income or co-payment as determined by HHSC Medicaid
eligibility staff.
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Source Note: The provisions of this §554.2611 adopted to be September 3, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |