(a) General provisions. The fee for an individual's
support, maintenance, and treatment (SMT) is assessed in accordance
with this section.
(1) Charges to the individual or legally authorized
representative (LAR), as appropriate, will not exceed the facility's
current maximum rate.
(2) Failure of the individual or LAR to provide financial
information upon request or to assign third-party benefits may result
in charges equal to the facility's current maximum rate accruing to
the individual.
(3) The finances and assets of an adult's guardian
or the guardian of the estate of a minor, who is not also the legal
guardian of the minor, are not considered in assessing fees.
(4) Charges to a payor that is not an individual or
LAR may exceed the facility's current maximum rate.
(b) Necessary financial information. Upon an individual's
admission to a facility, or shortly afterward, the reimbursement office
shall provide the individual, and their personal representative, or
their LAR, with a property and financial statement form, appropriate
to the type of services provided to the individual.
(c) Assessing fees for services provided to minor individuals.
(1) The following sources of funds are property from
which the state may be reimbursed for a minor individual's SMT and
are considered separately in assessing a fee:
(A) third-party coverage of the minor individual;
(B) the minor individual's benefits from governmental
and non-governmental agencies and institutions;
(C) child support ordered in a divorce or attorney
general proceeding or a suit affecting the parent-child relationship
pursuant to Texas Health and Safety Code §552.014 and §593.077;
(D) real or personal property in the minor individual's
guardianship estate or owned by the minor individual;
(E) the net taxable income of the minor individual's
parents as authorized by the Texas Health and Safety Code §552.017, §593.075,
and §593.076, in accordance with the Taxable Income of Parents
formula, which may be obtained at www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals;
www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs;
or by contacting the Texas Health and Human Services Commission (HHSC)
Health and Specialty Care, Reimbursement Management, P.O. Box 12668,
Austin, Texas 78701-2668, and Internal Revenue Services' guidelines;
and
(F) monthly net income of the minor individual (excluding
income from the source described in subparagraph (B) of this paragraph)
receiving services at a state supported living center, in accordance
with the Individuals in State Supported Living Centers formula, which
may be obtained at www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs
or by contacting the facility reimbursement office.
(2) An order in a divorce proceeding that provides
for child support payments (as referenced in paragraph (1)(C) of this
subsection) does not limit the fee that may be assessed (except that
it may not exceed the current maximum rate), nor does the order exempt
either parent from liability for the charges.
(d) Assessing a fee for adult individuals in inpatient
mental health facilities. The following sources of funds are considered
separately in assessing a fee:
(1) third-party coverage of the adult individual;
(2) the adult individual's benefits from governmental
and non-governmental agencies and institutions;
(3) real or personal property in the adult individual's
guardianship estate or owned by the adult individual or spouse; and
(4) monthly gross income of the adult individual (excluding
income from the source described in paragraph (2) of this subsection)
and income of the spouse, in accordance with the Adult Individuals
in Inpatient Mental Health Facilities formula, which may be obtained
at www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals
or by contacting the facility reimbursement office.
(e) Assessing a fee for adult individuals in state
supported living centers and the ICF/IID component of the Rio Grande
State Center. The following sources of funds are considered separately
in assessing a fee:
(1) third-party coverage of the adult individual;
(2) the adult individual's benefits from governmental
and non-governmental agencies and institutions;
(3) real or personal property in the adult individual's
guardianship estate or owned by the adult individual or spouse;
(4) the adult individual's monthly net earned income
in accordance with the Individuals in State Supported Living Centers
formula, which may be obtained at www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs
or by contacting HHSC Health and Specialty Care, Reimbursement Management,
P.O. Box 12668, Austin, Texas 78701-2668; and
(5) income of the adult individual (excluding income
from the sources described in paragraphs (2) and (4) of this subsection)
and income of the spouse.
(f) Trusts. The provisions of the Texas Health and
Safety Code §552.018 and §593.081, apply to the fee assessment
for an individual who is a beneficiary of a trust or trusts.
(g) Notification of charges. After a fee has been assessed,
the reimbursement office shall provide written notification to the
individual or LAR of charges that includes:
(1) the date on the notification of charges;
(2) the name of the individual receiving SMT from the
facility;
(3) the fees and the sources of funds used to assess
the fees;
(4) the effective dates of the fees;
(5) the facility's current maximum rate;
(6) a statement that the individual or LAR is responsible
for notifying the facility's reimbursement office within 30 days of
the change, when there is a change in any of the sources of funds
HHSC uses to assess a fee or a change in family status that would
affect any assessed fee;
(7) information on possible payments from a third-party
payor; and
(8) a statement that the individual or LAR has the
right to appeal under the following conditions if they disagree with
the fee.
(A) If the individual or LAR has submitted complete
financial information, then the individual or LAR must notify the
reimbursement office of their intent to appeal the fee. The individual
or LAR must initiate the appeal, in accordance with §910.8(c)
of this chapter (relating to Appeal Process), within 45 business days
of the date on the notification of charges.
(B) If the individual or LAR has not submitted complete
financial information, the individual or LAR must contact the reimbursement
office and provide complete financial information within 15 business
days of the date on the notification of charges or the individual
or LAR forfeits the right to appeal. If the individual or LAR provides
complete financial information within 15 business days of the date
on the notification of charges, the individual or LAR must initiate
the appeal, in accordance with §910.8(c) of this chapter, within
45 business days of the date on the notification of charges.
(h) Complete financial information received within
15 business days of the date on the notification of charges. If the
reimbursement office receives complete financial information from
the individual or LAR within 15 business days of the date on the notification
of charges as required in subsection (g)(8)(B) of this section, the
reimbursement office shall, within 10 business days:
(1) review the financial information;
(2) revise the fee, if appropriate; and
(3) inform the individual or LAR in writing:
(A) of the fee amount;
(B) that the individual or LAR has a right to appeal
if they disagree with the fee; and
(C) that an appeal must be initiated, in accordance
with §910.8(c) of this chapter within 45 business days of the
date on the notification of charges referenced in subsection (g) of
this section.
(i) Fee revision. HHSC shall determine if a fee revision
is warranted each time HHSC receives information indicating:
(1) a change in any of the sources of funds HHSC uses
to assess a fee; and
(2) a change in family status that would affect any
assessed fee.
(j) Individuals transferring between two facilities.
If an individual is transferred between two facilities, only the receiving
facility may bill for the day of transfer. The transferring facility
may not bill on the individual's date of admission from a transfer
from another HHSC operated facility.
(k) Individuals receiving Medicaid Benefits. If an
individual is receiving Medicaid benefits, reimbursement will be completed
pursuant to applicable federal and state Medicaid laws.
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