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TITLE 40SOCIAL SERVICES AND ASSISTANCE
PART 1DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 9INTELLECTUAL DISABILITY SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES
SUBCHAPTER DHOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC)
RULE §9.170Reimbursement

Program provider reimbursement.

  (1) A program provider is paid for services as described in this paragraph.

    (A) DADS pays for supported home living, professional therapies, nursing, respite, employment assistance, supported employment, and CFC PAS/HAB in accordance with the reimbursement rate for the specific service.

    (B) DADS pays for host home/companion care, residential support, supervised living, and day habilitation in accordance with the individual's LON and the reimbursement rate for the specific service.

    (C) DADS pays for adaptive aids, minor home modifications, and dental treatment based on the actual cost of the item and, if requested, a requisition fee in accordance with the HCS Program Billing Guidelines, which are available at www.dads.state.tx.us.

    (D) DADS pays:

      (i) for TAS based on a Transition Assistance Services (TAS) Assessment and Authorization form authorized by DADS and the actual cost of the TAS as evidenced by purchase receipts required by the HCS Program Billing Guidelines; and

      (ii) if requested, a TAS service fee in accordance with the HCS Program Billing Guidelines.

    (E) DADS pays for pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment based on a Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized by DADS and the actual cost of the pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment as evidenced by documentation required by the HCS Program Billing Guidelines.

    (F) Subject to the requirements in the HCS Program Billing Guidelines, DADS pays for TAS, pre-enrollment minor home modifications, and a pre-enrollment minor home modifications assessment regardless of whether the applicant enrolls with the program provider.

    (G) DADS pays for CFC ERS based on the actual cost of the service, not to exceed the reimbursement rate ceiling for CFC ERS.

  (2) If an individual's HCS Program services or CFC services are suspended or terminated the program provider must not submit a claim for services 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 for the following services:

    (A) day habilitation;

    (B) supported home living;

    (C) respite;

    (D) employment assistance;

    (E) supported employment;

    (F) professional therapies;

    (G) nursing; and

    (H) CFC PAS/HAB.

  (3) If the program provider submits a claim for an adaptive aid that costs $500 or more or for a minor home modification that costs $1,000 or more, the claim must be supported by a written assessment from a licensed professional specified by DADS in the HCS Program Billing Guidelines and other documentation as required by the HCS Program Billing Guidelines.

  (4) DADS does not pay the program provider for a service or recoups any payments made to the program provider for a service if:

    (A) except for an individual receiving TAS, pre-enrollment minor home modifications, or a pre-enrollment minor home modifications assessment, the individual receiving the service is, at the time the service was provided, ineligible for the HCS Program or Medicaid benefits, or was an inpatient of a hospital, nursing facility, or ICF/IID;

    (B) except for TAS, pre-enrollment minor home modifications, and a pre-enrollment minor home modifications assessment:

      (i) the service is provided to an individual during a period of time for which there is not a signed, dated, and authorized IPC for the individual;

      (ii) the service is provided during a period of time for which there is not a signed and dated ID/RC Assessment for the individual;

      (iii) the service is provided during a period of time for which the individual did not have an LOC determination;

      (iv) the service is not provided in accordance with a signed, dated, and authorized IPC meeting the requirements set forth in §9.159(c) of this subchapter (relating to IPC);

      (v) the service is not provided in accordance with the individual's PDP or implementation plan;

      (vi) the service is provided before the individual's enrollment date into the HCS Program; or

      (vii) the service is not included on the signed, dated, and authorized IPC of the individual in effect at the time the service was provided, except as permitted by §9.166(d) of this subchapter (relating to Renewal and Revision of an IPC);

    (C) the service is not provided in accordance with the HCS Program Billing Guidelines or the CFC Billing Guidelines for HCS and TxHmL Program Providers;

    (D) the program provider provides the supervised living or residential support service in a residence in which four individuals or other person receiving similar services live without DADS approval as required in §9.188 of this subchapter (relating to DADS Approval of Residences);

    (E) the service is not documented in accordance with the HCS Program Billing Guidelines or the CFC Billing Guidelines for HCS and TxHmL Program Providers;

    (F) the claim for the service does not meet the requirements in §49.311 of this title (relating to Claims Payment) or the HCS Program Billing Guidelines or the CFC Billing Guidelines for HCS and TxHmL Program Providers;

    (G) the program provider does not have the documentation described in paragraph (3) of this section;

    (H) DADS determines that the service 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 the service;

    (I) before including employment assistance on an individual's IPC, the program provider does not ensure and maintain documentation in the individual's record that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);

    (J) before including supported employment on an individual's IPC, the program provider does not ensure and maintain documentation in the individual's record that supported employment is not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);

    (K) the service is provided by a service provider who does not meet the qualifications to provide the service as described in the HCS Program Billing Guidelines or the CFC Billing Guidelines for HCS and TxHmL Program Providers;

    (L) the service of host home/companion care, residential support, or supervised living is provided on the day of the individual's suspension or termination of HCS Program services;

    (M) the service was paid at an incorrect LON because the ID/RC Assessment electronically transmitted to DADS does not contain information identical to information on the signed and dated ID/RC Assessment;

    (N) for TAS, the service is not provided in accordance with a Transition Assistance Services (TAS) Assessment and Authorization form authorized by DADS;

    (O) for pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment, the service is not provided in accordance with a Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized by DADS;

    (P) for a CFC service, the service is provided to an individual receiving host home/companion care, supervised living, or residential support; or

    (Q) for transportation as a supported home living activity, the service is not provided in accordance with a transportation plan.

  (5) The program provider must refund to DADS any overpayment made to the program provider within 60 calendar days after the program provider's discovery of the overpayment or receipt of a notice of such discovery from DADS, whichever is earlier.

  (6) DADS conducts billing and payment reviews to monitor a program provider's compliance with this subchapter, the HCS Program Billing Guidelines, and the CFC Billing Guidelines for HCS and TxHmL Program Providers. DADS conducts such reviews in accordance with the Billing and Payment Review Protocol set forth in the HCS Program Billing Guidelines and the CFC Billing Guidelines for HCS and TxHmL Program Providers. As a result of a billing and payment review, DADS may:

    (A) recoup payments from a program provider; and

    (B) based on the amount of unverified claims, require a program provider to develop and submit, in accordance with DADS instructions, a corrective action plan that improves the program provider's billing practices.

  (7) A corrective action plan required by DADS in accordance with paragraph (6)(B) of this section must:

    (A) include:

      (i) the reason the corrective action plan is required;

      (ii) the corrective action to be taken;

      (iii) the person responsible for taking each corrective action; and

      (iv) a date by which the corrective action will be completed that is no later than 90 calendar days after the date the program provider is notified the corrective action plan is required;

    (B) be submitted to DADS within 30 calendar days after the date the program provider is notified the corrective action plan is required; and

    (C) be approved by DADS before implementation.

  (8) Within 30 calendar days after the corrective action plan is received by DADS, DADS notifies the program provider if a corrective action plan is approved or if changes to the plan are required.

  (9) If DADS requires a program provider to develop and submit a corrective action plan in accordance with paragraph (6)(B) of this section and the program provider requests an administrative hearing for the recoupment in accordance with §9.186 of this subchapter (relating to Program Provider's Right to Administrative Hearing), the program provider is not required to develop or submit a corrective action plan while a hearing decision is pending. DADS notifies the program provider if the requirement to submit a corrective action plan or the content of such a plan changes based on the outcome of the hearing.

  (10) If the program provider does not submit the corrective action plan or complete the required corrective action within the time frames described in paragraph (7) of this section, DADS may impose a vendor hold on payments due to the program provider under the contract until the program provider takes the corrective action.

  (11) If the program provider does not submit the corrective action plan or complete the required corrective action within 30 calendar days after the date a vendor hold is imposed in accordance with paragraph (10) of this section, DADS may terminate the contract.


Source Note: The provisions of this §9.170 adopted to be effective March 1, 2000, 25 TexReg 1649; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective June 1, 2006, 31 TexReg 4442; amended to be effective March 1, 2007, 32 TexReg 537; amended to be effective June 1, 2010, 35 TexReg 4441; amended to be effective January 1, 2013, 37 TexReg 9969; amended to be effective September 1, 2014, 39 TexReg 6516; amended to be effective November 15, 2015, 40 TexReg7827; amended to be effective March 20, 2016, 41 TexReg 1867

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