| (A) Pediatric care facility--Except as provided for
in subparagraph (C) of this paragraph, a pediatric care facility is
an entire facility that has maintained an average daily census of
80% or more children for the six-month period prior to its entry into
the pediatric care facility class based on the entire licensed facility.
A pediatric care facility can also be a distinct unit of a facility
that has maintained an average daily census of 85% or more children
for the six-month period prior to its entry into the pediatric care
facility class based on the distinct unit of the facility. To remain
a pediatric care facility, the pediatric care facility must maintain
an average daily census of 80% or more children if the pediatric care
facility is an entire facility and 85% or more children if the pediatric
care facility is a distinct unit of the facility. The contracted provider
must request in writing by certified mail or by special mail delivery
where the delivery can be verified to become a member of the pediatric
care facility special reimbursement class. The request must be sent
to the Texas Health and Human Services Commission.
(B) Distinct unit--A portion of a nursing facility
that is physically separate from (beds are not commingled with) other
units of the facility. The distinct unit can be an entire wing, a
separate building, an entire floor, or an entire hallway. The distinct
unit consists of all beds within the designated area. A distinct unit
must consist of 28 or more Medicaid-contracted beds.
(C) Children--For the purposes of this pediatric care
facility class, children are defined as being at or below 22 years
of age.
(i) Only for a pediatric care facility that is designated
in its entirety as a pediatric care facility, a limited number of
adults who were admitted to the facility as children but who are no
longer children (i.e., individuals who have "aged in place") may be
counted as children for purposes of determining if the facility meets
the requirements for remaining a pediatric care facility described
in subparagraph (A) of this paragraph. The number of such individuals
who may be counted as children for purposes of determining if the
facility continues to meet the requirements for remaining a pediatric
care facility is limited to 33% of the average daily census of the
facility.
(ii) Individuals who have "aged in place" as described
in clause (i) of this subparagraph may not be counted toward meeting
the requirements for a facility to initially become a pediatric care
facility nor can they be counted toward meeting the requirements for
a distinct unit to remain a pediatric care facility.
(3) Payment rate determination. Payment rates will
be determined in the following manner:
(A) Cost reports and payment rate determination for
pediatric care facilities are governed by the requirements specified
in Subchapter A of this chapter (relating to Cost Determination Process)
except that payment rates are determined annually, coincident with
the state's fiscal year, within available funds. A nursing facility
that contains a pediatric care facility distinct unit must complete
two cost reports: one report for the pediatric care facility distinct
unit and one report for the remainder of the facility.
(B) Payment rates for this class of service will be
determined on a facility-specific basis for the pediatric care facility.
The total allowable costs from the most recent cost report deemed
acceptable are adjusted for inflation from the cost report period
to the rate period. The adjusted cost is divided by the greater of
total patient days of service reported on the cost report or the days
of service at 85% of contracted capacity of the pediatric care facility.
The resulting cost per day is multiplied by a factor of 1.03 to determine
the final facility-specific rate. If no acceptable cost report is
available, the provider will be required to submit a cost report covering
the time period specified by HHSC.
(C) The facility-specific payment rate from paragraph
(3)(B) of this subsection will be paid for all Medicaid residents
of a qualifying pediatric care facility regardless of the RUG level
of the resident.
(D) Residents of the pediatric care facility will not
be eligible to receive the ventilator-dependent or the children-with-tracheostomies
supplemental reimbursements.
(E) Pediatric care facilities are not eligible to participate
in §355.308 of this title (relating to Enhanced Direct Care Staff
Rate).
(F) The facility's cost-based retrospective cost settlement
will be determined annually. An annual settlement payment will only
be made for fiscal years in which the average daily census for the
facility in that year was less than the average daily census of the
prior fiscal year, except that no settlement will be made for fiscal
years in which the average daily census for the facility exceeded
85 percent or for fiscal years in which the facility's Medicaid revenues
exceeded its Medicaid allowable costs.
(4) If HHSC determines that a pediatric care facility
that is designated in its entirety as a pediatric care facility no
longer qualifies as a member of such class according to paragraph
(2) of this subsection, HHSC will notify the facility in writing.
(A) Within 30 calendar days of the date on the written
notification, HHSC Rate Analysis must receive a written compliance
plan from the facility as described in subparagraph (B) of this paragraph.
If the 30th calendar day is a weekend day, national holiday, or state
holiday, the first business day following the 30th calendar day is
the final day receipt of the plan will be accepted.
(B) The compliance plan must indicate the facility's
intent to, within 180 calendar days of the date of HHSC's initial
written notification to the facility, come into compliance with paragraph
(2) of this subsection by:
(i) Managing a sufficient number of admissions and
discharges to come into compliance with the requirements of paragraphs
(2)(A) and (2)(C) of this subsection to remain a member of the pediatric
care facility special reimbursement class;
(ii) Creating a distinct unit of the facility as described
under paragraph (2)(B) of this subsection; or
(iii) Withdrawing the entire facility from the pediatric
care facility special class.
(C) HHSC will make a written determination regarding
approval or disapproval of the compliance plan. A facility that submits
a compliance plan that is subsequently disapproved will cease being
reimbursed as a member of the pediatric facility special class on
the first day of the month following HHSC's disapproval of the compliance
plan.
(D) A compliance plan that is not received by the stated
deadline will not be accepted, and the facility will be removed from
the pediatric care facility special reimbursement class retroactive
to the first day of the month following the date of HHSC's initial
written notification to the facility.
(E) A facility that obtains approval of its compliance
plan from HHSC Rate Analysis will continue to be reimbursed as a member
of the pediatric care special class until 180 calendar days of the
date of HHSC's initial written notification to the facility. If by
that time the facility has not achieved the stated goal of its compliance
plan, the facility will be removed from the pediatric care special
class effective the first day of the following month.
(F) If, at any time, HHSC determines that a facility
that has come into compliance with paragraph (2) of this subsection
by managing a sufficient number of admissions and discharges, as described
in subparagraph (B)(i) of this paragraph, no longer qualifies as a
member of such class, that facility will be excluded from the pediatric
care special class for 365 days from the date HHSC makes its determination.
The facility may apply to rejoin the class on the 366th day.
(G) A facility that is removed from or withdraws from
the pediatric care special class will be considered a new facility,
as described in §355.308(e) of this title for purposes of enrollment
in the Nursing Facility Direct Care Staff Rate enhancement.
(H) A facility that is removed or withdraws from the
pediatric care special class may not re-enter the class within one
year of its removal or withdrawal.
(d) Nurse aide training and competency evaluation costs.
(1) DADS reimburses nursing facilities for the actual
costs of training and testing nurse aides as required under the Omnibus
Budget Reconciliation Act of 1987 (OBRA '87). Payments are based on
cost reimbursement vouchers that are to be submitted quarterly. Allowable
costs are limited to those costs incurred for training provided after
October 1, 1990, for:
(A) actual training course expenses up to a set amount
determined by DADS per nurse aide;
(B) competency evaluation; or
Cont'd... |
