| (10) Reimbursement to individuals may not exceed the
reimbursement ceiling as detailed in paragraph (1)(A) of this subsection.
(e) Oxygen costs. Oxygen costs incurred on or after
January 1, 1995, will not be reimbursed on cost reimbursement vouchers.
Those oxygen costs must be reported as expenses on the cost report.
(f) TILE to RUG-III Hold Harmless Transition. For rates
effective September 1, 2008, payment rates for the direct care staff
component and the other recipient care component will be updated within
available funds, payment rates for the dietary, general/administration
and fixed capital asset rate components will be equal to the rates
in effect on August 31, 2008 times 1.025, payment rates for the professional
and general liability insurance add-on and the professional-only liability
insurance add-on will be equal to the rates in effect on August 31,
2008 times 1.024, and the payment rate for the general-only liability
insurance add-on will be equal to the rate in effect on August 31,
2008 times 1.018.
(1) To calculate the updated direct care staff per
diem rate component for each of the RUG-III case mix groups and for
the default groups, divide each of the standardized statewide case
mix indexes from subsection (b)(3)(C) of this section by 0.9908, which
is the weighted average TILE case mix index for the 1998 cost reporting
period, multiply each quotient by the statewide average TILE case
mix index for the period beginning the first day of December, 2007
and ending the last day of February, 2008 as represented in the Texas
Department of Aging and Disability Services (DADS) Claims Management
System (CMS) on or around June 1, 2008 and multiply each product by
the average updated direct care staff rate component.
(2) To calculate the updated other recipient care per
diem rate component for each of the RUG-III case mix groups and for
the default groups, divide each of the standardized statewide case
mix indexes from subsection (b)(3)(C) of this section by 1.0267, which
is the weighted average TILE case mix index for the 2005 cost reporting
period, multiply each quotient by the statewide average TILE case
mix index for the period beginning the first day of December, 2007
and ending the last day of February, 2008 as represented in the Texas
Department of Aging and Disability Services (DADS) Claims Management
System (CMS) on or around June 1, 2008 and multiply each product by
the average updated other recipient care rate component.
(3) For state fiscal year 2009 only, for each Medicaid-contracted
nursing facility, HHSC will:
(A) Calculate the sum of the weighted average TILE
direct care staff base rate (with no enhancements) and other recipient
care rate based on the TILE rates for these cost areas in effect on
August 31, 2008 and the facility's approved to be paid days of service
by TILE from January 1, 2008 through June 30, 2008 as represented
in the Texas Department of Aging and Disability Services (DADS) Claims
Management System (CMS) on or around November 3, 2008.
(B) Calculate the sum of the weighted average RUG-III
direct care staff base rate (with no enhancements) and other recipient
care rate based on the RUG rates for these cost areas in effect on
September 1, 2008 and the facility's approved to be paid days of service
by RUG-III for those recipients paid under RUG-III from September
1, 2008 through February 28, 2009 as represented in the DADS CMS on
or around March 31, 2009.
(C) Compare the sum from subparagraph (A) of this paragraph
to the sum from subparagraph (B) of this paragraph. If the sum from
subparagraph (A) is greater then the sum from subparagraph (B), DADS
will pay the facility 80 percent of the difference between the sum
from subparagraph (A) and the sum from subparagraph (B) times the
facility's approved to be paid days of service for those recipients
paid under RUG-III from September 1, 2008 through February 28, 2009
as represented in the DADS CMS on or around March 31, 2009.
(D) Calculate the sum of the weighted average RUG-III
direct care staff base rate (with no enhancements) and other recipient
care rate based on the RUG rates for these cost areas in effect on
September 1, 2008 and the facility's approved to be paid days of service
by RUG-III for those recipients paid under RUG-III from March 1, 2009
through August 31, 2009 as represented in the DADS CMS on or around
September 30, 2009.
(E) Compare the sum from subparagraph (A) of this paragraph
to the sum from subparagraph (D) of this paragraph. If sum from subparagraph
(A) is greater then the sum from subparagraph (D), DADS will pay the
facility 80 percent of the difference between the sum from subparagraph
(A) and the sum from subparagraph (D) times the facility's approved
to be paid days of service for those recipients paid under RUG-III
from March 1, 2009 through August 31, 2009 as represented in the DADS
CMS on or around September 30, 2009.
(F) Calculate the sum of the weighted average RUG-III
direct care staff base rate (with no enhancements) and other recipient
care rate based on the RUG rates for these cost areas in effect on
September 1, 2008, and the facility's approved to be paid days of
service by RUG-III for those recipients paid under RUG-III from September
1, 2008, through August 31, 2009, as represented in the DADS CMS on
or around January 4, 2010.
(G) Compare the sum from subparagraph (A) of this paragraph
to the sum from subparagraph (F) of this paragraph.
(i) If the sum from subparagraph (A) is greater than
the sum from subparagraph (F), determine the difference between the
sum from subparagraph (A) and the sum from subparagraph (F) times
the facility's approved to be paid days of service for those recipients
paid under RUG-III from September 1, 2008, through August 31, 2009,
as represented in the DADS CMS on or around January 4, 2010, and subtract
the hold harmless payments made under subparagraphs (C) and (E) from
the product calculated in this clause.
(I) If the result is a positive number, DADS will pay
the facility the difference.
(II) If the result is a negative number, DADS will
recoup the difference from the facility.
(ii) If the sum from subparagraph (A) is less than
the sum from subparagraph (F) and the facility received a hold harmless
payment under subparagraph (C) and/or (E), DADS will recoup from the
facility the hold harmless payments made under these subparagraphs.
(4) "On or around" as used in this subsection means
the date that the state pulls the information as described in the
subsection as close to the dates specified in subsection as feasible
and determined by the state. Once the state does the data pull, no
other pulls will be made for the purpose of calculating the values
described in this subsection. This means that once the paid days of
service for a paragraph have been determined for purposes of calculating
the TILE to RUG-III hold harmless transition, they will not be updated
for late Minimum Data Set (MDS) submissions, Utilization Review RUG-III
changes, retroactive eligibility or any other reason.
|
| Source Note: The provisions of this §355.307 adopted to be effective May 1, 2000, 25 TexReg 3517; amended to be effective September 1, 2001, 26 TexReg 6296; amended to be effective February 26, 2002, 27 TexReg 1311; amended to be effective September 1, 2003, 28 TexReg 7306; amended to be effective January 9, 2005, 29 TexReg 12121; amended to be effective August 21, 2008, 33 TexReg 6569; amended to be effective July 29, 2009, 34 TexReg 4857; amended to be effective September 1, 2013, 38 TexReg 5434; amended to be effective January 25, 2015, 40 TexReg 325; amended to be effective October 19, 2021, 46 TexReg 7039 |
