| (V) the case mix group's total direct care staff rate
component for that participating facility as determined in §355.308(l)
of this title (relating to Direct Care Staff Rate Component).
(ii) For nonparticipating facilities, for each of the
RUG-III case mix groups and for the default groups, the recommended
total per diem rate is the sum of the following five rate components:
(I) the dietary rate component from paragraph (1)(A)
of this subsection;
(II) the general/administration rate component from
paragraph (1)(B) of this subsection;
(III) the fixed capital asset use fee component from
paragraph (1)(C) of this subsection;
(IV) the case mix group's other recipient care per
diem rate component by case mix group from subparagraph (D) of this
paragraph; and
(V) the case mix group's total direct care staff base
rate component as determined in §355.308(k) of this title (relating
to Direct Care Staff Rate Component).
(F) Qualifying ventilator-dependent residents may receive
a supplement to the per diem rate specified in subparagraph (E) of
this paragraph.
(i) To qualify for supplemental reimbursement, a resident
must require artificial ventilation for at least six consecutive hours
daily and the use must be prescribed by a licensed physician.
(ii) A ventilator-dependent resource differential case
mix index for the other recipient care rate component is calculated
by subtracting the standardized statewide case mix index for the SE1
RUG-III case mix group from subparagraph (C) of this paragraph from
3.61. A ventilator-dependent resource differential case mix index
for the direct care staff base rate component is calculated by dividing
the resource differential case mix index for the other recipient care
rate component by 0.9908.
(iii) The per diem rate supplement is calculated by
multiplying the resource differential case mix index for the other
recipient care rate component times the per diem average other recipient
care rate component, as described in subparagraph (D) of this paragraph
and multiplying the resource differential case mix index for the direct
care staff base rate component by the average direct care staff base
rate component as described in §355.308(k) of this title (relating
to Direct Care Staff Rate) and summing the products.
(iv) The supplemental reimbursement for residents requiring
continuous artificial ventilation is 100% of the per diem ventilator
rate supplement.
(v) The supplemental reimbursement for residents not
requiring continuous artificial ventilation daily but requiring artificial
ventilation for at least six consecutive hours daily is 40% of the
per diem ventilator rate supplement.
(G) Qualifying children with tracheostomies requiring
daily care may receive a supplement to the per diem rate specified
in subparagraph (E) of this paragraph.
(i) To qualify for supplemental reimbursement, a resident
must be less than 22 years of age; require daily cleansing, dressing,
and suctioning of a tracheostomy; and be unable to do self care. The
daily care of the tracheostomy must be prescribed by a licensed physician.
(ii) The supplemental reimbursement for children receiving
daily tracheostomy care is 60% of the per diem ventilator rate supplement
as specified in subparagraph (F) of this paragraph.
(H) Children with qualifying conditions as specified
in subparagraphs (F) and (G) of this paragraph may receive only one
of the supplemental reimbursements. Therefore, children with tracheostomies
who are also ventilator-dependent are not eligible to receive both
supplemental reimbursements.
(c) Special reimbursement class. HHSC may define special
reimbursement classes, including experimental reimbursement classes
of service to be used in research and demonstration projects on new
reimbursement methods and reimbursement classes of service, to address
the cost differences of a select group of recipients. Special classes
may be implemented on a statewide basis, may be limited to a specific
region of the state, or may be limited to a selected group of providers.
Reimbursement for the Pediatric Care Facility Class is calculated
as specified in §355.316 of this subchapter (relating to Reimbursement
Methodology for Pediatric Care Facilities).
(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
(C) supplies and materials used in the nurse aide training
not already covered by the training course fee.
(2) Nurse aide salaries while in training are factored
into the vendor rate and are not to be included on the reimbursement
voucher.
(3) Training program costs that exceed the DADS cost
ceiling must have prior approval from DADS before costs can be reimbursed.
A written request to Provider Billing Services must include:
(A) name and vendor number of facility.
(B) description of training program for which the facility
is seeking reimbursement approval, to include:
(i) name, telephone number and address of the nurse
aide training and competency evaluation program (NATCEP);
(ii) whether the NATCEP program is facility or non-facility-based;
and
(iii) name of the NATCEP program director.
(C) an explanation of why the cost for the NATCEP exceeds
the reimbursement ceiling. The explanation must include:
(i) a completed nurse aide unit cost calculation form
for a facility-based NATCEP; or
(ii) a breakdown of the nurse aide unit cost by the
instructor fees and training materials for a non-facility-based NATCEP.
(D) an explanation of why the nursing facility cannot
utilize a training program at or below the reimbursement ceiling and
what steps the facility has taken to explore more cost efficient training
courses. The explanation must include:
(i) the availability of NATCEPs, such as the location
or the frequency of training offered, in the geographic region of
the facility;
(ii) the name and address of each NATCEP that the facility
has explored as a provider of nurse aide training; and
(iii) the cost per nurse aide for each NATCEP identified
in clause (i) of this subparagraph, as specified in subparagraph (C)(i)
or (ii) of this paragraph.
(4) All prior approval requests as outlined in paragraph
(3) of this subsection must be submitted to DADS, Provider Billing
Services that:
(A) may request additional information in order to
evaluate a reimbursement request; and
(B) will make the final decision on a reimbursement
request.
(5) All nurse aide training courses must be approved
by DADS before costs associated with them can be reimbursed.
(6) Nursing facilities are responsible for tracking
and documenting nurse aide training costs for each nurse aide trained.
All documentation is subject to DADS audits. If substantiating documentation
for amounts billed to DADS cannot be verified, DADS will immediately
recoup funds paid to the facility.
(7) Individuals who have successfully completed a nurse
aide training and competency evaluation program (NATCEP) may be directly
reimbursed for costs incurred in completing a NATCEP. The individual
must meet all of the conditions specified in subparagraphs (A) - (E)
of this paragraph.
(A) The individual must not have been employed at the
time of completing the NATCEP.
(B) The individual must have been employed by, or received
an offer of employment from, a nursing facility not later than 12
months after successfully completing the NATCEP.
(C) The individual must have been employed by the facility
for no less than six months.
(D) The nursing facility must not have claimed reimbursement
for training expenses for the individual.
(E) The individual must be listed on the current Nurse
Aide Registry.
(8) Individuals must submit cost reimbursement vouchers
to DADS with proof that the individual has been employed by a facility
for no less than six months.
(9) Individuals who leave nursing facility employment
before accruing the required six months of employment, as specified
in paragraph (7)(C) of this subsection, may receive 50% reimbursement
as long as the individual was employed for no less than three months.
Cont'd... |
