| (a) Definitions. In this section, the following words
and terms have the following meanings unless the context clearly indicates
otherwise.
(1) All conditions of eligibility--A recipient meets
all conditions of eligibility when the state Medicaid claims administrator
approves the recipient for medical necessity and the recipient meets
financial eligibility for Medicaid.
(2) On-time MDS assessment--An MDS assessment that
is submitted in accordance with the federal MDS submission schedule
and is received by the state Medicaid claims administrator within
31 days after the completion date.
(3) Missed MDS assessment--An MDS assessment that is
received by the state Medicaid claims administrator outside the time
period that the MDS assessment covers.
(b) MDS submission requirement. A nursing facility
must:
(1) complete all MDS assessments according to CMS'
instructions;
(2) submit a recipient's MDS assessment, including
an admission MDS assessment, a quarterly MDS assessment, and a significant
change in status assessment, to the state MDS database in compliance
with the federal MDS submission schedule;
(3) submit the Long-Term Care Medicaid Information
Section to the state Medicaid claims administrator; and
(4) submit the recipient's MDS assessment in compliance
with the federal MDS submission schedule even after the recipient
has permanent medical necessity as described in §19.2403(e)
of this subchapter (relating to Medical Necessity Determination).
(c) Admission MDS assessments.
(1) If a nursing facility discharges a recipient with
a status of return not anticipated, and the recipient returns to the
facility, the nursing facility must complete an admission MDS assessment
for a determination of medical necessity and establishment of a RUG
rate, regardless of the amount of time between the recipient's discharge
and return.
(2) A nursing facility must complete and submit an
admission MDS assessment to receive payment for a recipient's period
of stay in the nursing facility, even if the recipient leaves the
nursing facility before the MDS assessment is completed and never
returns long enough for the MDS assessment to be completed. See subsection
(i) of this section for completion of an admission MDS assessment
in the event of a recipient's death.
(3) DADS pays a calculated RUG rate for an admission
MDS assessment from the date the recipient was admitted to the nursing
facility, except as provided in §19.2611 of this chapter (relating
to Retroactive Vendor Payments).
(d) Payment of a calculated RUG rate. If a recipient
meets all conditions of eligibility, DADS pays a calculated RUG rate
for an MDS assessment if it is received by the state Medicaid claims
administrator during the time period that the MDS assessment covers.
(e) On-time MDS assessment. If a recipient meets all
conditions of eligibility, DADS pays a calculated RUG rate from the
completion date of the required MDS assessment, except for an admission
MDS assessment as described in subsection (c)(3) of this section.
(f) MDS assessments that are not on time. The state
Medicaid claims administrator stops payment for services if the state
Medicaid claims administrator does not receive an on-time MDS assessment.
Payment for services resumes when the state Medicaid claims administrator
receives all MDS assessments that are due as required by the federal
MDS submission schedule.
(g) Missed MDS assessments. When the state Medicaid
claims administrator receives a missed MDS assessment, DADS pays the
nursing facility a default RUG rate for the entire period of the missed
MDS assessment if the recipient meets financial eligibility for Medicaid,
except as provided in paragraph (2) of this subsection.
(1) If an MDS assessment is missed for the purpose
of calculating a RUG rate, the nursing facility must still submit
the MDS assessment to comply with §19.801 of this chapter (relating
to Resident Assessment).
(2) For a newly contracted nursing facility and a nursing
facility that undergoes a change of ownership, DADS pays the calculated
RUG rate for any missed MDS assessments that occur while the nursing
facility is unable to submit MDS assessments to the state MDS database.
(h) Significant change in status assessment, modification,
or significant correction. If a recipient meets all conditions of
eligibility, DADS pays the calculated RUG rate from the completion
date of a significant change in status assessment, modification, or
significant correction.
(i) Incomplete or erroneous MDS assessments. If an
applicant meets all conditions of eligibility, DADS pays a default
rate for an MDS assessment that is incomplete or has errors.
(j) Prohibition against recourse. A nursing facility
must not charge and must not take any other recourse against a recipient,
the recipient's family members, the recipient's estate or the recipient's
representative for a claim that is reduced because the facility failed
to comply with a DADS rule or procedure pertaining to reimbursement.
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| Source Note: The provisions of this §554.2413 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
