| (a) HHSC pays a program provider for on-site individualized
skills and socialization and off-site individualized skills and socialization
in accordance with the reimbursement rates.
(b) If an individual's DBMD Program services and CFC
services are suspended or terminated, a program provider must not
submit a claim for on-site individualized skills and socialization
or off-site individualized skills and socialization provided during
the period of the individual's suspension or after the termination,
except the program provider may submit a claim for the first calendar
day of the individual's suspension or termination.
(c) A program provider must not bill for and HHSC does
not pay a program provider for on-site individualized skills and socialization
or off-site individualized skills and socialization, or recoups any
payments made to the program provider for on-site individualized skills
and socialization or off-site individualized skills and socialization:
(1) if individualized skills and socialization is not
provided in accordance with this subchapter and Chapter 559, Subchapter
H of this title (relating to Individualized Skills and Socialization
Provider Requirements);
(2) if the individual receiving individualized skills
and socialization is, at the time individualized skills and socialization
was provided, ineligible for the DBMD Program;
(3) if individualized skills and socialization is provided
during a period of time for which there is not a signed and dated
ID/RC Assessment for the individual;
(4) if individualized skills and socialization is provided
during a period of time for which the individual did not have an LOC
determination;
(5) if individualized skills and socialization is not
provided in accordance with the individual's IPP;
(6) if the program provider did not comply with 40
TAC §49.305 (relating to Records);
(7) if the claim for the service did not meet the requirements
in 40 TAC §49.311 (relating to Claims Payment);
(8) if individualized skills and socialization is provided
by a service provider who did not meet the qualifications to provide
individualized skills and socialization as described in §260.513
of this subchapter (relating to Service Provider Qualifications and
Training) and §559.227 of this title (relating to Program Requirements);
(9) if the program provider did not comply with the
DBMD Program Manual;
(10) if HHSC determines that individualized skills
and socialization would have been paid for by a source other than
the DBMD Program if the program provider had submitted to the other
source a proper, complete, and timely request for payment for individualized
skills and socialization;
(11) if individualized skills and socialization was
not provided; or
(12) if individualized skills and socialization is
provided during a period of time that the individual produced marketable
goods and was paid below minimum wage for producing the goods in accordance
with Section 14(c) of the Fair Labor Standards Act.
(d) HHSC does not pay a program provider for day habilitation
or recoups any payments made to the program provider for day habilitation
provided on or after March 1, 2023, even if an individual's IPC includes
day habilitation on or after March 1, 2023.
(e) HHSC conducts contract and fiscal monitoring in
accordance with rules governing the DBMD Program to determine whether
a program provider is in compliance with this subchapter.
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