| (a) Payment rate determination. Payment rates are determined
based on the methodology described for each service array.
(1) Traumatic Brain Injury (TBI) and Spinal Cord Injury
(SCI) Inpatient Comprehensive Medical Rehabilitation Services Array.
The Texas Department of Assistive and Rehabilitative Services or its
successor agency (DARS) negotiates contracts with inpatient facilities
to provide services based on data from the Centers for Medicare &
Medicaid Services (CMS) Healthcare Cost Report Information System
(HCRIS).
(2) TBI and SCI Outpatient Services Array.
(A) For services and purchases for which a specific
rate can be established without regard to the individual receiving
the service or item, the Texas Health and Human Services Commission
(HHSC) will establish Comprehensive Rehabilitation Services (CRS)
fee-for-service rates based on a review of rates for similar services
as presented in one or more of the following data sources: HHSC fee
schedules, previous DARS fee schedules, Medicare fee schedules, other
states' Medicaid fee schedules, and/or commercial insurance fee schedules.
(i) Where information on comparable rates is not available,
HHSC will establish rates representing best value based on the factors
listed in §391.103(2) of this title (relating to Definitions).
(ii) To ensure adequate access to services, DARS medical
director, or optometric consultant may approve exceptions to established
rates, with review by the HHSC Provider Finance Department (PFD).
(B) For services and purchases for which a specific
rate can be established without regard to the individual receiving
the service or item, but for which a CRS rate has not yet been set
at the time an individual's program planning team determines that
the service is required, HHSC will establish an interim CRS rate.
(i) DARS will contact HHSC PFD to request an interim
CRS rate.
(ii) HHSC PFD will determine the interim CRS rate based
on the process in subparagraph (A) of this paragraph.
(iii) Claims paid at an interim rate established under
this subparagraph will not be adjusted once a rate is formally adopted
for that service.
(C) For services and purchases for which the cost of
the service or item purchased is specific to the individual receiving
the service or item, HHSC will establish a CRS rate at the time of
purchase, based on best value, as defined by the reasonable and customary
industry standards for each specific service or item purchased.
(3) Post-Acute Brain Injury (PABI) Residential Services
Array. DARS will pay providers a per diem rate for each allowable
day of PABI Residential Service. DARS will also pay providers for
such ancillary services as have been approved in the individual's
program plan and received by the individual.
(A) The initial per diem rate is the sum of a base
component, which covers room and board, administration, personal assistance,
and facility and operations costs; a core service component, which
covers core therapy services; and an additional amount for periodic
required evaluations.
(i) HHSC determines the base component as follows:
(I) determine the rates for the small and medium classes
of facilities in the Intermediate Care Facilities for Individuals
with an Intellectual Disability or Related Conditions (ICF/IID) program
as specified in §355.456 of this chapter (relating to Reimbursement
Methodology);
(II) adjust the ICF/IID rates to account for the specific
needs of the CRS population; and
(III) average the adjusted rates for individuals with
limited, extensive, pervasive, and pervasive plus levels of need,
weighting by the days of service for those individuals from the most
recently reviewed and accepted ICF/IID cost reports.
(ii) HHSC determines the core service component by
reviewing the rates or contracted payment amounts for similar services,
including the five common core therapy services (Physical Therapy,
Occupational Therapy, Speech/Language Therapy, Cognitive Rehabilitation
Therapy, and Neuropsychological Therapy) paid by the following payers:
HHSC, the Texas Department of Aging and Disability Services (DADS),
DARS, Medicare, other states' Medicaid programs, and commercial insurance
companies. Based on this review, HHSC determines an appropriate rate
per hour that is multiplied by the hours in the tier structure below
to determine the rate for each tier. Determination of the applicable
tier for a day of service is governed by DARS program standards.
(I) Base - 0 hours.
(II) Base Plus - 0.5 hours.
(III) Tier 1 - 1.5 hours.
(IV) Tier 2 - 2.5 hours.
(V) Tier 3 - 3.5 hours.
(VI) Tier 4 - 4.5 hours.
(VII) Tier 5 - 5.5 hours.
(VIII) Tier 6 - 6.5 hours.
(IX) Tier 7 - 7.5 hours.
(X) Tier 8 - 8.5 hours.
(iii) HHSC determines the additional amount for periodic
required evaluations by averaging the common core therapy evaluation
rates, multiplying the average by 12, and dividing the product by
the number of days in the rate year.
(B) If HHSC determines that adequate cost and services
delivery data is available, HHSC may rebase the per diem rate components.
(i) For the base component, if HHSC deems it appropriate
to require contracted providers to submit a cost report, HHSC will
determine if cost data collected as described in subsection (c) of
this section is reliable and sufficient to support development of
a cost report-based rate. If such reliable and sufficient data is
available, HHSC may develop a reimbursement rate using that data to
replace the initial base component.
(ii) For the core service component, HHSC will collect
and evaluate detailed service delivery data. HHSC may rebase the core
service component based on the detailed service delivery data.
(C) HHSC determines the ancillary services rates as
described in paragraph (2) of this subsection.
(4) PABI and Post-Acute SCI Non-Residential Services
Array. HHSC will set separate base rates for facility-based and community-based
services, as described in subparagraph (A) of this paragraph. DARS
will pay for each allowable billing increment, as defined by program
standards. DARS will also pay for such core and ancillary services
as have been approved in the individual's program plan and received
by the individual.
(A) Initial rates will consist of an hourly base rate
which covers administration, personal assistance, and facility and
operations costs.
(i) For providers offering Non-Residential Services
in a setting that is also a residential facility or shares space with
a residential facility, HHSC determines the initial hourly base rate
as follows:
(I) determine the rates for the small and medium classes
of facilities in the ICF/IID program as specified in §355.456
of this chapter;
(II) adjust the ICF/IID rates to account for the specific
needs of the CRS population and the base services to be provided in
a Non-Residential facility-based setting;
(III) average the adjusted rates for individuals with
limited, extensive, pervasive and pervasive plus levels of need, weighting
by the days of service for those individuals from the most recently
reviewed and accepted ICF/IID cost reports; and
(IV) divide the average by eight.
(ii) For providers offering Non-Residential Services
in the home of the individual receiving the service or in a community
setting not connected or affiliated with a residential setting, HHSC
determines the initial hourly base rate as follows:
(I) determine the case management and the other attendant
care cost components (also known as the administration and facility
cost area) of the habilitation base rate under the Community Living
Assistance and Support Services (CLASS) program, as described in §355.505
of this chapter (relating to Reimbursement Methodology for the Community
Living Assistance and Support Services Waiver Program); and
(II) adjust the rate to account for specific needs
of the CRS population and the base services to be provided in a non-residential
home or community setting.
(B) If HHSC deems it appropriate to require contracted
providers to submit a cost report, HHSC will determine if cost data
collected as described in subsection (c) of this section is reliable
and sufficient to support development of a cost-report-based rate.
If such reliable and sufficient data is available, HHSC may develop
cost-report-based rates to replace the initial hourly base rates.
(C) HHSC will determine the rates for core services
as described in paragraph (2)(A) of this subsection.
Cont'd... |
