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RULE §355.502Reimbursement Methodology for Common Services in Home and Community-Based Services Waivers

(a) General requirements. The Texas Health and Human Services Commission (HHSC) applies the general principles of cost determination as specified in §355.101 of this title (relating to Introduction). Common services are those services that are available in multiple home and community-based services (HCBS) waivers.

(b) Professional services. Professional services include nursing services provided by a registered nurse (RN) or a licensed vocational nurse (LVN) (including Adjunct Support and Respite in the Medically Dependent Children Program), physical therapy, occupational therapy, speech/language therapy, cognitive rehabilitative therapy, nutrition/dietary services, audiology services, and behavioral support services.

(c) Employment services. Employment services include employment assistance and supported employment.

(d) Rates for professional services, employment services, and in-home respite. The rates for these services are calculated in the following manner:

  (1) If there is sufficient reliable cost report data from which to determine reimbursements, rates are calculated in the following manner.

    (A) An allowable cost per unit of service for each cost report is calculated in accordance with the specific methodology for each HCBS waiver.

    (B) The allowable cost per unit of service for each cost report for all HCBS waivers is combined into an array.

    (C) The array of allowable costs per unit of service for all HCBS waivers is weighted by the number of units of service, and the median cost per unit of service is calculated.

  (2) If there is not sufficient, reliable cost report data from which to determine reimbursements, reimbursements will be developed by using pro forma costing. This approach involves using historical costs of delivering similar services, where appropriate data are available, and estimating the basic types and costs of products and services necessary to deliver services meeting federal and state requirements.

  (3) Specialized nursing rates will be determined for both RN and LVN services by multiplying the RN and LVN rates by 1.15. The specialized nursing rate is paid when a client requires, as determined by a physician, daily skilled nursing to cleanse, dress, and suction a tracheostomy or daily skilled nursing assistance with ventilator or respirator care. The client must be unable to do self-care and require the assistance of a nurse for the ventilator, respirator, or tracheostomy care.

(e) Transition assistance services. The reimbursement for transition assistance services will be determined as a one-time rate per client based on modeled costs of compensation and other support costs using data from surveys, cost reports, consultation with other professionals in delivering contracted services, or other sources determined appropriate by HHSC.

Source Note: The provisions of this §355.502 adopted to be effective September 1, 2009, 34 TexReg 5654; amended to be effective June 20, 2011, 36 TexReg 3707; amended to be effective April 1, 2014, 39 TexReg 2062

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