| (a) Pediatric Care Facility Class. The purpose of this
special class is to recognize, through the adoption of a special payment
rate, the cost differences that exist in a pediatric nursing facility
or distinct unit of a nursing facility that serves predominantly children.
(b) Definitions. The following terms, when used in
this section, have the following meanings, unless otherwise stated.
(1) Children--For the purposes of this pediatric care
facility class, children are defined as being at or below 22 years
of age.
(A) Only a pediatric care facility that is designated
in its entirety as a pediatric care facility may count as children
a limited number of adults who were admitted to the facility as children,
but who are no longer children (i.e., individuals who have "aged in
place"), for purposes of determining if the facility meets the requirements
for remaining a pediatric care facility described in paragraph (3)
of this subsection. The number of such individuals who may be counted
as children for purposes of determining if the facility continues
to meet the requirements for remaining a pediatric care facility is
limited to 33 percent of the average daily census of the facility.
(B) Individuals who have "aged in place" as described
in subparagraph (A) of this paragraph may not be counted toward meeting
the requirements for a facility to initially become a pediatric care
facility, nor can they be counted toward meeting the requirements
for a distinct unit to remain a pediatric care facility.
(2) Distinct unit--A portion of a nursing facility
that is physically separate from, and beds are not commingled with,
other units of the facility. The distinct unit can be an entire wing,
a separate building, an entire floor, or an entire hallway. The distinct
unit consists of all beds within the designated area. A distinct unit
must consist of 28 or more Medicaid-contracted beds.
(3) Pediatric care facility--Except as provided in
paragraph (1) of this subsection, a pediatric care facility is an
entire facility that has maintained an average daily census of 80
percent or more children for the six-month period prior to its entry
into the pediatric care facility class based on the entire licensed
facility. A pediatric care facility can also be a distinct unit of
a facility that has maintained an average daily census of 85 percent
or more children for the six-month period prior to its entry into
the pediatric care facility class based on the distinct unit of the
facility. To remain a pediatric care facility, the pediatric care
facility must maintain an average daily census of 80 percent or more
children if the pediatric care facility is an entire facility, and
85 percent or more children if the pediatric care facility is a distinct
unit of the facility. The contracted provider must request in writing
by certified mail or by special mail delivery where the delivery can
be verified to become a member of the pediatric care facility special
reimbursement class. The request must be sent to the Texas Health
and Human Services Commission (HHSC) Provider Finance Department.
(c) Payment rate determination. Payment rates will
be determined in the following manner.
(1) Cost reports for pediatric care facilities are
governed by the requirements specified in Subchapter A of this chapter
(relating to Cost Determination Process). A nursing facility that
contains a pediatric care facility distinct unit must complete two
cost reports: one report for the distinct pediatric care facility
unit and one report for the remainder of the facility.
(2) The payment rate methodology for this class of
service is based upon the unadjusted federal per diem rate for rural
Medicare skilled nursing facilities for the most recent federal fiscal
year as published in the Federal Register. Payment rates are based
on available funds and are subject to legislative appropriations.
(3) The payment rate described in paragraph (2) of
this subsection will be paid for all Medicaid residents of a qualifying
pediatric care facility.
(4) A facility will not be eligible to receive the
ventilator-dependent or the children-with-tracheostomies supplemental
reimbursements.
(5) Pediatric care facilities are not eligible to participate
in §355.308 of this subchapter (relating to Direct Care Staff
Rate Component).
(d) Disqualification. If HHSC determines that a pediatric
care facility that is designated in its entirety as a pediatric care
facility no longer qualifies as a member of such class according to
subsection (b) of this section, HHSC will notify the facility in writing.
(1) Within 30 calendar days of the date on the written
notification, the HHSC Provider Finance Department must receive a
written compliance plan from the facility as described in paragraph
(2) of this subsection. If the 30th calendar day is a weekend day,
national holiday, or state holiday, the first business day following
the 30th calendar day is the final day receipt of the plan will be
accepted.
(2) The compliance plan must indicate the facility's
intent to, within 180 calendar days of the date of HHSC's initial
written notification to the facility, come into compliance with subsection
(b) of this section by:
(A) managing a sufficient number of admissions and
discharges to come into compliance with the requirements of subsections
(b)(1) and (b)(3) of this section to remain a member of the pediatric
care facility special reimbursement class;
(B) creating a distinct unit of the facility as described
under subsection (b)(2) of this section; or
(C) withdrawing the entire facility from the pediatric
care facility special class.
(3) HHSC will make a written determination regarding
approval or disapproval of the compliance plan. A facility that submits
a compliance plan that is subsequently disapproved will no longer
be reimbursed as a member of the pediatric facility special class
on the first day of the month following HHSC's disapproval of the
compliance plan.
(4) A compliance plan that is received after the stated
deadline will not be accepted, and the facility will be removed from
the pediatric care facility special reimbursement class retroactive
to the first day of the month following the date of HHSC's initial
written notification to the facility.
(5) A facility that obtains approval of its compliance
plan from the HHSC Provider Finance Department will continue to be
reimbursed as a member of the pediatric care special class until 180
calendar days from the date of HHSC's initial written notification
to the facility. If the facility has not achieved the stated goal
of its compliance plan by that time, the facility will be removed
from the pediatric care special class effective the first day of the
following month.
(6) If, at any time, HHSC determines that a facility
that has come into compliance with subsection (b) of this section
by managing a sufficient number of admissions and discharges, as described
in paragraph (2)(A) of this subsection, no longer qualifies as a member
of the pediatric care facility special reimbursement class, that facility
will be excluded from the class for 365 days from the date HHSC makes
its determination. The facility may request to rejoin the class on
the 366th day.
(7) A facility that is removed or withdraws from the
pediatric care special reimbursement class will be considered a new
facility, as described in §355.308(e) of this title, for purposes
of enrollment in the Nursing Facility Direct Care Staff Rate Enhancement.
(8) A facility that is removed or withdraws from the
pediatric care special class may not re-enter the class within one
year of its removal or withdrawal.
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