(1) This section does not apply to the FC Program.
(2) A provider that chooses to request retroactive
payment must comply with the requirements of this section.
(b) Definition of retroactive payment. A retroactive
payment is payment by HHSC to a provider for services under the PHC
Program or CAS Program that are provided before the date the case
worker determines the individual's eligibility for the services.
(1) The provider may be reimbursed for services provided
before the date HHSC receives a completed, signed, and dated copy
of HHSC's Application for Assistance--Aged and Disabled form:
(A) for up to three months for an individual who does
not have Medicaid eligibility at the time of the request for retroactive
(B) for an indefinite period for an individual who
is Medicaid eligible at the time of the request for retroactive payment.
(2) HHSC only reimburses the provider for the:
(A) services described in §47.41 of this chapter
(relating to Allowable Tasks);
(B) number of hours of services allowed the individual
as described in §48.2918(c) of this title (relating to Primary
Home Care or Community Attendant Services); and
(C) allowable costs of the PHC Program or CAS Program,
as described in 1 TAC, Chapter 355, Subchapter A, (relating to Cost
(3) HHSC does not reimburse the provider for the retroactive
(A) the provider fails to submit the required documentation
within the required time frames; or
(B) the individual provided services does not meet
the requirements described in subsection (d) of this section.
(d) Requirements before requesting retroactive payment.
The provider may not request retroactive payment unless:
(1) the individual appears to be Medicaid eligible
as defined in §48.1201 of this title (relating to Definition
of Program Terms);
(2) the provider obtains a Practitioner's Statement
of Medical Need form as described in §47.47 of this chapter (relating
to Determination of Medical Need);
(3) the individual requires assistance with at least
one ADL as described in §47.41 of this chapter; and
(4) the provider has verified and documented that the
individual is not already receiving services under the PHC Program
or CAS Program from another provider.
(e) Pre-initiation activities. The provider must complete
the pre-initiation activities described in §47.45(a) of this
chapter (relating to Pre-Initiation Activities).
(f) Intake referral. On the day that the provider completes
the pre-initiation activities, the provider must contact HHSC and
make an intake referral by providing HHSC information on the individual
to start the eligibility process.
(g) Service initiation. HHSC does not pay a provider
for services provided to an individual before the date the provider
completes the pre-initiation activities and processes the intake referral
as described in subsections (e) and (f) of this section.
(h) Requesting retroactive payment.
(1) A provider's written request for retroactive payment
(A) a copy of the service delivery plan;
(B) a copy of HHSC's Practitioner's Statement of Medical
Need form; and
(C) the retroactive payment information, including
(i) name of the provider;
(ii) contact information for the individual;
(iii) date services were started;
(iv) tasks provided to the individual, including both
tasks allowed and not allowed by the PHC Program or CAS Program;
(v) weekly hours of service provided to the individual,
including hours allotted to tasks allowed and not allowed by the PHC
Program or CAS Program; and
(vi) cost per hour of service charged to the individual.
(2) The provider must submit the written request for
(A) to the case worker or, if no case worker has been
assigned, to HHSC intake staff; and
(B) within seven days after the date the provider processes
the intake referral.
(i) Charges to individuals who receive services.
(1) The provider may charge an individual for services
for which the provider intends to request retroactive payment, unless
the individual is Medicaid eligible.
(2) The provider must reimburse the entire amount of
all payments made by the individual to the provider for eligible services,
even if those payments exceed the amount HHSC will reimburse for the
services, if HHSC determines that the individual is eligible for the
PHC Program or CAS Program.
(j) Documentation of retroactive payment requests.
The provider must maintain documentation of retroactive payment requests
in the individual's file.