Current through Reg. 49, No. 38; September 20, 2024
(a) General
specifications. The Texas Health and Human Services Commission (HHSC)
determines the upper payment limits and reimbursement rates for each PACE
contractor. HHSC applies the general principles of cost determination as
specified in §
RSA 355.101 of this
title (relating to Introduction).
(b) Frequency of reimbursement determination.
The upper payment limits and reimbursement rates are determined coincident with
the state's biennium.
(c) Upper
payment limit determination. There are three upper payment limits calculated
for each PACE contract: one for clients eligible only for Medicaid services
(Medicaid-only clients), one for clients eligible for both Medicare and
Medicaid services (dual-eligible clients), and one for clients eligible for
only Medicare services as Qualified Medicare Beneficiaries (QMBs). An average
monthly historical cost per client receiving nursing facility services and Home
and Community Based Services (HCBS) under either the fee-for-service payment
system or the managed care program is calculated for the counties served by
each PACE contract for the upper payment limits for Medicaid-only clients and
for dual-eligible clients.
(1) The upper
payment limits for Medicaid-only and for dual-eligible clients for the biennium
are calculated for the base period using historical claims and encounter data
and member-month data from the most recent state fiscal year of complete claims
available prior to the state's biennium.
(2) The historical costs are derived from
claims data for clients age 55 and older receiving nursing facility services or
HCBS in the counties served by each PACE contract.
(3) The historical costs include:
(A) acute care services, including inpatient,
outpatient, professional, and other acute care services;
(B) prescriptions;
(C) medical transportation;
(D) nursing facility services;
(E) hospice services;
(F) long-term care specialized services, such
as physical therapy, occupational therapy, and speech therapy;
(G) HCBS;
(H) Primary Home Care (including Family Care)
services; and
(I) Day Activity and
Health Services.
(4)
Effective on and after January 1, 2006, the historical prescription costs from
paragraph (3)(B) of this subsection that are used in the calculation of the
upper payment limit, and as such the associated payment rate, for dual-eligible
clients for each PACE contract will exclude the costs of any drug that is in a
category covered by Medicare Part D.
(5) To determine an average monthly
historical cost for the counties served by each PACE contract, the total
historical claims data for the counties served by each PACE contract are
divided by the number of member months for the counties served by each PACE
contract.
(6) An adjustment for
administrative costs is added to the average monthly historical cost per
client. The per member month amount is added for:
(A) processing claims, based on the state's
cost to process claims under the managed care payment system; and
(B) case management, based on the state's
cost to provide case management under the managed care payment system for HCBS
clients.
(7) The sum of
the average monthly historical cost per client for each PACE contract and the
amounts from paragraph (5) of this subsection are projected from the claims
data base period identified in paragraph (1) of this subsection to the rate
period to account for anticipated changes in costs for each PACE contract. The
methodology used for trending historical costs for calculating PACE Upper
Payment Limits (UPLs) and rates is comparable to that used for trending costs
in the managed care program.
(8)
The PACE Upper Payment Limit (UPL) method may be adjusted to account for
statistical outliers, small populations, programmatic changes, catastrophic
events, or other economic changes, as determined by HHSC to be actuarially
appropriate. Data from sources other than those described in paragraphs (1) and
(2) of this subsection may be used, if deemed by HHSC necessary to calculate an
appropriate UPL. For example, HHSC may consider comparable data from other time
periods.
(d) HHSC
determines the UPL for Qualified Medicaid Beneficiaries (QMBs) on a statewide
basis using the average cost incurred by Medicaid for Medicare co-insurance and
deductibles.
(e) Payment rate
determination. HHSC calculates three reimbursement rates for each PACE
contract: one for clients eligible for Medicaid services (Medicaid Only rate),
one for clients eligible for both Medicare and Medicaid services (Dual Eligible
rate), and one for clients eligible for only Medicare services as QMBs. The
payment rates for the three client categories for each PACE contract are
determined by multiplying the UPLs calculated for each PACE contract by a
factor less than 1.0. HHSC may reduce the factor as necessary to establish a
rate consistent with available funds.
(1) In
setting the reimbursement rates under the PACE program, HHSC complies with
Texas Human Resources Code §
RSA
32.0532(b).
(2) The PACE payment rate is less than the
amount that would otherwise have been paid under the Texas State Plan if the
participants were not enrolled under the PACE program.
(f) Reporting of cost. HHSC may require the
PACE contractor to submit financial and statistical information on a cost
report or in a survey format designated by HHSC. Cost report completion is
governed by the requirements specified in Subchapter A of this chapter
(relating to Cost Determination Process). HHSC may also require the PACE
contractor to submit audited financial statements.
