Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter F - REIMBURSEMENT METHODOLOGY FOR PROGRAMS SERVING PERSONS WITH MENTAL ILLNESS OR INTELLECTUAL OR DEVELOPMENTAL DISABILITY
Section 355.781 - Rehabilitative Services Reimbursement Methodology
Universal Citation: 1 TX Admin Code § 355.781
Current through Reg. 49, No. 52; December 27, 2024
(a) Authority. Payments are made to qualified providers delivering rehabilitative services to Medicaid-eligible individuals who are eligible for rehabilitative services according to the program rules established by the Department of State Health Services (DSHS). The reimbursement determination authority is specified in § RSA 355.101 of this title (relating to Introduction).
(b) Reimbursement rates. Prospective and uniform statewide rates for rehabilitative services are determined for rehabilitative services specified in the Mental Health Services program rules in 25 TAC Chapter 419, Subchapter L (relating to Mental Health Rehabilitative Services) for the following:
(1) Day programs
for acute needs--adult;
(2) Crisis
intervention services--individual-child/adolescent and adult;
(3) Medication training and
support--individual-child/adolescent and adult;
(4) Medication training and
support--group-adult;
(5)
Medication training and support--group-child/adolescent;
(6) Psychosocial rehabilitative
services--individual-adult;
(7)
Psychosocial rehabilitative services--group-adult;
(8) Skills training and
development--individual-child/adolescent and adult;
(9) Skills training and
development--group-adult; and
(10)
Skills training and development-group-child/adolescent.
(c) Units of service. Qualified providers are reimbursed based on the following face-to-face units of service:
(1) Day programs for acute needs--45-60
continuous minutes;
(2) Crisis
intervention services--15 continuous minutes;
(3) Medication training and support--15
continuous minutes;
(4)
Psychosocial rehabilitative services--15 continuous minutes; and
(5) Skills training and development--15
continuous minutes.
(d) Rate methodology.
(1) Initial rates. Initial
statewide rates effective September 1, 2011, will be determined by summing the
total agency expenditures to provide rehabilitative services for each type of
service for the most recent cost-settled fiscal year, and dividing by the total
number of units of each type of service provided during that fiscal year. The
total agency expenditure to provide rehabilitative services includes both the
interim rates paid and any adjustments made to the interim rates, such as
additional payments or recoupments.
(2) Cost report-based rates. After the Texas
Health and Human Services Commission (HHSC) determines that cost data collected
as described in subsection (e) of this section are reliable and sufficient to
support development of a cost report-based rate, HHSC will develop statewide
reimbursement rates using that data to replace the initial rates as follows:
(A) Project each provider's total allowable
cost for each type of service from the historical cost reporting period to the
prospective reimbursement period using inflation factors set out in §
RSA
355.108 of this title (relating to
Determination of Inflation Indices) to arrive at the projected cost for each
type of service.
(B) For each
provider, divide the projected cost for each type of service, determined in
subparagraph (A) of this paragraph, by the provider's total units of service
for each type of service delivered during the historical cost-reporting period,
to arrive at the provider's projected cost for each unit of service for each
type of service.
(C) For each type
of service:
(i) Arrange all providers'
projected cost for each unit of service in an array from low to high, with the
corresponding total number of units of service for each provider;
(ii) Sum the total number of units of service
for each provider in the array progressively from low to high to create a
running total;
(iii) Divide the
total number of units of service by two;
(iv) Identify the value, from the running
total sums calculated in clause (ii) of this subparagraph, that is closest to
the result in clause (iii) of this subparagraph; and
(v) Identify the cost for each unit of
service that corresponds to the value identified in clause (iv) of this
subparagraph to arrive at the recommended rate for that service.
(e) Reporting of costs.
(1) All rehabilitative
services providers must submit a cost report unless the number of days between
the date the first client received services and the fiscal year end is 30 days
or fewer. The provider may be excused from submitting a cost report if
circumstances beyond the control of the provider make cost-report completion
impossible, such as the loss of records due to natural disasters or removal of
records from the provider's custody by any governmental entity. Requests to be
excused from submitting a cost report must be received by the HHSC Rate
Analysis Department before the due date of the cost report.
(2) Cost reporting. Rehabilitative services
providers must submit cost report data according to HHSC's specifications. In
addition to the requirements of this section, the cost reporting guidelines
will be governed by the information in §
RSA 355.101 of this
title (relating to Introduction), §
RSA
355.102 of this title (relating to General
Principles of Allowable and Unallowable Costs), §
RSA
355.103 of this title (relating to
Specifications for Allowable and Unallowable Costs), §
RSA 355.104 of this
title (relating to Revenues), §
RSA
355.105 of this title (relating to General
Reporting and Documentation Requirements, Methods, and Procedures), §
RSA
355.106 of this title (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports), §
RSA
355.107 of this title (relating to
Notification of Exclusions and Adjustments), §
RSA
355.108 of this title (relating to
Determination of Inflation Indices), §
RSA
355.109 of this title (relating to Adjusting
Reimbursement When New Legislation, Regulations, or Economic Factors Affect
Costs), §
RSA
355.110 of this title (relating to Informal
Reviews and Formal Appeals), and § 355.11 of this title (relating to
Administrative Contract Violation).
(3) Providers are responsible for reporting
only allowable costs on the cost report, except where cost report instructions
indicate that other costs are to be reported in specific lines or sections.
Only allowable cost information is used to determine recommended rates. To
ensure that the database reflects costs and other information that are
necessary for the provision of services and is consistent with federal and
state regulations, HHSC excludes from rate determination any unallowable
expenses included in the cost report and makes the appropriate adjustments to
expenses and other information reported by providers.
(4) Individual provider cost reports may not
be included in the database used for reimbursement determination if:
(A) there is reasonable doubt as to the
accuracy or allowability of a significant part of the information reported;
or
(B) an auditor determines that
reported costs are not verifiable.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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