Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter J - PURCHASED HEALTH SERVICES
Division 22 - REIMBURSEMENT METHODOLOGY FOR THE EARLY CHILDHOOD INTERVENTION PROGRAM
Section 355.8421 - Reimbursement for Case Management Services for Infants and Toddlers with Developmental Disabilities
Universal Citation: 1 TX Admin Code ยง 355.8421
Current through Reg. 49, No. 38; September 20, 2024
(a) Authority. Payments are made to qualified providers delivering case management services to Medicaid-eligible individuals who are eligible for services in the Early Childhood Intervention Program (ECI) according to the program rules established by the Department of Assistive and Rehabilitative Services (DARS). The reimbursement determination authority is specified in § RSA 355.101 of this title (relating to Introduction).
(b) Unit of service. Qualified providers are reimbursed based on a 15-minute unit of service that is a prospective and uniform statewide rate for the following types of services:
(1) face-to-face case management visit;
and
(2) telephone case management
visit.
(c) Rate methodology.
(1) Initial rates. The rate
effective October 1, 2011, will be the initial statewide rate.
(2) Cost report-based rates. After the Health
and Human Services Commission (HHSC) determines that cost data collected as
described in subsection (d) of this section is 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 per type of service from the historical cost reporting period to the
prospective reimbursement period, using inflation factors according to §
RSA
355.108 of this title (relating to
Determination of Inflation Indices), to arrive at the projected cost per type
of service;
(B) For each provider,
divide the projected cost per type of service, determined in subparagraph (A)
of this paragraph, by the provider's total units of service per type of service
delivered during the historical cost reporting period, to arrive at the
provider's projected cost per unit of service for each type of service;
and
(C) For each type of service:
(i) Arrange all providers' projected cost per
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 per unit of service
that corresponds to the value identified in clause (iv) of this subparagraph,
to arrive at the recommended rate for that service.
(d) Reporting of costs.
(1) All case management service 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. A
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 disaster 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 as set out in §
RSA
355.105(c) of this title
(relating to General Reporting and Documentation Requirements, Methods, and
Procedures).
(2) Cost reporting.
Case management service providers must submit cost report data according to
HHSC's specifications. In addition to the requirements of this section, the
following cost reporting requirements apply: §
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 §
RSA
355.111 of this title (relating to
Administrative Contract Violations).
(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
the reported costs are not verifiable.
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