Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. HHSC uses the methodology
described in this section to calculate a per diem reimbursement for covered
inpatient hospital services in freestanding psychiatric facilities.
(b) Reimbursement to freestanding psychiatric
facilities. HHSC reimburses freestanding psychiatric facilities using a
prospective facility-specific per diem rate. The per diem rate will be
determined based on the Medicare base per diem for inpatient psychiatric
facilities with facility-based adjustments for wages, rural location, and
length of stay as determined by Medicare, to the extent possible within
available funds. HHSC or its designee will not cost settle for services
provided to recipients admitted as inpatients to freestanding psychiatric
facilities reimbursed under the prospective payment system. The freestanding
psychiatric facility inpatient per diem rates are for Medicaid clients under 21
years of age. Per diem rates will be increased only if the Texas Legislature
appropriates funds for this specific purpose.
(c) Reimbursement to children's freestanding
psychiatric facilities. An in-state freestanding psychiatric facility that
serves primarily individuals under the age of 21 will be exempt from the
freestanding psychiatric facility prospective payment system methodology
described in subsection (b) of this section and instead be reimbursed under
methods and procedures described in the Tax Equity and Fiscal Responsibility
Act of 1982 (TEFRA) described in subsection (d) of this section, if the
facility meets the following requirements:
(1) After a Medicaid participating
freestanding psychiatric facility is recognized by Medicare as a freestanding
psychiatric facility, it must request of HHSC or its designee that the facility
be reimbursed as a children's psychiatric hospital. The hospital must submit
its request on or after September 1, 2008, in writing, to HHSC or its
designee's provider enrollment contact and include documentation showing that
during the previous two hospital fiscal years, at least 95 percent of the
hospital's total inpatient days were for services to individuals under the age
of 21. HHSC will cost settle the annual cost report for the hospital fiscal
year in which the request was submitted.
(2) After a freestanding psychiatric facility
has been recognized by HHSC as a children's psychiatric hospital, it must
annually submit documentation with its annual cost report to HHSC or its
designee responsible for receiving submitted cost reports for continued
recognition as a children's psychiatric hospital. The documentation must show
that at least 95 percent of its total inpatient days were for services to
individuals under the age of 21. A hospital that does not meet this 95 percent
threshold based on its annual cost report will be reimbursed based on the
prospective facility-specific per diem rate described in subsection (b) of this
section, effective the first day of the hospital fiscal year following the cost
reporting period in which the hospital did not meet the 95 percent
threshold.
(d)
Children's psychiatric hospital TEFRA reimbursement.
(1) HHSC or its designee reimburses in-state
children's psychiatric hospitals under methods and procedures described in the
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA).
(2) Interim payments are determined by
multiplying a hospital's charges allowed under Medicaid by the interim rate
effective on the date of admission. The interim rate is derived from the
hospital's most recent tentative or final Medicaid cost report
settlement.
(3) The amount and
frequency of interim payments will be subject to the availability of funds
appropriated for that purpose. Interim payments are subject to settlement at
both tentative and final audit of a hospital's cost report.
(4) Cost Settlement.
(A) The cost settlement process is limited by
the TEFRA target cap set pursuant to the Social Security Act §1886(b)
(RSA
1395ww(b)).
(B) Notwithstanding the process in
subparagraph (A) of this paragraph, HHSC or its designee uses each hospital's
final audited cost report, which covers a fiscal year ending during a base year
period, for calculating the TEFRA target cap for a hospital.
(C) HHSC or its designee selects a new base
year period for calculating the TEFRA target cap at least every three
years.
(D) HHSC increases a
hospital's TEFRA target cap in years in which the target cap is not reset under
this paragraph, by multiplying the target cap by the CMS Prospective Payment
System Hospital Market Basket Index adjusted to the hospital's fiscal
year.
(E) For a newly recognized
children's psychiatric hospital, the base year period for calculating the TEFRA
target cap is the hospital's first full 12-month cost reporting period
occurring after the effective date of recognition. For each cost reporting
period after the hospital's base year period, an increase in the TEFRA target
cap will be applied as described in subparagraph (D) of this paragraph, until
the TEFRA target cap is recalculated in subparagraph (C) of this
paragraph.
