Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter M - MISCELLANEOUS PROGRAMS
Division 3 - COMPREHENSIVE REHABILITATION SERVICES FOR INDIVIDUALS WITH A TRAUMATIC BRAIN INJURY OR TRAUMATIC SPINAL CORD INJURY
Section 355.9040 - Reimbursement Methodology for Comprehensive Rehabilitation Services Program
Universal Citation: 1 TX Admin Code ยง 355.9040
Current through Reg. 49, No. 38; September 20, 2024
(a) Payment rate determination. Payment rates are determined based on the methodology described for each service array.
(1) Traumatic Brain Injury (TBI) and Spinal
Cord Injury (SCI) Inpatient Comprehensive Medical Rehabilitation Services
Array. The Texas Department of Assistive and Rehabilitative Services or its
successor agency (DARS) negotiates contracts with inpatient facilities to
provide services based on data from the Centers for Medicare & Medicaid
Services (CMS) Healthcare Cost Report Information System (HCRIS).
(2) TBI and SCI Outpatient Services Array.
(A) For services and purchases for which a
specific rate can be established without regard to the individual receiving the
service or item, the Texas Health and Human Services Commission (HHSC) will
establish Comprehensive Rehabilitation Services (CRS) fee-for-service rates
based on a review of rates for similar services as presented in one or more of
the following data sources: HHSC fee schedules, previous DARS fee schedules,
Medicare fee schedules, other states' Medicaid fee schedules, and/or commercial
insurance fee schedules.
(i) Where information
on comparable rates is not available, HHSC will establish rates representing
best value based on the factors listed in §
391.103(2) of this
title (relating to Definitions).
(ii) To ensure adequate access to services,
DARS medical director, or optometric consultant may approve exceptions to
established rates, with review by the HHSC Provider Finance Department
(PFD).
(B) For services
and purchases for which a specific rate can be established without regard to
the individual receiving the service or item, but for which a CRS rate has not
yet been set at the time an individual's program planning team determines that
the service is required, HHSC will establish an interim CRS rate.
(i) DARS will contact HHSC PFD to request an
interim CRS rate.
(ii) HHSC PFD
will determine the interim CRS rate based on the process in subparagraph (A) of
this paragraph.
(iii) Claims paid
at an interim rate established under this subparagraph will not be adjusted
once a rate is formally adopted for that service.
(C) For services and purchases for which the
cost of the service or item purchased is specific to the individual receiving
the service or item, HHSC will establish a CRS rate at the time of purchase,
based on best value, as defined by the reasonable and customary industry
standards for each specific service or item purchased.
(3) Post-Acute Brain Injury (PABI)
Residential Services Array. DARS will pay providers a per diem rate for each
allowable day of PABI Residential Service. DARS will also pay providers for
such ancillary services as have been approved in the individual's program plan
and received by the individual.
(A) The
initial per diem rate is the sum of a base component, which covers room and
board, administration, personal assistance, and facility and operations costs;
a core service component, which covers core therapy services; and an additional
amount for periodic required evaluations.
(i)
HHSC determines the base component as follows:
(I) determine the rates for the small and
medium classes of facilities in the Intermediate Care Facilities for
Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
program as specified in §
355.456 of this chapter (relating
to Reimbursement Methodology);
(II)
adjust the ICF/IID rates to account for the specific needs of the CRS
population; and
(III) average the
adjusted rates for individuals with limited, extensive, pervasive, and
pervasive plus levels of need, weighting by the days of service for those
individuals from the most recently reviewed and accepted ICF/IID cost
reports.
(ii) HHSC
determines the core service component by reviewing the rates or contracted
payment amounts for similar services, including the five common core therapy
services (Physical Therapy, Occupational Therapy, Speech/Language Therapy,
Cognitive Rehabilitation Therapy, and Neuropsychological Therapy) paid by the
following payers: HHSC, the Texas Department of Aging and Disability Services
(DADS), DARS, Medicare, other states' Medicaid programs, and commercial
insurance companies. Based on this review, HHSC determines an appropriate rate
per hour that is multiplied by the hours in the tier structure below to
determine the rate for each tier. Determination of the applicable tier for a
day of service is governed by DARS program standards.
(I) Base - 0 hours.
(II) Base Plus - 0.5 hours.
(III) Tier 1 - 1.5 hours.
(IV) Tier 2 - 2.5 hours.
(V) Tier 3 - 3.5 hours.
(VI) Tier 4 - 4.5 hours.
(VII) Tier 5 - 5.5 hours.
(VIII) Tier 6 - 6.5 hours.
(IX) Tier 7 - 7.5 hours.
(X) Tier 8 - 8.5 hours.
(iii) HHSC determines the additional amount
for periodic required evaluations by averaging the common core therapy
evaluation rates, multiplying the average by 12, and dividing the product by
the number of days in the rate year.
(B) If HHSC determines that adequate cost and
services delivery data is available, HHSC may rebase the per diem rate
components.
(i) For the base component, if
HHSC deems it appropriate to require contracted providers to submit a cost
report, HHSC will determine if cost data collected as described in subsection
(c) of this section is reliable and sufficient to support development of a cost
report-based rate. If such reliable and sufficient data is available, HHSC may
develop a reimbursement rate using that data to replace the initial base
component.
(ii) For the core
service component, HHSC will collect and evaluate detailed service delivery
data. HHSC may rebase the core service component based on the detailed service
delivery data.
(C) HHSC
determines the ancillary services rates as described in paragraph (2) of this
subsection.
(4) PABI and
Post-Acute SCI Non-Residential Services Array. HHSC will set separate base
rates for facility-based and community-based services, as described in
subparagraph (A) of this paragraph. DARS will pay for each allowable billing
increment, as defined by program standards. DARS will also pay for such core
and ancillary services as have been approved in the individual's program plan
and received by the individual.
(A) Initial
rates will consist of an hourly base rate which covers administration, personal
assistance, and facility and operations costs.
(i) For providers offering Non-Residential
Services in a setting that is also a residential facility or shares space with
a residential facility, HHSC determines the initial hourly base rate as
follows:
(I) determine the rates for the small
and medium classes of facilities in the ICF/IID program as specified in §
355.456 of this chapter;
(II) adjust the ICF/IID rates to account for
the specific needs of the CRS population and the base services to be provided
in a Non-Residential facility-based setting;
(III) average the adjusted rates for
individuals with limited, extensive, pervasive and pervasive plus levels of
need, weighting by the days of service for those individuals from the most
recently reviewed and accepted ICF/IID cost reports; and
(IV) divide the average by
eight.
(ii) For providers
offering Non-Residential Services in the home of the individual receiving the
service or in a community setting not connected or affiliated with a
residential setting, HHSC determines the initial hourly base rate as follows:
(I) determine the case management and the
other attendant care cost components (also known as the administration and
facility cost area) of the habilitation base rate under the Community Living
Assistance and Support Services (CLASS) program, as described in §
355.505 of this chapter (relating
to Reimbursement Methodology for the Community Living Assistance and Support
Services Waiver Program); and
(II)
adjust the rate to account for specific needs of the CRS population and the
base services to be provided in a non-residential home or community
setting.
(B) If
HHSC deems it appropriate to require contracted providers to submit a cost
report, HHSC will determine if cost data collected as described in subsection
(c) of this section is reliable and sufficient to support development of a
cost-report-based rate. If such reliable and sufficient data is available, HHSC
may develop cost-report-based rates to replace the initial hourly base
rates.
(C) HHSC will determine the
rates for core services as described in paragraph (2)(A) of this
subsection.
(D) HHSC will determine
the rates for ancillary services as described in paragraph (2) of this
subsection.
(b) Related information. The information in § 355.101 of this chapter (relating to Introduction) and § 355.105(g) of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures) applies to this section.
(c) Reporting of cost. To gather adequate financial and statistical information upon which to base reimbursement, HHSC may require a contracted provider to submit a cost report for any service provided through the CRS program.
(1) Cost
Reports. If HHSC requires a provider to submit a cost report, the provider must
follow the cost reporting guidelines in §
355.105 of this chapter and the
guidelines for determining whether a cost is allowable or unallowable in §
355.102 of this chapter (relating
to General Principles of Allowable and Unallowable Costs) and §
355.103 of this chapter (relating
to Specifications for Allowable and Unallowable Costs).
(2) Excusal from submission of a cost report.
A provider is excused from the requirement to submit a cost report if the
provider meets one or more of the conditions in §
355.105(b)(4)(D)
of this chapter.
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