Current through Reg. 50, No. 13; March 28, 2025
The following requirements apply to program provider
reimbursement.
(1) HHSC pays a program
provider as described in this paragraph.
(A)
HHSC pays for supported home living, professional therapies, nursing, respite,
in-home respite, employment assistance, supported employment, and CFC PAS/HAB
in accordance with the reimbursement rate for the specific service.
(B) HHSC pays for host home/companion care,
residential support, supervised living, employment readiness, in-home day
habilitation and day habilitation in accordance with the individual's LON and
the reimbursement rate for the specific service.
(C) HHSC pays for adaptive aids, minor home
modifications, and dental treatment based on the actual cost of the item and,
if requested, a requisition fee in accordance with the HCS Program Billing
Requirements available on the HHSC website.
(D) HHSC pays:
(i) for TAS based on a Transition Assistance
Services (TAS) Assessment and Authorization form authorized by HHSC and the
actual cost of the TAS as evidenced by purchase receipts required by the HCS
Program Billing Requirements; and
(ii) if requested, a TAS service fee in
accordance with the HCS Program Billing Requirements.
(E) HHSC pays for pre-enrollment minor home
modifications and a pre-enrollment minor home modifications assessment based on
a Home and Community-based Services (HCS) Program Pre-enrollment MHM
Authorization Request form authorized by HHSC and the actual cost of the
pre-enrollment minor home modifications and a pre-enrollment minor home
modifications assessment, as evidenced by documentation required by the HCS
Program Billing Requirements.
(F)
Subject to the requirements in the HCS Program Billing Requirements, HHSC pays
for TAS, pre-enrollment minor home modifications, and a pre-enrollment minor
home modifications assessment regardless of whether the applicant enrolls with
the program provider.
(G) HHSC pays
for CFC ERS based on the actual cost of the service, not to exceed the
reimbursement rate ceiling for CFC ERS.
(2) To be paid for the provision of a
service, a program provider must submit a service claim that meets the
requirements in §
52.121 of this title (relating to
Claims Payment) and the HCS Program Billing Requirements or the CFC Billing
Requirements for HCS and TxHmL Program Providers.
(3) If an individual's HCS Program services
or CFC services are suspended or terminated a program provider must not submit
a claim for services provided during the period of the individual's suspension
or after the termination, except that the program provider may submit a claim
for the first day of the individual's suspension or termination for the
following services:
(A) in-home day
habilitation;
(C) supported home
living;
(F) employment assistance;
(G) supported employment;
(H) employment readiness;
(I) professional therapies;
(4) If a program provider submits a claim for
an adaptive aid that costs $500 or more or for a minor home modification that
costs $1,000 or more, the claim must be supported by a written assessment from
a licensed professional specified by HHSC in the HCS Program Billing
Requirements and other documentation as required by the HCS Program Billing
Requirements.
(5) HHSC does not pay
a program provider for:
(A) a service or
recoups any payments made to the program provider for a service if:
(i) except for an individual receiving TAS,
pre-enrollment minor home modifications, or a pre-enrollment minor home
modifications assessment, the individual receiving the service was, at the time
the service was provided, ineligible for the HCS Program or Medicaid benefits,
or was an inpatient of a hospital, nursing facility, or ICF/IID;
(ii) except for TAS, pre-enrollment minor
home modifications, and a pre-enrollment minor home modifications assessment:
(I) the service was provided to an individual
during a period of time for which there was not a signed, dated, and authorized
IPC for the individual;
(II) the
service was provided during a period of time for which there was not a signed
and dated ID/RC Assessment for the individual;
(III) the service was provided during a
period of time for which the individual did not have an LOC
determination;
(IV) the service was
not provided in accordance with a signed, dated, and authorized IPC meeting the
requirements set forth in §
263.301(c) of
this chapter (relating to IPC Requirements);
(V) the service was not provided in
accordance with the individual's PDP or implementation plan;
(VI) the service was provided before the
individual's enrollment date into the HCS Program; or
(VII) the service was not included on the
signed, dated, and authorized IPC of the individual in effect at the time the
service was provided, except as permitted by §
263.302(d) of
this chapter (relating to Renewal and Revision of an IPC);
(iii) the service was not provided in
accordance with the HCS Program Billing Requirements or the CFC Billing
Requirements for HCS and TxHmL Program Providers;
(iv) the service was not documented in
accordance with the HCS Program Billing Requirements or the CFC Billing
Requirements for HCS and TxHmL Program Providers;
(v) the program provider did not comply with
§
52.109 of this title (relating to
Records);
(vi) the claim for the
service was not prepared and submitted in accordance with the HCS Program
Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program
Providers;
(vii) the claim for the
service did not meet the requirements in §
52.121 of this title (relating to
Claims Payment) or the HCS Program Billing Requirements or the CFC Billing
Requirements for HCS and TxHmL Program Providers;
(viii) the program provider does not have the
documentation described in paragraph (3) of this section;
(ix) HHSC determines that the service would
have been paid for by a source other than the HCS Program if the program
provider had submitted to the other source a proper, complete, and timely
request for payment for the service;
(x) the service was provided by a service
provider who did not meet the qualifications to provide the service as
described in the HCS Program Billing Requirements or the CFC Billing
Requirements for HCS and TxHmL Program Providers;
(xi) the service was paid at an incorrect LON
because the information entered in the HHSC data system from a completed ID/RC
Assessment was not identical to the information on the completed ID/RC
Assessment; or
(xii) the service
was not provided;
(B)
supervised living or residential support, if the program provider provided the
supervised living or residential support service in a residence in which four
individuals or other persons receiving similar services live without HHSC's
approval as described in rules governing the HCS Program;
(C) employment assistance, if before
including the employment assistance on an individual's IPC, the program
provider did not ensure and maintain documentation in the individual's record
that employment assistance was not available to the individual under a program
funded under §110 of the Rehabilitation Act of 1973 or under a program
funded under the Individuals with Disabilities Education Act (20 U.S.C. §
1401 et seq.);
(D) supported employment, if before including
the supported employment on an individual's IPC, the program provider did not
ensure and maintain documentation in the individual's record that supported
employment was not available to the individual under a program funded under the
Individuals with Disabilities Education Act (20 U.S.C. §
1401
et seq.);
(E) employment readiness,
if before including the employment readiness on an individual's IPC, the
program provider did not ensure and maintain documentation in the individual's
record that employment readiness was not available to the individual under a
program funded under §110 of the Rehabilitation Act of 1973 or under a
program funded under the Individuals with Disabilities Education Act
(20 U.S.C. §
1401 et seq.);
(F) host home/companion care, residential
support, or supervised living, if the host home/companion care, residential
support, or supervised living was provided on the day of the individual's
suspension or termination of HCS Program services;
(G) TAS, if the TAS, was not provided in
accordance with a Transition Assistance Services (TAS) Assessment and
Authorization form authorized by HHSC;
(H) pre-enrollment minor home modifications
and a pre-enrollment minor home modifications assessment, if the pre-enrollment
minor home modifications and a pre-enrollment minor home modifications
assessment, was not provided in accordance with a Home and Community-based
Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized
by HHSC;
(I) a CFC service, if the
CFC service, was provided to an individual receiving host home/companion care,
supervised living, or residential support;
(J) supported home living, if the supported
home living, was not provided in accordance with a transportation plan and
§
263.5(a)(18) of
this chapter (relating to Description of HCS Program Services); or
(K) CFC PAS/HAB, in-home day habilitation
provided to an individual with a residential type of "own/family home," or
in-home respite, if the CFC PAS/HAB, in-home day habilitation, or in-home
respite, did not match the EVV visit transaction as required by 1 TAC §
354.4009(a)(4)
(relating to Requirements for Claims Submission and
Approval).
(6) A program
provider must refund to HHSC any overpayment made to the program provider
within 60 calendar days after the program provider's discovery of the
overpayment or receipt of a notice of such discovery from HHSC, whichever is
earlier.
(7) Except as provided in
paragraph (8) of this section, if HHSC approves an LOC requested in accordance
with §
263.105(b)(3) of
this chapter (relating to LOC Determination), HHSC pays a program provider for
services provided to an individual for a period of not more than 180 calendar
days after the individual's previous ID/RC Assessment expires.
(8) If HHSC determines that a program
provider submitted an ID/RC Assessment more than 180 calendar days after the
expiration date of the previous ID/RC Assessment, because of circumstances
beyond the program provider's control, HHSC may pay the program provider for a
period of more than 180 calendar days after the date the individual's previous
ID/RC Assessment expired.
(9) HHSC
conducts provider fiscal compliance reviews to determine whether a program
provider is in compliance with:
(B) the HCS Program
Billing Requirements;
(C) the CFC
Billing Requirements for HCS and TxHmL Program Providers;
(D) Chapter 52, Subchapter C of this title
(relating to Requirements of a Contractor); and
(E) the program provider's Community Services
Contract-Provider Agreement.
(10) HHSC conducts provider fiscal compliance
reviews in accordance with the Provider Fiscal Compliance Review Protocol set
forth in the HCS Program Billing Requirements and the CFC Billing Requirements
for HCS and TxHmL Program Providers. As a result of a provider fiscal
compliance review, HHSC may:
(A) recoup
payments from a program provider; and
(B) based on the amount of unverified claims,
require a program provider to develop and submit, in accordance with HHSC's
instructions, a corrective action plan that improves the program provider's
billing practices.
(11) A
corrective action plan required by HHSC in accordance with paragraph (10)(B) of
this section must:
(A) include:
(i) the reason the corrective action plan is
required;
(ii) the corrective
action to be taken;
(iii) the
person responsible for taking each corrective action; and
(iv) a date by which the corrective action
will be completed that is no later than 90 calendar days after the date the
program provider is notified the corrective action plan is
required;
(B) be
submitted to HHSC within 30 calendar days after the date the program provider
is notified the corrective action plan is required; and
(C) be approved by HHSC before
implementation.
(12)
Within 30 calendar days after HHSC receives a corrective action plan, HHSC
notifies the program provider if HHSC approves the corrective action plan or if
the plan requires changes.
(13) If
HHSC requires a program provider to develop and submit a corrective action plan
in accordance with paragraph (10)(B) of this section and the program provider
requests an administrative hearing for the recoupment in accordance with §
263.802 of this chapter (relating
to Program Provider's Right to Administrative Hearing), the program provider is
not required to develop or submit a corrective action plan while a hearing
decision is pending. HHSC notifies the program provider if the requirement to
submit a corrective action plan or the content of such a plan changes based on
the outcome of the hearing.
(14) If
a program provider does not submit a corrective action plan or complete a
required corrective action within the time frames described in paragraph (11)
of this section, HHSC may impose a vendor hold on payments due to the program
provider until the program provider takes the corrective action.
(15) If a program provider does not submit a
corrective action plan or complete a required corrective action within 30
calendar days after the date a vendor hold is imposed in accordance with
paragraph (14) of this section, HHSC may terminate the contract.
