Current through Reg. 50, No. 13; March 28, 2025
(a) Except as
provided in subsection (b) of this section, HHSC pays for on-site, off-site,
and in-home individualized skills and socialization provided to an individual
in accordance with an individual's LON and the reimbursement rates for on-site,
off-site, and in-home individualized skills and socialization.
(b) If approved in accordance with §
263.2027 of this subchapter
(relating to Enhanced Staffing Rate) HHSC pays:
(1) a level one enhanced staffing rate for
off-site individualized skills and socialization for an individual with a LON 1
or LON 5; and
(2) a level two
enhanced staffing rate for off-site individualized skills and socialization for
an individual with an LON 1, LON 5, LON 8, or LON 6.
(c) If an individual's HCS Program services
and CFC services are suspended or terminated, a program provider must not
submit a claim for on-site, off-site, or in-home individualized skills and
socialization 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.
(d) HHSC does not pay a program provider for
on-site, off-site, or in-home individualized skills and socialization, or
recoups any payments made to the program provider for on-site, off-site, or
in-home individualized skills and socialization, if:
(1) the individual receiving on-site,
off-site, or in-home individualized skills and socialization was, at the time
on-site, off-site, or in-home individualized skills and socialization was
provided, ineligible for the HCS Program;
(2) on-site, off-site, or in-home
individualized skills and socialization is provided to an individual during a
period of time for which there is not a signed, dated, and authorized IPC for
the individual;
(3) on-site,
off-site, or in-home individualized skills and socialization is provided during
a period of time for which there is not a signed and dated ID/RC Assessment for
the individual;
(4) on-site,
off-site, or in-home individualized skills and socialization is provided during
a period of time for which the individual did not have an LOC
determination;
(5) on-site,
off-site, or in-home individualized skills and socialization is not provided in
accordance with a signed, dated, and authorized IPC that includes on-site,
off-site, or in-home individualized skills and socialization;
(6) on-site, off-site, or in-home
individualized skills and socialization is not provided in accordance with the
individual's PDP or implementation plan;
(7) on-site, off-site, or in-home
individualized skills and socialization is provided before the individual's
enrollment date into the HCS Program;
(8) on-site, off-site, or in-home
individualized skills and socialization is not provided in accordance with this
subchapter; (9) on-site or off-site individualized skills and socialization is
not provided in accordance with Chapter 559, Subchapter H of this title
(relating to Individualized Skills and Socialization Provider
Requirements);
(10) on-site,
off-site, or in-home individualized skills and socialization is not provided in
accordance with the HCS Program Billing Requirements;
(11) on-site, off-site, or in-home
individualized skills and socialization is not documented in accordance with
the HCS Program Billing Requirements;
(12) the program provider did not comply with
40 TAC §
49.305(relating to
Records);
(13) the claim for
on-site, off-site, or in-home individualized skills and socialization did not
meet the requirements in 40 TAC §
49.311(relating to Claims Payment)
or the HCS Program Billing Requirements;
(14) HHSC determines that on-site, off-site,
or in-home individualized skills and socialization 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
on-site, off-site, or in-home individualized skills and
socialization;
(15) on-site or
off-site individualized skills and socialization is provided by a service
provider who did not meet the qualifications to provide on-site or off-site
individualized skills and socialization in accordance with §
559.227(a) of
this title (relating to Program Requirements) and the HCS Program Billing
Requirements;
(16) in-home
individualized skills and socialization is provided by a service provider who
did not meet the qualifications to provide in-home individualized skills and
socialization as described in §
263.2023 of this subchapter
(relating to Service Provider Qualifications and Training for In-Home
Individualized Skills and Socialization) and the HCS Program Billing
Requirements;
(17) on-site,
off-site, or in-home individualized skills and socialization was paid at an
incorrect LON because the information entered in the HHSC data system from a
completed ID/RC Assessment is not identical to the information on the completed
ID/RC Assessment;
(18) on-site,
off-site, or in-home individualized skills and socialization was not
provided;
(19) on-site or off-site
individualized skills and socialization is provided during a period of time
that the individual produced marketable goods and was paid below minimum wage
for producing the goods in accordance with Section 14(c) of the Fair Labor
Standards Act;
(20) in-home
individualized skills and socialization is not provided in the residence of the
individual as required by §
263.2013(a) of
this subchapter (relating to Provision of In-Home Individualized Skills and
Socialization); or
(21) in-home
individualized skills and socialization is provided to an individual without
the documentation required by §
263.2013(c) of
this subchapter.
(e) HHSC
does not pay a program provider for day habilitation, or recoups any payments
made to the program provider for day habilitation, if day habilitation is
provided on or after March 1, 2023, even if an individual's IPC includes day
habilitation on or after March 1, 2023.
(f) HHSC conducts provider fiscal compliance
reviews, also known as billing and payment reviews, in accordance with rules
governing the HCS Program and the HCS Program Billing Requirements to determine
whether a program provider is in compliance with this subchapter.
