Current through Reg. 50, No. 13; March 28, 2025
(a)
Applicability.
(1) This section does not
apply to the FC Program.
(2) A
provider that chooses to request retroactive payment must comply with the
requirements of this section.
(b) Definition of retroactive payment. A
retroactive payment is payment by HHSC to a provider for services under the PHC
Program or CAS Program that are provided before the date the case worker
determines the individual's eligibility for the services.
(c) Reimbursement.
(1) The provider may be reimbursed for
services provided before the date HHSC receives a completed, signed, and dated
copy of HHSC's Application for Assistance--Aged and Disabled form:
(A) for up to three months for an individual
who does not have Medicaid eligibility at the time of the request for
retroactive payment; and
(B) for an
indefinite period for an individual who is Medicaid eligible at the time of the
request for retroactive payment.
(2) HHSC only reimburses the provider for
the:
(A) services described in § 47.41 of
this chapter (relating to Allowable Tasks);
(B) number of hours of services allowed the
individual as described in § 48.2918(c) of this title (relating to Primary
Home Care or Community Attendant Services); and
(C) allowable costs of the PHC Program or CAS
Program, as described in 1 TAC, Chapter 355, Subchapter A, (relating to Cost
Determination Process).
(3) HHSC does not reimburse the provider for
the retroactive period if:
(A) the provider
fails to submit the required documentation within the required time frames;
or
(B) the individual provided
services does not meet the requirements described in subsection (d) of this
section.
(d)
Requirements before requesting retroactive payment. The provider may not
request retroactive payment unless:
(1) the
individual appears to be Medicaid eligible as defined in § 48.1201 of this
title (relating to Definition of Program Terms);
(2) the provider obtains a Practitioner's
Statement of Medical Need form as described in § 47.47 of this chapter
(relating to Determination of Medical Need);
(3) the individual requires assistance with
at least one ADL as described in § 47.41 of this chapter; and
(4) the provider has verified and documented
that the individual is not already receiving services under the PHC Program or
CAS Program from another provider.
(e) Pre-initiation activities. The provider
must complete the pre-initiation activities described in § 47.45(a) of
this chapter (relating to Pre-Initiation Activities).
(f) Intake referral. On the day that the
provider completes the pre-initiation activities, the provider must contact
HHSC and make an intake referral by providing HHSC information on the
individual to start the eligibility process.
(g) Service initiation. HHSC does not pay a
provider for services provided to an individual before the date the provider
completes the pre-initiation activities and processes the intake referral as
described in subsections (e) and (f) of this section.
(h) Requesting retroactive payment.
(1) A provider's written request for
retroactive payment must include:
(A) a copy
of the service delivery plan;
(B) a
copy of HHSC's Practitioner's Statement of Medical Need form; and
(C) the retroactive payment information,
including the:
(i) name of the provider
;
(ii) contact information for the
individual;
(iii) date services
were started;
(iv) tasks provided
to the individual, including both tasks allowed and not allowed by the PHC
Program or CAS Program;
(v) weekly
hours of service provided to the individual, including hours allotted to tasks
allowed and not allowed by the PHC Program or CAS Program; and
(vi) cost per hour of service charged to the
individual.
(2)
The provider must submit the written request for retroactive payment:
(A) to the case worker or, if no case worker
has been assigned, to HHSC intake staff; and
(B) within seven days after the date the
provider processes the intake referral.
(i) Charges to individuals who receive
services.
(1) The provider may charge an
individual for services for which the provider intends to request retroactive
payment, unless the individual is Medicaid eligible.
(2) The provider must reimburse the entire
amount of all payments made by the individual to the provider for eligible
services, even if those payments exceed the amount HHSC will reimburse for the
services, if HHSC determines that the individual is eligible for the PHC
Program or CAS Program.
(j) Documentation of retroactive payment
requests. The provider must maintain documentation of retroactive payment
requests in the individual's file.
