Current through Reg. 49, No. 12; March 22, 2024
(a) General provisions. The fee for an
individual's support, maintenance, and treatment (SMT) is assessed in
accordance with this section.
(1) Charges to
the individual or legally authorized representative (LAR), as appropriate, will
not exceed the facility's current maximum rate.
(2) Failure of the individual or LAR to
provide financial information upon request or to assign third-party benefits
may result in charges equal to the facility's current maximum rate accruing to
the individual.
(3) The finances
and assets of an adult's guardian or the guardian of the estate of a minor, who
is not also the legal guardian of the minor, are not considered in assessing
fees.
(4) Charges to a payor that
is not an individual or LAR may exceed the facility's current maximum
rate.
(b) Necessary
financial information. Upon an individual's admission to a facility, or shortly
afterward, the reimbursement office shall provide the individual, and their
personal representative, or their LAR, with a property and financial statement
form, appropriate to the type of services provided to the individual.
(c) Assessing fees for services provided to
minor individuals.
(1) The following sources
of funds are property from which the state may be reimbursed for a minor
individual's SMT and are considered separately in assessing a fee:
(A) third-party coverage of the minor
individual;
(B) the minor
individual's benefits from governmental and non-governmental agencies and
institutions;
(C) child support
ordered in a divorce or attorney general proceeding or a suit affecting the
parent-child relationship pursuant to Texas Health and Safety Code §
552.014
and §
593.077;
(D) real or personal property in the minor
individual's guardianship estate or owned by the minor individual;
(E) the net taxable income of the minor
individual's parents as authorized by the Texas Health and Safety Code §
552.017,
§
593.075, and
§
593.076,
in accordance with the Taxable Income of Parents formula, which may be obtained
at
www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals;
www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs;
or by contacting the Texas Health and Human Services Commission (HHSC) Health
and Specialty Care, Reimbursement Management, P.O. Box 12668, Austin, Texas
78701-2668, and Internal Revenue Services' guidelines; and
(F) monthly net income of the minor
individual (excluding income from the source described in subparagraph (B) of
this paragraph) receiving services at a state supported living center, in
accordance with the Individuals in State Supported Living Centers formula,
which may be obtained at
www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs
or by contacting the facility reimbursement office.
(2) An order in a divorce proceeding that
provides for child support payments (as referenced in paragraph (1)(C) of this
subsection) does not limit the fee that may be assessed (except that it may not
exceed the current maximum rate), nor does the order exempt either parent from
liability for the charges.
(d) Assessing a fee for adult individuals in
inpatient mental health facilities. The following sources of funds are
considered separately in assessing a fee:
(1)
third-party coverage of the adult individual;
(2) the adult individual's benefits from
governmental and non-governmental agencies and institutions;
(3) real or personal property in the adult
individual's guardianship estate or owned by the adult individual or spouse;
and
(4) monthly gross income of the
adult individual (excluding income from the source described in paragraph (2)
of this subsection) and income of the spouse, in accordance with the Adult
Individuals in Inpatient Mental Health Facilities formula, which may be
obtained at
www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals
or by contacting the facility reimbursement office.
(e) Assessing a fee for adult individuals in
state supported living centers and the ICF/IID component of the Rio Grande
State Center. The following sources of funds are considered separately in
assessing a fee:
(1) third-party coverage of
the adult individual;
(2) the adult
individual's benefits from governmental and non-governmental agencies and
institutions;
(3) real or personal
property in the adult individual's guardianship estate or owned by the adult
individual or spouse;
(4) the adult
individual's monthly net earned income in accordance with the Individuals in
State Supported Living Centers formula, which may be obtained at
www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs
or by contacting HHSC Health and Specialty Care, Reimbursement Management, P.O.
Box 12668, Austin, Texas 78701-2668; and
(5) income of the adult individual (excluding
income from the sources described in paragraphs (2) and (4) of this subsection)
and income of the spouse.
(f) Trusts. The provisions of the Texas
Health and Safety Code §
552.018 and
§
593.081, apply to
the fee assessment for an individual who is a beneficiary of a trust or
trusts.
(g) Notification of
charges. After a fee has been assessed, the reimbursement office shall provide
written notification to the individual or LAR of charges that includes:
(1) the date on the notification of
charges;
(2) the name of the
individual receiving SMT from the facility;
(3) the fees and the sources of funds used to
assess the fees;
(4) the effective
dates of the fees;
(5) the
facility's current maximum rate;
(6) a statement that the individual or LAR is
responsible for notifying the facility's reimbursement office within 30 days of
the change, when there is a change in any of the sources of funds HHSC uses to
assess a fee or a change in family status that would affect any assessed
fee;
(7) information on possible
payments from a third-party payor; and
(8) a statement that the individual or LAR
has the right to appeal under the following conditions if they disagree with
the fee.
(A) If the individual or LAR has
submitted complete financial information, then the individual or LAR must
notify the reimbursement office of their intent to appeal the fee. The
individual or LAR must initiate the appeal, in accordance with § 910.8(c)
of this chapter (relating to Appeal Process), within 45 business days of the
date on the notification of charges.
(B) If the individual or LAR has not
submitted complete financial information, the individual or LAR must contact
the reimbursement office and provide complete financial information within 15
business days of the date on the notification of charges or the individual or
LAR forfeits the right to appeal. If the individual or LAR provides complete
financial information within 15 business days of the date on the notification
of charges, the individual or LAR must initiate the appeal, in accordance with
§ 910.8(c) of this chapter, within 45 business days of the date on the
notification of charges.
(h) Complete financial information received
within 15 business days of the date on the notification of charges. If the
reimbursement office receives complete financial information from the
individual or LAR within 15 business days of the date on the notification of
charges as required in subsection (g)(8)(B) of this section, the reimbursement
office shall, within 10 business days:
(1)
review the financial information;
(2) revise the fee, if appropriate;
and
(3) inform the individual or
LAR in writing:
(A) of the fee
amount;
(B) that the individual or
LAR has a right to appeal if they disagree with the fee; and
(C) that an appeal must be initiated, in
accordance with § 910.8(c) of this chapter within 45 business days of the
date on the notification of charges referenced in subsection (g) of this
section.
(i)
Fee revision. HHSC shall determine if a fee revision is warranted each time
HHSC receives information indicating:
(1) a
change in any of the sources of funds HHSC uses to assess a fee; and
(2) a change in family status that would
affect any assessed fee.
(j) Individuals transferring between two
facilities. If an individual is transferred between two facilities, only the
receiving facility may bill for the day of transfer. The transferring facility
may not bill on the individual's date of admission from a transfer from another
HHSC operated facility.
(k)
Individuals receiving Medicaid Benefits. If an individual is receiving Medicaid
benefits, reimbursement will be completed pursuant to applicable federal and
state Medicaid laws.