SECTION 355.455. Payments to Non-State Operated Facilities

(a) HHSC or its designee will pay to non-state-operated facilities modeled rates that will vary by class of facility and a resident's level-of-need.

(b) The non-state operated facility modeled rates include payment for both residential and day program services. Residents receive medical and dental services through the Medicaid identification card. Any medical expenses other than Medicaid-covered services are the responsibility of the ICF/MR provider.

(c) With a limit of $5,000 per resident per year, HHSC or its designee will pay a provider for the actual cost of a resident's durable medical equipment, excluding augmentative communication devices, if:

(1) the cost of the equipment exceeds $1,000;

(2) the facility receives approval from HHSC or its designee to purchase the equipment;

(3) the provider submits a voucher to HHSC or its designee for the cost of the equipment; and

(4) the resident is eligible for Medicare benefits and the provider has submitted a Medicare claim and received a response to the claim prior to requesting payment from HHSC or its designee.

(d) Reimbursement for augmentative communication devices is governed by 40 TAC §9.228, relating to Augmentative Communication Device Systems.

Source Note: The provisions of this §355.455 adopted to be effective March 25, 1997, 22 TexReg 2760; transferred effective September 1, 1997, as published in the Texas Register December 26, 1997, 22 TexReg 12748; amended to be effective March 1, 2001, 26 TexReg 1696; amended to be effective August 13, 2009, 34 TexReg 5361