SECTION 355.781. Rehabilitative Services Reimbursement Methodology

(a) Authority. Payments are made to qualified providers delivering rehabilitative services to Medicaid-eligible individuals who are eligible for rehabilitative services according to the program rules established by the Department of State Health Services (DSHS). The reimbursement determination authority is specified in §355.101 of this title (relating to Introduction).

(b) Reimbursement rates. Prospective and uniform statewide rates for rehabilitative services are determined for rehabilitative services specified in the Mental Health Services program rules in 25 TAC Chapter 419, Subchapter L (relating to Mental Health Rehabilitative Services) for the following:

(1) Day programs for acute needs--adult;

(2) Crisis intervention services--individual-child/adolescent and adult;

(3) Medication training and support--individual-child/adolescent and adult;

(4) Medication training and support--group-adult;

(5) Medication training and support--group-child/adolescent;

(6) Psychosocial rehabilitative services--individual-adult;

(7) Psychosocial rehabilitative services--group-adult;

(8) Skills training and development--individual-child/adolescent and adult;

(9) Skills training and development--group-adult; and

(10) Skills training and development-group-child/adolescent.

(c) Units of service. Qualified providers are reimbursed based on the following face-to-face units of service:

(1) Day programs for acute needs--45-60 continuous minutes;

(2) Crisis intervention services--15 continuous minutes;

(3) Medication training and support--15 continuous minutes;

(4) Psychosocial rehabilitative services--15 continuous minutes; and

(5) Skills training and development--15 continuous minutes.

(d) Rate methodology.

(1) Initial rates. Initial statewide rates effective September 1, 2011, will be determined by summing the total agency expenditures to provide rehabilitative services for each type of service for the most recent cost-settled fiscal year, and dividing by the total number of units of each type of service provided during that fiscal year. The total agency expenditure to provide rehabilitative services includes both the interim rates paid and any adjustments made to the interim rates, such as additional payments or recoupments.

(2) Cost report-based rates. After the Texas Health and Human Services Commission (HHSC) determines that cost data collected as described in subsection (e) of this section are reliable and sufficient to support development of a cost report-based rate, HHSC will develop statewide reimbursement rates using that data to replace the initial rates as follows:

(A) Project each provider's total allowable cost for each type of service from the historical cost reporting period to the prospective reimbursement period using inflation factors set out in §355.108 of this title (relating to Determination of Inflation Indices) to arrive at the projected cost for each type of service.

(B) For each provider, divide the projected cost for each type of service, determined in subparagraph (A) of this paragraph, by the provider's total units of service for each type of service delivered during the historical cost-reporting period, to arrive at the provider's projected cost for each unit of service for each type of service.

(C) For each type of service:

(i) Arrange all providers' projected cost for each unit of service in an array from low to high, with the corresponding total number of units of service for each provider;

(ii) Sum the total number of units of service for each provider in the array progressively from low to high to create a running total;

(iii) Divide the total number of units of service by two;

(iv) Identify the value, from the running total sums calculated in clause (ii) of this subparagraph, that is closest to the result in clause (iii) of this subparagraph; and

(v) Identify the cost for each unit of service that corresponds to the value identified in clause (iv) of this subparagraph to arrive at the recommended rate for that service.

(e) Reporting of costs.

(1) All rehabilitative services providers must submit a cost report unless the number of days between the date the first client received services and the fiscal year end is 30 days or fewer. The provider may be excused from submitting a cost report if circumstances beyond the control of the provider make cost-report completion impossible, such as the loss of records due to natural disasters or removal of records from the provider's custody by any governmental entity. Requests to be excused from submitting a cost report must be received by the HHSC Rate Analysis Department before the due date of the cost report.

(2) Cost reporting. Rehabilitative services providers must submit cost report data according to HHSC's specifications. In addition to the requirements of this section, the cost reporting guidelines will be governed by the information in §355.101 of this title (relating to Introduction), §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures), §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), §355.107 of this title (relating to Notification of Exclusions and Adjustments), §355.108 of this title (relating to Determination of Inflation Indices), §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs), §355.110 of this title (relating to Informal Reviews and Formal Appeals), and §355.11 of this title (relating to Administrative Contract Violation).

(3) Providers are responsible for reporting only allowable costs on the cost report, except where cost report instructions indicate that other costs are to be reported in specific lines or sections. Only allowable cost information is used to determine recommended rates. To ensure that the database reflects costs and other information that are necessary for the provision of services and is consistent with federal and state regulations, HHSC excludes from rate determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers.

(4) Individual provider cost reports may not be included in the database used for reimbursement determination if:

(A) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or

(B) an auditor determines that reported costs are not verifiable.

Source Note: The provisions of this §355.781 adopted to be effective January 1, 1997, 21 TexReg 8933; duplicated effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660; amended to be effective November 14, 1999, 24 TexReg 9825; amended to be effective March 1, 2001, 26 TexReg 1696; amended to be effective October 4, 2001, 26 TexReg 7525; amended to be effective September 18, 2003, 28 TexReg 7975; amended to be effective August 31, 2004, 29 TexReg 8268; amended to be effective September 1, 2006, 31 TexReg 5453;amended to be effective September 1, 2011, 36 TexReg 4655