SECTION 910.4. Fee Assessment and Notification of Charges

(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.

Source Note: The provisions of this §910.4 adopted to be effective March 24, 2022, 47 TexReg 1457