SECTION 46.21. Reimbursement

(a) A unit of service is one billable day of authorized service delivered to a client.

(b) The unit rate reimbursed by the Department of Aging and Disability Services (DADS) includes any copayment. The combined reimbursement from DADS and the client or the client's representative for the required services described in §46.41 of this chapter (relating to Required Services) must not exceed the unit rate plus room and board specified for each type of setting. The unit rate does not include charges for services described in §46.15 of this chapter (relating to Additional Services and Fees).

(c) The facility must deduct the copayment amount from reimbursement claims submitted to DADS.

(d) The facility must not bill DADS for the day of discharge, unless the discharge is due to the death of the client.

(e) The facility must bill the double occupancy (Residential Care Apartment) rate for clients in the single occupancy (Assisted Living Apartment) setting who request double occupancy.

(f) The facility must bill DADS for the balance of the bedhold charge for any clients whose daily copayment is less than the maximum bedhold charge allowed by DADS.

(1) The facility must determine the client's daily copayment amount by dividing the client's monthly copayment charge by the number of days in the month.

(2) The facility must deduct the client's daily copayment amount from the bedhold rate and submit the claim to DADS.

(3) This subsection does not apply to the Assisted Living (AL) services allowed in the Community Based Alternatives (CBA) Program.

(g) The facility may bill DADS for emergency care provided to clients for:

(1) up 60 days per authorization for eligible clients; or

(2) five days for a client ineligible for emergency care.

(h) The facility must not bill for services provided before or after the authorized effective dates for CBA AL or Community Care for Aged and Disabled (CCAD) Residential Care (RC) services, as those dates are determined by DADS.

(i) When the facility requests a level of care reset, the facility may bill DADS at the new payment rate effective the date of the new assessment. The facility may request only two level of care resets during each calendar year for each CBA client for the following time periods:

(1) January through June; and

(2) July through December.

(j) CCAD RC services will be reimbursed at the double occupancy rate, regardless of the actual occupancy.

Source Note: The provisions of this §46.21 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2008, 33 TexReg 7285; amended to be effective September 1, 2014, 39 TexReg 6634