1 TAC §355.8401
The Texas Health and Human Services Commission (HHSC)
proposes to amend §355.8401, concerning Case Management Reimbursement
Methodology.
Background and Justification
Case management services for children and pregnant women are offered
through Medicaid, although the Department of State Health Services
(DSHS) administers the case management program under its rules in
25 TAC Chapter 27. HHSC, under its authority and responsibility to
administer and implement Medicaid reimbursement rates, is proposing
to amend §355.8401 to update and clarify the methodology used
to determine the Medicaid reimbursement rates for providers of Case
Management for Children and Pregnant Women services.
Section-by-Section Summary
The proposed amendment updates the title of the rule from "Case
Management Reimbursement Methodology" to "Reimbursement Methodology
for Case Management for Children and Pregnant Women" consistent with
the current naming convention within the subchapter.
The substance of the rule is generally new and not carried forward
from the current §355.8401.
Proposed new subsection (a) identifies the providers that are eligible
for reimbursement.
Proposed new subsection (b) limits case management services to
one unit of service, or contact, per day per client. Proposed new
subsection (b) also names the types of services that can be reimbursed.
Proposed new subsection (c)(1) describes the reimbursement methodology.
Proposed new subsection (c)(2) describes additional rules in Chapter
355 applicable to the reimbursement methodology.
Fiscal Note
Greta Rymal, Deputy Executive Commissioner for Financial Services,
has determined that, during the first five years the amendment is
in effect, there is no foreseeable fiscal impact to state government
or local governments.
Ms. Rymal does not anticipate that there will be an economic cost
to persons who are required to comply with the amendment for the first
five years the rule will be in effect. There is no anticipated negative
impact on local employment.
Small and Micro-business Impact Analysis
HHSC has determined that there will be no adverse economic effect
on small or micro-businesses based on the proposal as there is no
reduction in revenue or increase in costs to providers as a result
of the proposed amendment.
Public Benefit
Pam McDonald, Director of Rate Analysis, has determined that for
each of the first five years that the amended rule is in effect, the
public is expected to benefit because HHSC will have the accurate
and detailed reimbursement methodology for Case Management for Children
and Pregnant Women program services in its rule base.
Regulatory Analysis
HHSC has determined that this proposal is not a "major environmental
rule" as defined by §2001.0225 of the Texas Government Code.
A "major environmental rule" is defined to mean a rule the specific
intent of which is to protect the environment or reduce risk to human
health from environmental exposure and that may adversely affect,
in a material way, the economy, a sector of the economy, productivity,
competition, jobs, the environment or the public health and safety
of a state or a sector of the state. This proposal is not specifically
intended to protect the environment or reduce risks to human health
from environmental exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit
an owner's right to his or her private real property that would otherwise
exist in the absence of government action and, therefore, does not
constitute a taking under §2007.043 of the Government Code.
Public Comment
Written comments on the proposal may be submitted to Yvonne Moorad,
Senior Rate Analyst of Acute Care Services, Rate Analysis Department,
Texas Health and Human Services Commission, P.O. Box 85200, MC-H400,
Austin, Texas 78708-5200; by fax to (512) 491-1998; or by e-mail to
yvonne.moorad@hhsc.state.tx.us within 30 days of publication of this
proposal in the
Texas Register.
Statutory Authority
The amendment is proposed under Texas Government Code §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking
authority; Texas Human Resources Code §32.021 and Texas Government
Code §531.021(a), which provide HHSC with the authority to administer
the federal medical assistance (Medicaid) program in Texas; and Texas
Government Code §531.021(b), which establishes HHSC as the agency
responsible for adopting reasonable rules governing the determination
of fees, charges, and rates for medical assistance payments under
the Human Resources Code Chapter 32.
The amendment affects the Human Resources Code Chapter 32, and
the Texas Government Code Chapter 531. No other statutes, articles,
or codes are affected by this proposal.
§355.8401.[ Case Management ] Reimbursement Methodology for Case Management for Children and Pregnant Women .
(a)
Qualified providers.
Payments are made to qualified providers delivering case management
services to Medicaid-eligible individuals who are eligible for Case
Management for Children and Pregnant Women according to Department
of State Health Services (DSHS) rules at 25 TAC Chapter 27 (relating
to Case Management for Children and Pregnant Women).
(b)
Unit of service. Case
Management for Children and Pregnant Women services are limited to
one contact per day per client. Qualified providers are reimbursed
based on a prospective and uniform statewide rate for the following
types of services:
(1)
comprehensive visit;
(2)
face-to-face case management visit;
and
(3)
telephone case management visit.
(c)
Rate methodology.
(1)
The Health and Human Services Commission
determines Case Management for Children and Pregnant Women rates by
modeling a rate for similar case management activities and using relevant
costs and fees that provide information related to case management
services for children and high risk pregnant women. HHSC will utilize
the cost and fee survey data compiled as a basis for updating the
reimbursement rate. Total reported costs are projected from the historical
reporting period to the prospective rate period.
(2)
The reimbursement methodology for Case
Management for Children and Pregnant Women services is also governed
by §355.108 of this chapter (relating to Determination of Inflation
Indices) and §355.109 of this chapter (relating to Adjusting
Reimbursement When New Legislation, Regulations, or Economic Factors
Affect Costs).
[
(a)
General information.
The Health and Human Services Commission (HHSC) will reimburse qualified
providers for case management services provided to Medicaid-eligible
children and pregnant women. The HHSC determines reimbursement rates
at least annually for case management services. These rates are:]
[
(1)
uniform throughout the geographic area(s)
providing the service; and]
[
(2)
cost-related.]
[
(b)
Basis for rate analysis.]
[
(1)
For the initial reimbursement period,
providers are reimbursed based on rates set as a result of modeling
other rates for case management services, and cost information provided
by the Texas Department of Health.]
[
(2)
At some future date, as yet unspecified,
reimbursements will be based on cost-based prospective rates.]
This agency hereby certifies that the proposal
has been reviewed by legal counsel and found to be within the agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on May 2, 2013.
TRD-201301739
Steve Aragon
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 16, 2013
For further information, please call: (512) 424-6900