(a) HHSC pays a program provider for on-site individualized skills and socialization and off-site individualized skills and socialization in accordance with the reimbursement rates.
(b) If an individual's DBMD Program services and CFC services are suspended or terminated, a program provider must not submit a claim for on-site individualized skills and socialization or off-site individualized skills and socialization provided during the period of the individual's suspension or after the termination, except the program provider may submit a claim for the first calendar day of the individual's suspension or termination.
(c) A program provider must not bill for and HHSC does not pay a program provider for on-site individualized skills and socialization or off-site individualized skills and socialization, or recoups any payments made to the program provider for on-site individualized skills and socialization or off-site individualized skills and socialization:
  (1) if individualized skills and socialization is not provided in accordance with this subchapter and Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements);
  (2) if the individual receiving individualized skills and socialization is, at the time individualized skills and socialization was provided, ineligible for the DBMD Program;
  (3) if individualized skills and socialization is provided during a period of time for which there is not a signed and dated ID/RC Assessment for the individual;
  (4) if individualized skills and socialization is provided during a period of time for which the individual did not have an LOC determination;
  (5) if individualized skills and socialization is not provided in accordance with the individual's IPP;
  (6) if the program provider did not comply with 40 TAC §49.305 (relating to Records);
  (7) if the claim for the service did not meet the requirements in 40 TAC §49.311 (relating to Claims Payment);
  (8) if individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide individualized skills and socialization as described in §260.513 of this subchapter (relating to Service Provider Qualifications and Training) and §559.227 of this title (relating to Program Requirements);
  (9) if the program provider did not comply with the DBMD Program Manual;
  (10) if HHSC determines that individualized skills and socialization would have been paid for by a source other than the DBMD Program if the program provider had submitted to the other source a proper, complete, and timely request for payment for individualized skills and socialization;
  (11) if individualized skills and socialization was not provided; or
  (12) if individualized skills and socialization is provided during a period of time that the individual produced marketable goods and was paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act.
(d) HHSC does not pay a program provider for day habilitation or recoups any payments made to the program provider for day habilitation provided on or after March 1, 2023, even if an individual's IPC includes day habilitation on or after March 1, 2023.
(e) HHSC conducts contract and fiscal monitoring in accordance with rules governing the DBMD Program to determine whether a program provider is in compliance with this subchapter.

Source Note: The provisions of this §260.517 adopted to be effective January 1, 2023, 47 TexReg 8681