(a) Payment rate determination. Payment rates are determined based on the methodology described for each service array.
  (1) Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) Inpatient Comprehensive Medical Rehabilitation Services Array. The Texas Department of Assistive and Rehabilitative Services or its successor agency (DARS) negotiates contracts with inpatient facilities to provide services based on data from the Centers for Medicare & Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS).
  (2) TBI and SCI Outpatient Services Array.
    (A) For services and purchases for which a specific rate can be established without regard to the individual receiving the service or item, the Texas Health and Human Services Commission (HHSC) will establish Comprehensive Rehabilitation Services (CRS) fee-for-service rates based on a review of rates for similar services as presented in one or more of the following data sources: HHSC fee schedules, previous DARS fee schedules, Medicare fee schedules, other states' Medicaid fee schedules, and/or commercial insurance fee schedules.
      (i) Where information on comparable rates is not available, HHSC will establish rates representing best value based on the factors listed in §391.103(2) of this title (relating to Definitions).
      (ii) To ensure adequate access to services, DARS medical director, or optometric consultant may approve exceptions to established rates, with review by the HHSC Provider Finance Department (PFD).
    (B) For services and purchases for which a specific rate can be established without regard to the individual receiving the service or item, but for which a CRS rate has not yet been set at the time an individual's program planning team determines that the service is required, HHSC will establish an interim CRS rate.
      (i) DARS will contact HHSC PFD to request an interim CRS rate.
      (ii) HHSC PFD will determine the interim CRS rate based on the process in subparagraph (A) of this paragraph.
      (iii) Claims paid at an interim rate established under this subparagraph will not be adjusted once a rate is formally adopted for that service.
    (C) For services and purchases for which the cost of the service or item purchased is specific to the individual receiving the service or item, HHSC will establish a CRS rate at the time of purchase, based on best value, as defined by the reasonable and customary industry standards for each specific service or item purchased.
  (3) Post-Acute Brain Injury (PABI) Residential Services Array. DARS will pay providers a per diem rate for each allowable day of PABI Residential Service. DARS will also pay providers for such ancillary services as have been approved in the individual's program plan and received by the individual.
    (A) The initial per diem rate is the sum of a base component, which covers room and board, administration, personal assistance, and facility and operations costs; a core service component, which covers core therapy services; and an additional amount for periodic required evaluations.
      (i) HHSC determines the base component as follows:
        (I) determine the rates for the small and medium classes of facilities in the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) program as specified in §355.456 of this chapter (relating to Reimbursement Methodology);
        (II) adjust the ICF/IID rates to account for the specific needs of the CRS population; and
        (III) average the adjusted rates for individuals with limited, extensive, pervasive, and pervasive plus levels of need, weighting by the days of service for those individuals from the most recently reviewed and accepted ICF/IID cost reports.
      (ii) HHSC determines the core service component by reviewing the rates or contracted payment amounts for similar services, including the five common core therapy services (Physical Therapy, Occupational Therapy, Speech/Language Therapy, Cognitive Rehabilitation Therapy, and Neuropsychological Therapy) paid by the following payers: HHSC, the Texas Department of Aging and Disability Services (DADS), DARS, Medicare, other states' Medicaid programs, and commercial insurance companies. Based on this review, HHSC determines an appropriate rate per hour that is multiplied by the hours in the tier structure below to determine the rate for each tier. Determination of the applicable tier for a day of service is governed by DARS program standards.
        (I) Base - 0 hours.
        (II) Base Plus - 0.5 hours.
        (III) Tier 1 - 1.5 hours.
        (IV) Tier 2 - 2.5 hours.
        (V) Tier 3 - 3.5 hours.
        (VI) Tier 4 - 4.5 hours.
        (VII) Tier 5 - 5.5 hours.
        (VIII) Tier 6 - 6.5 hours.
        (IX) Tier 7 - 7.5 hours.
        (X) Tier 8 - 8.5 hours.
      (iii) HHSC determines the additional amount for periodic required evaluations by averaging the common core therapy evaluation rates, multiplying the average by 12, and dividing the product by the number of days in the rate year.
    (B) If HHSC determines that adequate cost and services delivery data is available, HHSC may rebase the per diem rate components.
      (i) For the base component, if HHSC deems it appropriate to require contracted providers to submit a cost report, HHSC will determine if cost data collected as described in subsection (c) of this section is reliable and sufficient to support development of a cost report-based rate. If such reliable and sufficient data is available, HHSC may develop a reimbursement rate using that data to replace the initial base component.
      (ii) For the core service component, HHSC will collect and evaluate detailed service delivery data. HHSC may rebase the core service component based on the detailed service delivery data.
    (C) HHSC determines the ancillary services rates as described in paragraph (2) of this subsection.
  (4) PABI and Post-Acute SCI Non-Residential Services Array. HHSC will set separate base rates for facility-based and community-based services, as described in subparagraph (A) of this paragraph. DARS will pay for each allowable billing increment, as defined by program standards. DARS will also pay for such core and ancillary services as have been approved in the individual's program plan and received by the individual.
    (A) Initial rates will consist of an hourly base rate which covers administration, personal assistance, and facility and operations costs.
      (i) For providers offering Non-Residential Services in a setting that is also a residential facility or shares space with a residential facility, HHSC determines the initial hourly base rate as follows:
        (I) determine the rates for the small and medium classes of facilities in the ICF/IID program as specified in §355.456 of this chapter;
        (II) adjust the ICF/IID rates to account for the specific needs of the CRS population and the base services to be provided in a Non-Residential facility-based setting;
        (III) average the adjusted rates for individuals with limited, extensive, pervasive and pervasive plus levels of need, weighting by the days of service for those individuals from the most recently reviewed and accepted ICF/IID cost reports; and
        (IV) divide the average by eight.
      (ii) For providers offering Non-Residential Services in the home of the individual receiving the service or in a community setting not connected or affiliated with a residential setting, HHSC determines the initial hourly base rate as follows:
        (I) determine the case management and the other attendant care cost components (also known as the administration and facility cost area) of the habilitation base rate under the Community Living Assistance and Support Services (CLASS) program, as described in §355.505 of this chapter (relating to Reimbursement Methodology for the Community Living Assistance and Support Services Waiver Program); and
        (II) adjust the rate to account for specific needs of the CRS population and the base services to be provided in a non-residential home or community setting.
    (B) If HHSC deems it appropriate to require contracted providers to submit a cost report, HHSC will determine if cost data collected as described in subsection (c) of this section is reliable and sufficient to support development of a cost-report-based rate. If such reliable and sufficient data is available, HHSC may develop cost-report-based rates to replace the initial hourly base rates.
    (C) HHSC will determine the rates for core services as described in paragraph (2)(A) of this subsection.
Cont'd...