1 Tex. Admin. Code § 355.501
Reimbursement Methodology for Program for All-Inclusive Care for the Elderly (PACE)
Effective Jul 1, 200227 TexReg 5164Source Note: The provisions of this §355.501 adopted to be effective March 15, 1992, 17 TexReg 1656; amended to be effective August 15, 1993, 18 TexReg 4510; amended to be effective February 15, 1994, 19 TexReg 512; amended to be effective June 1, 1996, 21 TexReg 4417; transferred effective September 1, 1997, as published in the Texas Register October 17, 1997, 22 TexReg 10311; amended to be effective July 1, 2002, 27 TexReg 5164.Texas Secretary of State
- (a) General specifications. The Texas Health and Human Services Commission (HHSC) determines the reimbursement for the provider, Bienvivir, under a Medicaid 1115 waiver program to provide care to recipients.
- (b) Frequency of reimbursement determination. The reimbursement is reviewed and revised, if appropriate, effective January 1 each year. The reimbursement may be determined more often if HHSC determines it to be necessary.
(c) Reimbursement determination. To determine the cost savings to the Nursing Facility program, the average cost of a nursing home recipient is calculated, including the cost of nursing home care; support services (rehabilitative and emergency dental); prescribed drugs; and acute care services. The calculated cost of care for an average nursing home recipient is multiplied by a factor of 0.95 to ensure a savings to the state for implementing this alternative to nursing home care. The following payment rate is calculated on a per diem basis:
- (1) the average nursing facility reimbursements weighted by the case mix Texas Index for Level of Effort (TILE) distribution for El Paso county clients;
- (2) plus the cost of support services (rehabilitative and emergency dental);
- (3) minus the average statewide applied income;
- (4) plus the average cost of prescribed drugs for nursing home recipients;
- (5) plus the DHS acute care premium, less the fee for administrative claims processing, for nursing facility recipients.
- (6) The resulting calculation from applying paragraphs (1)-(5) of this subsection is multiplied by 0.95.
- (7) The resulting calculation from applying paragraph (6) of this subsection is multiplied by the number of days in the year, and the product of the multiplication is divided by 12 months to convert the per diem amount from paragraph (6) of this subsection to a monthly payment rate.
- (d) Reporting of cost. HHSC may require submittal of financial and statistical information on a cost report or in a survey format designated by HHSC. Cost report completion is governed by the requirements specified in Subchapter A of this chapter (relating to Cost Determination Process). HHSC may also require submittal of audited financial statements of the provider.
Source Note:The provisions of this §355.501 adopted to be effective March 15, 1992, 17 TexReg 1656; amended to be effective August 15, 1993, 18 TexReg 4510; amended to be effective February 15, 1994, 19 TexReg 512; amended to be effective June 1, 1996, 21 TexReg 4417; transferred effective September 1, 1997, as published in the Texas Register October 17, 1997, 22 TexReg 10311; amended to be effective July 1, 2002, 27 TexReg 5164.