1. (a) General Requirements. The Texas Health and Human Services Commission (HHSC) determines payment rates for qualified contracted providers for the provision of long-term services and supports (LTSS) state plan and Medically Dependent Children Waiver Program (MDCP) services delivered through the STAR Kids and STAR Heath managed care programs. HHSC applies the general principles of cost determination as specified in §355.101 of this title (relating to Introduction).
2. (b) State plan services reimbursement determination. For LTSS state plan services delivered through STAR Kids and STAR Health, adult day care services are calculated as specified in §355.6907 of this title (relating to Reimbursement Methodology for Day Activity and Health Services); personal care services, nurse delegation and supervision services, and private duty nursing are calculated as specified in §355.8441 of this title (relating to Reimbursement Methodologies for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services); Community First Choice (CFC) attendant and habilitation and personal assistance services (PAS) are calculated as specified in §355.9090 of this title (relating to Reimbursement Methodology for Community First Choice); emergency response services are calculated as specified in §355.510 of this subchapter (relating to Reimbursement Methodology for Emergency Response Services (ERS)); prescribed pediatric extended care services are calculated as specified in §355.9080 of this title (relating to Reimbursement Methodology for Prescribed Pediatric Extended Care Centers); financial management services agency (FMSA) fees are calculated as specified in §355.114 of this title (relating to Consumer Directed Services Payment Option).

3. (c) MDCP reimbursement determination. Recommended payment rates are developed based on payment rates determined for other programs that provide similar services. If payment rates are not available from other programs that provide similar services, payment rates are determined using a pro forma analysis in accordance with §355.105(h) of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures). Recommended payment rates for MDCP services are determined as follows.

   1. (1) Reimbursement for nursing services. The rates for in-home respite and flexible family supports nursing services provided by a registered nurse (RN) or licensed vocational nurse (LVN) are determined in accordance with §355.502 of this subchapter (relating to Reimbursement Methodology for Common Services in Home and Community-Based Services Waivers).
   2. (2) Reimbursement for in-home respite and flexible family supports attendant services. The rates for in-home respite and flexible family supports provided by an attendant without delegation of the service by an RN are based on the STAR+PLUS Home and Community-Based Services (HCBS) waiver rate methodology for PAS in accordance with §355.503 of this subchapter (relating to Reimbursement Methodology for Long-Term Services and Supports State Plan and Home and Community-Based Services Waiver Program Services Delivered through the STAR+PLUS Managed Care Program) and §355.7052 of this chapter (relating to Reimbursement Methodology for Determining Attendant Cost Component). The rates for in-home respite and flexible family supports provided by an attendant with delegation of the service by an RN are based on the STAR+PLUS HCBS waiver rate methodology for PAS in accordance with §355.503 of this subchapter and are modeled to account for additional requirements of this service.
   3. (3) The rate ceiling for respite care. Camp setting services is equivalent to the Community Living Assistance and Support Services direct service agency (CLASS DSA) out-of-home respite rate. Actual payments for this service are the lesser of the rate ceiling or the actual cost of the camp.
   4. (4) Reimbursement for facility-based respite care. Facility-based respite care rates are determined on a 24-hour basis. The rates for facility-based respite care are calculated at 77 percent of the daily nursing facility rate methodology in accordance with §355.307 of this title (relating to Reimbursement Setting Methodology before September 1, 2025). After September 1, 2025, the rates for facility-based respite care are calculated at 77 percent of the daily nursing facility rate methodology in accordance with §355.318 of this title (relating to Reimbursement Setting Methodology for Nursing Facilities on or after September 1, 2025). The base rates used in this calculation do not include nursing facility rate add-ons.
   5. (5) Reimbursement for supported employment and employment assistance. The rates for supported employment and employment assistance are based on the rate methodology for supported employment and employment assistance in accordance with §355.503 of this subchapter.
   6. (6) Reimbursement for transition assistance services. Transition assistance services rates are determined in accordance with §355.502 of this subchapter.
4. (d) Cost reports. If HHSC deems it appropriate to require providers contracted with managed care organizations to deliver LTSS services in STAR Kids and STAR Health to submit a cost report, the following sections of this title will apply: §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures), §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), §355.107 of this title (relating to Notification of Exclusions and Adjustments), §355.108 of this title (relating to Determination of Inflation Indices), §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs), §355.110 of this title (relating to Informal Reviews and Formal Appeals), and §355.111 of this title (relating to Administrative Contract Violations).

Source Note:The provisions of this §355.507 adopted to be effective December 10, 2002, 27 TexReg 11527; amended to be effective September 1, 2007, 32 TexReg 5340; amended to be effective September 1, 2009, 34 TexReg 5654; amended to be effective June 20, 2011, 36 TexReg 3707; amended to be effective September 1, 2013, 38 TexReg 5435; amended to be effective April 14, 2025, 50 TexReg 2378; amended to be effective September 11, 2025, 50 TexReg 5899.