1. (a) Introduction. The Texas Health and Human Services Commission (HHSC) establishes the rate methodology for the attendant cost rate component used in the rate methodologies of long-term services and supports (LTSS) state plan and 1915(c), 1915(i) and 1115 waiver programs with personal attendant and attendant-like services.

2. (b) Meaning of attendant. An attendant is an unlicensed caregiver providing direct assistance to individuals with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). The following parameters apply to the attendant cost rate component.

   1. (1) An attendant includes the following:

      1. (A) a driver who is transporting individuals in the day activity and health services (DAHS), Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), and residential care (RC) and STAR+PLUS Home and Community-Based Services (STAR+PLUS HCBS) Assisted Living Facilities (ALF) programs and the Home and Community-Based Services supervised living and residential support services (HCS SL/RSS) and HCS and Texas Home Living (TxHmL) individualized skills and socialization settings;
      2. (B) a medication aide in the HCS SL/RSS setting, ICF/IID, and RC and ALF programs; and
      3. (C) direct care workers, direct care trainers, job coaches, employment assistance direct care workers, attendant supervisors, direct care worker supervisors, direct care trainer supervisors, job coach supervisors and supported employment direct care workers.
   2. (2) Attendants do not include the director; administrator; assistant director; assistant administrator; clerical and secretarial staff; professional staff; other administrative staff; licensed staff; cooks and kitchen staff; maintenance and groundskeeping staff; activity director; Deaf-Blind with Multiple Disabilities (DBMD) Interveners I, II, or III; Qualified Intellectual Disability Professionals (QIDPs) or assistant QIDPs; foster care providers; and laundry and housekeeping staff.
   3. (3) Staff other than attendants may deliver attendant services and be considered an attendant if they must perform attendant services that cannot be delivered by another attendant to prevent a break in service.

3. (c) Attendant cost center. This cost center will include employee compensation, contract labor costs, for attendants as defined in subsection (b) of this section.

   1. (1) Attendant compensation is the allowable compensation for attendants defined in §355.103(b)(1) of this chapter (relating to Specifications for Allowable and Unallowable Costs) and required to be reported as either salaries and/or wages, including payroll taxes and workers' compensation, or employee benefits. Benefits required by §355.103(b)(1)(A)(iii) of this chapter to be reported as costs applicable to specific cost report line items, except as noted in paragraph (3) of this subsection, are not to be included in this cost center.
   2. (2) Contract labor refers to personnel for whom the contracted provider is not responsible for the payment of payroll taxes, such as Federal Insurance Contributions Act, Medicare, and federal and state unemployment insurance, and who perform tasks routinely performed by employees where allowed by program rules.

   3. (3) The following costs are not included in the calculation of the attendant cost center.

      1. (A) Costs of required trainings for direct care or personal attendant workers.
      2. (B) Travel costs for direct care or personal attendant workers including mileage reimbursement or public transportation subsidies.
      3. (C) Costs of personal protective equipment for direct care or personal attendant workers.
   4. (4) For staff who provide attendant functions part time as specified in subsection (b)(3) of this section, the cost center includes only the proportion of staff compensation associated with the hours allowable attendant functions were performed.

4. (d) Programs with personal attendant services. The reimbursement methodology outlined in this section applies to services provided by personal attendants that meet the following parameters.

   1. (1) An employee or subcontractor of an HHSC contractor, or an employee of an employer in the Consumer Directed Services (CDS) option, who provides the following services, as described in 26 TAC §52.1 (relating to Application):

      1. (A) services in the Community Attendant Services program;
      2. (B) services in the Family Care program;
      3. (C) services in the Primary Home Care program;
      4. (D) DAHS;
      5. (E) RC;

      6. (F) services in the Community Living Assistance and Support Services Program:

         1. (i) community first choice personal assistance services/habilitation (CFC PAS/HAB);
         2. (ii) employment assistance;
         3. (iii) habilitation (transportation) and prevocational services;
         4. (iv) in-home respite;
         5. (v) service planning team meeting; or
         6. (vi) supported employment;

      7. (G) in the DBMD Program:

         1. (i) CFC PAS/HAB;
         2. (ii) chore services;
         3. (iii) employment assistance;
         4. (iv) individualized skills and socialization services;
         5. (v) in-home respite;
         6. (vi) intervener (excluding intervener I, II, and III);
         7. (vii) licensed assisted living;
         8. (viii) licensed home health assisted living;
         9. (ix) residential habilitation (transportation); or
         10. (x) service planning team meeting;

      8. (H) in the HCS Program:

         1. (i) CFC PAS/HAB;
         2. (ii) employment assistance;
         3. (iii) employment readiness;
         4. (iv) individualized skills and socialization services;
         5. (v) in-home and out-of-home respite;
         6. (vi) supported employment;
         7. (vii) supported home living (transportation); or
         8. (viii) SL/RSS; and

      9. (I) in the Texas Home Living Program:

         1. (i) CFC PAS/HAB;
         2. (ii) community support services (transportation);
         3. (iii) employment assistance;
         4. (iv) employment readiness;
         5. (v) individualized skills and socialization services;
         6. (vi) in-home and out-of-home respite; or
         7. (vii) supported employment.

   2. (2) An employee or subcontractor of an HHSC contractor who provides the following services in the Home and Community-Based Services--Adult Mental Health (HCBS-AMH) program, as described in 26 TAC §307.51 (relating to Purpose and Application):

      1. (A) assisted living services;
      2. (B) employment assistance;
      3. (C) in-home respite;
      4. (D) supported employment;
      5. (E) supported home living services; or
      6. (F) supervised living services.

   3. (3) An employee or subcontractor of an HHSC contractor or an employee of an employer in the CDS option who provides:

      1. (A) personal care services, as described in Chapter 363, Subchapter F of this title (relating to Personal Care Services); or
      2. (B) CFC habilitation (CFC HAB) or CFC personal assistance services (CFC PAS), as described in Chapter 354, Subchapter A, Division 27 of this title (relating to Community First Choice).

   4. (4) A provider, which has the meaning assigned in §353.2 of this title (relating to Definitions), or an employee of an employer in the CDS option who provides:

      1. (A) in the STAR+PLUS program and STAR+PLUS Home and Community-based Services (HCBS) program:

         1. (i) assisted living;
         2. (ii) CFC PAS;
         3. (iii) CFC HAB;
         4. (iv) employment assistance;
         5. (v) DAHS;
         6. (vi) in-home respite care;
         7. (vii) personal assistance services;
         8. (viii) protective supervision; or
         9. (ix) supported employment;

      2. (B) in the STAR Health program and Medically Dependent Children Program (MDCP):

         1. (i) CFC PAS;
         2. (ii) CFC HAB;
         3. (iii) employment assistance;
         4. (iv) DAHS;
         5. (v) flexible family support;
         6. (vi) in-home respite;
         7. (vii) personal care services; or
         8. (viii) supported employment; and

      3. (C) in the STAR Kids program and MDCP:

         1. (i) CFC PAS;
         2. (ii) CFC HAB;
         3. (iii) employment assistance;
         4. (iv) DAHS;
         5. (v) flexible family support;
         6. (vi) in-home respite;
         7. (vii) personal care services; or
         8. (viii) supported employment.
   5. (5) An employee or subcontractor of an HHSC contractor, who provides ICF/IID program services, as described in 26 TAC §261.203 (relating to Definitions).

5. (e) Determination of attendant cost component. The attendant cost component is calculated as follows.

   1. (1) For all programs with services as specified in subsection (d) of this section, except for DBMD, HCBS-AMH, HCS, ICF/IID, and TxHmL programs, HHSC will calculate an attendant cost rate component by calculating a median of attendant cost center data for each applicable attendant service, weighted by the applicable attendant service's units of service from the most recently examined cost report database for each program, and adjusted for inflation from the cost reporting period to the prospective rate period as specified in §355.108 of this chapter (related to Determination of Inflation Indices).

      1. (A) The weighted median cost component is multiplied by 1.044 for all attendant services specified in subsection (d) except for DAHS, RC, and STAR+PLUS ALF services. For these services, the weighted median cost component is multiplied by 1.07. The result is the attendant cost rate component.
      2. (B) If HHSC has insufficient cost data, the attendant compensation rate component will be established through a pro forma costing approach as defined in §355.105(h) of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures).
      3. (C) For DBMD and HCBS-AMH, the attendant cost component is modeled according to subparagraph (B) of this paragraph unless HHSC collects a cost report for the applicable program.

   2. (2) For ICF/IID program services, HHSC will calculate an attendant cost rate component for day habilitation (DH) and residential services by calculating a median of attendant cost center data as defined in subsection (b) of this section for each DH and Residential services, weighted by ICF/IID units of service from the most recently examined ICF/IID cost report database, and adjusted for inflation from the cost reporting period to the prospective rate period as specified in §355.108 of this chapter.

      1. (A) The weighted median attendant cost component is adjusted by modeled direct care hours to unit ratios to determine attendant compensation rate components for each level of need (LON).
      2. (B) The weighted median cost component is multiplied by 1.07 for both ICF/IID DH and residential services.
      3. (C) If HHSC has insufficient cost data, the attendant compensation rate component will be established through a pro forma costing analysis as defined in §355.105(h) of this chapter.

   3. (3) For HCS and TxHmL programs, HHSC will calculate an attendant compensation rate component for each service by calculating a median of attendant cost center data as defined in subsection (b) of this section for each applicable attendant service, weighted by the applicable attendant service's units of service from the most recently examined HCS/TxHmL cost report database, and adjusted for inflation from the cost reporting period to the prospective rate period as specified in §355.108 of this chapter.

      1. (A) The weighted median cost component is multiplied by 1.044 for the following services:

         1. (i) CFC PAS/HAB;
         2. (ii) employment assistance;
         3. (iii) in-home respite;
         4. (iv) out-of-home respite in a camp;
         5. (v) out-of-home respite in a respite facility;
         6. (vi) out-of-home respite in a setting where host home / companion care (HH/CC) is provided;
         7. (vii) out-of-home respite in a setting that is not listed;
         8. (viii) supported employment; and
         9. (ix) supported home living (transportation).

      2. (B) The weighted median cost component is multiplied by 1.07 for the following services:

         1. (i) individualized skills and socialization services;
         2. (ii) out-of-home respite in an individualized skills and socialization facility;
         3. (iii) out-of-home respite in a setting with SL or RSS is provided; and
         4. (iv) SL/RSS.
      3. (C) For services with rates that are variable by LON as specified in §355.723(b) of this chapter (relating to Reimbursement Methodology for Home and Community-Based Services and Texas Home Living Programs), the weighted median attendant cost component is adjusted by modeled direct care hours to unit or direct care staff to individual ratios to determine attendant compensation rate components for each LON.
      4. (D) If HHSC has insufficient cost data, the attendant compensation rate component will be established through a pro forma costing analysis as defined in §355.105(h) of this chapter.
      5. (E) The attendant cost component for employment readiness is calculated as a blend of the cost component for individualized skills and socialization services.
6. (f) Determination of attendant cost component for CDS option services. Attendant services delivered through the CDS option as specified in subsection (d) of this section have an attendant cost component that is equal to the attendant cost component of the same service delivered through the provider agency option as specified in §355.114 of this chapter (relating to Consumer Directed Services Payment Option).
7. (g) The adopted attendant cost rate component is limited to available levels of appropriated state and federal funds as specified in §355.201 of this chapter (relating to Establishment and Adjustment of Reimbursement Rates for Medicaid).

Source Note:The provisions of this §355.7052 adopted to be effective September 11, 2025, 50 TexReg 5899.