CLASS CSA, CLASS, DSA, HCS, TxHmL, CDA, and Local Authorities:

DADS is expanding utilization management and review activities for its Medicaid community entitlement and waiver programs, effective January 1, 2012. (Letter)

ADC, ALF, HCSSA, ICF/ID, and NF:

Beginning March 1, 2012, if the name of an applicant or associated person is listed in a health and human services agency record of adverse licensing, DADS may deny the person’s application for a license or renewal. (Letter)

Hospice, ICF/ID, and NF:

DADS clarified how to apply CMS S&C Letter 11-30-NH in the context of DADS’ current incident reporting requirements. An excerpt:

Here are some points of guidance with regard to applying the provisions of S&C 11-30-NH in the context of DADS’ current incident reporting requirements:

• Section 1150B requires reporting of “any reasonable suspicion of a crime” to at least one local law enforcement agency of jurisdiction and to DADS. Reports to DADS (and the Department of Family and Protective Services, if appropriate) must also be made in accordance with current reporting guidelines as outlined in Provider Letter 06-12 and 40 TAC §97.249 (Hospice), Provider Letter 06-43 (NF), Provider Letter 09-02 (non-licensed ICF/ID) and Provider Letter 10-24 (licensed ICF/ID).

• Facilities, per page 3 of S&C 11-30, should coordinate with local law enforcement entities to determine what actions are considered crimes within their political jurisdiction. In the event more than one local law enforcement entity may have jurisdiction, such as a local police or sheriff’s department, DADS recommends facilities confirm which law enforcement entity should receive reports. DADS also recommends that owners, operators, employees, managers, agents or contractors of facilities and agencies review the Texas Penal Code, in particular the offenses in Chapters 22 (Assaultive Offenses), 31 (Theft) and 32 (Fraud). The Texas Penal Code is available on the Texas Legislature’s website at http://www.statutes.legis.state.tx.us/. Incidents of abuse, neglect and exploitation reported to law enforcement may result in a criminal investigation for one or more of the offenses in Chapters 22, 31 or 32.

Community Care for the Aged and Disabled RC providers, CBA, AL/RC, and AFC:

CMS recently announced a 3.6 percent COLA increase in federal benefits. Because of late receipt of this news, HHSC will not implement the increase until February 1, 2012. (Letter)

NF, ICF, HCS, and TxHmL:

HHSC will delay the COLA increase in Retirement, Survivors and Disability Insurance, Supplemental Security Income, and Medicare Part A and B premium amounts to February 1, 2012. (Letter)

HCSSA w/ DADS contract:

DADS released the results of a joint streamlining project (with Access and Intake, Contract Oversight and Support, and Regulatory Services) conducted during fiscal year 2011. An excerpt:

We are pleased to report that DADS identified several opportunities to increase coordination or eliminate duplication and has changed policies and procedures accordingly. Those changes are as follows: Several items reviewed during Regulatory surveys will no longer be reviewed by contract managers, including:

• Several items reviewed during Regulatory surveys will no longer be reviewed by contract managers, including:

o verification that providers document, investigate and resolve complaints reported to the provider;

o verification that individuals are informed of their rights and how to file complaints;

o verification that providers are conducting criminal history checks on unlicensed attendants;

o evidence of provider compliance in delivering seldom-used therapies;

o evidence of supervisory visits; and

o verification that interdisciplinary team meetings were convened in required timeframes.

Hospice, ICF/ID, and NF:

DADS clarified how to apply CMS Survey and Certification letter provisions in the context of the DADS’s current incident reporting requirements. (Letter)

All ICF/ID:

DADS informed providers that some Board of Nursing rules are more specific to the practice of professional nursing in Texas and may be viewed as more restrictive than the ICF/ID federal regulations. Providers must comply with the more stringent rules. (Letter)

All ICF/ID:

DADS clarified the Board of Nursing’s position on an LVN providing on-call telephones services to individuals in the ICF/ID program:

The BON defines on-call telephone services as “providing telephone services anytime of the day to handle non-urgent, urgent and emergent conditions an individual may experience; and making a telephone assessment and providing instructions to an unlicensed person over the phone regarding that condition.” The BON has determined LVNs providing on-call services to individuals in the ICF/ID program to be out of the LVN’s scope of practice. (Letter)

Hospice care for nursing facility residents has grown nearly 70% since 2005. The OIG recommends that CMS monitor hospices that depend heavily on nursing facility residents and modify the payment system for hospice care in nursing facilities. According to the OIG, the current payment structure provides incentives for hospices to seek out nursing facility beneficiaries who often receive longer but less complex care.

HHSC approved rate changes for the Medicaid Hospice program FY2012. You’ll find the new rates at the HHSC Rate Analysis site. (Letter)

A sample of recently released DADS news alerts:

–  DADS revised Appendix XIV in the CBA provider manual, which updates ISP cost limits.

–  DADS hosted a webinar on Oct. 25, 2011, to discuss the Dining Experience. The webinar audience submitted questions, and the answers are provided here.

–  The 2012 MDS National Conference will be held on March 6-7, 2012 and March 8-9, 2012, at the Hyatt Regency St. Louis at the Arch in St. Louis, MO.

Hyatt Regency St. Louis at the Arch
315 Chestnut Street
St. Louis, Missouri 63102
314-655-1234 direct
314-241-6618 fax

See the news alert page for more information.

CBA, CDSA, DAHS, PHC, and CMPAS:

Beginning March 1, 2012, HHSC will implement changes to CHIP services delivery, which include expanding STAR and STAR+PLUS Medicaid managed care programs to new areas and transitioning about 880,000 people currently part of the Primary Care Case Management into managed care. (Letter)

Medicaid Hospice:

DADS will modify the hospice physician narrative review process, effective November 1, 2011. Providers are no longer required to submit the physician narrative for all individuals entering the program. (Letter)

HCSSA:

HCSSAs must still meet the applicable standards and requirements at  TAC Title 40, Part 1, Chapter 97, §97.247(a)(3) and §97.247(b)(3) pertaining to searching the nurse aide registry and the employee misconduct registry when the DADS site (http://www.dads.state.tx.us) is unavailable. (Letter)

Public Notice

DADS proposed to amend 40 TAC §92.2, Definitions, in the October 7, 2011, issue of the Texas Register and included outdated definitions for paragraph (8), “behavioral emergency” on page 6702, and paragraph (36), “personal care services” on page 6703, were erroneously included in the rule text of the proposal. Corrections:

(8) Behavioral emergency–Has the meaning given in §92.41(p)(2) of this chapter (relating to Standards for Type A and Type B Assisted Living Facilities).

(36) Personal care services–Assistance with feeding, dressing, moving, bathing, or other personal needs or maintenance; or general supervision or oversight of the physical and mental well-being of a person who needs assistance to maintain a private and independent residence in the facility or who needs assistance to manage his or her personal life, regardless of whether a guardian has been appointed for the person.

Proposed Rules

HHSC proposed to amend §354.1041, Benefits for Medicare/Medicaid Recipients; §354.1143, Coordination of Title XIX with Parts A and B of Title XVIII; and §354.1149, Exclusions and Limitations. The changes would limit payments for Medicare Part B services provided to dual eligibles to no more than the Medicaid payment amount for the same service, with the exception of renal dialysis services. See the Texas Register for more information.

• On DADS’ Behalf

HHSC proposed to repeal Subchapter I, §§1.401 – 1.405, 1.407, 1.409, and 1.411, In-Home and Family Support Mental Retardation Program, in Chapter 1, State Mental Retardation Authority Responsibilities, to remove rules related to the program.

HHSC also proposed to amend §2.315, MRA administrative functions, in Chapter 2, Mental Retardation Authority Responsibilities, which would remove the requirement that a MRA administer the In-Home and Family Support Program–Mental Retardation in its local service area. For more information about each proposed change, see the Texas Register.

Adopted Rules

HHSC adopted amendments to §360.117, cost sharing in the Medicaid Buy-In program, which exempts recipients who live in a federally declared disaster area from the requirement to pay premiums for up to three months, beginning with the month in which the disaster is declared. See the Texas Register for details.

• On DADS’ Behalf

HHSC adopted amendments to §§19.1001, 19.1002, 19.1510, and 19.1601, nursing services, additional nursing services staffing requirements, emergency medication kits and infection control in Chapter 19, Nursing Facility Requirements for Licensure and Medicaid Certification. Among other things, the changes make the code consistent with the federal requirements for posting nurse staffing information.

HHSC also adopted amendments to §30.16, election of hospice care, and §30.60, Medicaid hospice payments and limitations, in Chapter 30, Medicaid Hospice Program. The changes allow individuals under 21 enrolled in Medicaid or CHIP to elect hospice treatment services without waiving their rights to treatment for their terminal illnesses.

For more information, see the Texas Register.

Public Hearings and Notice

HHSC will hold a public hearing on October 27, 2011, at 9 a.m. to receive public comment on proposed rates for Hospice routine home, continuous home, inpatient respite, and general inpatient care, to be held in the Lone Star Conference Room.

HHSC intends to submit transmittal number 11-055 to the Texas State Plan for Medical Assistance, which would establish the Recovery Audit Contractor Program. For more information about the hearing and the amendment, see the Texas Register.

DADS will hold a public hearing on October 18, 2011, at 8:30 a.m. to receive public comment on proposed amendments and new sections to Chapter 9, Subchapter D, the HCS program; Chapter 45, the CLASS program; Chapter 48, Subchapter J, the CBA program; and the MDCP program. The hearing will be held in the Public Hearing Room of the John H. Winters Building, 701 W. 51st Street, Austin. For details, see the Texas Register.

Proposed Rules

HHSC proposes to amend §355.8620, Reimbursement Methodology for Outpatient Services, which would add inpatient services to the type provided by the Indian Health Service or a to a tribe that will be reimbursed. See the Texas Register for more information.

The Texas Medical Board proposes to amend §173.1, Profile Contents; and §173.3, Physician-Initiated Updates. An excerpt:

The amendment to §173.1 clarifies what utilization review services are subject to reporting on a physician’s profile and specifically excludes the reporting of utilization review provided in relation to worker’s compensation claims.

The amendment to §173.3 clarifies that changes in address to be reported to the Board by physicians within 30 days of their occurrence, applies to both mailing and practice address changes.

The board also proposes to amend §175.1, Application and Administrative Fees; §175.2, Registration and Renewal Fees; and §175.5, Payment of Fees or Penalties. An excerpt:

The amendment to §175.1 removes all language relating to surcharges as this term is used only for internal agency purposes and its removal eliminates confusion; increases the application fee for physician-in-training permits used to complete rotations in Texas by $1 due to fee increases set by the Department of Information Resources; and sets the fee at $18 for the processing of Physician/Physician Assistant Jointly-Owned Entity Annual Reports.

The amendment to §175.2 removes all language relating to surcharges as this term is used only for internal agency purposes and its removal eliminates confusion.

The amendment to §175.5 provides that additional fees shall be incurred by individuals who renew their applications online or through hard-copy, depending on the format.

• On DADS’ Behalf

HHSC proposes changes to the code in the following sections:

• Mental Retardation Services–Medicaid State Operating Agency Responsibilities
• Nursing Facility Administrators
• Community Living Assistance And Support Services
• Community Care For Aged And Disabled
• Medically Dependent Children Program
• Licensing Standards For Assisted Living Facilities
• Nurse Aides
• Medication Aides–Program Requirements

Adopted Rules

HHSC adopted §354.1042, concerning home health supplies provided by a pharmacy, and new §354.1877, concerning quantity limitations; and the repeal of Subchapter W concerning pharmacy limitations, which consists of §354.3047, concerning quantity limitations, and §354.3092, concerning review and evaluation.

Among other things, the changes would allow pharmacies enrolled in the Medicaid Vendor Drug Program to provide a limited set of basic home health supplies commonly found in pharmacies without requiring enrollment as a DME provider. See the Texas Register for details.

The Texas Board of Nursing adopted an amendment to §223.1, Fees, which increases the renewal fee for a professional nursing license by $8; the new fee is $73 every two years. See the Texas Register for more information.

• On DADS’ Behalf

HHSC adopted amendments to §§11.2 – 11.4, concerning definitions, quality assurance fee determination methodology, and required reports, in Chapter 11, Quality Assurance Fee. The changes are adopted to require ICF/MR providers to pay a quality assurance fee for all days of paid leave on a monthly basis and exclude durable medical equipment claims from total revenue calculations. For more information, see the Texas Register.

Proposed Rule Review

The Texas Medical Board proposes to review Chapter 173, Physician Profiles, §§173.1 – 173.5 and 173.7; and The Chapter 175, Fees and Penalties, §§175.1 – 175.3 and 175.5. This same Texas Register proposes amendments to §173.1 and §173.3; and §§175.1, 175.2 and 175.5. See the Texas Register for contact information.

Licensed Type C ALs:

DADS will conduct a two-year review of licensed Type C assisted living facilities that no longer serve adult foster care (AFC) clients, effective September 14, 2011, which replaces the assessment completed by the AFC contract specialist when the services were provided to those clients. Use Form 1123, Review of Assisted Living Facility Type C. (Letter)

HCSSAs:

Attached to this letter is a five-page document titled, “What to Expect during Your Agency’s Survey” (Replaces PLs 07-21, 05-47 and 05-28).

NFs:

DADS reminded NFs of the correct process for refunding Medicaid claims payments to DADS when a provider is paid by both private insurance and DADS for the same dates of service. An excerpt:

There are two valid methods for refunding DADS when providers are paid by both private insurance and by DADS for the same dates of service:

• Providers can send a check to DADS for the total amount due and should include the client name, Medicaid number, and dates of service on the check. Providers should also submit a copy of the client’s Explanation of Benefits. Checks are payable to Texas DADS and should be sent to Texas DADS Third Party Recovery (TPR) Unit (E-400), P. O. Box 149081, Austin, Texas 78714-9081.

• Providers can request DADS to process a deduction by contacting TPR at 512-438-2200, Option 4.

Community Services, Hospice, NF, and ICF/MR:

DADS is considering moving to all electronically-submitted Long Term Care (LTC) claims by early 2012, which will affect providers that use LTC Form 1290 to bill the TMHP for payment. See TexMedConnect for more information. (Letter)

ICF/MR with MR (excluding state-supported living centers):

DADS will conduct mortality reviews for deaths that occurred during Fiscal Year 2012 for decedents who lived in ICF/MR with MR at the time of their death; or died within 90 days of discharge. (Letter)

• DADS added a new section to its web site: Culture Change in Texas Long-term Care.

• The MDS Privacy Act Statement is available in Spanish in the MDS 3.0 RAI Manual.

• “Effective for dates of service or dates of discharge (services) on or after October 1, 2013, Medicaid fee-for-service, Medicaid managed care, Primary Care Case Management (PCCM), family planning (Titles V, X, and XX), the Children with Special Health Care Needs (CSHCN) Services Program, and the Long Term Care (LTC) program will transition medical diagnosis and inpatient procedure coding from ICD-9-CM to ICD-10 code sets.”

• CMS has begun assessing the Texas Medicaid program using the PERM review process to measure payment accuracy in that program and CHIP. Click here for more information on what to expect during review process, and click here for an overview of PERM.

For more information on these more recent news alerts, see the main page.

Medicaid Hospice:

HHCS approved new payment rates for Medicaid hospice room and board for recipients living in a NF or ICF/MR, effective September 1, 2011. You can access the new rates at the HHCS Rate Analysis web page. (Letter)

CBA AL/RC, CBA HCSSA, CLASS CMA and DSA, DAHS, DBMD, HCS, ICF/MR, NF, PHC, AL/RC, and TxHmL:

HHSC adopted amendments to its Cost Determination Process rules governing the Informal Reviews and Formal Appeals at 1 TAC §355.110, effective September 1, 2011, which indicate that a request for an informal review that does not meet the requirements of 1 TAC §355.110(c)(1)(B) will not be accepted. An excerpt:

These amendments indicate that a request for an informal review that does not meet the requirements of 1 TAC §355.110(c)(1)(B) will not be accepted. 1 TAC §355.110(c)(1)(B) requires that an interested party must, with its request for an informal review, submit the following:

1. A concise statement of the specific actions or determinations it disputes;

2. Its recommended resolution; and

3. Any supporting documentation the interested party deems relevant to the dispute.

CDSA:

DADS informed these providers of changes to the criminal conviction check procedures, and form and training materials for employers, effective September 1, 2011. This letter replaces Information Letter 2009-79, Criminal Conviction Checks for CDSAs. See Chapter 3 of the CDS Employer Handbook (PDF) for more information. (Letter)