Largest insurer in Kansas says no to governor’s Medicaid plan. “In a letter addressed ‘Dear provider,’ Angie Strecker, director of institutional relations for Blue Cross Blue Shield of Kansas, said the insurer ‘has decided not to submit a proposal to the state to be a Medicaid contractor.’” – McClatchy

Medicaid overhaul in Louisiana. “The first leg of Gov. Bobby Jindal’s Medicaid overhaul goes live today, with more than 180,000 southeast Louisiana residents, most of them children, being shifted from the state-run insurance program to private insurance networks. Jindal’s signature health care initiative, the Bayou Health rollout involves the south shore of Lake Pontchartrain from St. Bernard Parish to Jefferson Parish, and the north shore parishes of St. Tammany, Washington, Tangipahoa, St. Helena and Livingston.” – NOLA.com

Judge temporarily blocks 10 percent Medi-Cal cuts to providers. “In a 25-page order, the Los Angeles-based judge said she recognized the state’s budget problems but that the cuts raised the risk of ‘irreparable harm in the absence of an injunction.”…Advocacy groups have warned that reducing spending on Medi-Cal would make it more difficult for poor people to get healthcare. James T. Hay, president of the California Medical Assn., one of the organizations that sued the state to block the cut, called the judge’s decision encouraging.” – LA Times

HHSC proposed amendments to §355.101, Introduction, and §355.107, Notification of Exclusions and Adjustments. The changes would create a formal definition for the term “line item” and eliminate a reference to auditors. HHSC also proposed to amend §372.107, persons excluded from TANF certified group, and §372.1402, changes a SNAP household must report. The proposed rules would correct outdated rule references and reflect current federal regulations and HHSC policy. An excerpt:

Federal rule (Title 7, Code of Federal Regulations (CFR) §273.12) requires a household receiving SNAP food benefits to promptly report a change in residence and any change in the household’s shelter costs resulting from the change in residence, if the household does not have simplified reporting status. Shelter costs include expenses such as rent, house payments, taxes, insurance, and utilities. “Simplified reporting status” means a household meets the criteria for reporting certain changes less frequently than a household that does not meet the criteria.

The U.S. Department of Agriculture, Food and Nutrition Service (FNS), previously had given HHSC waivers from two reporting requirements in 7 CFR §273.12: (1) HHSC could require all households, even those with simplified reporting status, to promptly report a change in residence; and (2) HHSC could exempt all households, even those without simplified reporting status, from reporting shelter cost changes when they move. HHSC’s current rule at §372.1402 reflects these FNS waivers.

For details about each proposed rule, see the Texas Register.

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.

HHSC proposed new §354.1853, Specialty Drugs, which provides a definition and criteria for specialty drugs. An excerpt:

Section 1.02(d), Senate Bill 7, 82nd Legislature, First Called Session, 2011, amends Texas Government Code §533.005(a) by adding paragraph (23)(G) to require Medicaid managed care organizations (MCOs) and subcontracted pharmacy benefit managers (PBMs) to adopt policies and procedures for reclassifying prescription drugs from retail to specialty drugs that are consistent with rules adopted by the Executive Commissioner. MCOs and subcontracted PBMs cannot individually determine which retail drugs to reclassify as specialty drugs but will instead be required to follow HHSC’s specialty drugs list, as described in the proposed new rule.

HCS and TxHmL:

These providers must be in compliance with nursing changes by January 1, 2012, with the following requirements:

HCS and TxHmL program providers must be in compliance by January 1, 2012 with the following requirements:

• All licensed vocational nurses (LVNs) must be clinically supervised by a registered nurse (RN).

• Program providers must have a written plan and schedule to complete an initial comprehensive nursing assessment for all individuals enrolled in HCS.

HCS and TxHmL program providers must be in compliance by March 1, 2012 with the following requirements:

• LVNs participating in the pilot project may perform on-call services by telephone only if all conditions for pilot participation have been met. On-call services are defined as providing telephone services any time of the day or night to make an assessment by phone of non-urgent, urgent, and emergency conditions or issues an individual may experience. On-call services also includes providing instructions to an unlicensed person over the phone regarding a condition.

• LVNs who are not participating in the pilot project cannot provide on-call services.

HCS and TxHmL program providers must be in compliance by May 1, 2012 with the following requirements:

• Data reflecting nursing on-call services for March 1, 2012 and thereafter must be entered into the Client Assignment and Registration System (CARE). A separate information letter will be posted outlining the reporting requirements in CARE.

HCS:

An RN may exempt an HCS foster/companion care provider from the Board of Nursing definition of unlicensed person if the specified conditions are met. You will find the information at Question 5 on the FAQs page. (Letter)

CBA HCSSAs:

CBA nursing assessments will be required twice a year instead of four times a year, effective January 20, 2012. (Letter)

Public Notices

HHSC will hold a public hearing on February 15, 2012, at 1:30 p.m., to receive comment on proposed Medicaid payment rates for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies; payment rates for annual Healthcare Common Procedure Coding System; and Medicaid payment rates for the Medicaid Biennial Calendar Fee Review. The hearing will be held Lone Star Conference Room. For details, including where to send comments, see the Texas Register.

Emergency Rules

HHSC adopted new §355.8201, Transition-Period Waiver Payments to Hospitals, and §355.8202, Transition-Period Waiver Payments for Physician Services, which describe the methodology HHSC will use initially to make supplemental payments to Medicaid providers through a demonstration waiver under section 1115 of the Social Security Act. For more information, see the Texas Register.

Proposed Rules

HHSC proposed to repeal §355.8064, Reimbursement Adjustment for Hospitals Providing Inpatient Services to SSI and SSI-Related Clients. Because of the planned Medicaid managed care expansion, effective March 1, 2012, HHSC will no longer carve out inpatient hospital services from the managed care capitation payment in the managed care service areas. See the Texas Register for more information.

Adopted Rules

HHSC adopted an amendment to §355.8620, Medicaid Reimbursement Methodology for Services Provided in Indian Health Services and Tribal Facilities, which adds inpatient services to those provided to American Indians by a qualified facility operated by IHS or a tribe to be reimbursed at the applicable rate published and specified by the IHS in the Federal Register. For more information, see the Texas Register.

• On DADS’s Behalf

HHSC adopted an amendment to §49.1, Definitions, in Subchapter A, Definitions; an amendment to §49.12, General Requirements for Participation, and the repeal of §49.19, Advertising and Solicitation of Clients, in Subchapter B, Contractor Requirements; and an amendment to §49.61, Sanctions, in Subchapter F, Sanctions and Termination, in Chapter 49, Contracting for Community Care Services. The changes delete references to solicitation rules from the DADS rule base. See the Texas Register for details.

Assistant Living Facilities:

The legislature has made changes to the process of removing an inappropriately placed resident. An excerpt:

An inappropriately placed resident is a resident who was appropriate when admitted to the ALF, but whose condition has changed. All residents must be appropriate for the ALF licensure type when admitted to the facility. After admission, if the resident’s condition changes, the resident may no longer be appropriate for the facility’s license. An ALF is not required to keep a resident who is no longer appropriate for the facility’s license. DADS proposes rule amendments to require facilities to include information about the facility’s policies and procedures for aging in place in their disclosure statement.

All ICF/ID with capacity of 13 or fewer beds:

Unless an ICF/ID provider is enrolled in the pilot program, an LVN may not provide on-call services. (Letter)

All Community Services 1915(c) Waiver providers:

Effective January 1, 2012, Medicaid 1915(c) waiver services recipients enrolled in a Medicare Part D prescription drug plan will no longer have to pay for Part D prescription co-payments. (Letter)

Raising the age of Medicare eligibility. “Medicare provides health insurance to almost everyone who is 65 or older. If the eligibility age was raised above 65, fewer people would be eligible for Medicare, and outlays for the program would decline relative to those projected under current law. CBO expects that most people affected by the change would obtain health insurance from other sources, primarily employers or other government programs, although some would have no health insurance.” – Congressional Budget Office

Providers brace for Medicare pre-payment audits. “CMS last month published national plans to increase the number of reviews to 2.7 million claims a year, up from 1.2 million claims, according to American Medical News. Some providers voiced concerns about the audits, including the American Medical Association…” – FierceHealthCare

Update about the Texas Medicaid waiver. “The waiver allows Texas to keep drawing down billions of federal dollars even as the state expands Medicaid managed care programs designed to curb costs and make care more efficient for Texas’ neediest patients.” – Texas Tribune

Texas Democrats filed brief in support of health care reform law. “Opponents of the federal law, like Republican Texas Attorney General Greg Abbott, have argued that the key tenet of the reform — forcing people to carry health insurance — is an unconstitutional overreach.” – Texas Tribune

Public Notices

HHSC adopted a new per diem payment rate for the Tyler state-owned veterans nursing facility: $237.00. HHSC intends to submit to CMS a request to amend the Youth Empowerment Services waiver to expand the geographical area of the waiver to include Tarrant County in addition to Bexar and Travis Counties. See the Texas Register for more information.

Proposed Rules

HHCS proposes to amend §355.105, General Reporting and Documentation Requirements, Methods, and Procedures; §355.112, Attendant Compensation Rate Enhancement; §355.308, concerning Direct Care Staff Rate Component; §355.503, Reimbursement Methodology for the Community-Based Alternatives Waiver Program and the Integrated Care Management-Home and Community Support Services and Assisted Living/Residential Care Programs; §355.505, Reimbursement Methodology for the Community Living Assistance and Support Services Waiver Program; and §355.5902, Reimbursement Methodology for Primary Home Care.

The proposed changes would:

1) formalize certain existing practices; 2) clarify due dates for consolidated cost reports; 3) change how entities request that their cost reports be aggregated for purposes of determining compliance with Attendant Compensation Rate Enhancement (the Enhancement) spending requirements; 4) eliminate the requirement that all contracts in an aggregated group participate in the Enhancement at the same level; and 5) allow providers subject to a recoupment for failure to meet Enhancement spending requirements on a specific Attendant Compensation Report, and providers subject to recoupment for failure to meet Direct Care Staff Rate staffing and/or spending requirements on a specific Staffing and Compensation Report, to, in certain situations, request that HHSC recalculate their recoupment after combining that report with the provider’s next cost report or Attendant Compensation or Staffing and Compensation Report, as appropriate.

The Texas Medical Board proposes to amend §185.4, Procedural Rules for Licensure Applicants, which  provides grounds for the extension of licensure applications that have been on file with the Board for over one year and allow for an alternative licensure process for military spouses. See the Texas Register for details.

Withdrawn Rules

HHSC withdrew the proposed repeal of 1 TAC §355.8381, Case Management Reimbursement Methodology, which appeared in the June 24, 2011, issue of the Texas Register (36 TexReg 3771).

Adopted Rules

The Board of Nursing adopted amendments to §217.6, Failure to Renew License, which are necessary to implement the requirements of SB1733, enacted by the 82nd Legislature, Regular Session, effective June 17, 2011, which simplifies to licensure process for military spouse applicants without compromising the safety of the public. An excerpt:

First, the Board has determined that military spouse applicants should not be required to pay the late fees and fines normally required for reactivating an expired or delinquent license. Because military spouses are often transferred from state to state with little notice, the Board has determined that the purpose of the late fees and fines, which is to encourage a licensee’s timely renewal, is not applicable in such situations. As such, the adopted amendments exempt military spouse applicants from paying these late fees and fines. However, only those military spouse applicants who submit a reactivation application to the Board in paper form will be exempt from paying these late fees and fines. This is because the Board’s online system is unable to process applications that are not accompanied by full payment of the late fees and fines normally required for the reactivation of an expired or delinquent license. Because the Board is unable to alter its online system at this time, the adopted amendments specifically require the reactivation application to be submitted in paper form in order for a military spouse applicant to receive this exemption.

• On DADS’ Behalf

Each change in the sections below authorizes DADS to deny or refuse to renew a license if an applicant or certain persons associated with an applicant are listed in a health and human service agency’s record of adverse licensing action maintained in accordance with Texas Government Code §531.952.

• Nursing Facility Requirements For Licensure And Medicaid Certification
• Intermediate Care Facilities For Persons With Mental Retardation Or Related Conditions
• Licensing Standards For Assisted Living Facilities
• Licensing Standards For Home And Community Support Services Agencies
• Adult Day Care And Day Activity And Health Services Requirements
• Denial Or Refusal Of License

Rule Review

The Texas Medical Board proposes to review Chapter 185, Physician Assistants, §§185.1 – 185.27, pursuant to the Texas Government Code, §2001.039.  Elsewhere in this issue. the Texas Medical Board contemporaneously proposes amendments to §185.4.