TITLE 1. ADMINISTRATION
PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353. MEDICAID MANAGED CARE
SUBCHAPTER
R.
The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §353.1502, concerning Definitions; §353.1504, concerning Use of Telecommunications in Service Coordination and Service Management; and §353.1506, concerning Additional Requirements for Assessments and Service Management in STAR Health.
Section 353.1502 is adopted with changes to the proposed text as published in the December 20, 2024, issue of the Texas Register (49 TexReg 10167). This rule will be republished.
Section 353.1504 and §353.1506 are adopted without changes to the proposed text as published in the December 20, 2024, issue of the Texas Register (49 TexReg 10167). These rules will not be republished.
BACKGROUND AND JUSTIFICATION
The amendments are necessary to comply with House Bill 4, 87th Legislature, Regular Session, 2021, which requires telecommunications allowances to the new service coordination levels for STAR Health. The amendments reflect the STAR Health programmatic changes by incorporating service coordination levels and replacing the term "service management" with "service coordination." These changes allow the STAR Health managed care organization to conduct assessments and provide service coordination services using telecommunications or information technology when it is clinically effective and cost-effective to do so.
COMMENTS
The 31-day comment period ended January 20, 2025.
During this period, HHSC did not receive any comments regarding the proposed rules.
HHSC revised §353.1502(13) to make the definition of "HHSC" more consistent with the definition used in other HHSC rules.
STATUTORY AUTHORITY
The amendments are adopted under Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services system; Texas Government Code §531.033, which provides the executive commissioner of HHSC with broad rulemaking authority; Texas Human Resources Code §32.021, which provides HHSC with the authority to administer the federal medical assistance program in Texas and to adopt rules and standards for program administration in Texas and to establish methods of administration and adopt necessary rules for the proper and efficient operation of the medical assistance program.
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353.1502.
The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.
(1) Assessments--Managed care organization (MCO) evaluation of a member's medical and functional service needs, including community-based long-term services and supports, behavioral health services, therapies (e.g., physical, occupational, speech), and nursing services. This includes the MCO's completion of program-specific instruments and forms.
(2) Audio-only--Synchronous interactive, two-way audio communication that uses only sound and that meets the privacy requirements of the Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication. Audio-only does not include face-to-face communication.
(3) Audio-visual--Synchronous interactive, two-way audio and video communication that conforms to privacy requirements under the Health Insurance Portability and Accountability Act. Audio-visual does not include audio-only or in-person communication.
(4) C.F.R.--Code of Federal Regulations.
(5) Change in condition--A significant change in a member's health, caregiver support, or functional status that will not normally resolve itself without further intervention and requires review of and revision to the member's current service plan or individual service plan.
(6) Community-based long-term services and supports (LTSS)--Services provided to a qualified member in the member's home or another community-based setting necessary to allow the member to remain in the most integrated setting possible. Community-based LTSS includes Medicaid state plan services available to all members, as well as services available to members who qualify for the Home and Community Based Services (HCBS) Program or Medicaid 1915(c) waiver programs, including the STAR+PLUS Home and Community-Based Services (HCBS) Program and the Medically Dependent Children Program. Community-based LTSS is available to both HCBS -eligible and non-HCBS eligible members. Community-based LTSS in Medicaid managed care varies by program model.
(7) Community First Choice (CFC)--A Medicaid state plan benefit described in 1 TAC Chapter 354, Subchapter A, Division 27 (relating to Community First Choice).
(8) Covered services--Unless a service or item is specifically excluded under the terms of the state plan, a federal waiver, a managed care services contract, or an amendment to any of these, the phrase "covered services" means all health care, long term services and supports, nonemergency medical transportation services, or dental services or items that the MCO must arrange to provide and pay for on a member's behalf under the terms of the contract executed between the MCO and the Texas Health and Human Services Commission, including:
(A) all services or items comprising "medical assistance" as defined in Human Resources Code §32.003; and
(B) all value-added services under such contract.
(9) Declared state of disaster--A State of Disaster declared by the governor in accordance with Texas Government Code §418.014.
(10) Face-to-face--In-person or audio-visual communication that meets the requirements of the Health Insurance Portability and Accountability Act. Face-to-face does not include audio-only communication.
(11) Functionally necessary covered services--Community-based long-term services and supports provided to assist members with activities of daily living based on a functional assessment of the member's activities of daily living and a determination of the amount of supplemental supports necessary for the member to remain independent or in the most integrated setting.
(12) Healthcare service plan--An individualized plan developed with and for a member with special healthcare needs in the STAR Health program. The healthcare service plan includes the following:
(A) the member's history;
(B) a summary of current medical and social needs and concerns;
(C) short and long-term needs and goals; and
(D) a treatment plan to address the member's physical, psychological, and emotional healthcare problems and needs, including:
(i) a list of required services;
(ii) the frequency of each service;
(iii) a description of who will provide each service; and
(iv) for a member in the Early Childhood Intervention program, the individual family service plan.
(13) HHSC--The Texas Health and Human Services Commission or its designee.
(14) HIPAA--Health Insurance Portability and Accountability Act. Collectively, the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §§1320d et seq., and regulations adopted under that act, as modified by the Health Information Technology for Economic and Clinical Health Act (HITECH) (P.L. 111-105), and regulations adopted under that act at 45 CFR Parts 160 and 164.
(15) Individual service plan (ISP)--An individualized and person-centered plan in which a member enrolled in the STAR Kids, STAR Health or STAR+PLUS HCBS program operated by an MCO, with assistance as needed, identifies and documents the member's preferences, strengths, and health and wellness needs in order to develop short term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The ISP is supported by the results of a member's program-specific assessment and must meet the requirements of 42 C.F.R. §441.301.
(16) Information technology--Includes text, email, fax, secure transmission of clinical information, and HIPAA-compliant telecommunication tools such as health plan websites where a member or the member's legally authorized representative can access the member's healthcare information, including service plans.
(17) In-person (or in person)--Within the physical presence of another person. In-person or in person does not include audio-visual or audio-only communication.
(18) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and may, depending on the circumstances, include a parent, guardian, or managing conservator of a minor, or the guardian of an adult, or a representative designated pursuant to 42 C.F.R. §435.923.
(19) Managed care organization (MCO)--An entity licensed and approved by the Texas Department of Insurance with which HHSC contracts to provide Medicaid services and that complies with Chapter 353 of this title (relating to Medicaid Managed Care).
(20) Medical consenter--The person who may consent to medical care for a member under Texas Family Code Chapter 266.
(21) Medically Dependent Children Program (MDCP)--A 1915(c) waiver program that provides community-based services to assist Medicaid beneficiaries under age 21 to live in the community and avoid institutionalization.
(22) Medically necessary--Has the meaning as defined in §353.2 of this chapter (relating to Definitions).
(23) Medical Necessity Level of Care (MN/LOC)--An assessment instrument used to determine medical necessity for a nursing facility as defined by 26 TAC §554.2601. An MN/LOC is required for STAR+PLUS HCBS Program and CFC eligibility.
(24) Member--A person who is eligible for benefits under Medicaid, is in a Medicaid eligibility category included in the Medicaid managed care program, and is enrolled in a Medicaid MCO.
(25) Minimum data set (MDS)--Has the meaning as defined in 26 TAC §554.101.
(26) Nursing facility--An entity that provides organized and structured nursing care and services, and is subject to licensure under Texas Health and Safety Code, Chapter 242.
(27) Nursing facility level of care--The determination that the level of care required to adequately serve a member is at or above the level of care provided by a nursing facility.
(28) Person-centered care--An approach to care that focuses on members as individuals and supports caregivers working most closely with members. It involves a continual process of listening, testing new approaches, and changing routines and organizational approaches in an effort to individualize and de-institutionalize the care environment.
(29) Resident Assessment Instrument (RAI)--Has the meaning as defined in 26 TAC §554.101.
(30) Resource Utilization Group (RUG)--A categorization method, consisting of multiple categories based on the minimum data set core elements in a resident assessment instrument, that is used to determine a recipient's service and care requirements for a nursing facility. A RUG determination is necessary for MDCP and the STAR+PLUS HCBS Program eligibility because these programs require a nursing facility level of care.
(31) Service coordination--A specialized care management service that is performed or arranged by the MCO to identify needs, including physical health, mental health services and long term support services, facilitate development of a service plan or individualized service plan to address those identified needs, and coordination of services among the member's primary care provider, specialty providers, and non-medical providers to ensure timely access to covered services, non-capitated services, and community services.
(32) Service coordinator--The person with primary responsibility for providing service coordination to Medicaid managed care members.
(33) Service plan (SP)--An individualized and person-centered plan in which a member, with assistance as needed, identifies and documents the member's preferences, strengths, and needs in order to develop short-term objectives and action steps to ensure personal outcomes are achieved within the most integrated setting by using identified supports and services. The service plan is supported by the results of the member's program-specific assessment. In STAR+PLUS, a service plan applies to members who are not enrolled in the STAR+PLUS HCBS Program.
(34) STAR+PLUS Home and Community-Based Services (HCBS) Program--The program that provides person-centered care services that are delivered in the home or in a community setting, as authorized through a federal waiver under §1115 of the Social Security Act, to qualified Medicaid-eligible clients who are age 21 or older, as cost-effective alternatives to institutional care in nursing facilities.
(35) Telecommunications--An exchange of information by electronic and electrical means.
(36) Telephonic--Audio-only communication using a telephone. Telephonic communication does not include audio-visual communication.
(37) Verbal consent--The spoken agreement of a member, a member's legally authorized representative, or a member's medical consenter.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on March 25, 2025.
TRD-202501005
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: April 14, 2025
Proposal publication date: December 20, 2024
For further information, please call: (512) 438-2910
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER
D.
The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts an amendment to §355.456, concerning Reimbursement Methodology.
Section 355.456 is adopted without changes to the proposed text as published in the November 15, 2024, issue of the Texas Register (49 TexReg 9134). This rule will not be republished.
BACKGROUND AND JUSTIFICATION
The adoption updates the reimbursement methodology for the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) high medical needs add-on rates based on the Patient Driven Payment Model Long-Term Care (PDPM LTC) for nursing facilities. The current reimbursement methodology for the ICF/IID high medical needs add-on is based on the Resource Utilization Group version 3 (RUG-III) classification system and associated costs. The 2024-25 General Appropriations Act, House Bill 1, 88th Legislature, Regular Session, 2023 (Article II, Health and Human Services Commission, Rider 25) directed HHSC to "develop and implement a Texas version of the Patient Driven Payment Model methodology for the reimbursement of long-term stay nursing facility services in the Medicaid program." The PDPM LTC methodology implements a new nursing facility classification system for Medicaid residents. This amendment uses PDPM LTC classifications to establish the reimbursement methodology for the ICF/IID high medical needs add-ons.
COMMENTS
The 31-day comment period ended December 16, 2024.
During this period, HHSC did not receive any comments regarding the proposed rule.
STATUTORY AUTHORITY
The amendment is adopted under Texas Government Code §524.0151, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; and Texas Human Resources Code §32.021 and Texas Government Code §532.0051(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; and Texas Government Code §532.0057(a), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on March 25, 2025.
TRD-202501003
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: April 14, 2025
Proposal publication date: November 15, 2024
For further information, please call: (512) 867-7817
SUBCHAPTER
E.
The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §355.503, concerning 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 §355.507, concerning Reimbursement Methodology for Long-Term Services and Supports State Plan and Medically Dependent Children Waiver Program Services Delivered through the STAR Kids and STAR Health Managed Care Programs.
Section 355.503 and §355.507 are adopted without changes to the proposed text as published in the November 1, 2024, issue of the Texas Register (49 TexReg 8635). The rules will not be republished.
BACKGROUND AND JUSTIFICATION
The purpose of the proposal is to clarify the reimbursement methodologies for the Long-term Services and Supports (LTSS) state plan and waiver services delivered through managed care. HHSC maintains fee schedules for LTSS programs and services delivered in STAR+PLUS or STAR Kids programs that represent the rates HHSC would pay contracted providers for these services if the services were delivered under a fee-for-service delivery model. The adoption ensures that HHSC has an established rate methodology for all the services delivered in managed care based on the STAR+PLUS and STAR Kids LTSS billing matrices. The adoption relabels and adds language to the rules to reference the STAR+PLUS and STAR Kids managed care programs and removes references to the expired Community-Based Alternatives Waiver Program and Integrated Care Management-Home and Community Support Services Program. The adoption also consolidates rate methodologies for LTSS state plan services delivered through STAR+PLUS and STAR Kids into the applicable Texas Administrative Code rule. The adoption revises the rate methodology for out-of-home respite under the STAR Kids Medically Dependent Children Program (MDCP) to mirror waiver changes and the published billing matrix. Finally, the adoption adds language to the rules to distinguish in-home and out-of-home settings for home health care services. These services include nursing, occupational therapy, and physical therapy, ensuring compliance with the 21st Century Cures Act, which requires all states to implement the use of electronic visit verification (EVV).
COMMENTS
The 31-day comment period ended December 2, 2024.
During this period, HHSC did not receive any comments regarding the proposed rules.
STATUTORY AUTHORITY
The amendments are adopted under Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; and Texas Human Resources Code §32.021 and Texas Government Code §532.0051(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; and Texas Government Code §532.0057(a), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on March 25, 2025.
TRD-202501004
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: April 14, 2025
Proposal publication date: November 1, 2024
For further information, please call: (512) 867-7817