Texas Register, Volume 34, Number 33, Pages 5445-5614, August 14, 2009 Page: 5,456
5445-5614 p. ; 28 cm.View a full description of this periodical.
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(A) covered benefits under 354.1175 of this title (re-
lating to Organ Transplants);
(B) care, services, and supplies otherwise authorized by
HHSC; and
(C) physician services as allowed by Title XIX laws and
regulations and state law;
(16) [(E-4)] any services or supplies that are experimental
or investigational [services, supplies, Or procedures as determined by
the United States Public Health Service; - a state organization; -or other
medical authority, including the department].
(b) Outpatient Behavioral Health Services. Benefits to an in-
dividual for the diagnosis or treatment of mental disease, psychoneu-
rotic, and personality disorders while not confined as an inpatient in a
hospital are limited to 30 visits to enrolled practitioners per calendar
year. This utilization control limitation may be exceeded when prior
authorized on a case-by-case basis.
(c) Private Room Facilities. Private room facilities are not a
benefit unless a facility submits [considered medically necessary ex-
cept when on the basis ofedialopinion critical or contagious illness
exists, or when the eligible recipient's condition results in undue ds-
turbance t other patients r the need for- care is emergent and lower
co.s facilities are not immediately available. The health insuring agent
requires hospi-tal to fie with the health insuring agent] a physician's
certification of [such] medical necessity to HHSC or its designee cer-
tifying that one of the following conditions is met:[.]
(1) the recipient, based on a medical opinion, has a critical
or contagious illness;
(2) the eligible recipient's condition results in undue dis-
turbance to other patients; or
(3) the need for care is emergent and lower cost facilities
are not immediately available.
(d) Institutional Care. Separate payments are not made for ser-
vices and supplies in an institution where the reimbursement formula
and vendor payment include such services or supplies as a part of the
institutional care.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal author-
ity to adopt.Filed with the Office of the Secretary of State on July 30, 2009.
TRD-200903222
Steve Arag6n
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: September 13, 2009
For further information, please call: (512) 424-6900
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER M. MISCELLANEOUS
MEDICAID PROGRAMS
DIVISION 4. YOUTH EMPOWERMENT
SERVICES WAIVER PROGRAM
1 TAC 355.9060The Texas Health and Human Services Commission (HHSC)
proposes to add new 355.9060, Reimbursement Methodology
for the Youth Empowerment Services Waiver Program, to Title
1, Part 15, Chapter 355, Subchapter M, Division 4, Reimburse-
ment Methodology for the Youth Empowerment Services Waiver
Program.
Background and Justification
The Department of State Health Services (DSHS) has developed
the Youth Empowerment Services (YES) waiver to provide inten-
sive, community-based services to children and youth who meet
the criteria for inpatient psychiatric hospitalization. The waiver
will implement a pilot program to provide certain services to chil-
dren and adolescents in Bexar and Travis counties. The goals
of the proposed waiver include:
providing a more complete continuum of community-based ser-
vices and supports for children with severe emotional distur-
bances;
preventing or reducing inpatient psychiatric admissions for chil-
dren with severe emotional disturbances;
preventing entry and recidivism into the foster care system;
reducing out-of-home placements by all child-serving agencies;
and
improving the clinical and functional outcomes of youth and their
families.
The Centers for Medicare and Medicaid Services approved the
YES waiver effective September 1, 2009.
This proposed rule describes the rate methodology for the YES
waiver.
Section-by-Section Summary
Subsection (a) establishes that the rates for the YES waiver are
developed based on rates determined for other programs that
provide similar services. If payment rates are not available from
other programs that provide similar services, HHSC will model
rates based a pro forma analysis. A pro-forma analysis makes
assumptions about staff salaries and service requirements and
estimates the basic types and costs of products and services
necessary to deliver services that meet federal and state require-
ments.
Subsection (b) establishes that YES waiver rate development
is governed by 1 TAC 355.101 (relating to Introduction) and
355.105 (relating to General Reporting and Documentation Re-
quirements, Methods and Procedures).
Fiscal Note
Machelle Pharr, Chief Financial Officer for the Department of
State Health Services, has determined that, for each year of the
first five-year period that the proposed rule is in effect, there are
positive fiscal implications for state government as a result of
enforcing or administering this rule. The proposed rule will not
result in fiscal implications for local health and human services
agencies. There are no fiscal implications for local governments
as a result of enforcing and administering the section.
The effect on state government for the first five years the
proposed rule is in effect is an estimated decrease in cost of
$1,141,260 in fiscal year (FY) 2010; $839,742 in FY 2011;
$823,056 in FY 2010; $823,056 in FY 2011; and $823,056 in
FY 2012. The decrease is due to the cost savings associated
with waiver programs.34 TexReg 5456 August 14, 2009
Texas Register
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Texas. Secretary of State. Texas Register, Volume 34, Number 33, Pages 5445-5614, August 14, 2009, periodical, August 14, 2009; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth90865/m1/11/: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.