Section 355.723 - Reimbursement Methodology for Home and Community-Based Services and Texas Home Living Programs(a) Prospective payment rates. The Texas Health and Human Services Commission (HHSC) sets payment rates to be paid prospectively to Home and Community-based Services (HCS) and Texas Home Living (TxHmL) providers.(b) Levels of need. (1) Variable rates. Rates vary by level of need (LON) for the following services:(A) host home/companion care (HH/CC);(B) individualized skills and socialization;(C) residential support services (RSS); and(D) supervised living (SL).(2) Non-variable rates. Rates do not vary by LON for the following services:(C) cognitive rehabilitative therapy (CRT);(D) community first choice personal assistance services/habilitation (CFC PAS/HAB);(E) community support services transportation (CSS);(G) employment assistance (EA);(I) licensed vocational nurse (LVN);(J) occupational therapy (OT);(K) out-of-home respite (OHR);(L) physical therapy (PT);(M) registered nurse (RN);(P) supported employment (SE); and(Q) supported home living transportation (SHL).(c) Recommended rates. The recommended payment rates are determined for each HCS and TxHmL service listed in subsections (b)(1) and (2) of this section by type and, for services listed in subsection (b)(1) of this section, by LON to include the following cost areas.(1) Attendant compensation cost area. The determination of the attendant compensation cost area is calculated as specified in § 355.112 of this chapter (relating to Attendant Compensation Rate Enhancement). The attendant compensation cost area includes personal attendant staffing costs (wages, benefits, modeled staffing ratios for attendant staff, direct care trainers, and job coaches).(2) Other direct care cost area. The other direct care cost area includes other direct service staffing costs (wages and benefits for direct care and attendant supervisors). The other direct care cost area is determined by calculating a median from allowable other direct care costs for each service, weighed by units of service for the applicable service from the most recently examined HCS/TxHmL cost report adjusted for inflation from the cost reporting period to the prospective rate period as specified in § 355.108 of this chapter (relating to Determination of Inflation Indices).(A) For the following services, multiply the other direct care cost area as specified in this paragraph by 1.044:(iv) OHR in a respite facility;(v) OHR in a setting where HH/CC is provided;(vi) OHR in a setting that is not listed; and(B) For the following services, multiply the other direct care cost area as specified in this paragraph by 1.07:(i) individualized skills and socialization;(ii) in-home and out-of-home individualized skills and socialization;(iii) OHR in an individualized skills and socialization facility;(iv) OHR in a setting with SL or RSS is provided;(3) Administration and operations cost area. The administration and operation cost area includes: (A) administration and operation costs; and(B) professional consultation and program support costs, including:(i) allowable costs for required case management and service coordination activities; and(ii) service-specific transportation costs.(4) Projected costs. Projected costs are determined by allowable administrative and operations costs from the most recently audited cost report adjusted for inflation from the cost reporting period to the prospective rate period as specified in § 355.108 of this chapter. The steps to determine projected costs are as follows. (A) Step 1. Determine total projected administration and operation costs and projected units of service by service type using cost reports submitted by HCS and TxHmL providers in accordance with § 355.722 of this subchapter (relating to Reporting Costs by Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Providers).(B) Step 2. Determine the HH/CC coordinator component of the HH/CC rate as follows: This component is determined by summing total reported HH/CC coordinator wages and allocated payroll taxes and benefits from the most recently available audited HCS cost report, inflating those costs to the rate period, and dividing the resulting product by the total number of host home units of service reported on that cost report.(C) Step 3. Determine total HH/CC coordinator dollars as follows. Multiply the HH/CC coordinator component of the HH/CC rate from subparagraph (B) of this paragraph by the total number of HH/CC units of service reported on the most recently available, reliable audited HCS cost report database.(D) Step 4. Determine total projected administration and operation costs after offsetting total HH/CC coordinator dollars as follows. Subtract the total HH/CC coordinator dollars from subparagraph (C) of this paragraph from the total projected administration and operation costs from subparagraph (A) of this paragraph.(E) Step 5. Determine projected weighted units of service for each HCS and TxHmL service type as follows.(i) SL and RSS in HCS. Projected weighted units of service for SL and RSS equal projected SL and RSS units of service times a weight of 1.00.(ii) Individualized skills and socialization in HCS and TxHmL. Projected weighted units of service for individualized skills and socialization equal projected individualized skills and socialization units of service times a weight of 0.25.(iii) HH/CC in HCS. Projected weighted units of service for HH/CC equal projected HH/CC units of service times a weight of 0.50.(iv) SHL in HCS, high medical needs support in HCS, and CSS in TxHmL. For each service, projected weighted units of service equal projected units of service times a weight of 0.30.(v) Respite in HCS and TxHmL. Projected weighted units of service for respite equal projected respite units of service times a weight of 0.20.(vi) SE in HCS and TxHmL. Projected weighted units of service for SE equal projected units of service times a weight of 0.25.(vii) Behavioral support in HCS and TxHmL. Projected weighted units of service for behavioral support equal projected behavioral support units of service times a weight of 0.18.(viii) Audiology, CRT, OT, PT, and speech therapy in HCS and TxHmL. Projected weighted units of service for audiology, CRT, OT, PT, and speech therapy equal projected audiology, CRT, OT, PT, and speech therapy units of service times a weight of 0.18.(ix) Social work in HCS. Projected weighted units of service for social work equal projected social work units of service times a weight of 0.18.(x) Nursing in HCS and TxHmL and high medical needs nursing in HCS. Projected weighted units of service for nursing and high medical needs nursing equal projected nursing and high medical needs nursing units of service times a weight of 0.25.(xi) EA in HCS and TxHmL. Projected weighted units of service for EA equal projected EA units of service times a weight of 0.25.(xii) Dietary in HCS and TxHmL. Projected weighted units of service for dietary equal projected dietary units of service times a weight of 0.18.(F) Step 6. Calculate the total projected weighted units of service by summing the projected weighted units of service from subparagraph (E) of this paragraph.(G) Step 7. Calculate the percent of total administration and operation costs to be allocated to the service type by dividing the projected weighted units for the service type from subparagraph (E) of this paragraph by the total projected weighted units of service from subparagraph (F) of this paragraph.(H) Step 8. Calculate the total administration and operation cost to be allocated to the service type by multiplying the percent of total administration and operation costs allocated to the service type from subparagraph (G) of this paragraph by the total administration and operation costs after offsetting total HH/CC coordinator dollars from subparagraph (D) of this paragraph.(I) Step 9. Calculate the administration and operation cost component per unit of service for each HCS and TxHmL service type by dividing the total administration and operation cost to be allocated to that service type from subparagraph (H) of this paragraph by the projected units of service for that service type from subparagraph (A) of this paragraph.(J) Step 10. The final recommended administration and operation cost area per unit of service for each HCS and TxHmL service type is calculated as follows. (i) For the following services, multiply the administration and operation cost area from this subparagraph by 1.044: (IV) in-home individualized skills and socialization;(VII) OHR in a respite facility;(VIII) OHR in a setting where HH/CC is provided;(IX) OHR in a setting that is not listed;(ii) For the following services, multiply the administration and operation cost area from this subparagraph by 1.07: (I) individualized skills and socialization;(II) in-home and out-of-home individualized skills and socialization;(III) OHR in an individualized skills and socialization facility;(5) The facility cost area. The facility cost area includes the following: (A) room and board costs, including rent, mortgage interest, depreciation expenses, property taxes, property insurance, and food costs as defined in § 355.103 of this chapter (relating to Specifications for Allowable and Unallowable Costs), unless excluded if unallowable under Federal Medicaid rules; and(B) non-room and board costs not already reimbursed through the monthly amount collected from the individual receiving services as defined in 26 TAC § 565.27(a).(6) The facility cost area is determined by calculating a median cost for each service using allowable facility costs, weighted by units of service for the applicable service from the most recently audited cost report, adjusted for inflation from the cost reporting period to the prospective rate period as specified in §355.108. (A) For the following services, multiply the facility cost component by 1.044:(iii) OHR in a respite facility; and(iv) OHR in a setting where HH/CC is provided.(B) For the following services, multiply the facility cost component by 1.07:(i) individualized skills and socialization;(ii) in-home and out-of-home DH;(iii) OHR in a DH or individualized skills and socialization facility;(iv) OHR in a setting where SL or RSS are provided;(d) Recommended payment rates are determined for each service by the following. (1) CFC PAS/HAB. The recommended payment rate is calculated by summing the attendant compensation cost area and the administration and operations cost area as defined in subsection (c) of this section. The recommended rate for CFC PAS/HAB does not include a cost component for other direct care staffing costs.(2) CRT. The recommended payment rate is developed based on payment rates determined for other programs that provide similar services. If payment rates are not available from other programs that provide similar services, payment rates are determined using a pro forma analysis in accordance with § 355.105(h) of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures).(3) HH/CC. The recommended payment rate is determined by summing the direct care worker component, HH/CC coordinator cost area, administration and operations component, and facility cost area. The direct care worker component is calculated using the median of allowable direct care worker costs, weighted by HH/CC units of service from the most recently examined cost report database. The result is adjusted for each LON. The HH/CC coordinator cost area and administration and operations components are calculated as determined in subsection (c) of this section. The facility cost area is calculated as determined in subsection (c) of this section but does not include room and board costs as defined in subsection (c)(5)(A) of this section. If HHSC lacks reliable cost report data, the rate is developed based on payment rates determined for other programs that provide similar services. If payment rates are not available from other programs that provide similar services, payment rates are determined using a pro forma analysis in accordance with § 355.105(h) of this chapter.(4) In-home respite. The recommended payment rate is calculated by summing the attendant compensation cost area and the administration and operations component as defined in subsection (c) of this section.(5) Individualized skills and socialization. The recommended payment cost areas are adjusted using modeled staffing ratios to establish recommended rates for on-site and off-site rates by LON. The recommended rates are calculated by summing the attendant compensation cost area, other direct care cost area, the administration and operations component, and the facility cost component as defined in subsection (c) of this section. Transportation costs are calculated as a standalone component separate from the administration and operations component for off-site services. The enhanced staffing level one rate is equal to the LON 8 individualized skills and socialization off-site recommended rate. The enhanced staffing level two rate is modeled and assumes a one-staff-to-one-individual staffing ratio.(6) Nursing services provided by an RN, nursing services provided by an LVN, physical therapy, occupational therapy, speech/language therapy, behavioral support services, audiology services, dietary services, EA, SE, and transition assistance services are determined based on § 355.725 of this subchapter (relating to Reimbursement Methodology for Common Waiver Services in Home and Community-based Services (HCS) and Texas Home Living (TxHmL)).(7) OHR. The recommended payment cost areas may be adjusted using modeled direct care worker hour-per-unit ratios for similar services to calculate OHR rates that vary by setting where the service is provided. The recommended payment rates are calculated by summing the attendant compensation cost area, other direct care cost area, the administration and operations component, and the facility cost component as defined in subsection (c) of this section.(8) SHL and CSS. The recommended payment rates for SHL and CSS are calculated by summing the attendant compensation cost area and the administration and operations cost area as defined in subsection (c) of this section.(9) SL and RSS. The recommended payment cost areas are adjusted using modeled direct care worker hour-per-unit ratios updated by actual hours reported on the most recently audited cost report to calculate variable rates by LON. The recommended rates are calculated by summing the attendant compensation cost area, other direct care cost area, and the administration and operations component as defined in subsection (c) of this section. The facility cost area is calculated as determined in subsection (c) of this section but does not include room and board costs defined in subsection (c)(5)(A) of this section.(10) Social work. The recommended payment rate is calculated using the weighted median social worker hourly cost from the most recently audited cost report, and the administration and operations cost component as determined in subsection (c) of this section. If HHSC lacks reliable cost report data, the rate is developed based on payment rates determined for other programs that provide similar services. If payment rates are not available from other programs that provide similar services, payment rates are determined using a pro forma analysis in accordance with § 355.105(h) of this chapter.(e) Other sources of cost information. If HHSC has determined that there is not sufficient reliable cost report data from which to set reimbursements and reimbursement ceilings for waiver services, reimbursements and reimbursement ceilings will be developed by using rates for similar services from other Medicaid programs, data from surveys, cost report data from other similar programs, consultation with other service providers or professionals experienced in delivering contracted services, and similar sources. If HHSC has insufficient cost data, the recommended payment rate for each service is developed based on payment rates determined for other programs that provide similar services. If payment rates are not available from other programs that provide similar services, payment rates are determined using a pro forma analysis in accordance with § 355.105(h) of this chapter.(f) Refinement and adjustment. Refinement and adjustment of the rate components and model assumptions will be considered, as appropriate, by HHSC. All adopted rates are limited to available levels of appropriated state and federal funds as defined in § 355.201 of this chapter (relating to Establishment and Adjustment of Reimbursement Rates for Medicaid).1 Tex. Admin. Code § 355.723
The provisions of this §355.723 adopted to be effective March 25, 1997, 22 TexReg 2772; transferred effective September 1, 1997, as published in the Texas Register December 26, 1997, 22 TexReg 12748; Amended to be effective April 5, 1998, 23 TexReg 3255; Amended to be effective March 1, 2000, 25 TexReg 1592; Amended to be effective March 1, 2001, 26 TexReg 1696; Amended to be effective September 1, 2007, 32 TexReg 5341; Amended to be effective September 20, 2009, 34 TexReg 6317; Amended to be effectiveSeptember 1, 2010, 35 TexReg 5030; Amended to be effective June 20, 2011, 36 TexReg 3709; Amended to be effective September 1, 2011, 36 TexReg 5331; Amended to be effective April 1, 2014, 39 TexReg 2062; Amended by Texas Register, Volume 40, Number 34, August 21, 2015, TexReg 5297, eff. 9/1/2015; Amended by Texas Register, Volume 42, Number 26, June 30, 2017, TexReg 3371, eff. 8/1/2017; Amended by Texas Register, Volume 43, Number 03, January 19, 2018, TexReg 0340, eff. 3/1/2018; Amended by Texas Register, Volume 44, Number 35, August 30, 2019, TexReg 4701, eff. 9/2/2019; Amended by Texas Register, Volume 46, Number 02, January 8, 2021, TexReg 0300, eff. 1/10/2021; Amended by Texas Register, Volume 48, Number 34, August 25, 2023, TexReg 4632, eff. 9/1/2023