26 Tex. Admin. Code § 554.2413 - Determination of Payment Rate Based on the MDS Assessment Submission
(a) Definitions. In this section, the
following words and terms have the following meanings unless the context
clearly indicates otherwise.
(1) All
conditions of eligibility--A recipient meets all conditions of eligibility when
the state Medicaid claims administrator approves the recipient for medical
necessity and the recipient meets financial eligibility for Medicaid.
(2) On-time MDS assessment--An MDS assessment
that is submitted in accordance with the federal MDS submission schedule and is
received by the state Medicaid claims administrator within 31 days after the
completion date.
(3) Missed MDS
assessment--An MDS assessment that is received by the state Medicaid claims
administrator outside the time period that the MDS assessment covers.
(b) MDS submission requirement. A
nursing facility must:
(1) complete all MDS
assessments according to CMS' instructions;
(2) submit a recipient's MDS assessment,
including an admission MDS assessment, a quarterly MDS assessment, and a
significant change in status assessment, to the state MDS database in
compliance with the federal MDS submission schedule;
(3) submit the Long-Term Care Medicaid
Information Section to the state Medicaid claims administrator; and
(4) submit the recipient's MDS assessment in
compliance with the federal MDS submission schedule even after the recipient
has permanent medical necessity as described in §
554.2403(e) of
this subchapter (relating to Medical Necessity Determination).
(c) Admission MDS assessments.
(1) If a nursing facility discharges a
recipient with a status of return not anticipated, and the recipient returns to
the facility, the nursing facility must complete an admission MDS assessment
for a determination of medical necessity and establishment of a RUG rate,
regardless of the amount of time between the recipient's discharge and
return.
(2) A nursing facility must
complete and submit an admission MDS assessment to receive payment for a
recipient's period of stay in the nursing facility, even if the recipient
leaves the nursing facility before the MDS assessment is completed and never
returns long enough for the MDS assessment to be completed. See subsection (i)
of this section for completion of an admission MDS assessment in the event of a
recipient's death.
(3) DADS pays a
calculated RUG rate for an admission MDS assessment from the date the recipient
was admitted to the nursing facility, except as provided in §
554.2611 of this chapter (relating
to Retroactive Vendor Payments).
(d) Payment of a calculated RUG rate. If a
recipient meets all conditions of eligibility, DADS pays a calculated RUG rate
for an MDS assessment if it is received by the state Medicaid claims
administrator during the time period that the MDS assessment covers.
(e) On-time MDS assessment. If a recipient
meets all conditions of eligibility, DADS pays a calculated RUG rate from the
completion date of the required MDS assessment, except for an admission MDS
assessment as described in subsection (c)(3) of this section.
(f) MDS assessments that are not on time. The
state Medicaid claims administrator stops payment for services if the state
Medicaid claims administrator does not receive an on-time MDS assessment.
Payment for services resumes when the state Medicaid claims administrator
receives all MDS assessments that are due as required by the federal MDS
submission schedule.
(g) Missed MDS
assessments. When the state Medicaid claims administrator receives a missed MDS
assessment, DADS pays the nursing facility a default RUG rate for the entire
period of the missed MDS assessment if the recipient meets financial
eligibility for Medicaid, except as provided in paragraph (2) of this
subsection.
(1) If an MDS assessment is
missed for the purpose of calculating a RUG rate, the nursing facility must
still submit the MDS assessment to comply with §
554.801 of this chapter (relating
to Resident Assessment).
(2) For a
newly contracted nursing facility and a nursing facility that undergoes a
change of ownership, DADS pays the calculated RUG rate for any missed MDS
assessments that occur while the nursing facility is unable to submit MDS
assessments to the state MDS database.
(h) Significant change in status assessment,
modification, or significant correction. If a recipient meets all conditions of
eligibility, DADS pays the calculated RUG rate from the completion date of a
significant change in status assessment, modification, or significant
correction.
(i) Incomplete or
erroneous MDS assessments. If an applicant meets all conditions of eligibility,
DADS pays a default rate for an MDS assessment that is incomplete or has
errors.
(j) Prohibition against
recourse. A nursing facility must not charge and must not take any other
recourse against a recipient, the recipient's family members, the recipient's
estate or the recipient's representative for a claim that is reduced because
the facility failed to comply with a DADS rule or procedure pertaining to
reimbursement.
Notes
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