26 Tex. Admin. Code § 554.2611 - Retroactive Vendor Payment
(a) In this
section, retroactive vendor payment is payment DADS makes retroactively to a
nursing facility for services the nursing facility provided to an individual
who was eligible for, but had not yet applied for, Medicaid. A nursing facility
is eligible for up to three months retroactive vendor payment for services it
provided, if:
(1) the individual resided in a
Medicaid-certified nursing facility, or a distinct part, during the time
services were provided;
(2) the
individual did not receive Supplemental Security Income cash
benefits;
(3) the individual met
Medicaid financial eligibility requirements;
(4) the state Medicaid claims administrator
has a current MDS assessment for the individual that the facility submitted in
compliance with the federal MDS submission requirements; and
(5) the nursing facility met physician
certification and plan of care requirements during the time services were
provided.
(b) After
receipt of an application for Medicaid, Texas Health and Human Services
Commission (HHSC) Medicaid eligibility staff notify the applicant whether the
applicant meets financial eligibility. The state Medicaid claims administrator
uses the applicant's current MDS assessment to make the MN determination and
determine the effective date of the MN determination. For the purpose of
establishing three months prior eligibility, the effective date of the MN
determination for a new recipient is the first day of the month in which the
recipient qualified for MN.
(c) If
the requirements in subsection (a) of this section are met, DADS makes a
retroactive vendor payment based on the recipient's calculated RUG rate for the
period covered by the retroactive vendor payment.
(d) DADS or HHSC may verify that the
recipient's record includes the required physician's certification,
recertification, and plans of care, and that the plans were reviewed as
required during the applicable periods.
(e) If a recipient paid the nursing facility
for services for which the facility later receives retroactive vendor payment,
the facility must reimburse the recipient the full amount the recipient paid,
beginning with the effective date of Medicaid eligibility, minus any applied
income or co-payment as determined by HHSC Medicaid eligibility
staff.
Notes
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