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The following report focuses only on selected agenda items from the Medical Care Advisory Committee meeting on February 13, 2014.
 
Home and Community-Based Services (HCS)
Dana Williamson, Department of Aging and Disability Services (DADS)

  • Revises provider requirements for individuals who deliver HCS through a micro-board to three or fewer individuals by allowing individuals with unpaid experience to deliver services
  • Expands consumer-directed services option to additional services
  • Expands the list of qualified providers of behavioral support services
  • Adds camp as an out of home respite option
  • Clarifies that back-up plans are required for individuals receiving critical services
  • New recertification process for level of care if there is a reduction in need
  • Adds new mandatory participation requirements

 
Janelle Edwards, Providers Alliance for Community Services of Texas

  • The rules do not give enough time for a provider to fix issues when punitive action is recommended as the result of a review
  • Would like more time to get the due process part right in the rules
  • The informal review process should be complete before the provider begins their thirty day period allotted to correct the problem
  • Williamson remarked that extending the time period could put individuals at risk when there is a significant area of noncompliance
    • Edwards responded that the immediate jeopardy provision should take effect in those situations
  • Vice Chair Dr. Gilbert Handal suggested that tightening up the definition of “serious” in the rules may take care of the problem
  • Committee member Mary Tieken asked what could take longer than 30 days to correct
    • Edwards responded that a system-wide change may be necessary or the correction of multiple issues which could take longer than 30 days

 
Susanne Elrod, Texas Council of Community Centers

  • Supports the current proposed version because of the inclusion of multiple review processes in regard to the mandatory participation piece
  • Committee member Colleen Horton feels that the process is very provider friendly and that there is not enough due process for the consumer

 
Jessica Ramos, Texas Council for Developmental Disabilities

  • The mandatory participation policy suggests that there are clients who should be terminated because they are too difficult to care for
  • There are no requirements for the termination review committee to develop possible solutions as opposed to approving a termination
  • Gary Jesse with the Health and Human Services Commission (HHSC) noted that mandatory participation is included in many programs; there is a maximum benefit that each client can receive and that has to be taken into account as well, it is difficult to say that a provider should bring in supports to help with any case because costs are unknown and can be higher than the maximum benefit will allow; this policy is not likely to result in mass terminations as is being suggested
  • Committee member Dr. Joane Baumer suggested that it might be helpful to create a review process that DADS is responsible for when termination is recommended; asked if the client is present during the review process
    • Williamson replied that the client is interviewed by the program provider and the service coordinator

 
Susan Murphree, Disability Rights Texas

  • Asked that the mandatory participation section be pulled out and reworked to all stakeholders’ satisfaction
  • Having an option to suspend services, as there has been in other programs, would add a graduated process that may be more suitable
  • This policy represents a very dangerous change in the program

 
Jeff Miller, ARC of Texas

  • The rule as written does not lay out protections for the consumer
  • Would like for the mandatory participation section to be left off

 
Robert Ham, D&S Community Services

  • Clients are not removed on a whim
  • There is a process that is started every time to ensure the best possible care is given

 
Heather Vasek, Providers Alliance for Community Services in Texas

  • One issue that has to be taken into consideration is that it is a liability of an employer to provide a safe work environment for their employees; if a dangerous situation has been encountered and something happens to an employee, the employer can be sued
  • The safety of the provider must be considered as well

 
The committee approved the proposal, excluding the section on mandatory participation.
 
Hospital-Specific Methodology
Pam McDonald, HHSC

  • This rule proposal will appear in the February 14 Texas Register and has not been before the committee yet due to it being part of an expedited process
  • The section the proposal affects describes how the hospital specific limit (HSL) is calculated
  • The federal Centers for Medicare and Medicaid Services (CMS) issued guidance in this regard and the calculations were changed for FY 2011
    • CMS stated that HSL calculation must not include revenue hospitals receive from third-party payers for the delivery of babies with low birth weight who are auto-enrolled in Medicaid
  • The change was a big issue with many hospitals because it decreased their HSL by a significant amount
  • The proposal is an attempt to deal with conflicting direction from CMS and the state legislature; the proposal uses language from SB 7, 83R, with a caveat that if it is not accepted by CMS language will revert to a CMS acceptable form
  • The proposal is currently in front of CMS and no response has yet been received
  • The issue is also under litigation between a children’s hospital and the state

 
Paul Bollinger, Doctors Hospital at Renaissance

  • There is currently a disincentive in the proposal to serve dual-eligibles because Medicare makes most of the payment to hospitals; the proposal should strike the word “commercial” and allow all third-party payers
  • Full costs aren’t being taken into account for hospitals with a high Medicare to Medicaid ratio

 
This was not an action item.
 
Substitute Physicians
Pam McDonald, HHSC

  • The current rules were out of compliance with federal Medicaid regulations
  • This proposal is an effort to bring them back into compliance
  • Changes the billing timeframe for reciprocal arrangements from 16 to 14 days
  • Changes the billing timeframe for locum tenens arrangements from 60 to 90 days

 
The committee approved the proposal.
 
Medicaid Managed Care
Emily Zalkovsky, HHSC

  • Amending the current rules to put provisions of SB7, 83R, into effect
  • Expands STAR+PLUS to 3 Medicaid rural service areas
  • Adds nursing facilities to STAR+PLUS
  • Adds individuals with developmental disabilities to STAR+PLUS for acute care only
  • Includes a requirement from SB 406, 83R, which requires MCOs to contract with physicians assistants and nurse practitioners for PCP services
  • Makes some changes to STAR rules

 
Sandy Klein, Texas Healthcare Association

  • Per SB7, reimbursement rates are to be set by the commission, MCOs are to provide discharge planning, educational programs related to discharge, etc., there is to be a single claims portal
  • Many provisions of SB7 have been left out of the rule proposal
  • Would like to see MCOs have a standard contract and to ensure there is a provision for dispute resolution
  • Horton asked why SB7 provisions have been left out
    • Zalkovsky replied that the provisions are in the contracts with the MCOs not necessarily in the rules

 
Susanne Murphree, Disability Rights Texas

  • The disenrollment provisions are confusing
  • Would like disenrollment piece to include a provisions that says  “a members behavior not related to their disability or health condition” is grounds for disenrollment

 
Rachel Hammon, Texas Association for Home Care and Hospice

  • Would like the provisions of SB7 regarding accessibility of services to be added to the rules as well

 
The committee approved the proposal.
 
 
Reimbursement Methodology for Physicians and Other Practitioners
Pam McDonald, HHSC

  • The proposal includes no change to the reimbursement methodology, only takes out a reference to a rule that is being deleted

 
The committee approved the proposal.
 
Cost Determination Process
Pam McDonald, HHSC

  • The proposal would insert language to describe cost reporting for providers who contract with MCOs for long-term services and supports
  • This would allow the agency to continue to collect those types of cost reports; Texas will have about 97% of services provided through MCOs and HHSC doesn’t want to lose that cost information so this rule will allow them to collect the reports

 
The committee approved the proposal.
 
1115 Waiver Payments for Uncompensated Care (UC) and for Other Performers
Mance Fine, HHSC

  • The proposal adds definitions and criteria to conform rules to CMS protocols
  • It will also eliminate old references that have become obsolete
  • Committee member Peggy Deming noted that the rule is significant because it could result in payment recoupment from hospitals from their UC payment; hospitals do not want a stagnant level of UC payments because the amount of care they provide could fluctuate over a short period of time
    • McDonald noted that HHSC believes that if the rules would allow for requests to increase UC payments they should also require reporting of decreased UC given; there is a problem because it is a small pool of money and it needs to be distributed evenly
  • Deming believes the rule doesn’t allow flexibility, the highest pro-rata share should go to hospitals with the greatest UC given

 
Deming made a motion to strike Sec. 355.8201(g)(4)(A)(iii) which states that a hospital may not request any changes to increase its interim hospital specific limit; revise Sec. 355.8203(e) to increase the payment frequency from twice per year to four times per year; and create a provision to make changes apply to demonstration year 3.  The committee approved the proposal with changes suggested by Deming.
 
Attendant Compensation Rate Enhancement
Pam McDonald, HHSC

  • The current program allows for providers to be paid an enhanced rate for attendants before services are provided with the provision that they must increase the attendant’s pay; if they do not increase the pay the payments can be recouped
  • The proposal cleans up language referencing redistribution of recouped payments which has been deleted from rules
  • The proposal adds language describing how IDD provider recoupment is handled when they are from more than 8 quarters prior; the computer system cannot go back 8 quarters prior so the proposal allows providers to write a check for the recoupment amount

 
The committee approved the proposal.
 
 
Inpatient Hospital Reimbursement
Laura Skaggs, HHSC

  • This proposal is solely a cleanup provision
  • Changes were made last summer in an expedited process
  • Errors were made regarding method of calculation for children’s and rural hospitals
  • The proposal also makes a change to the methodology for determining payments for new rural hospitals because new hospitals do not have a base year

 
The committee approved the proposal.
 
Contract Administration
Kathie Carlton-Morales, DADS

  • The proposal is a repeal of rules necessary because a different chapter will now govern contracts for community services

 
The committee approved the proposal.
 
Consumer-Directed Services (CDS)
Dana Williamson, DADS

  • CMS recently requested that the state provide performance measures for clients using the CDS option
  • The proposal adds a new section that outlines the expectations of CDS employers
  • The proposal requires employers to enter into a signed agreement that they understand service expectations
  • The proposal adds a requirement for a nurse to ensure CDS attendants comply with Board of Nursing rules
  • The rules require an RN to do an initial evaluation to determine if tasks being carried out by an attendant are daily tasks or health maintenance activities
  • Horton noted that the rule was supposed to go to the CDS Workgroup but that meeting was canceled because of a bad weather day and the group has not reviewed the rule yet

 
Kathy Cranston, ADAPT Texas; Personal Attendant Coalition of Texas

  • CDS was created to allow a client to hire, supervise, train and manage their employee on their own
  • This proposal allows a nurse to decide whether a client has the ability to train their own attendant
  • There is no problem that needs to be addressed or any data that shows there is a need for this requirement
  • The nurse requirement will add a hefty cost to the CDS budget
  • Williamson noted the intent is to have the least amount of impact on the autonomy of an individual in CDS while ensuring their health and safety; the nurse only comes in on the front end to potentially reduce negative outcomes

 
Dusty Johnston, General Counsel, Texas Board of Nursing

  • Because CDS has moved into many areas, it is important to move delegation rules to other areas
  • The rule is there because care is being provided by an unlicensed person

 
The committee tabled the proposal and suggested that it should go before the CDS Workgroup first.
 
The next committee meeting will be May 8, 2014 at 9AM.