Texas Health and Human Services Commission (HHSC) has adopted new rules that affect various provisions of Chapter 353 Medicaid Managed Care. The following rules are amended (from the August 25 Texas Register):

§353.2, Definitions; §353.3, Experience Rebate in the Managed Care Program; §353.403, Enrollment; §353.405, Marketing; §353.407, Requirements of Health Maintenance Organizations; §353.409, Scope of Services; §353.411, Accessibility of Services; §353.413, Managed Care Benefits and Services for Children Under 21 Years of Age; §353.415, Member Complaint Procedures; §353.417, Quality Assessment and Performance Improvement; and §353.419, Financial Standards.

You may look up the appropriate sections in the Texas Administrative Code (TAC) here.

On behalf of the Texas Department of Disability Services (DADS), HHSC amends, adds a new section, and repeals sections of Chapter 2, Subchapter F, regarding Continuity of Services–State Mental Retardation Facilities. Read about these changes in detail here. The corresponding TAC sections can be found here.

Other matters:

HHSC re-advertises its Request for Proposals “for consultant services to assist the state of Texas in optimization of case management to enhance the quality outcomes and cost savings.” Proposals are due by 2:00 p.m. CT on September 5, 2006. Also found in that section are public notices and corrections.

The Office of Inspector General (OIG) of the U.S. Department Health and Human Services has released a report titled, “Nursing Home Emergency Preparedness and Response During Recent Hurricanes.”

OIG reviewed 20 nursing homes for the study. According to the report, 94 percent of nursing homes met government guidelines for emergency plans, and 80 percent met guidelines for sufficient emergency training in 2004-2005.

However, nursing homes didn’t always follow the plans. For example, 5 of the 20 deviated from their emergency plans for various reasons. In some cases, there was a lack of coordination between state and local emergency entities.

OIG recommended that the Centers for Medicare and Medicaid Services strengthen certification standards for nursing home emergency plans by developing a “core set of required elements” and encourage better communication between government entities and nursing homes.

For more information about the report, see “Study of Nursing Home Disasters in Last Year’s Hurricanes Recommends Changes.”

You may download the 48-page report here (PDF).

Citing the figure as “somewhat excessive,” the Centers for Medicare and Medicaid Services rejected Georgia’s attempt to raise the state’s Medicaid estate recovery exemption from $25,000 to $100,000. (Medical News Today)

To offset the costs of nursing home care, states are required by federal law to recover money from a beneficiary’s estate. Current Georgia law exempts the first $25,000.

For more information, visit on Medicaid estate recovery in Texas, visit the estate recovery program section at DADS.

In other Georgia news, a group of physicians is suing three private HMOs, alleging that providers have not been paid for millions of dollars in claims. Because of late payments, the group alleges, they’ve had to reduce treatment for Medicaid beneficiaries. (Medical News Today)

Nursing facilities will be subject to new rules related to permanency planning, effective September 1, 2006.

The amended sections of 40 Texas Administrative Code (TAC) Chapter 19 (§19.802 and §19.805) reflect changes made by the legislature concerning the annual review of a child’s comprehensive care plan and the involvement of a child’s legally authorized representative.

Attached to the letter are the amended 40 TAC sections. You may download the six-page document here.

According to a new study published by Health Services Research, nursing home residents receiving hospice care reduce their chances of hospitalization by half compared to those who don’t receive hospice care. From SeniorJournal.com:

People who choose hospice, which focuses on comfort instead of cure, tend to refuse aggressive end-of-life treatment anyway, Gozalo said. But even taking this into consideration, hospice still makes a significant difference in keeping people out of the hospital in their last days, the study shows.

The study also looked at characteristics of nursing home residents who receive hospice care. They are more likely to have a cancer diagnosis, although “two-thirds of nursing- home residents in hospice have a noncancer diagnosis,” Gozalo said. Hospice patients are also more likely to be female, white and married compared to residents not receiving hospice care.

Last week the Texas Department of Aging and Disability Services (DADS) issued provider letters for hospice and nursing facilities, and community services and therapy providers:

• August 9 - DADS reminded hospice and nursing facilities that the current DOS-based form system is being upgraded to a web-based system called LTC Online Portal, effective August 21. Providers that don’t have access to the new system can mail hardcopies to Provider Claims Services. The PCS fax lines will be discontinued. You may download the letter here.
• August 11 - DADS reminded hospice and nursing facilities of their roles and responsibilities when electing to contract for hospice services. For a primer and helpful Q&A, download the letter here.
• August 11 - As you may know, the new fiscal year begins on September 1. FY 04 claims - from September 1, 2003 through August 31, 2004 - received after August 15 are processed as “Miscellaneous” and will not be paid through the standard payment process. For more information, download the letter (addressed to nursing facilities, community services and therapy providers) here.

There were several new provider letters issued last week for Intermediate Care Facilities for Persons with Mental Retardation or a Related Condition (ICF-MR/RC).

In an August 3 provider letter, the Texas Department of Aging and Disability Services (DADS) described providers’ options when an ICF-MR/RC survey team determines that a person living in one of these facilities no longer needs “active treatment services” (standard W 198). To read about these options, download the letter here.

In a letter dated August 7, DADS alerted ICFs to changes in the timing of the annual recertification survey for some facilities with a capacity of 17 or more people. Read about these and other changes in the letter.

In the most recent letter, dated August 11, DADS reminded ICF facilities of their roles and responsibilities when choosing to contract for hospice services. The six-page letter includes a helpful question and answer section. An excerpt:

Can a Medicaid recipient elect hospice care if they are residing in an ICF-MR/RC?
Yes, a Medicaid recipient living in an ICF-MR/RC may elect to receive hospice care in an ICF-MR/RC that has a contract with a Medicaid hospice provider.

Are ICF-MR/RC and hospice providers required to enter into contracts with each other?
Yes, an ICF-MR/RC and a hospice provider must enter into a contract with each other for the hospice provider to provide Medicaid hospice services to residents of the ICF-MR/RC. However, the decision to enter into any particular contract is made by the parties to the contract, i.e., by the ICF-MR/RC and the hospice provider.

What should an ICF-MR/RC do if it does not contract for any hospice services or with a specific hospice provider requested by a resident?
The ICF-MR/RC must assist the resident in locating an ICF-MR/RC that contracts for hospice services.

You may download the letter here.

Updated (8/16): In two letters recently posted, DADS informed ICF/MR Service Group 5 and Service Group 6 providers that FY 04 claims - from September 1, 2003 through August 31, 2004 - received after August 15 are processed as “Miscellaneous” and will not be paid through the standard payment process. The letters also contain information about DADS and State Comptroller cut-off dates.

The Texas Health and Human Services Commission (HHSC) adopted §354.1450, which governs auditing of Medicaid providers. HHSC must notify providers of an upcoming audit no later than seven days before the field portion of the audit starts. If a pharmacy is being audited, HHSC must notify the pharmacy’s corporate office. For more information on the new rule, see this section of the July 21 Texas Register.

HHSC has extended comment periods and issued hearing notices for two proposed amendments of interest to long term care providers:

• Provider Participation Requirements
• Reimbursement Adjustments for Hospitals Providing Inpatient Services to Supplemental Security Income (SSI) and SSI-Related Clients

HHSC issued two more hearing notices:

• Notice of Hearing on Proposed Provider Reimbursement Rates applicable to providers of Home and Community-based Services, Texas Home Living and Community Living Assistance and Support Services
• Notice of Hearing on Proposed Provider Reimbursement Rates applicable to non-state operated providers of Intermediate Care Facility for Persons with Mental Retardation

The federal government and the states currently share responsibility for Medicaid long term care. Tommy Thompson, former U.S. Health and Human Services secretary, says that should change in light of the approaching retirement of the baby boomers.

Medicaid is already burdening the states, and it will get worse in the next few years. Thompson believes the federal government should be responsible for long term care of the elderly, while the states focus on “acute care for those under 65.” (Washington Post - free registration required)

Thompson notes the feds and the states would still share financial responsibility for the program. Under his proposal, the feds would run the long term care portion of the program, which he believes will save money for both:

The federal government is the only one large enough to handle this growing problem…The states are going broke right now under the Medicaid system. Who else is going to be able to handle the elderly?

Any new plan designed to make Medicaid more efficient and less expensive must include incentives for preventive care.

Blogger Alan Greenblatt of 13th Floor (Governing.com) says this about Medicaid reform: Fuhgeddaboutit.

(Photo credit: Bill O’leary - Twp)

Over the last few months, medical device makers and lawmakers have pressured the Bush administration to rethink a proposed rule that would have cut Medicare reimbursements for implanted cardiac devices by up to 30 percent in an effort to close loopholes used by specialty hospitals.

The lobbying efforts worked. Under the final rule issued by the Centers for Medicare and Medicaid Services (CMS), reimbursement cuts will be smaller and phased in over three years. Groups like AdvaMed, which represents medical device makers, had asked for a year-long delay so parties could review and assess changes.

Reimbursements for cardiac specialty hospitals will decrease by more than 5 percent between 2005 and 2007, substantially less than 30 percent. Hospitals will see reimbursements increase by 3.5 percent, and only 2 percent of facilities will see a decrease. (Kaiser Network)

These changes are part of an overall effort to improve the accuracy of Medicare’s payment for inpatient stays. Mike Leavitt, Health and Human Services secretary said, “Hospital payments should promote the best care for all patients, not the treatments that happen to be most profitable, and we are now on a path to making sure that happens.” (CMS press release)