Nursing Facility Provider Manual

NFPM, Section 1000 Introduction

Revision 14-0; Effective April 11, 2014

 

1010 Purpose

Revision 14-0 Effective April 11, 2014

 

This manual is a complement to the state rules in the Texas Administrative Code (TAC), Title 40, Part 1, Chapter 19, Nursing Facility Requirements for Licensure and Medicaid Certification; however, in all cases where discrepancies exist between the information provided in this manual and the rules in Chapter 19 or the federal regulations, the rules or regulations apply.

 

1020 Basis, Scope and Definitions

Revision 14-0;Effective April 11 2014

Rules:

 

1030 Role of the (DADS)

Revision 14-0; Effective April 11 2014

 

DADS works directly with nursing facility (NF) providers in the following areas:

 

1031 Medicaid

Revision 14-0; Effective April 11 2014

 

Medicaid is a joint program (state and federally funded) created by Title XIX of the Social Security Act to provide medical assistance for individuals who meet financial eligibility and service-specific criteria. NF services are one of the options provided under Medicaid. An NF provider must meet federal requirements and any state requirements to participate in Medicaid. Section 1902(a)(33)(B) of the Social Security Act requires the state agency responsible for licensing health institutions to determine whether an NF meets the requirements for participation in Medicaid. DADS, as the designated state NF licensing agency, manages this function, as well as performing the survey tasks for NFs to determine if they comply with Medicaid regulations. For additional information about certification requirements, refer to 40 TAC, Chapter 19, Subchapter X, Requirements for Medicaid-Certified Facilities.

 

1032 Medicare

Revision 14-0; Effective April 11 2014

 

Medicare is a federal health insurance program created by Title XVIII of the Social Security Act to provide health care for the aged and individuals with disabilities. Medicare covers a wide range of benefits for specific periods of time through providers and suppliers that participate in the program. Providers must meet the standards established by the Centers for Medicare & Medicaid Services (CMS) to be certified to participate in the program. Section 1864(a) of the Social Security Act authorizes the secretary of the U.S. Department of Health and Human Services to enter into agreements with state survey agencies to determine if an NF meets the federal requirements to participate in Medicare as an SNF. DADS, as the state survey agency, has an 1864 agreement with the secretary of the U.S. Department of Health and Human Services.

 

1033 Dually Certified Facilities

Revision 14-0; Effective April 11 2014

 

A dually certified facility is an NF that elects to participate in both the Medicaid and Medicare programs. A dually certified facility must adhere to both Medicaid and Medicare requirements to be certified as eligible to participate in the programs.

 

1040 Resources

Revision 14-0; Effective April 11 2014

 

NFPM, Section 2000 License, Certification and Contract Requirements

Revision 14-0; Effective April 11 2014

 

Rules that apply to Section 2000 are located at 40 Texas Administrative Code (TAC), Chapter 19, Nursing Facility Requirements for Licensure and Medicaid Certification.

 

2010 Licensing Process

Revision 14-0; Effective April 11 2014

 

Rule: 40 TAC, Chapter 19, Subchapter C, Nursing Facility Licensure Application Process

 

A facility must obtain a license to operate a nursing facility in Texas. An applicant must apply for a license and be determined by the (DADS) to meet the requirements for a license. All forms and instructions are available on the application webpage.

 

2020 Medicaid Contracting Requirements

Revision 14-0; Effective April 11 2014

 

DADS provides complete information and contract application forms on its How to become a nursing facility provider webpage.

 

2030 Medicaid and Medicare Certification Process

Revision 14-0; Effective April 11 2014

 

A facility may choose between offering private-pay only services (a facility with no certification), becoming certified for Medicaid or Medicare, or becoming dually certified. To become a Medicaid nursing facility (NF) provider, a facility must apply for a Medicaid contract and be certified as meeting the Medicaid requirements for participation and any additional DADS requirements.

 

2040 Facility Construction

Revision 14-0; Effective April 11 2014

 

Rule: 40 TAC, Chapter 19, Subchapter D, Facility Construction (§§19.300–19.344)

 

2041 Asbestos Survey and Abatement

Revision 14-0; Effective April 11 2014

 

Rule: 40 TAC, Chapter 19, §19.331, Construction Standards for Additions, Remodeling and New Nursing Facilities

 

An asbestos survey may be necessary before conducting renovation activities that pose a potential risk of asbestos exposure to residents, staff or visitors of a facility. See requirements at:

On the Texas Department of State Health Services (DSHS) Asbestos Program website, there are links to the TAC and CFR references bulleted above. In addition, there is a link titled Locate Asbestos Licensees, which navigates to a public directory of licensed entities that can perform an asbestos survey and design an asbestos abatement project, if required. A plan for an asbestos abatement project must address preventing resident exposure to airborne asbestos or settled asbestos fibers that could be disturbed by normal facility operations.

For more information about the risks of asbestos as a carcinogen, providers may review the ASBESTOS CAS #1332-21-4 fact sheet issued by the Public Health Service Agency of Toxic Substances and Disease Registry of the U.S. Department of Health and Human Services, dated September 2001.

To find answers to questions about asbestos or how the asbestos rules may apply to a specific facility, providers are encouraged to contact DSHS at 512-834-6770 or 800-572-5548. For questions about this policy, please contact an architect in the DADS Architectural unit at 512-438-2371.

NFPM, Appendices

NFPM, Appendix I, Nursing Facility Contacts

Revision 14-0; Effective April 11, 2014

 

Helpful numbers may be obtained from the Nursing facility contacts webpage.

NFPM, Appendix II, Abbreviations and Acronyms

Revision 14-0; Effective April 11, 2014

 

APS Adult Protective Services
CARE Client Assessment, Review and Evaluation
CCP Comprehensive Care Program
CMS Centers for Medicare & Medicaid Services
DADS  
DME durable medical equipment
DSHS Texas Department of State Health Services
EDP Emergency Dental Program
EDS emergency dental services
EOB Explanation of Benefits
EPSDT Early and Periodic Screening, Diagnosis and Treatment
EIN employer identification number (9 digits, issued by the Internal Revenue Service)
HHSC Texas Health and Human Services Commission
ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification
ICF/IID intermediate care facilities for individuals with an intellectual disability or related conditions
IME incurred medical expense
MAO medical assistance only
MDS Assessment Minimum Data Set Assessment
ME Medicaid eligibility
MED Medicaid eligibility date
MEPD Medicaid for the Elderly and People with Disabilities
MESAV Medicaid Eligibility Service Authorization Verification
MI mental illness
MN medical necessity
NATCEP Nurse Aide Training and Competency Evaluation Program
NF nursing facility
OBRA Omnibus Budget Reconciliation Act
PASRR Preadmission Screening and Resident Review
PC purpose code
Permanent MN permanent medical necessity
PIN payee identification number (14 digits)
RC related condition
Regulatory Services DADS division of Regulatory Services
RUGs Resource Utilization Groups
SNF skilled nursing facility (Medicare)
SSA Social Security Administration
SSI Supplemental Security Income
TILE Texas Index for Level of Effort
TMHP Texas Medicaid & Healthcare Partnership

NFPM, Appendix III, DSHS Public Health Regions and Regional Directors

Revision 14-0; Effective April 11, 2014

 

A list of Texas Department of State Health Services (DSHS) public health regional directors and a map of DSHS regions may be obtained at the DSHS website.

NFPM, Appendix IV HIV/AIDS in the Workplace

NFPM, Appendix V Medicaid for the Elderly and People with Disabilities

NFPM, Appendix VI List of Excluded Individuals and Entities (LEIE)

NFPM, Appendix VII Advance Directives

NFPM, Forms

Form Title
0090-I Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution
1038 Medical Facility Referral
1205 Trust Fund Monitoring Findings
1207 Notification of Eligibility Special Medicaid Programs
1207-S Notification of Eligibility Special Medicaid Programs (Spanish)
1214 Request for Pension Information
1214-TSI Request for Pension Information - TSI
1220 Patient Trust Fund Monitoring Report
1230 Notification of Eligibility - Regular Medicaid Benefits
1230-TP-30-Att Notification of Eligibility - Emergency Medicaid Program
1232 Notification of Ineligibility
1235 Notice of Appointment or Delay
1247 Notice of Delay in Certification
1259 Correction of Applied Income
1290 Long Term Care Claim
2076 Authorization to Release Medical Information
3600 Application for Participation in Title XIX Medicaid: ICF/IID, Nursing Facility or Rural Hospital Swingbed Program
3604 Ownership Transfer Affidavit
3641 Alzheimer's Assisted Living Disclosure Statement
3643 Nursing Restorative Care Report
3645 Monthly Medicaid Occupancy Report
3646 Request for Formal Hearing
3707 Fire Report for Long Term Care Facilities
3716 Application to Increase Licensed Capacity of a Long-Term Care Facility
3720-N Application for Nursing Facility License and Participation in Title XIX Medicaid
3725 Licensure Change of Ownership Affidavit
4719 Fire Drill Report
4732 Nongovernmental Contractor Certification
4732-A Nongovernmental Contractor Certification (Part II)
8730 Nursing Facility Augmentative Communication Device (ACD) System Authorization
H1200 Application for Assistance - Your Texas Benefits

Informacion in espanol = form also available in Spanish.

NFPM, Revisions

NFPM, 14-0, New Handbook

Effective April 11, 2014

 

The Nursing Facility Provider Manual (NFPM) replaces the former Medicaid Provider Manual for Long-Term Care Facilities (MPM-LTCF). Additional sections will be added in the future.

NFPM, Contact Us

For questions about the Nursing Facility Provider Manual, email: NFRules@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: handbookfeedback@hhsc.state.tx.us