Revision 14-1; Effective September 1, 2014    

A provider must have a Texas Department of Aging and Disability Services (DADS) Medicaid contract to receive Medicaid payment for the Medically Dependent Children Program (MDCP). The provider is paid at periodic intervals, depending on when the provider submits bills for approved services.

6100 TMHP Remittance and Status (R&S) Report

Revision 14-1; September 1, 2014

The R&S Report contains information on pending, paid, denied and adjusted claims. The Texas Medicaid & Healthcare Partnership (TMHP) provides weekly R&S Reports to give providers detailed information about the status of the claims submitted to TMHP.

6110 R&S Report Resources

Revision 14-1; September 1, 2014

6200 Reimbursement Rates

Revision 14-1; September 1, 2014

The Rate Analysis Department (RAD) of the Texas Health and Human Services Commission develops reimbursement methodology rules for determining payment rates or rate ceilings for MDCP.

6210 Reimbursement Methodology

Revision 14-1; September 1, 2014

Rule: 1 TAC Chapter 355, §355.507, Reimbursement Methodology for the Medically Dependent Children Program

6220 Rate Analysis and Posted Rates

Revision 14-1; September 1, 2014

The Texas Health and Human Services Commission (HHSC) approves rate changes, either increases or decreases, for the MDCP program. Rates are posted on the HHSC Rate Analysis website.

6300 Authorization of OHR Services in an Accredited Camp Setting

Revision 14-1; September 1, 2014

MDCP providers cannot request additional payment for Out-of-Home Respite (OHR) services in an accredited camp setting, including administrative fees, from MDCP individuals or their families when participating in camp activities.

6310 Rate in an Accredited Camp Setting

Revision 14-1; September 1, 2014

The maximum allowable rate for Out-of-Home Respite (OHR) services in an accredited camp setting for individuals enrolled in MDCP is based upon the rates approved by the Texas Health and Human Services Commission (HHSC) at this link.

As indicated on the website, HHSC has approved one rate (Service Code 11G) for MDCP OHR services in an accredited camp setting when services are provided by an agency holding a Provider Agreement for MDCP with DADS.

The service unit is one hour. DADS case managers authorize the number of service units according to the number of hours the individual is expected to use during the service plan year.

DADS requires providers to bill the actual hourly cost to provide the service or the maximum allowable rate.

6311 Administrative Fees for OHR Services in an Accredited Camp Setting

Revision 14-1; September 1, 2014

The Provider Agreement states the provider must accept reimbursement rates that are in effect, or as amended, as payment in full for the services delivered. The provider must not make any additional charge to the individual, any member of his or her family, or to any other source for any supplementation for services, unless specifically allowed by DADS rules. The provider cannot charge the individual when the waiver (i.e., Medicaid) is paying.

The Provider Agreement also requires services to be provided in the same manner and to the same degree that those services are provided to the general public. Therefore, MDCP providers of accredited camp settings cannot request payment from individuals or their families for additional charges related to membership in a “Respite Club” or any similar designation.

DADS will not authorize any additional payments or administrative fees requested by the service provider in the authorization request for this service. Providers of an accredited camp setting must reimburse individuals or their family members for any administrative fees collected that relate to the provision of Out-of-Home Respite services in an accredited camp setting.

6400 Reimbursement for OHR Services Provided by Nursing Facilities

Revision 14-1; September 1, 2014

The billing codes for these rates and other necessary information needed for billing is located in the Long-Term Care Billing Code crosswalk.

Any changes requested to current authorizations will be completed as a revision to the Individual Plan of Care (IPC) according to current policy and in the same manner as any other IPC change. Providers must contact the DADS case manager to request changes to the IPC. Providers must maintain documentation to support the need for these services.

Before billing for these services, providers should check the Medicaid Eligibility Service Authorization Verification (MESAV) system to ensure that the authorization has been entered into the Service Authorization System (SAS).

Providers may contact the Texas Health and Human Services Commission Rates Analysis mailbox at RateAnalysisDept@hhsc.state.tx.us for additional information pertaining to MDCP rates.

6500 Rounding When Billing

Revision 14-1; September 1, 2014

All MDCP Home and Community Support Services Agencies (HCSSAs) must bill DADS for MDCP respite and flexible family support services in quarter-hour (15 minutes) increments. For a given billing cycle, HCSSAs must total all respite units and flexible family support units provided to an individual by any staff. If the billing cycle total is not a whole number or unit increment, the HCSSA must round up or down prior to billing. Within each quarter-hour increment, HCSSAs must round up to the next quarter-hour when the actual time worked is eight minutes or more, and round down to the previous quarter hour when the actual time worked is seven minutes or less.

A provider should bill respite and flexible family support services according to the following schedule: 1 hour = 1 unit, 45 minutes = .75 unit, 30 minutes = .50 unit, and 15 minutes = .25 unit. These services may be provided by an attendant, an attendant with delegation, a licensed vocational nurse or a registered nurse.

The following are offered as examples:

  • In December, Betty Doe received 30 hours and 10 minutes of respite services. The total amount of service delivery time billed would be 30.25 units of respite services.
  • In December, Jerry Doe received 30 hours and 7 minutes of respite services. The total amount of service delivery time billed would be 30 units of respite services.
  • In January, Betty Doe received 32 hours and 31 minutes of respite services. The total amount of service delivery time billed would be 32.50 units of respite services.
  • In January, Jerry Doe received 32 hours and 38 minutes of respite services. The total amount of service delivery time billed would be 32.75 units of respite services.

Rounding may affect the total amount of service delivery time available when compared to the amount authorized on the individual plan of care and the amount saved for use in a subsequent month.