Federal, Statutory and State Requirements

 

Effective June 5, 2020

 

Vendor Payment

An intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) provider may receive payment when a resident is absent from a facility for a therapeutic leave, an extended therapeutic leave or special activities leave, as described in 40 Texas Administrative Code (TAC), Chapter 9, Subchapter E, §9.226 Leaves; 42 Code of Federal Regulations (CFR); and Section 4.19(c) of the Texas State Plan Amendment.

 

Provider Responsibilities

For all types of leave, an ICF/IID program provider must:

• ensure a resident’s Individual Program Plan (IPP) provides for the specific type of leave;
• comply with service authorization and claims payment functionality associated with the movement of an ICF/IID resident to be entered into the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal, as described in the TMHP ICF/IID Online Portal User Guide;
• electronically submit movement of a resident within three days after a resident returns from leave; and
• enter the actual return date to ensure the system correctly counts the applicable service authorization days (i.e., billable or charge days). Note: A provider may view a resident’s service authorization information on Medicaid Eligibility Service Authorization Verification (MESAV) available through the provider’s TMHP TexMedConnect account. A service authorization will remain open during a leave event; however, if a leave event exceeds the maximum number of charge days, non-billable days will appear in the Client Hold Information section of MESAV.

 

Leave Codes and Medicaid Charge Days

Portal Code/ Leave Type	Description	Medicaid Charge Days
Absence Therapeutic Visit (ATH) Leave	Duration of absence must be at least one full day but no more than three consecutive full days. There is no limit on number of ATH events a resident may take. Day of departure and day of return are not included in the leave count. Example: Resident goes on a pre-placement visit to another facility February 1 returning on February 4. ATH and Return from Absence (RET) are submitted in the Portal for the two-day leave as: ATH 02/01/2016 (2, 3) and RET 02/04/2016.	Day of departure + three days
Absence Extended Therapeutic Visit (AEV) Leave	Duration of absence must be at least four days but no more than 10 days per calendar year. Day of departure and day of return are not included in the leave count. AEV can be used a maximum of twice per calendar year for a given resident. The 10-day maximum may be taken as a single absence (i.e., 10 consecutive days) or split between two separate events (e.g., six consecutive days plus four consecutive days). If AEV event begins near the end of the calendar year (e.g., on December 28) and ends in the next calendar year (e.g., on January 8), AEV is counted against the maximum allowed for the calendar year in which the AEV event began. Example 1: Resident uses six AEV days in March and has four AEV days remaining. The four remaining AEV days may be used by the same provider or by another ICF/IID provider if the resident moves to the new provider before the end of the calendar year.    Example 2: Resident is on an extended stay with family during the holidays, leaving on December 28 and returning on January 8. AEV and RET are entered in the Portal for the extended therapeutic leave as: AEV 12/28 (29, 30, 31, Jan.1, 2, 3, 4, 5, 6, 7) and RET 01/08.   Example 3: Resident goes on a pre-placement visit to another facility June 1 and returning June 6. AEV and RET are entered in the Portal for the four-day extended leave as: AEV 06/01/2016 (2, 3, 4, 5) and RET 06/06/2016.   Example 4: Resident goes home July 1, returning on July 8. Submit AEV and RET in the Portal for the six-day extended leave as: AEV 07/01/2016 (2, 3, 4, 5, 6, 7) and RET 07/08/2016.	Day of departure + 10 days
ATH/AEV Combination	Once per calendar year, a resident may take ATH combined with an AEV without staying overnight in the facility between the two leave events. For successful submission to occur in the TMHP Portal when combining ATH and AEV leave codes, a return must be submitted between the two codes at least one minute apart. Example: Resident goes on a family vacation March 2, returning March 17. Submit entry in the Portal for three-day ATH combined with 10-day AEV as: ATH 03/02/2016 (3, 4, 5); RET 03/06/2016 @ 8:00A; AEV 03/06/2016 @ 8:01A (7, 8, 9, 10, 11, 12, 13, 14, 15, 16); and RET 03/17/2016.	Day of departure for each event + three days ATH and 10 days AEV
Absence Special Activity (ASA) Leave	Duration of absence is one full day or more to attend special activities. There is no limit on number of ASA days a resident may take. During ASA, sufficient direct care staff of the program provider must be with the individual to meet the requirements set forth in 42 CFR §483.430(d) and during the absence, the program provider incurs the usual costs associated with providing services to the individual, including but not limited to, costs necessary to provide meals, lodging, and staff, and ensure that the special activity is part of the resident’s active treatment program and documentation of the activity in the resident’s IPP to explain how participation in the special activity will help the resident progress toward a specific goal. Example: May be used when a resident participates in Special Olympics accompanied by staff.	All
Absence Other (AX) Leave	For use when a resident is absent for an event not covered by another approved leave code.	Day of Departure

 

Hold on Residential Placement Payment Option

A provider can accept payment from a resident or other person to hold the residential placement in the facility in accordance with 40 TAC, Chapter 9, Subchapter E, §9.227(j)(1)-(4).

Rules require a provider to execute a written contract that is signed and dated by the program provider and the individual or other person before each discharge – defined in rule as an absence for a full day or more not during a therapeutic, extended or special leave. The written contract must specify:

• the amount, not to exceed the state’s rate of reimbursement based on the resident’s level of need, that the individual or other person agrees to pay the program provider to hold the individual’s residential placement;
• the period of time for which the individual’s residential placement in the facility will be held by the program provider;
• that the program provider is not obligated to hold the individual’s residential placement after the period of time described in the written contract; and
• agreement by the program provider that the individual or other person may terminate the contract immediately upon written notice to the program provider.   

There is no code associated with a residential placement that is on hold and subject to a written contract as described above.

 

View the Approved Diagnostic Codes for Persons with Related Conditions List at:

https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf