Effective June 5, 2020
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, Section 9.226 Leaves; 42 Code of Federal Regulations (CFR); and Section 4.19(c) of the Texas State Plan Amendment.
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 (PDF);
- 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|
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
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|
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|
Example: May be used when a resident participates in Special Olympics accompanied by staff.
|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.