1100  Role of the Department of Aging and Disability Services (DADS)

DADS is responsible for working directly with nursing facility (NF) providers in the following areas:

• DADS staff conduct inspections and grant licenses to facilities that comply with Chapter 242 of the Health And Safety Code.
• DADS staff conduct inspections to determine if federal and state standards of care for participation in the Medicaid NF program and Medicare skilled nursing facility (SNF) program are met.
• DADS issues Medicaid contracts to NFs that have met Medicaid participation requirements.
• DADS staff conduct unannounced, on-site visits to each NF to determine if the quality of care provided meets state and federal standards and is appropriate for each recipient's particular needs.

1200  Participating in Medicaid or Medicare

Medicaid

Medicaid is a joint program (state and federally funded) created by the Social Security Act to provide medical assistance for the indigent. NF services are mandated under Medicaid. An NF must meet federal requirements and any state agency requirements to participate in Medicaid. Section 1902(a)(33)(B) of the Social Security Act provides for state survey agencies to perform the same survey tasks for NFs to determine if they comply with Medicaid regulations.

Medicare

Medicare is a federal health insurance program created by the Social Security Act to provide health care for the aged and disabled. 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 to be certified to participate in the program. Section 1864(a) of the Social Security Act authorizes the Secretary of the Department of Health and Human Services to enter into agreements with state survey agencies to determine if SNFs meet the federal participation requirements for Medicare.

Dually Certified

Dually certified facilities are those that elect to participate in both the Medicaid and Medicare programs. Dually certified facilities must adhere to Medicaid and Medicare certification requirements.

1300  Medicaid/Medicare Fraud

Section 1909 of the Social Security Act explicitly states the penalties applied to providers who commit certain fraudulent acts in the administration of Medicaid programs. The Department of Aging and Disability Services (DADS) urges providers to become familiar with this section of the act and to abide by it. Providers involved in fraudulent practices are subject to review, fraud referral, and/or administrative sanctions that could result in withholding vendor payments, termination, or suspension of Medicaid contracts. The Attorney General's office investigates suspected Medicaid provider fraud that could result in a felony conviction. Examples of activities that may result in administrative sanctions against providers are:

• presenting any false or fraudulent claim for services or merchandise;
• submitting false information to obtain greater compensation than that to which the provider is legally entitled;
• submitting false information to meet Medicaid contracting requirements;
• failing to disclose and/or make available upon demand to DADS or its authorized agent records of services provided to Medicaid recipients and of payments made for those services;
• failing to comply with the terms of the Medicaid provider contract;
• rebating or accepting a fee or portion of a fee or charge for a Medicaid patient referral;
• being excluded from Medicare because of fraudulent or abusive practices;
• charging recipients for Medicaid-allowable services over and above that paid by DADS, except when specifically allowed by DADS;
• failing to correct deficiencies in provider operations after receiving written notice of the deficiencies from DADS;
• being convicted of a criminal offense relating to performance of a provider agreement with the state;
• failing to repay or make arrangements to repay identified overpayment or otherwise erroneous payments;
• failing to abide by applicable civil rights statutes; and
• falsifying or failing to submit a cost report.

Individuals with knowledge of actual or suspected Medicaid fraud or abuse of provider services should report this to the Health and Human Services Commission (HHSC), Office of Investigations and Enforcement, at 888-752-4888 (hotline), fax 512-453-1859, or write to:

1400  Medicaid Services

The following is a brief summary of some services that are available to all Medicaid recipients. Some services require prior approval from the Department of Aging and Disability Services (DADS) or Texas Medicaid and Healthcare Partnership (TMHP). Providers should review specific program provider manuals to determine if a particular service is a Medicaid benefit and to learn details relevant to the service in question. TMHP's Texas Medicaid Provider Procedures Manual may be accessed at the following web address:

http://www.tmhp.com/Medicaid

1410  Dental

Routine dental care is not a covered Medicaid expense for recipients 21 years of age or older. However, recipients with applied income (AI) may pay for physician-ordered dental services through the Incurred Medical Expense (IME) process. Contact the Medicaid eligibility specialist for assistance.

1411  Emergency Dental Program (EDP)

EDP covers dental problems that could become potentially life-threatening if not treated. Reimbursement is limited to procedures necessary to control bleeding, relieve pain and eliminate acute infection. Examples of covered emergency dental procedures include, but are not limited to:

• extractions,
• root canal,
• alleviation of pain, and
• treatment of infection.

Examples of excluded services include, but are not limited to:

• cleanings,
• dentures,
• amalgam or fillings,
• bridges, and
• crowns.

To qualify for EDP services, the recipient must be a resident of a Medicaid-contracted facility, be referred by the attending physician, and have the services provided by a dentist licensed by the Texas State Board of Dental Examiners.

Dental services must be billed through the Claims Management System. Claims for services must be received by the 365th day from the date of service. Rejected or adjusted claims must be resubmitted within the same time frame.

The facility must accept payment by DADS as payment in full for services. Neither the dentist nor the facility may charge an additional fee to the recipient, his family or his trust fund. EDP makes no payment for services that are available under any other Texas Medical Assistance Program. EDP does not reimburse for missed appointments.

Charges associated with outpatient or inpatient hospital admissions for dental services are not payable by EDP. Hospital admissions are payable by Texas Medicaid and Healthcare Partnership for medical conditions only.

1412  Dental Training for Nursing Staff

Department of State Health Services (DSHS) has a Nursing Home Oral Health Program and has prepared a Nursing Home Oral Health Manual (DSHS Publication 8-15). The program is designed to foster an understanding of the causes of oral disease and methods of preventing oral health problems. The manual is designed to teach nurse aides basic oral health care. DSHS regional dental directors provide oral health training, which must be arranged through regional offices. The list of DSHS regional program directors and a map of the regions may be accessed at the following website:

http://www.dshs.state.tx.us/dental/default.shtm

1420  Medical Professions

1421  Physician

Medicaid pays for reasonable and medically necessary services provided by or under the supervision of a physician who participates in the program. A patient may receive the services in the physician's office, a hospital or an NF.

Phone contacts by physicians are not reimbursed under the Texas Medicaid Program. Reimbursement for evaluation and management services requires face-to-face contact with the patient. The signing of forms is included as part of the global fee for services rendered by the physician. Some physicians have attempted to charge recipients or NFs extra money for phone calls and signing forms. These are not allowable charges in the Medicaid program.

If physicians have questions regarding appropriate charges, please refer them to Texas Medicaid and Healthcare Partnership's Customer Service Department at 800-925-9126 (option 5 for a customer service representative).

1422  Podiatrist

Services are not covered for clients age 21 years or older.

1423  Chiropractor

Services are not covered for clients age 21 years or older.

1430  Eyeglasses

Services are not covered for clients age 21 years or older.

1440  Laboratory, X-Ray and Radiation Therapy

Laboratory work, x-rays and radiation therapy ordered by a physician and given by or under his direction are a covered benefit.

1450  Drugs

1451  Prescription Drugs

Medicaid pays for unlimited prescriptions through the Medicaid Vendor Drug Program for nursing facility recipients. Some prescription drugs may not be covered. The Texas HHSC administers the Vendor Drug Program.

1452  Over-the-Counter Drugs

The Vendor Drug Program does not cover non-legend drugs other than insulin. If a physician orders non-legend drugs such as aspirin or vitamins, the facility must provide them to Medicaid recipients. The NF does not have to provide a specific brand of non-legend drug, unless the physician specifically orders it. A recipient who wants a non-legend brand other than that provided by the facility must pay for it.

1460  Hearing Aids

Services are not covered for clients age 21 years or older.

1470  Transportation

1471  Routine/Non-Emergency Medical Transportation

The NF is responsible for providing normal transportation for recipients to medical services outside the facility. The attending physician must have ordered the medical service. Refer to §19.2320 of the Nursing Facility Requirements for Licensure and Medicaid Certification for additional information.

Nursing facilities are responsible for providing or arranging non-emergency transportation for severely disabled Medicaid recipients. Prior authorization is required. Information regarding non-emergency transportation prior authorization may be obtained by contacting Texas Medicaid and Healthcare Partnership (TMHP) Customer Service at 800-925-9126. Completed prior authorization forms may be faxed to TMHP Ambulance Prior Authorization at 512/514-4204.

1472  Emergency Medical Transportation

Emergency medical transportation for recipients in NFs is payable by Texas Medicaid and Healthcare Partnership as a Medicaid benefit. Specific criteria must be met. Refer to §19.2320 of the Nursing Facility Requirements for Licensure and Medicaid Certification for additional information.

1480  Children's Services

Routine dental care such as cleaning, fluoride treatment and fillings are covered through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program for Medicaid recipients under age 21. In Texas, this program is known as Texas Health Steps (THSteps).

Through the Texas Health Steps-Comprehensive Care Program (THSteps-CCP)(formerly EPSDT Comprehensive Care (CCP)), Medicaid covers certain medically necessary durable medical equipment (DME) for youth under age 21 who reside in NFs.

For NF recipients under 21, THSteps-CCP makes available the following items:

• adaptive strollers and customized wheel chairs,
• orthotics,
• prosthesis, and
• adaptive communication devices.

Payment for these items is made directly to the DME vendor. The equipment belongs to the client and/or family. Requests must be made by a physician in accordance with THSteps-CCP policy. The state, not a child's physician, makes the final determination regarding the medical necessity of medical equipment. Texas Medicaid and Healthcare Partnership's Texas Medicaid Provider Procedures Manual contains the policy and forms for using THSteps and THSteps-CCP. A copy of the manual may be accessed at the following web address: http://www.tmhp.com/Medicaid

All medically necessary items require completion of the THSteps-CCP Prior Authorization Request for DME. This request must be mailed or faxed to:

THSteps is a DSHS program. THSteps-CCP is an HHSC program. Additional THSteps program information may be obtained from DSHS regional offices. Additional THSteps-CCP program information may be obtained by contacting HHSC customer service.

1500  Services Not Covered by Medicaid

• Special shoes or other support devices for the feet and walking aids.
• Care or services that are paid in full by Medicare or private health insurance.
• Routine dental services for persons at least 21 years old.
• Private duty nurses or sitters. A relative may provide these services without any effect on the recipient's Medicaid eligibility.
• Services given by a relative or member of a household.
• Medical equipment such as wheelchairs, crutches, walkers and bed rails. NFs are required to provide certain necessary medical equipment for recipient. See §19.2601(b)(7) of the Nursing Facility Requirements for Licensure and Medicaid Certification for additional information about this provision.
• Any services or supplies that are not necessary to diagnose or treat an illness or an injury or to improve a malformed part of the body.
• Prosthetic devices such as artificial arms and legs; braces for arms, legs, back and neck; and dentures.

Providers should refer to the Texas Medicaid and Healthcare Partnership (TMHP) Texas Medicaid Provider Procedures Manual for further information pertaining to Medicaid services. Inquiries should be addressed to the TMHP Customer Service Department, which can be reached at 800-925-9126.

1600  Grievances and Complaints

Providers must inform NF residents of their right to file complaints. To aid the reporting of grievances, abuse, neglect or exploitation, the Department of Aging and Disability Services (DADS) provides each NF a complaint poster that gives the DADS toll-free telephone number (800-458-9858). The poster must be conspicuously and prominently posted in an area of the facility that is readily available to residents, employees and visitors.

DADS investigates allegations of abuse, neglect or exploitation when the act occurs in the NF, when the facility is responsible for supervision of the resident at the time the act occurred or when the alleged perpetrator is affiliated with the facility. A person who reports suspected instances of abuse or neglect will be immune from civil or criminal liability that may result from making the report, except for a person who reports in bad faith or with malice. Criminal liability exists if anyone fails to report known abuses and is subject to the criminal penalty of a Class A misdemeanor.

DADS is required to hold an open hearing in a facility to receive comments and complaints from residents, their family members and members of the community if DADS:

• has taken a punitive action against the facility in the preceding 12 months; or
• receives a complaint from an ombudsman, advocate, resident or relative of a resident relating to a serious or potentially serious problem in the facility that DADS has reasonable cause to believe is valid.

Rules regarding open hearings are in §19.2119 of the Nursing Facility Requirements for Licensure and Medicaid Certification.