Department of Assistive and Rehabilitative Services
Response to Public Comments
Proposed Rate Setting Methodologies for the Comprehensive Rehabilitation
Services Program
Below are comments or questions submitted by stakeholders and the Department of
Assistive and Rehabilitative Services’ (DARS) responses regarding the proposed rate
setting methodologies presented during the March 4, 2015, public meeting. The
PowerPoint presentation from the meeting is posted on the DARS website.
1) Comments expressing concerns with providing feedback or submitting an
application to provide Comprehensive Rehabilitation Services (CRS) program
services without more specific detailed information about new rates.
 Comment addressed difficulty in assessing the proposed methodology without
inclusion of actual rates, including the proposed Post-Acute Brain Injury (PABI)
per diem rate using intermediate care facility for individuals who have an
intellectual disability or related condition (ICF/IID-RC) data, and for therapy
hourly rates.
 Comment expressed concerns with providing a robust response since there are
so few details provided about the new rate methodology and the rates
themselves.
 Comment strongly encourages DARS to schedule workshops to explain the
methodology and proposed rates to providers so they can assess whether they
can continue to be a CRS provider.
 Asking providers to renew contracts with such limited information is asking
providers to take a big leap of faith, especially those who already are not able
to cover their CRS costs.
 Commenter finds it difficult to comment on rate setting methodology for the
base component which has no relationship to their entity type (inpatient
rehabilitation hospital) without an attached or associated rate that could be
benchmarked against current rates or assessed against the cost of services
rendered.
Response
DARS proposes to extend current CRS PABI contracts through November 30,
2015, at current contract rates. Prior to any new procurement and contract
development, more detailed information on proposed rate changes will be
shared. New CRS rules, provider standards and policies will be effective
September 1, 2015.
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2) Comments related to core service component of the PABI per diem rate.
 Many comments received suggested that DARS and the Public Consulting
Group (PCG) did not clearly communicate that service elements included in the
proposed methodology for calculating the PABI per diem were not service
requirements.
 Concerns were expressed with the perceived requirement to provide five hours
of therapy per day, five days per week, delivered by a licensed professional on
an individual basis. Comments include:
o Brain injury services must be individualized. Dictating five hours of
individual, licensed therapy five days per week may not meet the
individual needs of the consumer and may unnecessarily inflate cost;
o Group based interventions must be recognized as a valid part of postacute brain injury rehabilitation;
o Commission on Accreditation of Rehabilitation Facilities (CARF), a
nationally recognized accrediting body for rehabilitation facilities, does not
require specific minimum number of licensed therapy hours; and
o CARF focuses on individualized assessment and treatment planning with
emphasis on providing the right services at the right time.
Response
The inclusion of specific core services, provided on an individual basis and
delivered by a licensed professional, was for the purpose of developing the core
service component of the PABI per diem rate. The core service component
represents an estimate of average service levels received across consumers
served and will be paid for all consumers regardless of the specific services
provided based on the consumer’s individual service plan.
To calculate the daily core service component, a rate representative of the five
most common therapy services (physical therapy, occupational therapy, speech
therapy, cognitive therapy, and neuropsychological services, including
counseling) provided for five hours per day, for five days a week will be
calculated and that number will be divided by seven days. To determine the
representative therapy rate, DARS will evaluate current DARS medical rates, as
well as Medicaid, Medicare, and Texas commercial insurance rates.
DARS’ expectation is that providers continue to provide the appropriate and
necessary services to treat the consumer, as recommended by the
Interdisciplinary Team. The CRS Service Arrays are located on the DARS
website.
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The core service component of the statewide per diem rate is intended to cover
PABI core therapy services. Rates may be adjusted in the future following
collection of adequate data to support re-evaluation.
3) Comments related to the base rate component for PABI residential services,
based on ICF/IID-RC.
Comments addressed concerns with the exclusion of one-to-one services in the
base component and questioned the relevance of ICF/IID-RC levels to provision
of services for people with moderate to severe brain injuries. The population of
individuals with a Traumatic Brain Injury (TBI) may require a higher level of care
than what is typically provided in an ICF/IID-RC facility.
Response
In order to determine expenses for the base component of the per diem rate,
detailed cost reports or provider financial records would have to be evaluated.
This information is currently not required by DARS and is not available for the FY
2016 rate setting process. As a result, DARS evaluated multiple care settings
and determined that expenses incurred for these types of base services in
ICF/IID-RC best reflect a post-acute environment compared to other care
settings. The ICF/IID-RC program is a long-term services program, authorized by
Title XIX of the Social Security Act and administered by the Department of Aging
and Disability Services. Individuals residing in these facilities are provided with all
necessary residential and community living supports.
To calculate the base rate component, ICF/IID-RC residential rate components
and days of service, for non-state operated facilities with fewer than 14 beds and
levels of need 5, 8, 6 and 9, were utilized to determine the weighted average of
the daily base component of the per diem rate. The levels are based on the
Inventory for Client and Agency Planning (ICAP). The ICAP measures both
adaptive and maladaptive behaviors and gathers additional information to
determine the type and amount of special assistance that people with disabilities
may need. These assessments have been used nationally not only for
individuals with developmental disabilities, but also with people who become
disabled as adults through accident or illness and with elderly individuals who
have lost their ability to function independently.
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4) Comments related to the Post-Acute Brain Injury (PABI) Residential Services
statewide per diem rate.
 Comment disagrees with DARS’ intent to pay all facilities the same per diem;
recommends payment based on the intensity and type of services
offered/delivered by the facility.
 Commenter believes that payment rate should be more for a higher intensity
and quality of service versus what is paid to a facility offering fewer services or
services delivered by less qualified staff.
o Comment expressed concern that not paying based on intensity of
services provided will encourage a decrease in intensity of services being
offered and the credentials of the staff providing the services.
o Commenter understands that DARS plans to collect data to distinguish
between facilities in the future. Believes DARS has the data already. The
monthly Mayo-Portland data, combined with length of stay, service hours
per day, credentials of staff delivering the service, could be used to
differentiate programs. Or DARS could consider Veterans Affairs (VA)
methodology for distinguishing between intensity of services and resulting
payment rates.
 Commenter is unclear about how payments for specialized therapies will be
determined and paid and requests clarification. Asks if specialized therapies
are included in statewide per diem.
Response
DARS is not currently considering either a facility-based or tiered system for CRS
rates, largely due to the absence of data necessary to develop such rates.
Services previously identified as specialized therapies are now included in core
services and reimbursement is included in the core service rate of the statewide
per diem.
5) Comments related to payment for services which are not included in the base
or core services rate components.
 How will ancillary services be paid?
 What ancillary services would be eligible for payment?
Response
Ancillary services are not included in the base or core services rate components.
These services will be paid on a fee-for-service basis based on DARS rates.
Approved ancillary services are located on the DARS website.
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6) Comments related to provider qualifications
 Commenters requested further clarification regarding the use of certified
professionals, including potential use of Certified Brain Injury Specialists
(CBIS), whether Certified Nursing Assistants (CNAs) and Certified Medication
Aids (CMAs) should be identified as certified professionals as they are not
qualified to provide medical therapies to people who have a traumatic brain
injury, and that DARS consider defining “delivery by a licensed professional” to
permit delivery of certain therapy services under the supervision or direction of
a licensed therapist and/or physician in accordance with the State of Texas
clinical practice guidelines.
 Comments asked for clarification on which licensed professionals can deliver
services, including what licensed professionals can provide cognitive
rehabilitation therapy (CRT).
 There are no recognized standards for which discipline is licensed to provide
CRT. In addition, some of the therapeutic interventions require practice time
that can be overseen by trained paraprofessionals under the direction of the
licensed professionals. This would not be allowed under the proposed rate and
is directly counter to the treatment model developed by some of the
participating providers.
Response
Based on stakeholder and provider input, the role of paraprofessionals will be
limited; however certified individuals may participate in the delivery of a number
of therapeutic services such as OT, PT and Speech Language Pathology (SLP)
as allowed by State of Texas clinical practice guidelines.
With regards to Certified Brain Injury Specialist (CBIS), these specialists are
considered certified personnel. A CBIS does not receive the level of formal
training and certifications like the Certified Occupational Therapy Assistant
(COTA). When allowed by clinical practice guidelines, a CBIS, CNA or CMA may
provide services. Any services provided by a CBIS, CNA or CMA will be covered
in the base component of the PABI per diem rate.
CRT services must be provided by one of the following professionals:
o A psychologist licensed by the State Board of Examiners of Psychologists;
o A psychiatrist licensed by the State Board of Medical Examiners;
o An occupational therapist licensed by the Executive Council of Physical
Therapy and Occupational Therapy Examiners; or
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o A speech and language pathologist certified by the State Committee of
Examiners for Speech and Language Pathologists and Audiologists.
Core services must be delivered by professionals who meet State of Texas
clinical practice guidelines. These services must also be billable under a Current
Procedural Terminology (CPT) or Healthcare Common Procedure Coding
System (HCPCS) code, or by a code to be provided by DARS. Costs for services
not associated with a HCPCS/CPT or DARS code will be reimbursed as part of
the base rate of the PABI per diem.
7) Comment related to VA methodologies
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Comment requested that DARS consider VA governmental pricing for a full
rehabilitation day.
Comment requested that DARS consider the VA Assisted Living Pilot Program
approach to rate setting. Program uses a tiered system with a designated rate
for each tier. Tiers are differentiated by total number of intervention hours and
number of individual intervention hours. The VA does not specify who provides
the intervention services.
At least six documented hours (i.e., frequency, type, intensity of services) of
therapeutic intervention per day with specific community reintegration goals;
must include a minimum of three hours of individual therapy interventions, as
approved by VA
At least four documented hours (i.e., frequency, type, intensity of services) of
therapeutic intervention per day with specific community reintegration goals;
must include a minimum of two hours of individual therapy interventions, as
approved by VA
At least two documented hours (i.e., frequency, type, intensity of services) of
therapeutic intervention per day with specific community reintegration goals,
as approved by VA
Response
DARS does not have sufficient data at this time to develop a tiered rate structure
similar to VA Assisted Living Pilot Program.
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For combat-related traumatic brain injuries (TBIs) associated with veterans, there
are primarily three levels of severity for TBI (mild, moderate, and severe). The
typical treatment course begins with evaluation and acute rehabilitation and
progresses to post-acute care. As a result, the VA program can structure the
post-acute care payment structure as a tier approach, to reflect the multiple
levels of therapy treatment required based on the original diagnosis (mild,
moderate, severe). This type of service for veterans is not comparable to
consumers of the DARS CRS program.
The VA rate is an all-inclusive per day rate which covers non-therapy services,
including ancillary services. The proposed CRS rate methodology covers nontherapy and ancillary services separately and therefore the VA per day rates
should not be compared to the per diem rate of the proposed methodology.
8) Comments related to actions required to approve rates
 Will the rates be included in the appropriations process for the legislature or will
they be handled differently?
 Will providers have to go before the legislature in order to approve these rates?
Response
DARS does not have to go before the legislature to have CRS rates
approved. The CRS budget is appropriated by the legislature. DARS cannot
exceed the appropriated amount. Rates for services will be proposed for public
comment, a rate hearing will be held, and final rates will be approved by the
Health and Human Services Commission Executive Commissioner.
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