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Effective September 1, 2025: Change in Rate Methodology to Patient Driven Payment Model Long-Term Care for Assisted Living Facility Providers

Date: 07/31/25

Effective September 1, 2025, the Texas Health and Human Services (HHSC) is implementing the Patient Driven Payment Model Long-Term Care (PDPM LTC) Model to replace the Resource Utilization Group (RUG) methodology for reimbursing services under the new Nursing Facility Waiver Program. As a result, there are new additional modifiers being added to the Long-Term Service and Supports (LTSS) Billing Matrix for Assisted Living Services that will be effective September 1, 2025.

Please reference the PDPM ALF Respite Billing Matrix (Effective 9/1/25) (PDF) which represents the procedure codes and modifiers for the various types of Assisted Living Facility (ALF) with the PDPM levels associated with each. The procedure billing codes for ALF service billing remain unchanged, but there are additional modifiers that must be submitted on ALF claims to facilitate proper reimbursement for PDPM.

Effective on and after September 1, 2025, members’ current RUG level will remain the same until a new assessment is completed and a PDPM level is assigned for each member. Providers should continue to bill using the existing authorizations, as well as current codes and modifiers until the new assessment and annual Individual Service Plan (ISP) is completed. Superior HealthPlan will issue a new authorization to the provider with the associated PDPM level for the new ISP year. The provider will obtain the new authorizations and begin billing using the updated LTSS matrix to submit the appropriate codes and modifiers for the ALF level and associated PDPM level on the effective date of the new ISP and associated authorization. An example scenario is included below.

ALF Billing Example RUG vs. PDPM

I. RUG level reimbursement - Single Occupancy, Level 6 ALF

STAR+PLUS Waiver ISP and Authorization timespan: 4/1/2025 – 3/31/2026

  • Claim Billing for 4/1/2025 – 3/31/2026
    • One Modifier: U6

II. PDPM level reimbursement - Single Occupancy, Level 6 ALF

STAR+PLUS Waiver ISP and Authorization timespan: 4/1/2026 – 3/31/2027

  • Claim Billing for 4/1/2026 – 3/31/2027
    • Procedure Code: HCPC T2031
    • Two Modifiers: U6 and U2

For further questions or details, contact your dedicated Provider Representative. To access their information, visit the  Find My Provider Representative webpage.