| (s) Total attendant compensation rate for participating
providers. Each participating provider's total attendant compensation
rate will be equal to the attendant compensation base rate from subsection
(n) of this section plus any add-on payments associated with enhanced
attendant compensation levels selected by and awarded to the provider
during open enrollment.
(t) Spending requirements for participating contracts
and component codes. HHSC will determine from the Attendant Compensation
Report or cost report functioning as an Attendant Compensation Report,
as specified in subsection (i) of this section and other appropriate
data sources, the amount of attendant compensation spending per unit
of service delivered. The provider's compliance with the spending
requirement is determined based on the total attendant compensation
spending as reported on the Attendant Compensation Report or cost
report functioning as an Attendant Compensation Report for each participating
contract or component code. Compliance with the spending requirement
is determined separately for each program specified in subsection
(a) of this section, except for providers delivering services in both
the HCS and TxHmL programs whose compliance is determined by combining
both programs. HHSC will calculate recoupment, if any, as follows.
(1) The accrued attendant compensation revenue per
unit of service is multiplied by 0.90 to determine the spending requirement
per unit of service. The accrued attendant compensation spending per
unit of service will be subtracted from the spending requirement per
unit of service to determine the amount to be recouped. If the accrued
attendant compensation spending per unit of service is greater than
or equal to the spending requirement per unit of service, there is
no recoupment.
(2) The amount paid for attendant compensation per
unit of service after adjustments for recoupment must not be less
than the amount determined for nonparticipating contracts or component
codes in subsection (k) of this section.
(3) In cases where more than one enhancement level
is in effect during the reporting period, the spending requirement
will be based on the weighted average enhancement level in effect
during the reporting period calculated as follows.
(A) Multiply the first enhancement level in effect
during the reporting period by the most recently available, reliable
Medicaid units of service utilization data for the time period the
first enhancement level was in effect.
(B) Multiply the second enhancement level in effect
during the reporting period by the most recently available, reliable
Medicaid units of service utilization data for the time period the
second enhancement level was in effect.
(C) Sum the products from subparagraphs (A) and (B)
of this paragraph.
(D) Divide the sum from subparagraph (C) of this paragraph
by the sum of the most recently available, reliable Medicaid units
of service utilization data for the entire reporting period used in
subparagraphs (A) and (B) of this paragraph.
(u) Notification of recoupment. The estimated amount
to be recouped is indicated in the State of Texas Automated Information
Reporting System (STAIRS), the online application for submitting cost
reports and Attendant Compensation reports. STAIRS will generate an
email to the entity contact, indicating that the provider's estimated
recoupment is available for review. The entity contact is the provider's
authorized representative per the signature authority designation
form applicable to the provider's contract or ownership type. If a
subsequent review by HHSC or audit results in adjustments to the Attendant
Compensation Report or cost reporting, as described in subsection
(i) of this section, that change the amount to be repaid, the provider
will be notified by email to the entity contact that the adjustments
and the adjusted amount to be repaid are available in STAIRS for review.
HHSC, or its designee, will recoup any amount owed from a provider's
vendor payment(s) following the date of the initial or subsequent
notification. For the HCS and TxHmL programs, if HHSC, or its designee,
is unable to recoup owed funds in an automated fashion, the requirements
detailed under subsection (dd) of this section apply.
(v) Enrollment limitations. A provider will not be
enrolled in the attendant compensation rate enhancement at a level
higher than the level it achieved on its most recently available audited
Attendant Compensation Report or cost report functioning as an Attendant
Compensation Report. HHSC will notify a provider of its enrollment
limitations after HHSC has completed a financial examination of the
report in accordance with §355.106 of this title (concerning
Basic Objectives and Criteria for Audit and Desk Review of Cost Reports).
(1) Notification of enrollment limitations. The enrollment
limitation level is indicated in STAIRS. STAIRS will generate an e-mail
to the entity contact, indicating that the provider's enrollment limitation
level is available for review.
(2) Informal reviews and formal appeals. The filing
of a request for an informal review or formal appeal relating to a
provider's most recently available audited Attendant Compensation
Report or cost report functioning as an Attendant Compensation Report
under §355.110 of this title (relating to Informal Reviews and
Formal Appeals) does not stay or delay implementation of an enrollment
limitation applied in accordance with the requirements of this subsection.
If an informal review or formal appeal relating to a provider's most
recently available audited Attendant Compensation Report or cost report
functioning as an Attendant Compensation Report is pending at the
time the enrollment limitation is applied, the result of the informal
review or formal appeal shall be applied to the provider's enrollment
retroactively to the beginning of the rate year to which the enrollment
limitation was originally applied.
(3) New owners after a contract assignment or change
of ownership that is an ownership change from one legal entity to
a different legal entity. Enhancement levels for a new owner after
a contract assignment or change of ownership that is an ownership
change from one legal entity to a different legal entity will be determined
in accordance with subsection (i) of this section. A new owner after
a contract assignment or change of ownership that is an ownership-change
from one legal entity to a different legal entity will not be subject
to enrollment limitations based upon the prior owner's performance.
(4) New providers. A new provider's enrollment will
be determined in accordance with subsection (h) of this section.
(w) Contract terminations. For contracted providers
or component codes required to submit an Attendant Compensation Report
due to a termination as described in subsection (i) of this section,
HHSC, or its designee, will place a vendor hold on the payments of
the contracted provider until HHSC receives an acceptable Attendant
Compensation Report, as specified in subsection (i) of this section,
and funds identified for recoupment from subsection (t) of this section
are repaid to HHSC or its designee. Informal reviews and formal appeals
relating to these reports are governed by §355.110 of this title.
HHSC, or its designee, will recoup any amount owed from the provider's
vendor payments that are being held. In cases where funds identified
for recoupment cannot be repaid from the held vendor payments, the
responsible entity from subsection (dd) of this section will be jointly
and severally liable for any additional payment due to HHSC or its
designee. Failure to repay the amount due or submit an acceptable
payment plan within 60 days of notification will result in the recoupment
of the owed funds from other HHSC contracts controlled by the responsible
entity, placement of a vendor hold on all HHSC contracts controlled
by the responsible entity, and will bar the responsible entity from
enacting new contracts with HHSC until repayment is made in full.
The responsible entity for these contracts will be notified as described
in subsection (u) of this section prior to the recoupment of owed
funds, placement of vendor hold on additional contracts, and barring
of new contracts.
(x) Contract assignments. The following applies to
contract assignments.
(1) Definitions. The following words and terms have
the following meanings when used in this subsection.
(A) Assignee--A legal entity that assumes a Community
Care contract through a legal assignment of the contract from the
contracting entity as provided in 40 TAC §49.210 (relating to
Contractor Change of Ownership or Legal Entity).
(B) Assignor--A legal entity that assigns its Community
Care contract to another legal entity as provided in 40 TAC §49.210.
(C) Contract assignment--The transfer of a contract
by one legal entity to another legal entity as provided in 40 TAC §49.210.
(i) Type One Contract Assignment--A contract assignment
by which the assignee is an existing Community Care contract.
Cont'd... |
