| (3) Accrued allowable Medicaid direct care staff fee-for-service
expenses for the rate year will be compared to the spending floor
from paragraph (2) of this subsection. HHSC or its designee will recoup
the difference between the spending floor and accrued allowable Medicaid
direct care staff fee-for-service expenses from facilities whose Medicaid
direct care staff spending is less than their spending floor.
(4) At no time will a participating facility's direct
care rates after spending recoupment be less than the direct care
base rates.
(p) Dietary and Fixed Capital Mitigation. Recoupment
of funds described in subsection (o) of this section may be mitigated
by high dietary and/or fixed capital expenses as follows.
(1) Calculate dietary cost deficit. At the end of the
facility's rate year, accrued Medicaid dietary per diem revenues will
be compared to accrued, allowable Medicaid dietary per diem costs.
If costs are greater than revenues, the dietary per diem cost deficit
will be equal to the difference between accrued, allowable Medicaid
dietary per diem costs and accrued Medicaid dietary per diem revenues.
If costs are less than revenues, the dietary cost deficit will be
equal to zero.
(2) Calculate dietary revenue surplus. At the end of
the facility's rate, accrued Medicaid dietary per diem revenues will
be compared to accrued, allowable Medicaid dietary per diem costs.
If revenues are greater than costs, the dietary per diem revenue surplus
will be equal to the difference between accrued Medicaid dietary per
diem revenues and accrued, allowable Medicaid dietary per diem costs.
If revenues are less than costs, the dietary revenue surplus will
be equal to zero.
(3) Calculate fixed capital cost deficit. At the end
of the facility's rate year, accrued Medicaid fixed capital per diem
revenues will be compared to accrued, allowable Medicaid fixed capital
per diem costs as defined in §355.306(b)(2)(A) of this title
(relating to Cost Finding Methodology). If costs are greater than
revenues, the fixed capital cost per diem deficit will be equal to
the difference between accrued, allowable Medicaid fixed capital per
diem costs and accrued Medicaid fixed capital per diem revenues. If
costs are less than revenues, the fixed capital cost deficit will
be equal to zero. For purposes of this paragraph, fixed capital per
diem costs of facilities with occupancy rates below 85% are adjusted
to the cost per diem the facility would have accrued had it maintained
an 85% occupancy rate throughout the rate year.
(4) Calculate fixed capital revenue surplus. At the
end of the facility's rate year, accrued Medicaid fixed capital per
diem revenues will be compared to accrued, allowable Medicaid fixed
capital per diem costs as defined in §355.306(b)(2)(A) of this
title. If revenues are greater than costs, the fixed capital revenue
per diem surplus will be equal to the difference between accrued Medicaid
fixed capital per diem revenues and accrued, allowable Medicaid fixed
capital per diem costs. If revenues are less than costs, the fixed
capital revenue surplus will be equal to zero. For purposes of this
paragraph, fixed capital per diem costs of facilities with occupancy
rates below 85% are adjusted to the cost per diem the facility would
have accrued had it maintained an 85% occupancy rate throughout the
rate year.
(5) Facilities with a dietary per diem cost deficit
will have their dietary per diem cost deficit reduced by their fixed
capital per diem revenue surplus, if any. Any remaining dietary per
diem cost deficit will be capped at $2.00 per diem.
(6) Facilities with a fixed capital cost per diem deficit
will have their fixed capital cost per diem deficit reduced by their
dietary revenue per diem surplus, if any. Any remaining fixed capital
per diem cost deficit will be capped at $2.00 per diem.
(7) Each facility's recoupment, as calculated in subsection
(o) of this section, will be reduced by the sum of that facility's
dietary per diem cost deficit as calculated in paragraph (5) of this
subsection and its fixed capital per diem cost deficit as calculated
in paragraph (6) of this subsection.
(q) Adjusting staffing requirements. Facilities that
determine that they will not be able to meet their staffing requirements
from subsection (m) of this section may request a reduction in their
staffing requirements and associated rate add-on. These requests will
be effective on the first day of the month following approval of the
request.
(r) Voluntary withdrawal. Facilities wishing to withdraw
from participation must notify HHSC in writing by certified mail and
the request must be signed by an authorized representative as designated
per the HHSC signature authority designation form applicable to the
provider's contract or ownership type. Facilities voluntarily withdrawing
must remain nonparticipants for the remainder of the rate year. Facilities
that voluntarily withdraw from participation will have their participation
end effective on the date of the withdrawal, as determined by HHSC.
(s) Notification of recoupment based on Annual Staffing
and Compensation Report or cost report. The estimated amount to be
recouped is indicated in STAIRS. STAIRS will generate an e-mail to
the entity contact, indicating that the facility's estimated recoupment
is available for review. If a subsequent review by HHSC or audit results
in adjustments to the Annual Staffing and Compensation Report or cost
report as described in subsection (f) of this section that changes
the amount to be repaid to HHSC or its designee, the facility will
be notified by e-mail 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 facility's
vendor payment(s) following the date of the initial or subsequent
notification.
(t) Change of ownership and contract terminations.
Facilities required to submit a Staffing and Compensation Report due
to a change of ownership or contract termination as described in subsection
(f) of this section will have funds held as per 26 TAC §554.210
(relating to Change of Ownership and Notice of Changes) until an acceptable
Staffing and Compensation Report is received by HHSC and funds identified
for recoupment from subsections (n) and/or (o) 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
(relating to Informal Reviews and Formal Appeals). HHSC or its designee
will recoup any amount owed from the facility'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 (x) 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 Medicaid contracts controlled by the responsible entity,
placement of a vendor hold on all Medicaid contracts controlled by
the responsible entity and will bar the responsible entity from receiving
any new contracts with HHSC or its designees until repayment is made
in full. The responsible entity for these contracts will be notified
as described in subsection (s) of this section prior to the recoupment
of owed funds, placement of vendor hold and barring of new contracts.
(u) Failure to document staff time and spending. Undocumented
direct care staff and contract labor time and compensation costs will
be disallowed and will not be used in the determination of direct
care staff time and costs per unit of service.
(v) All other rate components. All other rate components
will be calculated as specified in §355.307 of this title (relating
to Reimbursement Setting Methodology) and will be uniform for all
providers.
(w) Appeals. Subject matter of informal reviews and
formal appeals is limited as per §355.110(a)(3) of this title
(relating to Informal Reviews and Formal Appeals).
(x) Responsible entities. The contracted provider,
owner, or legal entity that received the revenue to be recouped upon
is responsible for the repayment of any recoupment amount.
(y) Change of ownership. Participation in the enhanced
direct care staff rate confers to the new owner as defined in 26 TAC §554.210
(relating to Change of Ownership and Notice of Changes) when there
is a change of ownership. The new owner is responsible for the reporting
requirements in subsection (f) of this section for any reporting period
days occurring after the change. If the change of ownership occurs
during an open enrollment period as defined in subsection (c) of this
section, then the owner recognized by HHSC or its designee on the
last day of the enrollment period may request to modify the enrollment
status of the facility in accordance with subsection (d) of this section.
Cont'd... |
