| (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 DADS 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 and request for recalculation.
(1) Notification of recoupment. 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.
(2) Request for recalculation. Providers notified of
a recoupment based on an Annual Staffing and Compensation Report described
in subsection (f)(2)(A) or (f)(2)(F) of this section may request that
HHSC recalculate their recoupment after combining the Annual Staffing
and Compensation Report with the provider's next cost report or Staffing
and Compensation Report, as appropriate. The request must be received
by HHSC Rate Analysis no later than 30 days after the date on the
e-mail notification of recoupment. If the 30th calendar day is a weekend
day, national holiday, or state holiday, then the first business day
following the 30th calendar day is the final day the receipt of the
request will be accepted.
(A) The request must be made by e-mail to the e-mail
address specified in STAIRS, by hand delivery, United States (U.S.)
mail, or special mail delivery. An e-mail request must be typed on
the provider's letterhead, signed by a person indicated in subparagraph
(B) of this paragraph, then scanned and sent by e-mail to HHSC.
(B) The request must be signed by an individual legally
responsible for the conduct of the provider, such as the sole proprietor,
a partner, a corporate officer, an association officer, a governmental
official, a limited liability company member, a person authorized
by the applicable signature authority designation form for the provider
at the time of the request, or a legal representative for the provider.
The administrator or director of a facility or program is not authorized
to sign the request unless the administrator or director holds one
of these positions. HHSC will not accept a request that is not signed
by an individual responsible for the conduct of the provider.
(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 40 TAC §19.2308
(relating to Change of Ownership) 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 40 TAC §19.2308
(relating to Change of Ownership) 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... |
