| (a) General requirements. The Texas Health and Human
Services Commission (HHSC) applies the general principles of cost
determination as specified in §355.101 of this title (relating
to Introduction). Providers are reimbursed for waiver services provided
to individuals who meet the criteria for alternatives to nursing facility
care. Additionally, providers are reimbursed a one-time administrative
expense fee for a pre-enrollment assessment of potential waiver participants.
The pre-enrollment assessment covers care planning for the participant.
(b) Other sources of cost information. If HHSC has
determined that there is not sufficient reliable cost report data
from which to determine reimbursements and reimbursement ceilings
for waiver services, reimbursements and reimbursement ceilings will
be developed by using data from surveys; cost report data from other
similar programs, consultation with other service providers or professionals
experienced in delivering contracted services; and other sources.
(c) Waiver reimbursement determination. Recommended
reimbursements are determined in the following manner:
(1) Unit of service reimbursement. Reimbursement for
personal assistance services and in-home respite care services, and
cost per unit of service for nursing services provided by a registered
nurse (RN), nursing services provided by a licensed vocational nurse
(LVN), physical therapy, occupational therapy, speech/language therapy,
supported employment, employment assistance, and day activity and
health services will be determined on a fee-for-service basis in the
following manner:
(A) Total allowable costs for each provider will be
determined by analyzing the allowable historical costs reported on
the cost report.
(B) Total allowable costs are reduced by the amount
of the pre-enrollment expense fee and requisition fee revenues accrued
for the reporting period.
(C) Each provider's total reported allowable costs,
excluding depreciation and mortgage interest, are projected from the
historical cost-reporting period to the prospective reimbursement
period as described in §355.108 of this title (relating to Determination
of Inflation Indices). The prospective reimbursement period is the
period of time that the reimbursement is expected to be in effect.
(D) Payroll taxes and employee benefits are allocated
to each salary line item on the cost report on a pro rata basis based
on the portion of that salary line item to the amount of total salary
expense for the appropriate group of staff. Employee benefits will
be charged to a specific salary line item if the benefits are reported
separately. The allocated payroll taxes are Federal Insurance Contributions
Act (FICA) or Social Security, Medicare Contributions, Workers' Compensation
Insurance (WCI), the Federal Unemployment Tax Act (FUTA), and the
Texas Unemployment Compensation Act (TUCA).
(E) Allowable administrative and facility costs are
allocated or spread to each waiver service cost component on a pro
rata basis based on the portion of each waiver service's units of
service to the amount of total waiver units of service.
(F) For nursing services provided by an RN, nursing
services provided by an LVN, physical therapy, occupational therapy,
speech/language therapy, supported employment, employment assistance,
and in-home respite care services, an allowable cost per unit of service
is calculated for each contracted provider cost report for each service.
The allowable cost per unit of service, for each contracted provider
cost report is multiplied by 1.044. This adjusted allowable cost per
unit of service may be combined into an array with the allowable cost
per unit of service of similar services provided by other programs
in determining rates for these services in accordance with §355.502
of this title (relating to Reimbursement Methodology for Common Services
in Home and Community-Based Services Waivers).
(G) For personal assistance services, two cost areas
are created:
(i) The attendant cost area includes salaries, wages,
benefits, and mileage reimbursement calculated as specified in §355.112
of this title (relating to Attendant Compensation Rate Enhancement).
(ii) Another attendant cost area is created which includes
the other personal attendant services costs not included in clause
(i) of this subparagraph as determined in subparagraphs (A) - (E)
of this paragraph. An allowable cost per unit of service is determined
for each contracted provider cost report for the other attendant cost
area. The allowable cost per unit of service for each contracted provider
cost report are arrayed. The units of service for each contracted
provider cost report in the array are summed until the median unit
of service is reached. The corresponding expense to the median unit
of service is determined and is multiplied by 1.044.
(iii) The attendant cost area and the other attendant
cost area are summed to determine the personal assistance services
cost per unit of service.
(2) Per day reimbursement.
(A) The reimbursement for Adult Foster Care (AFC) and
out-of-home respite care in an AFC home will be determined as a per
day reimbursement using a method based on modeled projected expenses,
which are developed using data from surveys, cost report data from
other similar programs, consultation with other service providers
or professionals experienced in delivering contracted services, and
other sources. The room and board payments for AFC Services are not
covered in these reimbursements and will be paid to providers from
the client's Supplemental Security Income, less a personal needs allowance.
(B) The reimbursement for Assisted Living/Residential
Care (AL/RC) will be determined as a per day reimbursement in accordance
with §355.509(a) - (c)(2)(E)(iii) of this title (relating to
Reimbursement Methodology for Residential Care).
(i) The per day reimbursement for attendant care for
each of the six levels of care will be determined based upon client
need for attendant care.
(ii) A total reimbursement amount will be calculated
and the proposed reimbursement is equal to the total reimbursement
less the client's room and board payments.
(iii) The room and board payment is paid to the provider
by the client from the client's Supplemental Security Income (SSI),
less a personal needs allowance.
(iv) The reimbursement for out-of-home respite in an
AL/RC facility is determined using the same methodology as the reimbursement
for AL/RC except that the out-of-home respite rates:
(I) are set at the rate for providers who choose not
to participate in the attendant compensation rate enhancement; and
(II) include room and board costs equal to the client's
SSI, less a personal needs allowance.
(v) When the SSI is increased or decreased by the Federal
Social Security Administration, the reimbursement for AL/RC and out-of-home
respite provided in an AL/RC facility will be adjusted in amounts
equal to the increase or decrease in SSI received by clients.
(C) The reimbursement for out-of-home respite care
provided in a Nursing Facility will be based on the amount determined
for the Nursing Facility case mix class into which the CBA participant
is classified.
(D) The reimbursement for Personal Care 3 will be composed
of two rate components, one for the direct care cost center and one
for the non-direct care cost center.
(i) Direct care costs. The rate component for the direct
care cost center will be determined by modeling the cost of the minimum
required staffing for the Personal Care 3 setting, as specified by
the Department of Aging and Disability Services, and using staff costs
and other statistics from the most recently audited cost reports from
providers delivering similar care.
(ii) Non-direct care costs. The rate component for
the non-direct care cost center will be equal to the non-attendant
portion of the non-apartment assisted living rate per day for non-participants
in the Attendant Compensation Rate Enhancement. Providers receiving
the Personal Care 3 rate are not eligible to participate in the Attendant
Compensation Rate Enhancement and receive direct care add-on's to
the Personal Care 3 rates.
(3) Emergency Response Services. The reimbursement
for Emergency Response Services will be determined as monthly reimbursement
ceiling, based on the ceiling amount determined in accordance with §355.510
of this title (relating to Reimbursement Methodology for Emergency
Response Services (ERS)).
(4) Requisition fees. Requisition fees are reimbursements
paid to the CBA home and community support services contracted providers
for their efforts in acquiring adaptive aids, medical supplies, dental
services, and minor home modifications for CBA participants. Reimbursement
for requisition fees for adaptive aids, medical supplies, dental services,
and minor home modifications will vary based on the actual cost of
the adaptive aids, medical supplies, dental services, and minor home
modifications. Reimbursements are determined using a method based
on modeled Cont'd... |
