| (a) General requirements. The Texas Health and Human
Services Commission (HHSC) or its designee applies the general principles
of cost determination as specified in §355.101 of this title
(relating to Introduction). Whenever the term "HHSC" occurs, it means
the Texas Health and Human Services Commission or its designee.
(b) General reporting guidelines. Providers must follow
the cost-reporting guidelines as specified in §355.105 of this
title (relating to General Reporting and Documentation Requirements,
Methods, and Procedures).
(c) Reimbursement ceiling determination. When HHSC
does not require a cost report, HHSC may adjust the rate ceiling as
appropriate based upon cost data collected in the form of special
surveys or reports submitted by all contracted providers, or other
appropriate cost data related to the Emergency Response Services program.
(d) Reimbursement ceiling determination based on a
cost-reporting process. If HHSC deems it appropriate to require cost
reporting, cost reports will be governed by the information in this
subsection.
(1) Reimbursement ceiling. The reimbursement ceiling
is determined for a per-month unit of service. The ceiling applies
to all provider agencies uniformly, regardless of geographic location
or other factors.
(2) Excused from submission of cost reports. If required
by HHSC, a contracted provider must submit a cost report unless the
provider meets one or more of the conditions in §355.105(b)(4)(D)
of this title.
(3) Exclusion of cost reports.
(A) Providers are responsible for reporting only allowable
costs on the cost report, except where cost report instructions indicate
that other costs are to be reported in specific lines or sections.
Only allowable cost information is used to determine recommended reimbursement.
HHSC excludes from reimbursement determination any unallowable expenses
included in the cost report and makes the appropriate adjustments
to expenses and other information reported by providers. The purpose
is to ensure that the data base reflects costs and other information
which are necessary for the provision of services and are consistent
with federal and state regulations.
(B) Individual cost reports may not be included in
the data base used for reimbursement determination if:
(i) there is a reasonable doubt as to the accuracy
or allowability of a significant part of the information reported;
or
(ii) an auditor determines that reported costs are
not verifiable.
(4) Recommended reimbursement ceiling. HHSC determines
a recommended reimbursement ceiling in the following manner. The reimbursement
ceiling is determined by the analysis of financial and statistical
data submitted by provider agencies on cost reports and, as deemed
appropriate, a market survey analysis of emergency response equipment
suppliers.
(A) HHSC allocates payroll taxes and employee benefits
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. The employee benefits for administrative staff are allocated
directly to the corresponding salaries for those positions. The allocated
payroll taxes are Federal Insurance Contributions Act (FICA) or social
security, Workers' Compensation Insurance (WCI), the Federal Unemployment
Tax Act, and Texas Unemployment Compensation Act.
(B) Allowable expenses, excluding depreciation and
mortgage interest, are projected from the provider agency's reporting
period to the next ensuing reimbursement period. HHSC determines reasonable
and appropriate economic inflators or adjusters as described in §355.108
of this title (relating to Determination of Inflation Indices) to
calculate a prospective expense. HHSC also adjusts reimbursement if
new legislation, regulations, or economic factors affect costs as
specified in §355.109 of this title (relating to Adjusting Reimbursement
When New Legislation, Regulations, or Economic Factors Affect Costs).
(C) Allowable reported expenses are combined into three
cost areas: responder, program operations, and facility. To determine
the projected cost per unit of service, a contracted provider's projected
expenses in each cost area are divided by its total units of service
for the reporting period.
(D) The contracted providers' projected costs per unit
of service are ranked from low to high in each cost area, with corresponding
units of service.
(E) The 80th percentile cost, weighted by units of
service, is determined for each cost area. The recommended reimbursement
ceiling is the sum of the 80th percentile costs of the three cost
areas.
(F) The reimbursement determination authority for this
reimbursement ceiling is specified in §355.101 of this title
(relating to Introduction).
(e) Contract-specific unit reimbursement. The actual
reimbursement for each contract is negotiated between DADS staff and
the provider agency. The contract-specific reimbursement DADS pays
the provider agency is the full cost for emergency response services.
The provider agency must not bill the client for any additional charges.
In no instance may the negotiated unit reimbursement exceed the per-month
reimbursement ceiling.
(f) Reviews and field audits of cost reports. HHSC
staff perform either desk reviews or field audits on all contracted
providers. The frequency and nature of the field audits are determined
by HHSC staff to ensure the fiscal integrity of the program. Desk
reviews and field audits will be conducted in accordance with §355.106
of this title (relating to Basic Objectives and Criteria for Audit
and Desk Review of Cost Reports), and providers will be notified of
the results of a desk review or a field audit in accordance with §355.107
of this title (relating to Notification of Exclusions and Adjustments).
Providers may request an informal and, if necessary, an administrative
hearing to dispute an action taken by HHSC under §355.110 of
this title (relating to Informal Reviews and Formal Appeals).
(g) Factors affecting allowable costs. In determining
whether a cost is allowable or unallowable, providers must follow
the guidelines specified in §355.102 of this title (relating
to General Principles of Allowable and Unallowable Costs). Providers
must follow the guidelines for allowable and unallowable costs as
specified in §355.103 of this title (relating to Specifications
for Allowable and Unallowable Costs) and follow the guidelines for
unallowable costs specific to the ERS program as specified in this
subsection.
(h) Unallowable cost. The unallowable cost specific
to the ERS program is the expense of base station equipment at the
response center.
(i) Reporting revenue. Revenue must be reported on
the cost report according to §355.104 of this title (relating
to Revenue).
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| Source Note: The provisions of this §355.510 adopted to be effective September 1, 1996, 21 TexReg 7896; amended to be effective January 1, 2002, 26 TexReg 10391; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013; amended to be effective December 13, 2010, 35 TexReg 10944; amended to be effective November 25, 2012, 37 TexReg 9086 |
