|(a) General information. 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 are deaf-blind with multiple disabilities.
(b) Other sources of cost information. If HHSC has
determined that there is not sufficient reliable cost report data
from which to set reimbursements and reimbursement ceilings for waiver
services, reimbursements and reimbursement ceilings will be developed
by using rates for similar services from other Medicaid programs;
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 rate determination methodology. If HHSC
deems it appropriate to require contracted providers to submit a cost
report, recommended reimbursements for waiver services will be determined
on a fee-for-service basis in the following manner for each of the
(1) Total allowable costs for each provider will be
determined by analyzing the allowable historical costs reported on
the cost report.
(2) 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.
(3) 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).
(4) Allowable administrative and overall facility/operations
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
service units reported to the amount of total waiver service units
reported. Service-specific facility and operations costs for out-of-home
respite and day habilitation services will be directly charged to
the specific waiver service.
(5) 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, behavioral
support services, audiology services, dietary services, employment
assistance, and supported employment, an allowable cost per unit of
service is calculated for each contracted provider cost report in
accordance with paragraphs (1) - (4) of this subsection. The allowable
costs per unit of service for each contracted provider cost report
is multiplied by 1.044. This adjusted allowable costs 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).
(6) Requisition fees are reimbursements paid to the
Deaf Blind with Multiple Disabilities (DBMD) Waiver contracted providers
for their efforts in acquiring adaptive aids, medical supplies, dental
services, and minor home modifications for DBMD participants. Reimbursement
for adaptive aids, medical supplies, dental services, and minor home
modifications will vary based on the actual cost of the adaptive aid,
medical supply, dental service, and minor home modification. Reimbursements
are determined using a method based on modeled projected expenses,
which are developed by using data from surveys; cost report data from
similar programs; consultation with other service providers or professionals
experienced in delivering contracted services; or other sources.
(7) For day habilitation, residential habilitation,
chore, and intervener (excluding Interveners I, II and III) services,
two cost areas are created:
(A) The attendant cost area, which includes salaries,
wages, benefits, and mileage reimbursement calculated as specified
in §355.112 of this title (relating to Attendant Compensation
(B) An "other direct care" cost area, which includes
costs for services not included in subparagraph (A) of this paragraph
as determined in paragraphs (1) - (4) of this subsection. An allowable
cost per unit of service is determined for each contracted provider
cost report for the other direct care cost area. The allowable costs
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.
(C) The attendant cost area and the other direct care
cost area are summed to determine the cost per unit of service.
(8) For Interveners I, II and III, payment rates are
developed based on rates determined for other programs that provide
similar services. If payment rates are not available from other programs
that provide similar services, payment rates are determined using
a pro forma approach in accordance with §355.105(h) of this title
(relating to General Reporting and Documentation Requirements, Methods,
and Procedures). Interveners I, II and III are not considered attendants
for purposes of the Attendant Compensation Rate Enhancement described
in §355.112 of this title and providers are not eligible to receive
direct care add-ons to the Intervener I, II or III rates.
(9) Assisted living services payment rates are determined
using a pro forma approach in accordance with §355.105(h) of
this title. The rates are adjusted periodically for inflation. The
room and board payments for waiver clients receiving assisted living
services are covered in the reimbursement for these services and will
be paid to providers from the client's Supplemental Security Income,
less a personal needs allowance.
(10) Pre-enrollment assessment services and case management
services payment rates are determined by modeling the salary for a
Case Manager staff position. This rate is periodically updated for
(11) The orientation and mobility services payment
rate is determined by modeling the salary for an Orientation and Mobility
Specialist staff position. This rate is updated periodically for inflation.
(12) HHSC may adjust reimbursement if new legislation,
regulations, or economic factors affect costs, according to §355.109
of this title (relating to Adjusting Reimbursement When New Legislation,
Regulations, or Economic Factors Affect Costs).
(d) Authority to determine reimbursement. The authority
to determine reimbursement is specified in §355.101 of this title.
(e) Reporting of cost.
(1) Cost-reporting guidelines. If HHSC requires a cost
report for any waiver service in this program, providers must follow
the cost-reporting guidelines as specified in §355.105 of this
(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) Reporting and verification of allowable cost.
(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 reimbursements.
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, in order
to ensure the database reflects costs and other information necessary
for the provision of services and is consistent with federal and state
(B) Individual cost reports may not be included in
the database used for reimbursement determination if:
(i) there is 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
(4) Allowable and unallowable costs. Providers must
follow the guidelines specified in §355.102 and §355.103
of this title (relating to General Principles of Allowable and Unallowable
Costs and Specifications for Allowable and Unallowable Costs), in
determining whether a cost is allowable or unallowable. In addition,
providers must adhere to the following principles:
(A) Client room and board expenses are not allowable,
except for those related to respite care.
(B) The actual cost of adaptive aids, medical supplies,
dental services, and minor home modifications is not allowable for
cost-reporting purposes. Allowable labor costs associated with acquiring
adaptive aids, medical supplies, dental services, and home modifications
should be reported in the cost report. Any item purchased for participants
in this program and reimbursed through a voucher payment system is
unallowable. Refer to §355.103(b)(20)(K) of this title.
(f) Reporting revenue. Revenues must be reported on
the cost report in accordance with §355.104 of this title (relating
(g) Reviews and field audits of cost reports. Desk
reviews or field audits are performed on cost reports for all contracted
providers. The frequency and nature of 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 review and, if necessary, an administrative
hearing to dispute an action taken under §355.110 of this title
(relating to Informal Reviews and Formal Appeals).
|Source Note: The provisions of this §355.513 adopted to be effective September 1, 2009, 34 TexReg 5654; amended to be effective December 13, 2010, 35 TexReg 10944; amended to be effective June 20, 2011, 36 TexReg 3707; amended to be effective November 25, 2012, 37 TexReg 9086; amended to be effective January 1, 2015, 39 TexReg 9193