| (a) Introduction. Reimbursement is available to a Local
Education Agency (LEA) for providing certain direct medical and transportation
services, known as SHARS, to a Medicaid-enrolled student with a disability
age 20 years of age or younger. SHARS services are described in and
must be prescribed in accordance with §354.1341 of this title
(relating to Benefits and Limitations).
(b) Definitions. The following words and terms, when
used in this section, have the following meanings, unless the context
clearly indicates otherwise.
(1) Cost report--An annual report documenting the LEA's
Medicaid-allowable costs for all SHARS delivered during the previous
federal fiscal year. The cost report is due on or before April 1 of
the year following the reporting period and must be certified in a
manner specified by the Texas Health and Human Services Commission
(HHSC). The primary purposes of the cost report are to:
(A) document the LEA's total Medicaid-allowable costs
for delivering SHARS, including direct costs and indirect costs, based
on federally mandated cost allocation methodologies; and
(B) reconcile interim payments to total Medicaid-allowable
costs based on approved cost allocation methodology procedures.
(2) Eligible student--A Medicaid-enrolled student with
a disability age 20 years of age or younger that receives a direct
medical or transportation service as prescribed by §354.1341
of this title.
(3) Interim claim--A claim for a direct medical or
transportation service paid at the interim rate that is provisional
in nature pending the completion of a cost reconciliation and cost
settlement for the cost reporting period.
(4) Local Education Agency (LEA)--A Texas independent
school district or public charter school.
(5) Time study--A statistically valid random sampling
method used to identify the percentage of time spent performing actual
direct medical services irrespective of payer and administrative cost.
(c) Parental Consent. Prior to submitting its annual
cost report, the LEA must meet the parental consent requirements in §354.1342
of this title (relating to Conditions for Participation) for each
student included in the numerator of the following ratios required
in the cost report.
(1) IEP ratio--A comparison of the total number of
students enrolled in Medicaid with individualized education programs
(IEPs) requiring direct medical services to the total number of students
with IEPs requiring direct medical services.
(2) One-way trip ratio--A comparison of the total one-way
trips for students enrolled in Medicaid with IEPs requiring specialized
transportation services, who received direct medical services the
same day, to the total one-way trips for all students with IEPs requiring
specialized transportation services.
(3) Section 504 Plan ratio--A comparison of the total
number of students enrolled in Medicaid with Section 504 Plans requiring
audiology services to the total number of students with Section 504
Plans requiring audiology services.
(d) Time study. The LEA must participate in the HHSC-administered
time study in the manner prescribed by HHSC.
(e) Reimbursement methodology. LEAs are reimbursed
for direct medical and transportation services provided under the
SHARS program on a cost basis.
(1) Interim rates. The interim rate is developed based
on a percentage of the average per-unit cost for each SHARS service
using actual cost data collected on cost reports and is subject to
change under §355.109 of this chapter (relating to Adjusting
Reimbursement When New Legislation, Regulations, or Economic Factors
Affect Costs). Interim rates are updated annually or as determined
by HHSC.
(2) Interim claims.
(A) LEAs must submit:
(i) at least one interim claim for each direct medical
service that an eligible student receives within the cost report period;
(ii) interim claims for all personal care services
that an eligible student receives within the cost report period; and
(iii) interim claims for all eligible specialized transportation
trips provided within the cost report period.
(B) Requirements for interim claims will be adjusted
as needed based on direction from the Centers for Medicare and Medicaid
Services.
(C) Interim claims must be valid and reimbursed to
meet the requirements in this paragraph.
(3) Interim payment. LEAs are reimbursed for SHARS
direct medical services and transportation services per unit of service
at the lesser of:
(A) the LEA's billed charges; or
(B) the interim rate.
(4) Final reimbursement. The LEA's final reimbursement
amount is arrived at by a cost reconciliation and cost settlement
process. As reported in the cost report, the LEA's total costs for
both direct medical and transportation services are adjusted using
the federally mandated allocation methodologies.
(A) Direct medical services costs. Salary and contract
costs must be reported in the manner prescribed by HHSC.
(i) Direct costs. From the annual cost report, HHSC
aggregates allowable costs for direct medical services, resulting
in total direct costs. Direct costs for direct medical services include
payroll costs and other costs that can be directly charged to direct
medical services provided by contractors and LEA staff (i.e., salaries,
benefits, and contract compensation). Direct medical services costs
do not include transportation personnel costs.
(ii) Indirect costs. Indirect costs are determined
by applying the LEA's specific unrestricted indirect cost rate to
its net direct costs. Texas LEAs use predetermined fixed rates for
indirect costs. The Texas Education Agency (TEA) has, in cooperation
with the United States Department of Education (USDE), developed an
indirect cost plan to be used by LEAs in Texas. As authorized in 34
CFR §75.561(b), TEA approves unrestricted indirect cost rates
for LEAs for the USDE, which is the cognizant agency for LEAs.
(iii) Net allowable cost. Direct and indirect costs
are added together and adjusted by the direct medical time study percentage,
the IEP ratio, and the 504 Plan ratio, resulting in a net Medicaid
allowable cost for direct medical services.
(B) Transportation services. Salary and contract costs
must be reported in the manner prescribed by HHSC.
(i) Direct costs. From the annual cost report, HHSC
aggregates allowable direct costs for transportation, resulting in
total direct costs. Direct costs for covered transportation services
include payroll costs and other costs that can be directly charged
to covered transportation services. Direct payroll costs include total
compensation (i.e., salaries, benefits, and contract compensation)
of bus drivers and mechanics. Other direct costs include costs directly
related to the delivery of covered transportation services, such as
professional and contracted services, contracted transportation costs,
gasoline and other fuels, other maintenance and repair costs, vehicle
insurance, interest, rentals, and vehicle depreciation.
(ii) Indirect costs. Indirect costs are determined
by applying the LEA's specific unrestricted indirect cost rate to
its net direct costs. Texas public LEAs use predetermined fixed rates
for indirect costs. TEA has, in cooperation with the USDE, developed
an indirect cost plan to be used by LEAs in Texas. As authorized in
34 CFR §75.561(b), TEA approves unrestricted indirect cost rates
for LEAs for the USDE, which is the cognizant agency for LEAs.
(iii) Net allowable cost. Net direct costs and indirect
costs are added together and adjusted by the one-way trip ratio, resulting
in a net Medicaid allowable cost for transportation services.
(f) Cost reporting requirements. HHSC excludes from
reimbursement determinations any unallowable expenses included in
the cost report and makes the appropriate adjustments to expenses
and other information reported by LEAs.
(1) Certification. Each LEA certifies through the cost
report process its total actual federal and non-federal costs and
expenditures.
(2) Reimbursement determinations and allowable costs.
LEAs are responsible for reporting only allowable costs on the cost
report, except where HHSC prescribes that other costs are to be reported
in specific lines or sections. Only allowable cost information is
used to determine recommended reimbursement. All costs relating to
Shared Service Arrangements and Co-operatives must be allocated to
each respective LEA.
(g) Cost reconciliation. The Medicaid-allowable costs
for direct medical and transportation services are added together
and adjusted by the federal Medicaid assistance percentage (FMAP)
to arrive at the federal share owed to the LEA. This amount is then
reconciled with interim payments already made to the LEA.
(h) Cost settlement. HHSC uses a cost settlement process
as follows.
Cont'd... |
