| (8) Reviews of exclusions or adjustments. An ICF/MR provider who disagrees with HHSC's exclusion or adjustment of items in cost reports may request an informal review and, when appropriate, an administrative hearing as specified in §355.110 of this title (relating to Informal Reviews and Formal Appeals). (c) Fiscal accountability. For services delivered on or before August 31, 2009, HHSC will require providers to report all direct costs incurred in their annual fiscal year. HHSC will compare the reported direct service costs to the direct service cost component of the modeled rates. (1) Fiscal accountability calculation. The total direct service revenue of the modeled rates is the direct service portion of the rate multiplied by the number of allowable units paid for services provided during the reporting period. (A) Providers whose direct service costs are 90% or more of the direct service revenues will not be subject to repayment under this section. (B) Providers whose direct service costs are less than 85% of the direct service revenues will be required to pay to HHSC the difference between the direct service costs and 95% of the direct service revenues. (C) Providers whose direct service costs are less than 90% but greater than or equal to 85% of the direct service revenues will be required to pay to HHSC 75% of the difference between the direct service costs and 90% of the direct service revenues. (D) Providers who do not submit an acceptable cost report as described in subsection (b)(4) or (5) of this section will be assumed to have direct service costs equal to 65% of the direct services revenues and HHSC will recoup the difference between 65% of the direct services revenues and 95% of the direct service revenues, subject to the provisions of subsection (b)(4) or (5) of this section. (2) Notification of recoupment. Providers will be notified, by certified mail, within 90 days of the determination of their recoupment amount by HHSC of the amount to be repaid to HHSC. If a subsequent review by HHSC or audit results in adjustments to the Cost Report as described in subsection (b)(7) of this section that changes the amount to be repaid to HHSC, the provider will be notified in writing of the adjustments and the adjusted amount to be repaid. HHSC will recoup any amount owed from a provider's vendor payment(s) following the date of the notification letter. (3) Repayment. Repayment will be collected from the following: (A) the provider or legal entity submitting the report; (B) any other legal entity responsible for the debts or liabilities of the submitting entity; or (C) the legal entity on behalf of which a report is submitted. (4) Repayment when ownership change or contract termination occurs. For providers undergoing an ownership change or contract termination, HHSC will recoup any amount owed from the provider'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 paragraph (3) of this subsection will be jointly and severally liable for any additional payment due to HHSC. 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 until repayment is made in full. The responsible entity for these contracts will be notified as described in paragraph (2) of this subsection prior to the recoupment of owed funds, placement of vendor hold and barring of new contracts. (5) Aggregation. (A) Definitions. The following words and terms have the following meanings when used in this paragraph. (i) Aggregation--For an entity defined in clause (iii) of this subparagraph that controls, as defined in clause (iv) of this subparagraph, more than one ICF/MR component code, the process of determining compliance with the spending requirements detailed in paragraph (1) of this subsection for all component codes controlled by the entity in the aggregate rather than requiring each component code to meet its spending requirement individually. For commonly owned corporations defined in clause (ii) of this subparagraph, the process of determining compliance with the spending requirements detailed in paragraph (1) of this subsection for all component codes in the controlled small group in the aggregate rather than requiring each component code to meet its spending requirement individually. Corporations that do not meet the definitions under clauses (ii) - (iii) of this subparagraph are not eligible for aggregation. (ii) Commonly owned corporations--two or more corporations where five or fewer identical persons who are individuals, estates, or trusts own greater than 50 percent of the total voting power in each corporation. (iii) Entity--a parent company, sole member, individual, limited partnership, or group of limited partnerships controlled by the same general partner. (iv) Control--greater than 50% ownership by the entity. (B) Component Codes Included in Aggregation. If an entity controlling more than one ICF/MR component code or commonly owned corporations requests aggregation, compliance with the spending requirements will be evaluated in the aggregate for all ICF/MR component codes that the entity or commonly owned corporations controlled at the end of its fiscal year or at the effective date of the change of ownership or termination of its last ICF/MR contract. (C) Aggregation Request. To exercise the aggregation option, the entity or commonly owned corporations must submit an aggregation request, in a manner prescribed by HHSC, at the time each cost report is submitted. In limited partnerships in which the same single general partner controls all the limited partnerships, that single general partner must make this request. Other such aggregation requests will be reviewed on a case-by-case basis. (D) Frequency of Aggregation Requests. The entity or commonly owned corporations must submit a separate request for aggregation for each reporting period. (E) Ownership Changes and Contract Terminations. ICF/MR contracts that change ownership or terminate effective after the end of the applicable reporting period, but prior to the determination of compliance with spending requirements as per paragraph (1) of this subsection, are excluded from all aggregate spending calculations. These contracts' compliance with spending requirements will be determined on an individual basis and the costs and revenues will not be included in the aggregate spending calculation. |
| Source Note: The provisions of this §355.457 adopted to be effective March 25, 1997, 22 TexReg 2760; transferred effective September 1, 1997, as published in the Texas Register December 26, 1997, 22 TexReg 12748; amended to be effective April 5, 1998, 23 TexReg 3251; amended to be effective December 20, 1998, 23 TexReg 12652; amended to be effective March 1, 2001, 26 TexReg 1696; amended to be effective December 23, 2001, 26 TexReg 10277; amended to be effective August 31, 2004, 29 TexReg 8116; amended to be effective May 29, 2005, 30 TexReg 3089; amended to be effective June25, 2008, 33 TexReg 4859; amended to be effective September 1, 2009, 34 TexReg 5654; amended to be effective September 1, 2010, 35 TexReg 5026; amended to be effective October 2, 2011, 36 TexReg 6259 |
