| projected expenses, which are developed by using data from
surveys; cost report data from similar programs; consultation with
other service providers and/or professionals experienced in delivering
contracted services; and/or other sources.
(5) Pre-enrollment expense fee. Reimbursement for pre-enrollment
assessment is determined using a method based on modeled projected
expenses that are developed by using data from surveys; cost report
data from other similar programs; consultation with other service
providers and/or professionals experienced in delivering contracted
services; and other sources.
(6) Home-Delivered Meals. The reimbursement for Home-Delivered
Meals will be determined on a per meal basis, based on the ceiling
amount determined in accordance with §355.511 of this title (relating
to Reimbursement Methodology for Home-Delivered Meals).
(7) Exceptions to the reimbursement determination methodology.
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
title (relating to General Reporting and Documentation Requirements,
Methods, and Procedures).
(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) Number of cost reports to be submitted.
(A) Contracted providers participating in the attendant
compensation rate enhancement.
(i) At the same level of enhancement. If all the contracts
under the legal entity participate in the enhancement at the same
level of enhancement, the contracted provider must submit one cost
report for the legal entity.
(ii) At different levels of enhancement. If all the
contracts under the legal entity participate in the enhancement but
they participate at more than one enhancement level, the contracted
provider must submit one cost report for each level of enhancement.
(B) Contracted providers not participating in the attendant
compensation rate enhancement. If all the contracts under the legal
entity do not participate in the enhancement, the contracted provider
must submit one cost report for the legal entity.
(C) Contractors participating and not participating
in attendant compensation rate enhancement.
(i) At the same level of enhancement. If some of the
contracts under the legal entity do not participate in the enhancement
and the rest of the contracts under the legal entity participate at
the same level of enhancement, the contracted provider must submit:
(I) one cost report for the contracts that do not participate;
and
(II) one cost report for the contracts that do participate.
(ii) At different levels of enhancement. If some of
the contracts under the legal entity do not participate in the enhancement
and the rest of the contracts under the legal entity participate in
the enhancement but they participate at more than one enhancement
level, the contracted provider must submit:
(I) one cost report for the contracts that do not participate;
and
(II) one cost report for each level of enhancement.
(4) 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; the purpose
is to ensure that the database 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 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
not verifiable.
(5) Allowable and unallowable costs. Providers must
follow the guidelines in determining whether a cost is allowable or
unallowable as 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
addition to the following.
(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 home modifications are 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 for cost reporting purposes. 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
to Revenues).
(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 the field audits are determined
by HHSC 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 §355.503 adopted to be effective September 1, 1996, 21 TexReg 7890; transferred effective September 1, 1997, as published in the Texas Register October 17, 1997, 22 TexReg 10311; amended to be effective June 21, 1998, 23 TexReg 6197; amended to be effective June 25, 2000, 25 TexReg 5867; amended to be effective October 9, 2000, 25 TexReg 10131; amended to be effective September 1, 2001, 26 TexReg 6297; amended to be effective July 1, 2002, 27TexReg 5164; amended to be effective April 13, 2003, 28 TexReg 3047; amended to be effective August 16, 2004, 29 TexReg 7965; amended to be effective January 19, 2006, 31 TexReg 286; amended to be effective October 28, 2007, 32 TexReg 7461; amended to be effective February 3, 2008, 33 TexReg 667; amended to be effective September 3, 2008, 33 TexReg 7153; amended to be effective September 1, 2009, 34 TexReg 5654; amended to be effective June 20, 2011, 36 TexReg 3707; amended to be effective April 1, 2012, 37 TexReg 2068; amended to be effective November 25, 2012, 37 TexReg 9086; amended to be effective September 1, 2013, 38 TexReg 5435; amended to be effective January 1, 2015, 39 TexReg 9193 |
