| (B) The request must be signed by an individual legally
responsible for the conduct of the provider, such as the sole proprietor,
a partner, a corporate officer, an association officer, a governmental
official, a limited liability company member, a person authorized
by the applicable signature authority designation form for the provider
at the time of the request, or a legal representative for the provider.
The administrator or director of a facility or program is not authorized
to sign the request unless the administrator or director holds one
of these positions. HHSC will not accept a request that is not signed
by an individual responsible for the conduct of the provider.
(t) Change of ownership and contract terminations.
Facilities required to submit a Staffing and Compensation Report due
to a change of ownership or contract termination as described in subsection
(f) of this section will have funds held as per 40 TAC §19.2308
(relating to Change of Ownership) until an acceptable Staffing and
Compensation Report is received by HHSC and funds identified for recoupment
from subsections (n) and/or (o) of this section are repaid to HHSC
or its designee. Informal reviews and formal appeals relating to these
reports are governed by §355.110 of this title (relating to Informal
Reviews and Formal Appeals). HHSC or its designee will recoup any
amount owed from the facility'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 subsection (x)
of this section will be jointly and severally liable for any additional
payment due to HHSC or its designee. 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 or its designees until repayment is made in full. The responsible
entity for these contracts will be notified as described in subsection
(s) of this section prior to the recoupment of owed funds, placement
of vendor hold and barring of new contracts.
(u) Failure to document staff time and spending. Undocumented
direct care staff and contract labor time and compensation costs will
be disallowed and will not be used in the determination of direct
care staff time and costs per unit of service.
(v) All other rate components. All other rate components
will be calculated as specified in §355.307 of this title (relating
to Reimbursement Setting Methodology) and will be uniform for all
providers.
(w) Appeals. Subject matter of informal reviews and
formal appeals is limited as per §355.110(a)(3) of this title
(relating to Informal Reviews and Formal Appeals).
(x) Responsible entities. The contracted provider,
owner, or legal entity that received the revenue to be recouped upon
is responsible for the repayment of any recoupment amount.
(y) Change of ownership. Participation in the enhanced
direct care staff rate confers to the new owner as defined in 40 TAC §19.2308
(relating to Change of Ownership) when there is a change of ownership.
The new owner is responsible for the reporting requirements in subsection
(f) of this section for any reporting period days occurring after
the change. If the change of ownership occurs during an open enrollment
period as defined in subsection (c) of this section, then the owner
recognized by HHSC or its designee on the last day of the enrollment
period may request to modify the enrollment status of the facility
in accordance with subsection (d) of this section.
(z) Contract cancellations. If a facility's Medicaid
contract is cancelled before the first day of an open enrollment period
as defined in subsection (c) of this section and the facility is not
granted a new contract until after the last day of the open enrollment
period, participation in the enhanced direct care staff rate as it
existed prior to the date when the facility's contract was cancelled
will be reinstated when the facility is granted a new contract, if
it remains under the same ownership, subject to the availability of
funding. Any enrollment limitations from subsection (i) of this section
that would have applied to the cancelled contract will apply to the
new contract.
(aa) Determination of compliance with spending requirements
in the aggregate.
(1) Definitions. The following words and terms have
the following meanings when used in this subsection.
(A) Commonly owned corporations--two or more corporations
where five or fewer identical persons who are individuals, estates,
or trusts control greater than 50 percent of the total voting power
in each corporation.
(B) Entity--a parent company, sole member, individual,
limited partnership, or group of limited partnerships controlled by
the same general partner.
(C) Combined entity--one or more commonly owned corporations
and one or more limited partnerships where the general partner is
controlled by the same person(s) as the commonly owned corporation(s).
(D) Control--greater than 50 percent ownership by the
entity.
(2) Aggregation. For an entity, commonly owned corporation,
or combined entity that controls more than one participating nursing
facility contract, compliance with the spending requirements detailed
in subsection (o) of this section can be determined in the aggregate
for all participating nursing facility contracts controlled by the
entity, commonly owned corporations, or combined entity at the end
of the rate year, the effective date of the change of ownership of
its last participating NF contract, or the effective date of the termination
of its last participating NF contract rather than requiring each contract
to meet its spending requirement individually. Corporations that do
not meet the definitions under paragraph (1)(A) - (C) of this subsection
are not eligible for aggregation to meet spending requirements.
(A) Aggregation Request. To exercise aggregation, the
entity, combined entity, or commonly owned corporations must submit
an aggregation request, in a manner prescribed by HHSC, at the time
each Staffing and Compensation Report or cost report is submitted.
In limited partnerships in which the same single general partner controls
all the limited partnerships, the single general partner must make
this request. Other such aggregation requests will be reviewed on
a case-by-case basis.
(B) Frequency of Aggregation Requests. The entity,
combined entity, or commonly owned corporations must submit a separate
request for aggregation for each reporting period.
(C) Ownership changes or terminations. Nursing facility
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 subsection (o) of
this section, 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.
(bb) Medicaid Swing Bed Program for Rural Hospitals.
When a rural hospital participating in the Medicaid swing bed program
furnishes NF nursing care to a Medicaid recipient under 40 TAC §19.2326
(relating to Medicaid Swing Bed Program for Rural Hospitals), HHSC
or its designee makes payment to the hospital using the same procedures,
the same case-mix methodology, and the same RUG-III rates that HHSC
authorizes for reimbursing NFs receiving the direct care staff base
rate with no enhancement levels. These hospitals are not subject to
the staffing and spending requirements detailed in this section.
(cc) Reinvestment. For services delivered on or before
August 31, 2009, HHSC will reinvest recouped funds in the enhanced
direct care staff rate program, to the extent that there are qualifying
facilities. For services delivered beginning September 1, 2009, and
thereafter, HHSC will not reinvest recouped enhanced direct care staff
rate funds.
(1) Identify qualifying facilities. Facilities meeting
the following criteria during the most recent completed reporting
period are qualifying facilities for reinvestment purposes.
(A) The facility was a participant in the enhanced
direct care staff rate or, for state fiscal years 2004 and 2005 only,
had been a participant at level 0 in state fiscal year 2003 and was
reclassified as a nonparticipant due to the elimination of level 0
in state fiscal year 2004.
(B) The facility's unadjusted LVN-equivalent minutes
as determined in subsection (m)(1) of this section were greater than
the number of LVN-minutes required of the facility as determined in
subsection (j) of this section.
(C) The facility met its spending requirement as determined
in subsection (o) of this section.
Cont'd... |
