| Factors Affect Costs).
(i) Field Audit and Desk Review. 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).
(j) Total Medicaid Spending Requirement. Effective
for costs and revenues accrued on or after September 1, 2015, through
August 31, 2017, all non-state operated ICF/IID providers are required
to spend at least 90 percent of revenues received through the ICF/IID
daily Medicaid payment rates on Medicaid allowable costs under the
ICF/IID program.
(1) Compliance with the total Medicaid spending requirement
will be determined in the aggregate for all component codes controlled
by the same entity across the ICF/IID, Home and Community-based Services
(HCS), and Texas Home Living (TxHmL) programs within the same cost
report year.
(2) Compliance with the spending requirement is determined
on an annual basis using cost reports as described in Chapter 355,
Subchapter A, of this title (relating to Cost Determination Process)
and this subchapter.
(A) When a provider changes ownership through a contract
assignment, the prior owner must submit a report covering the period
from the beginning of the provider's fiscal year to the effective
date of the contract assignment as determined by HHSC or its designee.
This report is used as the basis for determining compliance with the
spending requirement.
(B) Providers whose contracts are terminated voluntarily
or involuntarily must submit a report covering the period from the
beginning of the provider's fiscal year to the date recognized by
HHSC or its designee as the contract termination date. This report
is used as the basis for determining compliance with the spending
requirement.
(C) When part of a cost reporting period is subject
to spending accountability and part is not subject to spending accountability,
a provider may choose to have HHSC divide their costs for the entire
cost reporting period between the part of the period subject to spending
accountability and the part of the period not subject to spending
accountability on a pro-rata basis (i.e., pro-rata allocation). For
example, if six months of a twelve month cost reporting period are
subject to spending accountability, HHSC would divide the provider's
costs for the entire cost reporting period by two to determine the
costs subject to spending accountability. Providers who do not choose
to have HHSC divide their costs on a pro-rata basis must report their
costs for the period subject to spending accountability separately
from their costs for the period not subject to spending accountability
(i.e., direct reporting). Once a provider indicates to HHSC their
choice between a pro-rata allocation and direct reporting for a specific
cost reporting period, that choice is irrevocable for that cost reporting
period.
(3) Allowable costs are those described in Chapter
355, Subchapter A, and this subchapter.
(4) The total Medicaid revenue for an ICF/IID provider
participating in the attendant compensation rate enhancement is offset
by any recoupment made under §355.112(s) of this title prior
to determining compliance with the spending requirement.
(5) Providers who fail to meet the 90 percent spending
requirement are subject to a recoupment of the difference between
the 90 percent spending requirement and their actual Medicaid allowable
ICF/IID costs. Recoupments for each rate period under this subsection
are limited to the difference between the provider's Medicaid revenues
for services provided at the rates subject to spending accountability
and what the provider's Medicaid revenues would have been for services
provided at the Medicaid rates in effect on August 31, 2015.
(6) The contracted provider, owner, or legal entity
which received the Medicaid payment is responsible for the repayment
of the recoupment amount. Failure to repay the amount due or submit
an acceptable payment plan within 60 days of notification results
in placement of a vendor hold on all HHSC and Texas Department of
Aging and Disability Services contracts controlled by the responsible
entity.
(7) Prior to each rate period through August 31, 2017,
providers will be given the option of receiving the Medicaid rates
adopted by HHSC for the rate period and the Medicaid rates that were
in effect on August 31, 2015. Providers who chose to receive the Medicaid
rates that were in effect on August 31, 2015, will not be subject
to the spending accountability requirements described in this subsection.
(8) For rate periods beginning on or after September
1, 2017, the Total Medicaid Spending Requirement described in this
subsection will no longer apply. Additionally, providers who chose
to receive the Medicaid rates that were in effect on August 31, 2015,
will receive the rates that were adopted effective September 1, 2015.
|
| Source Note: The provisions of this §355.456 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 August 28, 2001, 26 TexReg 6296; amended to be effective December 23, 2001, 26 TexReg 10277; amended to be effective August 31, 2004, 29TexReg8116; amended to be effective September 1, 2007, 32 TexReg 5337; amended to be effective September 1, 2010, 35 TexReg 5026; amended to be effective January 1, 2015, 39 TexReg 9884; amended to be effective September 1, 2015, 40 TexReg 5293; amended to be effective May 24, 2016, 41 TexReg 3689; amended to be effective March 1, 2018, 43 TexReg 339 |
