| nonparticipants in the prior year or by providers who were
participants in the prior year who seek additional enhancements. Using
the process described herein separately for each population of programs,
HHSC first determines the distribution of carry-over enhancements.
If funds are available after the distribution of carry-over enhancements,
HHSC determines the distribution of newly-requested enhancements.
HHSC may not distribute newly-requested enhancements to providers
owing funds identified for recoupment under subsection (s) of this
section.
(1) For all programs and levels except for CBA AL/RC
Level 1, HHSC determines projected units of service for contracts
and/or component codes requesting each enhancement level and multiplies
this number by the enhancement rate add-on amount associated with
that enhancement level as determined in subsection (n) of this section.
For CBA AL/RC Level 1, HHSC determines projected units of service
for CBA AL/RC contracts requesting Level 1 and multiplies this number
by the sum of the difference between the base rate and the nonparticipant
rate and the enhancement add-on amount associated with enhancement
Level 1 as follows: (Base Rate - Nonparticipant Rate) + Level 1 add-on
amount.
(2) HHSC compares the sum of the products from paragraph
(1) of this subsection to available funds.
(A) If the sum of the products is less than or equal
to available funds, all requested enhancements are granted.
(B) If the sum of the products is greater than available
funds, enhancements are granted beginning with the lowest level of
enhancement and granting each successive level of enhancement until
requested enhancements are granted within available funds. Based upon
an examination of existing compensation levels and compensation needs,
HHSC may grant certain enhancement options priority for distribution.
(q) Notification of granting of enhancements. Participating
contracts and component codes are notified, in a manner determined
by HHSC, as to the disposition of their request for attendant compensation
rate enhancements.
(r) Total attendant compensation rate for participating
providers. Each participating provider's total attendant compensation
rate will be equal to the attendant compensation base rate from subsection
(m) of this section plus any add-on payments associated with enhanced
attendant compensation levels selected by and awarded to the provider
during open enrollment.
(s) Spending requirements for participating contracts
and component codes. HHSC will determine from the Attendant Compensation
Report or cost report functioning as an Attendant Compensation Report,
as specified in subsection (h) of this section and other appropriate
data sources, the amount of attendant compensation spending per unit
of service delivered. The provider's compliance with the spending
requirement is determined based on the total attendant compensation
spending as reported on the Attendant Compensation Report or cost
report functioning as an Attendant Compensation Report for each participating
contract or component code. Compliance with the spending requirement
is determined separately for each program specified in subsection
(a) of this section, except for providers delivering both RC and CBA
AL/RC services in the same facility whose compliance is determined
by combining both programs and providers delivering services in both
the HCS and TxHmL programs whose compliance is determined by combining
both programs. HHSC will calculate recoupment, if any, as follows.
(1) The accrued attendant compensation revenue per
unit of service is multiplied by 0.90 to determine the spending requirement
per unit of service. The accrued attendant compensation spending per
unit of service will be subtracted from the spending requirement per
unit of service to determine the amount to be recouped. If the accrued
attendant compensation spending per unit of service is greater than
or equal to the spending requirement per unit of service, there is
no recoupment.
(2) The amount paid for attendant compensation per
unit of service after adjustments for recoupment must not be less
than the amount determined for nonparticipating contracts or component
codes in subsection (l) of this section.
(3) In cases where more than one enhancement level
is in effect during the reporting period, the spending requirement
will be based on the weighted average enhancement level in effect
during the reporting period calculated as follows:
(A) Multiply the first enhancement level in effect
during the reporting period by the most recently available, reliable
Medicaid units of service utilization data for the time period the
first enhancement level was in effect.
(B) Multiply the second enhancement level in effect
during the reporting period by the most recently available, reliable
Medicaid units of service utilization data for the time period the
second enhancement level was in effect.
(C) Sum the products from subparagraphs (A) and (B)
of this paragraph.
(D) Divide the sum from subparagraph (C) of this paragraph
by the sum of the most recently available, reliable Medicaid units
of service utilization data for the entire reporting period used in
subparagraphs (A) and (B) of this paragraph.
(4) Effective January 1, 2020, the recoupment for participating
providers reporting HCS RSS/SL services will be determined pursuant
to §355.727(f) of this chapter (relating to Add-on Payment Methodology
for Home and Community-Based Services Supervised Living and Residential
Support Services).
(t) Notification of recoupment and request for recalculation.
(1) Notification of recoupment. The estimated amount
to be recouped is indicated in the State of Texas Automated Information
Reporting System (STAIRS), the online application for submitting cost
reports and Attendant Compensation reports. STAIRS will generate an
email to the entity contact, indicating that the provider's estimated
recoupment is available for review. The entity contact is the provider's
authorized representative per the signature authority designation
form applicable to the provider's contract or ownership type. If a
subsequent review by HHSC or audit results in adjustments to the Attendant
Compensation Report or cost reporting, as described in subsection
(h) of this section, that change the amount to be repaid, the provider
will be notified by email to the entity contact that the adjustments
and the adjusted amount to be repaid are available in STAIRS for review.
HHSC, or its designee, will recoup any amount owed from a provider's
vendor payment(s) following the date of the initial or subsequent
notification. For the HCS and TxHmL programs, if HHSC, or its designee,
is unable to recoup owed funds in an automated fashion, the requirements
detailed under subsection (dd) of this section apply.
(2) Request for recalculation. Providers notified of
a recoupment based on an Attendant Compensation Report described in
subsection (h)(2)(A) or (h)(2)(F) of this section may request that
HHSC recalculate their recoupment after combining the Attendant Compensation
Report with the provider's most recently available, audited full-year
cost report. The request must be received by HHSC Rate Analysis no
later than 30 days after the date on the email notification of recoupment.
If the 30th calendar day is a weekend day, national holiday, or state
holiday, then the first business day following the 30th calendar day
is the final day the receipt of the request will be accepted.
(A) The request must be made by email to the email
address specified in STAIRS, hand delivery, United States (U.S.) mail,
or special mail delivery. An email request must be typed on the provider's
letterhead, signed by a person indicated in subparagraph (B) of this
paragraph, then scanned and sent by email to HHSC.
(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.
(u) Enrollment limitations. A provider will not be
enrolled in the attendant compensation rate enhancement at a level
higher than the level it achieved on its most recently available,
audited Attendant Compensation Report or cost report functioning as
an Attendant Compensation Report. HHSC will notify a provider of its
enrollment limitations (if any) prior to the first day of the open
enrollment period.
(1) Notification of enrollment limitations. The enrollment
limitation level is indicated in STAIRS. STAIRS will generate an e-mail
to the entity contact, indicating that the provider's enrollment limitation
level is available for review.
Cont'd... |
