| (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.
(2) Requests for revision. A provider may request a
revision of its enrollment limitation if the provider's most recently
available audited Attendant Compensation Report or cost report functioning
as an Attendant Compensation Report does not represent its current
attendant compensation levels.
(A) A request for revision of enrollment limitation
must include the documentation specified in subparagraph (B) of this
paragraph and must be received by HHSC Rate Analysis no later than
the deadline indicated in the notification of open enrollment specified
in subsection (e) of this section. A request for revision that is
not received by the stated deadline will not be accepted, and the
enrollment limitation specified in STAIRS will apply.
(B) A provider that requests a revision of its enrollment
limitation must submit documentation that shows that, for the period
beginning September 1 of the current rate year and ending April 30
of the current rate year, the provider met a higher attendant compensation
level than STAIRS indicates. In such cases, the provider's enrollment
limitation will be established at the level supported by its request
for revision documentation. It is the responsibility of the provider
to render all required documentation at the time of its request for
revision. Requests that fail to support an attendant compensation
level different from what is indicated STAIRS will result in a rejection
of the request, and the enrollment limitation specified in STAIRS
will apply.
(C) A request for revision must be signed by an individual
legally responsible for the conduct of the provider or legally authorized
to bind 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 DADS
signature authority designation form for the interested party on file
at the time of the request, or a legal representative for the interested
party. A request for revision that is not signed by an individual
legally responsible for the conduct of the interested party will not
be accepted, and the enrollment limitation specified in STAIRS will
apply.
(D) If the provider's Attendant Compensation Report
or cost report functioning as an Attendant Compensation Report for
the rate year that included the open enrollment period described in
subsection (e) of this section shows the provider compensated attendants
below the level it presented in its request for revision, HHSC will
immediately recoup all enhancement payments associated with the request
for revision documents, and the provider will be limited to the level
supported by the report for the remainder of the rate year.
(3) Informal reviews and formal appeals. The filing
of a request for an informal review or formal appeal relating to a
provider's most recently available, audited Attendant Compensation
Report or cost report functioning as an Attendant Compensation Report
under §355.110 of this title (relating to Informal Reviews and
Formal Appeals) does not stay or delay implementation of an enrollment
limitation applied in accordance with the requirements of this subsection.
If an informal review or formal appeal relating to a provider's most
recently available, audited Attendant Compensation Report or cost
report functioning as an Attendant Compensation Report is pending
at the time the enrollment limitation is applied, the result of the
informal review or formal appeal shall be applied to the provider's
enrollment retroactively to the beginning of the rate year to which
the enrollment limitation was originally applied.
(4) New owners after a contract assignment or change
of ownership that is an ownership change from one legal entity to
a different legal entity. Enhancement levels for a new owner after
a contract assignment or change of ownership that is an ownership
change from one legal entity to a different legal entity will be determined
in accordance with subsection (w) of this section. A new owner after
a contract assignment or change of ownership that is an ownership-change
from one legal entity to a different legal entity will not be subject
to enrollment limitations based upon the prior owner's performance.
Cont'd... |
