| (IV) Exhibit 3 - Visit Reconciliation - Contract Service
Providers.
(iii) All items must be complete and accurate.
(C) Change of Effective Rate Cost Report. The change
of effective rate cost report is used by in-state or out-of-state
FQHCs that are requesting a change in their effective rate due to
a change in scope or operating in an efficient manner. The cost report
must contain at least six (6) months of financial information. The
documents needed for in-state and out-of-state providers filing a
change of effective rate cost report are the same as required for
the as-filed cost report in paragraph (8)(A) of this subsection.
(D) Projected Cost Report. The projected cost report
is used by in-state or out-of-state FQHCs that are requesting an initial
interim rate. The cost report must contain at least twelve (12) months
of projected financial information. The required documents are the
same as required for the as-filed cost report in paragraph (8)(A)
of this subsection, except that the information contained in clauses
(iii), (iv) and (v) are not required.
(E) Low Medicare Utilization Cost Report. The low Medicare
utilization cost report is used by in-state and out-of-state providers
to meet the annual filing requirements for providers not required
to file a full cost report with Medicare. A provider filing the Low
Medicare Utilization cost report must complete and submit all required
forms and supporting documentation described in paragraph (8)(A) of
this subsection for all rate determination processes described in
paragraph (10) of this subsection.
(F) If a provider fails to submit a required cost report,
HHSC or its designee may delay or withhold vendor payment to the provider
until a complete cost report has been received and accepted by HHSC
or its designee.
(9) Cost Report Filing Requirement. Each FQHC must
submit a copy of its Final Audited Medicare Cost Report, as described
in paragraph (8)(B) of this subsection, to HHSC or its designee within
thirty (30) days of receipt of the report from Medicare. An FQHC filing
a Low Utilization Cost Report with Medicare may comply with this subsection
by filing a copy of such cost report with HHSC annually, within thirty
(30) days of filing the report with Medicare.
(10) FQHC rate determination process.
(A) New FQHC.
(i) A new FQHC must file a projected cost report, pursuant
to paragraph (8)(D) of this subsection, within 90 days of their designation
as an FQHC to establish an initial interim base rate. The cost report
must contain the FQHC's reasonable costs anticipated to be incurred
during the FQHC's initial fiscal year. The initial interim base rate
for a new FQHC shall be set at the lesser of eighty percent (80%)
of the anticipated reasonable costs or eighty percent (80%) of the
average rate paid to FQHCs on January 1 of the calendar year during
which the FQHC first applies as a new FQHC or for a change in scope,
if applicable.
(ii) Each new FQHC must submit to HHSC or its designee
an As-Filed Medicare Cost Report, pursuant to paragraph (8)(A) of
this subsection, within five (5) calendar months after the end of
the FQHC's first full fiscal year. HHSC will determine an updated
interim base rate based on one hundred percent (100%) of the reasonable
costs contained in the As-Filed Medicare Cost Report. An As-Filed
Medicare Cost Report must reflect twelve (12) months of continuous
service that meets the requirements of paragraph (7)(B) of this subsection.
Interim rates will be adjusted prospectively until the Final Audited
Medicare Cost Report reflecting twelve (12) months of continuous service
is processed. HHSC will, within eleven (11) months of receipt of the
As-Filed Medicare Cost Report reflecting twelve (12) months of continuous
service determine the updated interim base rate.
(iii) Each new FQHC must submit to HHSC or its designee
a Final Audited Medicare Cost Report, pursuant to paragraph (9) of
this subsection. The Final Audited Medicare Cost Report settlement,
reflecting twelve (12) months of continuous service, must be completed
within eleven (11) months of receipt of a cost report. The rate established
shall be the final base rate. HHSC will reconcile payments back to
the beginning of the interim period applying the final base rate.
If the final base rate is greater than the interim base rate, HHSC
will compute and pay the FQHC a settlement payment that represents
the difference in rates for the services provided during the interim
period. If the final base rate is less than the interim base rate,
HHSC will compute and recoup from the FQHC any overpayment resulting
from the difference in rates for the services provided during the
interim period. The final base rate is adjusted in accordance with
paragraph (4) of this subsection to determine the effective rate.
(iv) If a new FQHC cost report described in clause
(ii) or (iii) of this subparagraph does not meet the requirement of
reflecting twelve (12) months of continuous service that meets the
requirements of paragraph (7)(B) of this subsection, HHSC will prospectively
establish the interim rate based on the lesser of the interim rate
determined by the cost report or eighty percent (80%) of the average
rate paid to FQHCs on January 1 of the calendar year during which
the FQHC first applies as a new FQHC or for a change in scope, if
applicable, adjusted by applicable increases.
(B) Change of Ownership. If an existing FQHC facility
changes ownership, the new owner must notify HHSC of the ownership
change within ten (10) calendar days of the change.
(i) If the new owner of an FQHC facility owns no other
FQHC facility in Texas, HHSC will treat the FQHC facility as a new
FQHC. HHSC will set an initial interim base rate equal to one hundred
percent (100%) of the previous owner's effective rate, and will then
follow the procedures under subparagraph (A)(ii) and (iii) of this
paragraph.
(ii) If the new owner of an FQHC facility owns one
or more FQHC facilities in Texas and will include the new facility
on the Medicare cost report of another FQHC facility, then HHSC will
apply the rate assigned to the other FQHC.
(iii) If the new owner of an FQHC facility owns one
or more FQHC facilities in Texas, but will not include the new facility
on the Medicare cost report of another FQHC facility, then HHSC will
determine a rate for the facility in accordance with clause (i) of
this subparagraph.
(iv) If the new owner is ultimately not allowed by
Medicare to include its new FQHC facility on the Medicare cost report
of the other FQHC facility that it owns, then HHSC will determine
a rate for the facility in accordance with subparagraph (A) of this
paragraph.
(C) Request for Change of Effective Rate.
(i) An FQHC that requests an adjustment of its effective
rate due to a change in scope or operating in an efficient manner
must file a Change of Effective Rate Cost Report described in paragraph
(8)(C) of this subsection. The FQHC must include the necessary documentation
to support a claim that the FQHC has undergone a change in scope or
is operating in an efficient manner pursuant to paragraph (7) of this
subsection. A cost report filed to request an adjustment in the effective
rate may be filed at any time during an FQHC's fiscal year, but no
later than five (5) calendar months after the end of the FQHC's fiscal
year. All requests for adjustment in the FQHC's effective rate must
include at least six (6) months of financial data. Within sixty (60)
days of receiving the Change of Effective Rate Cost Report described
in paragraph (8)(C) of this subsection, HHSC or its designee will
make a determination regarding a new interim base rate.
(ii) If HHSC determines through the review of the information
provided in clause (i) of this subparagraph that an adjustment to
the effective rate is warranted, HHSC will determine an interim base
rate based on one hundred percent (100%) of the reasonable costs contained
in the Change of Effective Rate Cost Report. Interim payments will
be adjusted prospectively until the final audited cost report is processed.
(iii) The FQHC must submit to HHSC or its designee
an As-Filed Medicare Cost Report, described in paragraph (8)(A) of
this subsection, within five (5) calendar months after the end of
the FQHC's fiscal year. HHSC and the FQHC will then follow the procedures
under subparagraph (A)(ii) and (iii) of this paragraph.
(D) State Initiated Review.
(i) For an in-state FQHC that has chosen the APPS methodology,
HHSC may prospectively reduce the FQHC's effective rate to reflect
one hundred percent (100%) of its reasonable costs or the PPS effective
rate, whichever is greater. After reviewing the Final Audited Medicare
Cost Report described in paragraph (8)(B) of this subsection, HHSC
will determine if an in-state FQHC is being reimbursed more than one
hundred percent (100%) of its reasonable cost or the PPS effective
rate, whichever is greater, through the following steps:
(I) Determine the reasonable cost per encounter from
the Final Audited Medicare Cost Report;
Cont'd... |
