| (iii) Allocating allowable costs. A provider's total
allowable reported costs for ambulance services are allocated to Medicaid
and uninsured patients based on the ratio of charges for Medicaid
and uninsured patients to the charges for all patients. Only allocable
expenditures related to Medicaid, Medicaid managed care, and uncompensated
care as defined and approved in the Texas Healthcare Transformation
and Quality Improvement 1115 Waiver Program (1115 Waiver) will be
included for supplemental payment.
(D) Calculation of supplemental payments and enhanced
supplemental payments.
(i) For services provided from October 1, 2011, through
February 29, 2012, a governmental ambulance provider may be eligible
to receive a supplemental payment equal to its Medicaid shortfall
for the cost reporting period multiplied by the federal Medical assistance
percentage (FMAP) in effect during the cost reporting period.
(ii) For services provided on or after March 1, 2012,
and subject to approval by CMS, a governmental ambulance provider
may be eligible to receive a supplemental payment equal to its uncompensated
care costs for the cost reporting period multiplied by the FMAP in
effect during the cost reporting period.
(iii) Supplemental payments based on uncompensated
care costs are limited by the maximum aggregate amount of the estimated
uncompensated care costs for all eligible governmental ambulance providers
as determined by §355.8201 of this chapter (relating to Waiver
Payments to Hospitals for Uncompensated Care).
(iv) If the actual aggregate uncompensated care costs
for all eligible governmental ambulance providers is greater than
the maximum aggregate amount of the estimated uncompensated care costs
for all eligible governmental ambulance providers as described in
clause (iii) of this subparagraph, then HHSC will reduce the supplemental
payments for all participating governmental ambulance providers proportionately.
(v) The supplemental payment is contingent upon the
governmental ambulance provider's certificate of public expenditures
submitted with each cost report.
(vi) If the federal government disallows federal financial
participation related to the receipt or use of supplemental payments
under this section, HHSC will recoup an amount equal to the federal
share of supplemental payments overpaid or disallowed.
(E) Enhanced supplemental payment.
(i) For ground services reimbursed on a fee-for-service
basis provided on or after October 1, 2019, a governmental ambulance
provider may be eligible to receive an enhanced supplemental payment
equal to the difference between the average commercial rate and the
sum of its reimbursed costs for the cost reporting period.
(I) HHSC will determine the paid Medicaid claims fees
and enhanced supplemental payment amounts for all procedure codes
specified in the application for each eligible publicly owned fee-for-service
ground emergency ambulance service provider.
(II) HHSC will calculate an overall average commercial
rate for the ambulance service providers based on the cost and payment
data provided from each eligible ambulance provider.
(III) HHSC will apply the overall average commercial
rate to an ambulance provider's total Medicaid utilization to determine
the ambulance provider's total commercial reimbursement.
(IV) HHSC will subtract the ambulance provider's total
Medicaid reimbursement from the ambulance provider's total commercial
reimbursement calculated for each of the eligible services.
(V) HHSC will calculate each ambulance provider's maximum
payment limit by summing each of the differences calculated in subclause
(IV) of this clause for each of the provider's eligible services.
(VI) HHSC will re-determine the average commercial
rate at least annually.
(VII) The enhanced supplemental payment is contingent
upon the governmental ambulance provider's data submitted with each
cost report. HHSC will determine payment amounts on a quarterly basis,
with a reimbursement of up to 100 percent for each ambulance provider's
average commercial rate.
(ii) If CMS disallows federal financial participation
related to a provider's receipt or use of enhanced supplemental payments
under this section, HHSC will recoup from the provider an amount equal
to the disallowance. If HHSC identifies an overpayment to a provider
related to the receipt or use of enhanced supplemental payments under
this section, HHSC will recoup from the provider an amount equal to
the overpayment.
(d) General information. In addition to the requirements
of this section, cost reporting guidelines are governed by: §355.101
of this chapter; §355.102 of this chapter (relating to General
Principles of Allowable and Unallowable Costs); §355.103 of this
chapter (relating to Specifications for Allowable and Unallowable
Costs); §355.104 of this chapter (relating to Revenues); §355.105
of this chapter (relating to General Reporting and Documentation Requirements,
Methods, and Procedures); §355.106 of this chapter (relating
to Basic Objectives and Criteria for Audit and Desk Review of Cost
Reports); §355.107 of this chapter (relating to Notification
of Exclusions and Adjustments); §355.108 of this chapter (relating
to Determination of Inflation Indices); §355.109 of this chapter
(relating to Adjusting Reimbursement When New Legislation, Regulations,
or Economic Factors Affect Costs); and §355.110 of this chapter
(relating to Informal Reviews and Formal Appeals). If conflicts arise
between this section and other sections governing cost reporting,
the provisions of this section prevail.
|
| Source Note: The provisions of this §355.8600 adopted to be effective September 1, 2003, 28 TexReg 7335; amended to be effective September 1, 2007, 32 TexReg 5353; amended to be effective November 27, 2011, 36 TexReg 7860; amended to be effective October 27, 2013, 38 TexReg 7299; amended to be effective January 10, 2019, 44 TexReg 230; amended to be effective April 27, 2021, 46 TexReg 2723 |
