| (iv) Within sixty (60) days of receiving a workable
cost report, HHSC or its designee shall make a determination regarding
a new effective rate.
(C) HHSC also may adjust the effective rate of an RHC
on its own initiative if it is determined that a change in scope has
occurred and an adjustment to the effective rate is warranted based
on the audit of the cost report defined in subsection (l) of this
section. The new effective rate shall become effective the first day
of the month immediately following its determination and shall not
be applied retroactively.
(3) Final base rate Reconciliation.
(A) When HHSC determines a final base rate, interim
payments will be reconciled back to the beginning of the interim period.
(B) If the final base rate is greater than the interim
base rate, HHSC will compute and pay the RHC a settlement payment
that represents the difference in rates for the services provided
during the interim period.
(C) If the final base rate is less than the interim
base rate, HHSC will compute and recover from the RHC a recoupment
payment that represents the difference in rates for the services provided
during the interim period.
(i) Any request to adjust an effective rate must be
accompanied by documentation showing that the RHC has had a change
in scope. A change in scope of services provided by an RHC includes
the addition or deletion of a service or a change in the magnitude,
intensity, or character of services currently offered by an RHC or
one of the RHC's sites. A change in scope includes:
(1) an increase in service intensity attributable to
changes in the types of patients served, including but not limited
to, patients with HIV/AIDS, the homeless, the elderly, migrants, those
with other chronic diseases or special populations;
(2) any changes in services or provider mix provided
by an RHC or one of its sites;
(3) changes in operating costs that have occurred during
the fiscal year and which are attributable to capital expenditures,
including new service facilities or regulatory compliance;
(4) changes in operating costs attributable to changes
in technology or medical practices at the RHC;
(5) indirect medical education adjustment and a direct
graduate medical education payment that reflects the costs of providing
teaching services to interns and residents; or
(6) any changes in scope approved by the Health Resources
and Service Administration (HRSA).
(j) A complete and workable cost report includes the
following:
(1) for a hospital-based RHC, complete Form CMS-2552-10
and include the attached data:
(A) M-1 (analysis of provider-based RHC costs);
(B) M-2 (allocation of overhead to RHC services);
(C) M-3 (calculation of reimbursement settlement for
RHC services);
(D) M-5 (analysis of payments to hospital-based RHC
services rendered to program beneficiaries);
(E) S-8 (statistical data/information purposes);
(F) RHC net expenses for allocation of costs for services
rendered on or after January 1, 1998, reported on the hospital's worksheet
A, column 7 traced properly to the RHC's total facility costs on line
32, column 7 on M-1 worksheet; and
(G) hospital's overhead worksheet expenses allocated
to each of the hospital-based RHC cost centers on worksheet B, Part
I (column 27 minus column 0) traced properly to line 15, column 5
on M-2 worksheet for each hospital-based RHC.
(2) for a freestanding RHC, a complete and accurate
Form CMS-222-17.
(k) Once the final base rate for an RHC has been calculated,
the RHC will be paid its effective rate without the need to file a
cost report unless requested by HHSC. A cost report will be required
if the RHC is seeking to adjust its effective rate as an RHC or the
state may request, on a periodic basis, that an RHC file a cost report
for its most current fiscal year, within five (5) months of notification
by HHSC or its designee. HHSC or its designee may delay or withhold
vendor payment to a provider upon failure to submit a requested cost
report until a complete and workable cost report has been received
by HHSC or its designee.
(l) New hospital-based and new freestanding RHCs cost
report requirements, rate calculations, and cost settlements.
(1) Projected Cost Report.
(A) Cost reports containing reasonable costs anticipated
to be incurred during the RHC's initial fiscal year may be filed by
new RHCs within 90 days of enrollment.
(B) New hospital-based RHCs interim base rate.
(i) RHCs associated with a hospital with 50 beds or
less, the interim base rate will be set at eighty percent (80%) of
the anticipated reasonable cost.
(ii) RHCs associated with a hospital with more than
50 beds, the interim base rate will be the lesser of the anticipated
reasonable costs or the Medicare maximum payment rate (federal ceiling).
(C) New freestanding RHCs interim base rate will be
set at the lesser of the anticipated reasonable costs or the Medicare
maximum payment rate (federal ceiling).
(2) All RHCs opting not to file a projected cost report
will have its interim base rate set at seventy-five percent (75%)
of the federal ceiling.
(3) Cost settlement.
(A) The cost settlement must be completed within six
(6) months of receipt of the first 12-month cost report.
(B) The rate established by the cost settlement process
shall be the final base rate. When HHSC determines a final base rate,
interim payments will be reconciled back to the beginning of the interim
period.
(C) If the final base rate is greater than the interim
base rate, HHSC will compute and pay the RHC a settlement payment
that represents the difference in rates for the services provided
during the interim period.
(D) If the final base rate is less than the interim
base rate, HHSC will compute and recover from the RHC a recoupment
payment that represents the difference in rates for the services provided
during the interim period.
(E) Each RHC must file a cost report with HHSC or its
designee within five (5) months of the end of the RHC's initial fiscal
year.
(F) If a provider fails to submit a cost report, HHSC
or its designee may delay or withhold vendor payment to the provider
until a complete and workable cost report has been received by HHSC
or its designee.
(4) A new Freestanding RHC location established by
an existing Freestanding RHC participating in the Medicaid program
will receive the same effective rate as the RHC establishing the new
location.
(5) A Freestanding RHC establishing a new location
may request an adjustment to its effective rate as provided herein
if its costs have increased as a result of establishing a new location.
(m) A medical visit is a face-to-face or telemedicine
medical service encounter between an RHC patient and a physician,
physician assistant, advanced nurse practitioner, certified nurse-midwife,
visiting nurse, or clinical nurse practitioner. Encounters with more
than one health professional and multiple encounters with the same
health professional that take place on the same day and at a single
location constitute a single visit, except where one of the following
conditions exists:
(1) after the first encounter, the patient suffers
illness or injury requiring additional diagnosis or treatment; or
(2) the RHC patient has a medical visit and an "other"
health visit as defined in subsection (n) of this section.
(n) An "other" health visit includes, but is not limited
to, a face-to-face or telehealth service encounter between an RHC
patient and a clinical social worker.
|
| Source Note: The provisions of this §355.8101 adopted to be effective July 1, 1978, 3 TexReg 3507; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660; amended to be effective October 13, 2002, 27 TexReg 9310; amended to be effective September 12, 2004, 29 TexReg 8795; amended to be effective September 1, 2010, 35 TexReg 7044; amended to be effective April 12, 2022, 47 TexReg 1887 |
