| (1) HHSC retains one percent of the federal share of
the total certified Medicaid allowable cost as an administrative fee
to be used for Health and Human Services administrative activities,
including compliance monitoring, technical assistance, and to establish
and maintain an audit reserve fund.
(2) If an LEA's interim payments exceed 99 percent
of the LEA's federal portion of the total certified Medicaid allowable
costs, HHSC recoups the overpayment using one of these two methods:
(A) HHSC offsets all future claims payments from the
LEA until the amount is recovered; or
(B) the LEA returns an amount equal to the amount owed.
(3) If 99 percent of the LEA's federal portion of the
total certified Medicaid allowable costs exceeds the interim Medicaid
payments, HHSC pays the difference to the LEA.
(4) HHSC issues a notice of settlement within 24 months
of the end of the reporting period.
(i) Informal review. An LEA who disputes an action
or determination under this chapter may request an informal review
under §355.110 of this title (relating to Informal Reviews and
Formal Appeals). This section provides clarification unique to the
SHARS program.
(1) HHSC Provider Finance must receive a written request
for an informal review in a manner prescribed by HHSC no later than
30 calendar days from the date on the written notification of the
adjustments. 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 written request will be accepted.
HHSC Provider Finance will extend this deadline if it receives a written
request for the extension in a manner prescribed by HHSC, no later
than 30 calendar days from the date of the written notice of adjustments.
The extension gives the requester a total of 45 calendar days from
the date of the written notice of adjustment to file a request for
an informal review. If the 45th calendar day is a weekend day, national
holiday, or state holiday, then the 45th day is considered the next
business day following the 45th calendar day. A request for an informal
review or extension that is not received by the stated deadline will
not be accepted.
(2) An LEA must, with its request for an informal review,
submit a concise statement of the specific actions or determinations
it disputes, its recommended resolution, and any supporting documentation
the LEA deems relevant to the dispute. It is the responsibility of
the LEA to render all pertinent information at the time of its request
for an informal review. Disputed actions or determinations that are
not explicitly stated in the request will not be considered by HHSC,
and failure of HHSC to act on implied items of dispute will not be
considered grounds for a formal appeal. A request for an informal
review that does not meet the requirements of this paragraph will
not be accepted.
(3) The written request for the informal review or
extension must be signed by an individual legally responsible for
the conduct of the LEA or a legal representative for the LEA. The
administrator or director of the LEA is not authorized to sign the
request unless the administrator or director has this legal authority.
A request for an informal review that is not signed by an individual
legally responsible for the conduct of the LEA or a legal representative
for the LEA will not be accepted.
(j) General information. In addition to the requirements
of this section, the cost reporting guidelines will be governed by
the information in: §355.101 of this chapter (relating to Introduction); §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; and §355.110 of this chapter. If there is a
conflict between an applicable section of Chapter 355, Subchapter
A of this title (related to Cost Determination Process) and the provisions
of this section, the provisions of this section will prevail.
(k) In addition to the requirements of this section,
the LEA must comply with all provisions outlined in §354.1341
of this title and §354.1342 of this title.
(l) Administrative contract violations. HHSC may take
the following actions against an LEA for administrative contract violations.
(1) Time study. For failure to participate in or meet
all time study requirements, HHSC will recoup all interim payments
made during the cost reporting period and will not allow the LEA to
submit a cost report for that reporting period.
(2) Interim claims. The LEA is ineligible to submit
a cost report if they fail to submit interim claims in the manner
and format prescribed by HHSC, or its designee, including the requirements
in subsection (e)(2) of this section. If a service category, student,
employee, or related cost is claimed in the cost report without having
been appropriately claimed in compliance with program requirements,
that specific service category, student, employee, or related cost
will be disallowed from the cost report.
(3) Cost reports.
(A) For failure to submit a cost report by the due
date, HHSC will recoup all interim payments made during the cost reporting
period.
(B) HHSC will remove all unallowable costs and reserve
the right to update a certified cost report if inaccurate information
is identified or reported by the LEA.
(4) Other administrative contract violations. For all
other administrative contract violations, HHSC will recoup all interim
payments made during the cost reporting period.
(5) Appeals. An LEA may request a hearing to appeal
HHSC's action concerning an administrative contract violation. Formal
appeals are conducted in accordance with the provisions of Chapter
357, Subchapter I of this title (relating to Hearings under the Administrative
Procedure Act). If there is a conflict between an applicable section
of Chapter 357 of this title (relating to Hearings) and the provisions
of this chapter, the provisions of this chapter will prevail.
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| Source Note: The provisions of this §355.8443 adopted to be effective October 1, 2011, 36 TexReg 4656; amended to be effective May 17, 2015, 40 TexReg 2527; amended to be effective November 27, 2017, 42 TexReg 6615; amended to be effective October 9, 2022, 47 TexReg 6425 |
