| (4) HHSC may require additional financial and other
statistical information, in the form of special surveys or reports,
to ensure the fiscal integrity of the program. Providers must submit
such additional information and/or special surveys or reports to HHSC
Provider Finance Department upon request by the date specified by
HHSC Provider Finance Department in its transmittal or cover letter
to the special survey, report, or request for additional information.
(d) Amended cost report due dates. HHSC accepts submittal
of provider-initiated or HHSC-requested amended cost reports as follows.
(1) Provider-initiated amended cost reports must be
received no later than the date in subparagraph (A) or (B) of this
paragraph, whichever occurs first. Amended cost reports received after
the required date have no effect on the reimbursement determination.
Amended cost report information that cannot be verified will not be
used in reimbursement determinations. Provider-initiated amended cost
reports must be received no later than the earlier of:
(A) 60 days after the original due date of the cost
report; or
(B) 30 days prior to the public hearing on proposed
reimbursement or reimbursement parameter amounts.
(2) HHSC-required amendments to the cost reports must
be received on or before the date specified by HHSC in its request
for the amended cost report. Failure to submit the requested amendment
to the cost report by the due date is considered a failure to complete
a cost report as specified in subsection (b)(4)(C) of this section.
(e) Field audit standards. HHSC performs cost report
field audits in a manner consistent with Government Auditing Standards
issued by the Comptroller General of the United States.
(f) Cost of out-of-state audits. As specified in §355.106
of this title (relating to Basic Objectives and Criteria for Audit
and Desk Review of Cost Reports), HHSC conducts desk reviews of all
cost reports not selected for field audit. HHSC also conducts field
audits of provider records and cost reports. Although the number of
field audits performed each year may vary, HHSC seeks to maximize
the number of field audited cost reports available for use in its
cost projections. Whenever possible, all the records necessary to
verify information submitted to HHSC on cost reports, including related
party transactions and other business activities engaged in by the
provider, must be accessible to HHSC audit staff within the state
of Texas within fifteen working days of field audit or desk review
notification. When records are not available to HHSC audit staff within
the state of Texas, the provider must pay the actual costs for HHSC
staff to travel and review the records out-of-state. HHSC must be
reimbursed for these costs within 60 days of the request for payment.
(1) For nursing facilities, failure to reimburse HHSC
for these costs within 60 days of the request for payment may result
in vendor hold as specified in §355.403 of this title.
(2) For SHARS, failure to reimburse HHSC for these
costs within 60 days of the request for payment constitutes an administrative
contract violation. In the case of an administrative contract violation,
procedural guidelines and informal reconsideration and/or appeal processes
are specified in §355.8443 of this title.
(3) For all other programs, failure to reimburse HHSC
for these costs within 60 days of the request for payment constitutes
an administrative contract violation. In the case of an administrative
contract violation, procedural guidelines and informal reconsideration
and/or appeal processes are specified in §355.111 of this title.
(g) Public hearings.
(1) Uniform reimbursements. For programs where reimbursements
are uniform by class of service and/or provider type, HHSC will hold
a public hearing on proposed reimbursements before HHSC approves reimbursements.
The purpose of the hearing is to give interested parties an opportunity
to comment on the proposed reimbursements. Notice of the hearing will
be provided to the public. The notice of the public hearing will identify
the name, address, and telephone number to contact for the materials
pertinent to the proposed reimbursements. At least ten calendar days
before the public hearing takes place, material pertinent to the proposed
statewide uniform reimbursements will be made available to the public.
This material will include the proposed reimbursements, the inflation
adjustments used to determine them, and the impact on reimbursements
of the major cost limits. This material will be furnished to anyone
who requests it. After the public hearing, if negative comments are
received, a summary of the comments made during the public hearing
will be presented to HHSC.
(A) Preliminary Rates. To ensure access to care and
prompt provider reimbursement, HHSC will establish preliminary reimbursement
rates prior to a public hearing for non-discretionary items or services,
including but not limited to, new Health Care Common Procedure Coding
System updates, federally mandated reimbursement rates (e.g., Indian
Health Services or Medical Transportation Program), or physician-administered
drugs or biological products.
(B) Duration of Preliminary Rates. Preliminary rates
will be in place until HHSC conducts a public hearing on proposed
reimbursement rates. Rate hearing procedures for preliminary rates
will follow guidelines as outlined in paragraph (1) of this subsection.
(2) Contractor-specific reimbursements. For programs
in which reimbursements are contractor-specific, HHSC will hold a
public hearing on the reimbursement determination parameter dollar
amounts (e.g., ceilings, floors, or program reimbursement formula
limits) before HHSC approves parameter dollar amounts. The purpose
of the hearing is to give interested parties an opportunity to comment
on the proposed reimbursement parameter dollar amounts. Notice of
the hearing will be provided to the public. The notice of the public
hearing will identify the name, address, and telephone number to contact
for the materials pertinent to the proposed reimbursement parameter
dollar amounts. At least ten calendar days before the public hearing
takes place, material pertinent to the proposed reimbursement parameter
dollar amounts will be made available to the public. This material
will include the proposed reimbursement parameter dollar amounts,
the inflation adjustments used to determine them, and the impact on
the reimbursement parameter dollar amounts of the major cost limits.
This material will be furnished to anyone who requests it. After the
public hearing, if negative comments are received, a summary of the
comments made during the public hearing will be presented to HHSC.
(h) Insufficient cost data. If an insufficient number
of accurate, full-year cost reports is submitted, as would occur with
a new program, or if there are insufficient available data, as would
occur in changes in program design, changes in the definition of units
of service or changes in regulations or program requirements, reimbursements
may be based on a pro-forma analysis by HHSC staff. A pro-forma analysis
is defined as an item-by-item, or classes-of-items, calculation of
the reasonable and necessary expenses for a provider to operate. The
analysis may involve assumptions about the salary of an administrator
or program director, staff salaries, employee benefits and payroll
taxes, building depreciation, mortgage interest, contracted client
care expenses, and other building or administration expenses. To determine
the cost per unit of service, HHSC adds all the pro-forma expenses
and divides the total by the estimated number of units of service
that a fully operational provider is likely to provide. The pro-forma
analysis is based on available information that is determined to be
sufficient, accurate, and reliable by HHSC, including valid cost report
data and survey data. The pro-forma analysis is conducted in a way
that ensures that the resultant reimbursements are sufficient to support
the requirements of the contracted program. When HHSC staff determine
that sufficient and reliable cost report data have become available,
the pro-forma reimbursement determination may be replaced with a process
based on cost reports.
(i) Limits on related-party compensation. HHSC may
place upper limits or caps on related-party compensation as follows:
(1) For related-party administrators and directors,
the upper limit for compensation is equal to the 90th percentile in
the array of all non-related-party annualized compensation as reported
by all contracted providers within a program. In addition, the hourly
compensation for related-party administrators and directors is limited
to the annualized upper limit for related-party administrators and
directors divided by 2,080.
(2) For related-party assistant administrators and
assistant directors, the upper limit for compensation is equal to
the 90th percentile in the array of all non-related party annualized
compensation as reported by all contracted providers within a program.
In addition, the hourly compensation for related-party assistant administrators
and assistant directors is limited to the annualized upper limit for
related-party assistant administrators and assistant directors divided
by 2,080.
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