| recoupment will become permanent.
(3) Comparison of direct-service costs to total direct-service
revenue. HHSC will require providers to report all direct costs incurred
on an annual fiscal year basis. HHSC will compare the reported direct
service costs to the total direct service revenue.
(4) Calculation of direct-service revenues and fiscal
accountability repayment. Direct Service Revenues are calculated by
multiplying the number of units eligible for payment that have been
paid for services delivered during the reporting period times the
appropriate direct service portion of the rate for the service billed.
(A) Providers whose direct service costs are 90% or
more of the direct service revenues will not be subject to repayment
under this section.
(B) Providers whose direct service costs are less than
90% but greater than or equal to 85% of the direct service revenues
will be required to pay to DADS 50% of the difference between the
direct service costs and 90% of the direct service revenues.
(C) Providers whose direct service costs are less than
85% but greater than or equal to 80% of the direct service revenues
will be required to pay to DADS 100% of the difference between the
direct service costs and 85% of the direct service revenues plus 50%
of the difference between 85% and 90% of the direct service revenues.
(D) Providers whose direct service costs are less than
80% of the direct service revenues will be required to pay to DADS
the difference between the direct service costs and 95% of the direct
service revenues.
(E) Providers who do not submit a cost report as described
in paragraph (2)(B) or (C) of this subsection will be assumed to have
direct service costs equal to 65% of the direct services revenues
and will be required to pay to DADS the difference between 65% of
the direct services revenues and 95% of the direct service revenues,
subject to the provisions of paragraph (2)(B) or (C) of this subsection.
(5) Notification of recoupment. Providers will be notified,
by certified mail, within 90 days of the determination of their recoupment
amount by HHSC of the amount to be repaid to HHSC. If a subsequent
review by HHSC or audit results in adjustments to the cost report
as described in subsection (a) of this section that change the amount
to be repaid to HHSC, the provider will be notified in writing of
the adjustments and the adjusted amount to be repaid. Providers will
submit the repayment amount within 60 days of notification.
(6) Repayment. Repayment will be made by the following:
(A) the provider or legal entity submitting the report;
(B) any other legal entity responsible for the debts
or liabilities of the submitting entity; or
(C) the legal entity on behalf of which a report is
submitted.
(7) Providers required to repay revenues to DADS will
be jointly and severally liable for any repayment. DADS will apply
a vendor hold on Medicaid payments to a provider for not making the
payment to DADS within 60 days of receiving notice.
(8) Aggregation.
(A) Definitions. The following words and terms have
the following meanings when used in this paragraph.
(i) Aggregation--For an entity defined in clause (iii)
of this subparagraph that controls, as defined in clause (iv) of this
subparagraph, more than one HCS component code, the process of determining
compliance with the spending requirements detailed in paragraph (4)
of this subsection for all component codes controlled by the entity
in the aggregate rather than requiring each component code to meet
its spending requirement individually. For commonly owned corporations
defined in clause (ii) of this subparagraph, the process of determining
compliance with the spending requirements detailed in paragraph (4)
of this subsection for all component codes in the controlled small
group in the aggregate rather than requiring each component code to
meet its spending requirement individually. Corporations that do not
meet the definitions under clauses (ii) - (iii) of this subparagraph
are not eligible for aggregation.
(ii) Commonly owned corporations--two or more corporations
where five or fewer identical persons who are individuals, estates,
or trusts own greater than 50 percent of the total voting power in
each corporation.
(iii) Entity--a parent company, sole member, individual,
limited partnership, or group of limited partnerships controlled by
the same general partner.
(iv) Control--greater than 50% ownership by the entity.
(B) Component Codes Included in Aggregation. If an
entity controlling more than one HCS component code or commonly owned
corporations requests aggregation, compliance with the spending requirements
will be evaluated in the aggregate for all HCS component codes that
the entity or commonly owned corporations controlled at the end of
its fiscal year or at the effective date of the change of ownership
or termination of its last HCS contract.
(C) Aggregation Request. To exercise the aggregation
option, the entity or commonly owned corporations must submit an aggregation
request, in a manner prescribed by HHSC, at the time each cost report
is submitted. In limited partnerships in which the same single general
partner controls all the limited partnerships, that single general
partner must make this request. Other such aggregation requests will
be reviewed on a case-by-case basis.
(D) Frequency of Aggregation Requests. The entity or
commonly owned corporations must submit a separate request for aggregation
for each reporting period.
(E) Ownership Changes and Contract Terminations. HCS
contracts that change ownership or terminate effective after the end
of the applicable reporting period, but prior to the determination
of compliance with spending requirements as per paragraph (4) of this
subsection, are excluded from all aggregate spending calculations.
These contracts' compliance with spending requirements will be determined
on an individual basis and the costs and revenues will not be included
in the aggregate spending calculation.
|
| Source Note: The provisions of this §355.722 adopted to be effective March 25, 1997, 22 TexReg 2772; transferred effective September 1, 1997, as published in the Texas Register December 26, 1997, 22 TexReg 12748; amended to be effective April 5, 1998, 23 TexReg 3255; amended to be effective December 20, 1998, 23 TexReg 12654; amended to be effective March 1, 2001, 26 TexReg 1696; amended to be effective August 31, 2004, 29 TexReg 8116; amended to be effective September 1, 2007, 32 TexReg5340; amended to be effective June 25, 2008, 33 TexReg 4862; amended to be effective September 1, 2009, 34 TexReg 5658; amended to be effective September 1, 2010, 35 TexReg 5030; amended to be effective October 2, 2011, 36 TexReg 6260; amended to be effective March 1, 2018, 43 TexReg 339; amended to be effective February 22, 2024, 49 TexReg 858 |
