| (a) Introduction. Reimbursement is available to a Local
Education Agency (LEA) for providing certain direct medical and transportation
services, known as SHARS, to a Medicaid-enrolled student with a disability
age 20 years of age or younger. SHARS services are described in and
must be prescribed in accordance with §354.1341 of this title
(relating to Benefits and Limitations).
(b) Definitions. The following words and terms, when
used in this section, have the following meanings, unless the context
clearly indicates otherwise.
(1) Cost report--An annual report documenting the LEA's
Medicaid-allowable costs for all SHARS delivered during the previous
federal fiscal year. The cost report is due on or before April 1 of
the year following the reporting period and must be certified in a
manner specified by the Texas Health and Human Services Commission
(HHSC). The primary purposes of the cost report are to:
(A) document the LEA's total Medicaid-allowable costs
for delivering SHARS, including direct costs and indirect costs, based
on federally mandated cost allocation methodologies; and
(B) reconcile interim payments to total Medicaid-allowable
costs based on approved cost allocation methodology procedures.
(2) Eligible student--A Medicaid-enrolled student with
a disability age 20 years of age or younger that receives a direct
medical or transportation service as prescribed by §354.1341
of this title.
(3) Interim claim--A claim for a direct medical or
transportation service paid at the interim rate that is provisional
in nature pending the completion of a cost reconciliation and cost
settlement for the cost reporting period.
(4) Local Education Agency (LEA)--A Texas independent
school district or public charter school.
(5) Time study--A statistically valid random sampling
method used to identify the percentage of time spent performing actual
direct medical services irrespective of payer and administrative cost.
(c) Parental Consent. Prior to submitting its annual
cost report, the LEA must meet the parental consent requirements in §354.1342
of this title (relating to Conditions for Participation) for each
student included in the numerator of the following ratios required
in the cost report.
(1) IEP ratio--A comparison of the total number of
students enrolled in Medicaid with individualized education programs
(IEPs) requiring direct medical services to the total number of students
with IEPs requiring direct medical services.
(2) One-way trip ratio--A comparison of the total one-way
trips for students enrolled in Medicaid with IEPs requiring specialized
transportation services, who received direct medical services the
same day, to the total one-way trips for all students with IEPs requiring
specialized transportation services.
(3) Section 504 Plan ratio--A comparison of the total
number of students enrolled in Medicaid with Section 504 Plans requiring
audiology services to the total number of students with Section 504
Plans requiring audiology services.
(d) Time study. The LEA must participate in the HHSC-administered
time study in the manner prescribed by HHSC.
(e) Reimbursement methodology. LEAs are reimbursed
for direct medical and transportation services provided under the
SHARS program on a cost basis.
(1) Interim rates. The interim rate is developed based
on a percentage of the average per-unit cost for each SHARS service
using actual cost data collected on cost reports and is subject to
change under §355.109 of this chapter (relating to Adjusting
Reimbursement When New Legislation, Regulations, or Economic Factors
Affect Costs). Interim rates are updated annually or as determined
by HHSC.
(2) Interim claims.
(A) LEAs must submit:
(i) at least one interim claim for each direct medical
service that an eligible student receives within the cost report period;
(ii) interim claims for all personal care services
that an eligible student receives within the cost report period; and
(iii) interim claims for all eligible specialized transportation
trips provided within the cost report period.
(B) Requirements for interim claims will be adjusted
as needed based on direction from the Centers for Medicare and Medicaid
Services.
(C) Interim claims must be valid and reimbursed to
meet the requirements in this paragraph.
(3) Interim payment. LEAs are reimbursed for SHARS
direct medical services and transportation services per unit of service
at the lesser of:
(A) the LEA's billed charges; or
(B) the interim rate.
(4) Final reimbursement. The LEA's final reimbursement
amount is arrived at by a cost reconciliation and cost settlement
process. As reported in the cost report, the LEA's total costs for
both direct medical and transportation services are adjusted using
the federally mandated allocation methodologies.
(A) Direct medical services costs. Salary and contract
costs must be reported in the manner prescribed by HHSC.
(i) Direct costs. From the annual cost report, HHSC
aggregates allowable costs for direct medical services, resulting
in total direct costs. Direct costs for direct medical services include
payroll costs and other costs that can be directly charged to direct
medical services provided by contractors and LEA staff (i.e., salaries,
benefits, and contract compensation). Direct medical services costs
do not include transportation personnel costs.
(ii) Indirect costs. Indirect costs are determined
by applying the LEA's specific unrestricted indirect cost rate to
its net direct costs. Texas LEAs use predetermined fixed rates for
indirect costs. The Texas Education Agency (TEA) has, in cooperation
with the United States Department of Education (USDE), developed an
indirect cost plan to be used by LEAs in Texas. As authorized in 34
CFR §75.561(b), TEA approves unrestricted indirect cost rates
for LEAs for the USDE, which is the cognizant agency for LEAs.
(iii) Net allowable cost. Direct and indirect costs
are added together and adjusted by the direct medical time study percentage,
the IEP ratio, and the 504 Plan ratio, resulting in a net Medicaid
allowable cost for direct medical services.
(B) Transportation services. Salary and contract costs
must be reported in the manner prescribed by HHSC.
(i) Direct costs. From the annual cost report, HHSC
aggregates allowable direct costs for transportation, resulting in
total direct costs. Direct costs for covered transportation services
include payroll costs and other costs that can be directly charged
to covered transportation services. Direct payroll costs include total
compensation (i.e., salaries, benefits, and contract compensation)
of bus drivers and mechanics. Other direct costs include costs directly
related to the delivery of covered transportation services, such as
professional and contracted services, contracted transportation costs,
gasoline and other fuels, other maintenance and repair costs, vehicle
insurance, interest, rentals, and vehicle depreciation.
(ii) Indirect costs. Indirect costs are determined
by applying the LEA's specific unrestricted indirect cost rate to
its net direct costs. Texas public LEAs use predetermined fixed rates
for indirect costs. TEA has, in cooperation with the USDE, developed
an indirect cost plan to be used by LEAs in Texas. As authorized in
34 CFR §75.561(b), TEA approves unrestricted indirect cost rates
for LEAs for the USDE, which is the cognizant agency for LEAs.
(iii) Net allowable cost. Net direct costs and indirect
costs are added together and adjusted by the one-way trip ratio, resulting
in a net Medicaid allowable cost for transportation services.
(f) Cost reporting requirements. HHSC excludes from
reimbursement determinations any unallowable expenses included in
the cost report and makes the appropriate adjustments to expenses
and other information reported by LEAs.
(1) Certification. Each LEA certifies through the cost
report process its total actual federal and non-federal costs and
expenditures.
(2) Reimbursement determinations and allowable costs.
LEAs are responsible for reporting only allowable costs on the cost
report, except where HHSC prescribes that other costs are to be reported
in specific lines or sections. Only allowable cost information is
used to determine recommended reimbursement. All costs relating to
Shared Service Arrangements and Co-operatives must be allocated to
each respective LEA.
(g) Cost reconciliation. The Medicaid-allowable costs
for direct medical and transportation services are added together
and adjusted by the federal Medicaid assistance percentage (FMAP)
to arrive at the federal share owed to the LEA. This amount is then
reconciled with interim payments already made to the LEA.
(h) Cost settlement. HHSC uses a cost settlement process
as follows.
(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.
Cont'd... |
