| (a) General requirements. The Texas Health and Human
Services Commission (HHSC) applies the general principles of cost
determination as specified in §355.101 of this title (relating
to Introduction). Providers are reimbursed for waiver services provided
to Medicaid-enrolled persons with related conditions. Additionally,
providers will be reimbursed a one-time administrative expense fee
for a pre-enrollment assessment of potential waiver participants.
The pre-enrollment assessment covers care planning for the participant.
(b) Reporting of cost.
(1) Providers must follow the cost reporting guidelines
as specified in §355.105 of this title (relating to General Reporting
and Documentation Requirements, Methods, and Procedures).
(2) Number of cost reports to be submitted. All legal
entities must submit a cost report unless the number of days between
the date the legal entity's first Texas Department of Aging and Disability
Services (DADS) client received services and the legal entity's fiscal
year end is 30 days or fewer.
(A) Contracted providers participating in the attendant
compensation rate enhancement.
(i) At the same level of enhancement. If all the contracts
under the legal entity participate in the enhancement at the same
level of enhancement, the contracted provider must submit one cost
report for the legal entity.
(ii) At different levels of enhancement. If all the
contracts under the legal entity participate in the enhancement but
they participate at more than one enhancement level, the contracted
provider must submit one cost report for each level of enhancement.
(B) Contracted providers not participating in the attendant
compensation rate enhancement. If all the contracts under the legal
entity do not participate in the enhancement, the contracted provider
must submit one cost report for the legal entity.
(C) Contractors participating and not participating
in attendant compensation rate enhancement.
(i) At the same level of enhancement. If some of the
contracts under the legal entity do not participate in the enhancement
and the rest of the contracts under the legal entity participate at
the same level of enhancement, the contracted provider must submit:
(I) one cost report for the contracts that do not participate;
and
(II) one cost report for the contracts that do participate.
(ii) At different levels of enhancement. If some of
the contracts under the legal entity do not participate in the enhancement
and the rest of the contracts under the legal entity participate in
the enhancement but they participate at more than one enhancement
level, the contracted provider must submit:
(I) one cost report for the contracts that do not participate;
and
(II) one cost report for each level of enhancement.
(3) Excused from submission of cost reports. If required
by HHSC, a contracted provider must submit a cost report unless the
provider meets one or more of the conditions in §355.105(b)(4)(D)
of this title.
(c) Waiver reimbursement determination methodology.
(1) Unit of service reimbursement or reimbursement
ceiling by unit of service. Reimbursement or reimbursement ceilings
for related-conditions waiver services, habilitation, nursing services
provided by a registered nurse (RN), nursing services provided by
a licensed vocational nurse (LVN), physical therapy, occupational
therapy, speech/language therapy, behavioral support, auditory integration
training/auditory enhancement training (audiology services), nutritional
services, employment assistance, supported employment, day activity
and health services, and in-home and out-of-home respite care services
will be determined on a fee-for-service basis. These services are
provided under §1915(c) of the Social Security Act Medicaid waiver
for persons with related conditions.
(2) Monthly reimbursement. The reimbursement for case
management waiver service will be determined as a monthly reimbursement.
This service is provided under the §1915(c) of the Social Security
Act Medicaid waiver for persons with related conditions.
(3) Reporting and verification of allowable cost.
(A) Providers are responsible for reporting only allowable
costs on the cost report, except where cost report instructions indicate
that other costs are to be reported in specific lines or sections.
Only allowable cost information is used to determine recommended reimbursements.
HHSC excludes from reimbursement determination any unallowable expenses
included in the cost report and makes the appropriate adjustments
to expenses and other information reported by providers; the purpose
is to ensure that the database reflects costs and other information
that are necessary for the provision of services and are consistent
with federal and state regulations.
(B) Individual cost reports may not be included in
the database used for reimbursement determination if:
(i) there is reasonable doubt as to the accuracy or
allowability of a significant part of the information reported; or
(ii) an auditor determines that reported costs are
not verifiable.
(4) Reimbursement determination. Recommended unit of
service reimbursements and reimbursement ceilings by unit of service
are determined in the following manner:
(A) Unit of service reimbursement for habilitation,
and cost per unit of service for nursing services provided by an RN,
nursing services provided by an LVN, physical therapy, occupational
therapy, speech/language therapy, behavioral support services, auditory
integration training/auditory enhancement training (audiology services),
nutritional services, employment assistance, supported employment,
and in-home and out-of-home respite care are determined in the following
manner:
(i) The total allowable cost for each contracted provider
cost report will be determined by analyzing the allowable historical
costs reported on the cost report and other pertinent cost survey
information.
(ii) The total allowable cost is reduced by the amount
of the administrative expense fee and requisition fee revenues accrued
for the reporting period.
(iii) Each provider's total allowable cost, excluding
depreciation and mortgage interest, is projected from the historical
cost reporting period to the prospective reimbursement period as described
in §355.108 of this title (relating to Determination of Inflation
Indices).
(iv) Payroll taxes and employee benefits are allocated
to each salary line item on the cost report on a pro rata basis based
on the portion of that salary line item to the amount of total salary
expense for the appropriate group of staff. Employee benefits will
be charged to a specific salary line item if the benefits are reported
separately. The allocated payroll taxes are Federal Insurance Contributions
Act (FICA) or social security, Medicare contributions, Workers' compensation
Insurance (WCI), the Federal Unemployment Tax Act (FUTA), and the
Texas Unemployment Compensation Act (TUCA).
(v) Allowable administrative and facility costs are
allocated or spread to each waiver service cost component on a pro
rata basis based on the portion of each waiver service's units of
service to the amount of total waiver units of service.
(vi) Each provider's projected total allowable cost
is divided by the number of units of service to determine the projected
cost per unit of service.
(vii) For nursing services provided by an RN, nursing
services provided by an LVN, physical therapy, occupational therapy,
speech/language therapy, in-home respite care, behavioral support
services, auditory integration training/auditory enhancement training
(audiology services), nutritional services, employment assistance,
and supported employment, the projected cost per unit of service,
for each provider is multiplied by 1.044. This adjusted allowable
cost per unit of service may be combined into an array with the allowable
cost per unit of service of similar services provided by other programs
in determining rates for these services in accordance with §355.502
of this title (relating to Reimbursement Methodology for Common Services
in Home and Community-Based Services Waivers).
(viii) For habilitation services two cost areas are
created:
(I) The attendant cost area includes salaries, wages,
benefits, and mileage reimbursement calculated as specified in §355.112
of this title (relating to Attendant Compensation Rate Enhancement).
(II) Another attendant cost area is created which includes
the other habilitation services costs not included in subclause (I)
of this clause as determined in clauses (i) - (v) of this subparagraph
to create an other attendant cost area. An allowable cost per unit
of service is calculated for the other habilitation cost area. The
allowable costs per unit of service for each contracted provider cost
report are arrayed and weighted by the number of units of service,
and the median cost per unit of service is calculated. The median
cost Cont'd... |
