| (a) The information in §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), and §355.105
of this chapter (relating to General Reporting and Documentation Requirements,
Methods, and Procedures) applies to Intermediate Care Facilities for
Persons with Mental Retardation, Home and Community-based Services,
Service Coordination/Targeted Case Management, Rehabilitative Services,
School Health and Related Services, and Texas Home Living programs
cost reports pertaining to providers' fiscal years ending in calendar
year 2004 and subsequent years. For all other programs these sections
apply to cost reports pertaining to the providers' fiscal years ending
in calendar year 1997 and subsequent years.
(b) The following terms, when used in this subchapter,
have the following meanings:
(1) DADS--The Texas Department of Aging and Disability
Services, its successor agency, or designee.
(2) DARS--The Texas Department of Assistive and Rehabilitative
Services, its successor agency, or designee.
(3) DSHS--The Texas Department of State Health Services,
its successor agency, or designee.
(4) HHSC--The Health and Human Services Commission,
its successor agency, or designee.
(5) Line item--A specific informational, statistical,
revenue, or expense data element in a cost report.
(6) TEA--The Texas Education Agency, its successor
agency, or designee.
(c) HHSC reimburses providers for contracted client
services through reimbursement amounts determined as described in
this chapter and in reimbursement methodologies for each program.
Statewide, uniform reimbursements and reimbursement ceilings are approved
by HHSC. Where reimbursements are contractor-specific, HHSC approves
the reimbursement parameter dollar amounts, e.g., ceilings, floors,
or program reimbursement formula limits. In approving reimbursement
amounts HHSC takes into consideration staff recommendations based
on the application of formulas and procedures described in this chapter
and in reimbursement methodologies for each program. However, HHSC
may adjust staff recommendations when HHSC deems such adjustments
are warranted by particular circumstances likely to affect achievement
of program objectives, including economic conditions and budgetary
considerations. Methodology rules are developed and recommended for
approval to HHSC. HHSC has oversight authority with respect to the
state's reimbursement methodology and cost determination rules.
(1) Reimbursement amounts will be determined coincident
with the state's biennium.
(2) Objective of cost determination process. The objective
of the cost determination process is to define direct and indirect
costs that are allowable and, therefore, may be considered for use
in the overall reimbursement determination process. The cost determination
process seeks to collect accurate financial and other statistical
data that constitutes the foundation upon which reimbursements are
determined.
(A) Cost-reporting. In order to ensure adequate financial
and statistical information upon which to base reimbursement, HHSC
requires that each contracted provider submit a periodic cost report
or supplemental report. It is the responsibility of the provider to
submit accurate and complete information, in accordance with all pertinent
HHSC cost reporting rules and cost report instructions, on the cost
report and any supplemental reports required by HHSC.
(B) Pro forma costing. When historical costs are unavailable,
such as in the case of a new program, reimbursement may be based on
a pro forma approach. This approach involves using historical costs
of delivering similar services, where appropriate data are available,
and estimating the basic types and costs of products and services
necessary to deliver services meeting federal and state requirements.
(3) Relationship between cost determination and reimbursement
determination processes. The cost determination process seeks to evaluate
individual cost items of providers to determine their allowability
and to determine whether individual cost reports are of reasonable
accuracy for potential use in reimbursement determination. The reimbursement
determination process takes the evaluation of allowable costs one
step further by comparing allowable costs across providers to identify
those levels of cost, either for individual cost items or groups of
cost items, which must be incurred by efficient and economic providers
of services meeting all state and federal standards. Thus, all costs
allowed in the cost determination process may not necessarily be used
in the reimbursement determination process. The basic objective of
the reimbursement methodologies employed by HHSC is to facilitate
and balance the broader objectives of the programs administered by
the agencies by:
(A) promoting reasonable access for eligible clients
to services that meet federal and state quality standards via contracting
with an adequate number of qualified providers; and
(B) expending taxpayer dollars in a reasonable and
prudent manner such that eligible clients are served at the lowest
cost to taxpayers consistent with state and federal laws, standards
and regulations, and with program objectives.
(d) Providers contracted with Managed Care Organizations.
To ensure that HHSC has adequate financial and statistical information
upon which to base reimbursement, each provider that has contracted
with a Managed Care Organization (MCO) to provide Long-Term Services
and Supports to State of Texas Medicaid clients must submit to HHSC
periodic cost reports and supplemental reports as required by this
subchapter. This required cost reporting must follow rules and requirements
as set forth in this subchapter. An MCO will be responsible for enforcing
the vendor hold and administrative penalties relating to cost reporting
violations as described in this subchapter, and §355.403 of this
chapter (relating to Vendor Hold), if HHSC notifies the MCO that a
violation has occurred.
|
| Source Note: The provisions of this §355.101 adopted to be effective September 1, 1996, 21 TexReg 7866; duplicated effective September 1, 1997, as published in the Texas Register October 17, 1997, 22 TexReg 10311; amended to be effective September 27, 1999, 24 TexReg 7397; amended to be effective September 1, 2000, 25 TexReg 7629; amended to be effective December 1, 2001, 26 TexReg 9565; amended to be effective August 31, 2004, 29 TexReg 8093; amended to be effective September 1, 2011, 36 TexReg 4795; amended to be effective May 8, 2012, 37 TexReg 3394; amended to be effective September 1, 2014, 39 TexReg 6406 |
