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(xiii)Management fees paid to related parties must be documented as to the actual costs of the related party for materials, supplies, and services provided to the individual provider, and upon which the management fees were based. If the cost to the related party includes owner compensation or compensation to related parties, documentation guidelines for those costs are specified in clause (xi) of this subparagraph. Documentation must be maintained that indicates stated objectives, periodic assessment of those objectives, and evaluation of the progress toward those objectives. (xiv)For central office and/or home office costs, documentation must be maintained that indicates the organization of the business entity, including position, titles, functions, and compensation. For multi-state organizations, documentation must be maintained that clearly defines the relationship of costs associated with any level of management above the individual Texas contracted entity which are allocated to the individual Texas contracted entity. (xv)Documentation regarding depreciable assets includes, at a minimum, historical cost, date of purchase, depreciable basis, estimated useful life, accumulated depreciation, and the calculation of gains and losses upon disposal. (xvi)Providers must maintain documentation clearly itemizing their employee relations expenditures. For employee entertainment expenses, documentation must show the names of all persons participating, along with classification of the person attending, such as employee, nonemployee, owner, family of employee, client, or vendor. (xvii)Adequate documentation substantiating the offsetting of grants and contracts from federal, state, or local governments prior to reporting either the net expenses or net revenue must be maintained by the provider. As specified in §355.103(b)(15) of this title (relating to Specifications for Allowable and Unallowable Costs), such offsetting is required prior to reporting on the cost report. The provider must maintain written documentation as to the purpose for which the restricted revenue was received and the offsetting of the restricted revenue against the allowable and unallowable costs for which the restricted revenue was used. (xviii)During the course of an audit or an audit desk review, the provider must furnish any reasonable documentation requested by DHS auditors within ten working days of the request or a later date as specified by the auditors. If the provider does not present the requested material within the specified time, the audit or audit desk review is closed, and DHS automatically disallows the costs in question. (xix)Any expense which cannot be adequately documented or substantiated is disallowed. DHS is not responsible for the contracted provider's failure to adequately document and substantiate reported costs. (xx)Any cost report which is determined unauditable through a field audit or which cannot have its costs verified through a desk review will not be used in the reimbursement determination process. (3)Cost report and methodology certification. Providers must certify the accuracy of cost reports submitted to DHS in the format specified by DHS. Providers may be liable for civil and/or criminal penalties if the cost report is not completed according to DHS requirements or is determined to contain misrepresented or falsified information. Cost report preparers must certify that they received reimbursement methodology rules regarding allowable and unallowable costs, that they read the reimbursement methodology and cost report instructions, and that they understand that the cost report must be prepared in accordance with the methodology rules and cost report instructions. Not all persons who contributed to the completion of the cost report must sign the certification page. However, the certification page must be signed by a responsible party with direct knowledge of the preparation of the cost report. A person with supervisory authority over the preparation of the cost report who reviewed the completed cost report may sign a certification page in addition to the actual preparer. (4)Requirements for cost report completion. (A)A completed cost report must: (i)be completed according to the cost determination rules of this chapter, program-specific allowable and unallowable rules, cost report instructions, and policy clarifications; (ii)contain a signed, notarized, original certification page; (iii)be legible with entries in sufficiently dark print to be photocopied; (iv)contain all pages and schedules; (v)be submitted on the proper cost report form; (vi)be completed using the correct cost reporting period; and (vii)contain a copy of the state-issued cost report training certificate, beginning with the 1997 cost report. (B)Providers are required to report amounts on the appropriate line items of the cost report pursuant to guidelines established in the methodology rules, cost report instructions, and/or policy clarifications. Refer to program-specific reimbursement methodology rules, cost report instructions, and/or policy clarifications for guidelines used to determine placement of amounts on cost report line items. (i)For nursing facilities, placement on the cost report of an amount which was determined to be inaccurately placed may result in vendor hold as specified in §355.403 of this title (relating to Vendor Hold). (ii)For all other programs, placement on the cost report of an amount which was determined to be inaccurately placed 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 (relating to Administrative Contract Violations). (C)A completed cost report must be filed by the cost report due date. (i)For nursing facilities, failure to file a completed cost report by the cost report due date may result in vendor hold as specified in §355.403 of this title (relating to Vendor Hold). (ii)For all other programs, failure to file a completed cost report by the cost report due date 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 (relating to Administrative Contract Violations). (D)DHS may excuse providers from the requirement to submit a cost report. Exceptions are granted by DHS as described by the program-specific reimbursement methodology rules. Providers who are excused from cost report submission will receive written notice from DHS verifying that an exception has been granted. (5)Cost report year. Effective for reporting periods beginning on September 1, 2001 and thereafter, a provider's cost report year must coincide with the provider's fiscal year as used by the provider for reports to the Internal Revenue Service (IRS) or with the state of Texas' fiscal year, which begins September 1 and ends August 31. (A)Providers whose cost report year coincides with their IRS fiscal year are responsible for reporting to HHSC any change in their IRS fiscal year and subsequent cost report year by submitting written notification of the change to HHSC along with supportive IRS documentation. HHSC must be notified of the provider's change in IRS fiscal year no later than 30 days following the provider's receipt of approval of the change from the IRS. (B)Providers who chose to change their cost report year from their IRS fiscal year to the state fiscal year or from the state fiscal year to their IRS fiscal year must submit a written request to HHSC by August 1 of state fiscal year in question. (6)Failure to report allowable costs. DHS is not responsible for the contracted provider's failure to report allowable costs, however any omitted costs which are identified during the desk review or audit process will be included in the cost report or brought to the attention of the provider to correct by submitting an amended cost report. (c)Cost report due date. (1)Providers must submit cost reports to DHS no later than 90 days following the end of the provider entity's fiscal year or 90 days from the transmittal date of the cost report forms, whichever due date is later. (2)DHS may grant extensions of due dates for good cause. A good cause is defined as a circumstance which the provider could not reasonably be expected to control and for which adequate advance planning and organization would not have been of any assistance. Providers must submit requests for extensions in writing to DHS. Requests for extensions must be received by DHS prior to the cost report due date. DHS staff will respond in writing to requests within 15 days of receipt. (3)DHS 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 DHS upon request by the date specified by DHS in its transmittal or cover letter to the special survey, report, or request for additional information. (d)Amended cost report due dates. DHS accepts submittal of provider-initiated or DHS-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)for Medicaid programs, 30 days prior to the public hearing on proposed reimbursement or reimbursement parameter amounts; and for non-Medicaid programs 30 days prior to the administrative closing of the cost report database for reimbursement determination. (2)DHS-required amendments to the cost reports must be received on or before the date specified by the DHS 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. DHS 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), DHS conducts desk reviews of all cost reports not selected for field audit. DHS also conducts field audits of provider records and cost reports. Although the number of field audits performed each year may vary, DHS 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 DHS on cost reports, including related party transactions and other business activities engaged in by the provider, must be accessible to DHS audit staff within the state of Texas within fifteen working days of field audit or desk review notification. When records are not available to DHS audit staff within the state of Texas, the provider must pay the actual costs for DHS staff to travel and review the records out-of-state. DHS must be reimbursed for these costs within 60 days of the request for payment. (1)For nursing facilities, failure to reimburse DHS for these costs within 60 days of the request for payment may result in vendor hold as specified in §355.403 of this title (relating to Vendor Hold). (2)For all other programs, failure to reimburse DHS 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 (relating to Administrative Contract Violations). (g)Public hearings. (1)Uniform reimbursements. For Medicaid programs where reimbursements are uniform by class of service and/or provider type, DHS and the HHSC will hold a public hearing on proposed reimbursements before the 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 working days before the public hearing takes place, material pertinent to the proposed statewide uniform Medicaid 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 the HHSC. (2)Contractor-specific reimbursements. For Medicaid programs in which reimbursements are contractor-specific, DHS and the HHSC will hold a public hearing on the reimbursement determination parameter dollar amounts (e.g., ceilings, floors, or program reimbursement formula limits) before the 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 working 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 the 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 DHS 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, DHS 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 DHS, 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 DHS 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.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on November 9, 2001
TRD-200106934 Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Effective date: December 1, 2001
Proposal publication date: September 28, 2001
For further information, please call: (512) 438-3734
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