40 TAC §47.5902
The amendment is proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes the department to administer
public and medical assistance programs; and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The amendment implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§47.5902.Reimbursement Methodology for Primary Home Care and Family Care Services.
(a)
General requirements. For the completion and submittal
of cost reports pertaining to providers' fiscal years ending in calendar year
1997 and subsequent years, providers must apply the information in this section.
The
Texas Department of Human Services (DHS)
or its designee
applies the general principles of cost determination as specified in §20.101
of this title (relating to Introduction).
(b)
Cost reporting. Providers must follow the cost-reporting
guidelines as specified in §20.105 of this title (relating to General
Reporting and Documentation Requirements, Methods and Procedures).
(1)
All contracted providers must submit a cost report unless
the number of days between the date the first DHS client received services
and the provider's fiscal year end is 30 days or fewer. The provider may be
excused from submitting a cost report if circumstances beyond the control
of the provider make cost report completion impossible, such as the loss of
records due to natural disasters or removal of records from the provider's
custody by any governmental entity. Requests to be excused from submitting
a cost report must be received
at the address specified in the letter
mailed with the cost report
[
by DHS's Rate Analysis Department
] before the due date of the cost report.
(2)
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 reimbursement. DHS
or its designee
excludes from reimbursement determination 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 which are necessary
for the provision of services and are consistent with federal and state regulations.
(A) - (B)
(No change.)
(c)
Reimbursement determination.
Reimbursement is determined
[
DHS determines reimbursement
] in the following manner.
(1)
Cost determination by cost area.
Allowable costs are
combined
[
DHS combines reported allowable costs
] for Primary
Home Care and Family Care into four cost areas, after allocating payroll taxes
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 and
after applying employee benefits directly to the corresponding salary line
item.
(A) - (D)
(No change.)
(2)
Recommended reimbursement by cost area. For the cost areas
described in paragraph (1)(A) and (D) of this subsection, the following is
calculated:
(A)
Projected costs.
Each provider's total allowable costs
[
DHS projects allowable expenses
], excluding depreciation
and mortgage interest, per unit of service
are projected
from each
provider agency's reporting period to the next ensuing reimbursement period
,
[
. DHS determines reasonable and appropriate economic adjusters
] as described in §20.108 of this title (relating to Determination
of Inflation Indicies) to calculate the projected expenses.
Reimbursement
may be adjusted
[
DHS also adjusts reimbursement
] where new
legislation, regulations, or economic factors affect costs as specified in §20.109
of this title (relating to Adjusting Reimbursement When New Legislation, Regulations,
or Economic Factors Affect Costs).
(B)
(No change.)
(C)
Projected cost arrays.
All provider agencies' projected
allowable costs per unit of service are rank ordered from low to high, along
with
[
DHS rank orders from low to high all provider agencies' projected
allowable costs per unit of service and
] each provider
agency's
[
agencies'
] corresponding units of service for each cost
area.
(D)
(No change.)
(3)
Total recommended reimbursement.
(A)
For nonpriority clients.
The
[
DHS determines
the
] recommended reimbursement
is determined
by summing the
recommended reimbursement described in paragraph (2) of this subsection and
the cost area component from paragraph (1)(B) of this subsection.
(B)
For Priority 1 clients.
The
[
DHS determines
the
] recommended reimbursement
is determined
by summing the
recommended reimbursement described in paragraph (2) of this subsection and
the cost area component from paragraph (1)(C) of this subsection.
(4)
For 1929(b) clients participating in the
vendor fiscal intermediary payment option. The hourly payment rate for required
annual and other assessments performed by a registered nurse (RN) is the hourly
payment rate determined for RN services in the Community Based Alternatives
program.
(d)
[
(4)
] Reimbursement determination
authority. The reimbursement determination authority is specified in §20.101
of this title (relating to Introduction).
(e)
[
(5)
] Desk reviews and field audits
of cost reports.
Desk
[
DHS performs desk
] reviews or
field audits
are performed
on
cost reports for
all contracted
providers. The frequency and nature of the field audits are determined by
DHS to ensure the fiscal integrity of the program. Desk reviews and field
audits will be conducted in accordance with §20.106 of this title (relating
to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports),
and providers will be notified of the results of a desk review or an audit
in accordance with §20.107 of this title (relating to Notification of
Exclusions and Adjustments). Providers may request an informal review and,
if necessary, an administrative hearing to dispute an action taken [
by DHS
] under §20.110 of this title (relating to Informal Reviews
and Formal Appeals).
(f)
[
(d)
] Factors affecting allowable
costs. Providers must follow the guidelines in determining whether a cost
is allowable or unallowable as specified in §20.102 this title (relating
to General Principles of Allowable and Unallowable Costs) and §20.103
of this title (relating to Specifications for Allowable and Unallowable Costs).
(g)
[
(e)
] Reporting revenues. Revenues
must be reported on the cost report in accordance with §20.104 of this
title (relating to Revenues).
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on March 15, 2002.
TRD-200201619
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: April 28, 2002
For further information, please call: (512) 438-3734