1 TAC §355.781
The Texas Health and Human Services Commission (HHSC) proposes
an amendment to §355.781, concerning Rehabilitative Services Reimbursement
Methodology, in its Medicaid Reimbursement Rates chapter.
This rule is being amended to comply with the Health Insurance Portability
and Accountability Act (HIPAA) and to make the rule more consistent with other
HHSC Medicaid Rate Analysis Division rules. Section 355.781 explains the methodology
for rate setting and the requirements for cost reporting for the Texas Department
of Mental Health and Mental Retardation Medicaid rehabilitative services.
Tom Suehs, Deputy Commissioner for Financial Services, has determined that
during the first five years the amended rule is in effect there will be no
fiscal implications to state, federal or local governments as a result of
enforcing or administering this rule.
Steve Lorenzen, Director of Rate Analysis has determined that during the
first five years the proposed amendment is in effect, the public benefit anticipated
as a result of enforcing this rule is that HHSC reimbursement rules will be
in compliance with federal law. There is no anticipated impact on small businesses
and micro-businesses to comply with the amendment, as they will not be required
to alter their business practices as a result of the amendment. There are
no anticipated economic costs to persons required to comply with the proposed
rule, nor any impact on local employment.
HHSC has determined that this proposed rule does not restrict or limit
an owner's right to their property that would otherwise exist in the absence
of governmental action and therefore does not constitute a taking under §2007.043,
Government Code.
Written comments on the proposed rule may be submitted to Judy Myers, Rate
Analyst, Medicaid Rate Analysis, Texas Health and Human Services Commission,
1100 W. 49th, Austin, Texas 78756, within 30 days of publication of this proposal
in the
Texas Register
.
A public hearing is scheduled for July 7, 2003 from 9 a.m. to 10 a.m. The
hearing will be held in the Public Hearing Room, 12555 Riata Vista Circle,
Bldg. 3, Austin, Texas 78727.
The amendment is proposed under the Texas Government Code, §531.033,
which provides the Commissioner of HHSC with broad rule making authority;
Human Resources Code, §32.021 and the Texas Government Code, §531.021(a),
which provide HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas; and the Texas Government Code, §531.021(b),
which provides HHSC with the authority to propose and adopt rules governing
the determination of Medicaid reimbursements.
The proposed amendment implements the Human Resources Code, Chapter 32
and the Texas Government Code, Chapter 531.
§355.781.Rehabilitative Services Reimbursement Methodology.
(a)
General information.
(1)
The Texas Health and Human Services Commission (HHSC) will
reimburse qualified rehabilitative services providers for rehabilitative services
provided to Medicaid-eligible persons with mental illness.
(2)
The HHSC establishes the reimbursement
rate. The HHSC sets reimbursement rates that reflect cost-effective operations
and are within State appropriation constraints.
[
(2)
HHSC determines reimbursement
according to §§355.701- 355.709 of this subchapter, relating to
General Reimbursement Methodology for all Texas Department of Mental Health
and Mental Retardation Medical Assistance Programs. Rehabilitative services
providers are reimbursed a uniform, statewide, interim rate with a cost-related
year-end settle-up. The interim rate is determined prospectively and at least
annually. An interim rate is set for each service type by settle-up category.]
(b)
Definitions.
(1)
Interim rate--Rate paid to a rehabilitative services provider
prior to settle-up conducted in accordance with subsection (d)(4) of this
section.
(2)
Service type--Types of Medicaid reimbursable rehabilitative
services as specified in §419.453 of
Title 25
[
this title
] (relating to Definitions); §419.456 of
Title 25
[
this title
] (relating to Community Support Services); §419.457
of
Title 25
[
this title
] (relating to Day Programs for
Acute Needs); §419.458 of
Title 25
[
this title
]
(relating to Day Programs for Skills Training); §419.459 of
Title
25
[
this title
] (relating to Day Programs for Skills Maintenance);
and §419.460 of
Title 25
[
this title
] (relating
to Rehabilitative Treatment Plan Oversight):
(A)
Day programs for acute needs--adult;
(B)
Day programs for skills training--adult;
(C)
Day programs for skills maintenance--adult;
(D)
Day programs for acute needs--child;
(E)
Day programs for skills training--child;
(F)
Community support services by professional--individual;
(G)
Community support services by paraprofessional--individual;
(H)
Community support services by professional--group;
(I)
Community support services by paraprofessional--group;
and
(J)
Rehabilitative treatment plan oversight.
(3)
Unit of service--The amount of time an individual, eligible
for Medicaid rehabilitative services or non-Medicaid rehabilitative services
(or parent or guardian of the person of an eligible minor), is engaged in
face-to-face contact with a person described in §419.455(d) of
Title 25
[
this title
] (relating to Rehabilitative Services:
General Requirements) plus any time spent by such person traveling to and
from the off-site location of the eligible individual to provide the contact.
The units of service are as follows:
(A)
Individual and group community support services--
15 continuous minutes
[
up to 1/2 hour
];
(B)
Day programs--
45-60 continuous minutes
[
up to 1 hour
]; and
(C)
Rehabilitative treatment plan oversight--one contact
of 15 or more continuous minutes
.
(4)
Settle-up categories--The settle-up process utilizes the
following groupings of service types:
(A)
Category 1:
(i)
Day programs for acute needs--adult;
(ii)
Day programs for acute needs--child; and
(iii)
Day programs for skills maintenance--adult.
(B)
Category 2:
(i)
Day programs for skills training--adult;
(ii)
Day programs for skills training--child;
(iii)
Community support services by professional--group; and
(iv)
Community support services by paraprofessional--group;
(C)
Category 3:
(i)
Community support services by professional--individual;
and
(ii)
Community support services by paraprofessional--individual.
(D)
Category 4: Rehabilitative treatment plan oversight.
(c)
Reporting of Costs.
(1)
Cost reporting. Rehabilitative services providers must
submit information quarterly, unless otherwise specified, on a cost report
formatted according to
the
HHSC's specifications. Rehabilitative
services providers must complete the cost report according to
§§355.701-355.709
of this subchapter, (relating to General Reimbursement Methodology For All
Medical Assistance Programs).
[
the rules and specifications set
forth in this section.
]
(2)
Reporting period and due date. Rehabilitative services
providers must prepare the cost report to reflect rehabilitative services
provided during the designated cost report reporting period. The cost reports
must be submitted to
the
HHSC no later than 45 days following the
end of the designated reporting period unless otherwise specified by
the
HHSC.
(3)
Extension of the due date.
The
HHSC may grant
extensions of due dates for good cause. A good cause is one that the rehabilitative
services provider could not reasonably be expected to control. Rehabilitative
services providers must submit requests for extensions in writing [
to
]
. Requests for extensions must be received by
HHSC
prior to
[
before
] the cost report due date. HHSC will respond
to requests within
15 days
[
10 workdays
] of receipt.
(4)
Failure to file an acceptable cost report. If a rehabilitative
services provider fails to file a cost report according to all applicable
rules and instructions,
the
HHSC will notify TDMHMR to place the
rehabilitative services provider on hold until the rehabilitative services
provider submits an acceptable cost report.
(5)
Allocation method. If allocations of cost are necessary,
rehabilitative services providers must use and be able to document reasonable
methods of allocation. HHSC adjusts allocated costs if HHSC considers the
allocation method to be unreasonable. The rehabilitative services provider
must retain work papers supporting allocations for a period of three years
or until all audit exceptions are resolved (whichever is longer).
(6)
Cost report certification. Rehabilitative services providers
must certify the accuracy of cost reports submitted to HHSC in the format
specified by HHSC. Rehabilitative services providers may be liable for civil
and/or criminal penalties if they misrepresent or falsify information.
(7)
Cost data supplements. HHSC may require additional financial
and statistical information other than the information contained on the cost
report.
(8)
Allowable and unallowable costs.
Cost reports may only include costs that meet the requirements as specified
in §355.708 of this title (relating to Allowable and Unallowable Costs).
(9)
[
(8)
] Review of cost reports. HHSC
reviews each cost report to ensure that financial and statistical information
submitted conforms to all applicable rules and instructions. The review of
the cost report includes a desk audit. HHSC reviews all cost reports according
to the criteria specified in §355.703 of this title (relating to Basic
Objectives and Criteria for Review of Cost Reports). If a rehabilitative services
provider fails to complete the cost report according to instructions or rules,
HHSC returns the cost report to the rehabilitative services provider for proper
completion. HHSC may require information other than that contained in the
cost report to substantiate reported information.
(10)
[
(9)
] On-site audits. HHSC may
perform on-site audits on all rehabilitative services providers that participate
in the Medicaid program for rehabilitative services. HHSC determines the frequency
and nature of such audits but ensures that they are not less than that required
by federal regulations related to the administration of the program.
(11)
[
(10)
] Notification of exclusions
and adjustments. HHSC notifies rehabilitative services providers of exclusions
and adjustments to reported expenses made during desk reviews and on-site
audits of cost reports.
(12)
Reviews and administrative
hearings. Rehabilitative services providers may request an informal review
and, if necessary, an administrative hearing to dispute the action taken by
HHSC under §355.707 of this title (relating to Reviews and Administrative
Hearings).
(13)
[
(11)
] Access to records. Each
rehabilitative services provider must allow access to all records necessary
to verify cost report information submitted to HHSC. Such records include
those pertaining to related-party transactions and other business activities
engaged in by the rehabilitative services provider. If a rehabilitative services
provider does not allow inspection of pertinent records within 14 days following
written notice HHSC will notify TDMHMR to place the rehabilitative services
provider on vendor hold until access to the records is allowed. If the rehabilitative
services provider continues to deny access to records, TDMHMR may terminate
the rehabilitative services provider agreement with the rehabilitative services
provider.
(14)
[
(12)
] Record keeping requirements.
Rehabilitative services providers must maintain service delivery records and
eligibility determination for a period of five years or until any audit exceptions
are resolved (whichever is later). Rehabilitative services providers must
ensure that records are accurate and sufficiently detailed to support the
financial and statistical information contained in cost reports.
(15)
[
(13)
] Failure to maintain adequate
records. If a rehabilitative services provider fails to maintain adequate
records to support the financial and statistical information reported in cost
reports, HHSC allows 30 days for the rehabilitative services provider to bring
record keeping into compliance. If a rehabilitative services provider fails
to correct deficiencies within 30 days from the date of notification of the
deficiency, HHSC will notify TDMHMR to terminate the rehabilitative services
provider agreement with the rehabilitative services provider.
(d)
Reimbursement determination.
The HHSC determines reimbursement
according to §§355.701-355.709 of this subchapter, (relating to
General Reimbursement Methodology For All Medical Assistance Programs). Rehabilitative
services providers are reimbursed a uniform, statewide, interim rate with
a cost-related year-end settle-up. The
HHSC determines reimbursement
in the following manner:
(1)
Inclusion of certain reported expenses. Rehabilitative
services providers must ensure that all
allowable
[
requested
] costs are included in the cost report.
(2)
Data collection.
The
HHSC collects several different
kinds of data. These include the number of units of service that individuals
receive and cost data, including direct costs, programmatic indirect costs,
and general and administrative overhead costs. These costs include salaries,
benefits, and other costs. Other costs include nonsalary related costs such
as building and equipment maintenance, repair, depreciation, amortization,
and insurance expenses; employee travel and training expenses; utilities;
and material and supply expenses.
(3)
Interim rate methodology.
The interim rate is determined
prospectively and at least annually. An interim rate is set for each service
type by settle-up category.
[
HHSC projects and adjusts reported
costs from the historical reporting period to determine the interim rate for
the prospective reimbursement period. Cost projections adjust the allowed
historical costs based on significant changes in cost-related conditions anticipated
to occur between the historical cost period and the prospective reimbursement
period. Changes in cost-related conditions include, but are not limited to,
inflation or deflation in wage or price, changes in program utilization and
occupancy, modification of federal or state regulations and statutes, and
implementation of federal or state court orders and settlement agreements.
Costs are adjusted for the prospective reimbursement period by a general cost
inflation index as specified in §355.704 of this tile (relating to Determination
of Inflation Indices).
]
(A)
The HHSC projects and adjusts
reported costs from the historical reporting period to determine the interim
rate for the prospective reimbursement period. Cost projections adjust the
allowed historical costs based on significant changes in cost-related conditions
anticipated to occur between the historical cost period and the prospective
reimbursement period. Changes in cost-related conditions include, but are
not limited to, inflation or deflation in wage or price, changes in program
utilization and occupancy, modification of federal or state regulations and
statutes, and implementation of federal or state court orders and settlement
agreements. Costs are adjusted for the prospective reimbursement period by
a general cost inflation index as specified in §355.704 of this title
(relating to Determination of Inflation Indices).
(B)
[
(A) Reimbursement determination.
]
For each settle-up category, each rehabilitative services provider's projected
cost per unit of service is calculated. The mean rehabilitative services provider
cost per unit of service is calculated, and the statistical outliers (those
rehabilitative services providers whose unit costs exceed plus or minus (+/-)
two standard deviations of the mean rehabilitative services provider cost)
are removed. After removal of the statistical outliers, the mean cost per
unit of service is calculated. This mean cost per unit of service becomes
the recommended reimbursement per unit of service.
[
(B)
Reimbursement setting authority.
HHSC establishes the reimbursement rate. HHSC sets reimbursements that, in
its opinion, are within budgetary constraints, adequate to reimburse the cost
of operations for an economic and efficient rehabilitative services provider,
and justifiable given current economic conditions.]
[
(C)
Reviews of cost report disallowances.
A rehabilitative services provider may request notification of the exclusions
and adjustments to reported expenses made during either desk reviews or on-site
audits, according to §355.705 of this title (relating to Notification).
Rehabilitative services providers may request an informal review and, if necessary,
an administrative hearing to dispute the action taken by HHSC under §355.707
of this title (relating to Reviews and Administrative Hearings).]
[
(D)
Allowable and unallowable
costs. Cost reports may only include costs that meet the requirements as specified
in §355.708 of this title (relating to Allowable and Unallowable Costs).]
(4)
Settle-up process. At the end of each reimbursement period,
the
HHSC will compare the amount reimbursed at the interim rate for
each settle-up category and the rehabilitative services provider's costs for
each category, as submitted on its cost report in accordance with subsection
(c) of this section.
(A)
Rehabilitative
[
If a rehabilitative
]
service provider's
whose
costs are less than 95% of the amount
reimbursed at the interim rate, [
HHSC
] will
be required to
pay to TDMHMR 100% of the difference between its allowable costs
[
demand that payment be made to TDMHMR by the rehabilitative services provider
of the difference between its allowable costs
] and 95% of the amount
reimbursed at the interim rate for each settle-up category. TDMHMR will notify
the rehabilitative services provider of the amount due by certified mail
and the rehabilitative services provider will remit the repayment amount within
60 days of notification. TDMHMR will apply a vendor hold on Medicaid payments
to a rehabilitative services provider for not making the payment to TDMHMR
within 60 days of receiving notice
.
[
(i)
A rehabilitative services
provider may request an administrative hearing in accordance with 25 TAC Chapter
409, Subchapter B (relating to Adverse Actions) to contest the demand for
payment.]
[
(ii)
If the rehabilitative services
provider does not request an administrative hearing to contest the demand
for payment, the provider must pay TDMHMR the amount due within 30 days after
the demand for payment was received by the provider, as indicated by the certified
mail receipt. If TDMHMR has not received payment of the amount due within
this time period, TDMHMR may impose a vendor hold on or recoup Medicaid payments
due to the rehabilitative services provider.]
(B)
If a rehabilitative services provider's costs exceed the
amount reimbursed at the interim rate, TDMHMR will reimburse the rehabilitative
services provider the difference between its allowable costs and the reimbursement
at the interim rate up to 125% of the interim rate for each settle-up category.
TDMHMR will notify the rehabilitative services provider of the amount owed
to the provider via certified mail. TDMHMR will make payment within 30 days
of the date the notice was received, as indicated by the certified mail receipt.
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 June 9, 2003.
TRD-200303434
Steve Aragón
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: July 20, 2003
For further information, please call: (512) 424-6576