Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 352.
QUALITY ASSURANCE FEE
1 TAC §352.10
The Texas Health and Human Services Commission (HHSC) proposes
new §352.10, concerning the Quality Assurance Fee for the Home and Community-Based
Services and Community Living Assistance and Support Services Waiver Programs,
in its Quality Assurance Fee chapter. Elsewhere in this issue of the
Background and Justification
HHSC proposes a new rule for the quality assurance fee program under Chapter
252, Subchapter H, Quality Assurance Fee, of the Health and Safety Code, by
providing for a quality assurance fee for services provided under a home and
community-based services waiver or a community living assistance and support
services waiver.
Section-by-Section Summary
HHSC proposes to add a new §352.10, Quality Assurance Fee for the
Home and Community-based Services and Community Living Assistance and Support
Services.
Proposed §352.10(a), Definitions, establishes terms and definitions
for this rule.
Proposed §352.10(b), Determination of the Fee, establishes that the
Health and Human Services Commission (HHSC) shall establish the quality assurance
fee amount.
Proposed §352.10(c), Total monthly fee, establishes for each provider
the total monthly fee amount, including the formula used to obtain the monthly
fee.
Proposed §352.10(d), Monthly reporting, establishes that all contracted
providers must file a report with the Department of Aging and Disability Services
(DADS) in a format prescribed by DADS that includes the accrued units of service
delivered to Medicaid clients for the reporting period and the net operating
revenues received for private clients during the reporting period.
Proposed §352.10(e), Payment of the fee, sets forth that the provider
must include with the monthly report submitted from subsection (c) of this
section, payment of the total fee amount calculated from the monthly report.
In addition, DADS must receive the payment of the total fee amount no later
than 30 calendar days following the end of each month.
Proposed §352.10(f), Audit of monthly reports, sets forth that HHSC
will conduct desk reviews and field audits of monthly reports in order to
ensure that all information reported in the reports conforms to all applicable
rules and instructions. HHSC may require supporting documentation other than
that contained in the monthly report to substantiate reported information.
The provider must allow access to the records of the provider or any parent
company
Proposed §352.10(g), Penalties, establishes that a penalty assessed
under this subsection is in an amount equal to one-half the amount of the
estimated outstanding quality assurance fee amount, not to exceed $20,000.
Proposed §352.10(h), Continued responsibility, establishes that assessment
of a penalty under this section does not relieve a provider from providing
services to clients and complying with licensure and certification requirements.
Proposed §352.10(i), Vendor Hold, establishes that a provider that
fails to pay the quality assurance fee by the due date will be placed on vendor
hold until all overdue fee amounts are paid to DADS.
Proposed §352.10(j), Informal Review and Formal Appeal, establishes
that a provider that disagrees with an adjustment made to their monthly report
may request an informal review in accordance with §355.110(d) and (e)
of this part (related to Informal Reviews and Formal Appeals).
This proposed rule changes the title of Chapter 352 from "Quality Assurance
Fee for Long-Term Care Facilities" to "Quality Assurance Fee" to reflect the
inclusion of the identified waiver services in the quality assurance fee program.
Fiscal Note
Tom Suehs, Deputy Executive Commissioner for Financial Services, has determined
that during the first 5-year period the proposed rule is in effect, there
will be a fiscal impact to state government. There is a cost to implementing
this legislation associated with reimbursing providers through the Medicaid
rate. In addition, there are ongoing administrative cost of developing an
automated system to bill and track Quality Assurance Fee (QAF) collections.
These costs will be offset by a gain in general revenue (dedicated funds)
generated from the fee paid by providers. State fiscal year 2006 cost: $24,634,195
general revenue and $62,432,795 total funds. State fiscal years 2007-2010
annual cost: $26,165,790 general revenue and $67,878,435 total funds. Revenue
gain to general revenue-dedicated: $26,090,098 for state fiscal years 2006-2010.
The proposed rule will result in any fiscal implications for local health
and human services agencies. Local governments will not incur additional costs.
Small and Micro Business Impact Analysis
Mr. Suehs has also determined that there will be no effect on small businesses
or micro businesses to comply with the amendment, as they will not be required
to alter their business practices as a result of the rule. There are will
be no anticipated economic costs to persons who are required to comply with
the proposed rule. There is no anticipated negative impact on local employment.
Public Benefit
Ed White, Director for Rate Setting and Forecasting, has determined that
for each year of the first five years the sections are in effect, the public
benefit anticipated as a result of enforcing the rule is that the quality
assurance fee that is collected for services under a home and community-based
services waiver or a community living assistance and support services waiver
will be used as matching funds to draw down Medicaid federal funding for rate
increases for these programs. There is no anticipated economic cost to persons
who are required to comply with the proposed sections. There is no anticipated
effect on local employment in geographic areas affected by these sections.
Regulatory Analysis
HHSC has determined that this proposal is not a "major environmental rule"
as defined by §2001.0225 of the Texas Government Code. "Major environmental
rule" is defined to mean a rule, the specific intent of which is to protect
the environment or reduce risk to human health from environment exposure and
that may adversely affect, in a material way, the economy, a sector of the
economy, productivity, competition, jobs, the environment or the public health
and safety of a state or a sector of the state. This proposal is not specifically
intended to protect the environment or reduce risks to human health from environment
exposure.
Takings Impact Assessment
HHSC has determined that this proposal does not restrict or limit an owner's
right to his or her property that would otherwise exist in the absence of
government action and, therefore, does not constitute a taking under §2007.043
of the Government Code.
Under §2007.003(b) of the Government Code, HHSC has determined that
Chapter 2007 of the Government Code does not apply to this rule. The changes
this rule makes do not implicate a recognized interest in private real property.
Accordingly, HHSC is not required to complete a takings impact assessment
regarding this rule.
Public Comment
Written comments on the proposed amendments to the rules may be submitted
to Gilbert Estrada, Policy Analyst, at the Texas Health and Human Services
Commission, Medicaid/CHIP Division, Policy Development Support, P.O. Box 85200-5200,
MC - H600, Austin, Texas 78708-5200, by fax to (512) 491-1953, or by e-mail
to gilbert.estrada@hhsc.state.tx.us within 30 days of publication of this
proposal in the
Texas Register
.
Public Hearing
A public hearing is scheduled for August 30, 2005, at 10:00 a.m. The hearing
will be held in the Public Hearing Room (Lone Star), Braker Building, Health
and Human Services Commission, 11209 Metric Boulevard, Building H, Austin,
Texas. Persons requiring further information, special assistance, or accommodations
should contact Carmen Capetillo at 512-491-1104.
Statutory Authority
The new rule is proposed under the Texas Government Code, §531.033,
which provides the Executive Commissioner of HHSC with broad rulemaking authority;
the 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 new rule affects the Human Resources Code, Chapter 32, and
the Texas Government Code, Chapter 531. No other statutes, articles, or codes
are affected by this proposal.
§352.10.Quality Assurance Fee for the Home and Community-based Services and Community Living Assistance and Support Services.
(a)
Definitions. The following definitions apply to this section.
(1)
Provider. A person or entity that contracts with the Department
of Aging and Disability Services (DADS) as a Home and Community-based Services
Program Provider, Community Living Assistance and Support Services-Direct
Services Agency Provider, or Community Living Assistance and Support Services-Case
Management Agency.
(2)
Gross receipts. Money received as compensation for services
under an intermediate care facilities for the mentally retarded waiver program
such as a home and community services waiver or a community living assistance
and support services waiver. The term does not include a charitable contribution,
revenues received for services or goods other than waivers, or any money received
from consumers or their families as reimbursement for services or goods not
normally covered by the waivers.
(3)
Net operating revenues. Gross receipts less any deducted
amounts for bad debts, charity care, and payer discounts.
(4)
Units of service. The units of service by rate type and
by level of need, where applicable, that were accrued for the reporting period.
Units of service that were delivered and not yet billed or paid to the provider
are to be included as units of service.
(b)
Determination of the fee. The Health and Human Services
Commission (HHSC) shall establish the quality assurance fee as a percentage
of net operating revenues such that the total of all fees collected does not
exceed six percent of the total annual net operating revenues received by
providers in the state under the programs identified in subsection (a)(1)
of this section. The quality assurance fee amount may be adjusted as necessary
for all providers to ensure that the fees collected do not exceed six percent
of the total annual net operating revenues received by providers in the state
under the programs identified in subsection (a)(1) of this section.
(c)
Total monthly fee amount. For each provider, the total
monthly fee amount is equal to the percentage determined in subsection (b)
of this section times the number of units of service delivered under the programs
identified in subsection (a)(1) of this section during the reporting period
times the payment rate in effect on the day the unit of service was delivered
plus the percentage determined in subsection (b) of this section times the
net operating revenues received for private clients during the reporting period.
(d)
Monthly reporting. All contracted providers must file a
report with DADS in a format prescribed by DADS and in accordance with instructions
provided by DADS that includes the accrued units of service delivered to clients
under the programs identified in subsection (a)(1) of this section for the
reporting period and the net operating revenues received for private clients
during the reporting period. A separate report must be completed for each
contract held by the provider. The report must be received by DADS no later
than 30 calendar days following the end of each month unless the 30th calendar
day is a weekend day, national holiday, or state holiday, then the first business
day following the 30th calendar day is the final day for the receipt of the
monthly report. Additional reports may be required as needed at the discretion
of HHSC.
(e)
Payment of the fee. The provider must include with the
monthly report submitted from subsection (d) of this section, payment of the
total fee amount calculated from the monthly report. The payment of the total
fee amount must be received by DADS no later than 30 calendar days following
the end of each month unless the 30th calendar day is a weekend day, national
holiday, or state holiday, then the first business day following the 30th
calendar day is the final day for the receipt of the monthly report. The quality
assurance fee must be paid by this deadline even if an appeal of the fee has
been filed with DADS, the provider's contract has terminated, or the contract
has been assigned. HHSC or DADS will not grant any exceptions from the payment
of the quality assurance fee, monthly reporting requirements related to the
fee, or the collection of other data necessary for the determination of the
fee amount to be paid.
(f)
Audit of monthly reports. HHSC conducts desk reviews and
field audits of monthly reports in order to ensure that all information reported
in the reports conforms to all applicable rules and instructions. HHSC may
require supporting documentation other than that contained in the monthly
report to substantiate reported information. The provider must allow access
to the records of provider or any parent company, affiliate, or related party
for the purposes of verifying the information contained in the monthly report.
For providers contracted with the State of Texas to provide Home and Community-based
Services or Community Living Assistance and Support Services, failure to submit
monthly reports by the due date, to allow auditors access to the records necessary
to verify the amounts reported on the monthly reports, or to complete the
monthly reports according to instructions and rules 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).
The provider will be notified of any revisions made to their monthly reports
and of any amounts owed or to be returned to the provider based on the revisions.
Amounts owed must be paid within 30 days of notification of the amount that
is owed.
(g)
Penalties. A penalty assessed under this subsection is
in an amount equal to one-half the amount of the estimated outstanding quality
assurance fee amount, not to exceed $20,000. DADS will assess a financial
penalty to be paid by the provider if any of the following occurs:
(1)
The provider fails to pay the total fee amount owed for
the month.
(2)
The provider files a false, erroneous or fraudulent monthly
report that either HHSC or DADS concludes resulted in the assessment of a
quality assurance fee that is less than the provider should have been assessed.
(3)
The provider fails to pay the amounts due from subsection
(f) of this section within 30 days of notification.
(4)
Penalties are in addition to owed quality assurance fees
and are non-refundable.
(h)
Continued responsibility. The assessment of a penalty under
this section does not relieve a provider from:
(1)
Providing services to clients in accordance with its obligations
under contract or the law;
(2)
Paying additional quality assurance fees that may be assessed
to the provider; or
(3)
Otherwise complying with licensure and certification requirements.
(i)
Vendor Hold. A provider that fails to pay the quality assurance
fee by the due date will be placed on vendor hold until all overdue fee amounts
are paid to DADS.
(j)
Informal review and formal appeal. A provider that disagrees
with an adjustment to their monthly report made in accordance with subsection
(f) of this section may request an informal review in accordance with §355.110(c)
of this title (relating to Informal Reviews and Formal Appeals) and an administrative
appeal in accordance with §355.110(d) and (e) of this title (relating
to Informal Reviews and Formal Appeals).
(k)
Sections §352.1 through §352.9 do not apply to
this section.
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 August 8, 2005.
TRD-200503292
Steve Aragón
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: September 18, 2005
For further information, please call: (512) 424-6900
Subchapter H. REIMBURSEMENT METHODOLOGY FOR 24-HOUR CHILD CARE FACILITIES
Chapter 355.
REIMBURSEMENT RATES