Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355.
MEDICAID REIMBURSEMENT RATES
The Texas Health and Human Services Commission (HSSC) adopts new §355.112
and adopts amendments to §355.503, §355.505, §355.5902, and §355.6907.
Sections 355.5902 and 355.6907 are adopted without changes to the proposed
text published in the March 31, 2000, issue of the
Texas Register
(25 TexReg 2733) and will not be republished. New §355.112
and amendments to §355.503 and §355.505 are adopted with changes
to the proposed text and will be republished in this issue.
Justification for the new section and the amendments is to implement appropriations
rider 37 regarding community care programs passed by the 76th legislature.
The section establishes procedures for providers to obtain additional funds
for increased compensation to attendants in select community care programs
(Community Based Alternatives Waiver, Community Living Assistance and Support
Services, Primary Home Care, Day Activity and Health Services, and Deaf-Blind
Multiple Disabilities Waiver). Providers receiving the additional funds must
demonstrate compliance with spending the increased funds on attendant compensation.
If a participating provider's allowable attendant compensation times 1.07
is less than the revenue accrued, the difference will be recouped by the Texas
Department of Human Services (DHS). Providers who choose not to participate
will have their total direct care staff rate increase each year limited to
adjustments necessitated by increases in the minimum wage. The section modifies
the cost areas of these programs to separate the new attendant compensation
cost area from other cost areas. Changes to the Day Activity and Health Services,
Primary Home Care, and Residential Care programs are adopted to combine some
of the cost areas.
The sections will function by being a mechanism for increasing compensation
to attendants in certain community care programs.
DHS adopts similar policy for non-Medicaid funded services, codified at
40 TAC §§20.112, 46.7002, 47.5902, and 98.6907 in this issue of
the
Texas Register
.
The commission received comments on the proposal at a public hearing held
April 17, 2000. Comments were received from representatives of American Disabled
for Attendant Programs Today, the Texas Association for Home Care, the Adult
Day Care Association of Texas, the Institute for Disability Access, three
Day Activity and Health Services (DAHS) providers, and a Community Living
Assistance and Support Services provider. Summaries of the comments and the
responses follow.
General comments: Seven commenters were in support of increasing wages
to attendants and wanted to insure that increases in rates would be used to
increase wages for attendants.
Response: The purpose of these rules is to implement the DHS appropriations
rider 37 regarding community care passed by the 76th Legislature. This rider
directs the commission to incentivize increased attendant wages and benefits
to attendants in select community care programs. These rules support the increase
of wages to attendants.
General comment: One commenter questioned how the attendant compensation
rate enhancements will reach providers in the Star+Plus Pilot in Harris County.
Response: These rules only apply to providers contracting directly with
DHS and do not apply to providers contracting with HMOs in the Star+Plus Pilot
in Harris County.
Comment concerning §355.112(b): One commenter stated that, for the
purpose of defining attendants in the DAHS program, attendants be defined
as direct care staff with duties as attendants, driver/attendants, activity
directors and kitchen attendants.
Response: The rules would include attendants and drivers that perform attendant
functions at least 80% of their total time worked. The rider directed the
commission to incentivize attendant wages and benefits and not the wages and
benefits of other staff working for the provider. The Health and Human Services
Commission (HHSC) is adopting the subsection without change.
Comment concerning §355.112(c)(1): One commenter stated that we need
to make sure it is clear that "workers' compensation" also includes expenses
paid by the agency to or on behalf of the employee, related to on-the-job
injuries, since many employers do not participate in the workers' compensation
program and, therefore, have only actual expenses rather than paid premiums.
Response: Language at §355.112(c)(1) references §355.103(b)(1)
which identifies the allowable compensation for attendants, including workers'
compensation insurance. Language at §355.112(j) states that all Attendant
Compensation Reports must be completed in accordance with the provisions of §§355.102-355.105
which includes §355.103(b)(10) that further defines insurance, which
includes workers' compensation, as purchased commercial insurance or self-
insurance. Self-insurance costs are allowable on a claims-paid basis subject
to the limitations specified in §355.103(b)(10). HHSC is adopting the
paragraphs without change.
Comment concerning §355.112(f): One commenter suggested that the language
in this subsection be changed to specify that a Primary Home Care (Family
Care) contracted provider must specify on the enrollment contract amendment
its desire to participate in the priority one and/or non-priority component(s)
within each contract.
Response: Language has been added at §355.112(f) and (k) to specify
that a Primary Home Care provider (which includes Family Care) must specify
its desire to participate in the attendant compensation rate enhancement for
either the priority one, non-priority, or both components within each contract.
Comment concerning §355.112(f) and (g): One commenter stated that
vendor hold was not necessary for failure to submit the enrollment contract
amendment by the deadline. The commenter indicated that if the enrollment
contract amendment was not received by the deadline, the provider would not
be eligible to participate.
Response: Language has been amended in §355.112(f) and (g) to specify
that providers that fail to submit enrollment contract amendments by the end
of the enrollment period would be considered nonparticipants.
Comment concerning §355.112(h): One commenter requested that DHS keep
in mind when procedures are drafted for the six-month report and the annual
report that providers could not afford to further increase administrative
hours for preparing complicated or time-consuming reports.
Response: Rider 37 also directs HHSC to ensure that providers will comply
with the new wage rules. These reports are necessary to ensure that the funds
intended to enhance attendant wages and benefits are spent for that purpose.
These reports will capture only the information required to verify spending
on attendant compensation.
Comment concerning §355.112(h)(1) and (2), and (t): One commenter
stated that the provider should be allowed at least 60 days and preferably
90 days from the end of the rate year to submit the annual report to assure
the most accurate data. This would allow time for late time sheets to be processed,
30 days to process payroll, and 30 days to process the report.
Response: Language has been changed in §355.112(h)(1) and (2) to change
the due date of the Attendant Compensation Reports to 60 days after the end
of the reporting period.
Comment concerning §355.112(h)(1), (2) and (4): One commenter stated
that a full vendor hold was unnecessary for participating providers who fail
to submit a report by the due date. The commenter stated that only the differential
between the participating and nonparticipating reimbursement rates should
be held until an acceptable report is received (not processed) by DHS.
Response: Vendor hold is necessary to ensure compliance with the requirements
to submit Attendant Compensation Reports which verify the required spending
on attendant compensation. HHSC is adopting the paragraphs without change.
Comment concerning §355.112(i)(3): One commenter stated that the word
"accrued" was confusing and should be changed to the word "provided".
Response: The commission has modified §355.112(i) to eliminate from
the rule the specificity of the information required in the Attendant Compensation
Report. The data collected on these documents could change as data needs change.
The language in §355.112(j) specifies that the reports must be completed
in accordance with the provisions of §§355.102-355.105 which require
all information on the reports to be reported on the accrual basis of accounting,
which would capture the units of service accrued or provided during the reporting
period regardless of whether they have been submitted for billing or if payment
had been received.
Comment concerning §355.112(l)(3) and (s)(1): One commenter stated
that multiplying the median attendant component by 1.044 and then establishing
the spending threshold within 7% of that number does not provide sufficient
margin of error for the setting of the attendant component, and does not take
into account the ability of the provider to cover costs in other components
and to retain the 4.4% margin provided for in the current methodology.
Response: Language has been changed in §20.112(s)(1) to change the
spending threshold from 7% to 9% for the first rate year to allow for a phase-in
of the Attendant Compensation Rate Enhancement spending requirements.
Comment concerning §355.112(n): One commenter stated that having multiple
increments for each program will be unnecessarily complicated and that a single
minimum increment should be determined for each program. The commenter stated
that the provider should be asked if they wish to participate at that level
and, if not, they should be asked to indicate the minimum level at which they
wish to participate.
Response: By having multiple increments, each provider may select the level
which best suits their particular situation. Providers may reduce their level
of participation by notifying the commission in writing in accordance with §355.112(y).
HHSC is adopting the subsection without change.
Comment concerning §355.112(o): One commenter stated that the phrase
"Participating contracts desiring to provide attendant compensation above
the level included in subsection (l) ..." should be replaced with "Participating
contracts may request attendant compensation enhancements above the level
included in subsection (l) ...", because participating contracts are not necessarily
desiring to provide attendant compensation above the level included in subsection
(l) since this amount includes the 1.044 incentive factor which may be used
to cross-subsidize other components or other purposes.
Response: The phrase in this subsection describes the intent of the rules
that increased attendant compensation rate increments paid to contracted providers
are to be used to increase the wages and benefits of attendants. HHSC is adopting
the subsection without change.
Comment concerning §355.112(p)(2)(B): One commenter indicated that
the phrase "in a proportional manner" is not explicit enough and that the
granting of increments should be filled from the bottom up until the funds
are used. The commenter also questioned how DHS would grant enhancement options
a priority.
Response: The language at §355.112(p)(2)(B) has been revised to better
describe the granting of increments by each level, one level at a time from
the lowest level to the highest level, until funds intended for this purpose
have been distributed. As the rule states, DHS may determine priority distribution
based on attendant compensation needs.
Comment concerning §355.112(q): One commenter stated that DHS should
have time frames for notifying participating contracts since there is only
one month between the end of the open enrollment and the beginning of the
rate year.
Response: There is one month between the end of the open enrollment period
and the beginning of the rate period during which DHS will notify the contracted
provider of the outcome of the granting of enhancement levels, allowing sufficient
time for notification of enhancement levels. HHSC is adopting the subsection
without change.
Comment concerning §355.112(s): One commenter suggested that each
provider should be given the same increase in the unit rate and that this
additional revenue should be spent on increased wages and benefits for attendants
above the current level of attendant compensation spending of each provider.
Response: The use of the current level of attendant compensation spending
of each provider as the basis from which additional funds would be required
to be spent would create a lower attendant spending level requirement for
providers who historically have paid lower attendant wages and benefits. Likewise,
it would create a higher spending level requirement for providers who historically
have paid higher attendant wages and benefits. HHSC is adopting the subsection
without change.
Comment concerning §355.112(s)(2): One commenter questioned the meaning
of the phrase "accrued attendant compensation revenue" and stated that costs
and revenues should be consistent with the reporting period.
Response: By requiring that the revenue be accrued revenue as opposed to
cash-basis revenue ensures that revenues for the reporting period are matched
against the costs accrued for the reporting period as required for reporting
on the Attendant Compensation Reports. HHSC is adopting the paragraph without
change.
Comment concerning §355.112(u): One commenter stated that exclusion
of providers from participation if their full-year report and subsequent six-month
report indicates that they have not expended 90% of their attendant compensation
rate on attendant compensation spending is very punitive for first-time offenders.
Response: The rule allows the contracted provider the rate year to come
into compliance with the 90% spending requirement; and, for those contracted
providers not coming into compliance during the rate year, an additional six
months are allowed for the contracted provider to come into compliance before
they are excluded from participation. The intent of these rules is to increase
attendant wages and benefits and to ensure that increased rates intended for
this purpose are spent on attendant compensation. HHSC is adopting the subsection
without change.
In addition to the changes detailed above, the commission has made the
following changes.
The commission has modified §355.112(b) to add the reference to §355.105(b)(2)(B)(i)
which specifies the minimum criteria for a time study and to clarify that
failure to perform the time study for staff that are not full time attendants
performing attendant functions will result in the commission considering the
staff as not being attendants.
The commission has clarified in §355.112(b)(2) that in the PHC/FC,
CBA HCSS, CLASS and DBMD programs, staff other than attendants may provide
attendant services to prevent a break in service.
The commission has added in §355.112(s) the phrase "and other appropriate
data sources" to allow the commission to access data sources in addition to
the Attendant Compensation Report to verify amounts spent on attendant compensation.
The commission has clarified in §355.112(h)(1), (o), (s), (u), (v),
(w), (x), and (y) that a contract that terminates; undergoes a contract assignment;
or is excluded from participation is handled differently for purposes of participation;
Attendant Compensation Report submittal; requesting enhancements; spending
requirements; exclusion requirements; voluntarily withdrawing from participation;
and adjusting attendant compensation requirements depending upon whether the
contracted provider's participating contracts are participating as a group
or as individuals.
The commission has clarified in §355.112(f) and (k) that if a provider
serves both Residential Care (RC) and Community Based Alternatives (CBA) Assisted
Living/Residential Care (AL/RC)clients in the same facility, that their participation
includes both the RC and the CBA AL/RC.
The commission has modified §355.112(g) to make attendant compensation
rates effective on the first of the month following the receipt by the commission
of an acceptable enrollment contract amendment for new contracts.
The commission also made editorial changes to §355.112, §355.503,
and §355.505.
Subchapter A. COST DETERMINATION PROCESS
1 TAC §355.112
The new section is adopted under the Government Code, §531.033,
which authorizes the commissioner of the Health and Human Services Commission
to adopt rules necessary to carry out the commission's duties, and §531.021(b),
which establishes the commission as the agency responsible for adopting reasonable
rules governing the determination of fees, charges, and rates for medical
assistance payments under Chapter 32, Human Resources Code.
The new section implements the Government Code, §531.033 and §531.021(b).
§355.112.Attendant Compensation Rate Enhancement.
(a)
Eligible programs. Providers contracted in the Primary
Home Care, including Family Care (PHC/FC); Day Activity and Health Services
(DAHS); Residential Care (RC); Community Living Assistance and Support Services
(CLASS) - Direct Service Agency; Community Based Alternatives (CBA) - Home
and Community Support Services (HCSS); Deaf-Blind Multiple Disabilities Waiver
(DBMD); and CBA - Assisted Living/Residential Care (AL/RC) programs are eligible
to participate in the attendant compensation rate enhancement.
(b)
Definition of attendant. An attendant is the unlicensed
caregiver providing direct assistance to the clients with Activities of Daily
Living (ADL) and Instrumental Activities of Daily Living (IADL).
(1)
In the case of DAHS, RC, and AL/RC programs, the attendant
may perform some nonattendant functions. In such cases, the attendant must
perform attendant functions at least 80% of his or her total time worked.
Staff in these settings not providing attendant services at least 80% of their
total time worked are not considered attendants. Time studies must be performed
in accordance with §355.105(b)(2)(B)(i) for staff in the DAHS, RC, and
AL/RC programs that are not full-time attendants but perform attendant functions
to determine if a staff member meets this 80% requirement. Failure to perform
the time studies for these staff will result in the staff not being considered
to be attendants.
(2)
Attendants do not include the director, administrator,
assistant director, assistant administrator, clerical and secretarial staff,
professional staff, other administrative staff, licensed staff, attendant
supervisors, cooks and kitchen staff, maintenance and groundskeeping staff,
and laundry and housekeeping staff. In the case of PHC/FC, CLASS, CBA HCSS,
and DBMD staff other than attendants may deliver attendant services and be
considered an attendant if they must perform attendant services that cannot
be delivered by another attendant to prevent a break in service.
(3)
An attendant also includes a driver in the DAHS program.
(c)
Attendant compensation cost center. This cost center will
include employee compensation, contract labor costs, and personal vehicle
mileage reimbursement for attendants as defined in subsection (b) of this
section.
(1)
Attendant compensation is the allowable compensation for
attendants defined in §355.103(b)(1) of this title (relating to Compensation
of Employees) and required to be reported as either salaries and/or wages,
including payroll taxes and workers' compensation, or employee benefits. Benefits
required by §355.103(b)(1)(A)(iii) of this title (relating to Specifications
for Allowable and Unallowable Costs) to be reported as costs applicable to
specific cost report line items, except as noted in paragraph (3) of this
subsection, are not to be included in this cost center.
(2)
Contract labor refers to personnel for whom the contracted
provider is not responsible for the payment of payroll taxes, such as FICA,
Medicare, and federal and state unemployment insurance, and who perform tasks
routinely performed by employees where allowed by program rules. Allowable
contract labor costs are defined in §355.103(b)(2)(C) of this title (relating
to Specifications for Allowable and Unallowable Costs).
(3)
Mileage reimbursement paid to the attendant for the
use of his or her personal vehicle and which is not subject to payroll taxes
is considered compensation for this cost center.
(d)
Rate year. The rate year begins on the first day of September
and ends on the last day of August of the following year.
(e)
Open enrollment. Open enrollment begins on the first day
of July and ends on the last day of that same July preceding the rate year
for which payments are being determined.
(f)
Enrollment contract amendment. All contracted providers
must submit an enrollment contract amendment during the open enrollment period.
On the enrollment contract amendment the provider must specify for each contract
his desire to participate or his desire not to participate. The participating
provider must specify for each program if he wishes to have all participating
contracts be considered as a group or individually for purposes related to
the attendant compensation rate enhancement. For the PHC/FC program, the participating
provider must also specify if he wishes to have either priority 1, nonpriority,
or both priority 1 and nonpriority services participating in the attendant
compensation rate enhancement. If the PHC/FC provider selects to have their
contracts participating as a group, then the provider must select to have
either priority 1, nonpriority, or both priority 1 and nonpriority services
participate for the entire group of contracts. For providers delivering services
to both RC and CBA AL/RC clients in the same facility, participation includes
both the RC and CBA AL/RC programs. The provider also must submit with the
contract amendment all required documentation to DHS in a manner specified
by DHS. Any provider failing to submit an acceptable enrollment contract amendment
by the end of the open enrollment period will be a nonparticipating contract
for the entire rate year following the open enrollment period.
(g)
New contracts. For the purposes of this section, for each
rate year a new contract is defined as a contract delivering its first day
of service to a DHS client on or after the first day of the open enrollment
period, as defined in subsection (e) of this section, for that rate year.
Contracts that underwent a contract assignment are not considered new contracts.
New contractors must complete the enrollment contract amendment specified
in subsection (f) of this section within 30 days of notification by DHS. Any
provider failing to submit an acceptable enrollment contract amendment within
30 days of notification by DHS will be a nonparticipating contract for the
remainder of the rate year. New contracts will receive the attendant compensation
rate as specified in subsection (l) of this section until:
(1)
based on the enrollment contract amendment information
received, participating contracts will have their attendant compensation rate
adjusted effective on the first day of the month following receipt of an acceptable
enrollment contract amendment.
(2)
based on the enrollment contract amendment information
received, nonparticipating contracts will have their attendant compensation
rate adjusted as specified in subsection (m) of this section retroactive to
the first day of their contract. attendant compensation rate will be adjusted
effective on the sixty-first day of the contract with DHS.
(h)
Attendant Compensation Report submittal requirements. Attendant
Compensation Reports must be submitted by participating contracted providers
as follows.
(1)
Annual report. Participating contracted providers will
provide DHS, in a method specified by DHS, an annual Attendant Compensation
Report reflecting the activities of the provider while delivering contracted
services from the first day of the rate year through the last day of the rate
year. This report must be submitted for each participating contract if the
provider requested participation individually for each contract; or, if the
provider requested participation as a group, the report must be submitted
as a single aggregate report covering all participating contracts within one
program of the provider. The aggregate report must include excluded from participation,
new, and contract assignment contracts (for the legal entity accepting the
contract assignment), as defined in subparagraphs (A)-(E) of this paragraph,
which were part of the group for any portion of the rate year. A participating
contract which has been terminated in accordance with subsection (v) of this
section or that has undergone a contract assignment in accordance with subsection
(w)(3) of this section will be considered to have participated on an individual
basis for compliance with reporting requirements. This report will be used
as the basis for determining compliance with the spending requirements and
recoupment amounts as described in subsection (s) of this section. Contracted
providers failing to submit an acceptable annual Attendant Compensation Report
within 60 days of the end of the rate year will be placed on vendor hold until
such time as an acceptable report is received and processed by DHS. Contracted
providers participating for less than a full year must provide Attendant Compensation
Reports as follows.
(A)
A participating provider whose contract is terminated either
voluntarily or involuntarily before the end of the rate year must submit an
Attendant Compensation Report covering the period from the beginning of the
rate year to the date recognized by DHS as the contract termination date.
This report will be used as the basis for determining recoupment as described
in subsection (s) of this section.
(B)
In cases where a participating provider changes ownership
through a contract assignment from one legal entity to another legal entity,
the owner prior to the change of ownership must submit an Attendant Compensation
Report covering the period from the beginning of the rate year to the effective
date of the contract assignment as determined by DHS. The owner after the
change of ownership must submit an Attendant Compensation report within 60
days of the end of the rate year, covering the period from the effective date
of the contract assignment as determined by DHS to the end of the rate year.
This report will be used as the basis for determining recoupment as described
in subsection (s) of this section.
(C)
A participating provider who is excluded from participation
as per subsection (u) of this section must submit an Attendant Compensation
Report within 60 days from the date of notification of the exclusion, covering
the period from the beginning of the rate year to the date of exclusion as
determined by DHS. DHS will use this report as the basis for determining recoupment
as described in subsection (s) of this section.
(D)
A participating provider who voluntarily withdraws from
participation as per subsection (x) of this section must submit an Attendant
Compensation Report within 60 days from the date of withdrawal as determined
by DHS, covering the period from the beginning of the rate year through the
date of withdrawal as determined by DHS. DHS will use this report as the basis
for determining recoupment as described in subsection (s) of this section.
(E)
A participating provider who is a new contract as per subsection
(g) of this section must submit an Attendant Compensation Report within 60
days of the end of the rate year, covering the period from the sixty-first
day of the contract as determined by DHS through the end of the rate year.
(2)
Six-month report. Participating contracted providers
will provide DHS, in a method specified by DHS, a six-month Attendant Compensation
Report reflecting the activities of the provider while delivering contracted
services from the first day of the rate year through the last day of February
of the rate year. DHS will place on vendor hold contracted providers failing
to submit an acceptable six-month Attendant Compensation Report within 60
days of the last day of February of the rate year until DHS receives and processes
an acceptable report. The report must be submitted for each participating
contract if the provider requested participation individually for each contract;
or, if the provider requested participation as a group, the report must be
submitted as a single aggregate report covering all participating contracts
within one program of the provider. If the provider requested participation
as a group the report must be submitted as a single aggregate report covering
all participating contracts within one program of the provider. Participating
providers will use this six-month report to assist them in determining their
level of compliance with the spending requirements and to take any appropriate
action necessary to come into compliance with the spending requirements. The
provider is responsible for the management of attendant compensation expenditures
in compliance with the spending requirements stated in subsection (s) of this
section.
(3)
Other reports. DHS may require other reports from
all contracts as needed.
(4)
Vendor hold. DHS will place on hold the vendor payments
for any contractor who does not submit an Attendant Compensation Report completed
in accordance with all applicable rules and instructions by the due dates
described in this subsection. This vendor hold will remain in effect until
an acceptable Attendant Compensation Report is received by DHS.
(i)
Attendant Compensation Report contents. Each Attendant
Compensation Report will include any information required by DHS to implement
this attendant compensation rate enhancement.
(j)
Completion of compensation reports. All Attendant Compensation
Reports must be completed in accordance with the provisions of §§355.102-355.105
of this title (relating to General Principles of Allowable and Unallowable
Costs, Specifications for Allowable and Unallowable Costs, Revenues, and General
Reporting and Documentation Requirements, Methods, and Procedures) and may
be reviewed or audited in accordance with §355.106 of this title (relating
to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports).
(k)
Enrollment. Providers choosing to participate in the attendant
compensation rate enhancement must submit to DHS a signed enrollment contract
amendment as described in subsection (f) of this section. Participation is
determined separately for each program specified in subsection (a) of this
section, except for providers delivering services to both RC and CBA AL/RC
clients in the same facility, participation includes both the RC and CBA AL/RC
programs. For PHC/FC participation is also determined separately for priority
1 and nonpriority services. Participation will remain in effect, subject to
availability of funds, until the provider notifies DHS, in accordance with
subsection (x) of this section, that it no longer wishes to participate or
until DHS excludes the contract from participation for reasons outlined in
subsection (u) of this section. Contracts voluntarily withdrawing from participation
will have their participation end effective with the date of withdrawal as
determined by DHS. Contracts excluded from participation will have their participation
end effective on the date determined by DHS.
(l)
Determination of attendant compensation rate component
for participating contracts. For each of the programs identified in subsection
(a) of this section an attendant compensation rate component will be calculated
for participating contracts from subsection (k) of this section and for the
first 60 days of a new contract from subsection (g) of this section as follows.
(1)
Determine for each contract included in the cost report
data base used in the determination of rates in effect on September 1, 1999,
the attendant compensation cost center from subsection (c) of this section.
(2)
Adjust the cost center data from paragraph (1) of
this subsection, as specified in §355.108 of this title (relating to
Determination of Inflation Indices), to inflate the costs to the prospective
rate year.
(3)
For each contract included in the cost report data
base used in the determination of rates in effect on September 1, 1999, divide
the result from paragraph (2) of this subsection by the units of service and
multiply the result by 1.044 for all programs in subsection (a) of this section
except for RC and AL/RC which are multiplied by 1.07. The result is the attendant
compensation rate component for participating contracts and the first 60 days
of new contracts.
(4)
The cost base from paragraph (1) of this subsection
used in determining the attendant compensation rate component will not change
over time, except for adjustments for inflation from paragraph (2) of this
subsection. DHS may recommend adjustments to the rates in accordance with §355.109
of this title (relating to Adjusting Reimbursement When New Legislation, Regulations,
or Economic Factors Affect Costs).
(m)
Determination of attendant compensation rate component
for nonparticipating contracts. For each of the programs identified in subsection
(a) of this section DHS will calculate an attendant compensation rate component
will be calculated for nonparticipating contracts as follows.
(1)
Determine for each contract included in the cost report
data base used in determination of rates in effect on September 1, 1999, the
attendant compensation cost center from subsection (c) of this section.
(2)
Adjust the cost center data from paragraph (1) of
this subsection in order to account for inflation utilizing the inflation
factors used in the determination of the September 1, 1999 rates.
(3)
For each contract included in the cost report data
base used in determination of rates in effect on September 1, 1999, divide
the result from paragraph (2) of this subsection by the units of service and
multiply the result by 1.044 for all programs in subsection (a) of this section
except for RC and AL/RC which is multiplied by 1.07. The result is the attendant
compensation rate component for nonparticipating contracts.
(4)
The attendant compensation rate component will remain
constant over time, except for adjustments necessitated by increases in the
minimum wage. In such cases, adjustments to the nonparticipating rates are
limited to ensuring that these rates are adequate to cover mandated minimum
wage levels.
(n)
Determination of attendant compensation rate enhancements.
DHS will determine attendant compensation rate enhancement increments associated
with each enhanced attendant compensation level. The attendant compensation
rate enhancement increments will be determined by using data from sources
such as cost reports, surveys, and/or other relevant sources. The attendant
compensation rate enhancement increments will be determined by taking into
consideration quality of care, labor market conditions, economic factors,
and budget constraints. The attendant compensation rate enhancement increments
will be determined on a per-unit-of-service basis applicable to each program
or service.
(o)
Enhanced attendant compensation. Participating contracts
desiring to provide attendant compensation above the level included in subsection
(l) of this section may request attendant compensation increments from an
array of enhanced attendant compensation options and associated add-on payments
determined in subsection (n) of this section during open enrollment. Participating
providers who select to have all of their contracts participate in a program
as a group must request a single attendant compensation increment for the
entire group of contracts. PHC/FC providers participating as a group must
select a single attendant compensation increment for their entire group of
contracts for the priority 1 and/or nonpriority services they have selected
for participation.
(p)
Granting additional attendant compensation rate enhancement
increments. DHS divides all requests for attendant compensation rate enhancement
increments into two groups: pre-existing rate enhancement increments which
providers requested to carry over from the prior year and newly requested
rate enhancement increments. Newly requested rate enhancement increments may
be requested by providers who were nonparticipants in the prior year or by
providers who were participants during the prior year desiring to be granted
additional rate enhancement increments. Using the process described herein,
DHS first determines the distribution of carry-over rate enhancement increments.
If funds are available after the distribution of carry- over rate enhancement
increments, DHS determines the distribution of newly requested rate enhancement
increments as follows:
(1)
DHS determines projected units of service for contracts
requesting each enhancement increment and multiplies this number by the enhancement
rate add-on amount associated with that enhancement increment as determined
in subsection (n) of this section.
(2)
DHS compares the sum of the products from paragraph
(1) of this subsection to available funds.
(A)
If the product is less than or equal to available funds,
all requested enhancements are granted.
(B)
If the product is greater than available funds, enhancements
are granted beginning with the lowest level of enhancement and granting each
successive level of enhancement until requested enhancements are granted within
available funds. Based upon an examination of existing compensation levels
and compensation needs, DHS may grant certain enhancement options priority
for distribution.
(q)
Notification of granting of enhancements. Participating
contracts are notified, in a manner determined by DHS, as to the disposition
of their request for additional attendant compensation rate enhancement increments.
(r)
Total attendant compensation rate for participating contracts.
Each participating contract will receive an attendant compensation rate equal
to the attendant compensation rate component for participating contracts from
subsection (l) of this section, plus any additional attendant compensation
rate enhancement payments granted to the contract.
(s)
Spending requirements for participating contracts. DHS
will determine from the Attendant Compensation Report, as specified in subsection
(h) of this section and other appropriate data sources, the amount of attendant
compensation spending per unit of service delivered. The providers' compliance
with the spending requirement is determined based on the total attendant compensation
spending as reported on the Attendant Compensation Report for each participating
contract if the provider requested participation individually for each contract.
A participating contract that has been terminated in accordance with subsection
(v) of this section or that has undergone a contract assignment in accordance
with subsection (w)(3) of this section will be considered to have participated
on an individual basis for compliance with the spending requirement. If the
provider specified that he wished to have all participating contracts be considered
as a group for purposes related to the attendant compensation rate enhancement,
as specified in subsection (f) of this section, compliance with the spending
requirement is based on the total attendant compensation as reported on the
single aggregate attendant compensation report described in subsection (h)
of this section. Compliance with the spending requirement is determined separately
for each program specified in subsection (a) of this section. DHS will calculate
recoupment, if any, as follows.
(1)
For the rate year beginning September 1, 2000, the attendant
compensation spending per unit of service will be multiplied by 1.09 to determine
the adjusted attendant compensation per unit of service. For the rate year
beginning September 1, 2001, and thereafter, the attendant compensation spending
per unit of service will be multiplied by 1.07 to determine the adjusted attendant
compensation per unit of service.
(2)
The adjusted attendant compensation per unit of service
from paragraph (1) of this subsection will be subtracted from the accrued
attendant compensation revenue to determine the amount to be recouped by DHS.
If the adjusted attendant compensation per unit of service is greater than
or equal to the accrued attendant compensation revenue per unit of service,
there is no recoupment.
(3)
The amount paid for attendant compensation per unit
of service after adjustments for recoupment must not be less than the amount
determined in subsection (m) of this section.
(t)
Notification of recoupment. Providers will be notified
in a manner specified by DHS within 90 days of the due date of their annual
Attendant Compensation Report as described in subsection (h)(1) of this section
or within 90 days of the date the report is submitted, whichever is later,
of the amount to be repaid to DHS. If a subsequent review or audit results
in audit adjustments to the annual Attendant Compensation Report that changes
the amount to be repaid to DHS, the provider will be notified in writing of
the adjustments and the adjusted amount to be repaid to DHS. DHS will recoup
any amount owed from a provider's vendor payment(s) following the date of
the notification letter.
(u)
Exclusion from participation. If the attendant compensation
report described in subsection (h)(1) of this section indicates that the participating
provider did not spend 90% of the accrued total attendant compensation rate
described in subsection (r) of this section on attendant compensation spending
as determined from subsection (s) of this section, DHS will notify the provider
of the noncompliance. If the subsequent six-month compensation report from
subsection (h)(2) of this section indicates that the provider has not spent
90% of the attendant compensation revenue on attendant compensation spending,
the contract will be excluded from participation in the attendant rate enhancement
effective immediately upon notice of failure to meet the spending requirement.
The contract will be excluded from participation in the attendant compensation
rate enhancement and will remain a nonparticipant for the remainder of the
rate year plus an additional rate year. Providers whose contracts are participating
as a group must meet the requirements of this subsection as a group or all
the contracts of the group will be excluded.
(v)
Contract terminations. For terminating participants DHS
will place a vendor hold on the payments of the contracted provider until
DHS receives an acceptable Attendant Compensation Report, as specified in
subsection (h)(1)(A) of this section, and funds identified for recoupment
from subsection (s) of this section are repaid to DHS. DHS will recoup any
amount owed from the provider's vendor payments that are being held. In cases
where funds identified for recoupment cannot be repaid by the terminating
provider's last vendor payment, the responsible entity from subsection (cc)
of this section will be jointly and severally liable for any additional payment
due to DHS. Failure to repay the amount due or submit an acceptable payment
plan within 60 days of notification will result in placement of a vendor hold
on all DHS contracts controlled by the responsible entity and will bar the
responsible entity from enacting new contracts with DHS until repayment is
made in full.
(w)
Contract assignments. The following applies to contract
assignments.
(1)
Contracts participating under the prior legal entity will
continue participation under the legal entity accepting the contract assignment.
When the provider or legal entity accepting the contract assignment has their
contracts participating as individuals, participation in the attendant compensation
rate enhancement confers to the provider or legal entity accepting the contract
assignment. When the provider or legal entity accepting the contract assignment
has their contracts participating as a group, the contract will participate
with the group of the legal entity accepting the contract assignment for purposes
related to the attendant compensation rate enhancement.
(2)
When the contract assignment is a change only in the
organizational structure or name of the legal entity, the provider or legal
entity accepting the contract assignment is responsible for the reporting
requirements in subsection (h) of this section and for any recoupment amount
owed to DHS for the entire rate year identified, even if part of the rate
year was under the responsibility of the previous legal entity.
(3)
When the contract assignment is an ownership change
from one legal entity to a different legal entity, DHS will place a vendor
hold on the payments of the existing contracted provider until DHS receives
an acceptable Attendant Compensation Report specified in subsection (h)(1)(B)
of this section and until funds identified for recoupment from subsection
(s) of this section are repaid to DHS. DHS will recoup any amount owed from
the provider's vendor payments that are being held. In cases where funds identified
for recoupment cannot be repaid by the existing contracted provider's vendor
payments that are being held, the responsible entity from subsection (cc)
of this section will be jointly and severally liable for any additional payment
due to DHS. Failure to repay the amount due or submit an acceptable payment
plan within 60 days of notification will result in placement of a vendor hold
on all DHS contracts controlled by the responsible entity and will bar the
responsible entity from enacting new contracts with DHS until repayment is
made in full.
(x)
Voluntary withdrawal. Participating contracts wishing to
withdraw from the attendant compensation rate enhancement must notify DHS
in writing by certified mail. Contracts voluntarily withdrawing must remain
nonparticipants for the remainder of the rate year and are excluded from participation
the following rate year. Providers whose contracts are participating as a
group must request withdrawal of all the contracts in the group.
(y)
Adjusting attendant compensation requirements. Providers
that determine that they will not be able to meet their attendant compensation
requirements may request a reduction to their attendant compensation requirements
and associated enhancement payment. These requests will be effective the first
of the month following 30 days from the receipt of the request. Providers
whose contracts are participating as a group must request the same reduction
for all of the contracts in the group.
(z)
All other rate components. All other rate components will
continue to be calculated as specified in the program-specific reimbursement
methodology and will be uniform for all providers.
(aa)
Failure to document spending. Undocumented attendant compensation
expenses will be disallowed and will not be used in the determination of the
attendant compensation spending per unit of service in subsection (s) of this
section.
(bb)
Appeals. Subject matter of informal reviews and formal
appeals is limited as per §355.110 of this title (relating to Informal
Reviews and Formal Appeals).
(cc)
Responsible entities. The contracted provider, owner,
or legal entity which received the attendant compensation rate enhancement
is responsible for the repayment of the recoupment amount.
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 June 5, 2000.
TRD-200003958
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Effective date: June 25, 2000
Proposal publication date: March 31, 2000
For further information, please call: (512) 438-3734
1 TAC §355.503, §355.505
The amendments are adopted under the Government Code, §531.033,
which authorizes the commissioner of the Health and Human Services Commission
to adopt rules necessary to carry out the commission's duties, and §531.021(b),
which establishes the commission as the agency responsible for adopting reasonable
rules governing the determination of fees, charges, and rates for medical
assistance payments under Chapter 32, Human Resources Code.
The amendments implement the Government Code, §531.033 and §531.021(b).
§355.503.Reimbursement Methodology for the Community-based Alternatives Waiver Program--a 1915(c) Medicaid Home and Community-based Waiver for Aged and Disabled Adults Who Meet Criteria for Alternatives to Nursing Facility Care.
(a)
General requirements. Cost reports pertaining to providers'
fiscal year ending in calendar year 1997 and subsequent years will be governed
by the information in this section. The Texas Department of Human Services
(DHS) applies the general principles of cost determination as specified in §355.101
of this title (relating to Introduction).
(b)
General. DHS will reimburse qualified Texas Medicaid contracted
providers for waiver services provided to individuals who meet the criteria
for alternatives to nursing facility care. Additionally, DHS will reimburse
qualified Texas Medicaid contracted providers for a pre-enrollment assessment
of potential waiver participants. The pre- enrollment assessment covers care
planning for the participant and is reimbursed by a one-time administrative
expense fee which is not included in the waiver services but will be paid
from Medicaid administrative funds.
(c)
Other sources of cost information. If DHS has determined
that there is not sufficient reliable cost report data from which to set waiver
services, reimbursements and reimbursement ceilings will be developed by using
data from surveys; cost report data from other similar programs, consultation
with other service providers and/or professionals experienced in delivering
contracted services; and other sources.
(d)
Waiver reimbursement determination. Recommended reimbursements
are determined in the following manner.
(1)
Unit of service reimbursement. Reimbursement for personal
assistance services, nursing, physical therapy, occupational therapy, speech
pathology, and in-home respite care services will be determined on a fee-for-service
basis in the following manner.
(A)
Total allowable costs for each provider will be determined
by analyzing the allowable historical costs reported on the cost report.
(B)
Total allowable costs are reduced by the amount of the
pre-enrollment expense fee, requisition fee, and reassessment fee revenues
accrued for the reporting period.
(C)
Each provider's total reported allowable costs, excluding
depreciation and mortgage interest, are projected from the historical cost-reporting
period to the prospective reimbursement period as described in §355.108
of this title (relating to Determination of Inflation Indices). The prospective
reimbursement period is the period of time that the reimbursement is expected
to be in effect.
(D)
Payroll taxes and employee benefits are allocated 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 for the appropriate
group of staff. Employee benefits will be charged to a specific salary line
item if the benefits are reported separately. The allocated payroll taxes
are Federal Insurance Contributions Act (FICA) or Social Security, Medicare
Contributions, Workers' Compensation Insurance (WCI), the Federal Unemployment
Tax Act (FUTA), and the Texas Unemployment Compensation Act (TUCA).
(E)
Allowable administrative and facility costs are allocated
or spread to each waiver service cost component on a pro rata basis based
on the portion of each waiver services' service units reported to the amount
of total waiver service units reported.
(F)
For nursing, physical therapy, occupational therapy, speech
pathology, and in-home respite care services, an allowable cost per unit of
service is calculated for each contracted provider for each service. The allowable
costs per unit of service for each contracted provider are arrayed. The units
of service for each contracted provider in the array are summed until the
median unit of service is reached. The corresponding expense to the median
unit of service is determined and is multiplied by 1.044. The allowable costs
per unit of service may be combined into an array with the allowable cost
per unit of service of similar services provided by other programs in determining
the median cost per unit of service.
(G)
For personal assistance services two cost areas are created:
(i)
The attendant cost area includes salaries, wages, benefits,
and mileage reimbursement calculated as specified in §355.112 of this
title (relating to Attendant Compensation Rate Enhancement).
(ii)
Another attendant cost area is created which includes
the other personal attendant services costs not included in subparagraph (G)(i)
of this paragraph as determined in subparagraphs (A)-(E) of this paragraph.
An allowable cost per unit of service is determined for each contracted provider
for the other attendant cost area. The allowable costs per unit of service
for each contracted provider are arrayed. The units of service for each contracted
provider in the array are summed until the median unit of service is reached.
The corresponding expense to the median unit of service is determined and
is multiplied by 1.044.
(iii)
The attendant cost area and the other attendant cost
area are summed to determine the personal assistance services cost per unit
of service.
(2)
Per day reimbursement.
(A)
The reimbursement for Adult Foster Care (AFC), Assisted
Living/Residential Care (AL/RC) and out-of-home respite care provided in AFC
and AL/RC settings, will be determined as a per day reimbursement using a
method based on modeled projected expenses which are developed by using data
from surveys; cost report data from other similar programs, consultation with
other service providers and/or professionals experienced in delivering contracted
services; and other sources. The room and board payments for AFC and AL/RC
Services are not covered in these reimbursements and will be paid to providers
from the client's Supplemental Security Income, less a personal needs allowance.
(B)
The reimbursement for out-of-home respite care provided
in a Nursing Facility will be based on the amount determined for the Texas
Index of Level of Effort (TILE) for the CBA participant.
(3)
Monthly reimbursement ceiling. The reimbursement
for Emergency Response, will be determined as monthly reimbursement ceiling
based on the ceiling amount determined for the Emergency Response Services
Program.
(4)
Requisition fees. Requisition fees are reimbursements
paid to the CBA home and community support services contracted providers for
their efforts in acquiring adaptive aids and minor home modifications for
CBA participants. Reimbursement for adaptive aids and minor home modifications
will vary based on the actual cost of the adaptive aid and minor home modification.
Reimbursements are determined using a method based on modeled projected expenses
which are developed by using data from surveys; cost report data from similar
programs; consultation with other service providers and/or professionals experienced
in delivering contracted services; and/or other sources.
(5)
Reassessment fees. Reassessment fees are reimbursements
paid to CBA home and community support services contracted providers for performing
annual reassessments. Reimbursements are determined using a method based on
modeled projected expenses which are developed by using data from surveys;
cost report data from similar programs; consultation with other service providers
and/or professionals experienced in delivering contracted services; and/or
other sources.
(6)
Pre-enrollment expense fee. Reimbursement for pre-enrollment
assessment is determined using a method based on modeled projected expenses
which are developed by using data from surveys; cost report data from other
similar programs, consultation with other service providers and/or professionals
experienced in delivering contracted services; and other sources.
(7)
Exceptions to the reimbursement determination methodology.
DHS may adjust reimbursement if new legislation, regulations, or economic
factors affect costs, according to §355.109 of this title (relating to
Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors
Affect Costs).
(e)
Authority to determine reimbursement. The authority to
determine reimbursement is specified in §355.101 of this title (relating
to Introduction).
(f)
Reporting of cost.
(1)
Cost reporting guidelines. If DHS requires a cost report
for any waiver services in this program, providers must follow the cost-reporting
guidelines as specified in §355.105 of this title (relating to General
Reporting and Documentation Requirements, Methods, and Procedures).
(2)
Excused from submission of cost reports. If required
by DHS, 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 regulatory agency.
Requests to be excused from submitting a cost report must be received by DHS's
Rate Analysis Department before the due date of the cost report.
(3)
Reporting and verification of allowable cost.
(A)
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 reimbursements. DHS excludes
from reimbursement determination any 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.
(B)
Individual cost reports may not be included in the database
used for reimbursement determination if:
(i)
there is reasonable doubt as to the accuracy or allowability
of a significant part of the information reported; or
(ii)
an auditor determines that reported costs are not verifiable.
(C)
When material pertinent to proposed reimbursements is made
available to the public, the material will include the number of cost reports
eliminated from reimbursement determination for the reason stated in subparagraph
(B)(i) of this paragraph.
(4)
Allowable and unallowable costs. Providers must
follow the guidelines in determining whether a cost is allowable or unallowable
as specified in §355.102 and §355.103 of this title (relating to
General Principles of Allowable and Unallowable Costs, and Specifications
for Allowable and Unallowable Costs), in addition to the following.
(A)
Client room and board expenses are not allowable, except
for those related to respite care.
(B)
The actual cost of adaptive aids and home modifications
are not allowable for cost reporting purposes. Allowable labor costs associated
with acquiring adaptive aids and home modifications should be reported in
the cost report. Any item purchased for participants in this program and reimbursed
through a voucher payment system is unallowable for cost reporting purposes.
Refer to §355.103(17)(K) of this title (relating to Specifications for
Allowable and Unallowable Costs).
(g)
Reporting revenue. Revenues must be reported on the cost
report in accordance with §355.104 of this title (relating to Revenues).
(h)
Reviews and field audits of cost reports. DHS staff perform
desk reviews or field audits on all contracted providers. The frequency and
nature of the field audit are determined by DHS staff to ensure the fiscal
integrity of the program. Desk reviews and field audits will be conducted
in accordance with §355.106 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 a field audit in accordance
with §355.107 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 §355.110
of this title (relating to Informal Reviews and Formal Appeals).
§355.505.Reimbursement Methodology for the Community Living Assistance and Support Services Waiver Program--a 1915(c) Medicaid Home and Community-based Waiver for Persons with Related Conditions.
(a)
General requirements. Cost reports pertaining to providers'
fiscal years ending in calendar year 1997 and subsequent years will be governed
by the information in this section. The Texas Department of Human Services
(DHS) applies the general principles of cost determination as specified in §355.101
of this title (relating to Introduction).
(b)
General. DHS will reimburse qualified providers for waiver
services provided to Medicaid-eligible persons with related conditions (waiver
services). Additionally, DHS will reimburse qualified Texas Medicaid contracted
providers for a pre-enrollment assessment of potential waiver participants.
The pre-enrollment assessment covers care planning for the participant and
is reimbursed by a one-time administrative expense fee which is not included
in the waiver services but will be paid from Medicaid administrative funds.
(c)
Reporting of cost.
(1)
Providers must follow the cost reporting guidelines as
specified in §355.105 of this title (relating to General Reporting and
Documentation Requirements, Methods, and Procedures).
(2)
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.
(3)
A 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 by the Rate Analysis
Department before the due date of the cost report.
(d)
Waiver reimbursement determination methodology.
(1)
Unit of service reimbursement or reimbursement ceiling
by unit of service. Reimbursement or reimbursement ceilings for related-conditions
waiver services, habilitation, nursing, physical therapy, occupational therapy,
speech pathology, and psychological and respite care services will be determined
on a fee-for-service basis. These services are provided under the §1915(c)
of the Social Security Act Medicaid waiver for persons with related conditions.
(2)
Monthly reimbursement. The reimbursement for the related-conditions
case management waiver service will be determined as a monthly reimbursement.
This service is provided under the §1915(c) of the Social Security Act
Medicaid waiver for persons with related conditions.
(3)
Reporting and verification of allowable cost.
(A)
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 reimbursements. DHS excludes
from reimbursement determination any 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.
(B)
Individual cost reports may not be included in the database
used for reimbursement determination if:
(i)
there is reasonable doubt as to the accuracy or allowability
of a significant part of the information reported; or
(ii)
an auditor determines that reported costs are not verifiable.
(C)
When material pertinent to proposed reimbursements is made
available to the public, the material will include the number of cost reports
eliminated from reimbursement determination for the reason stated in subparagraph
(B)(i) of this paragraph.
(4)
Reimbursement determination. Recommended unit
of service reimbursements are determined in the following manner.
(A)
Unit of service reimbursement for habilitation, nursing,
physical therapy, occupational therapy, speech pathology, and psychological
services are determined in the following manner:
(i)
Total allowable costs for each provider will be determined
by analyzing the allowable historical costs reported on the cost report and
other pertinent cost survey information.
(ii)
Total allowable costs are reduced by the amount of the
administrative expense fee, requisition fee, and reassessment fee revenues
accrued for the reporting period.
(iii)
Each provider's total allowable costs, excluding depreciation
and mortgage interest, are projected from the historical cost reporting period
to the prospective reimbursement period as described in §355.108 of this
title (relating to Determination of Inflation Indices).
(iv)
Payroll taxes and employee benefits are allocated 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 for the appropriate
group of staff. Employee benefits will be charged to a specific salary line
item if the benefits are reported separately. The allocated payroll taxes
are Federal Insurance Contributions Act (FICA) or Social Security, Medicare
Contributions, Workers' Compensation Insurance (WCI), the Federal Unemployment
Tax Act (FUTA), and the Texas Unemployment Compensation Act (TUCA).
(v)
Allowable administrative, facility, and vehicle costs are
allocated or spread to each waiver service cost component on a pro rata basis
based on the portion of each waiver services' service units reported to the
amount of total waiver service units reported.
(vi)
For nursing, physical therapy, occupational therapy, speech
pathology, and psychological services:
(I)
An allowable cost per unit of service is calculated for
each service. The allowable costs per unit of service for each contracted
provider are arrayed and weighted by the number of units of service, and the
median cost per unit of service is calculated. The allowable costs per unit
of service may be combined into an array with the allowable cost per unit
of service of similar services provided by other programs in determining the
median cost per unit of service.
(II)
The median cost per unit of service for each waiver service
is multiplied by 1.044.
(vii)
For habilitation services two cost areas are created:
(I)
The attendant cost area includes salaries, wages, benefits,
and mileage reimbursement calculated as specified in §355.112 of this
title (relating to Attendant Compensation Rate Enhancement).
(II)
Another attendant cost area is created which includes
the other habilitation services costs not included in subclause (I) of this
clause as determined in clauses (i)-(v) of this subparagraph to create an
other attendant cost area. An allowable cost per unit of service is calculated
for the other habilitation cost area. The allowable costs per unit of service
for each contracted provider are arrayed and weighted by the number of units
of service, and the median cost per unit of service is calculated. The median
cost per unit of service is multiplied by 1.044.
(III)
The attendant cost area and the other attendant cost
area are summed to determine the habilitation attendant cost per unit of service.
(B)
Unit of service reimbursement and reimbursement ceilings
for respite care services are determined in the following manner:
(i)
For in-home respite care services, a unit of service reimbursement
is determined using a method based on modeled projected expenses which are
developed using data from surveys, cost report data from other similar programs
or services, professionals' experience in delivering similar type services,
and other relevant sources.
(ii)
For out-of-home respite care services, a unit of service
reimbursement ceiling is determined using a method based on modeled projected
expenses which are developed using data from surveys, cost report data from
other similar programs or services, professionals' experience in delivering
similar type services, and other relevant sources.
(C)
The monthly reimbursement for case management services
is determined in the following manner:
(i)
Total allowable costs for each provider will be determined
by analyzing the allowable historical costs reported on the cost report and
other pertinent cost survey information.
(ii)
Total allowable costs are reduced by the amount of administrative
expense fee revenues reported.
(iii)
Each provider's total allowable costs, excluding depreciation
and mortgage interest, are projected from the historical cost reporting period
to the prospective reimbursement period as described in §355.108 of this
title (relating to Determination of Inflation Indices).
(iv)
Payroll taxes and employee benefits are allocated 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 for the appropriate
group of staff. Employee benefits will be charged to a specific salary line
item if the benefits are reported separately. The allocated payroll taxes
are Federal Insurance Contributions Act (FICA) or social security, Medicare
contributions, Workers' compensation Insurance (WCI), the Federal Unemployment
Tax Act (FUTA), and the Texas Unemployment Compensation Act (TUCA).
(v)
Each provider's projected total allowable costs are divided
by the number of monthly units of service to determine the projected cost
per client month of service.
(vi)
Each provider's projected cost per client month of service
is arrayed from low to high and weighted by the number of units of service
and the median cost per client month of service is calculated.
(vii)
The median projected cost per client month of service
is multiplied by 1.044.
(D)
DHS also adjusts reimbursement according to §355.109
of this title (relating to Adjusting Reimbursement When New Legislation, Regulations,
or Economic Factors Affect Costs) if new legislation, regulations, or economic
factors affect costs.
(e)
Administrative expense fee determination methodology.
(1)
One-time administrative expense fee. Reimbursement for
the pre-enrollment assessment and care planning process required to determine
eligibility for the waiver program will be provided as a one-time administrative
expense fee.
(2)
Administrative expense fee determination process.
The recommended administrative expense fee is determined using a method based
on modeled projected expenses which are developed using data from surveys,
cost report data from other similar programs or services, professionals' experience
in delivering similar services, and other relevant sources.
(f)
Requisition fees. Requisition fees are reimbursements paid
to the CLASS direct service agency contracted providers for their efforts
in acquiring adaptive aids and minor home modifications for CLASS participants.
Reimbursement for adaptive aids and minor home modifications will vary based
on the actual cost of the adaptive aid and minor home modification. Reimbursements
are determined using a method based on modeled projected expenses which are
developed by using data from surveys; cost report data from similar programs;
consultation with other service providers and/or professionals experienced
in delivering contracted services; and/or other sources.
(g)
Reassessment fees. Reassessment fees are reimbursements
paid to CLASS direct service agency contracted providers for performing annual
reassessments. Reimbursements are determined using a method based on modeled
projected expenses which are developed by using data from surveys; cost report
data from similar programs, consultation with other service providers and/or
professionals experienced in delivering contracted services; and/or other
sources.
(h)
Allowable and unallowable costs.
(1)
Providers must follow the guidelines in determining whether
a cost is allowable or unallowable as specified in §355.102 and §355.103
of this title (relating to General Principles of Allowable and Unallowable
Costs, and Specifications for Allowable and Unallowable Costs) as well as
the following provisions.
(2)
Participant room and board expenses are not allowable,
except for those related to respite care.
(3)
The cost of adaptive aids and home modifications is
not allowable. Allowable labor costs associated with acquiring adaptive aids
and home modifications should be reported in the cost report. Any item purchased
for participants in this program and reimbursed through a voucher payment
system is unallowable. Refer to §355.103(b)(17)(K) of this title (relating
to Specifications for Allowable and Unallowable Costs).
(i)
Authority to determine reimbursement. The authority to
determine reimbursement is specified in §355.101 of this title (relating
to Introduction).
(j)
Reporting revenue. Revenues must be reported on the cost
report in accordance with §355.104 of this title (relating to Revenues).
(k)
Reviews and field audits of cost reports. DHS staff perform
desk reviews or field audits on all contracted providers. The frequency and
nature of the field audit are determined by DHS to ensure the fiscal integrity
of the program. Desk reviews and field audits will be conducted in accordance
with §355.106 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 a field audit in accordance with §355.107
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 §355.110 of this title (relating
to Informal Reviews and Formal Appeals).
(l)
Reporting requirements. The program director's full salary
is to be reported on the line item of the cost report designated for the director.
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 June 5, 2000.
TRD-200003959
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Effective date: June 25, 2000
Proposal publication date: March 31, 2000
For further information, please call: (512) 438-3734
1 TAC §355.5902, §355.6907
The amendments are adopted under the Government Code, §531.033,
which authorizes the commissioner of the Health and Human Services Commission
to adopt rules necessary to carry out the commission's duties, and §531.021(b),
which establishes the commission as the agency responsible for adopting reasonable
rules governing the determination of fees, charges, and rates for medical
assistance payments under Chapter 32, Human Resources Code.
The amendments implement the Government Code, §531.033 and §531.021(b).
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 June 5, 2000.
TRD-200003960
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Effective date: June 25, 2000
Proposal publication date: March 31, 2000
For further information, please call: (512) 438-3734
Subchapter E. COMMUNITY CARE FOR AGED AND DISABLED
Subchapter G. TELEMEDICINE SERVICES
Subchapter J. PURCHASED HEALTH SERVICES