Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355.
MEDICAID REIMBURSEMENT RATES
Subchapter E. COMMUNITY CARE FOR AGED AND DISABLED
The Texas Health and Human Services Commission (HHSC) proposes the
repeal of §355.502, concerning 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, and §355.5901, concerning reimbursement methodology for
Primary Home Care Services and Family Care Services; and amendments to §355.501,
concerning reimbursement methodology for Program for All-Inclusive Care for
the Elderly (PACE), §355.503, concerning 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, and §355.5902, concerning reimbursement
methodology for Primary Home Care and Family Care Services, in its Medicaid
Reimbursement Rates chapter.
The purpose of the proposed amendment to §355.501 is to modify the
payment rate methodology for the Program for All-Inclusive Care for the Elderly
(PACE) to eliminate obsolete language regarding cost reporting requirements
formerly required by the Centers for Medicare and Medicaid Services during
the research and demonstration timeframe of the program. The proposal establishes
January 1 of each year as the effective date of the payment rate for this
program. Also, references to the Texas Department of Human Services (DHS)
were changed to references for the Texas Health and Human Services Commission
and references to DHS were eliminated where appropriate.
The purpose of the proposed amendment to §355.503 is to add the Home-Delivered
Meals payment rate ceiling methodology to the Community Based Alternatives
(CBA) program through a reference to the rules regarding the Reimbursement
Methodology for Home-Delivered Meals. Also, references to the Texas Department
of Human Services (DHS) were changed to references for the Texas Health and
Human Services Commission and references to DHS were eliminated where appropriate.
In addition, it is clarified that a weighted median is used in the determination
of payment rates for nursing services provided by a registered nurse (RN),
nursing services provided by a Licensed Vocational Nurse (LVN), therapies,
and in-home respite services. Section 355.502, the reimbursement methodology
for CBA that pertained to the1996 cost report, is being repealed because it
is obsolete.
The purpose of the proposed amendment to §355.5902 is to establish
the Community Based Alternatives (CBA) RN payment rate as the amount that
is deducted from the client's budget under the Primary Home Care (PHC) vendor
fiscal intermediary option to pay for required assessments performed by an
RN. This payment rate amount is paid to PHC contracted providers that perform
required RN assessments for clients whose care is funded by §1929(b)
of the Social Security Act. This amendment also expands references to DHS
to include DHS or its designee and eliminates references to DHS where appropriate.
Section 355.5901, the reimbursement methodology for PHC that pertained to
the 1994, 1995, and 1996 cost reports, is being repealed because it is obsolete.
DHS is proposing related policy in DHS's Chapter 47, concerning Primary
Home Care, in this issue of the
Texas Register
.
Don Green, Chief Financial Officer, has determined that for the first five-year
period the sections are in effect there will be no fiscal implications for
state government or local governments as a result of enforcing or administering
the sections.
Commissioner Don Gilbert 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 §355.501 will be that the reimbursement methodology
will specify the effective date for the payment rate and that obsolete language
will be eliminated. Changing references from DHS to HHSC reflects the change
in responsibility for oversight of the rate determination process to HHSC.
Commissioner Gilbert 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 §355.503 will be that the reimbursement methodology will
be specified for Home-Delivered Meals paid for through the CBA program. Changing
references from DHS to HHSC reflects the change in responsibility for oversight
of the rate determination process to HHSC and clarifies use of the weighted
median for specific services. The repeal of §355.502 removes an obsolete
rule.
Commissioner Gilbert 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 amendment to §355.5902 will be that a separate payment
rate will be identified for required RN assessments conducted for these clients.
Currently there is no RN payment rate that is separately identified in the
PHC program. Expanding the references to DHS to include its designee reflects
the payment rate development that is performed by the Texas Health and Human
Services Commission for DHS. Also, the repeal of §355.5901 removes an
obsolete rule.
There will be no adverse economic effect on small or micro businesses as
a result of enforcing or administering the proposal, because the proposal
does not increase any requirements of the contracted providers in these programs.
The proposal repeals obsolete rules, establishes payment rates, clarifies
use of weighted median, and changes references from one state agency to another.
There is no anticipated economic cost to persons who are required to comply
with the proposed sections. There will be no anticipated effect on local employment
in geographic areas affected by these sections.
Questions about the content of this proposal may be directed to Carolyn
Pratt at (512) 438- 4057 in HHSC's Rate Analysis Department. Written comments
on the proposal may be submitted to Supervisor, Rules and Handbooks Unit-079,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
. To make the proposed amendment to §355.5902 available for public
review, contact local offices of DHS or Carolyn Pratt at (512) 438-4057 in
HHSC's Rate Analysis Department.
1 TAC §355.501, §355.503
The amendments are proposed 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).
§355.501.Reimbursement Methodology for Program for All-Inclusive Care for the Elderly (PACE).
(a)
General specifications. The Texas
Health and Human
Services Commission (HHSC)
[
(b)
Frequency of reimbursement determination. [
(c)
Reimbursement determination. To determine the cost savings
to the Nursing Facility program, the average cost of a nursing home recipient
is calculated, including the cost of nursing home care; support services (rehabilitative
and emergency dental); prescribed drugs; and acute care services. The calculated
cost of care for an average nursing home recipient is multiplied by a factor
of 0.95 to ensure a savings to the state for implementing this alternative
to nursing home care. The following
payment rate
[
(1)-(6)
(No change.)
(7)
The resulting calculation from applying paragraph (6) of
this subsection is multiplied by the number of days in the year, and the product
of the multiplication is divided by 12 months to convert the per diem amount
from paragraph (6) of this subsection to a monthly
payment rate
[
(d)
Reporting of cost. [
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
§355.503.Reimbursement Methodology for the Community-Based Alternatives Waiver Program [
(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
Health and Human Services
Commission (HHSC)
[
(b)
General. [
(c)
Other sources of cost information. If
HHSC
[
(d)
Waiver reimbursement determination. Recommended reimbursements
are determined in the following manner.
(1)
Unit of service reimbursement. Reimbursement for personal
assistance services, nursing services provided by
a registered nurse
(RN)
[
(A)-(D)
(No change.)
(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
service's units of service
[
(F)
For nursing
services provided by an RN, nursing services
provided by an LVN
, 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
weighted
median cost per unit of service.
(G)
(No change.)
(2)
(No change.)
(3)
Monthly reimbursement
ceilings
[
(4)-(5)
(No change.)
(6)
Exceptions to the reimbursement determination methodology.
HHSC
[
(e)
(No change.)
(f)
Reporting of cost.
(1)
Cost reporting guidelines. If
HHSC
[
(2)
Excused from submission of cost reports. If required by
HHSC
[
(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.
HHSC
[
(B)-(C)
(No change.)
(4)
(No change.)
(g)
(No change.)
(h)
Reviews and field audits of cost reports.
Desk
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on March 15, 2002.
TRD-200201629
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Earliest possible date of adoption: April 28, 2002
For further information, please call: (512) 438-3734
1 TAC §355.502
(Editor's note: The text of the following section proposed
for repeal will not be published. The section may be examined in the offices
of the Texas Health and Human Services Commission or in the Texas Register
office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeal is proposed 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 repeal implements the Government Code, §531.033 and §531.021(b).
§355.502.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.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on March 15, 2002.
TRD-200201628
Marina Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Earliest possible date of adoption: April 28, 2002
For further information, please call: (512) 438-3734
Department of Human Services (DHS)
] determines the reimbursement for the provider, Bienvivir, under a
Medicaid 1115 waiver program to provide care to recipients. [
The effective
date of this reimbursement methodology is the same date as implementation
of the waiver, contingent upon Health Care Financing Administration (HCFA)
approval of the waiver.
]
DHS determines
reimbursement for the provider at least annually.
] The reimbursement
is
reviewed and
revised
, if appropriate, effective January
1 each year
[
each time the reimbursements for the Nursing Facility
program are revised
]. The reimbursement may be determined more often
if
HHSC
[
the DHS board
] determines it to be necessary.
reimbursement
] is calculated on a per diem basis:
reimbursement
].
The provider must submit an independently
certified annual cost report, in the form and detail prescribed by HCFA.
]
HHSC may
[
DHS reserves the right to
] require submittal of
financial and statistical information on a cost report or in a survey format
designated by
HHSC
[
DHS
].
Cost report completion
is governed by the requirements specified in Subchapter A of this chapter
(relating to Cost Determination Process). HHSC may also require submittal
of audited financial statements of the provider.
(1)
Cost report due date. The
annual cost report must be submitted to DHS no later than 180 days after the
end of the fiscal year.]
(2)
Reporting periods. The provider
must prepare the cost report to reflect the activities of the provider's entire
fiscal year. Cost reports may be required for other periods at the discretion
of DHS. Should the provider agency terminate its contract (provider agreement)
with the department, a cost report must be submitted for that period beginning
with the first day of the provider's fiscal year and ending with the effective
date of termination of its contract.]
(3)
Allowable and unallowable
costs. The provider must complete the cost report according to Medicare guidelines
regarding allowable and unallowable costs as specified in 42 CFR 417.536 through
417.550, and the chart of accounts as specified by HCFA.]
(4)
Failure to file an acceptable
cost report. If the provider fails to file a cost report or cost report supplement
by the due date or fails to submit a cost report according to all applicable
rules and instructions, the department may withhold all provider payments
until the provider agency submits an acceptable cost report.]
(5)
Accounting requirements. The
provider must ensure that financial and statistical information submitted
in cost reports is based upon the accrual method of accounting. The provider
agency's treatment of any financial or statistical item must reflect the application
of the generally accepted accounting principles (GAAP) approved by the American
Institute of Certified Public Accountants. If there are any differences between
GAAP and Medicare guidelines, Medicare guidelines take precedence.]
(6)
Allocation method. If allocation
of cost is necessary, the provider must use reasonable methods of allocation.
DHS adjusts allocated costs if the department considers the allocation method
to be unreasonable. The provider agency must retain work papers supporting
allocations.]
(7)
Cost report certification.
The provider must certify in the format specified by HCFA the accuracy of
the cost report submitted to DHS. The provider agency may be liable for civil
and/or criminal penalties in the case of misrepresented or falsified information.]
(8)
Cost report supplements. The
department may at times require additional financial and statistical information
other than the information contained in the cost report.]
(9)
Review of the cost report.
DHS staff review the cost report to ensure that all financial and statistical
information submitted conforms to all applicable rules and instructions. The
review of the cost report includes a desk audit. DHS reviews cost reports
according to the criteria in 40 TAC §24.201 (Basic Objectives and Criteria
for Desk Review of Cost Reports). If the provider agency fails to complete
cost reports according to instructions or rules, the department returns the
cost reports to the provider agency for proper completion. The department
may require information other than that contained in the cost report to substantiate
reported information.]
(10)
On-site audits. The department
may perform on-site audits of the provider agencies that participate in the
program. DHS determines the frequency and nature of audits but ensures that
they are not less than that required by federal regulations related to the
administration of the program.]
(11)
Notification of exclusions
and adjustments. DHS notifies the provider of exclusions and adjustments to
reported expenses made during desk reviews and on-site audits of cost reports
as specified in 40 TAC §24.401 (Notification).]
(12)
Reviews of cost report disallowances.
A provider who disagrees with the determination of exclusions and adjustments
to reported expenses may request an informal review and, when necessary, an
administrative hearing as specified in 40 TAC §24.601 (Reviews and Administrative
Hearings).]
(13)
Access to records. The provider
and its designated agent(s) must allow access to all records necessary to
verify information submitted to DHS on cost reports. This requirement includes
records pertaining to related-party transactions and other business activities
engaged in by the provider agency. If the provider agency does not allow inspection
of pertinent records within 30 days following written notice from DHS, a hold
is placed on vendor payments until access to the records is allowed. If the
provider agency continues to deny access to records, DHS may cancel the provider
agency's contract.]
(14)
Record-keeping requirements.
The provider agency must maintain records according to the requirements of
42 CFR 417.480. Records must be retained for five years from the end of the
fiscal period to which they apply.]
(15)
Failure to maintain adequate
records. If the provider agency fails to maintain adequate records to support
the financial and statistical information reported in cost reports, the department
allows 90 days for the provider agency to bring record-keeping into compliance.
If the provider agency fails to correct deficiencies within 90 days from the
date of notification of the deficiency, the department may cancel the provider
agency's contract for services.]
--a 1915(c) Medicaid Home and Community-Based Waiver for Aged and Disabled Adults Who Meet Criteria for Alternatives to Nursing Facility Care ].
Department of Human Services (DHS)
] applies
the general principles of cost determination as specified in §355.101
of this title (relating to Introduction).
DHS will reimburse qualified
] Texas
Medicaid contracted providers
will be reimbursed
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
will be reimbursed
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.
DHS
] has determined that there is not sufficient reliable cost report
data from which to
determine reimbursements and reimbursement ceilings
for
[
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.
an RN
], nursing services provided by
a licensed
vocational nurse (LVN)
[
an LVN
], 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.
services' service units reported
] to the amount of total waiver
units of service
[
service units reported
].
ceiling
]. The reimbursement for Emergency Response
Services
[
,
] will be determined as monthly reimbursement ceiling
,
based
on the ceiling amount determined
in accordance with 40 TAC §52.504
(relating to Reimbursement Methodology for Emergency Response Services)
[
for the Emergency Response Services Program
].
The reimbursement
for Home-Delivered Meals will be determined on a per meal basis, based on
the ceiling amount determined in accordance with 40 TAC §48.9806 (relating
to Reimbursement Methodology for Home-Delivered Meals).
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).
DHS
] requires a cost report for any waiver
service
[
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).
DHS
], all contracted providers must submit a cost report
unless the number of days between the date the first
Texas Department
of Human Services (DHS)
[
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. An AL/RC provider may also be excused from submitting a
cost report if the total number of days serving DHS AL/RC or Residential Care
residents
is
[
are
] 366 or fewer during
its
[
their
] fiscal year. Requests to be excused from submitting a cost
report must be received by
HHSC
[
DHS's Rate Analysis Department
] before the due date of the cost report.
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.
DHS staff perform desk
] reviews or field audits
are performed
on
cost reports for
all contracted providers. The frequency
and nature of the field audit are determined by
HHSC
[
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).
Subchapter G. TELEMEDICINE SERVICES