Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter A - COST DETERMINATION PROCESS
Section 355.101 - Introduction

Universal Citation: 1 TX Admin Code ยง 355.101

Current through Reg. 49, No. 38; September 20, 2024

(a) The information in § RSA 355.102 of this chapter (relating to General Principles of Allowable and Unallowable Costs), § RSA 355.103 of this chapter (relating to Specifications for Allowable and Unallowable Costs), § RSA 355.104 of this chapter (relating to Revenues), and § RSA 355.105 of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures) applies to Intermediate Care Facilities for Persons with Mental Retardation, Home and Community-based Services, Service Coordination/Targeted Case Management, Rehabilitative Services, School Health and Related Services, and Texas Home Living programs cost reports pertaining to providers' fiscal years ending in calendar year 2004 and subsequent years. For all other programs these sections apply to cost reports pertaining to the providers' fiscal years ending in calendar year 1997 and subsequent years.

(b) The following terms, when used in this subchapter, have the following meanings:

(1) DADS--The Texas Department of Aging and Disability Services, its successor agency, or designee.

(2) DARS--The Texas Department of Assistive and Rehabilitative Services, its successor agency, or designee.

(3) DSHS--The Texas Department of State Health Services, its successor agency, or designee.

(4) HHSC--The Health and Human Services Commission, its successor agency, or designee.

(5) Line item--A specific informational, statistical, revenue, or expense data element in a cost report.

(6) TEA--The Texas Education Agency, its successor agency, or designee.

(c) HHSC reimburses providers for contracted client services through reimbursement amounts determined as described in this chapter and in reimbursement methodologies for each program. Statewide, uniform reimbursements and reimbursement ceilings are approved by HHSC. Where reimbursements are contractor-specific, HHSC approves the reimbursement parameter dollar amounts, e.g., ceilings, floors, or program reimbursement formula limits. In approving reimbursement amounts HHSC takes into consideration staff recommendations based on the application of formulas and procedures described in this chapter and in reimbursement methodologies for each program. However, HHSC may adjust staff recommendations when HHSC deems such adjustments are warranted by particular circumstances likely to affect achievement of program objectives, including economic conditions and budgetary considerations. Methodology rules are developed and recommended for approval to HHSC. HHSC has oversight authority with respect to the state's reimbursement methodology and cost determination rules.

(1) Reimbursement amounts will be determined coincident with the state's biennium.

(2) Objective of cost determination process. The objective of the cost determination process is to define direct and indirect costs that are allowable and, therefore, may be considered for use in the overall reimbursement determination process. The cost determination process seeks to collect accurate financial and other statistical data that constitutes the foundation upon which reimbursements are determined.
(A) Cost-reporting. In order to ensure adequate financial and statistical information upon which to base reimbursement, HHSC requires that each contracted provider submit a periodic cost report or supplemental report. It is the responsibility of the provider to submit accurate and complete information, in accordance with all pertinent HHSC cost reporting rules and cost report instructions, on the cost report and any supplemental reports required by HHSC.

(B) Pro forma costing. When historical costs are unavailable, such as in the case of a new program, reimbursement may be based on a pro forma approach. This approach involves using historical costs of delivering similar services, where appropriate data are available, and estimating the basic types and costs of products and services necessary to deliver services meeting federal and state requirements.

(3) Relationship between cost determination and reimbursement determination processes. The cost determination process seeks to evaluate individual cost items of providers to determine their allowability and to determine whether individual cost reports are of reasonable accuracy for potential use in reimbursement determination. The reimbursement determination process takes the evaluation of allowable costs one step further by comparing allowable costs across providers to identify those levels of cost, either for individual cost items or groups of cost items, which must be incurred by efficient and economic providers of services meeting all state and federal standards. Thus, all costs allowed in the cost determination process may not necessarily be used in the reimbursement determination process. The basic objective of the reimbursement methodologies employed by HHSC is to facilitate and balance the broader objectives of the programs administered by the agencies by:
(A) promoting reasonable access for eligible clients to services that meet federal and state quality standards via contracting with an adequate number of qualified providers; and

(B) expending taxpayer dollars in a reasonable and prudent manner such that eligible clients are served at the lowest cost to taxpayers consistent with state and federal laws, standards and regulations, and with program objectives.

(d) Providers contracted with Managed Care Organizations. To ensure that HHSC has adequate financial and statistical information upon which to base reimbursement, each provider that has contracted with a Managed Care Organization (MCO) to provide Long-Term Services and Supports to State of Texas Medicaid clients must submit to HHSC periodic cost reports and supplemental reports as required by this subchapter. This required cost reporting must follow rules and requirements as set forth in this subchapter. An MCO will be responsible for enforcing the vendor hold and administrative penalties relating to cost reporting violations as described in this subchapter, and § RSA 355.403 of this chapter (relating to Vendor Hold), if HHSC notifies the MCO that a violation has occurred.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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