Current through Reg. 49, No. 38; September 20, 2024
(a) Types of
facilities. There are two types of facilities for purposes of rate setting:
state-operated and non-state operated. Facilities are further divided into
classes that are determined by the size of the facility.
(b) Classes of non-state operated facilities.
There is a separate set of reimbursement rates for each class of non-state
operated facilities, which are as follows.
(1) Large facility--A facility with a
Medicaid certified capacity of 14 or more as of the first day of the full month
immediately preceding a rate's effective date or, if certified for the first
time after a rate's effective date, as of the date of initial
certification.
(2) Medium
facility--A facility with a Medicaid certified capacity of nine through 13 as
of the first day of the full month immediately preceding a rate's effective
date or, if certified for the first time after a rate's effective date, as of
the date of initial certification.
(3) Small facility--A facility with a
Medicaid certified capacity of eight or fewer as of the first day of the full
month immediately preceding a rate's effective date or, if certified for the
first time after a rate's effective date, as of the date of initial
certification.
(c)
Classes of state-operated facilities. There is a separate interim rate for each
class of state-operated facilities, which are as follows:
(1) Large facility--A facility with a
Medicaid certified capacity of 17 or more as of the first day of the full month
immediately preceding a rate's effective date or, if certified for the first
time after a rate's effective date, as of the date of initial
certification.
(2) Small
facility--A facility with a Medicaid certified capacity of 16 or less as of the
first day of the full month immediately preceding a rate's effective date or,
if certified for the first time after a rate's effective date, as of the date
of initial certification.
(d) Reimbursement rate determination for
non-state operated facilities. HHSC will adopt the reimbursement rates for
non-state operated facilities in accordance with §
RSA 355.101 of this
title (relating to Introduction) and this subchapter.
(1) Reimbursement rates combine residential
and day program services, i.e., payment for the full 24 hours of daily
service.
(2) Reimbursement rates
are differentiated based on the level of need (LON) of the individual receiving
the service. The levels of need are intermittent, limited, extensive,
pervasive, and pervasive plus.
(3)
The recommended modeled rates are based on cost components deemed appropriate
for economically and efficiently operated services. The determination of these
components is based on cost reports submitted by Intermediate Care Facilities
for Individuals with an Intellectual Disability or Related Conditions (ICF/IID)
providers.
(4) Direct service
workers cost area. This cost area includes direct service workers' salaries and
wages, benefits, and mileage reimbursement expenses. The reimbursement rate for
this cost area is calculated as specified in §
RSA
355.112 of this title (relating to Attendant
Compensation Rate Enhancement).
(5)
Direct care trainers and job coaches cost area. This cost area includes direct
care trainers' and job coaches' salaries and wages, benefits, and mileage
reimbursement expenses. The reimbursement rate for this cost area is calculated
as specified in §
RSA
355.112 of this title.
(6) Add-on reimbursement rate. There is an
available add-on reimbursement rate, in addition to the daily reimbursement
rate, for certain individuals.
(A) The add-on
is based on the Resource Utilization Group (RUG-III) 34 group classification
system as described in §
RSA
355.307 of this title (relating to
Reimbursement Setting Methodology).
(B) There are three add-on groupings based on
certain RUG-III 34 classification groups and the assessed Activities of Daily
Living (ADL) score.
(i) Group 1 includes
Extensive Services 3 (SE3), Extensive Services 2 (SE2), and Rehabilitation with
ADL score of 17-18 (RAD).
(ii)
Group 2 includes Rehabilitation with ADL score of 14-16 (RAC), Rehabilitation
with ADL score of 10-13 (RAB), Extensive Services 1 (SE1), Special Care with
ADL score of 17-18 (SSC), Special Care with ADL score of 15-16 (SSB), and
Special Care with ADL score of 4-14 (SSA).
(iii) Group 3 includes Rehabilitation with
ADL score of 4-9 (RAA), Clinically Complex with Depression and ADL score of
17-18 (CC2), Clinically Complex with ADL score of 17-18 (CC1), Clinically
Complex with Depression and ADL score of 12-16 (CB2), Clinically Complex and
ADL score of 12-16 (CB1), Clinically Complex with Depression and ADL score of
4-11 (CA2), and Clinically Complex and ADL score of 4-11 (CA1).
(C) An individual must meet the
following criteria to be eligible to receive the add-on rate:
(i) be assigned a RUG-III 34 classification
in Group 1, Group 2, or Group 3;
(ii) be a resident of a large state-operated
facility for at least six months immediately prior to referral or a resident of
a Medicaid-certified nursing facility immediately prior to referral;
and
(iii) for residents of a large
state-operated facility only, have a LON which includes a medical LON increase
as described in 40 TAC §RSA 9.241(relating to Level of Need Criteria), but
not be assessed a LON of pervasive plus.
(D) The add-on for each Group is determined
based on data and costs from the most recent nursing facility cost reports
accepted by HHSC.
(i) For each Group, compute
the median direct care staff per diem base rate component for all facilities as
specified in §
RSA
355.308 of this title (relating to Direct
Care Staff Rate Component); and
(ii) Subtract the average nursing portion of
the current recommended modeled rates as specified in subsection (d)(3) of this
section.
(e) Reimbursement determination for
state-operated facilities. Except as provided in paragraph (2) of this
subsection and subsection (f) of this section, state-operated facilities are
reimbursed an interim rate with a settlement conducted in accordance with
paragraph (1)(B) of this subsection. HHSC will adopt the interim reimbursement
rates for state-operated facilities in accordance with §
RSA 355.101 of this
title and this subchapter.
(1) State-operated
facilities certified prior to January 1, 2001, will be reimbursed using an
interim reimbursement rate and settlement process.
(A) Interim reimbursement rates for
state-operated facilities are based on the most recent cost report accepted by
HHSC.
(B) Settlement is conducted
each state fiscal year by class of facility. If there is a difference between
allowable costs and the reimbursement paid under the interim rate, including
applied income, for a state fiscal year, federal funds to the state will be
adjusted based on that difference.
(2) A state-operated facility certified on or
after January 1, 2001, will be reimbursed using a pro forma rate determined in
accordance with §
RSA
355.101(c)(2)(B) and §
RSA
355.105(h) of this title
(relating to Introduction and General Reporting and Documentation Requirements,
Methods, and Procedures). A facility will be reimbursed under the pro forma
rate methodology until HHSC receives an acceptable cost report which includes
at least 12 months of the facility's cost data and is available to be included
in the annual interim rate determination process.
(f) HHSC may define experimental classes of
service to be used in research and demonstration projects on new reimbursement
methods. Demonstration or pilot projects based on experimental classes may be
implemented on a statewide basis or may be limited to a specific region of the
state or to a selected group of providers. Reimbursement for an experimental
class is not implemented, however, unless HHSC and the Centers for Medicare and
Medicaid Services (CMS) approve the experimental methodology.
(g) Cost Reporting.
(1) Providers must follow the cost-reporting
guidelines as specified in §
RSA
355.105 of this title.
(2) Providers must follow the guidelines in
determining whether a cost is allowable or unallowable as specified in §
RSA
355.102 and §
RSA
355.103 of this title (relating to General
Principles of Allowable and Unallowable Costs, and Specifications for Allowable
and Unallowable Costs).
(3)
Revenues must be reported on the cost report in accordance with §
RSA 355.104 of this
title (relating to Revenues).
(h) Adjusting costs. 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 §
RSA
355.108 of this title (relating to
Determination of Inflation Indices). HHSC may adjust reimbursement if new
legislation, regulations, or economic factors affect costs, according to §
RSA
355.109 of this title (relating to Adjusting
Reimbursement When New Legislation, Regulations, or Economic Factors Affect
Costs).
(i) Field Audit and Desk
Review. Desk reviews or field audits are performed on cost reports for all
contracted providers. The frequency and nature of the field audits are
determined by HHSC to ensure the fiscal integrity of the program. Desk reviews
and field audits will be conducted in accordance with §
RSA
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 §
RSA
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
under §
RSA
355.110 of this title (relating to Informal
Reviews and Formal Appeals).
(j)
Total Medicaid Spending Requirement. Effective for costs and revenues accrued
on or after September 1, 2015, through August 31, 2017, all non-state operated
ICF/IID providers are required to spend at least 90 percent of revenues
received through the ICF/IID daily Medicaid payment rates on Medicaid allowable
costs under the ICF/IID program.
(1)
Compliance with the total Medicaid spending requirement will be determined in
the aggregate for all component codes controlled by the same entity across the
ICF/IID, Home and Community-based Services (HCS), and Texas Home Living (TxHmL)
programs within the same cost report year.
(2) Compliance with the spending requirement
is determined on an annual basis using cost reports as described in Chapter
355, Subchapter A, of this title (relating to Cost Determination Process) and
this subchapter.
(A) When a provider changes
ownership through a contract assignment, the prior owner must submit a report
covering the period from the beginning of the provider's fiscal year to the
effective date of the contract assignment as determined by HHSC or its
designee. This report is used as the basis for determining compliance with the
spending requirement.
(B) Providers
whose contracts are terminated voluntarily or involuntarily must submit a
report covering the period from the beginning of the provider's fiscal year to
the date recognized by HHSC or its designee as the contract termination date.
This report is used as the basis for determining compliance with the spending
requirement.
(C) When part of a
cost reporting period is subject to spending accountability and part is not
subject to spending accountability, a provider may choose to have HHSC divide
their costs for the entire cost reporting period between the part of the period
subject to spending accountability and the part of the period not subject to
spending accountability on a pro-rata basis (i.e., pro-rata allocation). For
example, if six months of a twelve month cost reporting period are subject to
spending accountability, HHSC would divide the provider's costs for the entire
cost reporting period by two to determine the costs subject to spending
accountability. Providers who do not choose to have HHSC divide their costs on
a pro-rata basis must report their costs for the period subject to spending
accountability separately from their costs for the period not subject to
spending accountability (i.e., direct reporting). Once a provider indicates to
HHSC their choice between a pro-rata allocation and direct reporting for a
specific cost reporting period, that choice is irrevocable for that cost
reporting period.
(3)
Allowable costs are those described in Chapter 355, Subchapter A, and this
subchapter.
(4) The total Medicaid
revenue for an ICF/IID provider participating in the attendant compensation
rate enhancement is offset by any recoupment made under §
RSA
355.112(s) of this title
prior to determining compliance with the spending requirement.
(5) Providers who fail to meet the 90 percent
spending requirement are subject to a recoupment of the difference between the
90 percent spending requirement and their actual Medicaid allowable ICF/IID
costs. Recoupments for each rate period under this subsection are limited to
the difference between the provider's Medicaid revenues for services provided
at the rates subject to spending accountability and what the provider's
Medicaid revenues would have been for services provided at the Medicaid rates
in effect on August 31, 2015.
(6)
The contracted provider, owner, or legal entity which received the Medicaid
payment is responsible for the repayment of the recoupment amount. Failure to
repay the amount due or submit an acceptable payment plan within 60 days of
notification results in placement of a vendor hold on all HHSC and Texas
Department of Aging and Disability Services contracts controlled by the
responsible entity.
(7) Prior to
each rate period through August 31, 2017, providers will be given the option of
receiving the Medicaid rates adopted by HHSC for the rate period and the
Medicaid rates that were in effect on August 31, 2015. Providers who chose to
receive the Medicaid rates that were in effect on August 31, 2015, will not be
subject to the spending accountability requirements described in this
subsection.
(8) For rate periods
beginning on or after September 1, 2017, the Total Medicaid Spending
Requirement described in this subsection will no longer apply. Additionally,
providers who chose to receive the Medicaid rates that were in effect on August
31, 2015, will receive the rates that were adopted effective September 1,
2015.
