Current through Reg. 49, No. 52; December 27, 2024
(a) General requirements. The Texas Health
and Human Services Commission (HHSC), or its designee, applies the general
principles of cost determination as specified in §
RSA 355.101 of this
title (relating to Introduction).
(b) Cost reporting.
(1) Providers must follow the cost-reporting
guidelines as specified in §
RSA
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 HHSC, a contracted provider must submit a cost report unless the
provider meets one or more of the conditions in §
RSA
355.105(b)(4)(D) of this
title.
(c) Reimbursement
determination.
(1) Reporting and verification
of allowable costs.
(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 or its designee 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 that are necessary for the provision of services
and that 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.
(2) Residential care reimbursement.
Recommended per diem reimbursement for residential care is determined as
follows.
(A) Reported allowable expenses are
combined into four cost areas:
(iv) administration and
transportation.
(B)
Facility, transportation (vehicle), and administration expenses are lowered to
reflect expenses for a provider at the lower of:
(i) 85% occupancy rate; or
(ii) the overall average occupancy rate for
licensed beds in facilities included in the database during the cost-reporting
periods included in the base. The occupancy adjustment is applied if the
provider's occupancy rate is below 85% or the overall average, whichever is
lower. The occupancy adjustment is determined by the individual provider
occupancy rate being divided by .85 or the average occupancy rate of all
providers in the database.
(C) 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 and employee benefits are Federal Insurance
Contributions Act or Social Security, Medicare contributions, Workers'
Compensation Insurance, the Federal Unemployment Tax Act, and the Texas
Unemployment Compensation Act.
(D)
The attendant cost area from subparagraph (A)(i) of this paragraph will be
calculated as specified in §
RSA
355.112 of this title (relating to Attendant
Compensation Rate Enhancement).
(E)
The following applies to the cost areas from subparagraph (A)(ii) - (iv) of
this paragraph:
(i) 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). The prospective reimbursement period is
the period of time that the reimbursement is expected to be in
effect.
(ii) Cost area per diem
expenses are calculated by dividing total reported allowable costs for each
cost area by the total days of service. Cost area per diem expenses are rank
ordered from low to high to produce projected per diem expense
arrays.
(iii) Reimbursement is
determined by selecting from each cost area the median day of service and the
corresponding per diem expense times 1.07. The resulting cost area amounts are
totaled to determine the per diem reimbursement.
(iv) The client is required to pay for their
room and board portion of the per diem reimbursement. DADS will pay the
services portion of the per diem reimbursement. The room and board payments
will be paid to providers by the client from the client's Supplemental Security
Income (SSI). When SSI is increased or decreased by the Federal Social Security
Administration, the per diem reimbursement will be adjusted in amounts equal to
the increase or decrease in SSI received by clients.
(3) Exceptions to the
reimbursement determination methodology. Reimbursement may be adjusted in
accordance with §
RSA
355.109 of this title (relating to Adjusting
Reimbursement When New Legislation, Regulations, or Economic Factors Affect
Costs) when new legislation, regulations, or economic factors affect
costs.
(d) Authority to
determine reimbursement. The authority to determine reimbursement is specified
in §
RSA 355.101 of this
title.
(e) Allowable and
unallowable costs. In determining whether a cost is allowable or unallowable,
providers must follow the guidelines as specified in §
RSA
355.102 of this title (relating to General
Principles of Allowable and Unallowable Costs) and §
RSA
355.103 of this title (relating to
Specifications for Allowable and Unallowable Costs). In addition to these
sections, the following allowable and unallowable costs are applicable in the
Community Care for Aged and Disabled Residential Care program.
(1) Allowable costs. Medical supplies
required to provide residential care services are allowable. Allowable medical
costs include supply costs associated with the administration of medications,
such as medication cups, syringes for insulin injections, stethoscopes, blood
pressure cuffs, and thermometers.
(2) Unallowable costs. Unallowable costs
include prescription drugs; non-legend drugs; medical records costs; and
compensation for physicians, pharmacists, and medical directors.
(f) Reporting revenue. Revenues
must be reported on the cost report in accordance with §
RSA 355.104 of this
title (relating to Revenues).
(g)
Reviews and field audits of cost reports. Desk reviews or field audits are
performed on cost reports of all contracted providers. The frequency and nature
of the field audit are determined by HHSC or its designee 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).
