Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. Reimbursement is available
to a Local Education Agency (LEA) for providing certain direct medical and
transportation services, known as SHARS, to a Medicaid-enrolled student with a
disability age 20 years of age or younger. SHARS services are described in and
must be prescribed in accordance with §
RSA
354.1341 of this title (relating to Benefits
and Limitations).
(b) Definitions.
The following words and terms, when used in this section, have the following
meanings, unless the context clearly indicates otherwise.
(1) Cost report--An annual report documenting
the LEA's Medicaid-allowable costs for all SHARS delivered during the previous
federal fiscal year. The cost report is due on or before April 1 of the year
following the reporting period and must be certified in a manner specified by
the Texas Health and Human Services Commission (HHSC). The primary purposes of
the cost report are to:
(A) document the
LEA's total Medicaid-allowable costs for delivering SHARS, including direct
costs and indirect costs, based on federally mandated cost allocation
methodologies; and
(B) reconcile
interim payments to total Medicaid-allowable costs based on approved cost
allocation methodology procedures.
(2) Eligible student--A Medicaid-enrolled
student with a disability age 20 years of age or younger that receives a direct
medical or transportation service as prescribed by §
RSA
354.1341 of this title.
(3) Interim claim--A claim for a direct
medical or transportation service paid at the interim rate that is provisional
in nature pending the completion of a cost reconciliation and cost settlement
for the cost reporting period.
(4)
Local Education Agency (LEA)--A Texas independent school district or public
charter school.
(5) Time study--A
statistically valid random sampling method used to identify the percentage of
time spent performing actual direct medical services irrespective of payer and
administrative cost.
(c)
Parental Consent. Prior to submitting its annual cost report, the LEA must meet
the parental consent requirements in §
RSA
354.1342 of this title (relating to
Conditions for Participation) for each student included in the numerator of the
following ratios required in the cost report.
(1) IEP ratio--A comparison of the total
number of students enrolled in Medicaid with individualized education programs
(IEPs) requiring direct medical services to the total number of students with
IEPs requiring direct medical services.
(2) One-way trip ratio--A comparison of the
total one-way trips for students enrolled in Medicaid with IEPs requiring
specialized transportation services, who received direct medical services the
same day, to the total one-way trips for all students with IEPs requiring
specialized transportation services.
(3) Section 504 Plan ratio--A comparison of
the total number of students enrolled in Medicaid with Section 504 Plans
requiring audiology services to the total number of students with Section 504
Plans requiring audiology services.
(d) Time study. The LEA must participate in
the HHSC-administered time study in the manner prescribed by HHSC.
(e) Reimbursement methodology. LEAs are
reimbursed for direct medical and transportation services provided under the
SHARS program on a cost basis.
(1) Interim
rates. The interim rate is developed based on a percentage of the average
per-unit cost for each SHARS service using actual cost data collected on cost
reports and is subject to change under §
RSA
355.109 of this chapter (relating to
Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors
Affect Costs). Interim rates are updated annually or as determined by
HHSC.
(2) Interim claims.
(A) LEAs must submit:
(i) at least one interim claim for each
direct medical service that an eligible student receives within the cost report
period;
(ii) interim claims for all
personal care services that an eligible student receives within the cost report
period; and
(iii) interim claims
for all eligible specialized transportation trips provided within the cost
report period.
(B)
Requirements for interim claims will be adjusted as needed based on direction
from the Centers for Medicare and Medicaid Services.
(C) Interim claims must be valid and
reimbursed to meet the requirements in this paragraph.
(3) Interim payment. LEAs are reimbursed for
SHARS direct medical services and transportation services per unit of service
at the lesser of:
(A) the LEA's billed
charges; or
(B) the interim
rate.
(4) Final
reimbursement. The LEA's final reimbursement amount is arrived at by a cost
reconciliation and cost settlement process. As reported in the cost report, the
LEA's total costs for both direct medical and transportation services are
adjusted using the federally mandated allocation methodologies.
(A) Direct medical services costs. Salary and
contract costs must be reported in the manner prescribed by HHSC.
(i) Direct costs. From the annual cost
report, HHSC aggregates allowable costs for direct medical services, resulting
in total direct costs. Direct costs for direct medical services include payroll
costs and other costs that can be directly charged to direct medical services
provided by contractors and LEA staff (i.e., salaries, benefits, and contract
compensation). Direct medical services costs do not include transportation
personnel costs.
(ii) Indirect
costs. Indirect costs are determined by applying the LEA's specific
unrestricted indirect cost rate to its net direct costs. Texas LEAs use
predetermined fixed rates for indirect costs. The Texas Education Agency (TEA)
has, in cooperation with the United States Department of Education (USDE),
developed an indirect cost plan to be used by LEAs in Texas. As authorized in
RSA
75.561(b), TEA approves
unrestricted indirect cost rates for LEAs for the USDE, which is the cognizant
agency for LEAs.
(iii) Net
allowable cost. Direct and indirect costs are added together and adjusted by
the direct medical time study percentage, the IEP ratio, and the 504 Plan
ratio, resulting in a net Medicaid allowable cost for direct medical
services.
(B)
Transportation services. Salary and contract costs must be reported in the
manner prescribed by HHSC.
(i) Direct costs.
From the annual cost report, HHSC aggregates allowable direct costs for
transportation, resulting in total direct costs. Direct costs for covered
transportation services include payroll costs and other costs that can be
directly charged to covered transportation services. Direct payroll costs
include total compensation (i.e., salaries, benefits, and contract
compensation) of bus drivers and mechanics. Other direct costs include costs
directly related to the delivery of covered transportation services, such as
professional and contracted services, contracted transportation costs, gasoline
and other fuels, other maintenance and repair costs, vehicle insurance,
interest, rentals, and vehicle depreciation.
(ii) Indirect costs. Indirect costs are
determined by applying the LEA's specific unrestricted indirect cost rate to
its net direct costs. Texas public LEAs use predetermined fixed rates for
indirect costs. TEA has, in cooperation with the USDE, developed an indirect
cost plan to be used by LEAs in Texas. As authorized in
RSA
75.561(b), TEA approves
unrestricted indirect cost rates for LEAs for the USDE, which is the cognizant
agency for LEAs.
(iii) Net
allowable cost. Net direct costs and indirect costs are added together and
adjusted by the one-way trip ratio, resulting in a net Medicaid allowable cost
for transportation services.
(f) Cost reporting requirements. HHSC
excludes from reimbursement determinations any unallowable expenses included in
the cost report and makes the appropriate adjustments to expenses and other
information reported by LEAs.
(1)
Certification. Each LEA certifies through the cost report process its total
actual federal and non-federal costs and expenditures.
(2) Reimbursement determinations and
allowable costs. LEAs are responsible for reporting only allowable costs on the
cost report, except where HHSC prescribes that other costs are to be reported
in specific lines or sections. Only allowable cost information is used to
determine recommended reimbursement. All costs relating to Shared Service
Arrangements and Co-operatives must be allocated to each respective
LEA.
(g) Cost
reconciliation. The Medicaid-allowable costs for direct medical and
transportation services are added together and adjusted by the federal Medicaid
assistance percentage (FMAP) to arrive at the federal share owed to the LEA.
This amount is then reconciled with interim payments already made to the
LEA.
(h) Cost settlement. HHSC uses
a cost settlement process as follows.
(1) HHSC
retains one percent of the federal share of the total certified Medicaid
allowable cost as an administrative fee to be used for Health and Human
Services administrative activities, including compliance monitoring, technical
assistance, and to establish and maintain an audit reserve fund.
(2) If an LEA's interim payments exceed 99
percent of the LEA's federal portion of the total certified Medicaid allowable
costs, HHSC recoups the overpayment using one of these two methods:
(A) HHSC offsets all future claims payments
from the LEA until the amount is recovered; or
(B) the LEA returns an amount equal to the
amount owed.
(3) If 99
percent of the LEA's federal portion of the total certified Medicaid allowable
costs exceeds the interim Medicaid payments, HHSC pays the difference to the
LEA.
(4) HHSC issues a notice of
settlement within 24 months of the end of the reporting period.
(i) Informal review. An LEA who
disputes an action or determination under this chapter may request an informal
review under §
RSA
355.110 of this title (relating to Informal
Reviews and Formal Appeals). This section provides clarification unique to the
SHARS program.
(1) HHSC Provider Finance must
receive a written request for an informal review in a manner prescribed by HHSC
no later than 30 calendar days from the date on the written notification of the
adjustments. If the 30th calendar day is a weekend day, national holiday, or
state holiday, then the first business day following the 30th calendar day is
the final day the receipt of the written request will be accepted. HHSC
Provider Finance will extend this deadline if it receives a written request for
the extension in a manner prescribed by HHSC, no later than 30 calendar days
from the date of the written notice of adjustments. The extension gives the
requester a total of 45 calendar days from the date of the written notice of
adjustment to file a request for an informal review. If the 45th calendar day
is a weekend day, national holiday, or state holiday, then the 45th day is
considered the next business day following the 45th calendar day. A request for
an informal review or extension that is not received by the stated deadline
will not be accepted.
(2) An LEA
must, with its request for an informal review, submit a concise statement of
the specific actions or determinations it disputes, its recommended resolution,
and any supporting documentation the LEA deems relevant to the dispute. It is
the responsibility of the LEA to render all pertinent information at the time
of its request for an informal review. Disputed actions or determinations that
are not explicitly stated in the request will not be considered by HHSC, and
failure of HHSC to act on implied items of dispute will not be considered
grounds for a formal appeal. A request for an informal review that does not
meet the requirements of this paragraph will not be accepted.
(3) The written request for the informal
review or extension must be signed by an individual legally responsible for the
conduct of the LEA or a legal representative for the LEA. The administrator or
director of the LEA is not authorized to sign the request unless the
administrator or director has this legal authority. A request for an informal
review that is not signed by an individual legally responsible for the conduct
of the LEA or a legal representative for the LEA will not be
accepted.
(j) General
information. In addition to the requirements of this section, the cost
reporting guidelines will be governed by the information in: §
RSA 355.101 of this
chapter (relating to Introduction); §
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); §
RSA
355.105 of this chapter (relating to General
Reporting and Documentation Requirements, Methods, and Procedures); §
RSA
355.106 of this chapter (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports); §
RSA
355.107 of this chapter (relating to
Notification of Exclusions and Adjustments); §
RSA
355.108 of this chapter (relating to
Determination of Inflation Indices); §
RSA
355.109 of this chapter; and §
RSA
355.110 of this chapter. If there is a
conflict between an applicable section of Chapter 355, Subchapter A of this
title (related to Cost Determination Process) and the provisions of this
section, the provisions of this section will prevail.
(k) In addition to the requirements of this
section, the LEA must comply with all provisions outlined in §
RSA
354.1341 of this title and §
RSA
354.1342 of this title.
(l) Administrative contract violations. HHSC
may take the following actions against an LEA for administrative contract
violations.
(1) Time study. For failure to
participate in or meet all time study requirements, HHSC will recoup all
interim payments made during the cost reporting period and will not allow the
LEA to submit a cost report for that reporting period.
(2) Interim claims. The LEA is ineligible to
submit a cost report if they fail to submit interim claims in the manner and
format prescribed by HHSC, or its designee, including the requirements in
subsection (e)(2) of this section. If a service category, student, employee, or
related cost is claimed in the cost report without having been appropriately
claimed in compliance with program requirements, that specific service
category, student, employee, or related cost will be disallowed from the cost
report.
(3) Cost reports.
(A) For failure to submit a cost report by
the due date, HHSC will recoup all interim payments made during the cost
reporting period.
(B) HHSC will
remove all unallowable costs and reserve the right to update a certified cost
report if inaccurate information is identified or reported by the
LEA.
(4) Other
administrative contract violations. For all other administrative contract
violations, HHSC will recoup all interim payments made during the cost
reporting period.
(5) Appeals. An
LEA may request a hearing to appeal HHSC's action concerning an administrative
contract violation. Formal appeals are conducted in accordance with the
provisions of Chapter 357, Subchapter I of this title (relating to Hearings
under the Administrative Procedure Act). If there is a conflict between an
applicable section of Chapter 357 of this title (relating to Hearings) and the
provisions of this chapter, the provisions of this chapter will
prevail.
