PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 355. REIMBURSEMENT RATES
The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §355.102, concerning General Principles of Allowable and Unallowable Costs; §355.306, concerning Cost Finding Methodology; §355.314, concerning Supplemental Payments to Non-State Government-Owned Nursing Facilities; §355.458, concerning Supplemental Payments to Non-State Government-Owned Facilities; §355.722, concerning Reporting Costs by Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Providers; §355.743, concerning Reimbursement Methodology for Mental Health Case Management; §355.746, concerning Reimbursement Methodology for Mental Retardation Service Coordination; §355.781, concerning Rehabilitative Services Reimbursement Methodology; §355.8210, concerning Waiver Payments to Governmental Ambulance Providers for Uncompensated Charity Care; §355.8421, concerning Reimbursement for Case Management Services for Infants and Toddlers with Developmental Disabilities; §355.8422, concerning Reimbursement for Specialized Rehabilitation Services for Infants and Toddlers with Developmental Disabilities; and §355.9040, concerning Reimbursement Methodology for Comprehensive Rehabilitation Services Program.
BACKGROUND AND PURPOSE
In 2020, the Rate Analysis Department of HHSC underwent a rebranding to change the department's name to "Provider Finance Department." The purpose of the proposal is to amend several rules within the Texas Administrative Code that contain instances of the previous department name and replace them with the current department name.
SECTION-BY-SECTION
The proposed amendments to §355.102, §355.306, §355.314, §355.458, §355.722, §355.743, §355.746, §355.781, §355.8210, §355.8421, §355.8422, and §355.9040 replace instances of "Rate Analysis," "Rate Analysis Department," or "RAD" with "Provider Finance," "Provider Finance Department," and "PFD," respectively.
FISCAL NOTE
Trey Wood, Chief Financial Officer, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules does not have foreseeable implications relating to costs or revenues of state or local governments.
GOVERNMENT GROWTH IMPACT STATEMENT
HHSC has determined that during the first five years that the rules will be in effect:
(1) the proposed rules will not create or eliminate a government program;
(2) implementation of the proposed rules will not affect the number of HHSC employee positions;
(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;
(4) the proposed rules will not affect fees paid to HHSC;
(5) the proposed rules will not create a new rule;
(6) the proposed rules will not expand, limit, or repeal existing rules;
(7) the proposed rules will not change the number of individuals subject to the rules; and
(8) the proposed rules will not affect the state's economy.
SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS
Trey Wood has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities. The rules do not impose any additional costs on small businesses, micro-businesses, or rural communities that are required to comply with the rules.
LOCAL EMPLOYMENT IMPACT
The proposed rules will not affect a local economy.
COSTS TO REGULATED PERSONS
Texas Government Code §2001.0045 does not apply to these rules because the rules do not impose a cost on regulated persons.
PUBLIC BENEFIT AND COSTS
Victoria Grady, Director of Provider Finance, has determined that for each year of the first five years the rules are in effect, the public benefit will be improved communication with stakeholders and prevention of confusion regarding the Provider Finance Department's renaming.
Trey Wood has also determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules because there are no costs associated with the proposed amendments.
TAKINGS IMPACT ASSESSMENT
HHSC has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.
PUBLIC COMMENT
Questions about the content of this proposal may be directed to Alexa Hites at (512) 730-7455 in HHSC Provider Finance Department.
Written comments on the proposal may be submitted to Alexa Hites, Management Analyst, at H400, 4601 W Guadalupe St, Austin, TX 78751; or by e-mail to ProviderFinanceDept@hhs.texas.gov.
To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 23R003" in the subject line.
SUBCHAPTER A. COST DETERMINATION PROCESS
STATUTORY AUTHORITY
The amendment is authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.102.General Principles of Allowable and Unallowable Costs.
(a) Allowable and unallowable costs. Allowable and unallowable costs, both direct and indirect, are defined to identify expenses that are reasonable and necessary to provide contracted client care and are consistent with federal and state laws and regulations. When a particular type of expense is classified as unallowable, the classification means only that the expense will not be included in the database for reimbursement determination purposes because the expense is not considered reasonable and/or necessary. The classification does not mean that individual contracted providers may not make the expenditure. The description of allowable and unallowable costs is designed to be a general guide and to clarify certain key expense areas. This description is not comprehensive, and the failure to identify a particular cost does not necessarily mean that the cost is an allowable or unallowable cost.
(b) Cost-reporting process. The primary objective of the cost-reporting process is to provide a basis for determining appropriate reimbursement to contracted providers. To achieve this objective, the reimbursement determination process uses allowable cost information reported on cost reports or other surveys. The cost report collects actual allowable costs and other financial and statistical information, as required. Costs may not be imputed and reported on the cost report when no costs were actually incurred (except as stated in §355.103(b)(19)(A)(i) of this title (relating to Specifications for Allowable and Unallowable Costs) or when documentation does not exist for costs even if they were actually incurred during the reporting period).
(c) Accurate cost reporting. Accurate cost reporting is the responsibility of the contracted provider. The contracted provider is responsible for including in the cost report all costs incurred, based on an accrual method of accounting, which are reasonable and necessary, in accordance with allowable and unallowable cost guidelines in this section and in §355.103 of this title, revenue reporting guidelines in §355.104 of this title (relating to Revenues), cost report instructions, and applicable program rules. Reporting all allowable costs on the cost report is the responsibility of the contracted provider. The Texas Health and Human Services Commission (HHSC) is not responsible for the contracted provider's failure to report allowable costs; however, in an effort to collect reliable, accurate, and verifiable financial and statistical data, HHSC is responsible for providing cost report training, general and/or specific cost report instructions, and technical assistance to providers. Furthermore, if unreported and/or understated allowable costs are discovered during the course of an audit desk review or field audit, those allowable costs will be included on the cost report or brought to the attention of the provider to correct by submitting an amended cost report.
(d) Cost and accountability report training. It is the responsibility of the provider to ensure that each cost or accountability report preparer has completed the required state-sponsored training. Preparers may be employees of the provider or persons who have been contracted by the provider for the purpose of cost or accountability report preparation. Preparers must complete training for each program for which a cost or accountability report is submitted, as applicable. Contracted preparer's fees to complete training are considered allowable expenses for cost reporting purposes. Preparers that participate in training may be assessed a convenience fee, which will be determined by HHSC. Convenience fees assessed for training are allowable costs. Applicable federal and state accessibility standards apply to training. Beginning with the 2018 cost reports and 2019 accountability reports, reporting schedules per program are determined by HHSC and are published on the HHSC website.
(1) Training schedules.
(A) For programs with odd-year and even-year cost reports. Preparers must complete state-sponsored cost report training every other year in order to be eligible to complete both that odd-year cost report and the following even-year cost report. If a new preparer wishes to complete an even-year cost report and has not completed the previous odd-year cost report training, the preparer must complete an even-year cost report training.
(B) For programs with odd-year and even-year accountability reports. Preparers must complete state-sponsored accountability report training every other year in order to be eligible to complete both that odd-year accountability report and the following even-year accountability report. If a new preparer wishes to complete an even-year accountability report and has not completed the previous odd-year accountability report training, the preparer must complete an even-year accountability report training.
(C) For all other programs. Preparers must complete the state-sponsored training for each program for which a cost or accountability report is submitted. Beginning with the 2018 cost reports, new preparers must complete cost report training every other year for each program cost or accountability report being prepared in order to be eligible to complete both that year's cost report and the following year's accountability report, if applicable. If a new preparer wishes to complete an accountability report and has not completed the previous year's cost report training, the preparer must complete an accountability report training for that program for that year.
(2) Failure to complete the required cost or accountability report training.
(A) For nursing facilities, failure to file a completed cost or accountability report signed by preparers who have completed the required cost report training may result in vendor hold as specified in §355.403 of this title (relating to Vendor Hold).
(B) For School Health and Related Services (SHARS) providers, failure to complete the required cost report training may result in an administrative contract violation as specified in §355.8443 of this title.
(C) For all other programs, failure to file a completed cost or accountability report signed by preparers who have completed the required cost report training constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title (relating to Administrative Contract Violations).
(e) Generally accepted accounting principles. Except as otherwise specified by the cost determination process rules of this chapter, cost report instructions, or policy clarifications, cost reports should be prepared consistent with generally accepted accounting principles (GAAP), which are those principles approved by the American Institute of Certified Public Accountants (AICPA). Internal Revenue Service (IRS) laws and regulations do not necessarily apply in the preparation of the cost report. In cases where cost reporting rules differ from GAAP, IRS, or other authorities, HHSC rules take precedence for provider cost-reporting purposes.
(f) Allowable costs. Allowable costs are expenses, both direct and indirect, that are reasonable and necessary, as defined in paragraphs (1) and (2) of this subsection, and which meet the requirements as specified in subsections (i), (j), and (k) of this section, in the normal conduct of operations to provide contracted client services meeting all pertinent state and federal requirements. Only allowable costs are included in the reimbursement determination process.
(1) "Reasonable" refers to the amount expended. The test of reasonableness includes the expectation that the provider seeks to minimize costs and that the amount expended does not exceed what a prudent and cost-conscious buyer pays for a given item or service. In determining the reasonableness of a given cost, the following are considered:
(A) the restraints or requirements imposed by arm's-length bargaining, i.e., transactions with nonowners or other unrelated parties, federal and state laws and regulations, and contract terms and specifications; and
(B) the action that a prudent person would take in similar circumstances, considering his responsibilities to the public, the government, his employees, clients, shareholders, and members, and the fulfillment of the purpose for which the business was organized.
(2) "Necessary" refers to the relationship of the cost, direct or indirect, incurred by a provider to the provision of contracted client care. Necessary costs are direct and indirect costs that are appropriate in developing and maintaining the required standard of operation for providing client care in accordance with the contract and state and federal regulations. In addition, to qualify as a necessary expense, a direct or indirect cost must meet all of the following requirements:
(A) the expenditure was not for personal or other activities not directly or indirectly related to the provision of contracted services;
(B) the cost does not appear as a specific unallowable cost in §355.103 of this title;
(C) if a direct cost, it bears a significant relationship to contracted client care. To qualify as significant, the elimination of the expenditure would have an adverse impact on client health, safety, or general well-being;
(D) the direct or indirect expense was incurred in the purchase of materials, supplies, or services provided to clients or staff in the normal conduct of operations to provide contracted client care;
(E) the direct or indirect costs are not allocable to or included as a cost of any other program in either the current, a prior, or a future cost-reporting period;
(F) the costs are net of all applicable credits;
(G) allocated costs of each program are adequately substantiated; and
(H) the costs are not prohibited under other pertinent federal, state, or local laws or regulations.
(3) Direct costs are those costs incurred by a provider that are definitely attributable to the operation of providing contracted client services. Direct costs include, but are not limited to, salaries and nonlabor costs necessary for the provision of contracted client care. Whether or not a cost is considered a direct cost depends upon the specific contracted client services covered by the program. In programs in which client meals are covered program services, the salaries of cooks and other food service personnel are direct costs, as are food, nonfood supplies, and other such dietary costs. In programs in which client transportation is a covered program service, the salaries of drivers are direct costs, as are vehicle repairs and maintenance, vehicle insurance and depreciation, and other such client transportation costs.
(4) Indirect costs are those costs that benefit, or contribute to, the operation of providing contracted services, other business components, or the overall contracted entity. These costs could include, but are not limited to, administration salaries and nonlabor costs, building costs, insurance expense, and interest expense. Central office or home office administrative expenses are considered indirect costs. As specified in §355.8443 of this title, SHARS providers use an unrestricted indirect cost rate to determine indirect costs.
(g) Unallowable costs. Unallowable costs are expenses that are not reasonable or necessary, according to the criteria specified in subsection (f)(1) - (2) of this section and which do not meet the requirements as specified in subsections (i), (j), and (k) of this section or which are specifically enumerated in §355.103 of this title or program-specific reimbursement methodology. Providers must not report as an allowable cost on a cost report a cost that has been determined to be unallowable. Such reporting may constitute fraud. (Refer to §355.106(a) of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports)).
(1) For nursing facilities, placement as an allowable cost on a cost report of a cost which has been determined to be unallowable may result in vendor hold as specified in §355.403 of this title.
(2) For Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID), Home and Community-based Services (HCS), Service Coordination/Targeted Case Management, Rehabilitative Services, and Texas Home Living (TxHmL) programs, placement as an allowable cost on a cost report a cost, which has been determined to be unallowable, constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title.
(3) For SHARS providers, submission of a cost that has been determined to be unallowable may result in an administrative contract violation as specified in §355.8443 of this title.
(4) For all other programs, submission of a cost, which has been determined to be unallowable, constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title.
(h) Other financial and statistical data. The primary purpose of the cost report is to collect allowable costs to be used as a basis for reimbursement determination. In addition, providers may be required on cost reports to provide information in addition to allowable costs to support allowable costs, such as wage surveys, workers' compensation surveys, or other statistical and financial information. Additional data requested may include, when specified and in the appropriate section or line number specified, costs incurred by the provider which are unallowable costs. All information, including other financial and statistical data, shown on a cost report is subject to the documentation and verification procedures required for an audit desk review and/or field audit.
(1) For nursing facilities, inaccuracy in providing, or failure to provide, required financial and statistical data may result in vendor hold as specified in §355.403 of this title.
(2) For ICF/IID, HCS, Service Coordination/Targeted Case Management, Rehabilitative Services, and TxHmL programs, inaccuracy in providing, or failure to provide, required financial and statistical data constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title.
(3) For SHARS, inaccuracy in providing, or failure to provide, required financial and statistical data may result in an administrative contract violation as specified in §355.8443 of this title.
(4) For all other programs, inaccuracy in providing, or failure to provide, required financial and statistical data constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title.
(i) Related party transactions.
(1) In determining whether a contracted provider organization is related to a supplying organization, the tests of common ownership and control are to be applied separately. Related to a contracted provider means that the contracted provider to a significant extent is associated or affiliated with, has control of, or is controlled by the organization furnishing the services, equipment, facilities, leases, or supplies. Common ownership exists if an individual or individuals possess any ownership or equity in the contracted provider and the institution or organization serving the contracted provider. Control exists if an individual or an organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or institution. If the elements of common ownership or control are not present in both organizations, then the organizations are deemed not to be related to each other. The existence of an immediate family relationship will create an irrefutable presumption of relatedness through control or attribution of ownership or equity interests where the significance tests are met. The following persons are considered immediate family for cost-reporting purposes:
(A) husband and wife;
(B) natural parent, child, and sibling;
(C) adopted child and adoptive parent;
(D) stepparent, stepchild, stepsister, and stepbrother;
(E) father-in-law, mother-in-law, sister-in-law, brother-in-law, son-in-law, and daughter-in-law;
(F) grandparent and grandchild;
(G) uncles and aunts by blood or marriage;
(H) nephews and nieces by blood or marriage; and
(I) first cousins.
(2) A determination as to whether an individual (or individuals) or organization possesses ownership or equity in the contracted provider organization and the supplying organization, so as to consider the organizations related by common ownership, will be made on the basis of the facts and circumstances in each case. This rule applies whether the contracted provider organization or supplying organization is a sole proprietorship, partnership, corporation, trust or estate, or any other form of business organization, proprietary or nonprofit. In the case of a nonprofit organization, ownership or equity interest will be determined by reference to the interest in the assets of the organization, e.g., a reversionary interest provided for in the articles of incorporation of a nonprofit corporation.
(3) The term control includes any kind of control, whether or not it is legally enforceable and however it is exercisable or exercised. It is the reality of the control which is decisive, not its form or the mode of its exercise. The facts and circumstances in each case must be examined to ascertain whether legal or effective control exists. Since a determination made in a specific case represents a conclusion based on the entire body of facts and circumstances involved, such determination should not be used as a precedent in other cases unless the facts and circumstances are substantially the same. Organizations, whether proprietary or nonprofit, are considered to be related through control to their directors in common.
(4) Costs applicable to services, equipment, facilities, leases, or supplies furnished to the contracted provider by organizations related to the provider by common ownership or control are includable in the allowable cost of the provider at the cost to the related organization. However, the cost must not exceed the price of comparable services, equipment, facilities, leases, or supplies that could be purchased or leased elsewhere. The purpose of this principle is twofold: to avoid the payment of a profit factor to the contracted provider through the related organization (whether related by common ownership or control), and to avoid payment of artificially inflated costs which may be generated from less than arm's-length bargaining. The related organization's costs include all actual reasonable costs, direct and indirect, incurred in the furnishing of services, equipment, facilities, leases, or supplies to the provider. The intent is to treat the costs incurred by the supplier as if they were incurred by the contracted provider itself. Therefore, if a cost would be unallowable if incurred by the contracted provider itself, it would be similarly unallowable to the related organization. The principles of reimbursement of contracted provider costs described throughout this title will generally be followed in determining the reasonableness and allowability of the related organization's costs, where application of a principle in a nonprovider entity would be clearly inappropriate.
(5) An exception is provided to the general rule applicable
to related organizations. The exception applies if the contracted
provider demonstrates by convincing evidence to the satisfaction of
HHSC that certain criteria have been met. If all of the conditions
of this exception are met, then the charges by the supplier to the
contracted provider for such services, equipment, facilities, leases,
or supplies are allowable costs. If Medicare has made a determination
that a related party situation does not exist or that an exception
to the related party definition was granted, HHSC will review the
determination made by Medicare to determine if it is applicable to
the current situation of the contracted provider and in compliance
with this subsection (relating to related party transactions). In
order to have the Medicare determination considered for approval by
HHSC, a copy of the applicable Medicare determination must accompany
each written exception request submitted to HHSC, along with evidence
supporting the Medicare determination for the current cost-reporting
period. If the exception granted by Medicare no longer is applicable
due to changes in circumstances of the contracted provider or because
the circumstances do not apply to the contracted provider, HHSC may
choose not to consider the Medicare determination. Written requests
for an exception to the general rule applicable to related organizations
must be submitted for approval to the HHSC Provider Finance [Rate Analysis] Department no later than 45 days prior to the
due date of the cost report in order to be considered for that year's
cost report. Each request must include documentation supporting that
the contracted provider meets each of the four criteria listed in
subparagraphs (A) - (D) of this paragraph. Requests that do not include
the required documentation for each criteria will not be considered
for that year's cost report.
(A) The supplying organization is a bona fide separate organization. This means that the supplier is a separate sole proprietorship, partnership, joint venture, association or corporation and not merely an operating division of the contracted provider organization.
(B) A majority of the supplying organization's business activity of the type carried on with the contracted provider is transacted with other organizations not related to the contracted provider and the supplier by common ownership or control and there is an open, competitive market for the type of services, equipment, facilities, leases, or supplies furnished by the organization. In determining whether the activities are of similar type, it is important also to consider the scope of the activity. The requirement that there be an open, competitive market is merely intended to assure that the item supplied has a readily discernible price that is established through arm's-length bargaining by well-informed buyers and sellers.
(C) The services, equipment, facilities, leases, or supplies are those which commonly are obtained by entities such as the contracted provider from other organizations and are not a basic element of contracted client care ordinarily furnished directly to clients by such entities. This requirement means that entities such as the contracted provider typically obtain the services, equipment, facilities, leases, or supplies from outside sources, rather than producing them internally.
(D) The charge to the contracted provider is in line with the charge of such services, equipment, facilities, leases, or supplies in the open, competitive market and no more than the charge made under comparable circumstances to others by the organization for such services, equipment, facilities, leases, or supplies.
(6) Disclosure of all related-party information on the cost report is required for all costs reported by the contracted provider, including related-party transactions occurring at any level in the provider's organization, (e.g., the central office level, and the individual contracted provider level). The contracted provider must make available, upon request, adequate documentation to support the costs incurred by the related party. Such documentation must include an identification of the related person's or organization's total costs, the basis of allocation of direct and indirect costs to the contracted provider, and other business entities served. If a contracted provider fails to provide adequate documentation to substantiate the cost to the related person or organization, then the reported cost is unallowable. For further guidelines regarding adequate documentation, refer to §355.105(b)(2) of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures).
(7) When calculating the cost to the related organization, the cost-determination guidelines specified in this section and in §355.103 of this title apply.
(j) Cost allocation. Direct costing must be used whenever reasonably possible. Direct costing means that allowable costs, direct or indirect, (as defined in subsection (f)(3) - (4) of this section) incurred for the benefit of, or directly attributable to, a specific business component must be directly charged to that particular business component. For example, the payroll costs of a direct care employee who works across cost areas within one contracted program would be directly charged to each cost area of that program based upon that employee's continuous daily time sheets and the costs of a direct care employee who works across more than one service delivery area would also be directly charged to each service delivery area based upon that employee's continuous daily time sheets. Health insurance premiums, life insurance premiums, and other employee benefits must be direct costed.
(1) If cost allocation is necessary for cost-reporting purposes, contracted providers must use reasonable methods of allocation and must be consistent in their use of allocation methods for cost-reporting purposes across all program areas and business entities.
(A) The allocation method should be a reasonable reflection of the actual business operations. Allocation methods that do not reasonably reflect the actual business operations and resources expended toward each unique business entity are not acceptable. Allocated costs are adjusted if HHSC considers the allocation method to be unreasonable. An indirect allocation method approved by some other department, program, or governmental entity is not automatically approved by HHSC for cost-reporting purposes.
(B) HHSC reviews each cost-reporting allocation method on a case-by-case basis in order to ensure that the reported costs fairly and reasonably represent the operations of the contracted provider. If in the course of an audit it is determined that an existing or approved allocation method does not fairly and reasonably represent the operations of the contracted provider, then an adjustment to the allocation method will be made consistent with subsection (f)(3) - (4) of this section. A contracted provider may request an informal review, and subsequently an appeal, of a decision concerning its allocation methods in accordance with §355.110 of this title (relating to Informal Reviews and Formal Appeals).
(C) Any allocation method used for cost-reporting purposes must be consistently applied across all contracted programs and business entities in which the contracted provider has an interest.
(D) Providers must use an allocation method approved
or required by HHSC. Any change in cost-reporting allocation methods
from one year to the next must be fully disclosed by the contracted
provider on its cost report and must be accompanied by a written explanation
of the reasons and justification for such change. If the provider
wishes to use an allocation method that is not in compliance with
the cost-reporting allocation methods in paragraphs (3) - (4) of this
subsection, the contracted provider must obtain written prior approval
from HHSC's Provider Finance [Rate Analysis] Department.
(i) Requests for approval to use an allocation method
other than those identified in paragraphs (3) - (4) of this subsection
or for approval of a provider's change in cost-reporting allocation
method other than those identified in paragraphs (3) - (4) of this
subsection must be received by HHSC's Provider Finance [Rate
Analysis] Department prior to the end of the contracted provider's
fiscal year. Requests for approval of allocation methods will not
be acceptable as a basis for the extension of the cost report due date.
(ii) The HHSC Provider Finance [Rate
Analysis] Department will forward its written decision to the
contracted provider within 45 days of its receipt of the provider's
original written request. If sufficient documentation is not provided
by the provider to verify the acceptability of the allocation method,
then HHSC may extend the decision time frame. However, an extension
of the due date of the cost report will not be granted. Written decisions
made on or after the due date of the cost report will apply to the
next year's cost report. A contracted provider may request an informal
review, and subsequently an appeal, of a decision concerning its allocation
methods in accordance with §355.110 of this title.
(iii) Failure to use an allocation method approved or required by HHSC or to disclose a change in an allocation to HHSC will result in the following.
(I) For nursing facilities, failure to disclose a change in an allocation method or failure to use the allocation method approved or required by HHSC may result in vendor hold as specified in §355.403 of this title.
(II) For ICF/IID, HCS, Service Coordination/Targeted Case Management, Rehabilitative Services, and TxHmL programs, failure to use the allocation method approved or required by HHSC constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title.
(III) For SHARS, failure to use the allocation method approved or required by HHSC constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.8443 of this title.
(IV) For all other programs, failure to disclose a change in an allocation method or failure to use the allocation method approved or required by HHSC constitutes an administrative contract violation. In the case of an administrative contract violation, procedural guidelines and informal reconsideration and/or appeal processes are specified in §355.111 of this title.
(E) For small and large state-operated ICF/IID, designated as Bond Homes and State Supported Living Centers for cost reporting purposes, these facility types may use an allocation method other than those identified in paragraphs (3) - (4) of this subsection in order to represent indirect costs that are a reasonable reflection of the actual business operations. If an allocation method other than those identified in paragraphs (3) - (4) of this subsection is used for indirect costs, the allocation method must adhere to Generally Accepted Accounting Principles.
(2) Cost-reporting methods for allocating costs must be clearly and completely documented in the contracted provider's workpapers, with details as to how pooled costs are allocated to each segment of the business entity, for both contracted and noncontracted programs.
(A) If a contracted provider has questions regarding
the reasonableness of an allocation method, that contracted provider
should request written approval from the HHSC Provider Finance [Rate Analysis] Department prior to submitting a cost report
utilizing the allocation method in question. Requests for approval
must be received by the HHSC Provider Finance [Rate
Analysis] Department prior to the end of the contracted provider's
fiscal year. Requests for approval of allocation methods will not
be acceptable as a basis for the extension of the cost report due date.
(B) The HHSC Provider Finance [Rate
Analysis] Department will forward its written decision to the
contracted provider within 45 days of its receipt of the original
written request. If sufficient documentation is not provided by the
provider to verify the acceptability of the allocation method, HHSC
may extend the decision time frame. However, an extension of the due
date of the cost report will not be granted. Written decisions made
on or after the due date of the cost report will apply to the next
year's cost report. A contracted provider may request an informal
review, and subsequently an appeal, of a decision concerning its allocation
methods in accordance with §355.110 of this title.
(3) When a building is shared and the building usage is separate and distinct for each entity using the building, the building costs, identified as building and facility cost categories on the cost report, should be allocated based upon square footage and may not be allocated with other indirect costs as a pool of costs. When the same building space is shared by various entities, the shared building costs, identified as building and facility cost categories on the cost report, should be allocated using a reasonable method which reflects the actual usage, such as an allocation based on time in shared activity areas or a functional study of shared dietary costs related to shared dining and kitchen areas.
(4) Where costs are shared, are not directly chargeable and are allocated as a pool of costs, the following allocation methods are acceptable for cost-reporting purposes.
(A) If all the business components of a contracted provider have equivalent units of equivalent service, indirect costs must be allocated based upon each business component's units of service. For example, if a provider had two nursing facilities, indirect costs requiring allocation as a pool of costs must be allocated based upon each nursing facility's units of service, since the units of service are equivalent units and the services are equivalent services. If a provider had a nursing facility and a residential care program, indirect costs requiring allocation as a pool of costs could not be allocated based upon units of service because even though the units of service for a nursing facility and a residential care facility are equivalent units, the services are not equivalent services. If a home health agency has indirect costs requiring allocation as a pool of costs across its Medicare home health services and its Medicaid primary home care services, it could not use units of service to allocate those costs, since neither the units of service nor the services are equivalent.
(B) If all of a contracted provider's business components are labor-intensive without programmatic residential facility or residential building costs, the contracted provider must allocate its indirect costs requiring allocation as a pool of costs based either on each business component's pro rata share of salaries or labor costs or on a cost-to-cost basis.
(i) For cost-reporting cost allocation purposes, the term "salaries" includes wages paid to employees directly charged to the specific business component. The term "salaries" also includes fees paid to contracted individuals, excluding consultants, who perform services routinely performed by employees, which are directly charged to the specific business component. The term "salaries" does not include payroll taxes and employee benefits associated with the wages of employees.
(ii) For cost-reporting cost-allocation purposes, the term "labor costs" includes salaries as defined in clause (i) of this subparagraph, plus the payroll taxes and employee benefits associated with the wages of the employees.
(iii) The cost-to-cost method allocates costs based upon the percentage of each business component's directly-charged costs to the total directly-charged costs of all business components.
(C) If a contracted provider's business components are mixed, with some being labor-intensive and others having a programmatic residential or institutional component, the contracted provider must allocate its indirect costs requiring allocation as a pool of costs either:
(i) based upon the ratio of each business component's total costs less that business component's facility or building costs, as related to the contracted provider's total business component costs less facility or building costs for all the contracted provider's business components, with "facility or building costs" referring to those cost categories as identified on the cost report; or
(ii) based upon the labor costs method stated in subparagraph (B)(ii) of this paragraph.
(D) In order to achieve a more accurate and representative reporting of costs than results from allocating shared indirect costs as a pool of costs, a provider may choose to allocate its indirect shared expenses on an appropriate and reasonable functional basis. If allocating shared direct client care costs, a provider may use an appropriate and reasonable functional method. For example, costs of a central payroll operation could be allocated to all business components based on the number of checks issued; the costs of a central purchasing function could be allocated based on the number of purchases made or requisitions handled; payroll costs for an administrative employee working across business components could be directly charged based upon that employee's time sheets and/or allocated based upon a documented time study; food costs could be allocated based upon a functional study of shared dietary costs; transportation equipment costs could be allocated based upon mileage logs; and shared laundry costs could be allocated based upon a functional study of the number of pounds/loads of laundry processed. Providers choosing to allocate allowable employee-related self-insurance paid claims in accordance with §355.103(b)(13)(B)(ii) of this title should base the allocation on percentage of salaries of employees benefiting from the coverage for fully self-insured situations or on percentage of premiums of covered employees for partially self-insured situations since purchased premiums must be directly charged.
(E) Because the determination of reimbursement is based on cost data, allocation methods based upon revenue streams are inappropriate and unallowable.
(k) Net expenses. Net expenses are gross expenses less any purchase discounts or returns and allowances. Purchase discounts are cash discounts reducing the purchase price as a result of prompt payment, quantity purchases, or for other reasons. Purchase returns and allowances are reductions in expenses resulting from returned merchandise or merchandise which is damaged, lost, or incorrectly billed. Only net expenses may be reported on the cost report. Expenses reported on the cost report must be adjusted for all such purchase discounts or returns and allowances.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State October 2, 2023.
TRD-202303662
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455
STATUTORY AUTHORITY
The amendments are authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendments affect Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.306.Cost Finding Methodology.
(a) Cost reports. Cost reporting requirements vary depending on whether the provider participates in the Direct Care Staff Rate enhancement program. All providers who participate in the rate enhancement program must file a cost report, as described in §355.308 of this title (relating to Direct Care Staff Rate Component). A provider that is not participating in the rate enhancement program must file a cost report unless:
(1) the provider meets one or more of the conditions in §355.105(b)(4)(D) of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures); or
(2) the cost report would represent costs accrued during a time period immediately preceding a period of decertification, if the decertification period was greater than either 30 calendar days or one entire calendar month.
(b) Exclusion of and adjustments to certain reported expenses. Providers are responsible for eliminating unallowable expenses from the cost report. HHSC reserves the right to exclude any unallowable costs from the cost report and to exclude entire cost reports from the reimbursement determination database if there is reason to doubt the accuracy or allowability of a significant part of the information reported.
(1) Cost reports included in the database used for reimbursement determination.
(A) Individual cost reports will 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.
(B) In the event that all cost reports submitted for a specific facility are disqualified through the application of subparagraph (A)(i) and/or (ii) of this paragraph, the facility will not be represented in the reimbursement database for the cost report year in question.
(2) Adjustments and exclusions of cost report data include, but are not necessarily limited to:
(A) Fixed capital asset costs.
(i) HHSC staff determine fixed capital asset costs as detailed in this section.
(ii) Fixed capital asset costs are reimbursed in the form of a use fee calculated as described in §355.307 of this title (relating to Reimbursement Setting Methodology). The following fixed capital charges are excluded from the reimbursement base:
(I) building and building equipment depreciation and lease expense;
(II) mortgage interest;
(III) land improvement depreciation; and
(IV) leasehold improvement amortization.
(B) Limits on other facility and administration costs. To ensure that the results of HHSC's cost analyses accurately reflect the costs that an economic and efficient provider must incur, HHSC may place upper limits or caps on expenses for specific line items and categories of line items included in the rate base for the administration and facility cost centers. HHSC sets upper limits at the 90th percentile in the array of all costs per unit of service or total annualized cost, as appropriate for a specific line item or category of line item, as reported by all contracted facilities, unless otherwise specified. The specific line items and categories of line items that are subject to the 90th percentile cap are:
(i) total buildings and equipment rental or lease expense;
(ii) total other rental or lease expense for transportation, departmental, and other equipment;
(iii) building depreciation;
(iv) building equipment depreciation;
(v) departmental equipment depreciation;
(vi) leasehold improvement amortization;
(vii) other amortization;
(viii) total interest expense;
(ix) total insurance for buildings and equipment;
(x) facility administrator salary, wages, and/or benefits with the cap based on an array of nonrelated-party administrator salaries, wages, and/or benefits;
(xi) assistant administrator salary, wages, and/or benefits with the cap based on an array of nonrelated-party assistant administrator salaries, wages, and/or benefits;
(xii) facility owner, partner, or stockholder salaries, wages, and/or benefits (when the owner, partner, or stockholder is not the facility administrator or assistant administrator), with the cap based on an array of nonrelated-party administrator salaries, wages, and/or benefits;
(xiii) other administrative expenses including the cost of professional and facility malpractice insurance, advertising expenses, travel and seminar expenses, association dues, other dues, professional service fees, management consultant fees, interest expense on working capital, management fees, other fees, and miscellaneous office expenses; and
(xiv) total central office overhead expenses or individual central office line items. Individual line item caps are based on an array of all corresponding line items.
(C) Occupancy adjustments. HHSC adjusts the facility and administration costs of providers with occupancy rates below a target occupancy rate. The target occupancy rate is the lower of:
(i) 85%; or
(ii) the overall average occupancy rate for contracted beds in facilities included in the rate base during the cost reporting periods included in the base.
(D) Cost projections. HHSC projects certain expenses in the reimbursement base to normalize or standardize the reporting period and to account for cost inflation between reporting periods and the period to which the prospective reimbursement applies as specified in §355.108 of this title (relating to Determination of Inflation Indices).
(3) When material pertinent to proposed reimbursements is made available to the public, the material will include the number of cost reports eliminated from reimbursement determination for the reason stated in paragraph (1)(A)(i) of this subsection.
(c) Reimbursement determinations and allowable costs. 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 reimbursement. 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 providers.
(d) General information. In addition to the requirements of this section, cost reports will be governed by the information in §355.101 of this title (relating to Introduction), §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures), §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), §355.107 of this title (relating to Notification of Exclusions and Adjustments), §355.108 of this title (relating to Determination of Inflation Indices), §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs), and §355.110 of this title (relating to Informal Reviews and Formal Appeals).
(e) Final cost reports for change of ownership. When a facility changes ownership, for a provider who participates in the rate enhancement program, the prior owner must submit a final Staffing and Compensation Report as described in §355.308 of this title. When a facility changes ownership, for a provider not participating in the rate enhancement program, the prior owner is excused from submitting a final cost report and, if its prior cost report is pending audit completion, the audit will be suspended and the cost report excluded from the final cost report database.
(f) Requirements for cost report completion. A completed nursing facility cost report must:
(1) meet the definition of completed cost report specified in §355.105(b)(4)(A) of this title;
(2) have attached the property appraisal used to determine the allowable appraised property value as described in subsection (g) of this section;
(3) not report figures for days of service and number of beds that reflect occupancy of greater than 100%;
(4) have a management contract attached, if applicable; and
(5) have a lease agreement attached, if applicable.
(g) Allowable appraised property values. Allowable appraised property values are determined as follows:
(1) Proprietary facilities. The allowable appraised values of proprietary facilities to be reported on Texas Medicaid cost reports are determined from local property taxing authority appraisals. The year of the property appraisal must be the calendar year within which the provider's cost report fiscal year ends, or the prior calendar year.
(2) Tax exempt facilities. The allowable appraised property values for tax exempt facilities are determined as follows.
(A) Tax exempt facilities provided an appraisal from their local property taxing authority. Tax exempt facilities provided an appraisal from their local property taxing authority must report this appraised value on their Texas Medicaid cost report. The year of the property appraisal must be the calendar year within which the provider's cost report fiscal year ends, or the prior calendar year.
(B) Tax exempt facilities not provided an appraisal from their local property taxing authority. Tax exempt facilities not provided an appraisal from their local property taxing authority because of an "exempt" status must provide documentation received from the local taxing authority certifying exemption for the current reporting period and must contract with an independent appraiser to appraise the facility land and improvements. These independent appraisals must meet the following criteria.
(i) The appraisal must value land and improvements using the same basis used by the local taxing authority under Texas laws regarding appraisal methods and procedures.
(ii) The appraisal must be updated every five years with the initial appraisal setting the five-year interval.
(I) Facilities achieving exempt status during their
fiscal year ending in calendar year 1997 or a subsequent year must
submit an initial appraisal to HHSC's Provider Finance [Rate
Analysis] Department as part of their cost report for the fiscal
year during which the exempt status was achieved. This appraisal must
be reflective of the facility's appraised value during that fiscal year.
(II) If a facility is reappraised due to improvements or reconstruction as defined in clause (iii) of this subparagraph, a new five-year interval will be set.
(iii) Facilities making capital improvements, or requiring reconstruction due to fire, flood, or other natural disaster, when the improvements or reconstruction cost more than $2,000 per licensed bed, may contract with an independent appraiser to have land and improvements reappraised within the cost reporting period in which the improvement(s) is placed into service.
(iv) If for any reason an appraisal becomes available from the local taxing authority for a provider who previously lacked such an appraisal, the provider must report, on the next Texas Medicaid cost report submitted, the local taxing authority's appraised values instead of the independent appraisal values.
(3) Governmental facilities. Governmental facilities are exempt from the requirement to report an appraised property value.
(h) In addition to the requirements of §355.102 and §355.103 of this title, the following apply to costs for the nursing facilities (NF) program.
(1) Medical costs. The costs for medical services and items delineated in 40 TAC §19.2601 (relating to Vendor Payment) are allowable. These costs must also comply with the general definition of allowable costs as stated in §355.102 of this title.
(2) Chaplaincy or pastoral services. Expenses for chaplaincy or pastoral services are allowable costs.
(3) Voucherable costs. Except as detailed in subparagraphs (A) and (B) of this paragraph, any expenses directly reimbursable to the provider through a voucher payment and any expenses in excess of the limit, or ceiling, for a voucher payment system are unallowable costs.
(A) The ventilator dependent supplemental voucher system and the children with tracheostomies supplemental voucher system are not subject to the cost reporting restrictions described in this paragraph.
(B) Select voucher systems, when indicated by department procedures, are not subject to the cost reporting restrictions described in this paragraph. To avoid the possibility of providers being reimbursed through the voucher system and the daily rate for the same expenses, the department may not waive the cost reporting restrictions described in this paragraph unless the following criteria are met:
(i) the voucher system is a temporary system;
(ii) the costs represent ongoing costs; and
(iii) the costs are not represented in the payment rate until after the voucher system has been discontinued.
(4) Preferred items. Costs for preferred items which are billed to the recipient, responsible party, or the recipient's family are not allowable costs.
(5) Preadmission Screening and Annual Resident Review (PASARR) expenses. Any expenses related to the direct delivery of specialized services and treatment required by PASARR for residents are unallowable costs.
(6) Advanced Clinical Practitioner (ACP) or Licensed Professional Counselor (LPC) services. Expenses for services provided by an ACP or LPC are unallowable costs.
§355.314.Supplemental Payments to Non-State Government-Owned Nursing Facilities.
(a) Introduction. Notwithstanding other provisions of this subchapter and subject to the availability of funds, supplemental payments are available under this section for nursing facility services provided by eligible non-state government-owned nursing facilities.
(b) Definitions. When used in this section, the following definitions apply:
(1) Adjudicated claim--A claim for a covered Medicaid nursing facility service that has been paid by HHSC.
(2) HHSC--The Texas Health and Human Services Commission or its designee.
(3) Intergovernmental transfer (IGT)--A transfer of public funds from a non-state governmental entity to HHSC.
(4) Medicaid supplemental payment limit--The maximum supplemental payment available to a participating non-state government-owned nursing facility for a specific quarterly calculation period as calculated in subsection (f) of this section.
(5) Medicaid supplemental payment limit calculation period--The federal fiscal quarter determined by HHSC for which supplemental payment amounts are calculated based on adjudicated claims for days of service provided in the same quarter in the prior federal fiscal year.
(6) Non-state governmental entity--A hospital authority, hospital district, healthcare district, city, or county.
(7) Non-state government-owned nursing facility--A nursing facility where a non-state governmental entity holds the license and is party to the facility's Medicaid contract.
(8) Public funds--Funds derived from taxes, assessments, levies, investments, and other public revenues within the sole and unrestricted control of a non-state governmental entity that holds the license and is party to the Medicaid contract of the nursing facility identified in subsection (c) of this section. Public funds do not include gifts, grants, trusts, or donations, the use of which is conditioned on supplying a benefit solely to the donor or grantor of the funds.
(9) Upper payment limit--A reasonable estimate of the amount that would be paid for the services furnished by a non-state government-owned nursing facility under Medicare payment principles, as calculated in subsection (f) of this section.
(10) Upper payment limit calculation period--The federal fiscal quarter one year prior to the Medicaid supplemental payment limit calculation period. For example, October 1 - December 31, 2011, is the upper payment limit calculation period for the October 1 - December 31, 2012, Medicaid supplemental payment limit calculation period.
(c) Eligible nursing facilities.
(1) Supplemental payments are available under this section to all non-state government-owned nursing facilities that comply with the requirements described in subsection (d) of this section.
(2) A nursing facility participating in this supplemental
payment program must notify the HHSC Provider Finance [Rate
Analysis] Department of changes in ownership that may affect
the nursing facility's continued eligibility within 30 days after
such change.
(3) A nursing facility that has not received a payment under this supplemental payment program for four consecutive quarters is ineligible for future supplemental payments unless the nursing facility applies again for the supplemental payment program in accordance with subsection (d) of this section.
(d) Required application. Before a non-state government-owned nursing facility may receive supplemental payments under this section, the appropriate non-state governmental entity must certify certain facts, representations, and assurances regarding program requirements.
(1) The appropriate non-state governmental entity must certify the following facts on a form prescribed by HHSC before the first day of the next scheduled Medicaid supplemental payment limit calculation period in order for the nursing facility to receive a supplemental payment for that period:
(A) That it is a non-state government-owned nursing facility where a non-state governmental entity holds the license and is party to the facility's Medicaid contract.
(B) That all funds transferred to HHSC via IGT for use as the state share of supplemental payments are public funds.
(C) That no part of any supplemental payment paid to the nursing facility under this section will be used to pay a contingent fee, consulting fee, or legal fee associated with the nursing facility's receipt of the supplemental funds.
(D) That the person signing the certification on behalf of the nursing facility is legally authorized to bind the nursing facility and to certify the matters described in the application.
(2) The nursing facility is eligible for supplemental payments for Medicaid supplemental payment limit calculation periods that begin after HHSC receives completed application forms from the appropriate non-state governmental entity. A non-state governmental entity that has submitted a change of ownership (CHOW) application to the Department of Aging and Disability Services (DADS) may submit a provisional application for participation in the supplemental payment program. If the CHOW is finalized by DADS within six months of the submission of the provisional application for participation, the facility will be eligible for payments beginning on the effective date of the CHOW. If the CHOW is not finalized by DADS within six months of the submission of the provisional application for participation, the provisional application is denied and the facility will not be eligible for payments until the first day of the Medicaid supplemental payment limit calculation period that begins after the submission of a new application for participation.
(e) Source of funding.
(1) State funding for supplemental payments authorized under this section is limited to and obtained through IGTs of public funds from the non-state governmental entity that holds the license and is party to the Medicaid contract of the nursing facility identified in subsection (c) of this section.
(2) An IGT that is not received by the date specified by HHSC may not be accepted. In such a situation, the IGT will be returned to the non-state governmental entity and the NF will not be eligible to receive a supplemental payment.
(f) Medicaid supplemental payment limits. A quarterly supplemental payment amount for each non-state government owned nursing facility is calculated using the most recent reliable data available at the time the calculation is made by taking the difference between the upper payment limit from paragraph (1) of this subsection and the Medicaid payment from paragraph (2) of this subsection:
(1) The upper payment limit for each non-state government-owned nursing facility will be calculated based on Medicare payment principles and in accordance with the Medicaid upper payment limit provisions codified at Title 42 Code of Federal Regulations (CFR) §447.272. A total Medicare-equivalent payment is determined for each non-state government-owned facility as the sum of the products of Medicaid days of service by Resource Utilization Group (RUG) for adjudicated Medicaid days of service provided by the facility during the upper payment limit calculation period multiplied by the Medicare payment rate for that RUG that will be in effect during the associated Medicaid supplemental payment limit calculation period. If the Center for Medicare and Medicaid Services has not adopted Medicare RUG rates for the Medicaid supplemental payment limit calculation period at the time the calculation is performed, the Medicaid days of service by RUG will be multiplied by the Medicare payment rate for that RUG in effect on the last day of the upper payment limit calculation period.
(2) The Medicaid payment for each non-state government-owned nursing facility prior to the supplemental payment will be the sum of the following components calculated for that nursing facility from data derived from upper payment limit calculation period:
(A) The sum of Medicaid RUG payments for all adjudicated Medicaid days of service provided by the facility during the upper payment limit calculation period adjusted to reflect any changes in Medicaid RUG rates between the upper payment limit calculation period and the Medicaid supplemental payment limit calculation period; and
(B) Medicaid payments for pharmacy services as defined in 40 TAC Chapter 19, Subchapter P (relating to Pharmacy Services), specialized services as defined in 40 TAC §19.1303 (relating to Specialized Services in Medicaid-certified Facilities), customized equipment as defined in 40 TAC §19.2614 (relating to Customized Power Wheelchairs) and emergency dental services as defined in 40 TAC §19.1402 (relating to Medicaid-certified Nursing Facility Emergency Dental Services), not included in the Medicaid nursing facility rate in effect during the upper payment limit calculation period.
(i) Medicaid payments for pharmacy services are based on Texas specific pharmacy payment and rebate data for Texas Medicaid nursing facility residents during the upper payment limit calculation period.
(ii) Medicaid payments for emergency dental, customized equipment and specialized services are based on Texas specific emergency dental, customized equipment and specialized services payment data for Texas Medicaid nursing facility residents during the upper payment limit calculation period.
(3) Changes of ownership.
(A) For a nursing facility that changed ownership prior to the first day of the Medicaid supplemental payment limit calculation period but after the first day of the upper payment limit calculation period, the data used for the calculations described in paragraphs (1) and (2) of this subsection will include data from the facility for the entire upper payment limit calculation period including data relating to payments for days of service provided under the prior owner. The inclusion of data relating to payments for days of service provided under the prior owner will ensure that the calculation of the supplemental payment amount for the Medicaid supplemental payment limit calculation period reflects a full quarter of services.
(B) For a nursing facility that changes ownership on or after the first day of the Medicaid supplemental payment limit calculation period, the data used for the calculations described in paragraphs (1) and (2) of this subsection will include data from the facility for the entire upper payment limit calculation period relating to payments for days of service provided under the prior owner, pro-rated to reflect only the number of calendar days during the Medicaid supplemental payment limit calculation period that the facility is owned by the new owner.
(g) Payment frequency. HHSC will distribute supplemental payments to participating non-state government-owned nursing facilities on a quarterly basis subsequent to the Medicaid supplemental payment limit calculation period.
(h) Supplemental payment methodology.
(1) HHSC will give notice of the non-state government-owned nursing facility quarterly Medicaid supplemental payment limits determined in subsection (f) of this section, the maximum IGT amount that can be provided for each participating nursing facility based on the Federal Medical Assistance Percentage (FMAP) in place at the time notice is given, and the deadline for completing the transfer.
(2) The amount of the supplemental payment to the nursing facility will be calculated in proportion to the amount transferred by the non-state governmental entity.
(A) For governmental entities that own a single nursing facility:
(i) If the non-state governmental entity transfers the maximum IGT described in paragraph (1) of this subsection, the nursing facility will receive the Medicaid supplemental payment limit amount calculated for it in subsection (f) of this section.
(ii) If the non-state governmental entity transfers less than the maximum IGT described in paragraph (1) of this subsection, the nursing facility will receive a supplemental payment that is proportionate to the percentage of the maximum IGT that was actually transferred.
(B) For governmental entities that own multiple nursing facilities:
(i) If the non-state governmental entity transfers the maximum IGT described in paragraph (1) of this subsection for all of the nursing facilities it owns, each of the nursing facilities will receive the Medicaid supplemental payment limit amount calculated for it in subsection (f) of this section.
(ii) If the non-state governmental entity transfers less than the maximum IGT described in paragraph (1) of this subsection for all of the nursing facilities it owns, each of the nursing facilities will receive a proportion of the Medicaid supplemental payment limit amount calculated for it in subsection (f) of this section based on the proportion of the total maximum IGT for all of the nursing facilities owned by the non-state governmental entity that was actually transferred.
(C) Supplemental payments to remaining non-state government-owned nursing facilities will not be increased due to the failure of a non-state governmental entity to transfer the maximum IGT described in paragraph (1) of this subsection.
(3) A non-state governmental entity that did not transfer the maximum IGT described in paragraph (1) of this subsection in one or more of the first three quarters in a federal fiscal year, but was eligible to do so will be allowed to fund the remaining Medicaid supplemental payment limit from those quarters during the fourth quarter of that fiscal year. HHSC will give notice of the remaining Medicaid supplemental payment limits and the maximum IGT that can be provided for each non-state government-owned nursing facility. Such notice will also contain instructions and deadlines for governmental entities to notify HHSC of the fourth-quarter transfer amount.
(4) The amount of the payment to the nursing facility will be calculated using the FMAP in place when HHSC gave notice as described in paragraph (1) or (3) of this subsection, as applicable.
(i) Recoupment.
(1) If payments under this section result in overpayment to a nursing facility, or in the event of a disallowance by the federal Centers for Medicare and Medicaid Services (CMS) of federal participation related to a nursing facility's receipt or use of supplemental payments authorized under this section, HHSC may recoup an amount equivalent to the amount of supplemental payments overpaid or disallowed.
(2) Supplemental payments under this section may be subject to any adjustments for payments made in error, including, without limitation, adjustments made under the Texas Administrative Code, the Code of Federal Regulations and state and federal statutes. HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid payments as follows:
(A) HHSC will recoup from the nursing facility to which an overpayment was made or against which any disallowance was directed.
(B) If, within 30 days of the nursing facility's receipt of HHSC's written notice of recoupment, the nursing facility has not paid the full amount of the recoupment or entered into a written agreement with HHSC to do so, HHSC may withhold any or all Medicaid payments from the nursing facility until HHSC has recovered an amount equal to the amount overpaid or disallowed. If funds identified for recoupment cannot be repaid from the nursing facility's Medicaid payments, the non-state governmental entity that owns the nursing facility will be liable for any additional payment due to HHSC or its designee. Failure to repay the amount due or submit an acceptable payment plan within 60 days of notification will result in the recoupment of the owed funds from other Medicaid contracts controlled by the non-state governmental entity and will bar the non-state governmental entity from receiving any new contracts with HHSC or its designees until repayment is made in full.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on October 2, 2023.
TRD-202303663
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455
STATUTORY AUTHORITY
The amendment is authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.458.Supplemental Payments to Non-State Government-Owned Facilities.
(a) Introduction. Notwithstanding other provisions of this subchapter and subject to the availability of funds, supplemental payments are available under this section for intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) services provided by eligible non-state government-owned ICFs/IID.
(b) Definitions. When used in this section, the following definitions apply:
(1) Aggregate upper payment limit--A reasonable estimate of the amount that would be paid for the services furnished by non-state government-owned ICFs/IID under Medicare payment principles, as calculated in subsection (f) of this section.
(2) HHSC--The Texas Health and Human Services Commission or its designee.
(3) Intergovernmental transfer (IGT)--A transfer of public funds from a governmental entity to HHSC.
(4) Medicaid supplemental payment limit--The maximum supplemental payment available to a participating non-state government-owned ICF/IID for a specific Medicaid supplemental payment limit calculation period as calculated in subsection (f) of this section.
(5) Medicaid supplemental payment limit calculation period--The federal fiscal quarter determined by HHSC for which supplemental payment amounts are calculated.
(6) Non-state government-owned ICF/IID--An ICF/IID where a non-state governmental entity is party to the facility's Medicaid contract.
(7) Non-state governmental entity--A community center established under Chapter 534, Subchapter A of the Texas Health and Safety Code or a hospital authority, hospital district, healthcare district, city, or county.
(8) Public funds--Funds derived from taxes, assessments, levies, investments, and other public revenues within the sole and unrestricted control of the governmental entity that is party to the Medicaid contract of the ICF/IID identified in subsection (c) of this section. Public funds do not include gifts, grants, trusts, or donations, the use of which is conditioned on supplying a benefit solely to the donor or grantor of the funds.
(c) Eligible ICFs/IID.
(1) Supplemental payments are available under this section to all non-state government-owned ICFs/IID that comply with the requirements described in subsection (d) of this section.
(2) An ICF/IID participating in this supplemental payment
program must notify the HHSC Provider Finance [Rate
Analysis] Department of changes in ownership that may affect
the ICF/IID's continued eligibility within 30 days after such change.
(3) An ICF/IID that has not received a payment under this supplemental payment program for four consecutive quarters is ineligible for future supplemental payments unless the ICF/IID applies again for the supplemental payment program in accordance with subsection (d) of this section.
(d) Required application. Before a non-state government-owned ICF/IID may receive supplemental payments under this section, the appropriate governmental entity must certify certain facts, representations, and assurances regarding program requirements.
(1) The appropriate governmental entity must certify the following facts on a form prescribed by HHSC before the first day of the next scheduled Medicaid supplemental payment limit calculation period in order for the ICF/IID to receive a supplemental payment for that period:
(A) That a non-state governmental entity is party to the ICF/IID's Medicaid contract.
(B) That all funds transferred to HHSC via IGT for use as the state share of supplemental payments are public funds.
(C) That no part of any supplemental payment paid to the ICF/IID under this section will be used to pay a contingent fee, consulting fee, or legal fee associated with the ICF/IID's receipt of the supplemental funds.
(D) That the person signing the certification on behalf of the ICF/IID is legally authorized to bind the ICF/IID and to certify the matters described in the application; and
(2) The ICF/IID is eligible for supplemental payments for Medicaid supplemental payment limit calculation periods that begin after HHSC receives completed application forms from the appropriate governmental entity.
(e) Source of funding.
(1) State funding for supplemental payments authorized under this section is limited to and obtained through IGTs of public funds from the governmental entity that is party to the Medicaid contract of the ICF/IID identified in subsection (c) of this section.
(2) An IGT that is not received by the date specified by HHSC may not be accepted. In such a situation, the IGT will be returned to the governmental entity and the ICF/IID will not be eligible to receive a supplemental payment.
(f) Medicaid supplemental payment limits.
(1) The aggregate supplemental payment amount for non-state government-owned ICFs/IID is calculated for each Medicaid supplemental payment limit calculation period by taking the difference between the aggregate upper payment limit from subparagraph (A) of this paragraph and the aggregate Medicaid payment from subparagraph (B) of this paragraph:
(A) The aggregate upper payment limit for non-state government-owned ICFs/IID will be calculated based on Medicare payment principles and in accordance with the Medicaid upper payment limit provisions codified at Title 42 Code of Federal Regulations (CFR) §447.272. The aggregate upper payment limit is equal to the sum of the Medicare-equivalent payments for all non-state government-owned ICFs/IID. The Medicare-equivalent payment for each non-state government-owned ICF/IID is calculated as follows based on data from the most recent reliable Medicaid cost report:
(i) Determine the Medicare adjusted cost by subtracting ancillary and fixed capital costs from total Medicaid allowable costs and multiplying the remaining costs by 1.12.
(ii) Determine the Medicare adjusted cost per day of service by dividing the value from clause (i) of this subparagraph by the total days of service.
(iii) Determine the Medicare-equivalent payment by multiplying the dividend from clause (ii) of this subparagraph by the total Medicaid days of service.
(B) The aggregate Medicaid payment for non-state government-owned ICFs/IID prior to the supplemental payment will be the sum of Medicaid Level of Need (LON) payments for all non-state government-owned ICFs/IID as captured on the most recent reliable Medicaid cost report.
(2) The Medicaid supplemental payment limit for each participating non-state government-owned ICF/IID for each Medicaid supplemental payment limit calculation period will be determined by dividing that facility's Medicaid units of service during the Medicaid supplemental payment limit calculation period by the total Medicaid units of service during the Medicaid supplemental payment limit calculation period for all non-state government-owned ICFs/IID, multiplying the resulting percentage by the aggregate supplemental payment amount from paragraph (1) of this subsection, and dividing the resulting product by four.
(g) Payment frequency. HHSC will distribute supplemental payments to participating non-state government-owned ICFs/IID on a quarterly basis subsequent to the Medicaid supplemental payment limit calculation period.
(h) Supplemental payment methodology.
(1) HHSC will give notice of the non-state government-owned ICF/IID Medicaid supplemental payment limits determined in subsection (f) of this section, the maximum IGT amount that can be provided for each participating ICF/IID based on the Federal Medical Assistance Percentage (FMAP) in place at the time notice is given, and the deadline for completing the transfer.
(2) The amount of the supplemental payment to the ICF/IID will be calculated in proportion to the amount transferred by the governmental entity.
(A) For governmental entities that own a single ICF/IID:
(i) If the governmental entity transfers the maximum IGT described in paragraph (1) of this subsection, the ICF/IID will receive the Medicaid supplemental payment limit amount calculated for it in subsection (f) of this section.
(ii) If the governmental entity transfers less than the maximum IGT described in paragraph (1) of this subsection, the ICF/IID will receive a supplemental payment that is proportionate to the percentage of the maximum IGT that was actually transferred.
(B) For governmental entities that own multiple ICFs/IID:
(i) If the governmental entity transfers the maximum IGT described in paragraph (1) of this subsection for all of the ICFs/IID it owns, each of the ICFs/IID will receive the Medicaid supplemental payment limit amount calculated for it in subsection (f) of this section.
(ii) If the governmental entity transfers less than the maximum IGT described in paragraph (1) of this subsection for all of the ICFs/IID it owns, each of the ICFs/IID will receive a proportion of the Medicaid supplemental payment limit amount calculated for it in subsection (f) of this section based on the proportion of the total maximum IGT for all of the ICFs/IID owned by the governmental entity that was actually transferred.
(C) Supplemental payments to remaining non-state government-owned ICFs/IID will not be increased due to the failure of a governmental entity to transfer the maximum IGT described in paragraph (1) of this subsection.
(3) A governmental entity that did not transfer the maximum IGT described in paragraph (1) of this subsection in one or more of the first three quarters in a federal fiscal year will be allowed to fund the remaining Medicaid supplemental payment limit during the fourth quarter of that fiscal year, subject to the following:
(A) HHSC will give notice of the remaining Medicaid supplemental payment limits and the maximum IGT that can be provided for each non-state government-owned ICF/IID. Such notice will also contain instructions and deadlines for governmental entities to notify HHSC of the fourth-quarter transfer amount.
(B) Following the deadline for notification described in subparagraph (A) of this paragraph, if HHSC determines that the supplemental payments for the federal fiscal year will exceed the applicable aggregate supplemental payment amount for non-state government-owned ICFs/IID, HHSC will reduce the amount of the transfer for the fourth-quarter payment under this clause proportionately for each participating ICF/IID in an amount sufficient to ensure compliance with the applicable aggregate supplemental payment amount.
(4) The amount of the payment to the ICF/IID will be calculated using the FMAP in place when HHSC gave notice as described in paragraph (1) or (3) of this subsection, as applicable.
(i) Recoupment.
(1) If payments under this section result in overpayment to an ICF/IID, or in the event of a disallowance by the federal Centers for Medicare and Medicaid Services (CMS) of federal participation related to an ICF/IID's receipt or use of supplemental payments authorized under this section, HHSC may recoup an amount equivalent to the amount of supplemental payments overpaid or disallowed.
(2) Supplemental payments under this section may be subject to any adjustments for payments made in error, including, without limitation, adjustments made under the Texas Administrative Code, the Code of Federal Regulations and state and federal statutes. HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid payments as follows:
(A) HHSC will recoup from the ICF/IID to which an overpayment was made or against which any disallowance was directed.
(B) If, within 30 days of the ICF/IID's receipt of HHSC's written notice of recoupment, the ICF/IID has not paid the full amount of the recoupment or entered into a written agreement with HHSC to do so, HHSC may withhold any or all Medicaid payments from the ICF/IID until HHSC has recovered an amount equal to the amount overpaid or disallowed. If funds identified for recoupment cannot be repaid from the ICF/IID's Medicaid payments, the governmental entity that owns the ICF/IID will be liable for any additional payment due to HHSC or its designee. Failure to repay the amount due or submit an acceptable payment plan within 60 days of notification will result in the recoupment of the owed funds from other Medicaid contracts controlled by the governmental entity and will bar the governmental entity from receiving any new contracts with HHSC or its designees until repayment is made in full.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on October 2, 2023.
TRD-202303664
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455
1 TAC §§355.722, 355.743, 355.746, 355.781
STATUTORY AUTHORITY
The amendments are authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendments affect Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.722.Reporting Costs by Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Providers.
(a) Submittal of cost reports. On a biennial basis,
providers must submit cost reports to Texas Health and Human Services
Commission (HHSC) Provider Finance Department [Rate
Analysis] only in even years, beginning with providers' 2018
cost reports. HHSC applies the general principles of cost determination
as specified in §355.101 of this title (relating to Introduction).
(1) Attendant service costs. Attendant service costs are defined in §355.112 of this title (relating to Attendant Compensation Rate Enhancement).
(2) Staff who provide both attendant and non-attendant services. For staff whose duties include work other than the provision of attendant services for the provider, time spent providing attendant services and associated expenses may be reported as attendant service costs if properly documented in accordance with §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures).
(3) Providers must report the following costs:
(A) Staff wages related to the delivery of attendant services.
(B) These costs may be either the provider's actual expense or contracted expenditures.
(b) Reviews of exclusions or adjustments. A provider who disagrees with HHSC's exclusion or adjustment of items in cost reports may request an informal review and, when appropriate, an administrative hearing as specified in §355.110 of this title (relating to Informal Reviews and Formal Appeals).
(c) 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 §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports).
(d) Notification of exclusions and adjustments. HHSC will notify a provider of the results of a desk review or field audit in accordance with §355.107 of this title (relating to Notification of Exclusions and Adjustments).
(e) Cost reporting guidelines. Providers must follow the cost-reporting guidelines as specified in §355.105 of this title.
(f) Allowable and unallowable costs. Providers must follow the guidelines in determining whether a cost is allowable or unallowable as specified in §355.102 and §355.103 of this title (relating to General Principles of Allowable and Unallowable Costs, and Specifications for Allowable and Unallowable Costs).
(g) Revenues. Revenues must be reported on the cost report in accordance with §355.104 of this title (relating to Revenues).
(h) Related parties. Allowable compensation for owners and related parties and definitions of owners and related parties are specified in §355.102(i) and §355.103(b)(2) of this title.
(1) Time sheet requirement. Owners and related parties who provide multiple types of attendant service (e.g., direct care workers, direct care trainers, and job coaches) or both attendant services and non-attendant services must maintain daily time sheets that record the time spent on activities in each area. The provider must maintain documentation relating to the compensation, bonuses, and benefits of each owner or related party in accordance with §355.105(b)(2)(B)(xi) of this title.
(2) Calculation of allowable hourly wage rate and benefits. Allowable hourly wage rate and benefits for attendant service work must be the lesser of the actual hourly wage rate paid and benefits paid or the hourly wage rate and benefits for a comparable attendant assumed in the fully-funded model. The fully-funded model is the model as calculated under §355.723(d) of this title (relating to Reimbursement Methodology for Home and Community-based Services) prior to any adjustments made in accordance with §355.101 of this title and §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations or Economic Factors Affect Costs) for the rate period.
(3) Calculation of allowable hours for attendants. Allowable hours per unit of service for an attendant when the reported hours include related-party hours, are determined as follows:
(A) Step 1. Determine the hours per unit of service for a comparable attendant-service staff-type assumed in the fully-funded model as defined in paragraph (2) of this subsection, adjusted for the provider's average Level of Need (LON) during the reporting period. For TxHmL, until such time as LONs are established, the provider's average LON is assumed to be LON 5.
(B) Step 2. Determine the hours per unit of service encompassed by the 90th percentile in the array of hours per unit of service for comparable attendant-service staff-types as reported by those contracted providers not reporting any related-party hours for that staff-type, adjusted for the provider's average LON during the reporting period. For TxHmL, until such time as LONs are established, the provider's average LON is assumed to be LON 5.
(C) Step 3. Determine the greater of Step 1 and Step 2.
(D) Step 4. Determine the actual hours worked by the staff-type per unit of service.
(E) Step 5. Determine the lesser of Step 4 and Step 3. This value is the allowable hours per unit of service for the attendant-service staff-type in question.
(4) Exception to related-party adjustment. If at least 40 percent of total labor hours in a specific related-party's attendant-service staff-type were provided by non-related-parties, the related-party's hourly wage rate may be the higher of the model assumption for that attendant-service staff-type described in paragraph (2) of this subsection or the non-related party average for that attendant-service staff-type, so long as the non-related party average does not exceed the related-party's actual hourly wage.
(5) Maximum attendant-care hours. During any single fiscal year, the sum of all attendant-care hours reported on any cost report(s) for any individual owner or related party cannot exceed 2,600.
(6) Classification of hours over the limit. Hours, hourly wages and benefits above the limits described in paragraphs (2) - (5) of this subsection are to be reported as administrative hours, hourly wages and benefits.
(i) Adjusting reported cost. 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 §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 §355.109 of this title.
(j) Fiscal Accountability for HCS. This subsection applies to services delivered on or before August 31, 2009 and only for HCS program services.
(1) General principles. Fiscal accountability is a process used to gauge the ongoing financial performance under the reimbursement rates.
(2) Annual reporting. Fiscal accountability will consist of the annual reporting of the direct service costs including wages, and benefits, from all providers. The data will be collected on a cost report designed by HHSC in accordance with §355.105(b) of this title.
(A) The Department of Aging and Disability Services (DADS) will place a vendor hold on payments to a provider whose provider agreement is being assigned or terminated. The provider will submit a cost report for the current reporting period to HHSC. Upon receipt of an acceptable cost report and repayment of any amounts due in accordance with this section, the vendor hold will be released.
(B) Providers that do not submit a cost report completed in accordance with all applicable rules and instructions within 60 days of the placement of a vendor hold due to the failure to submit the cost report are subject to an immediate recoupment of funds related to fiscal accountability as described in paragraph (4)(E) of this subsection. The recouped funds will not be restored until the provider submits an acceptable cost report and has paid the actual amount due as specified in paragraphs (5) - (7) of this subsection. If an acceptable cost report is not received within 365 days of the due date, the recoupment will become permanent.
(C) Providers with an ownership change from one legal entity to a different legal entity or a contract termination that do not submit a cost report for the fiscal year of the ownership change or contract termination within 60 days of the change of ownership or contract termination are subject to recoupment of funds related to fiscal accountability as described in paragraph (4)(E) of this subsection. The recouped funds will not be restored until the provider submits an acceptable cost report and has paid the actual amount due as specified in paragraphs (5) - (7) of this subsection. If an acceptable cost report is not received within 365 days of the change of ownership or contract termination date, the recoupment will become permanent.
(3) Comparison of direct-service costs to total direct-service revenue. HHSC will require providers to report all direct costs incurred on an annual fiscal year basis. HHSC will compare the reported direct service costs to the total direct service revenue.
(4) Calculation of direct-service revenues and fiscal accountability repayment. Direct Service Revenues are calculated by multiplying the number of units eligible for payment that have been paid for services delivered during the reporting period times the appropriate direct service portion of the rate for the service billed.
(A) Providers whose direct service costs are 90% or more of the direct service revenues will not be subject to repayment under this section.
(B) Providers whose direct service costs are less than 90% but greater than or equal to 85% of the direct service revenues will be required to pay to DADS 50% of the difference between the direct service costs and 90% of the direct service revenues.
(C) Providers whose direct service costs are less than 85% but greater than or equal to 80% of the direct service revenues will be required to pay to DADS 100% of the difference between the direct service costs and 85% of the direct service revenues plus 50% of the difference between 85% and 90% of the direct service revenues.
(D) Providers whose direct service costs are less than 80% of the direct service revenues will be required to pay to DADS the difference between the direct service costs and 95% of the direct service revenues.
(E) Providers who do not submit a cost report as described in paragraph (2)(B) or (C) of this subsection will be assumed to have direct service costs equal to 65% of the direct services revenues and will be required to pay to DADS the difference between 65% of the direct services revenues and 95% of the direct service revenues, subject to the provisions of paragraph (2)(B) or (C) of this subsection.
(5) Notification of recoupment. Providers will be notified, by certified mail, within 90 days of the determination of their recoupment amount by HHSC of the amount to be repaid to HHSC. If a subsequent review by HHSC or audit results in adjustments to the cost report as described in subsection (a) of this section that change the amount to be repaid to HHSC, the provider will be notified in writing of the adjustments and the adjusted amount to be repaid. Providers will submit the repayment amount within 60 days of notification.
(6) Repayment. Repayment will be made by the following:
(A) the provider or legal entity submitting the report;
(B) any other legal entity responsible for the debts or liabilities of the submitting entity; or
(C) the legal entity on behalf of which a report is submitted.
(7) Providers required to repay revenues to DADS will be jointly and severally liable for any repayment. DADS will apply a vendor hold on Medicaid payments to a provider for not making the payment to DADS within 60 days of receiving notice.
(8) Aggregation.
(A) Definitions. The following words and terms have the following meanings when used in this paragraph.
(i) Aggregation--For an entity defined in clause (iii) of this subparagraph that controls, as defined in clause (iv) of this subparagraph, more than one HCS component code, the process of determining compliance with the spending requirements detailed in paragraph (4) of this subsection for all component codes controlled by the entity in the aggregate rather than requiring each component code to meet its spending requirement individually. For commonly owned corporations defined in clause (ii) of this subparagraph, the process of determining compliance with the spending requirements detailed in paragraph (4) of this subsection for all component codes in the controlled small group in the aggregate rather than requiring each component code to meet its spending requirement individually. Corporations that do not meet the definitions under clauses (ii) - (iii) of this subparagraph are not eligible for aggregation.
(ii) Commonly owned corporations--two or more corporations where five or fewer identical persons who are individuals, estates, or trusts own greater than 50 percent of the total voting power in each corporation.
(iii) Entity--a parent company, sole member, individual, limited partnership, or group of limited partnerships controlled by the same general partner.
(iv) Control--greater than 50% ownership by the entity.
(B) Component Codes Included in Aggregation. If an entity controlling more than one HCS component code or commonly owned corporations requests aggregation, compliance with the spending requirements will be evaluated in the aggregate for all HCS component codes that the entity or commonly owned corporations controlled at the end of its fiscal year or at the effective date of the change of ownership or termination of its last HCS contract.
(C) Aggregation Request. To exercise the aggregation option, the entity or commonly owned corporations must submit an aggregation request, in a manner prescribed by HHSC, at the time each cost report is submitted. In limited partnerships in which the same single general partner controls all the limited partnerships, that single general partner must make this request. Other such aggregation requests will be reviewed on a case-by-case basis.
(D) Frequency of Aggregation Requests. The entity or commonly owned corporations must submit a separate request for aggregation for each reporting period.
(E) Ownership Changes and Contract Terminations. HCS contracts that change ownership or terminate effective after the end of the applicable reporting period, but prior to the determination of compliance with spending requirements as per paragraph (4) of this subsection, are excluded from all aggregate spending calculations. These contracts' compliance with spending requirements will be determined on an individual basis and the costs and revenues will not be included in the aggregate spending calculation.
§355.743.Reimbursement Methodology for Mental Health Case Management.
(a) Authority. Payments are made to qualified providers delivering Mental Health Case Management (CM) to Medicaid-enrolled individuals who are eligible for CM according to program rules established by the Department of State Health Services (DSHS). The reimbursement determination authority is specified in §355.101 of this title (relating to Introduction).
(b) Reimbursement rates. Separate rates are set for services based on the following:
(1) Site-based setting. Routine CM is a face-to-face contact with the client at the provider's place of business (e.g., clinic, outpatient office).
(2) Community-based setting. Intensive CM is a face-to-face contact with the client at the client's home, work place, school, or other location that best meets the need of the client.
(c) Qualified providers are reimbursed based on a 15-minute face-to-face unit of service that is prospective and uniform statewide.
(d) Rate methodology.
(1) Initial rates. The initial rates effective September 1, 2011, will be determined by summing the total agency expenditures for each type of case management service for the most recent cost-settled fiscal year, and dividing by the total number of units of each type of service provided during that fiscal year. The total agency expenditures to provide case management services include both the interim rates paid and any adjustments made to the interim rates, such as additional payments or recoupments.
(2) Cost report-based rates. After the Health and Human Services Commission (HHSC) determines that cost data collected as described in subsection (e) of this section is reliable and sufficient to support development of a cost report-based rate, HHSC will develop statewide reimbursement rates using the data that replaced the initial rates as follows:
(A) Project each provider's total allowable cost per type of service from the historical cost reporting period to the prospective reimbursement period using inflation factors according to §355.108 of this title (relating to Determination of Inflation Indices);
(B) For each provider, divide the projected cost per type of service, determined in subparagraph (A) of this paragraph, by the provider's total units of service per type of service delivered during the historical cost reporting period, to arrive at the provider's projected cost per unit of service for each type of service; and
(C) For each type of service:
(i) Arrange all providers' projected cost per unit of service in an array from low to high, with the corresponding total number of units of service for each provider;
(ii) Sum the total number of units of service for each provider in the array progressively, from the lowest projected cost per unit to the highest, to create a running total;
(iii) Divide the total number of units of service by two;
(iv) Identify the value, from the running total sums calculated in clause (ii) of this subparagraph, that is closest to the result in clause (iii) of this subparagraph; and
(v) Identify the cost per unit of service that corresponds to the value identified in clause (iv) of this subparagraph, to arrive at the recommended rate for that service.
(e) Reporting of costs. CM providers must submit cost report data according to HHSC's specifications.
(1) All CM providers must submit a cost report unless
the number of days between the date the first client received services
and the 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 governmental entity. Requests to be
excused from submitting a cost report must be received by the HHSC Provider
Finance [Rate Analysis] Department before the due
date of the cost report.
(2) CM service providers must submit cost report data according to HHSC's specifications. In addition to the requirements of this section, the following cost reporting guidelines apply: §355.101 of this title (relating to Introduction); §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs); §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs); §355.104 of this title (relating to Revenues); §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures); §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports); §355.107 of this title (relating to Notification of Exclusions and Adjustments); §355.108 of this title (relating to Determination of Inflation Indices); §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs); §355.110 of this title (relating to Informal Reviews and Formal Appeals); and §355.111 of this title (relating to Administrative Contract Violation).
(3) 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 rates. To ensure that the database reflects costs and other information that are necessary for the provision of services and is consistent with federal and state regulations, HHSC excludes from rate determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers.
(4) Individual provider cost reports may not be included in the database used for reimbursement determination if:
(A) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or
(B) an auditor determines that reported costs are not verifiable.
§355.746.Reimbursement Methodology for Mental Retardation Service Coordination.
(a) Definitions. The following words and terms, when used in this section have the following meanings, unless the context clearly indicates otherwise.
(1) Allowable costs--Those expenses that are reasonable and necessary costs in the normal conduct of operations relating to case management services as defined in §355.102(f)(1) and (2) of this title (relating to General Principles of Allowable and Unallowable Costs).
(2) Provider--An entity delivering service coordination to Medicaid-enrolled individuals according to program rules established by Department of Aging and Disability Services (DADS).
(3) Collateral--An actively involved person as defined in 40 TAC §2.553(1) (relating to Definitions).
(4) Unit of Service--Two statewide encounter rates are established for Mental Retardation Service Coordination services. The encounter unit of service is established as follows:
(A) Comprehensive encounter (Encounter Type A) is a face-to-face contact with the client based on an average time of 45 minutes per contact. The comprehensive encounter is limited to one billable encounter per client per calendar month.
(B) Follow-up encounter (Encounter Type B) is a face-to-face, telephone, or telemedicine contact that involves interface with the client or collateral and is based on an average time of 15 minutes per contact. The follow-up encounter is limited to three follow-up encounters per provider per calendar month for each comprehensive encounter that has occurred within the calendar month. The follow-up encounter does not have to be provided to the client for whom the comprehensive encounter was provided.
(b) Rate methodology.
(1) Initial rates effective September 1, 2011. The initial rates will be determined by summing the total agency expenditures for each type of service coordination service for the most recent cost-settled fiscal year, and dividing that sum by the estimated total number of units of service by type of service for the fiscal year. The total cost to provide service coordination services includes both the interim rates paid and any adjustments made to the interim rates such as additional payments or recoupments.
(2) Cost-report based rates. After the Health and Human Services Commission (HHSC) determines that cost data collected as described in subsection (c) of this section is reliable and sufficient to support development of a cost-report based rate, HHSC will develop statewide reimbursement rates using that data to replace the initial rates as follows:
(A) Project each provider's total allowable costs per type of service from the historical cost reporting period to the prospective reimbursement period using inflation factors according to §355.108 of this title (relating to Determination of Inflation Indices) to arrive at the projected cost per type of service.
(B) For each provider, divide the projected cost per type of service, determined in subparagraph (A) of this paragraph, by the provider's total units of service per type of service delivered during the historical cost reporting period, to arrive at the provider's projected cost per unit of service for each type of service; and
(C) For each type of service:
(i) Arrange all providers' projected cost per unit of service in an array from low to high, with the corresponding total number of units of service for each provider;
(ii) Sum the total number of units of service for each provider in the array progressively, from the lowest projected cost per unit to the highest, to create a running total;
(iii) Divide the total number of units of service by two;
(iv) Identify the value, from the running total sums calculated in clause (ii) of this subparagraph, that is closest to the result in clause (iii) of this subparagraph; and
(v) Identify the cost per unit of service that corresponds to the value identified in clause (iv) of this subparagraph, to arrive at the recommended rate for that service.
(c) Reporting of costs. Service Coordination providers must submit cost report data according to HHSC's specifications.
(1) Exceptions. All Service Coordination providers must submit a cost report unless:
(A) the number of days between the date the first client received services and the fiscal year end is 30 days or fewer; or
(B) 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 governmental entity. To be excused from submitting
a cost report under this subparagraph, the HHSC Provider Finance [Rate Analysis] Department must receive the request before the
due date of the cost report.
(2) Additional requirements. In addition to following the requirements of this section, the provider must follow the cost reporting guidelines described in: §355.101 of this title (relating to Introduction); §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs); §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs); §355.104 of this title (relating to Revenues); §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures); §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports); §355.107 of this title (relating to Notification of Exclusions and Adjustments); §355.108 of this title (relating to Determination of Inflation Indices); §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs); §355.110 of this title (relating to Informal Reviews and Formal Appeals); and §355.11 of this title (relating to Administrative Contract Violation).
(3) Allowable costs. 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 rates.
(4) Unallowable costs. To ensure that the database reflects costs and other information that are necessary for the provision of services and is consistent with federal and state regulations, HHSC excludes from rate determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers. Individual provider cost reports may not be included in the database used for reimbursement determination if:
(A) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or
(B) an auditor determines that reported costs are not verifiable.
§355.781.Rehabilitative Services Reimbursement Methodology.
(a) Authority. Payments are made to qualified providers delivering rehabilitative services to Medicaid-eligible individuals who are eligible for rehabilitative services according to the program rules established by the Department of State Health Services (DSHS). The reimbursement determination authority is specified in §355.101 of this title (relating to Introduction).
(b) Reimbursement rates. Prospective and uniform statewide rates for rehabilitative services are determined for rehabilitative services specified in the Mental Health Services program rules in 25 TAC Chapter 419, Subchapter L (relating to Mental Health Rehabilitative Services) for the following:
(1) Day programs for acute needs--adult;
(2) Crisis intervention services--individual-child/adolescent and adult;
(3) Medication training and support--individual-child/adolescent and adult;
(4) Medication training and support--group-adult;
(5) Medication training and support--group-child/adolescent;
(6) Psychosocial rehabilitative services--individual-adult;
(7) Psychosocial rehabilitative services--group-adult;
(8) Skills training and development--individual-child/adolescent and adult;
(9) Skills training and development--group-adult; and
(10) Skills training and development-group-child/adolescent.
(c) Units of service. Qualified providers are reimbursed based on the following face-to-face units of service:
(1) Day programs for acute needs--45-60 continuous minutes;
(2) Crisis intervention services--15 continuous minutes;
(3) Medication training and support--15 continuous minutes;
(4) Psychosocial rehabilitative services--15 continuous minutes; and
(5) Skills training and development--15 continuous minutes.
(d) Rate methodology.
(1) Initial rates. Initial statewide rates effective September 1, 2011, will be determined by summing the total agency expenditures to provide rehabilitative services for each type of service for the most recent cost-settled fiscal year, and dividing by the total number of units of each type of service provided during that fiscal year. The total agency expenditure to provide rehabilitative services includes both the interim rates paid and any adjustments made to the interim rates, such as additional payments or recoupments.
(2) Cost report-based rates. After the Texas Health and Human Services Commission (HHSC) determines that cost data collected as described in subsection (e) of this section are reliable and sufficient to support development of a cost report-based rate, HHSC will develop statewide reimbursement rates using that data to replace the initial rates as follows:
(A) Project each provider's total allowable cost for each type of service from the historical cost reporting period to the prospective reimbursement period using inflation factors set out in §355.108 of this title (relating to Determination of Inflation Indices) to arrive at the projected cost for each type of service.
(B) For each provider, divide the projected cost for each type of service, determined in subparagraph (A) of this paragraph, by the provider's total units of service for each type of service delivered during the historical cost-reporting period, to arrive at the provider's projected cost for each unit of service for each type of service.
(C) For each type of service:
(i) Arrange all providers' projected cost for each unit of service in an array from low to high, with the corresponding total number of units of service for each provider;
(ii) Sum the total number of units of service for each provider in the array progressively from low to high to create a running total;
(iii) Divide the total number of units of service by two;
(iv) Identify the value, from the running total sums calculated in clause (ii) of this subparagraph, that is closest to the result in clause (iii) of this subparagraph; and
(v) Identify the cost for each unit of service that corresponds to the value identified in clause (iv) of this subparagraph to arrive at the recommended rate for that service.
(e) Reporting of costs.
(1) All rehabilitative services providers must submit
a cost report unless the number of days between the date the first
client received services and the 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 governmental entity. Requests
to be excused from submitting a cost report must be received by the
HHSC Provider Finance [Rate Analysis] Department
before the due date of the cost report.
(2) Cost reporting. Rehabilitative services providers must submit cost report data according to HHSC's specifications. In addition to the requirements of this section, the cost reporting guidelines will be governed by the information in §355.101 of this title (relating to Introduction), §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures), §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), §355.107 of this title (relating to Notification of Exclusions and Adjustments), §355.108 of this title (relating to Determination of Inflation Indices), §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs), §355.110 of this title (relating to Informal Reviews and Formal Appeals), and §355.11 of this title (relating to Administrative Contract Violation).
(3) 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 rates. To ensure that the database reflects costs and other information that are necessary for the provision of services and is consistent with federal and state regulations, HHSC excludes from rate determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers.
(4) Individual provider cost reports may not be included in the database used for reimbursement determination if:
(A) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or
(B) an auditor determines that reported costs are not verifiable.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on October 2, 2023.
TRD-202303665
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455
DIVISION 11. TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT
STATUTORY AUTHORITY
The amendment is authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.8210.Waiver Payments to Governmental Ambulance Providers for Uncompensated Charity Care.
(a) Introduction. Beginning October 1, 2019, Texas Healthcare Transformation and Quality Improvement 1115 Waiver payments are available under this section for eligible governmental ambulance providers to help defray the uncompensated cost of charity care. Waiver payments to governmental ambulance providers for uncompensated care provided before October 1, 2019, are described in §355.8600 of this subchapter (relating to Reimbursement Methodology for Ambulance Services).
(b) Definitions.
(1) Centers for Medicare & Medicaid Services (CMS)--The federal agency within the United States Department of Health and Human Services responsible for overseeing and directing Medicare and Medicaid, or its successor.
(2) Certified public expenditure (CPE)--An expenditure certified by a governmental entity to represent its contribution of public funds in providing services that are eligible for federal matching Medicaid funds.
(3) Charity care--Healthcare services provided without expectation of reimbursement to uninsured patients who meet the provider's charity-care policy. The charity-care policy should adhere to the charity-care principles of the Healthcare Financial Management Association Principles and Practices Board Statement 15 (December 2012). Charity care includes full or partial discounts given to uninsured patients who meet the provider's financial assistance policy. Charity care does not include bad debt, courtesy allowances, or discounts given to patients who do not meet the provider's charity-care policy or financial assistance policy.
(4) Demonstration year--The 12-month period beginning October 1 for which the payments calculated under this section are made. Demonstration year one was October 1, 2011, through September 30, 2012.
(5) Governmental entity--A state agency or a political subdivision of the state. A governmental entity includes a hospital authority, hospital district, city, county, or state entity.
(6) HHSC--The Texas Health and Human Services Commission or its designee.
(7) Public funds--Funds derived from taxes, assessments, levies, investments, and other public revenues within the sole and unrestricted control of a governmental entity. Public funds do not include gifts, grants, trusts, or donations, the use of which is conditioned on supplying a benefit solely to the donor or grantor of the funds.
(8) Governmental ambulance provider--An ambulance provider that uses paid government employees to provide ambulance services. The ambulance services must be directly funded by a governmental entity. A private ambulance provider under contract with a governmental entity to provide ambulance services is not considered a governmental ambulance provider for the purposes of this section.
(9) Uncompensated-care application--A form prescribed by HHSC to identify uncompensated costs for Medicaid-enrolled providers.
(10) Uncompensated-care payments--Payments intended to defray the uncompensated costs of charity care as defined in paragraph (3) of this subsection.
(11) Uninsured patient--An individual who has no health insurance or other source of third-party coverage for the services provided. The term includes an individual enrolled in Medicaid who received services that do not meet the definition of medical assistance in section 1905(a) of the Social Security Act (Medicaid services), if such inclusion is specified in the hospital's charity-care policy or financial assistance policy and the patient meets the hospital's policy criteria.
(12) Waiver--The Texas Healthcare Transformation and Quality Improvement Program Medicaid demonstration waiver under §1115 of the Social Security Act.
(c) Eligibility.
(1) A governmental ambulance provider must submit a
written request for eligibility for supplemental payment in a form
prescribed by HHSC to the HHSC Provider Finance [Rate
Analysis] Department by a date specified each year by HHSC.
An acceptable request must include:
(A) an overview of the governmental agency;
(B) a complete organizational chart of the governmental agency;
(C) a complete organizational chart of the ambulance department within the governmental agency providing ambulance services;
(D) an identification of the specific geographic service area covered by the ambulance department, by ZIP code;
(E) copies of all job descriptions for staff types or job categories of staff who work for the ambulance department and an estimated percentage of time spent working for the ambulance department and for other departments of the governmental agency;
(F) a primary contact person for the governmental agency who can respond to questions about the ambulance department; and
(G) a signed letter documenting the governmental ambulance provider's voluntary contribution of non-federal funds.
(2) If eligible, a governmental ambulance provider may begin to claim uncompensated-care costs related to services provided on or after the first day of the month after the request for eligibility is approved.
(d) Source of funding. The non-federal share of funding for payments under this section is limited to public funds from governmental entities. Prior to processing uncompensated-care payments for any payment period within a waiver demonstration year, HHSC will survey the governmental entities that provide public funds for the governmental ambulance providers in the pool to determine the amount of funding available to support payments from that pool.
(e) Payment frequency. HHSC will distribute uncompensated-care payments on a schedule to be determined by HHSC and posted on HHSC's website.
(f) Funding limitations.
(1) Payments made under this section are limited by the amount of funds allocated to the provider's uncompensated-care pool for the demonstration year as described in §355.8212 of this division (relating to Waiver Payments to Hospitals for Uncompensated Charity Care). If payments for uncompensated care for the governmental ambulance provider pool attributable to a demonstration year are expected to exceed the amount of funds allocated to that pool by HHSC for that demonstration year, HHSC will reduce payments to providers in the pool as described in subsection (g)(3) of this section.
(2) Payments made under this section are limited by the availability of funds identified in subsection (d) of this section. If sufficient funds are not available for all payments for which all governmental ambulance providers are eligible, HHSC will reduce payments as described in subsection (h)(2) of this section.
(g) Uncompensated-care payment amount.
(1) Cost reports. Governmental ambulance providers that are eligible for supplemental payments must submit an annual cost report for ground, water, and air ambulance services delivered to individuals who meet the provider's charity-care policy.
(A) The cost report form will be specified by HHSC. Providers certify through the cost report process their total actual federal and non-federal costs and expenditures for the cost reporting period.
(B) Cost reports must be completed for the full demonstration year for which payments are being calculated. HHSC may require a newly eligible provider to submit a partial-year cost report for their first year of eligibility. The beginning date for the partial-year cost report is the provider's first day of eligibility for supplemental payments as determined by HHSC. The ending date of the partial-year cost report is the last day of the demonstration year that encompasses the cost report beginning date.
(C) The cost report is due on or before March 31 of the year following the cost reporting period ending date and must be certified in a manner specified by HHSC.
(i) If March 31 falls on a federal or state holiday or weekend, the due date is the first working day after March 31.
(ii) A provider may request in writing an extension of up to 30 days after the due date to submit a cost report. HHSC will respond to all written requests for extensions, indicating whether the extension is granted. HHSC must receive a request for extension before the cost report due date. A request for extension received after the due date is considered denied.
(iii) A provider whose cost report is not received by the due date or the HHSC-approved extended due date is ineligible for supplemental payments for the federal fiscal year.
(iv) The individual who completes the cost report on behalf of the provider ("the preparer") must complete the state-sponsored cost report training every other year for the odd-year cost report in order to receive credit to complete both that odd-year cost report and the following even-year cost report. If a new preparer wishes to complete an even-year cost report and has not completed the previous odd-year cost report training, to receive training credit to complete the even-year cost report, the preparer must complete an even-year cost report training. No exemptions from the cost report training requirements will be granted.
(D) A cost report documents the provider's actual allowable charity-care costs for delivering ambulance services in accordance with the applicable state and federal regulations. Because the cost report is used to determine supplemental payments, a provider must submit a complete and acceptable cost report to be eligible for a supplemental payment.
(E) The uncompensated-care payment is contingent upon the governmental ambulance provider's CPEs related to charity-care services. There are two CPE forms that must be submitted with each cost report:
(i) The cost report certification form formally acknowledges that the cost report is true, correct, and complete, and was prepared in accordance to all applicable rules and regulations.
(ii) The certification of funds form acknowledges that the claimed expenditures are allocable and allowable to the State Medicaid program under Title XIX of the Social Security Act, and in accordance with all procedures, instructions, and guidance issued by the single state agency and in effect during the cost report federal fiscal year.
(2) Calculation. An ambulance provider's annual maximum uncompensated-care payment amount is calculated as follows:
(A) As detailed in the cost report instructions, a provider must report their charges associated with charity-care services provided to uninsured patients and any payments attributable to those services.
(B) A provider's total allowable reported costs for ambulance services are allocated to uninsured charity-care patients based on the ratio of charges for uninsured charity-care patients to the charges for all patients. Only allocable expenditures related to uninsured charity care as defined in subsection (b)(3) of this section will be included in calculating the uncompensated-care payment.
(C) The result of subparagraph (B) of this paragraph will be reduced by any related payments reported on the cost report to determine the provider's annual maximum uncompensated-care payment amount.
(3) Reduction to stay within the governmental ambulance provider uncompensated-care pool allocation amount. Prior to processing uncompensated-care payments for any payment period within a waiver demonstration year, HHSC will determine if such a payment would cause total uncompensated-care payments for the demonstration year for the governmental ambulance provider pool to exceed the allocation amount for the pool and will reduce the maximum uncompensated-care payment amounts for each provider in the pool by the same percentage as required to remain within the pool allocation amount.
(h) Recoupment.
(1) In the event of an overpayment identified by HHSC or a disallowance by CMS of federal financial participation related to a provider's receipt or use of payments under this section, HHSC may recoup an amount equivalent to the amount of the federal share of the overpayment or disallowance.
(2) Payments under this section may be subject to adjustment for payments made in error, including, without limitation, adjustments under §371.1711 of this title (relating to Recoupment of Overpayments and Debts), 42 CFR Part 455, and Chapter 403 of the Texas Government Code. HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid payments as follows:
(A) HHSC will recoup from the provider against which any overpayment was made or disallowance was directed.
(B) If, within 30 days of the provider's receipt of HHSC's written notice of recoupment, the provider has not paid the full amount of the recoupment or entered into a written agreement with HHSC to do so, HHSC may withhold any or all future Medicaid payments from the provider until HHSC has recovered an amount equal to the amount overpaid or disallowed.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on October 2, 2023.
TRD-202303667
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455
STATUTORY AUTHORITY
The amendments authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendments affect Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.8421.Reimbursement for Case Management Services for Infants and Toddlers with Developmental Disabilities.
(a) Authority. Payments are made to qualified providers delivering case management services to Medicaid-eligible individuals who are eligible for services in the Early Childhood Intervention Program (ECI) according to the program rules established by the Department of Assistive and Rehabilitative Services (DARS). The reimbursement determination authority is specified in §355.101 of this title (relating to Introduction).
(b) Unit of service. Qualified providers are reimbursed based on a 15-minute unit of service that is a prospective and uniform statewide rate for the following types of services:
(1) face-to-face case management visit; and
(2) telephone case management visit.
(c) Rate methodology.
(1) Initial rates. The rate effective October 1, 2011, will be the initial statewide rate.
(2) Cost report-based rates. After the Health and Human Services Commission (HHSC) determines that cost data collected as described in subsection (d) of this section is reliable and sufficient to support development of a cost report-based rate, HHSC will develop statewide reimbursement rates using that data to replace the initial rates as follows:
(A) Project each provider's total allowable cost per type of service from the historical cost reporting period to the prospective reimbursement period, using inflation factors according to §355.108 of this title (relating to Determination of Inflation Indices), to arrive at the projected cost per type of service;
(B) For each provider, divide the projected cost per type of service, determined in subparagraph (A) of this paragraph, by the provider's total units of service per type of service delivered during the historical cost reporting period, to arrive at the provider's projected cost per unit of service for each type of service; and
(C) For each type of service:
(i) Arrange all providers' projected cost per unit of service in an array from low to high, with the corresponding total number of units of service for each provider;
(ii) Sum the total number of units of service for each provider in the array progressively from low to high to create a running total;
(iii) Divide the total number of units of service by two;
(iv) Identify the value, from the running total sums calculated in clause (ii) of this subparagraph, that is closest to the result in clause (iii) of this subparagraph; and
(v) Identify the cost per unit of service that corresponds to the value identified in clause (iv) of this subparagraph, to arrive at the recommended rate for that service.
(d) Reporting of costs.
(1) All case management service providers must submit
a cost report unless the number of days between the date the first
client received services and the fiscal year end is 30 days or fewer.
A 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 disaster or removal of
records from the provider's custody by any governmental entity. Requests
to be excused from submitting a cost report must be received by the
HHSC Provider Finance [Rate Analysis] Department
before the due date of the cost report as set out in §355.105(c)
of this title (relating to General Reporting and Documentation Requirements,
Methods, and Procedures).
(2) Cost reporting. Case management service providers must submit cost report data according to HHSC's specifications. In addition to the requirements of this section, the following cost reporting requirements apply: §355.101 of this title (relating to Introduction), §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures), §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), §355.107 of this title (relating to Notification of Exclusions and Adjustments), §355.108 of this title (relating to Determination of Inflation Indices), §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs), §355.110 of this title (relating to Informal Reviews and Formal Appeals), and §355.111 of this title (relating to Administrative Contract Violations).
(3) 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 rates. To ensure that the database reflects costs and other information that are necessary for the provision of services and is consistent with federal and state regulations, HHSC excludes from rate determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers.
(4) Individual provider cost reports may not be included in the database used for reimbursement determination if:
(A) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or
(B) an auditor determines that the reported costs are not verifiable.
§355.8422.Reimbursement for Specialized Rehabilitation Services for Infants and Toddlers with Developmental Disabilities.
(a) Authority. Payments are made to qualified providers delivering specialized rehabilitation services to Medicaid-eligible individuals who are eligible for services in the Early Childhood Intervention Program (ECI) according to the program rules established by the Department of Assistive and Rehabilitative Services (DARS). The reimbursement determination authority is specified in §355.101 of this title (relating to Introduction).
(b) Unit of service. The unit of service is one hour and will be pro-rated for 15-minute intervals for specialized rehabilitation services on an individual and group basis.
(c) Rate methodology.
(1) Initial rates. The rate effective October 1, 2011, will be the initial statewide rate.
(2) Cost report-based rates. After the Health and Human Services Commission (HHSC) determines that cost data collected as described in subsection (d) of this section is reliable and sufficient to support development of a cost report-based rate, HHSC will develop statewide reimbursement rates using that data to replace the initial rates as follows:
(A) Project each provider's total allowable cost per type of service from the historical cost reporting period to the prospective reimbursement period, using inflation factors according to §355.108 of this title (relating to Determination of Inflation Indices), to arrive at the projected cost per type of service;
(B) For each provider, divide the projected cost per type of service, determined in subparagraph (A) of this paragraph, by the provider's total units of service per type of service delivered during the historical cost reporting period, to arrive at the provider's projected cost per unit of service for each type of service; and
(C) For each type of service:
(i) Arrange all providers' projected cost per unit of service in an array from low to high, with the corresponding total number of units of service for each provider;
(ii) Sum the total number of units of service for each provider in the array progressively from low to high to create a running total;
(iii) Divide the total number of units of service by two;
(iv) Identify the value, from the running total sums calculated in clause (ii) of this subparagraph, that is closest to the result in clause (iii) of this subparagraph; and
(v) Identify the cost per unit of service that corresponds to the value identified in clause (iv) of this subparagraph, to arrive at the recommended rate for that service.
(d) Reporting of costs.
(1) All rehabilitation services providers must submit
a cost report unless the number of days between the date the first
client received services and the fiscal year end is 30 days or fewer.
A 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 governmental entity. Requests
to be excused from submitting a cost report must be received by the
HHSC Provider Finance [Rate Analysis] Department
before the due date of the cost report as set out in §355.105(c)
of this title (relating to General Reporting and Documentation Requirements,
Methods, and Procedures).
(2) Cost reporting. Rehabilitation services providers must submit cost report data according to HHSC's specifications. In addition to the requirements of this section, the following cost reporting requirements apply: §355.101 of this title (relating to Introduction), §355.102 of this title (relating to General Principles of Allowable and Unallowable Costs), §355.103 of this title (relating to Specifications for Allowable and Unallowable Costs), §355.104 of this title (relating to Revenues), §355.105 of this title (relating to General Reporting and Documentation Requirements, Methods, and Procedures), §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports), §355.107 of this title (relating to Notification of Exclusions and Adjustments), §355.108 of this title (relating to Determination of Inflation Indices), §355.109 of this title (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs), §355.110 of this title (relating to Informal Reviews and Formal Appeals), and §355.11 of this title (relating to Administrative Contract Violation).
(3) 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 rates. To ensure that the database reflects costs and other information that are necessary for the provision of services and is consistent with federal and state regulations, HHSC excludes from rate determination any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers.
(4) Individual provider cost reports may not be included in the database used for reimbursement determination if:
(A) there is reasonable doubt as to the accuracy or allowability of a significant part of the information reported; or
(B) an auditor determines that the reported costs are not verifiable.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on October 2, 2023.
TRD-202303669
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455
STATUTORY AUTHORITY
The amendment is authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code Chapter 32.
The amendment affects Texas Government Code Chapter 531, and Texas Human Resources Code Chapter 32.
§355.9040.Reimbursement Methodology for Comprehensive Rehabilitation Services Program.
(a) Payment rate determination. Payment rates are determined based on the methodology described for each service array.
(1) Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) Inpatient Comprehensive Medical Rehabilitation Services Array. The Texas Department of Assistive and Rehabilitative Services or its successor agency (DARS) negotiates contracts with inpatient facilities to provide services based on data from the Centers for Medicare & Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS).
(2) TBI and SCI Outpatient Services Array.
(A) For services and purchases for which a specific rate can be established without regard to the individual receiving the service or item, the Texas Health and Human Services Commission (HHSC) will establish Comprehensive Rehabilitation Services (CRS) fee-for-service rates based on a review of rates for similar services as presented in one or more of the following data sources: HHSC fee schedules, previous DARS fee schedules, Medicare fee schedules, other states' Medicaid fee schedules, and/or commercial insurance fee schedules.
(i) Where information on comparable rates is not available, HHSC will establish rates representing best value based on the factors listed in §391.103(2) of this title (relating to Definitions).
(ii) To ensure adequate access to services, DARS medical
director, or optometric consultant may approve exceptions to established
rates, with review by the HHSC Provider Finance [Rate
Analysis] Department (PFD) [(RAD)].
(B) For services and purchases for which a specific rate can be established without regard to the individual receiving the service or item, but for which a CRS rate has not yet been set at the time an individual's program planning team determines that the service is required, HHSC will establish an interim CRS rate.
(i) DARS will contact HHSC PFD [(RAD)]
to request an interim CRS rate.
(ii) HHSC PFD [(RAD)] will determine
the interim CRS rate based on the process in subparagraph (A) of this paragraph.
(iii) Claims paid at an interim rate established under this subparagraph will not be adjusted once a rate is formally adopted for that service.
(C) For services and purchases for which the cost of the service or item purchased is specific to the individual receiving the service or item, HHSC will establish a CRS rate at the time of purchase, based on best value, as defined by the reasonable and customary industry standards for each specific service or item purchased.
(3) Post-Acute Brain Injury (PABI) Residential Services Array. DARS will pay providers a per diem rate for each allowable day of PABI Residential Service. DARS will also pay providers for such ancillary services as have been approved in the individual's program plan and received by the individual.
(A) The initial per diem rate is the sum of a base component, which covers room and board, administration, personal assistance, and facility and operations costs; a core service component, which covers core therapy services; and an additional amount for periodic required evaluations.
(i) HHSC determines the base component as follows:
(I) determine the rates for the small and medium classes of facilities in the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) program as specified in §355.456 of this chapter (relating to Reimbursement Methodology);
(II) adjust the ICF/IID rates to account for the specific needs of the CRS population; and
(III) average the adjusted rates for individuals with limited, extensive, pervasive, and pervasive plus levels of need, weighting by the days of service for those individuals from the most recently reviewed and accepted ICF/IID cost reports.
(ii) HHSC determines the core service component by reviewing the rates or contracted payment amounts for similar services, including the five common core therapy services (Physical Therapy, Occupational Therapy, Speech/Language Therapy, Cognitive Rehabilitation Therapy, and Neuropsychological Therapy) paid by the following payers: HHSC, the Texas Department of Aging and Disability Services (DADS), DARS, Medicare, other states' Medicaid programs, and commercial insurance companies. Based on this review, HHSC determines an appropriate rate per hour that is multiplied by the hours in the tier structure below to determine the rate for each tier. Determination of the applicable tier for a day of service is governed by DARS program standards.
(I) Base - 0 hours.
(II) Base Plus - 0.5 hours.
(III) Tier 1 - 1.5 hours.
(IV) Tier 2 - 2.5 hours.
(V) Tier 3 - 3.5 hours.
(VI) Tier 4 - 4.5 hours.
(VII) Tier 5 - 5.5 hours.
(VIII) Tier 6 - 6.5 hours.
(IX) Tier 7 - 7.5 hours.
(X) Tier 8 - 8.5 hours.
(iii) HHSC determines the additional amount for periodic required evaluations by averaging the common core therapy evaluation rates, multiplying the average by 12, and dividing the product by the number of days in the rate year.
(B) If HHSC determines that adequate cost and services delivery data is available, HHSC may rebase the per diem rate components.
(i) For the base component, if HHSC deems it appropriate to require contracted providers to submit a cost report, HHSC will determine if cost data collected as described in subsection (c) of this section is reliable and sufficient to support development of a cost report-based rate. If such reliable and sufficient data is available, HHSC may develop a reimbursement rate using that data to replace the initial base component.
(ii) For the core service component, HHSC will collect and evaluate detailed service delivery data. HHSC may rebase the core service component based on the detailed service delivery data.
(C) HHSC determines the ancillary services rates as described in paragraph (2) of this subsection.
(4) PABI and Post-Acute SCI Non-Residential Services Array. HHSC will set separate base rates for facility-based and community-based services, as described in subparagraph (A) of this paragraph. DARS will pay for each allowable billing increment, as defined by program standards. DARS will also pay for such core and ancillary services as have been approved in the individual's program plan and received by the individual.
(A) Initial rates will consist of an hourly base rate which covers administration, personal assistance, and facility and operations costs.
(i) For providers offering Non-Residential Services in a setting that is also a residential facility or shares space with a residential facility, HHSC determines the initial hourly base rate as follows:
(I) determine the rates for the small and medium classes of facilities in the ICF/IID program as specified in §355.456 of this chapter;
(II) adjust the ICF/IID rates to account for the specific needs of the CRS population and the base services to be provided in a Non-Residential facility-based setting;
(III) average the adjusted rates for individuals with limited, extensive, pervasive and pervasive plus levels of need, weighting by the days of service for those individuals from the most recently reviewed and accepted ICF/IID cost reports; and
(IV) divide the average by eight.
(ii) For providers offering Non-Residential Services in the home of the individual receiving the service or in a community setting not connected or affiliated with a residential setting, HHSC determines the initial hourly base rate as follows:
(I) determine the case management and the other attendant care cost components (also known as the administration and facility cost area) of the habilitation base rate under the Community Living Assistance and Support Services (CLASS) program, as described in §355.505 of this chapter (relating to Reimbursement Methodology for the Community Living Assistance and Support Services Waiver Program); and
(II) adjust the rate to account for specific needs of the CRS population and the base services to be provided in a non-residential home or community setting.
(B) If HHSC deems it appropriate to require contracted providers to submit a cost report, HHSC will determine if cost data collected as described in subsection (c) of this section is reliable and sufficient to support development of a cost-report-based rate. If such reliable and sufficient data is available, HHSC may develop cost-report-based rates to replace the initial hourly base rates.
(C) HHSC will determine the rates for core services as described in paragraph (2)(A) of this subsection.
(D) HHSC will determine the rates for ancillary services as described in paragraph (2) of this subsection.
(b) Related information. The information in §355.101 of this chapter (relating to Introduction) and §355.105(g) of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures) applies to this section.
(c) Reporting of cost. To gather adequate financial and statistical information upon which to base reimbursement, HHSC may require a contracted provider to submit a cost report for any service provided through the CRS program.
(1) Cost Reports. If HHSC requires a provider to submit a cost report, the provider must follow the cost reporting guidelines in §355.105 of this chapter and the guidelines for determining whether a cost is allowable or unallowable in §355.102 of this chapter (relating to General Principles of Allowable and Unallowable Costs) and §355.103 of this chapter (relating to Specifications for Allowable and Unallowable Costs).
(2) Excusal from submission of a cost report. A provider is excused from the requirement to submit a cost report if the provider meets one or more of the conditions in §355.105(b)(4)(D) of this chapter.
The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.
Filed with the Office of the Secretary of State on October 2, 2023.
TRD-202303670
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: November 19, 2023
For further information, please call: (512) 730-7455