Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter D - REIMBURSEMENT METHODOLOGY FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) › Section 355.457 - Cost Finding Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) General
				  principles. The Texas Health and Human Services Commission (HHSC) applies the
				  general principles of cost determination as specified in §
										RSA 355.101 of this
				  title (relating to Introduction).
(b) Additional requirements. In addition to
				  the requirements of §
										RSA
				  355.102 and §
										RSA
				  355.103 of this title (relating to General
				  Principles of Allowable and Unallowable Costs, and Specifications for Allowable
				  and Unallowable Costs), the following apply to costs for the intermediate care
				  facilities for persons with mental retardation (ICF/MR) program.
(1) Attendant service costs. Attendant
				  service costs are defined in §
											RSA
				  355.112 of this title (relating to Attendant
				  Compensation Rate Enhancement).
(2)
				  Provider responsibilities. The provider is responsible for submission of the
				  cost report to HHSC, and payment of amounts owed in accordance with subsection
				  (c) of this section for services delivered on or before August 31, 2009, and
				  payment of amounts owed in accordance with §
											RSA
				  355.112 of this title for services delivered
				  on or after September 1, 2010, regardless of whether the provider contracts
				  with another entity for the management or operation of the ICF/MR.
(A) If the provider contracts with another
				  entity for the management or operation of the ICF/MR, the provider must report
				  the specific costs of that entity as required in the cost report instructions
				  and not the amount for which the provider is contracting for the entity's
				  services.
(B) 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 §
												RSA
				  355.105 of this title (relating to General
				  Reporting and Documentation Requirements, Methods, and Procedures).
(C) Allowable compensation for owners and
				  related parties and definitions of owners and related parties are specified in
				  §
												RSA
				  355.102(i) and §
												RSA
				  355.103(b)(2) of this title.
(i) 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 §
													RSA
				  355.105(b)(2)(B)(xi) of this
				  title.
(ii) 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 §
													RSA
				  355.456(d) of this title
				  (relating to Reimbursement Methodology) prior to any adjustments made in
				  accordance with §
													RSA 355.101 of this
				  title (relating to Introduction) and §
													RSA
				  355.109 of this title (relating to Adjusting
				  Reimbursement When New Legislation, Regulations or Economic Factors Affect
				  Costs) for the rate period.
(iii)
				  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:
(I) 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 clause (ii) of this
				  subparagraph, adjusted for the provider's average Level of Need (LON) during
				  the reporting period.
(II) 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.
(III) Step 3. Determine the greater of Step 1
				  and Step 2.
(IV) Step 4. Determine
				  the actual hours worked by the staff-type per unit of service.
(V) 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.
(iv) 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 clause (ii) of this subparagraph
				  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.
(v) 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.
(vi) Classification of hours over the limit.
				  Hours, hourly wages and benefits above the limits described in clauses (ii) -
				  (v) of this subparagraph are to be reported as administrative hours, hourly
				  wages and benefits.
(3) Placement of vendor hold for change of
				  ownership and contract termination. For services delivered on or before August
				  31, 2009, the Department of Aging and Disability Services (DADS) will place a
				  vendor hold on a prior owner at a change of ownership which results in the
				  execution of a new provider agreement or a contract termination. The prior
				  owner must submit a cost report to HHSC for the current reporting period. Upon
				  receipt of an acceptable cost report and resolution of any outstanding
				  balances, the vendor hold will be released. For services delivered on or after
				  September 1, 2010, placement of vendor hold for change of ownership and
				  contract termination will be governed by the information in §
											RSA
				  355.112 of this title.
(4) Ownership change or contract termination
				  and failure to submit a cost report. For services delivered on or before August
				  31, 2009, 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
				  subsection (c)(1)(D) of this section. 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 subsection (c)(1)(A) - (C) of this section. 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.
				  For services delivered on or after September 1, 2010, recoupment of funds
				  related to failure to submit a cost report after an ownership change from one
				  legal entity to a different legal entity or a contract termination will be
				  governed by the information in §
											RSA
				  355.112 of this title.
(5) Failure to submit a cost report. For
				  services delivered on or before August 31, 2009, 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 subsection (c)(1)(D) of this section. 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 subsection
				  (c)(1)(A) - (C) of this section. If an acceptable cost report is not received
				  within 365 days of the due date, the recoupment will become permanent. For
				  services delivered on or after September 1, 2010, recoupment of funds related
				  to failure to submit a cost report within 60 days of the placement of a vendor
				  hold due to failure to submit the cost report will be governed by the
				  information in §
											RSA
				  355.112 of this title.
(6) Other applicable rules. For cost reports
				  pertaining to providers' fiscal years ending in calendar year 2004 and
				  subsequent years the following applies:
(A)
				  Providers must follow the cost-reporting guidelines as specified in §
												RSA
				  355.105 of this title.
(B) Providers must follow the guidelines in
				  determining whether a cost is allowable or unallowable as specified in §
												RSA
				  355.102 and §
												RSA
				  355.103 of this title.
(C) Revenues must be reported on the cost
				  report in accordance with §
												RSA 355.104 of this
				  title (relating to Revenues).
(7) Field audit and desk review. Desk reviews
				  or field audits are performed on cost reports for all contracted providers. The
				  frequency and nature of the field audits are determined by HHSC to ensure the
				  fiscal integrity of the program. Desk reviews and field audits will be
				  conducted in accordance with §
											RSA
				  355.106 of this title (relating to Basic
				  Objectives and Criteria for Audit and Desk Review of Cost Reports), and
				  providers will be notified of the results of a desk review or a field audit in
				  accordance with §
											RSA
				  355.107 of this title (relating to
				  Notification of Exclusions and Adjustments).
(8) Reviews of exclusions or adjustments. An
				  ICF/MR 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 §
											RSA
				  355.110 of this title (relating to Informal
				  Reviews and Formal Appeals).