Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter E - COMMUNITY CARE FOR AGED AND DISABLED › Section 355.503 - Reimbursement Methodology for the Community-Based Alternatives Waiver Program and the Integrated Care Management - Home and Community Support Services and Assisted Living/Residential Care Programs

Current through Reg. 49, No. 28; July 12, 2024
(a) General requirements. 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). Providers are reimbursed for waiver services
				  provided to individuals who meet the criteria for alternatives to nursing
				  facility care. Additionally, providers are reimbursed a one-time administrative
				  expense fee for a pre-enrollment assessment of potential waiver participants.
				  The pre-enrollment assessment covers care planning for the
				  participant.
(b) Other sources of
				  cost information. If HHSC has determined that there is not sufficient reliable
				  cost report data from which to determine reimbursements and reimbursement
				  ceilings for waiver services, reimbursements and reimbursement ceilings will be
				  developed by using data from surveys; cost report data from other similar
				  programs, consultation with other service providers or professionals
				  experienced in delivering contracted services; and other sources.
(c) Waiver reimbursement determination.
				  Recommended reimbursements are determined in the following manner:
(1) Unit of service reimbursement.
				  Reimbursement for personal assistance services and in-home respite care
				  services, and cost per unit of service for nursing services provided by a
				  registered nurse (RN), nursing services provided by a licensed vocational nurse
				  (LVN), physical therapy, occupational therapy, speech/language therapy,
				  supported employment, employment assistance, and day activity and health
				  services will be determined on a fee-for-service basis in the following manner:
(A) Total allowable costs for each provider
				  will be determined by analyzing the allowable historical costs reported on the
				  cost report.
(B) Total allowable
				  costs are reduced by the amount of the pre-enrollment expense fee and
				  requisition fee revenues accrued for the reporting period.
(C) Each provider's total reported allowable
				  costs, excluding depreciation and mortgage interest, are projected from the
				  historical cost-reporting period to the prospective reimbursement period as
				  described in §
												RSA
				  355.108 of this title (relating to
				  Determination of Inflation Indices). The prospective reimbursement period is
				  the period of time that the reimbursement is expected to be in
				  effect.
(D) Payroll taxes and
				  employee benefits are allocated to each salary line item on the cost report on
				  a pro rata basis based on the portion of that salary line item to the amount of
				  total salary expense for the appropriate group of staff. Employee benefits will
				  be charged to a specific salary line item if the benefits are reported
				  separately. The allocated payroll taxes are Federal Insurance Contributions Act
				  (FICA) or Social Security, Medicare Contributions, Workers' Compensation
				  Insurance (WCI), the Federal Unemployment Tax Act (FUTA), and the Texas
				  Unemployment Compensation Act (TUCA).
(E) Allowable administrative and facility
				  costs are allocated or spread to each waiver service cost component on a pro
				  rata basis based on the portion of each waiver service's units of service to
				  the amount of total waiver units of service.
(F) For nursing services provided by an RN,
				  nursing services provided by an LVN, physical therapy, occupational therapy,
				  speech/language therapy, supported employment, employment assistance, and
				  in-home respite care services, an allowable cost per unit of service is
				  calculated for each contracted provider cost report for each service. The
				  allowable cost per unit of service, for each contracted provider cost report is
				  multiplied by 1.044. This adjusted allowable cost per unit of service may be
				  combined into an array with the allowable cost per unit of service of similar
				  services provided by other programs in determining rates for these services in
				  accordance with §
												RSA
				  355.502 of this title (relating to
				  Reimbursement Methodology for Common Services in Home and Community-Based
				  Services Waivers).
(G) For personal
				  assistance services, two cost areas are created:
(i) The attendant cost area includes
				  salaries, wages, benefits, and mileage reimbursement calculated as specified in
				  §
													RSA
				  355.112 of this title (relating to Attendant
				  Compensation Rate Enhancement).
(ii) Another attendant cost area is created
				  which includes the other personal attendant services costs not included in
				  clause (i) of this subparagraph as determined in subparagraphs (A) - (E) of
				  this paragraph. An allowable cost per unit of service is determined for each
				  contracted provider cost report for the other attendant cost area. The
				  allowable cost per unit of service for each contracted provider cost report are
				  arrayed. The units of service for each contracted provider cost report in the
				  array are summed until the median unit of service is reached. The corresponding
				  expense to the median unit of service is determined and is multiplied by
				  1.044.
(iii) The attendant cost
				  area and the other attendant cost area are summed to determine the personal
				  assistance services cost per unit of service.