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 355.510 - Reimbursement Methodology for Emergency Response Services (ERS)

Current through Reg. 49, No. 28; July 12, 2024
(a) General requirements. The Texas Health
				  and Human Services Commission (HHSC) or its designee applies the general
				  principles of cost determination as specified in §
										RSA 355.101 of this
				  title (relating to Introduction). Whenever the term "HHSC" occurs, it means the
				  Texas Health and Human Services Commission or its designee.
(b) General reporting guidelines. Providers
				  must follow the cost-reporting guidelines as specified in §
										RSA
				  355.105 of this title (relating to General
				  Reporting and Documentation Requirements, Methods, and Procedures).
(c) Reimbursement ceiling determination. When
				  HHSC does not require a cost report, HHSC may adjust the rate ceiling as
				  appropriate based upon cost data collected in the form of special surveys or
				  reports submitted by all contracted providers, or other appropriate cost data
				  related to the Emergency Response Services program.
(d) Reimbursement ceiling determination based
				  on a cost-reporting process. If HHSC deems it appropriate to require cost
				  reporting, cost reports will be governed by the information in this subsection.
(1) Reimbursement ceiling. The reimbursement
				  ceiling is determined for a per-month unit of service. The ceiling applies to
				  all provider agencies uniformly, regardless of geographic location or other
				  factors.
(2) Excused from
				  submission of cost reports. If required by HHSC, a contracted provider must
				  submit a cost report unless the provider meets one or more of the conditions in
				  §
											RSA
				  355.105(b)(4)(D) of this
				  title.
(3) Exclusion of cost
				  reports.
(A) Providers are responsible for
				  reporting only allowable costs on the cost report, except where cost report
				  instructions indicate that other costs are to be reported in specific lines or
				  sections. Only allowable cost information is used to determine recommended
				  reimbursement. HHSC excludes from reimbursement determination any unallowable
				  expenses included in the cost report and makes the appropriate adjustments to
				  expenses and other information reported by providers. The purpose is to ensure
				  that the data base reflects costs and other information which are necessary for
				  the provision of services and are consistent with federal and state
				  regulations.
(B) Individual cost
				  reports may not be included in the data base used for reimbursement
				  determination if:
(i) there is a 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.
(4) Recommended reimbursement
				  ceiling. HHSC determines a recommended reimbursement ceiling in the following
				  manner. The reimbursement ceiling is determined by the analysis of financial
				  and statistical data submitted by provider agencies on cost reports and, as
				  deemed appropriate, a market survey analysis of emergency response equipment
				  suppliers.
(A) HHSC allocates payroll taxes
				  and employee benefits 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. The employee benefits for administrative staff are allocated
				  directly to the corresponding salaries for those positions. The allocated
				  payroll taxes are Federal Insurance Contributions Act (FICA) or social
				  security, Workers' Compensation Insurance (WCI), the Federal Unemployment Tax
				  Act, and Texas Unemployment Compensation Act.
(B) Allowable expenses, excluding
				  depreciation and mortgage interest, are projected from the provider agency's
				  reporting period to the next ensuing reimbursement period. HHSC determines
				  reasonable and appropriate economic inflators or adjusters as described in
				  §
												RSA
				  355.108 of this title (relating to
				  Determination of Inflation Indices) to calculate a prospective expense. HHSC
				  also adjusts reimbursement if new legislation, regulations, or economic factors
				  affect costs as specified in §
												RSA
				  355.109 of this title (relating to Adjusting
				  Reimbursement When New Legislation, Regulations, or Economic Factors Affect
				  Costs).
(C) Allowable reported
				  expenses are combined into three cost areas: responder, program operations, and
				  facility. To determine the projected cost per unit of service, a contracted
				  provider's projected expenses in each cost area are divided by its total units
				  of service for the reporting period.
(D) The contracted providers' projected costs
				  per unit of service are ranked from low to high in each cost area, with
				  corresponding units of service.
(E)
				  The 80th percentile cost, weighted by units of service, is determined for each
				  cost area. The recommended reimbursement ceiling is the sum of the 80th
				  percentile costs of the three cost areas.
(F) The reimbursement determination authority
				  for this reimbursement ceiling is specified in §
												RSA 355.101 of this
				  title (relating to Introduction).