1 Tex. Admin. Code § 355.510 - Reimbursement Methodology for Emergency Response Services (ERS)
(a) General
requirements. The Texas Health and Human Services Commission (HHSC) or its
designee applies the general principles of cost determination as specified in
§
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 §
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 §
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
§
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 §
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 §
355.101 of this title (relating to
Introduction).
(e) Contract-specific unit reimbursement. The
actual reimbursement for each contract is negotiated between DADS staff and the
provider agency. The contract-specific reimbursement DADS pays the provider
agency is the full cost for emergency response services. The provider agency
must not bill the client for any additional charges. In no instance may the
negotiated unit reimbursement exceed the per-month reimbursement
ceiling.
(f) Reviews and field
audits of cost reports. HHSC staff perform either desk reviews or field audits
on all contracted providers. The frequency and nature of the field audits are
determined by HHSC staff 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), and
providers will be notified of the results of a desk review or a field audit in
accordance with §
355.107 of this title (relating to
Notification of Exclusions and Adjustments). Providers may request an informal
and, if necessary, an administrative hearing to dispute an action taken by HHSC
under §
355.110 of this title (relating to
Informal Reviews and Formal Appeals).
(g) Factors affecting allowable costs. In
determining whether a cost is allowable or unallowable, providers must follow
the guidelines specified in §
355.102 of this title (relating to
General Principles of Allowable and Unallowable Costs). Providers must follow
the guidelines for allowable and unallowable costs as specified in §
355.103 of this title (relating to
Specifications for Allowable and Unallowable Costs) and follow the guidelines
for unallowable costs specific to the ERS program as specified in this
subsection.
(h) Unallowable cost.
The unallowable cost specific to the ERS program is the expense of base station
equipment at the response center.
(i) Reporting revenue. Revenue must be
reported on the cost report according to §
355.104 of this title (relating to
Revenue).
Notes
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