1 Tex. Admin. Code § 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(1) 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 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.
Notes
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