1 Tex. Admin. Code § 355.761 - Reimbursement Methodology for Institutions for Mental Diseases (IMD)
(a) The Health and
Human Services Commission (HHSC) determines IMD reimbursement biennially. A
statewide prospective reimbursement will be available to all eligible IMD
providers for reimbursable IMD services. This reimbursement is inclusive of all
costs allowable under Medicare payment principles.
(b) Initial reimbursement period. The initial
reimbursement period is defined as November 16, 1994-April 30, 1996. The
reimbursement for this period is determined from Medicare cost reports for
state-operated hospitals, which provided IMD services between September 1,
1993, and August 31, 1994. The Medicare cost reports are reviewed by HHSC to
assure that the costs used for calculating each hospital's average per diem
cost for IMD services are allowable under Medicare payment principles and are
only those costs incurred by the hospital for care and treatment provided to
persons 65 years and older and occupying a Medicare-certified bed. Using these
Medicare cost reports, each hospital's average per diem cost for IMD services
is calculated. HHSC adjusts each hospital's average per diem cost for IMD
services to the initial reimbursement period by applying a cost-of-living
index. The cost-of-living index used is the Centers for Medicare and Medicaid
Services (CMS) Market Basket Forecast Excluded Hospital Input Price Index (as
reported in the Dallas Regional Medical Services Letter Number 95-015). Due to
the length of the initial reimbursement period, the percentages by which the
average per diem costs are adjusted are prorated by taking 1/12 of the forecast
for calendar year 1994 plus 2/12 of the forecast for calendar year 1995 plus
4/12 of the forecast for calendar year 1996. After adjusting the average per
diem cost for each hospital, the average per diem costs for all of the
hospitals are arrayed from high to low. The median (50th percentile) average
per diem cost is selected as the prospective reimbursement for the initial
reimbursement period. If the 50th percentile falls between IMD providers, then
the immediately higher average per diem cost will be selected as the
reimbursement.
(c) The
reimbursement period begins on September 1 and ends on August 31 of the
following year.
(1) Annually, each IMD
provider is required to submit to HHSC a copy of its Medicare cost report for
its most recent fiscal year ending prior to September 1. Cost reports must be
received by HHSC no later than 90 days following the end of the IMD provider's
fiscal year. Each IMD provider is required to identify in its cost report as a
subunit (IMD unit) those Medicare-certified units on which reimbursable IMD
services were provided. The Medicare cost reports are reviewed by HHSC to
assure that the costs to be used for calculating each IMD provider's average
per diem cost for IMD services are allowable under Medicare payment principles
and are only those costs incurred for care and treatment provided to persons 65
years of age and older and occupying a Medicare-certified bed.
(2) Upon completion of the reviews of cost
reports, and prior to calculating average per diem costs for each IMD provider,
cost reports and prior payment histories are reviewed. To ensure the integrity
of the data and avoid bias in the resulting reimbursement due to low volume and
other inefficiencies, cost reports of IMD providers will be eliminated from the
database for any one of the following reasons:
(A) being in operation fewer than 90 calendar
days during the previous cost reporting period;
(B) having an occupancy rate on its IMD units
of less than 90% for 50% or more of the days covered during the previous cost
reporting period; or
(C)
individually accounting for fewer than 5.0% of the total days of care
reimbursed by Medicaid as IMD services during the previous cost reporting
period.
(3) Using the
Medicare cost reports in the database, HHSC calculates for each IMD provider an
average per diem cost for IMD services. Each IMD provider's average per diem
cost is adjusted to the future reimbursement period by applying a
cost-of-living index. The cost-of-living index used is the Centers for Medicare
and Medicaid Services (CMS) Market Basket Forecast Excluded Hospital Input
Price Index (as reported to the States in the Dallas Regional Medical Services
Letter for the federal fiscal quarter ending in December of the year preceding
the next reimbursement period). The percentage used for adjustments to each IMD
provider's average per diem cost is prorated, using 1/3 of the forecast for the
calendar year in which the reimbursement period begins (September through
December) plus 2/3 of the forecast for the next calendar year (January through
August).
(4) After adjusting the
average per diem cost for each IMD provider, the average per diem costs of all
IMD providers remaining in the database are arrayed from high to low. The
median (50th percentile) average per diem cost is selected as the prospective
reimbursement for the future reimbursement period. If the 50th percentile falls
between IMD providers, then the immediately higher average per diem cost will
be selected as the reimbursement. The prospective reimbursement rate is
compared to the Support, Maintenance and Treatment (SMT) rate. All IMD
providers will be paid the lower of the prospective rate or SMT rate for each
day during the next reimbursement period that IMD services are provided to an
eligible individual.
(d)
Financial Audits. Financial audits are performed periodically on all IMD
providers. IMD providers have the right to appeal exclusions and adjustments to
cost reports according to TDMHMR's informal reviews and administrative hearings
process.
Notes
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