1 Tex. Admin. Code § 355.8704 - Reporting and Monitoring
(a) A governmental
entity that provides funds for use as the non-federal share in the Medicaid
program must report information to the Texas Health and Human Services
Commission (HHSC) in a form and format to be determined by HHSC.
(b) The information must be reported at least
annually, no later than October 31, or upon request by HHSC.
(c) HHSC will review reported information
based on governmental entity funding sources, including:
(1) local provider participation funds
(LPPFs) authorized by the Texas Health and Safety Code Chapter 288 et
seq. or other provider tax structures;
(2) non-LPPF provider taxes;
(3) ad valorem tax revenue;
(4) patient revenue;
(5) donations; and
(6) other local funding
sources.
(d) HHSC will
use the information from the report to monitor each governmental entity's
funding sources and determine the likelihood that the funds are permissible for
use in the Medicaid program. The monitoring will include the following:
(1) Survey. An electronic annual survey that
will request the following:
(A) a list of all
Medicaid programs and health care providers (including name, type, and
ownership status) for which the governmental entity transferred or certified
funds as the non-federal share;
(B)
the relationship between the governmental entity and each health care provider,
including a copy of any formal or informal agreements between the governmental
entity and the health care provider;
(C) the source of the funds used as the
non-federal share transferred by the governmental entity;
(D) information on any debt instruments
(i.e., bonds, loans, etc.) that a governmental entity utilizes and the
relationship of the instrument to any transferred funds;
(E) to the extent patient revenue is used, a
description of payor mix (i.e., Medicaid, Medicare, commercial, uninsured,
self-pay, etc.) during the federal fiscal year (FFY) and any anticipated
changes;
(F) any transfer of funds
or provision of services from a health care provider or entity related to a
health care provider to the governmental entity, including in-cash or in-kind
donations, or any other transfer of value;
(G) overview of funds received from all
sources available to the governmental entity during the FFY;
(H) other information as determined necessary
and appropriate to determine compliance with federal or state statutes and
regulations, including attestations of compliance from the local government;
and
(I) any publicly available
information, such as:
(i) recordings of
discussions or written minutes from public meetings to set assessment rates or
gather feedback from health care providers or their representatives;
(ii) correspondence describing the
governmental entity's funding transferred to HHSC for use in the Medicaid
program;
(iii) links to websites
that describe the funds used as the non-federal share or any agreement between
the governmental entity and a health care provider or entity related to a
health care provider; and
(iv)
copies of any public notices, local orders, announcements, or other related
documentation.
(2) Risk Assessment.
(A) The risk assessment will include:
(i) a risk assessment score based on
self-reported annual survey responses; and
(ii) any adjustments made at HHSC's
discretion based on supplemental documentation and discussion with the impacted
governmental entity and review of additional documentation requests as may be
needed, in HHSC's sole discretion, to confirm, audit, or modify self-reported
data and qualitative descriptions.
(B) The funds used as the non-federal share
will be categorized as likely permissible, further review required, or likely
impermissible based on a review of a governmental entity's funding sources.
HHSC may elect to contact entities whose funding sources are categorized as
further review required or likely impermissible to obtain additional
information. The entity must furnish the requested information to HHSC within
10 business days of the date of the request.
(i) Likely permissible. Funding source
appears to comply with federal and state statutes and regulations.
(ii) Further review required. Funding source
compliance with federal and state statutes and regulations is
unclear.
(iii) Likely
impermissible. Funding source does not appear to comply with federal or state
regulations.
(3) In-depth Review. HHSC will select a
sample of survey respondents for an in-depth review in which HHSC may examine
supporting documentation, either on-site or electronically, at HHSC's
discretion. HHSC will select a sample of survey respondents sufficient to
result in a 95 percent confidence level with a 5 percent margin of error. HHSC
will select entities based on an initial risk assessment, and if additional
entities are necessary to complete the required sample size, they will be
randomly selected. HHSC will notify a governmental entity if an on-site review
will occur at least 10 calendar days prior to the visit.
(4) Determination. HHSC will notify the
governmental entity upon determination of the following:
(A) reporting compliance;
(B) risk assessment score;
(C) funding source category pursuant to
paragraph (2)(B) of this subsection.
(5) Post-Determination Review.
Post-determination review will be conducted as outlined in §
355.8705 of this subchapter
(relating to Post-Determination Review).
(6) Federal Reporting.
(e) If a governmental entity fails to submit
the required information or supplemental documentation as requested by HHSC by
the deadline specified in this section, HHSC may refuse further transfer of
funds for any Medicaid program from the governmental entity until the reporting
requirement is satisfied and may process recoupments for any payments resulting
from funds transferred determined to be non-compliant.
(f) Prior to the applicable deadline, a
governmental entity may request an extension of up to 10 business days for any
deadline contained in this subchapter. HHSC may grant or reject such request at
its sole discretion.
(g) After
review of any additional information provided, HHSC may also seek input on the
likely permissibility of the funds from the Centers for Medicare & Medicaid
Services (CMS). In the event HHSC elects to request input from CMS regarding
the compliance of a specific funding source as contemplated by this subchapter,
HHSC will notify the governmental entity prior to requesting such review. HHSC
may, at its discretion, accept or reject local funds from any governmental
entity; however, HHSC will reject funding and recoup all Medicaid payments
supported by a governmental entity's funding source that CMS deems
impermissible if CMS requires HHSC to do so.
(h) If a governmental entity is determined
not to have met the reporting requirements, or to have falsified any data in
its reporting, HHSC may refuse transfers from the governmental entity, and
payments to health care providers resulting from prior transfers may be
recouped.
Notes
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