Texas Register, Volume 14, Number 78, Pages 5585-5650, October 20, 1989 Page: 5,628
5585-5650 p. ; 28 cm.View a full description of this periodical.
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(8) provided in compliance with
federal, state and local laws, including di-
rectives, settlements and resolutions appli-
cable to the target population;
(9) provided in accordance with
ithe TDMHMR Community Standards for
Mental Retardation; and
(10) provided in compliance
with the TDMHMR guidelines for annual
financial and compliance audit.
31.11. Reimbursement Methodology for
Case Management for Individuals with
Mental Retamdation or Related Condition.
(a) General information. DHS will
reimburse qualified providers for case man-
agement services provided to Medicaid eli-
gible individuals with mental retardation or
a related condition. The Texas Board of
Human Services determines reimbursement
rates at least annually for case management
services. These rates are:
(1) uniform statewide;
(2) prospective (see 31.1 of
this title (relating to Definitions)); and
(3) cost related.
(b) Basis for rate analysis.
(1) For the initial reimbursement
period, providers will be reimbursed based
on rates set as a result of an analysis of a
survey of actual costs reported by a sample
of qualified providers and an analysis of
anticipated costs required to provide the
relevant targeted case management services.
(2) The anticipated costs will
reflect the estimated costs of hiring quali-
fied staff, as specified by DHS, in sufficient
number and appropriate mix to meet the
projected client load service mix.
(3) At some future date, as yet
unspecified, reimbursement rates will be
based on actual costs reported by qualified
providers.
(c) Reporting of cost.
(1) Cost reporting. Each individ-
ual case management provider unit must
submit financial and statistical information
in a cost report or survey format designated
by DHS. The cost report will capture the
expenses of the case management unit in-
cluding salaries and oenefits, administra-
tion, building and equipment, utilities,
supplies, travel, and indirect overhead ex-
penses related to the case management unit.
(2) The following requirements
apply:
(A) accounting requirements.
All information submitted on the cost re-
ports must be based upon the accrual
pethod of accounting unless the govern-
hental entity operates on a cash basis. The
provider must complete the cost report ac-
cording to the prescribed statement of al-
lowable and unallowable costs. Costreporting should be consistent with gener-
ally accepted accounting principles
(GAAP). In cases in which cost reporting
rules conflict with GAAP, IRS, or other
authorities, the cost reporting rules take pre-
cedence for Medicaid provider cost report-
ing;
(B) reporting period. The
provider must prepare the cost report to
reflect activities during the provider's fiscal
year. The cost report is due three months
after the end of this fiscal year, although an
extension may be granted for good cause.
DHS may require cost reports or other in-
formation for other time periods. Failure to
file an acceptable cost report or complete
required additional information will result
in a hold on the vendor payments until the
cost report information or additional infor-
mation is provided. The provider must cer-
tify the accuracy of the cost report or
additional information;
(C) review of cost reports.
DHS reviews each cost report or survey to
ensure that all fmancial and statistical infor-
mation submitted conforms to all applicable
rules and instructions. Cost reports not com-
pleted according to instructions or rules are
returned to the provider for proper comple-
tion.
(D) on-site audit of cost re-
ports. DHS staff perform a sufficient num-
ber of audits each year to ensure the fiscal
integrity of the case management reim-
bursement rate. The number of on-site au-
dits actually perfonned each year may vary.
Adjustments consistent with the results of
on-site audits are made to the rate base until
the rate base is closed for final rate analy-
sis;
(E) record-keeping require-
ments. Each provider must maintain records
for at least three years after the date he
submits his cost report. The provider must
ensure that the records are accurate and
sufficiently detailed to support the financial
and statistical information reported in the
cost report. If a provider does not maintain
records which support the financial and sta-
tistical information submitted on the cost
report, the provider will be given 90 days to
correct this record-keeping. A hold of the
vendor payments to the provider will be
made if the deficiency is not corrected
within 90 days from the date the provider is
notified;
(F) access to records. The
provider must allow DHS or its designated
agents access to any and all records neces-
sary to verify information on the cost re-
port;
(G) reviews of cost report
disallowances. A provider who disagreeswith disallowances of the items on a cost
report may request a review by DHS staff
of the disallowance; however, the request
must be in writing.
(d) Rate setting methodology.
(1) Rates by unit of service. Re-
imbursement rates for case management
services will be determined for a unit of
service defined as a case management con-
tact. The action can be face-to-face or by
telephone. See 31.1 (relating to Defini-
tions).
(2) Exclusion or adjustment of
expenses. Providers must eliminate unal-
lowable expenses from the cost report. DHS
or TDMHMR excludes from the rate base
any unallowable expenses included in the
cost report and makes adjustments to ex-
penses reported by providers to ensure that
the rate base reflects costs which are consis-
tent with efficiency, economy and quality of
care, are necessary for the provision of case
management services, and are consistent
with federal and state Medicaid regulations.
If there is doubt as to the accuracy or
allowability of a significant part of the in-
formation reported, individual cost reports
may be eliminated from the rate base.
(3) Rate determination process.
The Texas Board of Human Services deter-
mines reimbursement rates for a contact
which will reasonably reimburse the cost of
an economic and efficient provider. DHS
submits recommendations for reimburse-
ment rates. Recommended rates are deter-
mined in the following manner.
(A) Total allowable costs for
each provider will be determined from ana-
lyzing the allowable historical costs re-
ported on the cost report and the allowable
anticipated costs. This cost is based on the
estimated cost of hiring qualified staff in
sufficient number and appropriate mix to
meet the projected client load service mix.
(B) Each provider's total al-
lowable costs are projected from the histori-
cal cost reporting period to the prospective
rate period using inflation factors that rea-
sonably reflect expected changes in the cost
of providing case management services.
(C) An allowable cost per
contact will be calculated for each case
management site. The allowable costs per
contact for each site are arrayed and the
median point is calculated. A provider's
cost may be excluded from the cost array
based on a determination that there were
errors in cost reporting or the program was
not operating within the appropriate stan-
dard of quality.
(D) The median cost compo-
nent is multiplied by an appropriate per-
centage determined by the Texas Board of
Human Services to calculate the reconm-14 TexReg 5628 October 20, 1989 Texas Register *
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Texas. Secretary of State. Texas Register, Volume 14, Number 78, Pages 5585-5650, October 20, 1989, periodical, October 20, 1989; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth216067/m1/43/: accessed July 16, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.