Header:
TEXAS ADMINISTRATIVE CODE
TITLE 1. ADMINISTRATION
PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 355. REIMBURSEMENT RATES
SUBCHAPTER C. REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES
Date:
08/31/2009
Document:
1 TAC § 355.306 (2011)
§ 355.306. Cost Finding Methodology
(a) Providers excused from completing a cost report. Providers are excused from completing a cost report if:
(1) the cost report would represent costs accrued during a time period immediately preceding a period of decertification, if the decertification period was greater than either 30 calendar days or one entire calendar month.
(2) the cost report would be a final cost report (due to a change of ownership or if the facility no longer contracts to serve Medicaid clients) and one of the following applies:
(A) the final cost-reporting period would end after more than 30 calendar days, or more than one entire calendar month before the end of the facility's cost report fiscal year, during the reporting period in question; or
(B) the Texas Health and Human Services Commission (HHSC), or its designee, has excused the provider from submitting a final cost report because: (i) the report would be due before the appropriate cost report form was finalized, which would result in the final cost report being completed on an inappropriate cost report form; or (ii) the facility was controlled by at least two different owners during a single calendar year and each owner would otherwise have submitted a cost report with an ending date that fell within that calendar year.
(3) the cost-reporting period would be less than or equal to 30 calendar days or one entire calendar month.
(b) Exclusion of and adjustments to certain reported expenses. Providers are responsible for eliminating unallowable expenses from the cost report. HHSC reserves the right to exclude any unallowable costs from the cost report and to exclude entire cost reports from the reimbursement determination database if there is reason to doubt the accuracy or allowability of a significant part of the information reported.
(1) Cost reports included in the database used for reimbursement determination.
(A) Individual cost reports will not be included in the database used for reimbursement determination if: (i) there is 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.
(B) In the event that all cost reports submitted for a specific facility are disqualified through the application of subparagraph (A)(i) and/or (ii) of this paragraph, the facility will not be represented in the reimbursement database for the cost report year in question.
(2) Adjustments and exclusions of cost report data include, but are not necessarily limited to:
(A) Fixed capital asset costs. (i) HHSC staff determine fixed capital asset costs as detailed in this section. (ii) Fixed capital asset costs are reimbursed in the form of a use fee calculated as described in § 355.307 of this title (relating to Reimbursement Setting Methodology). The following fixed capital charges are excluded from the reimbursement base:
(I) building and building equipment depreciation and lease expense;
(II) mortgage interest;
(III) land improvement depreciation; and
(IV) leasehold improvement amortization.
(B) Limits on other facility and administration costs. To ensure that the results of HHSC's cost analyses accurately reflect the costs that an economic and efficient provider must incur, HHSC may place upper limits or caps on expenses for specific line items and categories of line items included in the rate base for the administration and facility cost centers. HHSC sets upper limits at the 90th percentile in the array of all costs per unit of service or total annualized cost, as appropriate for a specific line item or category of line item, as reported by all contracted facilities, unless otherwise specified. The specific line items and categories of line items that are subject to the 90th percentile cap are: (i) total buildings and equipment rental or lease expense; (ii) total other rental or lease expense for transportation, departmental, and other equipment; (iii) building depreciation; (iv) building equipment depreciation; (v) departmental equipment depreciation; (vi) leasehold improvement amortization; (vii) other amortization; (viii) total interest expense; (ix) total insurance for buildings and equipment; (x) facility administrator salary, wages, and/or benefits with the cap based on an array of nonrelated-party administrator salaries, wages, and/or benefits; (xi) assistant administrator salary, wages, and/or benefits with the cap based on an array of nonrelated-party assistant administrator salaries, wages, and/or benefits; (xii) facility owner, partner, or stockholder salaries, wages, and/or benefits (when the owner, partner, or stockholder is not the facility administrator or assistant administrator), with the cap based on an array of nonrelated-party administrator salaries, wages, and/or benefits; (xiii) other administrative expenses including the cost of professional and facility malpractice insurance, advertising expenses, travel and seminar expenses, association dues, other dues, professional service fees, management consultant fees, interest expense on working capital, management fees, other fees, and miscellaneous office expenses; and (xiv) total central office overhead expenses or individual central office line items. Individual line item caps are based on an array of all corresponding line items.
(C) Occupancy adjustments. HHSC adjusts the facility and administration costs of providers with occupancy rates below a target occupancy rate. The target occupancy rate is the lower of: (i) 85%; or (ii) the overall average occupancy rate for contracted beds in facilities included in the rate base during the cost reporting periods included in the base.
(D) Cost projections. HHSC projects certain expenses in the reimbursement base to normalize or standardize the reporting period and to account for cost inflation between reporting periods and the period to which the prospective reimbursement applies as specified in § 355.108 of this title (relating to Determination of Inflation Indices).
(3) When material pertinent to proposed reimbursements is made available to the public, the material will include the number of cost reports eliminated from reimbursement determination for the reason stated in paragraph (1)(A)(i) of this subsection.
(c) Reimbursement determinations and 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 reimbursement. HHSC excludes from reimbursement determinations any unallowable expenses included in the cost report and makes the appropriate adjustments to expenses and other information reported by providers.
(d) General information. In addition to the requirements of this section, cost reports will be governed by the information 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), and § 355.110 of this title (relating to Informal Reviews and Formal Appeals).
(e) Final cost reports for change of ownership. Except when excused from the requirement to submit a cost report according to subsection (a) of this section, when a facility changes ownership, the prior owner must submit a completed cost report reflecting the facility's activities from the beginning of the prior owner's cost report fiscal year until the ownership-change effective date. The prior owner's vendor payments may be held until HHSC receives an acceptable final cost report according to 40 TAC § 19.2308(c)(1)(A) (relating to Change of Ownership).
(1) In cases where the prior owner's vendor payment is held, within seven calendar days of receipt by HHSC of an acceptable final cost report, HHSC will forward the final cost report to audit.
(2) In cases where the facility is sold and its prior year's cost report is pending audit completion, the owner's vendor payment may be held until the audit of the prior year's cost report and the final cost report are complete.
(f) Requirements for cost report completion. A completed nursing facility cost report must:
(1) meet the definition of completed cost report specified in § 355.105(b)(4)(A) of this title;
(2) have attached the property appraisal used to determine the allowable appraised property value as described in subsection (g) of this section;
(3) not report figures for days of service and number of beds that reflect occupancy of greater than 100%;
(4) have a management contract attached, if applicable; and
(5) have a lease agreement attached, if applicable.
(g) Allowable appraised property values. Allowable appraised property values are determined as follows:
(1) Proprietary facilities. The allowable appraised values of proprietary facilities to be reported on Texas Medicaid cost reports are determined from local property taxing authority appraisals. The year of the property appraisal must be the calendar year within which the provider's cost report fiscal year ends, or the prior calendar year.
(2) Tax exempt facilities. The allowable appraised property values for tax exempt facilities are determined as follows.
(A) Tax exempt facilities provided an appraisal from their local property taxing authority. Tax exempt facilities provided an appraisal from their local property taxing authority must report this appraised value on their Texas Medicaid cost report. The year of the property appraisal must be the calendar year within which the provider's cost report fiscal year ends, or the prior calendar year.
(B) Tax exempt facilities not provided an appraisal from their local property taxing authority. Tax exempt facilities not provided an appraisal from their local property taxing authority because of an "exempt" status must provide documentation received from the local taxing authority certifying exemption for the current reporting period and must contract with an independent appraiser to appraise the facility land and improvements. These independent appraisals must meet the following criteria. (i) The appraisal must value land and improvements using the same basis used by the local taxing authority under Texas laws regarding appraisal methods and procedures. (ii) The appraisal must be updated every five years with the initial appraisal setting the five-year interval.
(I) Facilities achieving exempt status during their fiscal year ending in calendar year 1997 or a subsequent year must submit an initial appraisal to HHSC's Rate Analysis Department as part of their cost report for the fiscal year during which the exempt status was achieved. This appraisal must be reflective of the facility's appraised value during that fiscal year.
(II) If a facility is reappraised due to improvements or reconstruction as defined in clause (iii) of this subparagraph, a new five-year interval will be set. (iii) Facilities making capital improvements, or requiring reconstruction due to fire, flood, or other natural disaster, when the improvements or reconstruction cost more than $ 2,000 per licensed bed, may contract with an independent appraiser to have land and improvements reappraised within the cost reporting period in which the improvement(s) is placed into service. (iv) If for any reason an appraisal becomes available from the local taxing authority for a provider who previously lacked such an appraisal, the provider must report, on the next Texas Medicaid cost report submitted, the local taxing authority's appraised values instead of the independent appraisal values.
(3) Governmental facilities. Governmental facilities are exempt from the requirement to report an appraised property value.
(h) In addition to the requirements of § 355.102 and § 355.103 of this title, the following apply to costs for the nursing facilities (NF) program.
(1) Medical costs. The costs for medical services and items delineated in 40 TAC § 19.2601 (relating to Vendor Payment) are allowable. These costs must also comply with the general definition of allowable costs as stated in § 355.102 of this title.
(2) Chaplaincy or pastoral services. Expenses for chaplaincy or pastoral services are allowable costs.
(3) Voucherable costs. Except as detailed in subparagraphs (A) and (B) of this paragraph, any expenses directly reimbursable to the provider through a voucher payment and any expenses in excess of the limit, or ceiling, for a voucher payment system are unallowable costs.
(A) The ventilator dependent supplemental voucher system and the children with tracheostomies supplemental voucher system are not subject to the cost reporting restrictions described in this paragraph.
(B) Select voucher systems, when indicated by department procedures, are not subject to the cost reporting restrictions described in this paragraph. To avoid the possibility of providers being reimbursed through the voucher system and the daily rate for the same expenses, the department may not waive the cost reporting restrictions described in this paragraph unless the following criteria are met: (i) the voucher system is a temporary system; (ii) the costs represent ongoing costs; and (iii) the costs are not represented in the payment rate until after the voucher system has been discontinued.
(4) Preferred items. Costs for preferred items which are billed to the recipient, responsible party, or the recipient's family are not allowable costs.
(5) Preadmission Screening and Annual Resident Review (PASARR) expenses. Any expenses related to the direct delivery of specialized services and treatment required by PASARR for residents are unallowable costs.
(6) Advanced Clinical Practitioner (ACP) or Licensed Professional Counselor (LPC) services. Expenses for services provided by an ACP or LPC are unallowable costs.
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