| (2) The entity that owns the NF must certify, on a
form prescribed by HHSC, that no part of any payment made under the
QIPP will be used to pay a contingent fee; and that the entity's agreement
with the nursing facility does not use a reimbursement methodology
containing any type of incentive, direct or indirect, for inappropriately
inflating, in any way, claims billed to Medicaid, including the NF's
receipt of QIPP funds. The certification must be received by HHSC
with the enrollment application described in paragraph (1) of this
subsection.
(3) If a provider has changed ownership in the past
five years in a way that impacts eligibility for the program, the
provider must submit to HHSC, upon demand, copies of contracts it
has with third parties with respect to the transfer of ownership or
the management of the provider, and which reference the administration
of, or payment from, this program.
(4) The NF must ensure that HHSC has access to the
NF records referenced in subsection (c) of this section and the data
for the NF from one of the data sources listed in subsection (d) of
this section. Participating facilities must ensure that these records
and data are accurate and sufficiently detailed to support legal,
financial, and statistical information used to determine a NF's eligibility
during the program period.
(A) The NF must maintain these records and data through
the program period and until at least 90 days following the conclusion
of the runout period.
(B) The NF will have 14 business days from the date
of a request from HHSC to submit to HHSC the records and data.
(C) Failure to provide the records and data could result
in adjustments pursuant to §353.1301(k) of this subchapter.
(5) Report all quality data denoted as required as
a condition of participation in subsection (g) of this section.
(6) Failure to meet any conditions of participation
described in this subsection will result in removal of the provider
from the program and recoupment of all funds previously paid during
the program period.
(f) Non-federal share of QIPP payments. The non-federal
share of all QIPP payments is funded through IGTs from sponsoring
non-state governmental entities. No state general revenue is available
to support QIPP.
(1) HHSC will share suggested IGT responsibilities
for the program period with all QIPP eligible and enrolled non-state
government-owned NFs at least 15 days prior to the IGT declaration
of intent deadline. Suggested IGT responsibilities will be based on
the maximum dollars available under the QIPP program, plus eight percent,
for the program period as determined by HHSC; forecast STAR+PLUS NF
member months for the program period as determined by HHSC; and the
distribution of historical Medicaid days of service across non-state
government-owned NFs enrolled in QIPP for the program period. HHSC
will also share estimated maximum revenues each eligible and enrolled
NF could earn under QIPP for the program period. Estimates are based
on HHSC's suggested IGT responsibilities and an assumption that all
enrolled NFs will meet 100 percent of their quality metrics. The purpose
of sharing this information is to provide non-state government-owned
NFs with information they can use to determine the amount of IGT they
wish to transfer.
(2) Sponsoring governmental entities will determine
the amount of IGT they wish to transfer to HHSC for the entire program
period and provide a declaration of intent to HHSC 15 business days
before the first half of the IGT amount is transferred to HHSC.
(A) The declaration of intent is a form prescribed
by HHSC that includes the total amount of IGT the sponsoring governmental
entity wishes to transfer to HHSC and whether the sponsoring governmental
entity intends to accept Component One payments.
(B) The declaration of intent is certified to the best
knowledge and belief of a person legally authorized to sign for the
sponsoring governmental entity but does not bind the sponsoring governmental
entity to transfer IGT.
(3) Sponsoring governmental entities will transfer
the first half of the IGT amount by a date determined by HHSC. The
second half of the IGT amount will be transferred by a date determined
by HHSC. The IGT deadlines and all associated dates will be published
on the HHSC QIPP webpage by January 15 of each year.
(4) Reconciliation. HHSC will reconcile the actual
amount of the non-federal funds expended under this section during
each program period with the amount of funds transferred to HHSC by
the sponsoring governmental entities for that same period using the
methodology described in §353.1301(g) of this subchapter.
(g) QIPP capitation rate components. QIPP funds will
be paid to MCOs through four components of the STAR+PLUS NF managed
care per member per month (PMPM) capitation rates. The MCOs' distribution
of QIPP funds to the enrolled NFs will be based on each NF's performance
related to the quality metrics as described in §353.1304 of this
subchapter. The NF must have had at least one Medicaid client in the
care of that NF for each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 110 percent of the estimated amount of the non-federal share of
the QIPP.
(B) Interim allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) Private NFs are not eligible for payments from
Component One.
(D) The interim allocation of funds across qualifying
non-state government-owned NFs will be reconciled to the actual distribution
of Medicaid NF days of service across these NFs during the program
period as captured by HHSC's Medicaid contractors for fee-for-service
and managed care 120 days after the last day of the program period.
(E) NFs must report quality data as described in §353.1304
of this subchapter as a condition of participation in the program.
(2) Component Two.
(A) The total value of Component Two will be equal
to a percent of remaining QIPP funds after accounting for the funding
of Component One and Component Four.
(i) For the program period September 1, 2019, through
August 31, 2021, the percent will be equal to 30 percent.
(ii) For the program period beginning September 1,
2021, the percent will be equal to 40 percent.
(B) Allocation of funds across qualifying non-state
government-owned and private NFs will be proportional, based upon
historical Medicaid days of NF service.
(C) Monthly payments to NFs will be triggered by achievement
of performance requirements as described in §353.1304 of this
subchapter or a uniform rate increase for which a NF must report quality
data as described in §353.1304 of this subchapter as a condition
of participation in the program.
(3) Component Three.
(A) The total value of Component Three will be equal
to a percent of remaining QIPP funds after accounting for the funding
of Component One and Component Four.
(i) For the program period September 1, 2019, through
August 31, 2021, the percent will be equal to 70 percent.
(ii) For the program period beginning September 1,
2021, the percent will be equal to 60 percent.
(B) Allocation of funds across qualifying non-state
government-owned and private NFs will be proportional, based upon
historical Medicaid days of NF service.
(C) Quarterly payments to NFs will be triggered by
achievement of performance requirements as described in §353.1304
of this subchapter.
(4) Component Four.
(A) The total value of Component Four will be equal
to 16 percent of the funds of the QIPP.
(B) Allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) Quarterly payments to non-state government-owned
NFs will be triggered by achievement of performance requirements as
described in §353.1304 of this subchapter.
(D) Private NFs are not eligible for payments from
Component Four.
(5) Funds that are non-disbursed due to failure of
one or more NFs to meet performance requirements will be distributed
across all QIPP NFs based on each NF's proportion of total earned
QIPP funds from Components One, Two, Three, and Four combined.
(h) Distribution of QIPP payments.
(1) Prior to the beginning of the program period, HHSC
will calculate the portion of each PMPM associated with each QIPP-enrolled
NF broken down by QIPP capitation rate component, quality metric,
and payment period. For example, for a NF, HHSC will calculate the
portion of each PMPM associated with that NF that would be paid from
the MCO to the NF as follows.
Cont'd... |
