| (E) the percentage of Medicaid costs incurred by the
class of hospital in providing care to Medicaid managed care clients
that are reimbursed by Medicaid MCOs prior to any rate increase administered
under this section.
(f) Services subject to rate increase.
(1) HHSC may direct the MCOs in an SDA to increase
rates for all or a subset of inpatient services, all or a subset of
outpatient services, or all or a subset of both, based on the service
or services that will best advance the goals and objectives of HHSC's
managed care quality strategy.
(2) In addition to the limitations described in paragraph
(1) of this subsection, rate increases for a state-owned IMD or non-state-owned
IMD are limited to inpatient psychiatric hospital services provided
to individuals under the age of 21 and to inpatient hospital services
provided to individuals 65 years or older.
(3) CHIRP rate increases will apply only to the in-network
managed care claims billed under a hospital's primary National Provider
Identifier (NPI) and will not be applicable to NPIs associated with
non-hospital sub-providers owned or operated by a hospital.
(g) CHIRP capitation rate components. CHIRP funds will
be paid to MCOs through two components of the managed care per member
per month (PMPM) capitation rates. The MCOs' distribution of CHRIP
funds to the enrolled hospitals may be based on each hospital's performance
related to the quality metrics as described in §353.1307 of this
subchapter (relating to Quality Metrics and Required Reporting Used
to Evaluate the Success of the Comprehensive Hospital Increase Reimbursement
Program). The hospital must have provided at least one Medicaid service
to a Medicaid client for each reporting period to be eligible for
payments.
(1) In determining the percentages described under
subsection (i)(1) and (2) of this section, HHSC will consider:
(A) information from the participants in the SDA (including
hospitals, managed-care organizations, and sponsoring governmental
entities) on the amount of IGT the sponsoring governmental entities
propose to transfer to HHSC to support the non-federal share of the
increased rates for the first six months of a program period, as indicated
on the applications described in subsection (c) of this section;
(B) the class or classes of hospital determined in
subsection (e)(2) of this section;
(C) the type of service or services determined in subsection
(f) of this section;
(D) actuarial soundness of the capitation payment needed
to support the rate increase;
(E) available budget neutrality room under any applicable
federal waiver programs;
(F) hospital market dynamics within the SDA; and
(G) other HHSC goals and priorities.
(2) The Uniform Hospital Rate Increase Payment (UHRIP)
is the first component.
(A) The total value of UHRIP will be equal to a percentage
of the estimated Medicare gap on a per class basis.
(B) Allocation of funds across hospital classes will
be proportional to the combined Medicare gap of each hospital class
within an SDA to the total Medicare gap of all hospital classes within
the SDA.
(3) The Average Commercial Incentive Award (ACIA) is
the second component.
(A) The total value of ACIA will be equal to a percentage
of the ACR gap less payments received under UHRIP.
(B) The maximum ACIA payments will be equal to a percentage
of the total estimated ACR gap for the class, including hospitals
that are not participating in ACIA. For the program period proposed
to begin on September 1, 2021, and program periods thereafter, the
percentage is 90 percent.
(C) Allocation of funds across hospitals will be proportional
to each participating hospital's individual ACR gap to the total ACR
gap for all participating hospitals in the SDA. For example, if two
hospitals in a class in an SDA both have anticipated base payments
of $100 and UHRIP payments of $50, but one hospital has an estimated
ACR gap of $300 between its base payment and the estimate payment
it would have received from a commercial payor, and the other hospital
has an estimated ACR gap of $100, HHSC will first reduce the gaps
by the UHRIP payment of $50 to a gap of $250 and $50, respectively.
HHSC would then apply a uniform percentage of the gap (e.g., 50 percent
of the gap) and would calculate an ACIA payment of $125 and $25, respectively.
HHSC will then direct the MCOs to pay a percentage increase for the
first hospital of 125 percent in addition to the 50 percent increase
under UHRIP for the first hospital for a total increase of 175 percent
above the contracted base rate, and 25 percent in addition to the
50 percent increase under UHRIP for the second hospital for a total
increase of 75 percent.
(h) Distribution of CHIRP payments. CHIRP payments
will be based upon actual utilization and will be paid as a percentage
increase above the contracted rate between the MCO and the hospital.
(i) Determination of percentage of rate increase.
(1) HHSC will determine the percentage of rate increase
applicable to one or more classes of hospital by program component.
(A) UHRIP rate increases will be determined by HHSC
to be the percentage that is estimated to result in payments for the
class that are equivalent to the amount described under subsection
(g)(2)(A) of this section.
(B) ACIA will be determined by HHSC to be a percentage
that is estimated to result in payments for the hospital that are
equivalent to the amount described under subsection (g)(3)(A) of this
section.
(2) HHSC will limit the percentage rate increases determined
pursuant to this subsection to no more than the levels that are supported
by the amount described in subsection (j)(3) of this section. Nothing
in this section may be construed to limit the authority of the state
to require the sponsoring governmental entities to transfer additional
funds to HHSC following the reconciliation process described in §353.1301(g)
of this subchapter, if the amount previously transferred is less than
the non-federal share of the amount expended by HHSC in the SDA for
this program.
(3) After determining the percentage of rate increase
using the process described in paragraphs (1) and (2) of this subsection,
HHSC will modify its contracts with the MCOs in the SDA to direct
the percentage rate increases.
(j) Non-federal share of CHIRP payments. The non-federal
share of all CHIRP payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support
CHIRP.
(1) HHSC will communicate suggested IGT responsibilities
for the program period with all CHIRP hospitals at least 10 calendar
days prior to the IGT declaration of intent deadline. Suggested IGT
responsibilities will be based on the maximum dollars to be available
under the CHIRP program for the program period as determined by HHSC,
plus eight percent; and forecast member months for the program period
as determined by HHSC. HHSC will also communicate estimated revenues
each enrolled hospital could earn under CHIRP for the program period
with those estimates based on HHSC's suggested IGT responsibilities
and an assumption that all enrolled hospitals will meet 100 percent
of their quality metrics and maintain consistent utilization with
the prior year.
(2) Sponsoring governmental entities will determine
the amount of IGT they intend to transfer to HHSC for the entire program
period and provide a declaration of intent to HHSC no later than 21
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 intends to transfer to HHSC.
(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) HHSC will issue an IGT notification to specify
the date that IGT is requested to be transferred no fewer than 14
business days before IGT transfers are due. Sponsoring governmental
entities will transfer the first half of the IGT amount by a date
determined by HHSC, but no later than June 1. Sponsoring governmental
entities will transfer the second half of the IGT amount by a date
determined by HHSC, but no later than December 1. HHSC will publish
the IGT deadlines and all associated dates on its Internet website
no later than March 15 of each year.
(k) Effective date of rate increases. HHSC will direct
MCOs to increase rates under this section beginning the first day
of the program period that includes the increased capitation rates
paid by HHSC to each MCO pursuant to the contract between them.
(l) Changes in operation. If an enrolled hospital closes
voluntarily or ceases to provide hospital services in its facility,
the hospital must notify the HHSC Provider Finance Department by hand
delivery, United States (U.S.) mail, or special mail delivery within
10 business days of closing or ceasing to provide hospital services.
Notification is considered to have occurred when the HHSC Provider
Finance Department receives the notice.
(m) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
the 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.
(n) Recoupment. Payments under this section may be
subject to recoupment as described in §353.1301(j) and §353.1301(k)
of this subchapter.
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