(a) Introduction. This section establishes the Rural
Access to Primary and Preventive Services (RAPPS) program. RAPPS is
designed to incentivize rural health clinics (RHCs) to improve quality,
access, and innovation in the provision of medical services to Medicaid
recipients through the use of metrics that are expected to advance
at least one of the goals and objectives of the state's managed care
quality strategy.
(b) Definitions. The following definitions apply when
the terms are used in this section. Other terms used in this section
may be defined in §353.1301 of this subchapter (relating to General
Provisions) or §353.1317 of this subchapter (relating to Quality
Metrics for Rural Access to Primary and Preventive Services Program).
(1) Freestanding rural health clinic (RHC)--A network
RHC that is not affiliated with a hospital.
(2) Hospital-based RHC--A network RHC that is affiliated
with a hospital.
(3) Intergovernmental transfer (IGT) notification--Notice
and directions regarding how and when IGTs should be made in support
of RAPPS.
(4) Network RHC--An RHC located in the state of Texas
that has a contract with a managed care organization (MCO) for the
delivery of Medicaid-covered services to the MCO's enrollees.
(5) Program period--A period of time for which the
Texas Health and Human Services Commission (HHSC) contracts with MCOs
to pay increased capitation rates for the purpose of making RHC payments
under this section. Each program period is equal to a state fiscal
year beginning September 1 and ending August 31 of the following year.
(6) Rural health clinic (RHC)--Has the meaning assigned
by 42 U.S.C. §1396d(l)(1).
(7) Suggested IGT responsibility--Notice of potential
amounts that a sponsoring governmental entity may wish to consider
transferring in support of RAPPS.
(8) Total program value--The maximum amount available
under the RAPPS program for a program period, as determined by HHSC.
(c) Classes of RHCs.
(1) HHSC may direct an MCO to provide an increased
payment or percentage rate increase for certain services to all RAPPS-enrolled
RHCs in one or more of the following classes of RHCs with which the
MCO contracts for Medicaid services:
(A) hospital-based RHCs; and
(B) freestanding RHCs.
(2) If HHSC directs rate increases or payments to more
than one RHC class in the service delivery area (SDA), the rate increases
or payments may vary by RHC class. HHSC will consider the following
factors in identifying the amount of the rate increase or payment
for each class:
(A) the RHC class's contribution to the goals and objectives
in the HHSC managed care quality strategy, as required in 42 C.F.R. §438.340,
relative to other classes;
(B) the class or classes of RHC the sponsoring governmental
entity wishes to support through IGTs of public funds, as indicated
on the application described in subsection (f) of this section; and
(C) the actuarial soundness of the capitation payment
needed to support the rate increase or payment.
(d) Eligibility. An RHC is eligible to participate
in RAPPS if it meets the requirements described in this subsection.
(1) Location. The RHC must be located in an SDA with
at least one sponsoring governmental entity.
(2) Minimum number of Medicaid managed care encounters.
The RHC must have provided at least 30 Medicaid managed care encounters
in the prior state fiscal year.
(e) Data sources for historical units of service and
clients served. Historical units of service are used to determine
an RHC's eligibility status and the estimated distribution of RAPPS
funds across enrolled RHCs.
(1) HHSC will use encounter data and will identify
encounters based on the billing provider's national provider identification
(NPI) number and provider type code.
(2) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine the eligibility
status of an RHC.
(3) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine the distribution
of RAPPS funds across enrolled RHCs.
(4) In the event that the historical data are not deemed
appropriate for use by actuarial standards, HHSC may utilize data
from a different state fiscal year at HHSC's discretion.
(5) The data used to estimate eligibility and distribution
of funds will align with the data used for purposes of setting the
capitation rates for MCOs for the same period.
(6) To determine total program value, HHSC will calculate
the estimated rate that Medicare would have paid for the same services
using either each RHC's state fiscal year 2019 federal cost report
or its last submitted cost report. For RHCs where a filed cost report
was not found, the RHC's Medicare payments will be estimated using
the SDA weighted average ratio of Medicare encounter-based reimbursements
divided by MCO reimbursement data.
(7) Encounter data used to calculate RAPPS payments
must be designated as paid status with a reported paid amount greater
than zero. Encounters reported as paid status but with a reported
paid amount of zero or negative dollars will be excluded from the
data used to calculate RAPPS payments.
(8) If a provider with the same Tax Identification
Number as the payor is being paid more than 200 percent of the Medicaid
reimbursement on average for the same services in a one-year period,
then a related party adjustment will be applied to the encounter data
for those encounters. This adjustment will apply a calculated average
payment rate from the rest of the provider pool to the related party's
paid units of service.
(f) Conditions of Participation. As a condition of
participation, all RHCs participating in RAPPS, as well as any entities
billing on their behalf, must meet the following requirements.
(1) The RHC must submit a properly completed enrollment
application by the due date determined by HHSC. The enrollment period
will be no less than 21 calendar days, and the final date of the enrollment
period will be at least nine calendar days prior to the release of
suggested IGT responsibilities.
(A) Enrollment is conducted annually and participants
may not join the program after the enrollment period closes. Any updates
to enrollment information must be submitted prior to the publication
of the IGT notification under subsection (g)(3) of this section.
(B) Network status for providers for the entire program
period will be determined at the time of enrollment based on the submission
of documentation through the enrollment process that shows an MCO
has identified the provider as having a network agreement.
(2) An entity that bills on behalf of the RHC must
certify, on a form prescribed by HHSC, that no part of any RAPPS payment
will be used to pay a contingent fee and that the entity's agreement
with the RHC does not use a reimbursement methodology that contains
any type of incentive, directly or indirectly, for inappropriately
inflating, in any way, claims billed to the Medicaid program, including
the RHC's receipt of RAPPS funds. The certification must be received
by HHSC with the enrollment application described in paragraph (1)
of this subsection.
(3) If an RHC has changed ownership in the past five
years in a way that impacts eligibility for RAPPS, the RHC 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
RHC and which reference the administration of, or payments from, RAPPS.
(4) Report all quality data denoted as required as
a condition of participation in subsection (h) of this section.
(5) 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.
(g) Non-federal share of RAPPS payments. The non-federal
share of all RAPPS payments is funded with IGTs from sponsoring governmental
entities. No state general revenue is available to support RAPPS.
(1) HHSC will communicate the following information
for the program period to all RAPPS-enrolled hospital-based RHCs and
sponsoring governmental entities at least 10 calendar days prior to
the IGT declaration of intent deadline:
(A) suggested IGT responsibilities for the program
period, which will be based on:
(i) the maximum funding amount available under RAPPS
for the program period as determined by HHSC, plus ten percent;
(ii) forecasted member months for the program period
as determined by HHSC; and
Cont'd... |