(a) Purpose. In an effort to provide certainty to waiver
participants, HHSC will provide performer specific allocations. This
process requires that certain individual entities receive an allocation
based upon a Regional Healthcare Partnership (RHP) specific allocation.
(b) RHP allocation. All available DSRIP funds are allocated
among the RHPs for each demonstration year. The share of the DSRIP
pool allocated to an RHP will be calculated using the formula: RHP
Share of DSRIP Pool = (200%FPL + %MedicaidAcute + 2011UPL)/3, where:
(1) "200%FPL" is the region's share of the state's
population with income below 200% of the federal poverty level as
determined by the 2006-2010 American Community Survey for Texas;
(2) "%MedicaidAcute" is the region's share of all Texas
Medicaid acute care payments in state fiscal year (SFY) 2011. Texas
Medicaid acute care payments consist of the sum of Medicaid fee-for-service,
Medicaid managed care, Vendor Drug Program, and Primary Care Case
Management payments; and
(3) "2011UPL" is the region's share of the state's
Medicaid supplemental payments through the former Upper Payment Limit
program made to providers in the RHP for SFY 2011.
(c) DSRIP allocation among performers for the first
demonstration year. Anchors and performers may receive a DSRIP for
the first demonstration year after review and approval of the RHP
plan by HHSC.
(1) An anchor is allocated 20% of the RHP allocation
for the first demonstration year. An anchor may also receive a portion
of the allocation in paragraph (2) of this subsection if it independently
qualifies under that paragraph.
(2) The amount of the RHP allocation for the first
demonstration year not allocated to the anchor as described in paragraph
(1) of this subsection is allocated to performers as follows:
(A) First, divide the value of all of a performer's
DSRIP projects, as submitted by HHSC for CMS approval, by the total
value of all DSRIP projects in an RHP.
(B) Second, multiply the result in subparagraph (A)
of this paragraph by 80% of the RHP allocation for the first demonstration
year for that RHP. The result is the first demonstration year DSRIP
to the performer.
(3) In the event that the RHP plan or a DSRIP project
is not approved by the Centers for Medicare and Medicaid Services
or an RHP deletes a DSRIP project without a replacement, HHSC may
recoup the DSRIP for the first demonstration year.
(d) Three-pass process for allocating DSRIP. The DSRIP
pool is allocated to performers for the second through fifth demonstration
years through a three-stage process.
(1) The first stage (Pass One) sets an initial allocation
to each potential performer, described further in subsection (e) of
this section.
(2) Any unused DSRIP funds allocated in Pass One remain
in the RHP for the second stage (Pass Two). An RHP may begin Pass
Two if:
(A) the RHP funds the minimum number of Category 1
and Category 2 projects in accordance with §354.1632 of this
subchapter (relating to DSRIP Requirements for Regional Healthcare
Partnerships);
(B) each performer meets the allocation requirements
among the four DSRIP categories as described in subsection (h) of
this section;
(C) the minimum percentage of the Pass One allocation
to non-profit and other private hospitals is met as follows:
(i) A Tier 1 RHP must fund 30% of the Pass One allocation
to non-profit and other private hospitals.
(ii) A Tier 2 RHP must fund 30% of the Pass One allocation
to non-profit and other private hospitals.
(iii) A Tier 3 RHP must fund 15% of the Pass One allocation
to non-profit and other private hospitals.
(iv) A Tier 4 RHP must fund 5% of the Pass One allocation
to non-profit and other private hospitals; and
(D) the minimum number of safety net hospitals in an
RHP perform DSRIP projects. If there are fewer safety net hospitals
in an RHP than are required to perform as follows, then all safety
net hospitals in that RHP must perform DSRIP projects.
(i) At least five safety net hospitals in a Tier 1
RHP must perform DSRIP projects.
(ii) At least four safety net hospitals in a Tier 2
RHP must perform DSRIP projects.
(iii) At least two safety net hospitals in a Tier 3
RHP must perform DSRIP projects.
(iv) At least one safety net hospital in a Tier 4 RHP
must perform DSRIP projects.
(3) For purposes of this subsection, a safety net hospital
is any hospital that, as described in subsection (e) of this section:
(A) participated in the Disproportionate Share Hospital
(DSH) program and:
(i) received at least 15% of the RHP's Medicaid acute
care payments in SFY 2011 for all hospitals that receive a Pass One
allocation; or
(ii) has a trended 2012 hospital-specific limit (HSL)
that represents at least 15% of the RHP's total HSL; or
(B) has a Pass One allocation for demonstration years
two through five of greater than $60 million.
(4) Any unused funds allocated in Pass Two remain in
the RHP for the third stage (Pass Three), described further in subsection
(g) of this section.
(e) Pass One DSRIP allocation among performers. Entities
within an RHP may be allocated an amount from the RHP allocation described
in subsection (b) of this section.
(1) The RHP allocation is divided among certain classes
of providers within the RHP as follows:
(A) hospitals are allocated 75%;
(B) community mental health centers are allocated 10%;
(C) academic health science centers are allocated 10%;
and
(D) local health departments are allocated 5%.
(2) A hospital may receive a Pass One allocation only
if the hospital participated in FFY 2012 Disproportionate Share Hospital
program or the former Upper Payment Limit program in Federal Fiscal
Year (FFY) 2011.
(3) The share of the RHP allocation that is allocated
to hospitals is further divided among the hospitals according to the
following formula: Hospital Share of RHP Allocation = (.25 x 2011UPL)
+ (.25 x MedicaidAcute) + (.50 x HSLCharity), where:
(A) "HSLCharity" is the hospital's share of the total
hospital specific limit (HSL) for all hospitals in the RHP that receive
a Pass One allocation. If a hospital eligible for a Pass One allocation
does not have a FFY 2012 HSL, "HSLCharity" is measured by that hospital's
charity care costs as reported in the 2010 Annual Hospital Survey
trended to 2012 by a 4% total trend over the two-year period;
(B) "MedicaidAcute" is the hospital's share of all
Medicaid acute care payments in SFY 2011 to hospitals in the RHP that
receive a Pass One allocation. Texas Medicaid acute care payments
consist of the sum of Medicaid fee-for-service, Medicaid managed care,
and Primary Care Case Management payments; and
(C) "2011UPL" is the hospital's share of the Medicaid
supplemental payments through the former Upper Payment Limit program
made to hospitals that received a Pass One allocation in the RHP for
SFY 2011.
(4) Option for collaboration. Certain entities may
combine their Pass One allocation to create one or more DSRIP projects
that further the goal of regional transformation.
(A) A hospital in an RHP may combine its Pass One allocation
with other hospitals in the same RHP if all of the entities have a
Pass One allocation at or below $2 million for the second demonstration
year.
(B) An entity in a Tier 3 or 4 RHP as described by §354.1611(f)
of this subchapter (relating to Organization) may combine its Pass
One allocation with other entities in the same RHP.
(C) All entities involved in such collaboration must
state in the RHP plan that they are collaborating freely.
(D) Any DSRIP projects created under this paragraph
must still have only one performer, and that performer must follow
all other restrictions on performers.
(f) Pass Two DSRIP process. An RHP's unused DSRIP funds
from Pass One are reallocated within the RHP.
(1) Hospitals that are ineligible to participate in
Pass One that are interested in becoming performers are allocated
equal shares totaling 15% of their RHP's unused Pass One allocation.
(2) Physician group practices not affiliated with academic
health science centers that are interested in becoming performers
are allocated equal shares totaling 10% of their RHP's unused Pass
One allocation.
(3) Performers that participated in Pass One are allocated
75% of the unused Pass One allocation.
(A) To calculate an individual performer's Pass Two
allocation:
(i) First, determine each performer's percent of the
total Pass One funding used for demonstration years two through five;
and
Cont'd... |