(a) Category A and DSRIP payments. If a performer fails
to fulfill all of the Category A requirements described in §354.1749
of this division (relating to Category A Requirements for Performers)
for a demonstration year (DY), any DSRIP payments the performer received
for the DY will be recouped, and prospective DSRIP payments to the
performer will be withheld.
(1) DSRIP payments for DY9 include payments for DY9
Category B, Category C, or Category D milestones.
(2) DSRIP payments for DY10 include payments for DY10
Category B, Category C, or Category D milestones.
(b) Basis for payment of Category B. A performer's
payment for its MLIU PPP milestone for a DY is calculated as follows.
(1) If the performer's MLIU PPP goal achievement is
greater than or equal to 100 percent minus its allowable MLIU PPP
goal variation, the performer's MLIU PPP milestone payment is equal
to 100 percent of its MLIU PPP milestone valuation.
(2) If the performer's MLIU PPP goal achievement is
greater than or equal to 90 percent, and less than 100 percent minus
its allowable MLIU PPP goal variation, the performer's MLIU PPP milestone
payment is equal to 90 percent of its MLIU PPP milestone valuation.
(3) If the performer's MLIU PPP goal achievement is
greater than or equal to 75 percent, and less than 90 percent, the
performer's MLIU PPP milestone payment is equal to 75 percent of its
MLIU PPP milestone valuation.
(4) If the performer's MLIU PPP goal achievement is
greater than or equal to 50 percent, and less than 75 percent, the
performer's MLIU PPP milestone payment is equal to 50 percent of its
MLIU PPP milestone valuation.
(5) If the performer's MLIU PPP goal achievement is
less than 50 percent, the performer does not receive a MLIU PPP milestone
payment.
(c) Basis for payment of Category C.
(1) Reporting milestones. A performer must fully achieve
a reporting milestone to be eligible for payment related to the milestone.
(2) P4P measure goal achievement milestones. A P4P
measure has a goal achievement milestone for each DY. With the exception
of P4P measure goal achievement milestones described in subparagraph
(B) of this paragraph, partial payment for P4P measure goal achievement
milestones is available in quartiles for partial achievement measured
over baseline in Performance Year (PY) 1, PY2, PY3, and PY4.
(A) To calculate the payment for a P4P measure goal
achievement milestone, multiply the milestone valuation by the achievement
value calculated in clause (ii) of this subparagraph.
(i) The percent of the milestone's goal achieved by
the performer is determined as follows.
(I) Measures with a positive directionality where higher
scores indicate improvement:
(-a-) DY7 achievement = (PY1 Achieved - Baseline/ (DY7
Goal - Baseline).
(-b-) Carryforward of DY7 achievement = (PY2 Achieved
- Baseline)/ (DY7 Goal - Baseline).
(-c-) DY8 achievement = (PY2 Achieved - Baseline)/
(DY8 Goal - Baseline).
(-d-) Carryforward of DY8 achievement = (PY3 Achieved
- Baseline)/ (DY8 Goal - Baseline).
(-e-) DY9 achievement = (PY3 Achieved - Baseline)/
(DY9 Goal - Baseline).
(-f-) Carryforward of DY9 achievement = (PY4 Achieved
- Baseline)/ (DY9 Goal - Baseline).
(-g-) DY10 achievement = (PY4 Achieved - Baseline)/
(DY10 Goal - Baseline).
(II) Measures with a negative directionality where
lower scores indicate improvement:
(-a-) DY7 achievement = (Baseline - PY1 Achieved)/
(Baseline - DY7 Goal).
(-b-) Carryforward of DY7 achievement = (Baseline -
PY2 Achieved)/ (Baseline - DY7 Goal).
(-c-) DY8 achievement = (Baseline - PY2 Achieved)/
(Baseline - DY8 Goal).
(-d-) Carryforward of DY8 achievement = (Baseline -
PY3 Achieved)/ (Baseline - DY8 Goal).
(-e-) DY9 achievement = (Baseline - PY3 Achieved)/
(Baseline - DY9 Goal).
(-f-) Carryforward of DY9 achievement = (Baseline -
PY4 Achieved)/ (Baseline - DY9 Goal).
(-g-) DY10 achievement = (Baseline - PY4 Achieved)/
(Baseline - DY10 Goal).
(ii) The achievement value is determined as follows.
(I) If 100 percent of the goal is achieved, the achievement
value is 1.0.
(II) If less than 100 percent but at least 75 percent
of the goal is achieved, the achievement value is 0.75.
(III) If less than 75 percent but at least 50 percent
of the goal is achieved, the achievement value is 0.5.
(IV) If less than 50 percent but at least 25 percent
of the goal is achieved, the achievement value is 0.25.
(V) If less than 25 percent of the goal is achieved,
the achievement value is 0.
(B) If a P4P measure designated as Quality Improvement
System for Managed Care has a baseline above the High Performance
Level, the performer must achieve 100 percent of the goal achievement
milestone to be eligible for payment of the milestone; there is no
payment for partial achievement.
(C) If a P4P measure identified as a hospital safety
measure in the Measure Bundle Protocol has perfect performance at
baseline, the measure's goal achievement milestone is eligible for
full payment for maintenance of high performance.
(i) Perfect performance at baseline means that for
the baseline measurement period, the performer reports:
(I) zero numerator cases; and
(II) at least one denominator case.
(ii) Maintenance of high performance means that for
a performance year, the performer reports:
(I) zero numerator cases; and
(II) one numerator case that was not preventable.
(iii) If a performer wishes to report maintenance of
high performance for a performance year for a measure that is eligible
for full payment for maintenance of high performance, the performer
must determine a valid definition for a numerator case that is not
preventable and submit documentation of that definition to HHSC.
(iv) If HHSC determines that maintenance of high performance
is achieved, the achievement value for the goal achievement milestone
is 1.0.
(d) Basis for payment of Category D. A performer must
report on a measure in the Category D - Statewide Reporting Measure
Bundle for its provider type for a DY in accordance with §354.1755(d)
of this division (relating to Category D Requirements for Performers)
to be eligible for payment of the measure for that DY.
(e) At no point may a performer receive a DSRIP payment
for a milestone more than two years after the end of the DY in which
the milestone is to be completed.
(f) If a performer does not complete the remaining
milestones as described in §354.1751 of this division (relating
to Category B Requirements for Performers) or §354.1753 of this
division (relating to Category C Requirements for Performers), or
the Category D - Statewide Reporting Measure Bundle measures as described
in subsection (d) of this section, the associated DSRIP funding is
forfeited by the performer.
(g) Once the action associated with a milestone is
reported by the performer as complete, that milestone may not be counted
again toward DSRIP payment calculations.
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