| (a) Introduction. This section establishes the Texas
Incentives for Physicians and Professional Services (TIPPS) program.
TIPPS is designed to incentivize physicians and certain medical professionals
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. Terms that are used in this section
may be defined in §353.1301 of this subchapter (relating to General
Provisions) or §353.1311 of this subchapter (relating to Quality
Metrics for the Texas Incentives for Physicians and Professional Services
Program).
(1) Health Related Institution (HRI) physician group--A
network physician group owned or operated by an institution named
in Texas Education Code §63.002.
(2) Indirect Medical Education (IME) physician group--A
network physician group contracted with, owned, or operated by a hospital
receiving either a medical education add-on or a teaching medical
education add-on as described in §355.8052 of this title (relating
to Inpatient Hospital Reimbursement) for which the hospital is assigned
or retains billing rights for the physician group.
(3) Intergovernmental Transfer (IGT) Notification--Notice
and directions regarding how and when IGTs should be made in support
of the program.
(4) Network physician group--A physician group located
in the state of Texas that has a contract with a Managed Care Organization
(MCO) for the delivery of Medicaid covered benefits to the MCO's enrollees.
(5) Other physician group--A network physician group
other than those specified under paragraphs (1) and (2) of this subsection.
(6) Program period--A period of time for which an eligible
and enrolled physician group may receive the TIPPS amounts described
in this section. Each TIPPS program period is equal to a state fiscal
year beginning September 1 and ending August 31 of the following year.
(7) Total program value--The maximum amount available
under the TIPPS program for a program period, as determined by HHSC.
(8) Suggested IGT responsibility--Notice of potential
amounts that a governmental entity may wish to consider transferring
in support of the program.
(c) Eligibility for participation in TIPPS. A physician
group is eligible to participate in TIPPS if it complies with the
requirements described in this subsection.
(1) Physician group composition. A physician group
must indicate the eligible physicians, clinics, and other locations
to be considered for payment and quality measurement purposes in the
application process.
(2) Minimum volume. Physician groups must have a minimum
denominator volume of 30 Medicaid managed care patients in at least
50 percent of the quality metrics in each Component to be eligible
to participate in the Component.
(3) The physician group is:
(A) an HRI physician group;
(B) an IME physician group; or
(C) any other physician group that:
(i) can achieve the minimum volume as described in
paragraph (2) of this subsection;
(ii) is located in a service delivery area with at
least one sponsoring governmental entity; and
(iii) served at least 250 unique Medicaid managed care
clients in the prior state fiscal year.
(d) Data sources for historical units of service and
clients served. Historical units of service are used to determine
a physician group's eligibility status and the estimated distribution
of TIPPS funds across enrolled physician groups.
(1) HHSC will use encounter data and will identify
encounters based upon the billing provider's national provider identification
(NPI) number and taxonomy code combination that are billed as a professional
encounter only.
(2) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine eligibility
status of other physician groups.
(3) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine distribution
of TIPPS funds across eligible and enrolled physician groups.
(4) In the event of a disaster, HHSC may use 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
capitated rates for managed care organizations for the same period.
(6) HHSC will calculate the estimated rate that an
average commercial payor would have paid for the same services using
either data that HHSC obtains independently or data that is collected
from providers through the application process described in subsection
(c) of this section.
(7) If HHSC is unable to compute an actuarially sound
payment rate based on private payor information described in paragraph
(6) of this subsection for any services, then those services will
be removed from consideration from the TIPPS program.
(8) All services billed and delivered at a Federally
Qualified Health Center, dental services, and ambulance services are
excluded from the scope of the TIPPS program.
(9) Encounter data used to calculate payments for this
program must be designated as paid status. Encounters reported as
a paid status, but with zero or negative dollars as a reported paid
amount will not be included in the data used to calculate payments
for the TIPPS program.
(10) 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-parties
paid units of service.
(e) Conditions of Participation. As a condition of
participation, all physician groups participating in TIPPS must allow
for the following.
(1) The physician group 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 days prior to the release
of suggested IGT responsibilities.
(2) The entity that bills on behalf of the physician
group must certify, on a form prescribed by HHSC, that no part of
any TIPPS payment will be used to pay a contingent fee nor may the
entity's agreement with the physician group 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 physician group's receipt of TIPPS 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 TIPPS 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, the TIPPS program.
(4) Report all quality data denoted as required as
a condition of participation in §353.1311(d)(1) of this subchapter.
(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.
(f) Non-federal share of TIPPS payments. The non-federal
share of all TIPPS payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support
TIPPS.
(1) HHSC will communicate suggested IGT responsibilities
for the program period with all TIPPS eligible and enrolled HRI physician
groups and IME physician groups at least 10 calendar days prior to
the IGT declaration of intent deadline. Suggested IGT responsibilities
will be based on the maximum dollars available under the TIPPS program
for the program period as determined by HHSC, plus eight percent;
forecasted member months for the program period as determined by HHSC;
and the distribution of historical Medicaid utilization across HRI
physician groups and IME physician groups, plus estimated utilization
for eligible and enrolled other physician groups within the same service
delivery area, for the program period. HHSC will also communicate
estimated maximum revenues each eligible and enrolled physician group
could earn under TIPPS for the program period with those estimates
based on HHSC's suggested IGT responsibilities and an assumption that
all enrolled physician groups will meet 100 percent of their quality
metrics.
(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 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
by March 15 of each year.
(4) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually 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) TIPPS capitation rate components. TIPPS funds will
be paid to Managed Care Organizations (MCOs) through three components
of the managed care per member per month (PMPM) capitation rates.
The MCOs' distribution of TIPPS funds to the enrolled physician groups
will be based on each physician group's performance related to the
quality metrics as described in §353.1311 of this subchapter.
The physician group must have provided at least one Medicaid service
to a Medicaid client in each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 65 percent of total program value.
(B) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based upon historical Medicaid
clients served.
(C) Monthly payments to HRI and IME physician groups
will be a uniform rate increase.
(D) Other physician groups are not eligible for payments
from Component One.
(E) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(F) HHSC will reconcile the interim allocation of funds
across qualifying HRI and IME physician groups to the actual distribution
of Medicaid clients served across these physician groups during the
program period, as captured by Medicaid MCOs contracted with HHSC
for managed care 120 days after the last day of the program period.
(2) Component Two.
(A) The total value of Component Two will be equal
to 25 percent of total program value.
(B) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based upon historical Medicaid
utilization.
(C) Payments to physician groups will be a uniform
rate increase.
(D) Other physician groups are not eligible for payments
from Component Two.
(E) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(F) HHSC will reconcile the interim allocation of funds
across qualifying HRI and IME physician groups to the actual distribution
of Medicaid clients served across these physician groups during the
program period as captured by Medicaid MCOs contracted with HHSC for
managed care 120 days after the last day of the program period.
(3) Component Three.
(A) The total value of Component Three will be equal
to 10 percent of total program value.
(B) Allocation of funds across physician groups will
be proportional, based upon actual Medicaid utilization of specific
procedure codes as identified in the final quality metrics or performance
requirements described in §353.1311 of this subchapter.
(C) Payments to physician groups will be a uniform
rate increase.
Cont'd... |
