(a) Introduction. This section establishes the Directed
Payment Program for Behavioral Health Services (DPP BHS). DPP BHS
is designed to incentivize behavioral health providers to improve
quality, access, and innovation in the provision of medical and behavioral
health 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 §353.1322 of this subchapter (relating to Quality
Metrics for the Directed Payment Program for Behavioral Health Services).
(1) Average Commercial Reimbursement (ACR) gap--The
difference between what an average commercial payor is estimated to
pay for the services and what Medicaid actually paid for the same
services.
(2) Certified Community Behavioral Health Clinic (CCBHC)--A
clinic certified by the state in accordance with federal criteria
and with the requirements of the Protecting Access to Medicare Act
of 2014 (PAMA).
(3) CCBHC cost-reporting gap--The difference between
what Medicaid pays for services and what the reimbursement would be
based on the CCBHC cost-reporting methodology.
(4) Community Mental Health Center (CMHC)--An entity
that is established under Texas Health and Safety Code §534.0015
and that:
(A) Provides outpatient services, including specialized
outpatient services for children, the elderly, individuals with serious
mental illness, and residents of its mental health service area who
have been discharged from inpatient treatment at a mental health facility.
(B) Provides 24-hour-a-day emergency care services.
(C) Provides day treatment or other partial hospitalization
services, or psychosocial rehabilitation services.
(D) Provides screening for patients being considered
for admission to state mental health facilities to determine the appropriateness
of such admission.
(5) Intergovernmental transfer (IGT) notification--Notice
and directions regarding how and when IGTs should be made in support
of DPP BHS.
(6) Local Behavioral Health Authority (LBHA)--An entity
that is designated under Texas Health and Safety Code §533.0356.
(7) Program period--A period of time for which the
Texas Health and Human Services (HHSC) contracts with participating
managed care organizations (MCOs) to pay increased capitation rates
for the purpose of provider 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.
(8) Providers--For program periods on or before August
31, 2022, an entity described in paragraph (4) of this subsection.
For program periods on or after September 1, 2022, an entity described
in paragraph (4) or (6) of this subsection.
(9) Suggested IGT responsibility--Notice of potential
amounts that a sponsoring governmental entity may wish to consider
transferring in support of DPP BHS.
(10) Total program value--The maximum amount available
under the Directed Payment Program for Behavioral Health Services
for a program period, as determined by HHSC.
(c) Classes of participating providers.
(1) HHSC may direct the MCOs to provide a uniform percentage
rate increase or a uniform dollar increase to all providers within
one or more of the following classes of providers with which the MCO
contracts for services:
(A) For program periods beginning on or before September
1, 2023, providers that are certified CCBHCs and providers that are
not certified CCBHCs.
(B) For program periods beginning on or after September
1, 2024, providers who are certified CCBHCs.
(2) If HHSC directs rate or dollar increases to more
than one class of providers within the service delivery area, the
rate or dollar increases directed by HHSC may vary between classes.
(d) Data sources for historical units of service. Historical
units of service are used to determine a provider's eligibility status
to receive the estimated distribution of program funds across enrolled
providers.
(1) HHSC will use encounter data and will identify
encounters based upon the billing provider's national provider identification
(NPI) number.
(2) The most recently available Medicaid encounter
data for a complete state fiscal year will be used to determine the
distribution of program funds across eligible and enrolled providers.
(3) In the event that the historical data are not deemed
appropriate for use by actuarial standards, HHSC may use data from
a different state fiscal year at the discretion of the HHSC actuaries.
(4) The data used to estimate the distribution of funds
will align to the extent possible with the data used for purposes
of setting the capitation rates for MCOs for the same period.
(5) HHSC will calculate the estimated rate that an
average commercial payor or Medicare would have paid for similar services
or based on the CMS-approved CCBHC cost report rate methodology using
either data from Medicare cost reports or collected from providers.
(6) Encounter data used to calculate DPP BHS 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 DPP BHS payments.
(e) Conditions of Participation. As a condition of
participation, all providers participating in the program must allow
for the following.
(1) The provider must submit a properly completed enrollment
application by the due date determined by HHSC. The enrollment period
must 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 suggestion under subsection (j)(1) 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) The entity that bills on behalf of the provider
must certify, on a form prescribed by HHSC, that no part of any payment
made under the program will be used to pay a contingent fee and that
the entity's agreement with the provider 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 provider's receipt of program funds. The certification
must be received by HHSC with the enrollment application described
in paragraph (1) of this subsection.
(3) If a provider contracts with another entity to
provide DPP BHS-eligible services on behalf of the provider, the provider
must submit all claims to the MCO using an NPI assigned to the provider
as the billing provider's NPI.
(4) If a provider has changed ownership in the past
five years in a way that impacts eligibility for DPP BHS, 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, DPP BHS.
(5) Report all quality data denoted as required as
a condition of participation in subsection (h) of this section.
(6) Failure to meet any conditions of participation
described in this section will result in removal of the provider from
the program and recoupment of all funds previously paid during the
program period.
(f) Determination of percentage of rate and dollar
increase.
(1) HHSC will determine the percentage of rate or dollar
increase applicable to providers by program component.
(2) HHSC will consider the following factors when determining
the rate increase:
(A) the estimated Medicare gap for providers, based
upon the upper payment limit demonstration most recently submitted
by HHSC to the Centers for Medicare and Medicaid Services (CMS);
(B) the estimated Average Commercial Reimbursement
(ACR) gap for the class or individual providers, as indicated in data
collected from providers;
(C) the estimated gap for providers, based on the CCBHC
cost-reporting methodology that is consistent with the CMS guidelines;
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