| (a) A performer's total value for demonstration year
(DY) 6A is equal to the performer's total value for DY5 with the following
exceptions:
(1) HHSC notifies a performer that a DSRIP project’s
value may be reduced if the DSRIP project fails to complete DSRIP
project or metric goals by the end of DY5.
(2) Performers with a total value less than $250,000
for DY5 may increase their total value to up to $250,000 per each
subsequent DY beginning in DY6A. The increase in value is contingent
on funds availability as described in §354.1673 of this division
(relating to Remaining DSRIP Funds). Categories 1-4 will each be increased
proportionately. However, any funds in excess of the 10 percent maximum
for Category 4 will be allocated to Category 3. A performer may need
to increase a DSRIP project’s MLIU QPI goal for DY6A and beyond
in order to obtain the increased value. Performers eligible for this
option must make this choice by a date to be determined by HHSC.
(b) The DY5 IGT process, payment calculations, and
monitoring IGT are continued in the extension period. IGT entities
from DY5 will continue to provide funding for the extension period
unless a performer submits changes during the reporting period. No
new certifications (RHP Plan Section VI) are required for continuing
RHP participants.
(c) If a performer participated in Category 4 in DY5,
the performer will continue to participate in Category 4 in DY6A.
The performer's Category 4 value for DY6A will be equal to the performer's
Category 4 value for DY5, unless the performer's DY5 Category 4 value
is greater than 10 percent of the performer's total DY5 value. In
such a situation, the performer's DY6A Category 4 value will be reduced
to 10 percent of the performer's total DY5 value, and the funds above
the 10 percent threshold will be allocated to Category 3 in DY6A.
(d) The following Category 1 and 2 requirements must
be met in DY6A:
(1) Each DSRIP project must have the following four
milestones:
(A) a total Quantifiable Patient Impact (QPI) milestone
valued at 25 percent of each DSRIP project's Category 1 or 2 value;
(B) a Medicaid and Low-income or Uninsured (MLIU) QPI
milestone valued at 25 percent of each DSRIP project's Category 1
or 2 value;
(C) a core component reporting milestone valued at
25 percent of each DSRIP project’s Category 1 or 2 value; and
(D) a sustainability planning milestone valued at 25
percent of each DSRIP project’s Category 1 or 2 value.
(2) Total Quantitative Patient Impact (QPI) Milestone.
(A) HHSC will convert each total QPI metric to a total
QPI milestone with standardized language. However, if a DSRIP project
has multiple QPI metrics in DY5, that project may be exempted from
this conversion, based on criteria determined by HHSC and CMS.
(B) The total QPI goal is equal to the DY5 total QPI
goal.
(i) Certain DSRIP projects are eligible for an adjustment
to the total QPI goal. These DSRIP projects include projects for which
the provider reported 66 percent achievement or less of their DY4
total QPI metric as of April DY5 reporting, and for which:
(I) the value per MLIU individual is less than or equal
to $1,000; or
(II) the value per MLIU encounter is less than or equal
to $500.
(ii) Performers of a DSRIP project described in clause
(i) of this subparagraph may, by a date determined by HHSC in a form
determined by HHSC, request an adjustment to the DSRIP project's total
QPI goal.
(C) DSRIP projects must retain the same QPI grouping
from the initial demonstration period for total QPI.
(D) DSRIP projects must retain the same pre-DSRIP baseline
for total QPI from the initial demonstration period. If multiple metrics
are combined to form one total QPI milestone, the pre-DSRIP baselines
will also be combined.
(E) DSRIP projects may carry forward total QPI milestones
from DY6A to DY6B and DY7.
(3) MLIU QPI Milestone.
(A) Beginning in DY6A, there is an MLIU QPI milestone.
(B) For DSRIP projects that have an MLIU QPI requirement
in DY5:
(i) The MLIU QPI goal is equal to the DY5 MLIU QPI
goal. If, based on a determination pursuant to paragraph (2)(B) of
this subsection, the total QPI goal is changed, the MLIU QPI goal
will also be changed in proportion to the total QPI goal.
(ii) If the DSRIP project has an MLIU QPI metric in
DY5, it retains the same pre-DSRIP baseline for MLIU QPI used in the
initial demonstration period.
(iii) If the DSRIP project does not have an MLIU QPI
metric in DY5, the pre-DSRIP baseline for MLIU QPI is equal to the
pre-DSRIP baseline for total QPI multiplied by the earliest MLIU percentage
goal on record with HHSC.
(iv) The MLIU QPI milestone must be pay-for-performance
(P4P).
(C) For DSRIP projects that do not have an MLIU QPI
requirement in DY5:
(i) The MLIU QPI goal is equal to the DY5 MLIU percentage
goal multiplied by the DY5 total QPI goal, or as indicated in the
DY5 goal language. If, based on a determination pursuant to paragraph
(2)(B) of this subsection, the total QPI goal is changed, the MLIU
QPI goal will also be changed in proportion to the total QPI goal.
(ii) The pre-DSRIP baseline for MLIU QPI is equal to
the pre-DSRIP baseline for total QPI multiplied by the earliest MLIU
percentage goal on record with HHSC.
(iii) Although all DSRIP projects must include an MLIU
QPI goal, DSRIP projects under this subparagraph, with the exception
of projects subject to clause (iv) of this subparagraph, must include
an MLIU QPI milestone that is pay-for-reporting (P4R). This means
that the performer is eligible to receive payment for the project’s
MLIU QPI milestone by reporting their actual MLIU QPI achievement,
regardless of whether the performer achieved the MLIU QPI goal.
(iv) HHSC may determine that some of these DSRIP projects
must include an MLIU QPI milestone that is P4P, meaning that the performer
must demonstrate achievement of the project’s MLIU QPI goal
in order to receive payment for the MLIU QPI milestone.
(I) These DSRIP projects include the following:
(-a-) all Project Area 1.9 DSRIP projects, as described
by the RHP Planning Protocol;
(-b-) DSRIP projects that did not achieve the estimated
MLIU percentage in DY3, DY4, or DY5, and that caused them to have
a higher than expected value per MLIU individual/ encounter;
(-c-) DSRIP projects for which HHSC notified the performer
that the project was eligible to continue with changes, but the project’s
MLIU QPI milestone must be P4P; and
(-d-) DSRIP projects that included an MLIU goal in
their QPI metric Baseline/Goal statement (an embedded goal) of the
performer's own choosing or that were required to include MLIU to
receive CMS initial DSRIP project approval.
(II) A performer of a DSRIP project with an MLIU QPI
milestone that is P4P under this section may request to adjust the
pre-DSRIP baseline for MLIU QPI by a date determined by HHSC in a
form determined by HHSC. HHSC will consider requests to adjust the
pre-DSRIP baseline for MLIU QPI and may approve those requests with
a strong justification.
(D) Certain DSRIP projects are eligible for an adjustment
to the MLIU QPI goal. These DSRIP projects include:
(i) a DSRIP project that HHSC identifies as underperforming
on MLIU QPI estimates in the initial demonstration period;
(ii) a DSRIP project that is reporting on individuals
or encounters that meet the MLIU definition for the initial demonstration
period, but will not meet the MLIU definition for the extension period;
and
(iii) any other DSRIP project that HHSC determines
has a strong justification for an adjustment.
(E) Performers of a DSRIP project described in subparagraph
(D) of this paragraph may, by a date to be determined by HHSC, request
an adjustment to the DSRIP project's MLIU QPI goal.
(F) DSRIP projects must retain the same total QPI grouping
from the initial demonstration period for MLIU QPI.
(G) DSRIP projects may carry forward MLIU QPI milestones
from DY6A to DY6B and DY7.
(H) If a DSRIP project's DY6A MLIU QPI milestone is
P4R, the performer is eligible to report on, and receive payment for,
the DY6A MLIU QPI milestone once the performer has done the following:
(i) achieved or forfeited a DSRIP project's DY5 QPI
metric; and
Cont'd... |
