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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 354MEDICAID HEALTH SERVICES
SUBCHAPTER DTEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM
DIVISION 7DSRIP PROGRAM DEMONSTRATION YEARS 7-8
RULE §354.1713Category C Requirements for Performers

(a) Requirements for hospitals and physician practices.

  (1) Measure Bundle and measure selection.

    (A) A hospital or physician practice, with the exception of those described in subparagraph (J) of this paragraph, must select Measure Bundles from the Hospital and Physician Practice Measure Bundle Menu of the Measure Bundle Protocol in accordance with the requirements in subparagraphs (B) - (I) of this paragraph in the RHP plan update for its RHP.

    (B) Each Measure Bundle is assigned a point value as described in the Measure Bundle Protocol.

    (C) A hospital or physician practice is assigned a minimum point threshold (MPT) for Measure Bundle selection as described in paragraphs (6) and (7) of this subsection.

    (D) A hospital or physician practice must select Measure Bundles worth enough points to meet its MPT in order to maintain its total valuation for DY7 and DY8. If a hospital or physician practice does not select Measure Bundles worth enough points to meet its MPT, its total DY7 valuation will be reduced proportionately across its RHP Plan Update and Categories B-D funds for DY7, and its total DY8 valuation will be reduced proportionately across its Categories B-D funds for DY8, based on the point values of the Measure Bundles it selects.

    (E) A hospital or physician practice may only select a Measure Bundle for which its denominators for the baseline measurement period for at least half of the required measures in the Measure Bundle have significant volume.

    (F) A hospital or physician practice with a valuation greater than $2,500,000 per demonstration year (DY) for DY7-8 must:

      (i) select at least one Measure Bundle with at least one required three-point measure for which its denominator for the baseline measurement period has significant volume; or

      (ii) select at least one Measure Bundle with at least one optional three-point measure for which its denominator for the baseline measurement period has significant volume, and select at least one optional three-point measure in that Measure Bundle for which its denominator for the baseline measurement period has significant volume.

    (G) A hospital or physician practice with an MPT of 75 must select at least one Measure Bundle with at least one population-based clinical outcome measure as specified in the Measure Bundle Protocol.

    (H) A hospital or physician practice may only select an optional measure in a selected Measure Bundle for which its denominator for the baseline measurement period has significant volume.

    (I) Only a hospital with a valuation less than or equal to $2,500,000 per DY for DY7-8 may select a Measure Bundle identified as a rural Measure Bundle in accordance with the requirements in the Measure Bundle Protocol.

    (J) If a hospital or physician practice has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundle(s) appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the hospital or physician practice may request HHSC approval to select measures, rather than Measure Bundles, from the Measure Bundle Protocol. The hospital or physician practice must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by the Centers for Medicare & Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve such a request, the following requirements apply:

      (i) the hospital's or physician practice's total valuation for DY7 and DY8 may be reduced;

      (ii) the hospital or physician practice must select measures from the following menus of the Measure Bundle Protocol in accordance with the requirements in clauses (iii) - (v) of this subparagraph in the RHP plan update for its RHP:

        (I) the Measure Bundles on the Hospital and Physician Practice Measure Bundle Menu;

        (II) the Community Mental Health Center Measure Menu; or

        (III) the Local Health Department Measure Menu;

      (iii) each measure in a Measure Bundle on the Hospital and Physician Practice Measure Bundle Menu, and each measure on the Community Mental Health Center Measure Menu and the Local Health Department Measure Menu, is assigned a point value as described in the Measure Bundle Protocol;

      (iv) the hospital or physician practice is assigned an MPT for measure selection as described in paragraphs (5) and (6) of this subsection; and

      (v) the hospital or physician practice must select measures worth enough points to meet its MPT in order to maintain its total valuation for DY7 and DY8. If the hospital or physician practice does not select measures worth enough points to meet its MPT, its total DY7 valuation will be reduced proportionately across its RHP Plan Update and Categories B-D funds for DY7, and its total DY8 valuation will be reduced proportionately across its Categories B-D funds for DY8, based on the point values of the measures it selects.

  (2) DSRIP-attributed population. A hospital or physician practice must determine its DSRIP-attributed population to be applied to its selected Measure Bundles and measures as specified in the Measure Bundle Protocol.

  (3) Measure Bundle valuation. A hospital or physician practice may allocate its Category C valuation among its selected Measure Bundles in the RHP plan update for its RHP as it chooses, provided the following requirements are met:

    (A) The valuation for each selected Measure Bundle must be greater than or equal to (the Measure Bundle point value divided by the sum of all the selected Measure Bundles' point values) multiplied by 0.75 multiplied by the Category C valuation.

    (B) The valuation for each selected Measure Bundle without any required or selected optional three-point measures must be less than or equal to (the Measure Bundle point value divided by the sum of all the selected Measure Bundles' point values) multiplied by the Category C valuation.

    (C) The valuation for each selected Measure Bundle with a required or selected optional three-point measure must be less than or equal to (the Measure Bundle point value divided by the sum of all the selected Measure Bundles' point values) multiplied by 1.25 multiplied by the Category C valuation.

    (D) If a hospital or physician practice allocates to a Measure Bundle a percentage of its Category C valuation that is one percent greater than the Measure Bundle's point value as a percentage of all the selected Measure Bundles' point values, the hospital or physician practice must provide sufficient justification as specified in the Program Funding and Mechanics Protocol.

  (4) Measure valuation. The valuation for each measure in a selected Measure Bundle is equal to the Measure Bundle valuation divided by the number of measures in the selected Measure Bundle, so that the valuations of the measures in the selected Measure Bundle are equal, with the following exceptions:

    (A) If a Measure Bundle includes an innovative measure:

      (i) the valuation for each innovative measure in the Measure Bundle is equal to the Measure Bundle valuation divided by the number of the measures in the Measure Bundle subtracted by 0.5 for each innovative measure and divided by 2; and

      (ii) the valuation for each measure in the Measure Bundle that is not an innovative measure is equal to the Measure Bundle valuation divided by the number of measures in the Measure Bundle subtracted by 0.5 for each innovative measure.

    (B) If a hospital's or physician practice's denominator for a required measure or numerator for a population-based clinical outcome measure in a selected Measure Bundle for the baseline measurement period or a performance year has no volume, the measure is removed from the Measure Bundle, and its valuation for the applicable DY is redistributed among the remaining measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume for the applicable DY. The valuation for the applicable DY for each of the remaining measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume is equal to the valuation for the Measure Bundle for the applicable DY divided by the number of measures for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume, so that the valuations for the applicable DY for the measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume are equal.

    (C) If a hospital's or physician practice's denominator for a required measure or numerator for a P4R population-based clinical outcome measure in a selected Measure Bundle for the baseline measurement period or a performance year has insignificant volume, the measure's milestone valuations are adjusted in accordance with subsection (e)(2) of this section.

  (5) Milestone valuation. The measure milestones and corresponding valuations for DY7-8 are as described in subsection (e) of this section.

  (6) MPTs for hospitals.

    (A) The MPT for hospitals, with the exception of those described in subparagraphs (B) and (C) of this paragraph, is calculated as follows:

      (i) First, the hospital's statewide hospital factor (SHF) is equal to (.64 multiplied by (the hospital's Medicaid and uninsured inpatient days divided by the sum of all hospitals' Medicaid and uninsured inpatient days)) plus (.36 multiplied by (the hospital's Medicaid and uninsured outpatient costs divided by the sum of all hospitals' Medicaid and uninsured outpatient costs)).

      (ii) Second, the hospital's statewide hospital ratio (SHR) is equal to (the hospital's DY7 valuation divided by the sum of all hospitals' DY7 valuations) divided by the SHF.

      (iii) Third, the hospital's MPT is determined as follows:

        (I) If the SHR is less than or equal to 3, the MPT is the lesser of:

          (-a-) the DY7 valuation divided by $500,000; or

          (-b-) 75.

        (II) If the SHR is greater than 3 but less than or equal to 10, the MPT is the lesser of:

          (-a-) (the DY7 valuation divided by $500,000 multiplied by (the SHR divided by 3); or

          (-b-) 75.

        (III) If the SHR is greater than 10 and the DY7 valuation is less than or equal to $15 million, the MPT is the lesser of:

          (-a-) (the DY7 valuation divided by $500,000 multiplied by (the SHR divided by 3); or

          (-b-) 40.

        (IV) If the SHR is greater than 10 and the DY7 valuation is greater than $15 million, the MPT is the lesser of:

          (-a-) (the DY7 valuation divided by $500,000 multiplied by (the SHR divided by 3); or

          (-b-) 75.

    (B) If a hospital does not have the data needed for the SHF calculation in paragraph (5)(A)(i) of this subsection, or if a hospital did not participate in DSRIP during the initial demonstration period or DY6, its MPT is the lesser of:

      (i) the hospital's DY7 valuation divided by $500,000; or

      (ii) 75.

    (C) If a hospital has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundle(s) appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the hospital may request HHSC approval for a reduced MPT equal to the sum of the points for all the Measure Bundles for which the hospital could reasonably report on at least half of the required measures in the Measure Bundle. The hospital must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by the Centers for Medicare & Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve such a request, the hospital's total valuation for DY7 and DY8 may be reduced.

  (7) MPTs for physician practices.

    (A) The MPT for physician practices, with the exception of those described in subparagraph (B) of this paragraph, is the lesser of:

      (i) the physician practice's DY7 valuation divided by $500,000; or

      (ii) 75.

    (B) If a physician practice has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundles appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the physician practice may request HHSC approval for a reduced MPT equal to the sum of the points for all the Measure Bundles for which the physician practice could reasonably report on at least half of the required measures in the Measure Bundle. The physician practice must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by CMS. If HHSC and CMS, as appropriate, approve such a request, the physician practice's total valuation for DY7 and DY8 may be reduced.

(b) Requirements for community mental health centers (CMHCs).

  (1) Measure selection.

Cont'd...

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