| (a) Introduction. Notwithstanding other provisions
of this subchapter and subject to the availability of funds, supplemental
payments are available under this section for intermediate care facility
for individuals with an intellectual disability or related conditions
(ICF/IID) services provided by eligible non-state government-owned
ICFs/IID.
(b) Definitions. When used in this section, the following
definitions apply:
(1) Aggregate upper payment limit--A reasonable estimate
of the amount that would be paid for the services furnished by non-state
government-owned ICFs/IID under Medicare payment principles, as calculated
in subsection (f) of this section.
(2) HHSC--The Texas Health and Human Services Commission
or its designee.
(3) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(4) Medicaid supplemental payment limit--The maximum
supplemental payment available to a participating non-state government-owned
ICF/IID for a specific Medicaid supplemental payment limit calculation
period as calculated in subsection (f) of this section.
(5) Medicaid supplemental payment limit calculation
period--The federal fiscal quarter determined by HHSC for which supplemental
payment amounts are calculated.
(6) Non-state government-owned ICF/IID--An ICF/IID
where a non-state governmental entity is party to the facility's Medicaid
contract.
(7) Non-state governmental entity--A community center
established under Chapter 534, Subchapter A of the Texas Health and
Safety Code or a hospital authority, hospital district, healthcare
district, city, or county.
(8) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of the governmental entity that is party to the
Medicaid contract of the ICF/IID identified in subsection (c) of this
section. Public funds do not include gifts, grants, trusts, or donations,
the use of which is conditioned on supplying a benefit solely to the
donor or grantor of the funds.
(c) Eligible ICFs/IID.
(1) Supplemental payments are available under this
section to all non-state government-owned ICFs/IID that comply with
the requirements described in subsection (d) of this section.
(2) An ICF/IID participating in this supplemental payment
program must notify the HHSC Provider Finance Department of changes
in ownership that may affect the ICF/IID's continued eligibility within
30 days after such change.
(3) An ICF/IID that has not received a payment under
this supplemental payment program for four consecutive quarters is
ineligible for future supplemental payments unless the ICF/IID applies
again for the supplemental payment program in accordance with subsection
(d) of this section.
(d) Required application. Before a non-state government-owned
ICF/IID may receive supplemental payments under this section, the
appropriate governmental entity must certify certain facts, representations,
and assurances regarding program requirements.
(1) The appropriate governmental entity must certify
the following facts on a form prescribed by HHSC before the first
day of the next scheduled Medicaid supplemental payment limit calculation
period in order for the ICF/IID to receive a supplemental payment
for that period:
(A) That a non-state governmental entity is party to
the ICF/IID's Medicaid contract.
(B) That all funds transferred to HHSC via IGT for
use as the state share of supplemental payments are public funds.
(C) That no part of any supplemental payment paid to
the ICF/IID under this section will be used to pay a contingent fee,
consulting fee, or legal fee associated with the ICF/IID's receipt
of the supplemental funds.
(D) That the person signing the certification on behalf
of the ICF/IID is legally authorized to bind the ICF/IID and to certify
the matters described in the application; and
(2) The ICF/IID is eligible for supplemental payments
for Medicaid supplemental payment limit calculation periods that begin
after HHSC receives completed application forms from the appropriate
governmental entity.
(e) Source of funding.
(1) State funding for supplemental payments authorized
under this section is limited to and obtained through IGTs of public
funds from the governmental entity that is party to the Medicaid contract
of the ICF/IID identified in subsection (c) of this section.
(2) An IGT that is not received by the date specified
by HHSC may not be accepted. In such a situation, the IGT will be
returned to the governmental entity and the ICF/IID will not be eligible
to receive a supplemental payment.
(f) Medicaid supplemental payment limits.
(1) The aggregate supplemental payment amount for non-state
government-owned ICFs/IID is calculated for each Medicaid supplemental
payment limit calculation period by taking the difference between
the aggregate upper payment limit from subparagraph (A) of this paragraph
and the aggregate Medicaid payment from subparagraph (B) of this paragraph:
(A) The aggregate upper payment limit for non-state
government-owned ICFs/IID will be calculated based on Medicare payment
principles and in accordance with the Medicaid upper payment limit
provisions codified at Title 42 Code of Federal Regulations (CFR) §447.272.
The aggregate upper payment limit is equal to the sum of the Medicare-equivalent
payments for all non-state government-owned ICFs/IID. The Medicare-equivalent
payment for each non-state government-owned ICF/IID is calculated
as follows based on data from the most recent reliable Medicaid cost
report:
(i) Determine the Medicare adjusted cost by subtracting
ancillary and fixed capital costs from total Medicaid allowable costs
and multiplying the remaining costs by 1.12.
(ii) Determine the Medicare adjusted cost per day of
service by dividing the value from clause (i) of this subparagraph
by the total days of service.
(iii) Determine the Medicare-equivalent payment by
multiplying the dividend from clause (ii) of this subparagraph by
the total Medicaid days of service.
(B) The aggregate Medicaid payment for non-state government-owned
ICFs/IID prior to the supplemental payment will be the sum of Medicaid
Level of Need (LON) payments for all non-state government-owned ICFs/IID
as captured on the most recent reliable Medicaid cost report.
(2) The Medicaid supplemental payment limit for each
participating non-state government-owned ICF/IID for each Medicaid
supplemental payment limit calculation period will be determined by
dividing that facility's Medicaid units of service during the Medicaid
supplemental payment limit calculation period by the total Medicaid
units of service during the Medicaid supplemental payment limit calculation
period for all non-state government-owned ICFs/IID, multiplying the
resulting percentage by the aggregate supplemental payment amount
from paragraph (1) of this subsection, and dividing the resulting
product by four.
(g) Payment frequency. HHSC will distribute supplemental
payments to participating non-state government-owned ICFs/IID on a
quarterly basis subsequent to the Medicaid supplemental payment limit
calculation period.
(h) Supplemental payment methodology.
(1) HHSC will give notice of the non-state government-owned
ICF/IID Medicaid supplemental payment limits determined in subsection
(f) of this section, the maximum IGT amount that can be provided for
each participating ICF/IID based on the Federal Medical Assistance
Percentage (FMAP) in place at the time notice is given, and the deadline
for completing the transfer.
(2) The amount of the supplemental payment to the ICF/IID
will be calculated in proportion to the amount transferred by the
governmental entity.
(A) For governmental entities that own a single ICF/IID:
(i) If the governmental entity transfers the maximum
IGT described in paragraph (1) of this subsection, the ICF/IID will
receive the Medicaid supplemental payment limit amount calculated
for it in subsection (f) of this section.
(ii) If the governmental entity transfers less than
the maximum IGT described in paragraph (1) of this subsection, the
ICF/IID will receive a supplemental payment that is proportionate
to the percentage of the maximum IGT that was actually transferred.
(B) For governmental entities that own multiple ICFs/IID:
(i) If the governmental entity transfers the maximum
IGT described in paragraph (1) of this subsection for all of the ICFs/IID
it owns, each of the ICFs/IID will receive the Medicaid supplemental
payment limit amount calculated for it in subsection (f) of this section.
Cont'd... |
