|(a) Introduction. Texas Healthcare Transformation and
Quality Improvement Program §1115(a) Medicaid demonstration waiver
payments are available under this section for services provided between
October 1, 2017 and September 30, 2019, by eligible hospitals described
in subsection (c) of this section. Waiver payments to hospitals for
uncompensated charity care provided beginning October 1, 2019, are
described in §355.8212 of this division (relating to Waiver Payments
to Hospitals for Uncompensated Charity Care). Waiver payments to hospitals
must be in compliance with the Centers for Medicare & Medicaid
Services approved waiver Program Funding and Mechanics Protocol, HHSC
waiver instructions and this section.
(1) Affiliation agreement--An agreement, entered into
between one or more privately-operated hospitals and a governmental
entity that does not conflict with federal or state law. HHSC does
not prescribe the form of the agreement.
(2) Aggregate limit--The amount of funds approved by
the Centers for Medicare & Medicaid Services for uncompensated-care
payments for the demonstration year that is allocated to each uncompensated-care
provider pool, as described in subsection (f)(2) of this section.
(3) Anchor--The governmental entity identified by HHSC
as having primary administrative responsibilities on behalf of a Regional
Healthcare Partnership (RHP).
(4) Centers for Medicare & Medicaid Services (CMS)--The
federal agency within the United States Department of Health and Human
Services responsible for overseeing and directing Medicare and Medicaid,
or its successor.
(5) Clinic--An outpatient health care facility, other
than an Ambulatory Surgical Center or Hospital Ambulatory Surgical
Center, that is owned and operated by a hospital but has a nine-digit
Texas Provider Identifier (TPI) that is different from the hospital's
(6) Data year--A 12-month period that is described
in §355.8066 of this title (relating to Hospital-Specific Limit
Methodology) and from which HHSC will compile cost and payment data
to determine uncompensated-care payment amounts. This period corresponds
to the Disproportionate Share Hospital data year.
(7) Delivery System Reform Incentive Payments (DSRIP)--Payments
related to the development or implementation of a program of activity
that supports a hospital's efforts to enhance access to health care,
the quality of care, and the health of patients and families it serves.
These payments are not considered patient-care revenue and are not
offset against the hospital's costs when calculating the hospital-specific
limit as described in §355.8066 of this title.
(8) Demonstration year--The 12-month period beginning
October 1 for which the payments calculated under this section are
made. This period corresponds to the Disproportionate Share Hospital
(9) Disproportionate Share Hospital (DSH)--A hospital
participating in the Texas Medicaid program that serves a disproportionate
share of low-income patients and is eligible for additional reimbursement
from the DSH fund.
(10) Governmental entity--A state agency or a political
subdivision of the state. A governmental entity includes a hospital
authority, hospital district, city, county, or state entity.
(11) HHSC--The Texas Health and Human Services Commission
or its designee.
(12) Institution for mental diseases (IMD)--A hospital
that is primarily engaged in providing psychiatric diagnosis, treatment,
or care of individuals with mental illness.
(13) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(14) Large public hospital--An urban public hospital
- Class one as defined in §355.8065 of this title (relating to
Disproportionate Share Hospital Reimbursement Methodology).
(15) Mid-Level Professional--Medical practitioners
which include only these professions: Certified Registered Nurse Anesthetists,
Nurse Practitioners, Physician Assistants, Dentists, Certified Nurse
Midwives, Clinical Social Workers, Clinical Psychologists, and Optometrists.
(16) Private hospital--A hospital that is not a large
public hospital as defined in paragraph (14) of this subsection, a
small public hospital as defined in paragraph (21) of this subsection
or a state-owned hospital.
(17) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a governmental entity. 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.
(18) Regional Healthcare Partnership (RHP)--A collaboration
of interested participants that work collectively to develop and submit
to the state a regional plan for health care delivery system reform.
Regional Healthcare Partnerships will support coordinated, efficient
delivery of quality care and a plan for investments in system transformation
that is driven by the needs of local hospitals, communities, and populations.
(19) RHP plan--A multi-year plan within which participants
propose their portion of waiver funding and DSRIP projects.
(20) Rural hospital--A hospital enrolled as a Medicaid
provider that is:
(A) located in a county with 60,000 or fewer persons
according to the 2010 U.S. Census; or
(B) designated by Medicare as a Critical Access Hospital
(CAH) or a Sole Community Hospital (SCH); or
(C) designated by Medicare as a Rural Referral Center
(RRC) and is not located in a Metropolitan Statistical Area (MSA),
as defined by the U.S. Office of Management and Budget, or is located
in an MSA but has 100 or fewer beds.
(21) Small public hospital--An urban public hospital
- Class two or a non-urban public hospital as defined in §355.8065
of this title.
(22) Transition payment--Payments available only during
the first demonstration year to hospitals that previously participated
in a supplemental payment program under the Texas Medicaid State Plan.
For a hospital participating in the 2012 DSH program, the maximum
amount a hospital may receive in transition payments is the lesser
(A) the hospital's 2012 DSH room; or
(B) the amount the hospital received in supplemental
payments for claims adjudicated between October 1, 2010, and September
(23) Uncompensated-care application--A form prescribed
by HHSC to identify uncompensated costs for Medicaid-enrolled providers.
(24) Uncompensated-care payments--Payments intended
to defray the uncompensated costs of services that meet the definition
of "medical assistance" contained in §1905(a) of the Social Security
Act that are provided by the hospital to Medicaid eligible or uninsured
(25) Uninsured patient--An individual who has no health
insurance or other source of third-party coverage for services, as
defined by CMS.
(26) Urban rural referral center--A hospital designated
by Medicare as a Rural Referral Center (RRC) that is located in a
Metropolitan Statistical Area (MSA), as defined by the U.S. Office
of Management and Budget, and that has more than 100 beds.
(27) Waiver--The Texas Healthcare Transformation and
Quality Improvement Program Medicaid demonstration waiver under §1115
of the Social Security Act.
(c) Eligibility. A hospital that meets the requirements
described in this subsection may receive payments under this section.
(1) Generally. To be eligible for any payment under
(A) a hospital must have a source of public funding
for the non-federal share of waiver payments; and
(B) if it is a hospital not operated by a governmental
entity, it must have filed with HHSC an affiliation agreement and
the documents described in clauses (i) and (ii) of this subparagraph.
(i) The hospital must certify on a form prescribed
(I) that it is a privately-operated hospital;
(II) that no part of any payment to the hospital under
this section will be returned or reimbursed to a governmental entity
with which the hospital affiliates; and
(III) that no part of any payment under this section
will be used to pay a contingent fee, consulting fee, or legal fee
associated with the hospital's receipt of the supplemental funds.
(ii) The governmental entity that is party to the affiliation
agreement must certify on a form prescribed by HHSC:
(I) that the governmental entity has not received and
has no agreement to receive any portion of the payments made to any
hospital that is party to the agreement;
(II) that the governmental entity has not entered into
a contingent fee arrangement related to the governmental entity's
participation in the waiver program;
(III) that the governmental entity adopted the conditions
described in the certification form prescribed by or otherwise approved
by HHSC pursuant to a vote of the governmental entity's governing
body in a public meeting preceded by public notice published in accordance
with the governmental entity's usual and customary practices or the
Texas Open Meetings Act, as applicable; and
(IV) that all affiliation agreements, consulting agreements,
or legal services agreements executed by the governmental entity related
to its participation in this waiver payment program are available
for public inspection upon request.
(iii) Submission requirements.
(I) Initial submissions. The parties must initially
submit the affiliation agreements and certifications described in
this subsection to the HHSC Rate Analysis Department on the earlier
of the following occurrences after the documents are executed:
(-a-) The date the hospital submits the uncompensated-care
application that is further described in paragraph (2) of this subsection;
(-b-) Thirty days before the projected deadline for
completing the IGT for the first payment under the affiliation agreement.
The projected deadline for completing the IGT is posted on HHSC Rate
Analysis' website for each payment under this section.
(II) Subsequent submissions. The parties must submit
revised documentation as follows:
(-a-) When the nature of the affiliation changes or
parties to the agreement are added or removed, the parties must submit
the revised affiliation agreement and related hospital and governmental
(-b-) When there are changes in ownership, operation,
or provider identifiers, the hospital must submit a revised hospital
(-c-) The parties must submit the revised documentation
thirty days before the projected deadline for completing the IGT for
the first payment under the revised affiliation agreement. The projected
deadline for completing the IGT is posted on HHSC Rate Analysis' website
for each payment under this section.
(III) A hospital that submits new or revised documentation
under subclause (I) or (II) of this clause must notify the Anchor
of the RHP in which the hospital participates.
(IV) The certification forms must not be modified except
for those changes approved by HHSC prior to submission.
(-a-) Within 10 business days of HHSC Rate Analysis
receiving a request for approval of proposed modifications, HHSC will
approve, reject, or suggest changes to the proposed certification
(-b-) A request for HHSC approval of proposed modifications
to the certification forms will not delay the submission deadlines
established in this clause.
(V) A hospital that fails to submit the required documentation
in compliance with this subparagraph will not receive a payment under
(2) Uncompensated-care payments. For a hospital to
be eligible to receive uncompensated-care payments, in addition to
the requirements in paragraph (1) of this subsection, the hospital
(A) submit to HHSC an uncompensated-care application
for the demonstration year, as is more fully described in subsection
(g)(1) of this section, by the deadline specified by HHSC;
(B) submit to HHSC documentation of:
(i) its participation in an RHP; or
(ii) approval from CMS of its eligibility for uncompensated-care
payments without participation in an RHP;
(C) be actively enrolled as a Medicaid provider in
the State of Texas at the beginning of the demonstration year; and
(D) have submitted, and be eligible to receive payment
for, a Medicaid fee-for-service or managed-care inpatient or outpatient
claim for payment during the demonstration year.
(3) Changes that may affect eligibility for uncompensated-care
(A) If a hospital closes, loses its license, loses
its Medicare or Medicaid eligibility, withdraws from participation
in an RHP, or files bankruptcy before receiving all or a portion of
the uncompensated-care payments for a demonstration year, HHSC will
determine the hospital's eligibility to receive payments going forward
on a case-by-case basis. In making the determination, HHSC will consider
multiple factors including whether the hospital was in compliance
with all requirements during the demonstration year and whether it
can satisfy the requirement to cooperate in the reconciliation Cont'd...