| (a) Introduction. Beginning October 1, 2019, Texas
Healthcare Transformation and Quality Improvement 1115 Waiver payments
are available under this section for eligible publicly-owned dental
providers to help defray the uncompensated cost of charity care. Waiver
payments to publicly-owned dental providers for uncompensated care
provided before October 1, 2019, are described in §355.8441 of
this subchapter (relating to Reimbursement Methodologies for Early
and Periodic Screening, Diagnosis, and Treatment (EPSDT) Services).
(b) Definitions.
(1) 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.
(2) Charity care--Healthcare services provided without
expectation of reimbursement to uninsured patients who meet the provider's
charity-care policy. The charity-care policy should adhere to the
charity-care principles of the Healthcare Financial Management Association
Principles and Practices Board Statement 15 (December 2012). Charity
care includes full or partial discounts given to uninsured patients
who meet the provider's financial assistance policy. Charity care
does not include bad debt, courtesy allowances, or discounts given
to patients who do not meet the provider's charity-care policy or
financial assistance policy.
(3) Demonstration year--The 12-month period beginning
October 1 for which the payments calculated under this section are
made. Demonstration year one was October 1, 2011, through September
30, 2012.
(4) 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.
(5) HHSC--The Texas Health and Human Services Commission
or its designee.
(6) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(7) 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.
(8) Publicly-owned dental provider--A dental provider
that uses paid government employees to provide dental services directly
funded by a governmental entity.
(9) Uncompensated-care application--A form prescribed
by HHSC to identify uncompensated costs for Medicaid-enrolled providers.
(10) Uncompensated-care payments--Payments intended
to defray the uncompensated costs of charity care as defined in paragraph
(2) of this subsection.
(11) Uninsured patient--An individual who has no health
insurance or other source of third-party coverage for the services
provided. The term includes an individual enrolled in Medicaid who
received services that do not meet the definition of medical assistance
in section 1905(a) of the Social Security Act (Medicaid services),
if such inclusion is specified in the hospital's charity-care policy
or financial assistance policy and the patient meets the hospital's
policy criteria.
(12) Waiver--The Texas Healthcare Transformation and
Quality Improvement Program Medicaid demonstration waiver under §1115
of the Social Security Act.
(c) Eligibility. To be eligible for payments under
this section, a publicly-owned dental provider must submit to HHSC
an acceptable 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.
(d) Source of funding. The non-federal share of funding
for payments under this section is limited to public funds from governmental
entities.
(e) Payment frequency. HHSC will distribute uncompensated-care
payments on a schedule to be determined by HHSC and posted on HHSC's
website.
(f) Funding limitations.
(1) Payments made under this section are limited by
the amount of funds allocated to the provider's uncompensated-care
pool for the demonstration year as described in §355.8212 of
this division (relating to Waiver Payments to Hospitals for Uncompensated
Charity Care). If payments for uncompensated care for the publicly-owned
dental provider pool attributable to a demonstration year are expected
to exceed the amount of funds allocated to that pool by HHSC for that
demonstration year, HHSC will reduce payments to providers in the
pool as described in subsection (g)(3) of this section.
(2) Payments made under this section are limited by
the availability of funds identified in subsection (d) of this section.
If sufficient funds are not available for all payments for which all
publicly-owned dental providers are eligible, HHSC will reduce payments
as described in subsection (h)(2) of this section.
(g) Uncompensated-care payment amount.
(1) Uncompensated-care application. Payments to eligible
publicly-owned dental providers are based on cost and payment data
reported by the provider on an application form prescribed by HHSC
and on supporting documentation. Providers must certify that uncompensated-care
costs reported on the application have not been claimed on any other
application or cost report.
(2) Calculation. A dental provider's annual maximum
uncompensated-care payment amount is calculated as follows:
(A) As detailed in the cost report instructions, the
provider must report their charges associated with charity-care services
to uninsured patients and any payments attributable to those services.
(B) A cost-to-billed-charges ratio will be used to
calculate total allowable cost.
(C) The result of subparagraph (B) of this paragraph
will be reduced by any related payments to determine the provider's
annual maximum uncompensated-care payment amount.
(3) Reduction to stay within the publicly-owned dental
provider uncompensated-care pool allocation amount. Prior to processing
uncompensated-care payments for any payment period within a waiver
demonstration year, HHSC will determine if such a payment would cause
total uncompensated-care payments for the demonstration year for the
publicly-owned dental provider pool to exceed the allocation amount
for the pool and will reduce the maximum uncompensated-care payment
amounts for each provider in the pool by the same percentage as required
to remain within the pool allocation amount.
(h) Payment methodology.
(1) Notice. Prior to making any payment described in
subsection (g) of this section, HHSC will give notice of the following
information:
(A) the payment amount for each publicly-owned dental
provider in the pool;
(B) the maximum IGT amount necessary for providers
in the pool to receive the amounts described in subparagraph (A) of
this paragraph; and
(C) the deadline for completing the IGT.
(2) Payment amount. The amount of the payment to providers
in the pool will be determined based on the amount of funds transferred
by the governmental entities as follows:
(A) If the governmental entities transfer the maximum
amount referenced in paragraph (1) of this subsection, the providers
will receive the full payment amount calculated for that payment period.
(B) If the governmental entities do not transfer the
maximum amount referenced in paragraph (1) of this subsection, each
provider in the pool will receive a portion of its payment amount
for that period, based on the provider's percentage of the total payment
amounts for all providers in the pool.
(i) Recoupment.
(1) In the event of an overpayment identified by HHSC
or a disallowance by CMS of federal financial participation related
to a provider's receipt or use of payments under this section, HHSC
may recoup an amount equivalent to the amount of the overpayment or
disallowance. The non-federal share of any funds recouped from the
provider will be returned to the entity that owns or is affiliated
with the provider.
(2) Payments under this section may be subject to adjustment
for payments made in error, including, without limitation, adjustments
under §371.1711 of this title (relating to Recoupment of Overpayments
and Debts), 42 CFR Part 455, and Chapter 403 of the Texas Government
Code. HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid
payments as follows:
(A) HHSC will recoup from the provider against which
any overpayment was made or disallowance was directed.
(B) If, within 30 days of the provider's receipt of
HHSC's written notice of recoupment, the provider has not paid the
full amount of the recoupment or entered into a written agreement
with HHSC to do so, HHSC may withhold any or all future Medicaid payments
from the provider until HHSC has recovered an amount equal to the
amount overpaid or disallowed.
|
