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TITLE 1ADMINISTRATION
PART 15TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353MEDICAID MANAGED CARE
SUBCHAPTER ODELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES
RULE §353.1302Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019
Texas Register

  (2) Component Two.

    (A) The total value of Component Two will be equal to 30 percent of remaining QIPP funds after accounting for the funding of Component One and Component Four.

    (B) Allocation of funds across qualifying non-state government-owned and private NFs will be proportional, based upon historical Medicaid days of NF service.

    (C) Monthly payments to NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

  (3) Component Three.

    (A) The total value of Component Three will be equal to 70 percent of remaining QIPP funds after accounting for the funding of Component One and Component Four.

    (B) Allocation of funds across qualifying non-state government-owned and private NFs will be proportional, based upon historical Medicaid days of NF service.

    (C) Quarterly payments to NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

  (4) Component Four.

    (A) The total value of Component Four will be equal to 16 percent of the funds of the QIPP.

    (B) Allocation of funds across qualifying non-state government-owned NFs will be proportional, based upon historical Medicaid days of NF service.

    (C) Quarterly payments to non-state government-owned NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

    (D) Private NFs are not eligible for payments from Component Four.

  (5) Funds that are non-disbursed due to failure of one or more NFs to meet performance requirements will be distributed across all QIPP NFs based on each NF's proportion of total earned QIPP funds from Components One, Two, Three, and Four combined.

(h) Distribution of QIPP payments.

  (1) Prior to the beginning of the eligibility period, HHSC will calculate the portion of each PMPM associated with each QIPP-enrolled NF broken down by QIPP capitation rate component, quality metric, and payment period. For example, for a NF, HHSC will calculate the portion of each PMPM associated with that NF that would be paid from the MCO to the NF as follows.

    (A) Monthly payments from Component One as performance requirements are met will be equal to the total value of Component One for the NF divided by twelve.

    (B) Monthly payments from Component Two associated with each quality metric will be equal to the total value of Component Two associated with the quality metric divided by twelve.

    (C) Quarterly payments from Component Three associated with each quality metric will be equal to the total value of Component Three associated with the quality metric divided by four.

    (D) Quarterly payments from Component Four associated with each quality metric will be equal to the total value of Component Four associated with the quality metric divided by four.

    (E) For purposes of the calculations described in subparagraphs (B), (C), and (D) of this paragraph, each quality metric will be allocated an equal portion of the total dollars included in the component.

    (F) In situations where a NF does not have enough data for a quality metric to be calculated, the funding associated with that metric will be evenly distributed across all remaining metrics within the component.

  (2) MCOs will distribute payments to enrolled NFs as they meet their reporting and quality metric requirements. Payments will be equal to the portion of the QIPP PMPM associated with the achievement for the time period in question multiplied by the number of member months for which the MCO received the QIPP PMPM. In the event of a CHOW, the MCO will distribute the payment to the owner of the NF at the time of the payment.

(i) Changes of ownership.

  (1) A NF undergoing a CHOW from privately owned to non-state government owned or from non-state government owned to privately-owned will only be eligible to enroll as the new class of facility if HHSC received a completed CHOW application no later than 30 days prior to the first day of the enrollment period. All required documents pertaining to the CHOW (i.e., HHSC must have a complete application for a change of ownership license as described under 40 TAC §19.201 (relating to Criteria for Licensing), 40 TAC §19.210 (relating to Change of Ownership and Notice of Changes), and 40 TAC §19.2308 (relating to Change of Ownership)) must be submitted in the timeframe required by HHSC.

  (2) If an enrolled NF changes ownership, including to a new class of facility during the pendency of the application or during the eligibility period, the NF under the new ownership must meet the eligibility requirements described in this section for the new owner's facility class in order to continue QIPP participation during the eligibility period.

  (3) An enrolled NF must notify the MCOs it has contracts with of a potential CHOW at least 30 days before the anticipated date of the CHOW. An enrolled NF must also notify the HHSC Rate Analysis Department by hand delivery, United States (U.S.) mail, or special mail delivery at least 30 days before the anticipated date of the CHOW. Notification is considered to have occurred when HHSC receives the notice.

(j) Changes in operation. If an enrolled NF closes voluntarily or ceases to provide NF services in its facility, the NF must notify the HHSC Rate Analysis Department by hand delivery, United States (U.S.) mail, or special mail delivery within 10 business days of closing or ceasing to provide NF services. Notification is considered to have occurred when HHSC receives the notice.

(k) Recoupment. Payments under this section may be subject to recoupment as described in §353.1301(j) and §353.1301(k) of this subchapter.


Source Note: The provisions of this §353.1302 adopted to be effective December 30, 2018, 43 TexReg 8079

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