(D) Private NFs are not eligible for payments from
Component One.
(E) The interim allocation of funds across qualifying
non-state government-owned NFs will be reconciled to the actual distribution
of Medicaid NF days of service across these NFs during the eligibility
period as captured by HHSC's Medicaid contractors for fee-for-service
and managed care 180 days after the last day of the eligibility period.
This reconciliation will only be performed if the weighted average
(weighted by Medicaid NF days of service during the eligibility period)
of the absolute values of percentage changes between each NFs proportion
of historical Medicaid days of NF service and actual Medicaid days
of NF service is greater than 20 percent.
(2) Component Two.
(A) The total value of Component Two will be equal
to 35 percent of remaining QIPP funds after accounting for the funding
of Component One.
(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 subsection
(h) of this section.
(3) Component Three.
(A) The total value of Component Three will be equal
to 65 percent of remaining QIPP funds after accounting for the funding
of Component One.
(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 subsection
(h) of this section. Payments made to NFs meeting the standards of
Component Three will include both the 35 percent allocated for Component
Two and the remaining 65 percent allocated for Component Three.
(4) Funds that would lapse due to failure of one or
more NFs to meet QAPI reporting requirements or quality metrics will
be distributed across all QIPP NFs based on each NF's proportion of
total earned QIPP funds from Components One, Two, and Three 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 NF A, 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 QAPI reporting
requirements are met will be equal to the total value of Component
One for the NF divided by twelve.
(B) Quarterly 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 four.
(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) For purposes of the calculations described in subparagraphs
(B) and (C) of this paragraph, each metric will be allocated an equal
portion of the total dollars included in the component.
(E) In situations where a NF does not have enough data
for a metric to be calculated, the funding associated with that metric
will be evenly distributed across all remaining metrics.
(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.
(i) Performance requirements.
(1) Quality metrics.
(A) There will be a minimum of three quality metrics
for an eligibility period. For eligibility period one, there are the
following four quality metrics:
(i) high-risk long-stay residents with pressure ulcers;
(ii) percent of residents who received an antipsychotic
medication (long-stay);
(iii) residents experiencing one or more falls with
major injury; and
(iv) residents who were physically restrained.
(B) Quality metrics may change from eligibility period
to eligibility period but will always be limited to those under the
CMS Five-Star Quality Rating System. Information regarding specific
quality metrics for an eligibility period will be provided annually
through the QIPP webpage on the HHSC website on or before February
1 of the calendar year that also contains the first month of the eligibility
period.
(C) Quality metric baselines will be based on each
individual NF's average performance on the metric as reported by CMS
for the federal quarter that ends prior to the first day of the eligibility
period and the three prior federal quarters, or as determined by HHSC.
(D) Quality metric benchmarks will be based on the
national average for the metric as reported by CMS for the federal
quarter that ends prior to the first day of the eligibility period,
or as determined by HHSC.
(2) Achievement requirements. In order to receive payments
from Components Two and Three for a quality metric, a NF must show
improvement over the baseline or exceed the benchmark for the metric.
(A) To qualify for a payment from Component Two, a
NF must meet at least the initial quarterly goal of 1.7 percent improvement
from the baseline, with subsequent quarterly goals increasing to a
maximum of seven percent by the end of the eligibility period. For
example, to qualify for a payment from Component Two for a quality
metric for the second quarter of the eligibility period, the NF must
meet at least the second quarter goal of 3.4 percent improvement from
the baseline.
(B) To qualify for a payment from Component Three,
a NF must meet at least the initial quarterly goal of 5.0 percent
improvement from the baseline with subsequent quarterly goals increasing
to a maximum of 20 percent by the end of the eligibility period. For
example, to qualify for a payment from Component Three for a quality
metric for the second quarter of the eligibility period, the NF must
meet at least the second quarter goal of 10.0 percent improvement
from the baseline. A NF that qualifies for a payment from Component
Three for a metric automatically qualifies for a payment from Component
Two for the same metric.
(C) A NF that exceeds the benchmark for a metric qualifies
for a payment from both Component Two and Component Three for that
metric. A NF that exceeds the benchmark may decline in performance
and still qualify for a payment from both Component Two and Component
Three as long as the NF continues to exceed the benchmark for the
metric.
(j) Changes of ownership.
(1) If an enrolled NF changes ownership during the
eligibility period to private ownership, the NF under the new ownership
must meet the private NF eligibility requirements described in this
section in order to continue QIPP participation during the eligibility
period.
(2) If a non-state government-owned NF changes ownership
during the eligibility period to another non-state governmental entity,
the NF under the new ownership must meet the non-state government-owned
eligibility requirements described in this section in order to continue
QIPP participation during the eligibility period.
(k) Recoupment. Payments under this section may be
subject to recoupment as described in §353.1301(k) of this subchapter.
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