| (B) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the NF. If the Staffing
and Compensation Report covers less than a full year, reported values
are annualized to represent a full year. If no Staffing and Compensation
Report is available, the data source in subparagraph (C) of this paragraph
is must be used.
(C) The most recently available Medicaid NF cost report
for a prior owner of the NF. If the cost report covers less than a
full year, reported values are annualized to represent a full year.
If no Medicaid NF cost report for a prior owner of the NF is available,
the data source in subparagraph (D) of this paragraph must be used.
(D) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a prior owner of the
NF. If the Staffing and Compensation Report covers less than a full
year, reported values are annualized to represent a full year.
(e) Participation requirements. As a condition of participation,
all NFs participating in QIPP must allow for the following:
(1) HHSC must be able to access data for the NF from
one of the data sources listed in subsection (d) of this section.
(2) The NF must submit a properly completed enrollment
application by the due date determined by HHSC.
(3) The entity that owns the NF must certify, on a
form prescribed by HHSC, that no part of any payment made under the
QIPP will be used to pay a contingent fee, consulting fee, or legal
fee associated with the NF's receipt of QIPP funds and the certification
must be received by HHSC with the enrollment application described
in paragraph (2) of this subsection.
(4) The entity that owns the NF must submit to HHSC,
upon demand, copies of contracts it has with third parties that reference
the administration of, or payments from, QIPP.
(f) Non-federal share of QIPP payments. The non-federal
share of all QIPP payments is funded through IGTs from sponsoring
non-state governmental entities. No state general revenue is available
to support QIPP.
(1) HHSC will share suggested IGT responsibilities
for the eligibility period with all QIPP eligible and enrolled non-state
government-owned NFs on or around May 15 of the calendar year that
also contains the first month of the eligibility period. Suggested
IGT responsibilities will be based on the maximum dollars to be available
under the QIPP program for the eligibility period as determined by
HHSC, plus ten percent; forecast STAR+PLUS NF member months for the
eligibility period as determined by HHSC; and the distribution of
historical Medicaid days of service across non-state government-owned
NFs enrolled in QIPP for the eligibility period. HHSC will also share
estimated maximum revenues each eligible and enrolled NF could earn
under QIPP for the eligibility period with those estimates based on
HHSC's suggested IGT responsibilities and an assumption that all enrolled
NFs will meet 100 percent of their quality metrics. The purpose of
sharing this information is to provide non-state government-owned
NFs with information they can use to determine the amount of IGT they
wish to transfer.
(2) Sponsoring governmental entities will determine
the amount of IGT they wish to transfer to HHSC for the entire eligibility
period and will transfer one-half of that amount by May 31 of the
calendar year that also contains the first month of the eligibility
period. The second half of the IGT amount will be transferred by November
30 of the calendar year that also contains the first month of the
eligibility period.
(3) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
each eligibility period with the amount of funds transferred to HHSC
by the sponsoring governmental entities for that same period using
the methodology described in §353.1301(g) of this subchapter.
(g) QIPP capitation rate components. QIPP funds will
be paid to MCOs through three new components of the STAR+PLUS NF MC
per member per month (PMPM) capitation rates. The MCOs' distribution
of QIPP funds to the enrolled NFs will be based on each NF's performance
on a set of defined quality metrics.
(1) Component One.
(A) The total value of Component One will be equal
to 110 percent of the non-federal share of the QIPP program.
(B) Interim allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) Monthly payments to non-state government-owned
NFs will be triggered by the NF's submission to the MCOs of a monthly
QAPI Validation Report.
(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
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