| (C) Payments to NFs will be triggered by achievement
of performance requirements as described in §353.1304 of this
subchapter or, if applicable in a program period, a uniform rate increase
for which a NF must report quality data as described in §353.1304
of this subchapter as a condition of participation in the program.
(3) Component Three.
(A) The total value of Component Three will be equal
to:
(i) For the program periods beginning on or before
September 1, 2020, but on or before September 1, 2019, 70 percent
total program value for the program period after accounting for the
funding of Component One and Component Four.
(ii) For the program periods beginning on or before
September 1, 2023, but on or after September 1, 2021, 60 percent after
accounting for the funding of Component One and Component Four.
(iii) For the program period beginning September 1,
2024, 20 percent of the program period funds.
(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) 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 total program value for the program period.
(B) Allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) 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) Non-Disbursed Funds.
(A) For program periods that begin on or before September
1, 2023, 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.
(B) For program periods that begin on or after September
1, 2024, funds that are non-disbursed due to failure of one or more
NFs to meet performance requirements will be distributed across QIPP
NFs who have demonstrated achievement of a measure established in
accordance with §353.1304 of this subchapter and designated by
HHSC as the measure on which distribution of non-disbursed funds will
be based. Funds distributed under this subparagraph will be allocated
to each achieving NF based upon each NF's proportion of total earned
QIPP funds from Components One, Two, Three, and Four combined compared
to the total amount paid to achieving NFs from all components.
(h) Distribution of QIPP payments.
(1) Prior to the beginning of the program 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) Component One.
(i) For the program periods beginning on or before
September 1, 2023, but on or after September 1, 2019, monthly payments
from Component One as a uniform rate increase will be equal to the
total value of Component One for the NF divided by twelve.
(ii) For program periods beginning on or after September
1, 2024, quarterly payments from Component One associated with each
quality metric will be equal to the total value of Component One associated
with the quality metric divided by four.
(B) Component Two.
(i) For the program periods beginning on or before
September 1, 2023, but on or after September 1, 2019, 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.
(ii) For program periods beginning on or after September
1, 2024, 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) Component Three. For program periods beginning
on or after September 1, 2019, 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) Component Four. For program periods beginning on
or after September 1, 2019, 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) Allocation Across Quality Metrics.
(i) For program periods beginning on or before September
1, 2023, but on or after September 1, 2019, 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.
(ii) For program periods beginning on or after September
1, 2024, for purposes of the calculations described in subparagraph
(A) of this paragraph, achievement in 1 metric earns 90 percent and
achievement in 2 metrics earns 100 percent of total dollars included
in the component. For the calculations described in subparagraphs
(C) and (D) of this paragraph, each quality metric will be allocated
an equal portion of the total dollars included in the component.
(iii) For purposes of the calculations described in
subparagraph (B) of this paragraph:
(I) for program periods beginning on September 1, 2024,
achievement in 1 metric earns 70 percent and achievement in 2 metrics
earns 100 percent of total dollars included in the component;
(II) for program periods beginning on September 1,
2025, achievement in 1 metric earns 60 percent, achievement in 2 metrics
earns 85 percent, and achievement in 3 metrics earns 100 percent of
total dollars included in the component; and
(III) for program periods beginning on or after September
1, 2026, 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 all quality metrics to be calculated, the funding associated with
that metric will be evenly distributed across all remaining metrics
within the component. If a NF does not have enough data for any quality
metrics to be calculated, no funds will be earned.
(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 26 TAC §554.201
(relating to Criteria for Licensing) and 26 TAC §554.210 (relating
to Change of Ownership and Notice of Changes) must be submitted in
the timeframe required by HHSC.
(2) If an enrolled NF changes ownership, including
to a new class of facility following the enrollment period or during
the program 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 program period.
(3) For program periods beginning on or after September
1, 2025, if an enrolled NF undergoes a CHOW that changes the class
of the facility, from privately owned to non-state government-owned
or from non-state government-owned to privately owned, during the
program period, the enrolled NF will be removed from the program for
the remainder of the program period after the CHOW effective date.
(4) 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. Notification is considered to have occurred when the
MCO 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 Provider Finance Department by email at qipp@hhs.texas.gov.
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.
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