| (a) Introduction. This section establishes the Quality
Incentive Payment Program (QIPP) for nursing facilities (NFs) providing
services under Medicaid managed care on or after September 1, 2019.
QIPP is designed to incentivize NFs to improve quality and innovation
in the provision of NF services to Medicaid recipients through the
use of metrics that are expected to advance at least one of the goals
and objectives of the state's quality strategy.
(b) Definitions. The following definitions apply when
the terms are used in this section. Terms that are used in this and
other sections of this subchapter may be defined in §353.1301
(relating to General Provisions) or §353.1304 (relating to Quality
Metrics for the Quality Incentive Payment Program for Nursing Facilities
on or after September 1, 2019) of this subchapter.
(1) CHOW application--An application filed with HHSC
for a NF change of ownership (CHOW).
(2) Program period--A period of time for which an eligible
and enrolled NF may receive the QIPP amounts described in this section.
Each QIPP program period is equal to a state fiscal year (FY) beginning
September 1 and ending August 31 of the following year.
(3) Network nursing facility--A NF located in the state
of Texas that has a contract with a Managed Care Organization (MCO)
for the delivery of Medicaid covered benefits to the MCO's enrollees.
(4) Non-state government-owned NF--A network nursing
facility where a non-state governmental entity located in the state
of Texas holds the license and is a party to the NF's Medicaid provider
enrollment agreement with the state.
(5) Private NF--A network nursing facility not owned
by a governmental entity located in the state of Texas, and holds
a license.
(6) Regional Healthcare Partnership (RHP)--A collaboration
of interested participants that work collectively to develop and submit
to the state a regional plan for health care delivery system reform
as defined and established under Chapter 354, Subchapter D, of this
title (relating to Texas Healthcare Transformation and Quality Improvement
Program).
(7) Runout period--A period of 23 months following
the end of the program period during which the MCO may make adjustments
to the MCO member months.
(c) Eligibility for participation in QIPP. A NF is
eligible to participate in QIPP if it complies with the requirements
described in this subsection.
(1) The NF is a non-state government-owned NF.
(A) The non-state governmental entity that owns the
NF must certify the following facts on a form prescribed by HHSC.
(i) That it is a non-state government-owned NF where
a non-state governmental entity holds the license and is party to
the facility's Medicaid contract; and
(ii) That all funds transferred to HHSC via an intergovernmental
transfer (IGT) for use as the state share of payments are public funds.
(B) For the program periods beginning on or before
September 1, 2023, but on or after September 1, 2019, the NF must
be located in the state of Texas in the same RHP as, or within 150
miles of, the non-state governmental entity taking ownership of the
facility; must be owned by the non-state governmental entity for no
less than four years prior to the first day of the program period;
or must be able to certify in connection with the enrollment application
that they can demonstrate an active partnership between the NF and
the non-state governmental entity that owns the NF.
(C) For the program period beginning September 1, 2024,
the NF must be located in the state of Texas in the same county as,
or if separate counties, a contiguous county of, the non-state governmental
entity taking ownership of the facility; must be owned by the non-state
governmental entity for no less than four years prior to the first
day of the program period; or must be able to provide documentation
of activities that demonstrate an active partnership that have occurred
in the prior two months before application as well as a detailed plan
for maintaining the partnership in the months following the application
date through the end of the program period.
(D) For program periods beginning on or after September
1, 2025, the NF must be located in the state of Texas in the same
county as, or if separate counties, a contiguous county of, the non-state
governmental entity taking ownership of the facility; must be owned
by the non-state governmental entity for no less than four years prior
to the first day of the program period; or must be able to provide
documentation of activities that demonstrate an active partnership
that have occurred in the prior nine months before application as
well as a detailed plan for maintaining the partnership in the months
following the application date through the end of the program period.
(E) The following criteria demonstrate an active partnership
between the NF and the non-state governmental entity that owns the
NF.
(i) Monthly meetings (in-person or virtual) with NF
administrative staff to review the NF's clinical and quality operations
and identify areas for improvement. Meetings should include patient
observations; regulatory findings; review of Certification And Survey
Provider Enhanced Reports (CASPER) reports, quality measures, grievances,
staffing, risk, incidents, accidents, and infection control measures;
root cause analysis, if applicable; and design of performance improvement
plans.
(ii) Quarterly joint trainings on topics and trends
in nursing home care best practices or on needed areas of improvement.
(iii) Annual, on-site inspections of the NF by a non-state
governmental entity-sponsored Quality Assurance team.
(2) The NF is a private NF. The NF must have a percentage
of Medicaid NF days of service that is greater than or equal to 65
percent. For each private NF, the percentage of Medicaid NF days is
calculated by summing the NF's Medicaid NF fee-for-service and managed
care days of service, including dual-eligible demonstration days of
service, and dividing that sum by the facility's total days of service
in all licensed beds. Medicaid hospice days of service are included
in the denominator but excluded from the numerator.
(A) The days of service will be annualized based on
the NF's latest cost report or accountability report but from a year
in which HHSC required the submission of cost reports.
(B) HHSC will exclude any calendar days that the NF
was closed due to a natural or man-made disaster. In such cases, HHSC
will annualize the days of service based on calendar days when the
NF was open.
(d) Data sources for historical units of service. Historical
units of service are used to determine an individual private NF's
QIPP eligibility status and the distribution of QIPP funds across
eligible and enrolled NFs.
(1) All data sources referred to in this subsection
are subject to validation using HHSC auditing processes or procedures
as described under §355.106 of this title (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports).
(2) Data sources for the determination of each private
NF's QIPP eligibility status are listed in priority order below. For
each program period, the data source must be from a cost-reporting
year and must align with the NF's fiscal year.
(A) The most recently available Medicaid NF cost report
for the private NF. If no Medicaid NF cost report is available, the
data source in subparagraph (B) of this paragraph must be used.
(B) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the private NF. If
no Medicaid Direct Care Staff Rate Staffing and Compensation Report
is available, the data source in subparagraph (C) of this paragraph
must be used.
(C) The most recently available Medicaid NF cost report
for a prior owner of the private NF. If no Medicaid NF cost report
for a prior owner of the private 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
private NF. If no Medicaid Direct Care Staff Rate Staffing and Compensation
Report for a prior owner of the private NF is available, the private
NF is not eligible for participation in QIPP.
(3) Data sources for determination of distribution
of QIPP funds across eligible and enrolled NFs are listed in priority
order below. For each program period, the data source must be from
a cost-reporting year and must align with the NF's fiscal year.
(A) The most recently available Medicaid NF cost report
for 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 is available, the data source in subparagraph (B) of this
paragraph must be used.
Cont'd... |
