| (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 at least 15 days prior to the IGT declaration
of intent deadline. 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 eight 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 provide a declaration of intent to HHSC 15 business days
before the first half of the IGT amount is transferred to HHSC.
(A) The declaration of intent is a form prescribed
by HHSC that includes the total amount of IGT the sponsoring governmental
entity wishes to transfer to HHSC and whether the sponsoring governmental
entity intends to accept Component One payments.
(B) The declaration of intent is certified to the best
knowledge and belief of a person legally authorized to sign for the
sponsoring governmental entity but does not bind the sponsoring governmental
entity to transfer IGT.
(3) Sponsoring governmental entities will transfer
the first half of the IGT amount by a date determined by HHSC. The
second half of the IGT amount will be transferred by a date determined
by HHSC. The IGT deadlines and all associated dates will be published
on the HHSC QIPP webpage by January 15 of each year.
(4) 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 four components of the STAR+PLUS NF managed
care 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
related to the quality metrics as described in §353.1304 of this
subchapter. The NF must have had at least one Medicaid client in the
care of that NF for each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 110 percent of the non-federal share of the QIPP.
(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 achievement of performance requirements as
described in §353.1304 of this subchapter.
(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 18 percent.
(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.
Cont'd... |
