| (1) HHSC determines annually whether a safety-net hospital
may receive an incentive payment for performance on PPR incidence.
(2) The appropriated funds for the targeted incentive
payments are split in half, 50 percent for PPRs and 50 percent for
potentially preventable complications. HHSC may change the allocated
percentages based on review of data and the changing needs of the
program.
(3) The dataset used in the incentive analysis is the
same as the dataset used in the PPR reimbursement adjustments.
(4) Hospitals that are eligible for a targeted incentive
payment must meet the following requirements:
(A) be a safety-net hospital;
(B) have an actual-to-expected ratio of at least 10
percent lower than the statewide average (actual-to-expected ratio
is less than or equal to 0.90);
(C) have not received a penalty for either PPRs or
potentially preventable complications; and
(D) are not low-volume, as defined by HHSC.
(5) Calculation of targeted incentive payments.
(A) Calculate base allocation. Each eligible hospital
is awarded a base allocation not to exceed $100,000.
(B) Calculate variable allocation. Each eligible hospital
is awarded a variable allocation, which is calculated from remaining
funds after distribution of base allocations to all eligible hospitals.
The variable allocation has the following components:
(i) Hospital size score. Each eligible hospital's size
divided by the average size of the whole group of hospitals within
each incentive pool. Size is calculated based on total inpatient facility
claims paid to each eligible hospital. Each eligible hospital's size
calculation is capped at 2.00.
(ii) Hospital Performance score. Each eligible hospital's
performance divided by the average performance of the whole group
of hospitals within each incentive pool. Performance is calculated
by actual to expected ratio.
(iii) Composite score. Each eligible hospital receives
a composite score, which is the hospital's size score multiplied by
the hospital's performance score.
(iv) Each hospital's composite score divided by the
sum of all eligible hospitals' composite scores is multiplied by the
remaining incentive funds, after distribution of base allocations.
(C) Calculate final allocation: The final allocation
to each eligible hospital is equal to the eligible hospital's base
allocation plus the eligible hospital's variable allocation.
(6) Each eligible hospital's PPR incentive payment
will be divided between FFS and MCO reimbursements based on the percentage
of its total paid FFS and MCO Medicaid inpatient hospital reimbursements
for the reporting time period accruing from FFS.
(7) PPR incentive payments may be made as lump sum
payments or tied to particular claims or recipients, at HHSC's discretion.
(8) HHSC will post the methodology for calculating
and distributing incentives on its public website.
(9) Targeted incentive payments for safety-net hospitals
are not included in the calculation of a hospital's hospital-specific
limit or low income utilization rate.
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| Source Note: The provisions of this §354.1445 adopted to be effective April 21, 2013, 38 TexReg 2315; amended to be effective September 1, 2014, 39 TexReg 6403; amended to be effective May 15, 2016, 41 TexReg 3291 |
