| (C) If a hospital passes POA screening criteria during
a reporting time period, any future violations of the POA screening
criteria will be considered a first violation.
(6) The reimbursement adjustments based on POA screening
criteria will cease when the hospital passes HHSC-approved POA screening
criteria for an entire reporting time period, at which the hospital
will be subject to reimbursement adjustments, if applicable, based
on criteria outlined in subsection (f) of this section.
(7) Hospitals that receive a reimbursement adjustment
based on POA screening criteria outlined in paragraph (5) of this
subsection will not concurrently receive reductions outlined in subsection
(f) of this section.
(h) Targeted incentive payments for safety-net hospitals.
(1) HHSC determines annually whether a safety-net hospital
may receive an incentive payment for performance on PPC incidence.
(2) The appropriated funds for the targeted incentive
payments are split in half, 50 percent for PPCs and 50 percent for
potentially preventable readmissions. 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 PPC 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 PPCs or
potentially preventable readmissions; 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 PPC 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) PPC 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 §354.1446 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 |
