| (iii) that no part of any payment made under the Minimum
Payment Amount program under this section will be used to pay a contingent
fee, consulting fee, or legal fee associated with the nursing facility's
receipt of the Minimum Payment Amount funds.
(G) The Non-state Governmental Entity that owns the
nursing facility must submit to HHSC, upon demand, copies of any contracts
it has with third parties that reference the administration of, or
payments from, the Minimum Payment Amount program.
(5) Eligibility Period Three. A nursing facility is
eligible to receive the Minimum Payment Amounts for Eligibility Period
Three if it has met the following requirements:
(A) The nursing facility was eligible to receive the
Minimum Payment Amounts for Eligibility Period Two or Eligibility
Period Two-A.
(B) The Non-state Governmental Entity that owns the
nursing facility must have submitted its estimated IGT responsibility
for the entire eligibility period no later than a date determined
by HHSC.
(C) The Non-state Governmental Entity that owns the
nursing facility must certify the following facts on a form prescribed
by HHSC and the form must be received by HHSC by a date determined
by HHSC:
(i) that it is a Non-state Government-owned Nursing
Facility where a Non-state Governmental Entity holds the license and
is party to the facility's Medicaid contract;
(ii) that all funds transferred to HHSC via IGT for
use as the state share of payments are Public Funds; and
(iii) that no part of any payment made under the Minimum
Payment Amount program under this section will be used to pay a contingent
fee, consulting fee, or legal fee associated with the nursing facility's
receipt of the Minimum Payment Amount funds.
(D) The Non-state Governmental Entity that owns the
nursing facility must submit to HHSC, upon demand, copies of any contracts
it has with third parties that reference the administration of, or
payments from, the Minimum Payment Amount program.
(6) Geographic Proximity to Nursing Facility.
(A) For eligibility period one, any nursing facility
with a CHOW Application approved by DADS with an effective date on
or after October 1, 2014, must be located in the same Regional Healthcare
Partnership (RHP) as the Non-state Governmental Entity taking ownership
of the nursing facility.
(B) For eligibility periods two, two-A, and three,
any nursing facility with a CHOW Application approved by DADS with
an effective date on or after October 1, 2014, must be located in
the same RHP as, or within 150 miles of, the Non-state Governmental
Entity taking ownership of the nursing facility.
(f) Claims Filing Deadline. A Qualified Nursing Facility
must file a Clean Claim for a Nursing Facility Unit Rate no later
than 60 calendar days after the end of the Calculation Period within
which the service is provided for the claim to qualify for the Minimum
Payment Amount described in this section. The MCO must pay a Clean
Claim that is filed after this deadline but within 365 calendar days
of the date of service, at the standard rate established in the network
provider agreement for Nursing Facility Unit Services; however, claims
filed after the 60 deadline will not be incorporated in the calculation
of the Minimum Payment Amount.
(g) IGT Responsibility.
(1) Timing. HHSC will determine IGT responsibilities
prior to finalizing the managed care capitation rates that include
the increase in payments to the MCOs due to the Minimum Payment Amounts
program for the Eligibility Period.
(2) Aggregate IGT Responsibility. The aggregate IGT
responsibility for all Qualified Nursing Facilities for an Eligibility
Period will be equal to the non-federal share of the increase in the
MCOs' capitation rates due to the Minimum Payment Amount program multiplied
by the estimated number of member months for which the MCOs will receive
the capitation rate during the eligibility period multiplied by 1.1.
(3) Allocation of Aggregate IGT Responsibility to Individual
Nursing Facilities. HHSC will allocate the aggregate IGT responsibility
to each qualified nursing facility based on the percentage of the
total increase in the MCOs' capitation rates due to the Minimum Payment
Amount program associated with the nursing facility in the base period
data used to develop the capitation rates.
(4) Reconciliation. HHSC will complete the reconciliation
in two parts.
(A) The first reconciliation will occur no later than
120 days after the end of the eligibility period.
(i) HHSC will compare the amount transferred by the
Non-state Governmental Entity to HHSC for the eligibility period to
the non-federal amount expended during the eligibility period by HHSC
for all Qualified Nursing Facilities owned by the Non-state Governmental
Entity.
(ii) The calculation of the non-federal amount expended
during the eligibility period by HHSC for all Qualified Nursing Facilities
owned by the Non-state Governmental Entity will be the same as the
calculation of allocated aggregate IGT responsibility to all Qualified
Nursing Facilities owned by the Non-state Governmental Entity as described
in paragraphs (2) and (3) of this subsection with two exceptions:
(I) "Member months" will be revised to reflect actual
known member months for the eligibility period. The revision will
be conducted no sooner than the day after the last day of the eligibility
period and no later than 120 days after the end of the eligibility
period.
(II) The "Aggregate IGT Responsibility" described in
paragraph (2) of this subsection will be equal to the non-federal
share of the increase in the MCO's capitation rates due to the Minimum
Payment Amount program multiplied by the revised member months. The
calculation will not include the additional ten percent included in
the calculation of the original aggregate IGT responsibility.
(III) No other changes will be made to the calculation
of the allocated aggregate IGT responsibility and no other data points
included in the calculation will be updated for purposes of this reconciliation.
(iii) If the amount transferred by the Non-state Governmental
Entity exceeds the non-federal amount expended during the eligibility
period by HHSC for all Qualified Nursing Facilities owned by the Non-state
Governmental Entity, HHSC will refund the excess amount to the Non-state
Governmental Entity, less two percent of the amount expended during
the eligibility period by HHSC for all Qualified Nursing Facilities
owned by the Non-state Governmental Entity.
(iv) If the amount transferred by the Non-state Governmental
Entity is less than the non-federal amount expended during the eligibility
period by HHSC for all Qualified Nursing Facilities owned by the Non-state
Governmental Entity, HHSC will notify the Non-state Governmental Entity
of the amount of the shortfall and of a deadline for the Non-state
Governmental Entity to transfer the shortfall plus two percent of
the amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental Entity.
(B) For Eligibility Period Three only, HHSC may complete
interim reconciliations between August 31, 2017, and August 31, 2019,
as updated enrollment data for the Program Period, as reflected in
adjusted member months, becomes available. HHSC will follow the process
described in subparagraph (A) of this paragraph for such interim reconciliations.
(C) The second reconciliation will occur no later than
25 months after the end of the eligibility period.
(i) HHSC will compare the amount transferred by the
Non-state Governmental Entity to HHSC for the eligibility period to
the non-federal amount expended during the eligibility period by HHSC
for all Qualified Nursing Facilities owned by the Non-state Governmental
Entity.
(ii) The calculation of the non-federal amount expended
during the eligibility period by HHSC for all Qualified Nursing Facilities
owned by the Non-state Governmental Entity will be the same as the
calculation of allocated aggregate IGT responsibility to all Qualified
Nursing Facilities owned by the Non-state Governmental Entity as described
in subparagraph (A) of this paragraph except that member months will
be revised to reflect updated actual known member months for the eligibility
period. The revision will be conducted sometime during the 25th month
after the end of the eligibility period.
(iii) If the amount transferred by the Non-state Governmental
Entity exceeds the non-federal amount expended during the eligibility
period by HHSC for all Qualified Nursing Facilities owned by the Non-state
Governmental Entity, HHSC will refund the excess amount to the Non-state
Governmental Entity.
Cont'd... |
