| (C) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is less than the
aggregate limit for the pool, each provider is eligible to receive
their maximum uncompensated-care payment for the payment period from
subparagraph (B)(ii) of this paragraph without any reduction to remain
within the pool aggregate limit.
(D) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is more than the
aggregate limit for the pool, HHSC will calculate a revised maximum
uncompensated-care payment for the payment period for each provider
in the pool as follows:
(i) HHSC will calculate a capped payment amount equal
the product of the provider's annual maximum uncompensated-care payment
amount for the demonstration year from paragraph (2) of this subsection
and the pool-wide ratio calculated in subparagraph (B)(v) of this
paragraph.
(ii) If the payment period is not the final payment
period for the demonstration year, the revised maximum uncompensated-care
payment for the payment period equals the lesser of:
(I) the maximum uncompensated-care payment for the
payment period from subparagraph (B)(ii) of this paragraph; or
(II) the difference between the capped payment amount
from clause (i) of this subparagraph and the prior period payments
from subparagraph (B)(i) of this paragraph.
(iii) If the payment period is the final payment period
for the demonstration year:
(I) HHSC will calculate an IGT-supported maximum uncompensated-care
payment for the payment period equal to the amount of the maximum
uncompensated-care payment for the payment period from subparagraph
(B)(ii) of this paragraph that is supported by an IGT commitment.
(-a-) For hospitals and physician group practices,
HHSC will obtain from each RHP anchor a current breakdown of IGT commitments
from all governmental entities, including governmental entities outside
of the RHP that will be providing IGTs for uncompensated-care or transition
payments for each hospital and physician group practice within the
RHP that is eligible for such payments for the payment period.
(-b-) Ambulance and dental providers will be assumed
to have commitments for 100 percent of the non-federal share of their
payments. The non-federal share for ambulance providers is provided
through certified public expenditures (CPEs); for ambulance providers,
references to IGTs in this subsection should be read as references
to CPEs.
(II) HHSC will calculate an IGT-supported maximum uncompensated-care
payment for the demonstration year to equal the IGT-supported maximum
uncompensated-care payment for the payment period from subclause (I)
of this clause plus the provider's prior period payments from subparagraph
(B)(i) of this paragraph.
(III) For providers with an IGT-supported maximum uncompensated-care
payment amount for the demonstration year from subclause (II) of this
clause that is less than or equal to their capped payment amount from
clause (i) of this subparagraph, the provider's revised maximum uncompensated-care
payment for the payment period equals the IGT-supported maximum uncompensated-care
payment amount for the payment period from subclause (I) of this clause.
For these providers, the difference between their capped payment amount
from clause (i) of this subparagraph and their IGT-supported maximum
uncompensated-care payment amount for the demonstration year from
subclause (II) of this clause is their unfunded cap room.
(IV) HHSC will sum all unfunded cap room from subclause
(III) of this clause to determine the total unfunded cap room for
the pool.
(V) For providers with an IGT-supported maximum uncompensated-care
payment amount for the demonstration year from subclause (II) of this
clause that is greater than their capped payment amount from clause
(i) of this subparagraph, the provider's revised maximum uncompensated-care
payment amount for the payment period is calculated as follows:
(-a-) For each provider, HHSC will calculate an overage
amount to equal the difference between the IGT-supported maximum uncompensated-care
payment amount for the demonstration year from subclause (II) of this
clause and their capped payment amount for the demonstration year
from clause (i) of this subparagraph. Unfunded cap room from subclause
(IV) of this clause will be distributed to these providers based on
each provider's overage as a percentage of the pool-wide overage.
(-b-) For each provider, the provider's revised maximum
uncompensated-care payment amount for the payment period is equal
to the sum of its capped payment amount from clause (i) of this subparagraph
and its portion of its pool's unfunded cap room from item (-a-) of
this subclause less its prior period payments from subparagraph (B)(i)
of this paragraph.
(E) Once reductions to ensure that uncompensated-care
expenditures do not exceed the aggregate limit for the demonstration
year for the pool are calculated, HHSC will not re-calculate the resulting
payments for any provider for the demonstration year, including if
the IGT commitments upon which the reduction calculations were based
are different than actual IGT amounts.
(5) Advance payments.
(A) In a demonstration year in which uncompensated-care
payments will be delayed pending data submission or for other reasons,
HHSC may make advance payments to physician group practices that meet
the eligibility requirements described in subsection (c) of this section
and submitted an acceptable uncompensated-care physician application
for the preceding demonstration year from which HHSC calculated an
annual maximum uncompensated-care payment amount for that year.
(B) The amount of the advance payments will be a percentage,
to be determined by HHSC, of the annual maximum uncompensated-care
payment amount calculated by HHSC for the preceding demonstration
year.
(C) Advance payments are considered to be prior period
payments as described in paragraph (4)(B)(i) of this subsection.
(D) A physician group practice that did not submit
an acceptable uncompensated-care physician application for the preceding
demonstration year is not eligible for an advance payment.
(E) If a partial year uncompensated-care physician
application was used to determine the preceding demonstration year's
payments, data from that application may be annualized for use in
computation of an advance payment amount.
(6) Prohibition on duplication of costs. Eligible uncompensated-care
costs cannot be reported on multiple uncompensated-care applications,
including uncompensated-care applications for other programs. Reporting
on multiple uncompensated-care applications is duplication of costs.
(h) Payment methodology.
(1) Prior to making any payment described in subsection
(g) of this section, HHSC will give notice of the following information:
(A) the payment amount for the payment period (based
on whether the payment is made quarterly, semi-annually, or annually);
(B) the maximum IGT amount necessary for a physician
group practice to receive the amount described in subparagraph (A)
of this paragraph; and
(C) the deadline for completing the IGT.
(2) The amount of the payment to the physician group
practice under paragraph (1) of this subsection will be determined
based on the amount of funds transferred by the affiliated governmental
entity or entities as described as follows:
(A) If a governmental entity transfers the maximum
amount of funds described in paragraph (1)(B) of this subsection,
the physician group practice will receive the maximum allowable payment
amount for that period.
(B) If a governmental entity does not transfer the
maximum amount referenced in paragraph (1)(B) of this subsection,
HHSC will determine the payment amount to each physician group practice
owned by or affiliated with that governmental entity as follows:
(i) At the time the transfer is made, the governmental
entity notifies HHSC, on a form prescribed by HHSC, of the share of
the IGT to be allocated to each physician group practice owned by
or affiliated with that entity and provides the non-federal share
of uncompensated-care payments for each entity with which it affiliates
in a separate IGT transaction; or
(ii) In the absence of the notification described in
clause (i) of this subparagraph each physician group practice owned
by or affiliated with the governmental entity will receive a portion
of its payment amount for that period, based on the physician group
practice's percentage of the total payment amounts for all physician
group practices owned by or affiliated with that governmental entity.
Cont'd... |
