| (-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.
(i) Reconciliation. Beginning in the third year of
the waiver, data on the uncompensated-care physician application will
be used to reconcile actual costs incurred by the physician group
practice for a prior period with uncompensated-care payments, if any,
made to the physician group practice for the same period.
(1) If a physician group practice received payments
in excess of its actual costs, the overpaid amount will be recouped
from the physician group practice, as described in subsection (j)
of this section.
(2) If a physician group practice received payments
less than its actual costs, and if HHSC has available waiver funding
for the period in which the costs were accrued, the physician group
practice may receive reimbursement for some or all of those actual
documented unreimbursed costs.
(3) Transition payments are not subject to reconciliation
under this subsection.
(j) Recoupment.
(1) In the event of a disallowance by CMS of federal
financial participation related to a physician group practice's receipt
or use of payments under this section, HHSC may recoup an amount equivalent
to the amount of the overpayment or disallowance. The non-federal
share of any funds recouped from the physician group practice will
be returned to the entity that owns or is affiliated with the physician
group practice.
(2) Payments under this section may be subject to adjustment
for payments made in error, including, without limitation, adjustments
under §371.1711 of this title (relating to Recoupment of Overpayments
and Debts), 42 CFR Part 455, and Chapter 403, Texas Government Code.
HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid
payments as follows:
(A) HHSC will recoup from the physician group practice
against which any disallowance was directed or to which an overpayment
was made.
(B) If, within 30 days of the physician group practice's
receipt of HHSC's written notice of recoupment, the physician group
practice has not paid the full amount of the recoupment or entered
into a written agreement with HHSC to do so, HHSC may withhold any
or all future Medicaid payments from the physician group practice
until HHSC has recovered an amount equal to the amount overpaid or
disallowed.
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| Source Note: The provisions of this §355.8202 adopted to be effective July 1, 2012, 37 TexReg 4581; amended to be effective June 13, 2013, 38 TexReg 3526; amended to be effective June 12, 2014, 39 TexReg 4419; amended to be effective September 1, 2014, 39 TexReg 6407; amended to be effective January 10, 2019, 44 TexReg 230 |
