| (ii) the costs associated with an episode of care where
a physician group practice is paid under contract must be reduced
by any revenues associated with that episode of care prior to inclusion
in the uncompensated-care physician application.
(C) If a physician group practice withdraws from participation
in the waiver, the practice must submit an uncompensated-care application
reporting its actual costs and payments for any period during which
the practice received uncompensated-care payments. The uncompensated-care
physician application will be used for the purpose described in subparagraph
(A)(ii) of this paragraph. If a practice fails to submit the application
reporting its actual costs, HHSC will recoup the full amount of uncompensated-care
payments to the practice for the period at issue.
(2) Calculation. A physician group practice's annual
maximum uncompensated-care payment amount is the sum of the following
components:
(A) Its unreimbursed uninsured costs and Medicaid shortfall,
as reported on the uncompensated-care physician application; and
(B) Cost and payment adjustments, if any, as described
in paragraph (3) of this subsection.
(3) Adjustments. When submitting the uncompensated-care
physician application, physician group practices may request that
cost and payment data from the reporting period be adjusted to reflect
increases or decreases in costs resulting from changes in operations
or circumstances.
(A) A physician group practice may request that:
(i) Costs not reflected on the financial documents
supporting the application, but which would be incurred for the demonstration
year, be included when calculating payment amounts; or
(ii) Costs reflected on the financial documents supporting
the application, but which would not be incurred for the demonstration
year, be excluded when calculating payment amounts.
(B) Documentation supporting the request must accompany
the application. HHSC will deny a request if it cannot verify that
costs not reflected on the financial documents supporting the application
will be incurred for the demonstration year.
(4) Reduction to stay within physician group practice
uncompensated-care pool aggregate limits. Prior to processing uncompensated-care
payments for any payment period within a waiver demonstration year
for the physician group practice uncompensated-care pool described
in §355.8201 of this title, HHSC will determine if such a payment
would cause total uncompensated-care payments for the demonstration
year for the pool to exceed the aggregate limit for the pool and will
reduce the maximum uncompensated-care payment amounts providers in
the pool are eligible to receive for that period as required to remain
within the pool aggregate limit.
(A) Calculations in this paragraph are limited to the
physician group practice uncompensated-care pool.
(B) HHSC will calculate the following data points:
(i) For each provider, prior period payments to equal
prior period uncompensated-care for the demonstration year.
(ii) For each provider, a maximum uncompensated-care
payment for the payment period to equal the sum of:
(I) the portion of the annual maximum uncompensated-care
payment amount calculated for that provider (as described in this
section) that is attributable to the payment period; and
(II) the difference, if any, between the portions of
the annual maximum uncompensated-care payment amounts attributable
to prior periods and the prior period payments calculated in clause
(i) of this subparagraph.
(iii) The cumulative maximum payment amount to equal
the sum of prior period payments from clause (i) of this subparagraph
and the maximum uncompensated-care payment for the payment period
from clause (ii) of this subparagraph for all members of the pool
combined.
(iv) A pool-wide total maximum uncompensated-care payment
for the demonstration year to equal the sum of all pool member's annual
maximum uncompensated-care payment amounts for the demonstration year
from paragraph (2) of this subsection.
(v) A pool-wide ratio calculated as the pool aggregate
limit from §355.8201 of this title divided by the pool-wide total
maximum uncompensated-care payment amount for the demonstration year
from clause (iv) of this subparagraph.
(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.
Cont'd... |
