| (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; and
(v) a pool-wide ratio calculated as the pool allocation
amount from §355.8212 of this division 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
allocation amount 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 allocation amount.
(D) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is more than the
allocation amount for the pool, HHSC will calculate a revised maximum
uncompensated-care payment for the payment period for each provider
in the pool. 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. 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 this subparagraph and the prior period payments from subparagraph
(B)(i) of this paragraph.
(E) Once reductions to ensure that uncompensated-care
expenditures do not exceed the allocation amount 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 estimates of available non-federal-share funding 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:
(i) in demonstration year nine, be based on documentation
submitted by the physician group practice on a form designated by
HHSC for that purpose ; and
(ii) in demonstration years ten and after, 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 each physician group practice
in the pool for the payment period (based on whether the payment is
made quarterly, semi-annually, or annually);
(B) the maximum IGT amount necessary for the physician
group practices 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
practices under paragraph (1) of this subsection will be determined
based on the amount of funds transferred by the affiliated governmental
entities as described as follows:
(A) If the governmental entities transfer the maximum
amount of funds described in paragraph (1)(B) of this subsection,
the physician group practices will receive the maximum allowable payment
amounts for that period.
(B) If the governmental entities do not transfer the
maximum amount referenced in paragraph (1)(B) of this subsection,
each physician group practice in the pool 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
in the pool.
(i) Reconciliation. 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.
(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 of the 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.
|
