| (B) If a governmental entity does not transfer the
maximum amount referenced in paragraph (1) of this subsection, HHSC
will determine the payment amount to each hospital 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 hospital 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 hospital owned by or affiliated
with the governmental entity will receive a portion of its payment
amount for that period, based on the hospital's percentage of the
total payment amounts for all hospitals owned by or affiliated with
that governmental entity.
(C) For a hospital that is affiliated with multiple
governmental entities, in the event those governmental entities transfer
more than the maximum IGT amount that can be provided for that hospital,
HHSC will calculate the amount of IGT funds necessary to fund the
hospital to its payment limit and refund the remaining amount to the
governmental entities identified by HHSC.
(3) Final payment opportunity. Within payments described
in this section, a governmental entity that does not transfer the
maximum IGT amount described in paragraph (1) of this subsection during
a demonstration year will be allowed to fund the remaining payments
at the time of the final payment for that demonstration year. The
IGT will be applied in the following order:
(A) To the final payment up to the maximum amount;
(B) To remaining balances for prior payment periods
in the demonstration year.
(i) Reconciliation. HHSC will reconcile actual costs
incurred by the hospital for the demonstration year with uncompensated-care
payments, if any, made to the hospital for the same period:
(1) If a hospital received payments in excess of its
actual costs, the overpaid amount will be recouped from the hospital,
as described in subsection (j) of this section.
(2) If a hospital received payments less than its actual
costs, and if HHSC has available waiver funding for the demonstration
year in which the costs were accrued, the hospital may receive reimbursement
for some or all of those actual documented unreimbursed costs.
(3) If a hospital submitted a request as described
in subsection (g)(4)(A)(i) of this section that impacted its interim
hospital-specific limit, HHSC will conduct an additional reconciliation
for certain demonstration years as follows:
(A) For demonstration years 3-5 (October 1, 2013 -
September 30, 2016), HHSC will compare the hospital's adjusted interim
hospital-specific limit from subsection (g)(4)(A)(i) of this section
for the demonstration year to its final hospital-specific limit as
described in §355.8066(c)(2) of this title for the demonstration
year.
(B) For demonstration years 6-8 (October 1, 2016 -
September 30, 2019), HHSC will compare the hospital's adjusted interim
hospital-specific limit from subsection (g)(4)(A)(i) of this section
for the demonstration year to a proxy-final hospital-specific limit
that is described in §355.8066(c)(2) of this title for the demonstration
year, except this proxy-final hospital-specific limit will not offset
third-party and Medicare payments for claims and encounters where
Medicaid was a secondary payer.
(C) If the final hospital-specific limit for demonstration
years 3-5 or proxy-final hospital-specific limit for demonstration
years 6-8 limit is less than the adjusted interim hospital-specific
limit, HHSC will recalculate the hospital's uncompensated-care payment
for the demonstration year substituting the final hospital-specific
limit for demonstration years 3-5 or proxy-final hospital-specific
limit for demonstration years 6-8 for the adjusted interim hospital-specific
limit with no other changes to the data used in the original calculation
of the hospital's uncompensated-care payment other than any necessary
reductions to the original IGT amount and will recoup any payment
received by the hospital that is greater than the recalculated uncompensated-care
payment. Recouped funds may be redistributed to other hospitals that
received payments less than their actual costs using the methodology
described in subsection (k) of this section.
(4) Each hospital that received an uncompensated-care
payment during a demonstration year must cooperate in the reconciliation
process by reporting its actual costs and payments for that period
on the form provided by HHSC for that purpose, even if the hospital
closed or withdrew from participation in the uncompensated-care program.
If a hospital fails to cooperate in the reconciliation process, HHSC
may recoup the full amount of uncompensated-care payments to the hospital
for the period at issue.
(j) Recoupment.
(1) In the event of an overpayment identified by HHSC
or a disallowance by CMS of federal financial participation related
to a hospital'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
hospital will be returned to the entity that owns or is affiliated
with the hospital.
(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 hospital against which
any overpayment was made or disallowance was directed.
(B) If, within 30 days of the hospital's receipt of
HHSC's written notice of recoupment, the hospital 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 hospital until HHSC has recovered an amount equal to the
amount overpaid or disallowed.
(k) Redistribution of Recouped Funds. Following the
recoupments described in subsection (j) of this section, HHSC will
redistribute the recouped funds to eligible providers. For purposes
of this subsection, an eligible provider is a provider who has room
remaining in their final remaining uncompensated cost of care (UCC)
calculated in the reconciliation described in subsection (i) of this
section after considering all uncompensated-care payments made for
that program year. Recouped funds from state providers will be redistributed
proportionately to eligible state providers based on the percentage
that each eligible state provider's remaining final UCC calculated
in the reconciliation described in subsection (i) of this section
is of the total remaining final UCC calculated in the reconciliation
described in subsection (i) of this section of all eligible state
providers. Recouped funds from non-state providers will be redistributed
proportionately to eligible non-state providers as follows:
(1) For demonstration years 1-6 (October 1, 2011 -
September 30, 2017), HHSC will use the following methodology to redistribute
recouped funds:
(A) the non-federal share will be returned to the governmental
entity that provided it during the program year;
(B) the federal share will be distributed proportionately
among all non-state providers eligible for additional payments that
have a source of the non-federal share of the payments; and
(C) the federal share that does not have a source of
non-federal share will be returned to CMS.
(2) For demonstration years 7-8 (October 1, 2017 -
September 30, 2019), HHSC will use the following methodology to redistribute
recouped funds:
(A) To calculate a weight that will be applied to all
non-state providers, HHSC will divide the final hospital-specific
limit described in §355.8066(c)(2) of this title by the final
hospital-specific limit described in §355.8066(c)(2) of this
title that has not offset payments for third-party and Medicare claims
and encounters where Medicaid was a secondary payer. HHSC will add
1 to the quotient. Any non-state provider who has a resulting weight
of less than 1 will receive a weight of 1.
(B) HHSC will make a first pass allocation by multiplying
the weight described in subsection (k)(2)(A) of this section by the
final remaining UCC calculated in the reconciliation described in
subsection (i) of this section. HHSC will divide the product by the
total remaining UCCs for all non-state providers. HHSC will multiply
the quotient by the total amount of recouped dollars available for
redistribution described in subsection (j)(1) of this section.
Cont'd... |
