| (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.
(C) After the first pass allocation, HHSC will cap
non-state providers at their final remaining UCC. A second pass allocation
will occur in the event non-state providers were paid over their final
remaining UCC after the weight in subsection (k)(2)(A) of this section
was applied. HHSC will calculate the second pass by dividing the final
remaining UCC calculated in the reconciliation described in subsection
(i) of this section by the total remaining UCCs for all non-state
providers after accounting for first pass payments. HHSC will multiply
the quotient by the total amount of funds in excess of total UCCs
for non-state providers capped at their total UCC.
(l) Penalty for failure to complete Category 4 reporting
requirements for Regional Healthcare Partnerships. Hospitals must
comply with all Category 4 reporting requirements set out in Chapter
354 of this title, Subchapter D (relating to Texas Healthcare Transformation
and Quality Improvement Program). If a hospital fails to complete
required Category 4 reporting measures by the last quarter of a demonstration
year:
(1) the hospital will forfeit its uncompensated-care
payments for that quarter; or
(2) the hospital may request from HHSC a six-month
extension from the end of the demonstration year to report any outstanding
Category 4 measures.
(A) The fourth-quarter payment will be made upon completion
of the outstanding required Category 4 measure reports within the
six-month period.
(B) A hospital may receive only one six-month extension
to complete required Category 4 reporting for each demonstration year.
|
| Source Note: The provisions of this §355.8201 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 May 3, 2015, 40 TexReg 2259; amended to be effective November 26, 2018, 43 TexReg 7519; amended to be effective March 17, 2020, 45 TexReg 1849; amended to be effective July 15, 2020, 45 TexReg 4738; amended to be effective December 31, 2020, 45 TexReg 9408 |
