| (II) that the governmental entity has not entered into
a contingent fee arrangement related to the governmental entity's
participation in the waiver program;
(III) that the governmental entity adopted the conditions
described in the certification form prescribed by or otherwise approved
by HHSC pursuant to a vote of the governmental entity's governing
body in a public meeting preceded by public notice published in accordance
with the governmental entity's usual and customary practices or the
Texas Open Meetings Act, as applicable; and
(IV) that all affiliation agreements, consulting agreements,
or legal services agreements executed by the governmental entity related
to its participation in this waiver payment program are available
for public inspection upon request.
(iii) Submission requirements.
(I) Initial submissions. The parties must initially
submit the affiliation agreements and certifications described in
this subsection to the HHSC Rate Analysis Department on the earlier
of the following occurrences after the documents are executed:
(-a-) The date the hospital submits the uncompensated-care
application that is further described in paragraph (2) of this subsection;
or
(-b-) Thirty days before the projected deadline for
completing the IGT for the first payment under the affiliation agreement.
The projected deadline for completing the IGT is posted on HHSC Rate
Analysis' website for each payment under this section.
(II) Subsequent submissions. The parties must submit
revised documentation as follows:
(-a-) When the nature of the affiliation changes or
parties to the agreement are added or removed, the parties must submit
the revised affiliation agreement and related hospital and governmental
entity certifications.
(-b-) When there are changes in ownership, operation,
or provider identifiers, the hospital must submit a revised hospital
certification.
(-c-) The parties must submit the revised documentation
thirty days before the projected deadline for completing the IGT for
the first payment under the revised affiliation agreement. The projected
deadline for completing the IGT is posted on HHSC Rate Analysis' website
for each payment under this section.
(III) A hospital that submits new or revised documentation
under subclause (I) or (II) of this clause must notify the Anchor
of the RHP in which the hospital participates.
(IV) The certification forms must not be modified except
for those changes approved by HHSC prior to submission.
(-a-) Within 10 business days of HHSC Rate Analysis
receiving a request for approval of proposed modifications, HHSC will
approve, reject, or suggest changes to the proposed certification
forms.
(-b-) A request for HHSC approval of proposed modifications
to the certification forms will not delay the submission deadlines
established in this clause.
(V) A hospital that fails to submit the required documentation
in compliance with this subparagraph will not receive a payment under
this section.
(2) Uncompensated-care payments. For a hospital to
be eligible to receive uncompensated-care payments, in addition to
the requirements in paragraph (1) of this subsection, the hospital
must:
(A) submit to HHSC an uncompensated-care application
for the demonstration year, as is more fully described in subsection
(g)(1) of this section, by the deadline specified by HHSC;
(B) submit to HHSC documentation of:
(i) its participation in an RHP; or
(ii) approval from CMS of its eligibility for uncompensated-care
payments without participation in an RHP;
(C) be actively enrolled as a Medicaid provider in
the State of Texas at the beginning of the demonstration year; and
(D) have submitted, and be eligible to receive payment
for, a Medicaid fee-for-service or managed-care inpatient or outpatient
claim for payment during the demonstration year.
(3) Changes that may affect eligibility for uncompensated-care
payments.
(A) If a hospital closes, loses its license, loses
its Medicare or Medicaid eligibility, withdraws from participation
in an RHP, or files bankruptcy before receiving all or a portion of
the uncompensated-care payments for a demonstration year, HHSC will
determine the hospital's eligibility to receive payments going forward
on a case-by-case basis. In making the determination, HHSC will consider
multiple factors including whether the hospital was in compliance
with all requirements during the demonstration year and whether it
can satisfy the requirement to cooperate in the reconciliation process
as described in subsection (i) of this section.
(B) A hospital must notify HHSC Rate Analysis Department
in writing within 30 days of the filing of bankruptcy or of changes
in ownership, operation, licensure, Medicare or Medicaid enrollment,
or affiliation that may affect the hospital's continued eligibility
for payments under this section.
(d) Source of funding. The non-federal share of funding
for payments under this section is limited to timely receipt by HHSC
of public funds from a governmental entity.
(e) Payment frequency. HHSC will distribute waiver
payments on a schedule to be determined by HHSC and posted on HHSC's
website.
(f) Funding limitations.
(1) Payments made under this section are limited by
the maximum aggregate amount of funds allocated to the provider's
uncompensated-care pool for the demonstration year. If payments for
uncompensated care for an uncompensated-care pool attributable to
a demonstration year are expected to exceed the aggregate amount of
funds allocated to that pool by HHSC for that demonstration year,
HHSC will reduce payments to providers in the pool as described in
subsection (g)(5) of this section.
(2) HHSC will establish the following seven uncompensated-care
pools: a state-owned hospital pool; a large public hospital pool;
a small public hospital pool; a private hospital pool; a physician
group practice pool; a governmental ambulance provider pool; and a
publicly owned dental provider pool as follows:
(A) The state-owned hospital pool.
(i) The state-owned hospital pool funds uncompensated-care
payments to state-owned teaching hospitals, state-owned IMDs and state
chest hospitals.
(ii) HHSC will determine the allocation for this pool
at an amount less than or equal to the total annual maximum uncompensated-care
payment amount for these hospitals as calculated in subsection (g)(2)
of this section.
(B) Set-aside amounts. HHSC will determine set-aside
amounts as follows:
(i) For small public hospitals:
(I) that are also rural hospitals:
(-a-) Divide the amount of funds approved by CMS for
uncompensated-care payments for the demonstration year by the amount
of funds approved by CMS for uncompensated-care payments for the 2013
demonstration year and round the result to four decimal places.
(-b-) Determine the small rural public hospital set-aside
amount by multiplying the value from item (-a-) of this subclause
by the sum of the interim hospital specific limits from subsection
(g)(2)(A) of this section for all small rural public hospitals that
are eligible to receive uncompensated-care payments under this section
and that meet the definition of a small public hospital from subsection
(b)(21) of this section. Truncate the resulting value to zero decimal
places.
(II) that are also urban RRCs, for DY 7 only, determine
the small public urban RRC set-aside amount by multiplying by 54%
the sum of the interim hospital specific limits from subsection (g)(2)(A)
of this section for all small public urban RRCs that are eligible
to receive uncompensated-care payments under this section and that
meet the definition of an urban RRC from subsection (b)(26) of this
section. Truncate the resulting value to zero decimal places.
(ii) For private hospitals:
(I) that are also rural hospitals:
(-a-) Divide the amount of funds approved by CMS for
uncompensated-care payments for the demonstration year by the amount
of funds approved by CMS for uncompensated-care payments for the 2013
demonstration year and round the result to four decimal places.
(-b-) Determine the private rural hospital set-aside
amount by multiplying the value from item (-a-) of this subclause
by the sum of the interim hospital specific limits from subsection
(g)(2)(A) of this section for all private rural hospitals that are
eligible to receive uncompensated-care payments under this section
and that meet the definition of a small public hospital from subsection
(b)(21) of this section. Truncate the resulting value to zero decimal
places.
Cont'd... |
