| (1) Before the beginning of the program period, HHSC
will calculate the portion of each PMPM associated with each TIPPS
enrolled practice group broken down by TIPPS capitation rate component,
quality metric, and payment period. For example, for a physician group,
HHSC will calculate the portion of each PMPM associated with that
group that would be paid from the MCO to the physician group as follows.
(A) Monthly payments from Component One as performance
requirements are met will be equal to the total value of Component
One for the physician group divided by twelve.
(B) Semi-annual payments from Component Two associated
with each quality metric will be equal to the total value of Component
Two associated with the quality metric divided by 2.
(C) Payments from Component Three associated with each
quality metric will be equal to the total value of Component Three
attributed as a uniform rate increase based upon historical utilization.
(D) For purposes of the calculation described in subparagraph
(B) of this paragraph, a physician group must achieve a minimum of
75 percent of benchmark measures for which the provider has a minimum
denominator volume of 30 Medicaid managed care patients to be eligible
for full payment of the benchmark measures. If a physician group achieves
50 percent of benchmark measures for which the provider has a minimum
denominator volume of 30 Medicaid managed care patients, it is eligible
for 75 percent payment. If a physician group achieves 25 percent of
benchmark measures for which the provider has a minimum denominator
volume of 30 Medicaid managed care patients, it is eligible for 50
percent payment.
(E) For purposes of the calculation described in subparagraph
(C) of this paragraph, a physician group must achieve a minimum of
50 percent of benchmark measures for which the provider has a minimum
denominator volume of 30 Medicaid managed care patients to be eligible
for full payment.
(F) For purposes of the calculations described in subparagraph
(C) of this paragraph, in situations where a practice does not have
minimum denominator volume of 30 Medicaid managed care patients for
a quality metric to be calculated, the funding associated with that
metric will be evenly distributed across all remaining metrics within
the component for which the provider has the minimum denominator volume
of 30 Medicaid managed care patients.
(2) MCOs will distribute payments to enrolled physician
groups as they meet their reporting and quality metric requirements.
Payments will be equal to the portion of the TIPPS PMPM associated
with the achievement for the time period in question multiplied by
the number of member months for which the MCO received the TIPPS PMPM.
(i) Changes in operation. If an enrolled physician
group closes voluntarily or ceases to provide Medicaid services, the
physician group must notify the HHSC Provider Finance Department by
hand delivery, United States (U.S.) mail, or special mail delivery
within 10 business days of closing or ceasing to provide Medicaid
services. Notification is considered to have occurred when the HHSC
Provider Finance Department receives the notice.
(j) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
each program period with the amount of funds transferred to HHSC by
the sponsoring governmental entities for that same period using the
methodology described in §353.1301(g) of this subchapter and,
as applicable, subsection (g)(1)(E) of this section.
(k) Recoupment. Payments under this section may be
subject to recoupment as described in §353.1301(j) and §353.1301(k)
of this subchapter.
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