| (g) QIPP capitation rate components. QIPP funds will
be paid to MCOs through four components of the STAR+PLUS NF managed
care per member per month (PMPM) capitation rates. The MCOs' distribution
of QIPP funds to the enrolled NFs will be based on each NF's performance
related to the quality metrics as described in §353.1304 of this
subchapter. The NF must have had at least one Medicaid client in the
care of that NF for each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 110 percent of the estimated amount of the non-federal share of
the QIPP.
(B) Interim allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) Private NFs are not eligible for payments from
Component One.
(D) The interim allocation of funds across qualifying
non-state government-owned NFs will be reconciled to the actual distribution
of Medicaid NF days of service across these NFs during the program
period as captured by HHSC's Medicaid contractors for fee-for-service
and managed care 120 days after the last day of the program period.
(E) NFs must report quality data as described in §353.1304
of this subchapter as a condition of participation in the program.
(2) Component Two.
(A) The total value of Component Two will be equal
to a percent of remaining QIPP funds after accounting for the funding
of Component One and Component Four.
(i) For the program period September 1, 2019, through
August 31, 2021, the percent will be equal to 30 percent.
(ii) For the program period beginning September 1,
2021, the percent will be equal to 40 percent.
(B) Allocation of funds across qualifying non-state
government-owned and private NFs will be proportional, based upon
historical Medicaid days of NF service.
(C) Monthly payments to NFs will be triggered by achievement
of performance requirements as described in §353.1304 of this
subchapter or a uniform rate increase for which a NF must report quality
data as described in §353.1304 of this subchapter as a condition
of participation in the program.
(3) Component Three.
(A) The total value of Component Three will be equal
to a percent of remaining QIPP funds after accounting for the funding
of Component One and Component Four.
(i) For the program period September 1, 2019, through
August 31, 2021, the percent will be equal to 70 percent.
(ii) For the program period beginning September 1,
2021, the percent will be equal to 60 percent.
(B) Allocation of funds across qualifying non-state
government-owned and private NFs will be proportional, based upon
historical Medicaid days of NF service.
(C) Quarterly payments to NFs will be triggered by
achievement of performance requirements as described in §353.1304
of this subchapter.
(4) Component Four.
(A) The total value of Component Four will be equal
to 16 percent of the funds of the QIPP.
(B) Allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) Quarterly payments to non-state government-owned
NFs will be triggered by achievement of performance requirements as
described in §353.1304 of this subchapter.
(D) Private NFs are not eligible for payments from
Component Four.
(5) Funds that are non-disbursed due to failure of
one or more NFs to meet performance requirements will be distributed
across all QIPP NFs based on each NF's proportion of total earned
QIPP funds from Components One, Two, Three, and Four combined.
(h) Distribution of QIPP payments.
(1) Prior to the beginning of the program period, HHSC
will calculate the portion of each PMPM associated with each QIPP-enrolled
NF broken down by QIPP capitation rate component, quality metric,
and payment period. For example, for a NF, HHSC will calculate the
portion of each PMPM associated with that NF that would be paid from
the MCO to the NF as follows.
(A) Monthly payments from Component One as a uniform
rate increase will be equal to the total value of Component One for
the NF divided by twelve.
(B) Monthly 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 twelve.
(C) Quarterly payments from Component Three associated
with each quality metric will be equal to the total value of Component
Three associated with the quality metric divided by four.
(D) Quarterly payments from Component Four associated
with each quality metric will be equal to the total value of Component
Four associated with the quality metric divided by four.
(E) For purposes of the calculations described in subparagraphs
(B), (C), and (D) of this paragraph, each quality metric will be allocated
an equal portion of the total dollars included in the component.
(F) In situations where a NF does not have enough data
for all quality metrics to be calculated, the funding associated with
that metric will be evenly distributed across all remaining metrics
within the component. If a NF does not have enough data for any quality
metrics to be calculated, no funds will be earned.
(2) MCOs will distribute payments to enrolled NFs as
they meet their reporting and quality metric requirements. Payments
will be equal to the portion of the QIPP PMPM associated with the
achievement for the time period in question multiplied by the number
of member months for which the MCO received the QIPP PMPM. In the
event of a CHOW, the MCO will distribute the payment to the owner
of the NF at the time of the payment.
(i) Changes of ownership.
(1) A NF undergoing a CHOW from privately owned to
non-state government owned or from non-state government owned to privately-owned
will only be eligible to enroll as the new class of facility if HHSC
received a completed CHOW application no later than 30 days prior
to the first day of the enrollment period. All required documents
pertaining to the CHOW (i.e., HHSC must have a complete application
for a change of ownership license as described under 26 TAC §554.201
(relating to Criteria for Licensing) and 26 TAC §554.210 (relating
to Change of Ownership and Notice of Changes) must be submitted in
the timeframe required by HHSC.
(2) If an enrolled NF changes ownership, including
to a new class of facility following the enrollment period or during
the program period, the NF under the new ownership must meet the eligibility
requirements described in this section for the new owner's facility
class in order to continue QIPP participation during the program period.
(3) An enrolled NF must notify the MCOs it has contracts
with of a potential CHOW at least 30 days before the anticipated date
of the CHOW. Notification is considered to have occurred when the
MCO receives the notice.
(j) Changes in operation. If an enrolled NF closes
voluntarily or ceases to provide NF services in its facility, the
NF must notify the HHSC Provider Finance Department by email at qipp@hhsc.state.tx.us.
Notification is considered to have occurred when HHSC receives the
notice.
(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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| Source Note: The provisions of this §353.1302 adopted to be effective December 30, 2018, 43 TexReg 8079; amended to be effective August 19, 2021, 46 TexReg 5015; amended to be effective May 31, 2022, 47 TexReg 3113 |
