| (B) cost and payment adjustments, if any, as described
in paragraph (3) of this subsection.
(3) Adjustments. When submitting the uncompensated-care
physician application, physician group practices may request that
cost and payment data from the reporting period be adjusted to reflect
increases or decreases in costs resulting from changes in operations
or circumstances.
(A) A physician group practice may request that:
(i) costs not reflected on the financial documents
supporting the application, but which would be incurred for the demonstration
year, be included when calculating payment amounts; or
(ii) costs reflected on the financial documents supporting
the application, but which would not be incurred for the demonstration
year, be excluded when calculating payment amounts.
(B) Documentation supporting the request must accompany
the application and provide sufficient information for HHSC to verify
the link between the changes to the provider's operations or circumstances
and the specified numbers used to calculate the amount of the adjustment.
(i) Such supporting documentation must include:
(I) a detailed description of the specific changes
to the provider's operations or circumstances;
(II) verifiable information from the provider's general
ledger, financial statements, patient accounting records or other
relevant sources that support the numbers used to calculate the adjustment;
and
(III) if applicable, a copy of any relevant contracts,
financial assistance policies, or other policies or procedures that
verify the change to the provider's operations or circumstances.
(ii) HHSC will deny a request if it cannot verify that
costs not reflected on the financial documents supporting the application
will be incurred for the demonstration year.
(4) Reduction to stay within physician group practice
uncompensated-care pool allocation amount. Prior to processing uncompensated-care
payments for any payment period within a waiver demonstration year
for the physician group practice uncompensated-care pool described
in §355.8212 of this division, HHSC will determine if such a
payment would cause total uncompensated-care payments for the demonstration
year for the pool to exceed the allocation amount for the pool and
will reduce the maximum uncompensated-care payment amounts providers
in the pool are eligible to receive for that period as required to
remain within the pool allocation amount.
(A) Calculations in this paragraph are limited to the
physician group practice uncompensated-care pool.
(B) HHSC will calculate the following data points:
(i) for each provider, prior period payments to equal
prior period uncompensated-care for the demonstration year;
(ii) for each provider, a maximum uncompensated-care
payment for the payment period to equal the sum of:
(I) the portion of the annual maximum uncompensated-care
payment amount calculated for that provider (as described in this
section) that is attributable to the payment period; and
(II) the difference, if any, between the portions of
the annual maximum uncompensated-care payment amounts attributable
to prior periods and the prior period payments calculated in clause
(i) of this subparagraph;
(iii) the cumulative maximum payment amount to equal
the sum of prior period payments from clause (i) of this subparagraph
and the maximum uncompensated-care payment for the payment period
from clause (ii) of this subparagraph for all members of the pool
combined;
(iv) a pool-wide total maximum uncompensated-care payment
for the demonstration year to equal the sum of all pool member's annual
maximum uncompensated-care payment amounts for the demonstration year
from paragraph (2) of this subsection; and
(v) a pool-wide ratio calculated as the pool allocation
amount from §355.8212 of this division divided by the pool-wide
total maximum uncompensated-care payment amount for the demonstration
year from clause (iv) of this subparagraph.
(C) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is less than the
allocation amount for the pool, each provider is eligible to receive
its maximum uncompensated-care payment for the payment period from
subparagraph (B)(ii) of this paragraph without any reduction to remain
within the pool allocation amount.
(D) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is more than the
allocation amount for the pool, HHSC will calculate a revised maximum
uncompensated-care payment for the payment period for each provider
in the pool. HHSC will calculate a capped payment amount equal to
the product of the provider's annual maximum uncompensated-care payment
amount for the demonstration year from paragraph (2) of this subsection
and the pool-wide ratio calculated in subparagraph (B)(v) of this
paragraph. The revised maximum uncompensated-care payment for the
payment period equals the lesser of:
(i) the maximum uncompensated-care payment for the
payment period from subparagraph (B)(ii) of this paragraph; or
(ii) the difference between the capped payment amount
from this subparagraph and the prior period payments from subparagraph
(B)(i) of this paragraph.
(E) Once reductions to ensure that uncompensated-care
expenditures do not exceed the allocation amount for the demonstration
year for the pool are calculated, HHSC will not re-calculate the resulting
payments for any provider for the demonstration year, including if
the estimates of available non-federal-share funding upon which the
reduction calculations were based are different than actual IGT amounts.
(5) Physician group or non-state-owned physician group
SDA sub-pools. This section pertains to all physician groups prior
to demonstration year eleven and non-state-owned physician groups
beginning in demonstration year twelve. After HHSC completes the calculations
described in paragraph (4) of this subsection, HHSC will add each
physician group or non-state-owned physician group to a sub-pool with
the non-state-owned hospitals described in §355.8212 of this
division based on the physician group’s geographic location
in a designated Medicaid SDA for purposes of the calculations described
in subsection (h) of this section.
(6) Prohibition on duplication of costs. Eligible uncompensated-care
costs cannot be reported on multiple uncompensated-care applications,
including uncompensated-care applications for other programs. Reporting
on multiple uncompensated-care applications is a duplication of costs.
(7) Advance payments.
(A) In a demonstration year in which uncompensated-care
payments will be delayed pending data submission or for other reasons,
HHSC may make advance payments to physician group practices that meet
the eligibility requirements described in subsection (c) of this section
and submitted an acceptable uncompensated-care physician application
for the preceding demonstration year from which HHSC calculated an
annual maximum uncompensated-care payment amount for that year.
(B) The amount of the advance payments will:
(i) in demonstration year nine, be based on documentation
submitted by the physician group practice on a form designated by
HHSC for that purpose; and
(ii) in demonstration years ten and after, be a percentage,
to be determined by HHSC, of the annual maximum uncompensated-care
payment amount calculated by HHSC for the preceding demonstration
year.
(C) Advance payments are considered to be prior period
payments as described in paragraph (4)(B)(i) of this subsection.
(D) A physician group practice that did not submit
an acceptable uncompensated-care physician application for the preceding
demonstration year is not eligible for an advance payment.
(E) If a partial year uncompensated-care physician
application was used to determine the preceding demonstration year's
payments, data from that application may be annualized for use in
computation of an advance payment amount.
(h) Payment methodology.
(1) Prior to making any payment described in subsection
(g) of this section, HHSC will give notice of the following information:
(A) the payment amount for each physician group practice
in the pool for the payment period (based on whether the payment is
made quarterly, semi-annually, or annually);
(B) the maximum IGT amount necessary for the physician
group practices to receive the amount described in subparagraph (A)
of this paragraph; and
(C) the deadline for completing the IGT.
(2) The amount of the payment to the physician group
practices under paragraph (1) of this subsection will be determined
based on the amount of funds transferred by the affiliated governmental
entities as described as follows.
Cont'd... |
