| (1) For demonstration years nine and ten, payments
made under this section are limited by the maximum amount of funds
allocated to the physician group practice uncompensated-care pool
for the demonstration year as described in §355.8212 of this
division. If payments for uncompensated care for the physician group
practice uncompensated-care pool attributable to a demonstration year
are expected to exceed the 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)(4) of this section.
Payments made under this section are limited by the availability of
funds identified in subsection (d) of this section. If sufficient
funds are not available for all payments for which all physician group
practices are eligible, HHSC will reduce payments as described in
subsection (h)(2) of this section.
(2) Beginning in demonstration year eleven, payments
made under this section are limited by the maximum amount of funds
allocated to the non-state-owned physician group practice uncompensated-care
pool for the demonstration year as described in §355.8212 of
this division. Non-state-owned physicians as defined in subsection
(b) of this section, are reimbursed through the non-state-owned physician
group practice uncompensated-care pool. If payments for uncompensated
care for the non-state-owned physician group practice uncompensated-care
pool attributable to a demonstration year are expected to exceed the
amount of funds allocated to that pool by HHSC for that demonstration
year, HHSC will reduce payments to providers in the non-state-owned
pool as described in subsection (g)(4) of this section. Payments made
under this section are limited by the availability of funds identified
in subsection (d) of this section. If sufficient funds are not available
for all payments for which all physician group practices are eligible,
HHSC will reduce payments as described in subsection (h)(2) of this
section.
(g) Uncompensated-care payment amount.
(1) Uncompensated-care physician application. Payments
to eligible physician group practices are based on cost and payment
data reported by the physician group practice on an application form
prescribed by HHSC.
(A) Cost and payment data reported by the physician
group practice in the uncompensated-care physician application is
used to:
(i) calculate the annual maximum uncompensated-care
payment amount for the applicable demonstration year, as described
in paragraph (2) of this subsection; and
(ii) reconcile the actual uncompensated-care costs
reported by the physician group practice for a prior period with uncompensated-care
waiver payments, if any, made to the practice for the same period.
The reconciliation process is more fully described in subsection (j)
of this section.
(B) Unless otherwise instructed in the uncompensated-care
physician application:
(i) the cost and payment data reported in the uncompensated-care
physician application must be consistent with Medicare cost-reporting
principles and must comply with the application instructions or other
guidance issued by HHSC, and the physician group practice must maintain
sufficient documentation to support the reported data or information;
and
(ii) the costs associated with an episode of care where
a physician group practice is paid under contract must be reduced
by any revenues associated with that episode of care prior to inclusion
in the uncompensated-care physician application.
(C) If a physician group practice withdraws from participation
in the waiver, the practice must submit an uncompensated-care application
reporting its actual costs and payments for any period during which
the practice received uncompensated-care payments. The uncompensated-care
physician application will be used for the purpose described in subparagraph
(A)(ii) of this paragraph. If a practice fails to submit the application
reporting its actual costs, HHSC will recoup the full amount of uncompensated-care
payments to the practice for the period at issue.
(2) Calculation. A physician group practice's annual
maximum uncompensated-care payment amount is the sum of the following
components:
(A) its unreimbursed charity-care costs, as reported
on the uncompensated-care physician application; and
(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.
Cont'd... |
