| (iii) the distribution of historical Medicaid utilization
across RHCs, plus the estimated utilization for enrolled RHCs within
the same SDA, for the program period; and
(B) the estimated maximum revenues each enrolled RHC
could earn under RAPPS for the program period will be based on HHSC's
suggested IGT responsibilities and the assumption that all enrolled
RHCs will meet 100 percent of their quality metrics.
(2) The estimated maximum revenues each enrolled RHC
could earn under RAPPS for the program period, which will be based
on HHSC's suggested IGT responsibilities and the assumption that all
enrolled RHCs will meet 100 percent of their quality metrics.
(3) HHSC will issue an IGT notification to specify
the date that IGT is requested to be transferred, no fewer than 14
business days before IGT transfers are due. The IGT notification will
instruct sponsoring governmental entities as to the required IGT amounts.
Required IGT amounts will include all costs associated with RHC payments
and rate increases, including costs associated with MCO premium taxes,
risk margin, and administration, plus ten percent.
(4) Sponsoring governmental entities will transfer
the first half of the IGT amount by a date determined by HHSC, but
no later than June 1. Sponsoring governmental entities will transfer
the second half of the IGT amount by a date determined by HHSC, but
no later than December 1. HHSC will publish the IGT deadlines and
all associated dates on the HHSC website by March 15 of each year.
(h) RAPPS capitation rate components. RAPPS funds will
be paid to MCOs through the managed care per member per month (PMPM)
capitation rates. The MCOs' distribution of RAPPS funds to the enrolled
RHCs will be based on each RHC's performance related to the quality
metrics as described in §353.1317 of this subchapter. The RHC
must have provided at least one Medicaid service to a Medicaid client
for each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 75 percent of total program value for program periods beginning
on or before September 1, 2023. For program periods beginning on or
after September 1, 2024, Component One will be 100 percent of the
total program value.
(B) Allocation of funds across qualifying RHCs will
be based on historical Medicaid utilization and RHC class.
(C) Monthly payments to RHCs will be paid prospectively.
(D) HHSC will reconcile the interim allocation of funds
across RAPPS-enrolled RHCs to the actual Medicaid utilization across
these RHCs during the program period as captured by Medicaid MCOs
contracted with HHSC for managed care 120 days after the last day
of the program period.
(i) Redistribution resulting from the reconciliation
will be based on actual utilization of enrolled NPIs.
(ii) If a provider eligible for RAPPS payments was
not included in the monthly scorecards, the provider may be included
in the reconciliation by HHSC.
(E) Providers must report quality data as described
in §353.1317 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 25 percent of the total program value for program periods beginning
on or before September 1, 2023. For program periods beginning on or
after September 1, 2024, the total value of Component Two will be
equal to zero percent of the total program value.
(B) Allocation of funds across qualifying RHCs will
be based upon actual Medicaid utilization of specific procedure codes
as identified in the final quality metrics and performance requirements
described in §353.1317 of this subchapter.
(C) A percent increase on all applicable services will
begin when an RHC demonstrates achievement of performance requirements
as described in §353.1317 of this subchapter during the reporting
period.
(D) Providers must report quality data as described
in §353.1317 of this subchapter as a condition of participation
in the program.
(i) Distribution of RAPPS payments.
(1) Prior to the beginning of the program period, HHSC
will calculate the portion of each monthly prospective payment associated
with each RAPPS-enrolled RHC broken down by RAPPS capitation rate
component and payment period. The model for scorecard payments and
the reconciliation calculations will be based on the enrolled NPIs
at the time of the application under subsection (f)(1) of this section.
For example, for an RHC, HHSC will calculate the portion of each monthly
prospective payment associated with that RHC that would be paid from
the MCO to the RHC as follows.
(A) Monthly payments from Component One will be equal
to the total value of Component One for the RHC divided by twelve.
(B) For program periods beginning on or before September
1, 2023, payments from Component Two will be equal to the total value
of Component Two attributed as a rate increase for specific services
based upon historical utilization.
(C) For purposes of the calculation described in subparagraph
(B) of this paragraph, an RHC must achieve quality metrics to be eligible
for full payment as determined by performance requirements described
in §353.1317(d) of this subchapter.
(2) An MCO will distribute payments to an enrolled
RHC based on criteria established under this subsection.
(j) Changes in operation. If a RAPPS-enrolled RHC closes
voluntarily or ceases to provide Medicaid services, the RHC must notify
the HHSC Provider Finance Department by electronic mail to an address
designated by HHSC, by hand delivery, United States (U.S.) mail, or
by 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.
(k) 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.
(l) 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 §353.1315 adopted to be effective April 25, 2021, 46 TexReg 2717; amended to be effective May 31, 2022, 47 TexReg 3113; amended to be effective January 25, 2024, 49 TexReg 243 |
