| (D) the percentage of Medicaid costs incurred by providers
in providing care to Medicaid managed care clients that are reimbursed
by Medicaid MCOs prior to any rate increase administered under this
section; and
(E) the actuarial soundness of the capitation payment
needed to support the rate increase.
(g) Services subject to rate and dollar increase. HHSC
may direct the MCOs to increase rates or dollar amounts for all or
a subset of provider services.
(h) Program capitation rate components. Program funds
will be paid to MCOs through the managed care per member per month
(PMPM) capitation rates. The MCOs' distribution of program funds to
the enrolled providers will be based on each provider's performance
related to the quality metrics as described in §353.1322 of this
subchapter. The provider must have provided at least one Medicaid
service to a Medicaid managed care client for each reporting period
to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 65 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, Component One will be 100 percent of the
total program value.
(B) Allocation of funds across all qualifying providers
will be proportional, based upon historical Medicaid utilization.
(C) Monthly payments to providers will be a uniform
rate increase.
(D) The interim allocation of funds across qualifying
providers will be reconciled to the actual Medicaid utilization across
these providers 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 DPP BHS 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 §353.1322 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 35 percent of the total program value 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 0 percent of the total program value.
(B) Allocation of funds across all qualifying providers
will be based upon historical Medicaid utilization.
(C) Payments to providers will be a uniform rate increase.
(D) Providers must report quality data as described
in §353.1322 of this subchapter as a condition of participation
in the program.
(i) Distribution of the Directed Payment Program for
Behavioral Health Services payments.
(1) Prior to the beginning of the program period, HHSC
will calculate the portion of each payment associated with each enrolled
provider broken down by program capitation rate component and payment
period. The model for scorecard payments and the reconciliation calculations
will be based on the enrolled NPIs and the MCO network status at the
time of the application under subsection (e)(1) of this section. For
example, for a provider, HHSC will calculate the portion of each payment
associated with that provider that would be paid from the MCO to the
provider as follows.
(A) Monthly payments in the form of a uniform dollar
increase for Component One will be equal to the total value of Component
One attributed based upon historical utilization of the provider divided
by twelve. An annual reconciliation will be performed for each provider
based on actual utilization.
(B) For program periods beginning on or before September
1, 2023, rate increases from Component Two will be a uniform percentage
rate increase on applicable services calculated based on the total
value of Component Two for the providers divided by historical utilization
of the respective services.
(C) For purposes of the calculation described in subparagraph
(B) of this paragraph, a provider must achieve a minimum number of
measures as identified in §353.1322 of this subchapter to be
eligible for full payment.
(2) MCOs will distribute payments to enrolled providers
based on criteria established under paragraph (1) of this subsection.
(j) Non-federal share of DPP BHS payments. The non-federal
share of all DPP BHS payments is funded through IGTs from sponsoring
governmental entities. No state general revenue that is not otherwise
available to providers is available to support DPP BHS.
(1) HHSC will communicate suggested IGT responsibilities
for the program period with all DPP BHS eligible and enrolled providers
at least 10 calendar days prior to the IGT declaration of intent deadline.
Suggested IGT responsibilities will be based on the maximum dollars
available under DPP BHS for the program period as determined by HHSC,
plus 10 percent; forecasted member months for the program period as
determined by HHSC; and the distribution of historical Medicaid utilization
across providers, for the program period. HHSC will also communicate
estimated maximum revenues each eligible and enrolled provider could
earn under DPP BHS for the program period with those estimates based
on HHSC's suggested IGT responsibilities and an assumption that all
enrolled providers will meet 100 percent of their quality metrics.
(2) Sponsoring governmental entities will determine
the amount of IGT they intend to transfer to HHSC for the entire program
period and provide a declaration of intent to HHSC 21 business days
before the first half of the IGT amount is transferred to HHSC.
(A) The declaration of intent is a form prescribed
by HHSC that includes the total amount of IGT the sponsoring governmental
entity intends to transfer to HHSC.
(B) The declaration of intent is certified to the best
knowledge and belief of a person legally authorized to sign for the
sponsoring governmental entity but does not bind the sponsoring governmental
entity to transfer IGT.
(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. HHSC will instruct sponsoring
governmental entities as to the IGT amounts necessary to fund the
program at estimated levels. IGT amounts will include the non-federal
share of all costs associated with the provider rate increase, including
costs associated with MCO (Capitation) premium taxes, risk margin,
and administration, plus 10 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 its Internet website by March 15 of each year.
(k) Effective date of rate and dollar reimbursement
increases. HHSC will direct MCOs to increase reimbursements under
this section beginning the first day of the program period that includes
the increased capitation rates paid by HHSC to each MCO pursuant to
the contract between them.
(l) Changes in operation. If an enrolled provider closes
voluntarily or ceases to provide Medicaid services, the provider 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 special mail delivery within 10 business days of closing
or ceasing to provide Medicaid services. Notification is considered
to have occurred when HHSC Provider Finance Department receives the
notice.
(m) 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.
(n) Recoupment. Payments under this section may be
subject to recoupment as described in §353.1301(j) - (k) of this
subchapter.
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| Source Note: The provisions of this §353.1320 adopted to be effective April 21, 2021, 46 TexReg 2579; amended to be effective May 31, 2022, 47 TexReg 3113; amended to be effective January 25, 2024, 49 TexReg 243 |
