| (C) ACIA will be determined by HHSC to be a percentage
that is estimated to result in payments for the hospital that are
equivalent to the amount described under subsection (g)(3)(D) of this
section.
(2) For program periods beginning on or after September
1, 2024, CHIRP final payments for the APHRIQA component will be based
on achievement of performance measures established in accordance with §353.1307
of this subchapter.
(A) Except as otherwise provided by subparagraph (D)
of this paragraph, MCOs will be directed by HHSC to pay hospitals
on a monthly, quarterly, semi-annual, or annual basis that aligns
with the applicable performance achievement measurement period under §353.1307
of this subchapter.
(B) MCOs will be required to distribute payments to
providers within 20 business days of notification by HHSC of provider
achievement results.
(C) Funds that are not earned by a provider due to
failure to achieve performance requirements will be redistributed
to other hospitals in the same hospital SDA and class based on each
hospital's proportion of total earned APHRIQA funds in the SDA. If
no other hospital in the SDA and class receives performance payments,
unearned funds will be redistributed to all hospitals in the SDA based
on each hospital's proportion of total earned APHRIQA funds and projected
to be paid to the hospitals through UHRIP and ACIA.
(D) For any performance measures for which achievement
is determined on an annual basis, a hospital may elect, on the hospital's
enrollment application, to receive two interim payments the amount
of each which will be equal to 20 percent of the total estimated value
of the hospital's potential APHRIQA payment if the hospital were to
earn 100 percent of available payments under the APHRIQA component.
(i) Any interim payments will be reconciled with final
payment for APHRIQA after measurement achievement has been determined
under §353.1307 of this subchapter. If a hospital's final payment
is calculated to be less than the amount that the hospital was paid
on an interim basis, the interim payments are subject to recoupment
as described by this subparagraph. If a hospital's final payment is
calculated to be greater than the amount that the hospital was paid
on an interim basis, the hospital's final payment will be an amount
equal to the amount the hospital earned for measurement achievement
under §353.1307 of this subchapter minus the amount the hospital
was paid on an interim basis.
(ii) Prior to the beginning of the program period,
for hospitals that make the election described by this subparagraph,
HHSC will calculate the total estimated value of the hospital's potential
APHRIQA payment if the provider were to earn 100 percent of available
payments under the APHRIQA component. MCOs will distribute interim
payments described by this subparagraph to enrolled hospitals as directed
by HHSC.
(iii) Interim payments made under this subparagraph
are not an indication of presumed measurement achievement by a provider
under §353.1307 of this subchapter.
(iv) If a provider is notified by HHSC that an interim
payment, or any portion of an interim payment, is being recouped under
this subparagraph, the provider must return all funds subject to recoupment
to the MCO that made the interim payment subject to recoupment within
20 business days of notification by HHSC.
(3) HHSC will limit the amounts paid to providers determined
pursuant to this subsection to no more than the levels that are supported
by the amount described in subsection (i)(3) of this section. Nothing
in this section may be construed to limit the authority of the state
to require the sponsoring governmental entities to transfer additional
funds to HHSC following the reconciliation process described in §353.1301(g)
of this subchapter, if the amount previously transferred is less than
the non-federal share of the amount expended by HHSC in the SDA for
this program.
(4) After determining the percentage of rate increase
using the process described in paragraph (1) of this subsection, HHSC
will modify its contracts with the MCOs in the SDA to direct the percentage
rate increases.
(i) Non-federal share of CHIRP payments. The non-federal
share of all CHIRP payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support
CHIRP.
(1) HHSC will communicate suggested IGT responsibilities
for the program period with all CHIRP hospitals at least 10 calendar
days prior to the IGT declaration of intent deadline. Suggested IGT
responsibilities will be based on the maximum dollars to be available
under the CHIRP program for the program period as determined by HHSC,
plus eight percent; and forecast member months for the program period
as determined by HHSC. HHSC will also communicate estimated revenues
each enrolled hospital could earn under CHIRP for the program period
with those estimates based on HHSC's suggested IGT responsibilities
and an assumption that all enrolled hospitals will meet 100 percent
of their quality metrics and maintain consistent utilization with
the prior year.
(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 no later than 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. 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
no later than March 15 of each year.
(j) Effective date of rate increases. HHSC will direct
MCOs to increase rates 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.
(k) Changes in operation. If an enrolled hospital closes
voluntarily or ceases to provide hospital services in its facility,
the hospital must notify the HHSC Provider Finance Department by hand
delivery, United States (U.S.) mail, or special mail delivery within
10 business days of closing or ceasing to provide hospital services.
Notification is considered to have occurred when the HHSC Provider
Finance Department receives the notice.
(l) Data correction request. Any provider-requested
data or calculation correction must be submitted prior to the date
on which the first half of the IGT amount is due under subsection
(i)(3) of this section.
(m) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
the 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) and §353.1301(k)
of this subchapter.
|
| Source Note: The provisions of this §353.1306 adopted to be effective March 28, 2021, 46 TexReg 1977; amended to be effective May 31, 2022, 47 TexReg 3113; amended to be effective January 29, 2024, 49 TexReg 404 |
